AS-amyloidosis. Dual pathology or novel disease? A multimodality, multi-centre assessment across health and disease

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation

onbehalf

AS-Amyloidosis consortium

Background

The coexistence of severe aortic stenosis (lone AS) and transthyretin cardiac amyloidosis (lone amyloidosis) is common, but the resultant AS-amyloidosis phenotype is unclear.

Purpose

We characterised AS-amyloidosis, hypothesizing that the dual insult of AS-amyloidosis results is a severe phenotype.

Methods

We compared four cohorts with deep phenotyping: 81 older age controls, 359 lone AS, 36 AS-amyloidosis (Perugini grade 2 and 3) and 107 lone amyloidosis (Perugini grade 2 and 3).

Results

AS-amyloidosis was similar to lone AS with respect to left ventricular mass and LVEF (57 (45, 64)%). It was similar to lone amyloidosis with respect to lateral S" (0.04 (0.03, 0.06) m/s), NT-proBNP (4149 (1449, 6459) ng/L) and troponin T (56 (34, 100) ng/L). Whilst, prevalence of carpal tunnel syndrome (CTS) (17%) and diastolic function (E/A ratio 1.1 (0.8, 2.8)) were intermediate.

Conclusion

AS-amyloidosis is not a double insult from AS and amyloidosis, but a mixed phenotype with features similar to lone amyloidosis (cardiac biomarkers), lone AS (remodelling and LVEF) or intermediate (diastology and CTS).

Characteristics across all 4 groups Variable Older age controls (n = 81) Lone AS (n = 359) AS-amyloidosis (n = 36) Lone amyloidosis (n = 107) P value Age (years) 82 (80, 84)*†‡ 85 (80, 88)§∞ 88 (85, 92)# 80 (75, 84) <0.005 Sex (% male) 69 *‡ 49 ∞ 61 # 94 <0.005 Carpal tunnel syndrome (%) 0 2 § 17 # 38 <0.005 Voltage/mass ratio 0.22 (0.14, 0.27)‡ 0.18 (0.13, 0.28)∞ 0.18 (0.09, 0.21)# 0.07 (0.05, 0.10) <0.005 NT-ProBNP (ng/L) 131 (66, 221)*†‡ 1629 (639, 3941)§∞ 4149 (1449, 6459) 2888 (1755, 5483) <0.005 hsTnT (ng/L) 12 (8, 17)*†‡ 24 (15, 40)§∞ 56 (34, 100) 62 (41, 82) <0.005 Inferolateral wall thickness (cm) 0.9 (0.8, 1.0)*†‡ 1.1 (0.9, 1.3)∞ 1.3 (1.1, 1.5)# 1.7 (1.6, 1.9) <0.005 Anteroseptal wall thickness (cm) 1.0 (0.9, 1.2)*†‡ 1.4 (1.2, 1.6)§∞ 1.5 (1.3, 1.8) 1.7 (1.6, 1.9) <0.005 Indexed LV mass (g/m2) 79 (66, 102)*†‡ 128 (99, 152)∞ 126 (116, 140)# 174 (159, 200) <0.005 LVEF (%) 59 (54, 63)‡ 59 (50, 65)∞ 57 (45, 64)# 39 (31, 48) <0.005 Lateral S" (m/s) 0.08 (0.07, 0.09)*†‡ 0.07 (0.05, 0.08)§∞ 0.05 (0.04, 0.07) 0.05 (0.04, 0.06) <0.005 Septal S" (m/s) 0.06 (0.06, 0.08)*†‡ 0.05 (0.04, 0.06)∞ 0.04 (0.03, 0.06) 0.04 (0.03, 0.05) <0.005 E/A 0.7 (0.6, 0.8)*†‡ 0.8 (0.7, 1.3)§∞ 1.1 (0.8, 2.8)# 2.4 (1.8, 3.3) <0.005 RV Wall thickness (cm) 0.4 (0.3, 0.4)*†‡ 0.4 (0.4, 0.6)∞ 0.6 (0.4, 0.7)# 0.8 (0.7, 1.0) <0.005 TAPSE (cm) 2.4 (2.0, 2.7)*†‡ 2.1 (1.6, 2.5)∞ 1.9 (1.5, 2.1)# 1.4 (1.2, 1.9) <0.005 Classical LFLG AS (%) 9 13 0.472 * p < 0.05, Old age control vs Lone AS † p < 0.05, Old age control vs AS-amyloidosis ‡ p < 0.05, Old age control vs Lone amyloidosis § p < 0.05, Lone AS vs AS-amyloidosis ∞ p < 0.05, Lone AS vs Lone amyloidosis # p < 0.05, AS-amyloidosis vs Lone amyloidosis Abstract Figure. AS-amyloidosis compared to other cohorts

A proposed ''A to Z RAM (Radiograph Assessment Method)'' for triage of patients with a suspected bone tumour

INTRODUCTION

We propose a ''A to Z RAM (Radiograph Assessment Method)'' for evaluation of Radiograph of patients with a suspected bone tumour.

