Feeding lambs proportional mixtures of lucerne (Medicago sativa) and forage brassica (Brassica napus) grown under warm and dry conditions

Context Metabolisable energy (ME) and crude protein (CP) concentrations of forages are key determinants of lamb performance during pasture-based finishing. However, forage species often have unbalanced proportions of ME and CP, which can lead to below-optimum performance of lambs. This may be a problem with maturing lucerne (Medicago sativa L.) swards during dry summer conditions, and is a major challenge faced by grazing industries in Mediterranean environments. Aim We investigated whether two summer forages, lucerne and forage brassica (Brassica napus L. cv. Winfred), with differing ME and CP concentration could improve the growth of maternal-composite lambs when offered in mixtures compared with either forage fed alone. Methods A randomised complete block experiment with five treatments and 10 replicate animals per treatment was conducted in an animal house at Hamilton, Victoria, from February to March 2014. The treatments were 100% lucerne, 75% lucerne : 25% brassica, 50% lucerne : 50% brassica, 25% lucerne : 75% brassica, and 100% brassica on a dry-matter basis and fed to lambs. The lucerne and brassica were harvested daily and chopped to ~3 cm length before mixing and feeding. The lambs were adapted for 4 weeks before the start of the experimental phase. Key results Fasted liveweight gain of lambs increased linearly with an increasing proportion of brassica and a decreasing proportion of lucerne in the diet; no mixture performed better than brassica alone. Conclusions Under the warm and dry conditions of this experiment, the ME of lucerne was more limiting to lamb growth than its CP concentration. Implications The results suggest that a small increase in ME supply could improve the performance of lambs grazing a maturing lucerne sward during dry summer conditions. Further research is warranted into improving lamb growth and feed efficiency from lush lucerne and brassica forages.

Genetic Consequences of the Transatlantic Slave Trade in the Americas

According to historical records of transatlantic slavery, traders forcibly deported an estimated 12.5 million people from ports along the Atlantic coastline of Africa between the 16th and 19th centuries, with global impacts reaching to the present day, more than a century and a half after slavery's abolition. Such records have fueled a broad understanding of the forced migration from Africa to the Americas yet remain underexplored in concert with genetic data. Here, we analyzed genotype array data from 50,281 research participants, which-combined with historical shipping documents-illustrate that the current genetic landscape of the Americas is largely concordant with expectations derived from documentation of slave voyages. For instance, genetic connections between people in slave trading regions of Africa and disembarkation regions of the Americas generally mirror the proportion of individuals forcibly moved between those regions. While some discordances can be explained by additional records of deportations within the Americas, other discordances yield insights into variable survival rates and timing of arrival of enslaved people from specific regions of Africa. Furthermore, the greater contribution of African women to the gene pool compared to African men varies across the Americas, consistent with literature documenting regional differences in slavery practices. This investigation of the transatlantic slave trade, which is broad in scope in terms of both datasets and analyses, establishes genetic links between individuals in the Americas and populations across Atlantic Africa, yielding a more comprehensive understanding of the African roots of peoples of the Americas.

AB1173 RHEUMATOLOGIST CARE IS ASSOCIATED WITH FEWER EMERGENCY ROOM VISITS BY PERSONS WITH GOUT

Background:

Gout is one of the most common inflammatory arthropathies. By searching a large administrative data base (Symphony Integrated Dataverse), we found that persons with acute gout see a rheumatologist infrequently, whereas less than 50% of advanced gout patients are seen by a rheumatologist. Notably, however, gout patients seen by rheumatologists have more frequent urate measurements and are prescribed urate lowering therapy more frequently. This study sought to determine whether involvement of a rheumatologist in gout care had a positive impact on health outcomes

Objectives:

To determine whether involvement of a rheumatologist had a positive impact on health outcomes of patients with gout.

Methods:

We carried out a retrospective analysis to identify persons with gout over an approximately 3-year period from October 2015 to December 2018. This study used data from the Truven Marketscan®database, an administrative database covering over 190 million patients across the United States and based on fully adjudicated and paid insurance claims. Patients were identified as having gout if they were >18 years of age and had at least two medical claims for the diagnosis of gout on different days, separated by at least 3 months. Patients with acute gout were identified by ICD-10 code M10.*, chronic nontophaceous gout (M1A.***0), tophaceous gout (M1A.***1) and uncontrolled gout (M10.*, M1A.*), the latter manifested by three gout codes (any) in the primary diagnosis position and three urate measurements within the same calendar year. Particular attention was placed on Emergency Room (ER) visits by individuals in each category and by individuals who had been evaluated by a rheumatologist.