METHODS

In the current study, ten radiological features with letters 'A, B, C, D, E, F and Z' were used and which included the age of the patient, involved part of the bone, characteristics, content, distinctiveness, the exterior of the bone, fracture, and zone of transition. Four independent observers (orthopaedic oncologists and surgical oncologists) evaluated a set of 30 radiographs of bone tumour selected at random from our hospital database based on A to Z RAM. We classified the lesions into two groups according to the traffic signal system; Green (suspected benign lesion) and Red (suspected malignant lesion).

RESULTS

There were 18 (60%) benign bone lesions and 12 (40%) malignant lesions in the current study. 91.6% of malignant tumours and 88.8% of the benign tumours were identified correctly by the four observers. The inter-observer variability with Fleiss kappa was 0.884 (95% CI 0.7-1.03 p-value < 0.05), suggestive of agreement not by chance. These radiographs were again reassessed by the four observers after 3 months. The interobserver variability by Fleiss kappa was 1.0 (95% CI 0.8-1.1) suggesting complete agreement amongst the observers. Both orthopaedic oncologists had intra-observer kappa as 1.0 each and both surgical oncologists had 0.795 and 0.930 respectively.

CONCLUSION

The proposed A to Z RAM is an easy to use and reproducible method for reviewing radiographs in the out-patient department along with clinical findings for better management of patients with suspected bone lesions. The A to Z RAM can be a medical triage tool and subdivide bone lesions into two subgroups i.e. suspected benign lesion with a suggestion of further investigations with MRI and biopsy and suspected malignant lesion with a suggestion of MRI or early referral to a tertiary cancer center with expertise in orthopaedic oncology.

IMPLICATIONS FOR PRACTICE

The A to Z RAM (Radiologic Assessment Method) is a reproducible method for reviewing radiographs in the out-patient department and can be an aid for better management of patients. A to Z RAM is useful as a medical triage system, subdividing patients according to the probable diagnosis into a suspected benign lesion and suspected malignant lesion.

Healthcare staff perceptions and misconceptions regarding antibody testing in the United Kingdom: implications for the next steps for antibody screening

BACKGROUND

Healthcare workers have been at increased risk of exposure, infection and serious complications from COVID-19. Antibody testing has been used to identify staff members who have been previously infected by SARS-CoV-2, and has been rolled out rapidly in the United Kingdom. A number of comment and editorial articles have been published that raise concerns about antibody testing in this context. We present perceptions of National Health Service (NHS) healthcare workers in relation to SARS-CoV-2 antibody testing.

METHODS

An electronic survey regarding perceptions towards SARS-CoV-2 antibody testing was distributed to all healthcare workers at a major NHS tertiary hospital following implementation of antibody testing.

RESULTS

In total, 560 healthcare workers completed the survey (80% female; 25% of Black and Minority Ethnic background; 58% from frontline clinical staff). Exploring whether they previously had COVID-19 was the primary reported reason for choosing to undergo antibody testing (85.2%). In case of a positive antibody test, 72% reported that they would feel relieved, whilst 48% felt that they would be happier to work in a patient-facing area. Moreover, 12% responded that a positive test would mean "social distancing is less important", with 34% of the responders indicating that in this case they would be both less likely to catch COVID-19 and happier to visit friends/relatives.

CONCLUSIONS

NHS staff members primarily seek out SARS-CoV-2 antibody testing for an appropriate reason. Based on our findings and given the lack of definite data regarding the extent of immunity protection from a positive SARS-CoV-2 antibody test, significant concerns may be raised regarding the reported interpretation by healthcare workers of positive antibody test results. This needs to be further explored and addressed to protect NHS staff and patients.

Inhibition of the activin receptor improves cardiac remodelling in the ercc1 mouse model of accelerated ageing

Introduction

In the heart, ageing is associated with pathological remodelling due to an increase of DNA damage, oxidative stress and fibrosis that impairs function, often leading to heart failure. Ageing is also associated with activation of the activin signalling pathway which contributes to cardiac dysfunction. Previous studies have shown that inhibition of the activin signalling pathway preserves cardiac function during aging. However, the beneficial effects of this inhibition in cardiac disorders such as accelerated ageing remain unknown.

Purpose

We hypothesized that inhibition of the activin receptor would be beneficial for the pathological cardiac phenotype of the Ercc1Δ/− mouse model of accelerated ageing.

We aimed to determine the cardiac phenotype of the Ercc1 mouse, and how inhibition of activin signalling affects cardiac remodelling using immunological and biochemical analysis.

Methods

Using immunohistochemical staining, we investigated the cardiac phenotype in 16 week old Ercc1Δ/− progeric and Ercc1+/+ wildtype mice (n=4–6) with or without soluble activin receptor injections from the week 7 (sActRIIB, 10mg/kg). The Ercc1Δ/− mouse displays a deficiency in DNA repair, leading to an accelerated ageing phenotype. Experimentally, injections of the myostatin /activin antagonist called the soluble ActRIIB receptor trap (sActRIIB) can be used to pharmacologically target the activin signalling pathway.

Results

In Ercc1Δ/− mice at 16 weeks there was a 50% decrease in the heart weight in comparison to Ercc1+/+ wildtype mice (175±13 vs 85±4), (p&lt;0.001). Activin inhibition did not have any effect on the heart weight. To determine the extent of DNA damage, cardiac tissue was stained for γH2Ax. γH2Ax accumulates at double stranded DNA breaks where histone 2A becomes phosphorylated. Ercc1Δ/− mice displayed a 20% increase in double stranded DNA breaks in comparison to the Ercc1+/+ wildtype (0.6±0.5 vs 22.5±2.5 vs 15.8±0.7), (p&lt;0.01). Activin inhibition led to a significant 5% decrease (p&lt;0.05). Oxidative stress was determined by dihydroethidium staining. Ercc1Δ/− mice showed a 30% increase in oxidative stress (33.33±3 vs 49.98±3 vs 36.19±3), (p&lt;0.05). Activin inhibition reversed this increase of oxidative stress in Ercc1Δ/− mice (p&lt;0.05). Finally, cardiac fibrosis was assessed using picrosirius red staining. No differences were observed between the Ercc1Δ/− progerics and Ercc1+/+ wildtype mice, while activin inhibition led to a 50% decrease (4.9±0.3 vs 7.7±1.3 vs 2.9±0.1), (p&lt;0.01). Interestingly, Ercc1Δ/− mice display thicker cardiac interstitial collagen I (1.3±0.01 vs 1.4±0.05 vs 1.3±0.01), (p&lt;0.05). Activin inhibition also reversed this increased interstitial collagen (p&lt;0.05).

Conclusion

Inhibition of activin receptor signalling brings beneficial effects to the Ercc1Δ/− cardiac phenotype by attenuating oxidative stress, DNA damage and fibrosis.

Funding Acknowledgement

Type of funding source: None

Catheter ablation for atrial fibrillation in patients with reduced systolic function: a national perspective

Background

Randomized trials have shown improvement in hard clinical end points when catheter ablation (CA) was employed as a management strategy for certain atrial fibrillation (AF) patients with heart failure and reduced ejection fraction (HFrEF). We sought to determine real world data on mortality and complications after utilization of CA in such patients.

Methods and results

Data were derived from National Inpatient Sample from January 2008 to August 2015. Patients were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. Baseline characteristics and outcomes were compared among AF and HFrEF patients undergoing CA or not. Propensity matching was done to mitigate selection bias and balance confounding variables. Various CA related complications were assessed. Logistic regression was done to determine predictors of mortality in our study cohort. A total of 2,569,919 patients were enrolled and out of these approximately 7773 patients underwent CA. Mortality was significantly better in CA group in both unmatched (1.2% vs. 4.9%, p&lt;0.01) and propensity matched cohorts (1.2% vs. 3.6%, p&lt;0.01). Overall complication rate was 10.2% in CA cohort and were primarily cardiac and neurological in origin. In regression analysis, CA remains a strong predictor of reduced mortality (OR 0.301, 95% CI 0.184–0.494).

Conclusion

CA is associated with improved mortality in admitted AF patients with concomitant HFrEF. Overall complication rate after CA was modest at 10.2%.

Funding Acknowledgement

Type of funding source: None

Detecting national human enteric disease outbreaks linked to animal contact in the United States of America

Enteric pathogens, such as non-typhoidal Salmonella, Campylobacter and Escherichia coli, can reside in the intestinal tract of many animals, including livestock, companion animals, small mammals and reptiles. Often, these animals can appear healthy; nonetheless, humans can become infected after direct or indirect contact, resulting in a substantial illness burden. An estimated 14% of the 3.2 million illnesses that occur in the United States of America (USA) each year from such enteric pathogens are attributable to animal contact. Surveillance for enteric pathogens in the USA includes the compilation and interpretation of both laboratory and epidemiologic data. However, the authors feel that a collaborative, multisectoral and transdisciplinary - or One Health - approach is needed for data collection and analysis, at every level. In addition, they suggest that the future of enteric illness surveillance lies in the development of improved technologies for pathogen detection and characterisation, such as genomic sequencing and metagenomics. In particular, using whole-genome sequencing to compare genetic sequences of enteric pathogens from humans, food, animals and the environment, can help to predict antimicrobial resistance among these pathogens, determine their genetic relatedness and identify outbreaks linked to a common source. In this paper, the authors describe three recent, multi-state human enteric illness outbreaks linked to animal contact in the USA and discuss how integrated disease surveillance was essential to outbreak detection and response. Additional datasharing between public health and animal health laboratories and epidemiologists at the local, national, regional and international level may help to improve surveillance for emerging animal and human health threats and lead to new opportunities for prevention.