Results:

We identified 284,877 gout patients. The median age was 59.2 years and 79.0% were male. Of the 230,998 persons coded as acute gout, 10.7% were seen by a rheumatologist, whereas 26.9% of the 32,942 coded as chronic nontophaceous gout, 47.2% of the 7,723 coded as tophaceous gout and 43.6% of the13,514 coded as uncontrolled gout were seen by a rheumatologist. In each gout category, the frequency of ER visits was significantly reduced in persons who had been seen by a rheumatologist (Table 1). In acute gout, the frequencies of ER visits in those with and without rheumatologist care were 5.6% vs 6.6% (p<0.001), respectively. In chronic nontophaceous gout it was 5.5% vs 6.7% (p=0.001); in tophaceous gout it was 10.3% vs 14.7% (p<0.001); and in uncontrolled gout it was 12.8% vs 19.0%, respectively. If the frequencies of rheumatologist-associated gout patient ER visits were applied to all gout subjects, there would have been 3,088 less ER visits in this cohort of gout patients.

Table 1.Rheumatology BreakdownEmergency Room VisitsPopulationOverall NW/ RheumatologyPatients%With Gout ER Visit (%)p-value (comparing %)ER Visits* Per PatientAcute Gout230,698Yes24,63810.68%1373 (5.57%)<0.0011.47No206,06089.32%13632 (6.62%)1.53Non-Tophaceous Chronic32,942Yes8,86326.90%486 (5.48%)<0.0011.95No24,07973.10%1601 (6.65%)2.39Tophaceous Chronic7,723Yes3,64847.24%376 (10.31%)<0.0012.78No4,07552.76%597 (14.65%)2.89Uncontrolled13,514Yes5,88643.55%753 (12.79%)<0.0012.06No7,62856.45%1452 (19.04%)2.56

* ER Visits are only included in this analysis if the primary diagnosis code on the claim is a gout code (M10.X, M1A.X)

Conclusion:

There appears to be a positive impact of rheumatologist involvement in the care of gout patients, manifested by a significant decrease in the frequency of ER visits. Considering the inconvenience and cost of ER visits, rheumatologist care may have a significant impact on the well-being of gout patients and on the overall cost of their care.

Disclosure of Interests:

Naomi Schlesinger Grant/research support from: Pfizer, Amgen, Consultant of: Novartis, Horizon Therapeutics, Selecta Biosciences, Olatec, IFM Therapeutics, Mallinckrodt Pharmaceuticals, N. Lawrence Edwards Consultant of: Horizon Therapeutics, Takeda Pharmaceuticals US, Aclaris Therapeutics, Atom Biosciences, Sanders Clark: None declared, Peter Lipsky Consultant of: Horizon Therapeutics

Giant solitary fibrous tumour: an uncommon approach for an uncommon tumour

Complete surgical resection of a giant solitary fibrous tumour of the pleura can be challenging. We describe our technique for dealing with one such tumour. A clamshell incision proved inadequate for visualising the extent of the tumour. An additional lower sternotomy incision was then made, which significantly improved exposure. With the aid of cardiopulmonary bypass, it was then possible to mobilise and completely excise the tumour. Complete resection remains the mainstay of treatment for such pleural-based tumours. Every attempt must be made to achieve this, including any modification of the traditional approach if required.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Frailty and hospital outcomes within a low socioeconomic population

BACKGROUND

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage.

AIMS

To evaluate the association of the CFS with hospital-related outcomes.

DESIGN

Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%).

METHODS

The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses.

RESULTS

Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons.

CONCLUSIONS

The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

The LAPLAP study: a randomized placebo-controlled clinical trial assessing postoperative functional recovery using intraperitoneal local anaesthetic in laparoscopic colorectal surgery

AIM

Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery.

METHOD

Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded.

RESULTS

Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine.

CONCLUSION

Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.

Triton X-114 Phase Separation of Platelet Membrane Glycoproteins from Normal Subjects and a Patient with Type I Thrombasthenia

Surface-labelled normal and thrombasthenic platelets have been subjected to phase separation in Triton X-114. Triton-rich and Triton-poor fractions have been analysed by SDS-PAGE and IEF-SDS-PAGE. Partitioning characteristics of the major glycoproteins have been defined. The Triton-rich fraction contained GPIIb, III, IV, VI, VII, VIII, GP38 and the IIb β subunit. In contrast, the Triton-poor fraction contained the HMWGP, GPIa, Ib, IIb, III, V and GPIX.

Analysis of the platelet membrane glycoproteins of a patient with Type 1 thrombasthenia has been carried out using Triton X-114. The value of the method in diagnosis of this condition and differences between our findings and those published previously are discussed.