Delay in diagnosis of patients with head-and-neck cancer in Canada: impact of patient and provider delay

Background

Head-and-neck cancers (hncs) often present at an advanced stage, leading to poor outcomes. Late presentation might be attributable to patient delays (reluctance to seek treatment, for instance) or provider delays (misdiagnosis, prolonged wait time for consultation, for example). The objective of the present study was to examine the length and cause of such delays in a Canadian universal health care setting.

Methods

Patients presenting for the first time to the hnc multidisciplinary team (mdt) with a biopsy-proven hnc were recruited to this study. Patients completed a survey querying initial symptom presentation, their previous medical appointments, and length of time between appointments. Clinical and demographic data were collected for all patients.

Results

The average time for patients to have their first appointment at the mdt clinic was 15.1 months, consisting of 3.9 months for patients to see a health care provider (hcp) for the first time since symptom onset and 10.7 months from first hcp appointment to the mdt clinic. Patients saw an average of 3 hcps before the mdt clinic visit (range: 1-7). No significant differences in time to presentation were found based on stage at presentation or anatomic site.

Conclusions

At our tertiary care cancer centre, a patient's clinical pathway to being seen at the mdt clinic shows significant delays, particularly in the time from the first hcp visit to mdt referral. Possible methods to mitigate delay include education about hnc for patients and providers alike, and a more streamlined referral system.

Applying the WHO ICF Framework to the Outcome Measures Used in the Evaluation of Long-Term Clinical Outcomes in Coronavirus Outbreaks

(1) Objective: The World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) classification is a unified framework for the description of health and health-related states. This study aimed to use the ICF framework to classify outcome measures used in follow-up studies of coronavirus outbreaks and make recommendations for future studies. (2) Methods: EMBASE, MEDLINE, CINAHL and PsycINFO were systematically searched for original studies assessing clinical outcomes in adult survivors of severe acute respiratory distress syndrome (SARS), middle east respiratory syndrome (MERS) and coronavirus disease-19 (COVID-19) after hospital discharge. Individual items of the identified outcome measures were linked to ICF second-level and third-level categories using ICF linking rules and categorized according to an ICF component. (3) Results: In total, 33 outcome measures were identified from 36 studies. Commonly used (a) ICF body function measures were Pulmonary Function Tests (PFT), Impact of event scale (IES-R) and Hospital Anxiety and Depression Scale (HADS); (b) ICF activity was 6-Minute Walking Distance (6MWD); (c) ICF participation measures included Short Form-36 (SF-36) and St George’s Respiratory Questionnaire (SGRQ). ICF environmental factors and personal factors were rarely measured. (4) Conclusions: We recommend future COVID-19 follow-up studies to use the ICF framework to select a combination of outcome measures that capture all the components for a better understanding of the impact on survivors and planning interventions to maximize functional return.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease's pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Breath Is Life

This painting memorializes the lives of people who died in the COVID-19 pandemic and people who have died from police brutality.

External validation of the modified HOPPE score to predict low risk pulmonary embolism suitable for early discharge

Objective

Recently, a novel score for risk stratification of patients with pulmonary embolism (PE)—the HOPPE score—was derived. We aimed to externally validate the HOPPE score in emergency department-diagnosed PE, using SpO₂ as a surrogate for PaO₂—the modified HOPPE score.

Methods

Retrospective observational study of adult patients with an emergency department diagnosis of PE was performed. Data collected included demographics, co-morbidities, clinical features, electrocardiogram and test results, in-hospital mortality and non-fatal major adverse clinical events (MACE; survived cardiac arrest, cardiogenic shock or thrombolysis administration). The primary outcome of interest was clinical performance of the modified HOPPE score for inhospital mortality and the composite outcome of in-hospital death and MACE. A secondary outcome was comparison of predictive performance between the modified HOPPE score and the simplified Pulmonary Embolism Severity Index score.

Results

Two hundred and six patients were studied (median age 61, 55% female). There were no deaths or MACE in patients with a low risk modified HOPPE score of 0 to 6 (0%; 95% confidence interval, 0% to 1.8%). Negative predictive value of a low risk score was 100% (95% confidence interval, 92.2% to 100%) for in-hospital mortality and for the composite of in-hospital mortality or MACE. The modified HOPPE score had similar predictive performance to the simplified Pulmonary Embolism Severity Index score with an area under the curve of 0.88 vs. 0.80 for the composite outcome of in-hospital mortality or MACE (P=0.052). Twenty-eight percent of the patients were classified as low risk and potentially suitable for management as outpatients.

Conclusion

The modified HOPPE score showed good clinical performance. Prospective validation is warranted.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Long-term oncological outcomes following completely minimally invasive esophagectomy versus open esophagectomy

Open esophagectomy (OE) for esophageal and gastroesophageal junctional cancers is associated with high morbidity. Completely minimally invasive esophagectomy (CMIE) techniques have evolved over the last two decades and significantly reduce surgical trauma compared to open surgery. Despite this, long-term oncological outcomes following CMIE compared to OE remain unclear. This systematic review and meta-analysis aimed to compare overall 5-year survival (OFS) and disease-free 5-year survival (DFFS) between CMIE and OE. It was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive electronic literature search from MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials was conducted. The PROSPERO database was also searched for studies comparing OFS and DFFS between CMIE and OE. The Newcastle Ottawa Scale was used to assess study quality for included studies. Overall, seven studies (containing 949 patients: 527 OE and 422 CMIE) were identified from screening. On pooled meta-analysis, there was no significant difference in OFS or DFFS between CMIE and OE cohorts ([odds ratio 1.12; 95% CI: 0.85 to 1.48; P = 0.41] and [odds ratio 1.34; 95% CI: 0.81-2.22; P = 0.25] respectively). Sensitivity and subgroup analysis with high-quality studies, three highest sample sized studies, and three most recent studies also revealed no difference in long-term oncological outcomes between the two operative groups. This review demonstrates long-term oncological outcomes following CMIE appear equivalent to OE based on amalgamation of existing published literature. Limited high-level evidence comparing OFS and DFFS between CMIE and OE exists. Further research with a randomized controlled trial is required to clinically validate these findings.

Current technical surgical practice of emergency appendicectomy: a cross-sectional survey of surgical registrars in the UK

INTRODUCTION

Appendicectomy remains one of the most commonly performed procedures in general surgery. The aim of this study was to explore variation in operative techniques of an appendicectomy among surgical registrars in England.

MATERIALS AND METHODS

An anonymised survey was sent out to surgical registrars in the UK via email and social media. Subgroup analyses were performed comparing respondents based on their level of seniority and subspecialty background.

RESULTS

A total of 168 respondents completed the survey, of whom 77.4% (130/168) were specialty trainees years 3-8 and 44.6% (75/168) were colorectal trainees. The majority (98.8%) preferred a laparoscopic approach to appendicectomy. Overall, 73.2% opted to use diathermy to divide an uninflamed mesoappendix. Half of the respondents (50%) preferentially used diathermy to control the appendicular artery, followed by 44% preferring use of metal or polymeric clips. The appendicular stump was most often secured with Endoloops (85.7%) when removing a macroscopically uninflamed appendix but less readily used in the visibly inflamed appendix (75.6%, p = 0.01). Colorectal and upper gastrointestinal registrars were more likely to use diathermy on the mucosa of the appendix stump compared with other subspecialties (p = 0.03). The majority (82.1%) of respondents extracted the appendix via a retrieval bag. Regarding skin closure, most respondents (69%) adopted absorbable subcuticular sutures. Preferential duration of postoperative antibiotic use following appendicectomy for complicated appendicitis varied among the respondents.

CONCLUSION

There are similarities and differences across surgical registrars in terms of technical practice in appendicectomy, partially attributed to prior experience and training.

Clinical Guidance for the Management of Patients with Urothelial Cancers During the COVID-19 Pandemic - Rapid Review

The current COVID-19 pandemic presents a substantial obstacle to cancer patient care. Data from China as well as risk models suppose that cancer patients, particularly those on active, immunosuppressive therapies are at higher risks of severe infection from the illness. In addition, staff illness and restructuring of services to deal with the crisis will inevitably place treatment capacities under significant strain. These guidelines aim to expand on those provided by NHS England regarding cancer care during the coronavirus pandemic by examining the known literature and provide guidance in managing patients with urothelial and rarer urinary tract cancers. In particular, they address the estimated risk and benefits of standard treatments and consider the alternatives in the current situation. As a result, it is recommended that this guidance will help form a framework for shared decision making with patients. Moreover, they do not advise a one-size-fits-all approach but recommend continual assessment of the situation with discussion within and between centres.

Acceptability of Best Practice School Lunches by High School-Aged Participants in an Offer Setting

Objectives

A major barrier to improving school lunch dietary quality (DQ) is perceived low acceptability, currently investigated through participation, selection, and plate waste in school settings. The purpose of this study was to investigate differences in acceptability of NSLP-qualifying school lunches of high [Healthy Eating Index (HEI) = 90–95/100, best practice school lunch, BPSL] and moderate (HEI = 75/100, typical school lunch, TSL) DQ in a controlled offer setting by high school-aged children.

Methods

This randomized crossover trial included a convenience sample of 40 high school-aged students recruited from local National School Lunch Program (NSLP)-participating schools. Instruments included hunger scale, selection record, taste test survey, and weighted plate waste assessment. Participants were randomized into three groups, attending three meal conditions in a different order. Meal conditions (MC) had two options for each NSLP meal component: 1) BPSL/BPSL, 2) TSL/TSL, 3) BPSL/TSL. Data analysis included descriptive statistics, Cronbach's alpha, one-way ANOVA, ANCOVA, chi-squared, and regression analysis.

Results

Preliminary analysis showed one significant difference in acceptability between MC, for grain % plate waste (P &lt; 0.001), such that MC1 was significantly greater than MC2 and MC3 (ps &lt; 0.017, mean differences = 27.0% and 26.8%, respectively).

Conclusions

Preliminary results suggest minimal differences in acceptability between BPSL and TSL amongst high school students.

Funding Sources

Oklahoma State University.

Variability in Dietary Quality of an Elementary School Lunch Menu with Changes in National School Lunch Program Nutrition Standards

Objectives

There have been numerous changes to the National School Lunch Program (NSLP) nutrition standards over the past 10 years. The Healthy Hunger-Free Kids Act (HHFKA, 2010) presumably improved dietary quality (DQ) of reimbursable school meals from previous standards, while Child Nutrition Program Flexibilities (CNP Flexibilities, 2017) appear to decrease DQ. However, this variability in DQ has not been quantified. Thus, the purpose of this study was to determine differences in nutrient content and DQ between elementary school lunch menus meeting recent NSLP nutrition standards, School Meal Initiatives (SMI, 1995), HHFKA (2012), and CNP Flexibilities (2017), as well as with evidence-based school lunch best practices implemented (BP).

Methods

A base menu, deemed typical by expert opinion, was portioned per three versions of NSLP nutrition standards (SMI, HHFKA, CNP Flexibilities) and BP for elementary schoolchildren, and analyzed for nutrient content and DQ using ESHA Food Processor and The Healthy Eating Index (HEI) 2015. Statistical analyses included one-way ANOVA, Kruskal-Wallis, and Dunnett's test. The level of significance was set at P &lt; 0.0083.

Results

The BP menu had significantly higher whole fruit (317%) and whole grain (669%) HEI scores than the SMI menu. The BP and HHFKA menus had higher refined grain (156%) and added sugar (2%) HEI scores than the SMI menu. The SMI menu had lower total vegetable (49-50%) and saturated fat (43-51%) HEI scores compared to all other menus. Results were significant (ps &lt; 0.0083).

Conclusions

This study provides important information for guiding future policy towards further improving NSLP nutrition standards in their mission to provide healthy food to children, combatting malnutrition and obesity. Continuing to improve NSLP policy has the potential to impact the health, academic performance, and future of US children through higher DQ school lunches.

Funding Sources

None.

Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalisation or ICU admission: A systematic review and meta-analysis

OBJECTIVE

To determine long-term clinical outcomes in survivors of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus infections after hospitalization or intensive care unit admission.

DATA SOURCES

Ovid MEDLINE, EMBASE, CINAHL Plus, and PsycINFO were searched.

STUDY SELECTION

Original studies reporting clinical outcomes of adult SARS and MERS survivors 3 months after admission or 2 months after discharge were included.

DATA EXTRACTION

Studies were graded using the Oxford Centre for Evidence-Based Medicine 2009 Level of Evidence Tool. Meta-analysis was used to derive pooled estimates for prevalence/severity of outcomes up to 6 months after hospital discharge, and beyond 6 months after discharge.

DATA SYNTHESIS

Of 1,169 identified studies, 28 were included in the analysis. Pooled analysis revealed that common complications up to 6 months after discharge were: impaired diffusing capacity for carbon monoxide (prevalence 27%, 95% confidence interval (CI) 15–45%); and reduced exercise capacity (mean 6-min walking distance 461 m, CI 450–473 m). The prevalences of post-traumatic stress disorder (39%, 95% CI 31–47%), depression (33%, 95% CI 20–50%) and anxiety (30%, 95% CI 10–61) beyond 6 months after discharge were considerable. Low scores on Short-Form 36 were identified beyond 6 months after discharge.

CONCLUSION

Lung function abnormalities, psychological impairment and reduced exercise capacity were common in SARS and MERS survivors. Clinicians should anticipate and investigate similar long-term outcomes in COVID-19 survivors.

Mycosis fungoides: developments in incidence, treatment and survival

BACKGROUND

Prior studies have demonstrated improved disease-specific survival of mycosis fungoides (MF) patients over the last 50 years.

OBJECTIVE

To analyse patterns of survival and incidence from 1973 to 2016 and determine whether apparent improvements in MF-specific survival are due to lead-time bias rather than improvements in treatment.

METHODS

We performed an analysis of 10 155 patients diagnosed with MF from 1973 to 2016 in the United States cancer registries of SEER-18. We also performed a literature review of papers including stage data for unselected populations of MF patients prior to 2000.

RESULTS

Incidence of MF increased from 3.0 per million person-years in the 1970s to 5.9 in the 2010s. For all cohorts, non-Hodgkin lymphoma (including MF) was the leading cause of death. Survival analysis demonstrated marked improvement in disease-specific and overall survival from the 1970s to 2010s. Based on systematic review of the literature, 32%-73% of patients diagnosed prior to 2000 were diagnosed with early-stage disease, as opposed to 81% of patients in the SEER 2000-2016 cohort (P < 0.035 for all cohorts).

CONCLUSIONS

Although there have been improvements in MF-related survival over the last 50 years, these may reflect improvements in our ability to diagnose early-stage disease rather than improved treatment.

Do community mental health teams caring for severely mentally ill patients adjust treatments and services based on patients’ antisocial or criminal behaviours?

Background

Antisocial behaviour is common among patients with severe mental illness (SMI) requiring hospitalisation.

Aim

To determine whether differential treatments and services are provided to patients with SMI who engage in antisocial behaviour.

Method

A random sample of 161 inpatients with SMI were recruited from general adult wards and assessed at baseline and two years later. Information on symptoms, aggressive behaviour, substance misuse, and service use was obtained from patients and clinical files.

Results

Past antisocial behaviours were not associated with type or intensity of treatments and services. Severity of positive symptoms, aggressive behaviour, and illicit drug use were positively associated with the frequency of CMHT contact, but not with the type of CMHT, type of medication, or other treatments and benefits.

Conclusions

While the frequency of meetings with CMHTs increased with the severity of antisocial behaviours, no specific treatments were provided to patients with SMI engaging in antisocial behaviours.

The association of age with the clinicopathological characteristics and prognosis of colorectal cancer: a UK single-centre retrospective study

INTRODUCTION

Colorectal cancer (CRC) is uncommon in patients under the age of 40 years and its association with poor histological features and survival is uncertain. This study aimed to evaluate age-related differences in clinicopathological features and prognosis in patients diagnosed with CRC.

METHOD

A single-centre retrospective review of all patients diagnosed with CRC between 2004 and 2013 was performed. Patients were stratified into three age groups: (1) 18-40 years, (2) 41-60 years and (3)> 60 years. Clinicopathological characteristics and outcomes were compared between the three groups.

RESULTS

A total of 1328 patients were included, of whom 57.2% were men. There were 28 (2.1%) patients in group 1, 287 (21.6%) in group 2 and 1013 (76.3%) in group 3. Group 1 had the highest proportion of rectal tumours (57.1% in group 1, 50.2% in group 2 and 31.9% in group 3; P < 0.001). Tumour histology and disease stage were comparable between the groups. Group 1 had significantly worse disease-free survival (DFS) than the two older groups (44%, 78% and 77%, respectively; P = 0.022). Multivariate analysis demonstrated that age was not an independent prognostic factor whereas Stage III disease [hazard ratio (HR) 4.42; 95% CI 2.81-6.94; P < 0.001] and neoadjuvant chemotherapy (HR 1.65; 95% CI 1.06-2.58; P = 0.026) were associated with increased risk of recurrence.

CONCLUSION

Patients under the age of 40 are more likely to present with rectal cancer and have comparable histological features than the older groups. Despite higher rates of adjuvant and neoadjuvant treatment, the young group were found to have worse DFS.

Self-Administered Cognitive Testing by Older Adults At-Risk for Cognitive Decline

Self-administered computerized cognitive testing could effectively monitor older individuals at-risk for cognitive decline at home. In this study, we tested the feasibility and reliability of 3 tablet-based executive functioning measures and an executive composite score in a sample of 30 older adults (age 80±6) with high multimorbidity. The tests were examiner-administered at baseline and then self-administered by the participants at home across 2 subsequent days. Eight of the participants reported no prior experience with touchscreen technology. Twenty-seven participants completed both self-administered assessments, and 28 completed at least one. Cronbach's alpha (individual tests: .87-.89, composite: .93) and correlations between examiner-administered and self-administered performances (individual tests: .72-.91, composite: .93) were high. The participants who had never used a smartphone or a tablet computer showed comparable consistency. Remote self-administered tablet-based testing in older adults at-risk for cognitive decline is feasible and reliable, even among participants without prior technology experience.

Type 1 diabetes genetic risk score discriminates between monogenic and Type 1 diabetes in children diagnosed at the age of <5 years in the Iranian population

AIM

To examine the extent to which discriminatory testing using antibodies and Type 1 diabetes genetic risk score, validated in European populations, is applicable in a non-European population.

METHODS

We recruited 127 unrelated children with diabetes diagnosed between 9 months and 5 years from two centres in Iran. All children underwent targeted next-generation sequencing of 35 monogenic diabetes genes. We measured three islet autoantibodies (islet antigen 2, glutamic acid decarboxylase and zinc transporter 8) and generated a Type 1 diabetes genetic risk score in all children.

RESULTS

We identified six children with monogenic diabetes, including four novel mutations: homozygous mutations in WFS1 (n=3), SLC19A2 and SLC29A3, and a heterozygous mutation in GCK. All clinical features were similar in children with monogenic diabetes (n=6) and in the rest of the cohort (n=121). The Type 1 diabetes genetic risk score discriminated children with monogenic from Type 1 diabetes [area under the receiver-operating characteristic curve 0.90 (95% CI 0.83-0.97)]. All children with monogenic diabetes were autoantibody-negative. In children with no mutation, 59 were positive to glutamic acid decarboxylase, 39 to islet antigen 2 and 31 to zinc transporter 8. Measuring zinc transporter 8 increased the number of autoantibody-positive individuals by eight.

CONCLUSIONS

The present study provides the first evidence that Type 1 diabetes genetic risk score can be used to distinguish monogenic from Type 1 diabetes in an Iranian population with a large number of consanguineous unions. This test can be used to identify children with a higher probability of having monogenic diabetes who could then undergo genetic testing. Identification of these individuals would reduce the cost of treatment and improve the management of their clinical course.

Immunoglobulin heavy variable (IgHV) gene mutation and micro-RNA expression in Burkitt's lymphoma at Moi Teaching and Referral Hospital in Western Kenya

INTRODUCTION

Burkitt's lymphoma (BL) is a virus associated childhood B-cell cancer common in Eastern Africa. Continued survival of B-cells in germinal centres depend on expression of high affinity immunoglobulins (Ig) to complementary antigens by somatic hypermutation of Ig genes. Cellular microRNAs, non-coding RNAs have been reported to play role in cell cycle regulation. Both viral antigen dependent mutation and micro-RNA expression maybe involved in BL pathogenesis.

OBJECTIVE

To describe immunoglobulin heavy variable (IgHV) rearrangement and micro-RNA expressions in BL tumours.

METHODS

Genomic DNA were extracted and purified from BL tissue blocks at Moi Teaching and Referral Hospital, before amplification using IgHV consensus primers and sequencing. The sequences were then aligned with germline alleles in IMGT/V-QUEST® database. Total RNA extracted from tissue blocks and cell lines were used to determine relative expression of hsamiR-34a and hsa-miR-127.

RESULTS

In all tumours, allele alignment scores and number of mutations range were 89.2-93.2%, 15-24 respectively. The range of IgHV amino acid changes were higher in EBER-1+ (15-25) than EBER-1- (9-15). In MYC+ tumours, the relative expression were: hsa-miR-127(2.09);hsa-miR-34a (2.8) and MYC- hsa-miR-127 (1.2), hsa-miR-34a (1.0).

CONCLUSION

B-cell in BL contained somatic mutated IgHV gene and upregulated cellular microRNAs with possible pathogenetic role(s).

Assessment of the current D-dimer cutoff point in pulmonary embolism workup at a single institution: Retrospective study

Background:

The currently used D-dimer (DD) cutoff point is associated with a large number of negative CT-pulmonary angiographies (CTPA). We hypothesized presence of deficiency in the current cutoff and a need to look for a better DD threshold.

Materials and Methods:

We conducted a retrospective medical records analysis of all patients who had a CTPA as part of pulmonary embolism (PE) workup over a 1-year period. All emergency room (ER) patients who had DD assay checked prior to CTPA were included in the analysis. We assessed our institutional cutoff point and tried to test other presumptive DD thresholds retrospectively.

Results:

At our institution 1591 CTPA were performed in 2014, with 1220 scans (77%) performed in the ER. DD test was ordered prior to CTPA imaging in 238 ER patients (19.5%) as part of the PE workup. PE was diagnosed in 14 cases (6%). The sensitivity and specificity of the currently used DD cutoff (0.5 mcg/mL) were found to be 100% and 13%, respectively. Shifting the cutoff value from 0.5 to 0.85 mcg/mL would result in a significant increase in the specificity from 13% to 51% while maintaining the same sensitivity of 100%. This would make theoretically 84 CTPA scans, corresponding to 35% of CTPA imaging, unnecessary because DD would be considered negative based on this presumptive threshold.

Conclusions:

Our results suggest a significant deficiency in the institutional DD cutoff point with the need to find a better threshold through a large multicenter prospective trial to minimize unnecessary CTPA scans and to improve patient safety.