Clean Cut (adaptive, multimodal surgical infection prevention programme) for low-resource settings: a prospective quality improvement study

BACKGROUND

Clean Cut is an adaptive, multimodal programme to identify improvement opportunities and safety changes in surgery by enhancing outcomes surveillance, closing gaps in surgical infection prevention standards, and strengthening underlying processes of care. Surgical-site infections (SSIs) are common in low-income countries, so this study assessed a simple intervention to improve perioperative infection prevention practices in one.

METHODS

Clean Cut was implemented in five hospitals in Ethiopia from August 2016 to October 2018. Compliance data were collected from the operating room focused on six key perioperative infection prevention standards. Process-mapping exercises were employed to understand barriers to compliance and identify locally driven improvement opportunities. Thirty-day outcomes were recorded on patients for whom intraoperative compliance information had been collected.

RESULTS

Compliance data were collected from 2213 operations (374 at baseline and 1839 following process improvements) in 2202 patients. Follow-up was completed in 2159 patients (98·0 per cent). At baseline, perioperative teams complied with a mean of only 2·9 of the six critical perioperative infection prevention standards; following process improvement changes, compliance rose to a mean of 4·5 (P < 0·001). The relative risk of surgical infections after Clean Cut implementation was 0·65 (95 per cent c.i. 0·43 to 0·99; P = 0·043). Improved compliance with standards reduced the risk of postoperative infection by 46 per cent (relative risk 0·54, 95 per cent c.i. 0·30 to 0·97, for adherence score 3-6 versus 0-2; P = 0·038).

CONCLUSION

The Clean Cut programme improved infection prevention standards to reduce SSI without infrastructure expenses or resource investments.

[Effect of obstructive sleep apnea on cardiopulmonary function in patients with chronic obstructive pulmonary disease]

Objective: To study the characteristics of cardiopulmonary function in patients with chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) overlapping syndrome (OS). Methods: A total of 149 COPD patients, who were on stable treatment, were enrolled from the Second Affiliated Hospital of Soochow University from December 2017 to December 2019. The patients were divided into the OS group (n=56) and the COPD only group (n=93) according to their apnea hypopnea index (AHI) measured by the Apnealink device. Data were gathered from polysomnograph (PSG), spirometry, arterial blood gas and N-terminal pro-brain natriuretic peptide (NT-proBNP) assay to assess the cardiopulmonary function of patients. Partial correlation analysis was used to analyze the correlation between AHI and various factors, to study the characteristic changes in the cardiopulmonary function of these OS patients. Results: There were no significant cross-group differences in age and gender (all P>0.05). In the OS group, the forced expiratory volume in one second to forced vital capacity ratio (FEV₁/FVC), the forced expiratory volume in the first second expressed as percent predicted (FEV₁%pred), pH[M (Q₁, Q₃)], partial pressure of oxygen (PaO₂) and oxygen saturation (SaO₂) were lower than those in the COPD group [(49.46±12.98)% vs (54.38±11.72)%, (47.86±14.78)% vs (57.78±15.81)%, 7.37(7.34, 7.39) vs 7.40(7.39, 7.41), (80.75±10.20) vs (84.28±8.43) mmHg (1 mmHg=0.133 kPa), (94.46±2.52)% vs (95.74±2.28)%], whereas partial pressure of carbon dioxide (PaCO₂) [M (Q₁, Q₃)] was higher than that in the COPD group [55.00 (45.50, 60.00) vs 44.00(40.00, 48.00)mmHg] (all P<0.05). Pulmonary arterial pressure and plasma NT-proBNP levels [M (Q₁, Q₃)] in the OS group were significantly higher than those in the COPD group [38.90 (28.60, 49.05) vs 28.60 (24.95, 32.60) mmHg, 434.00 (273.75, 631.00) vs 136.00 (86.00, 205.00) pg/ml] (P<0.05). Partial correlation analysis showed that AHI was positively correlated with PaCO₂, pulmonary artery pressure, NT-proBNP, and acute exacerbation events (r values: 0.496, 0.544, 0.628, 0.446), and negatively correlated with FEV₁/FVC, FEV₁%pred, pH, PaO₂, and SaO₂ (r values:-0.309, -0.346, -0.410, -0.289, -0.267) (all P<0.05). Conclusion: Patients with OS suffer from more severe hypoxemia, hypercapnia and pulmonary function damage, and their pulmonary arterial pressure and NT-proBNP are significantly higher than those with COPD only.

POS0817 A NOVEL MODEL TO ASSESS DISEASE ACTIVITY IN TAKAYASU ARTERITIS BASED ON 18F-FDG-PET/CT: A CHINESE COHORT STUDY

Background:

Takayasu arteritis (TA) is a condition characterized by major large-vessel vasculitis (LVV), and is most commonly found in young women (age <40 years) of East Asia countries. 18F-FDG-PET/CT has been widely used in the diagnosis and follow-up of cancers to gather functional information based on metabolic activity. In the present study, we evaluated the value of different parameters in 18F-FDG-PET/CT for assessing active TA disease, and we establish a simple, quantifiable, and effective disease activity evaluation model based on 18F-FDG-PET/CT. A comparison in the ability to identify active disease was performed between the established Kerr score and the new 18F-FDG-PET/CT was also performed.

Objectives:

To investigate the utility of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in assessing disease activity in TA.

Methods:

Ninety-one patients with TA, were recruited from a Chinese cohort from October 2017 to January 2019. Clinical data, acute-phase reactants (APRs), and 18F-FDG-PET/CT findings were simultaneously recorded. The Physician Global Assessment was used as the gold standard to assess TA disease activity. The value of using 18F-FDG-PET/CT to identify active disease was evaluated, using erythrocyte sedimentation rate (ESR) as a reference. Disease activity assessment models were constructed and concordance index (C-index), net reclassification index (NRI), and integrated discrimination index (IDI) were evaluated to compare the benefits of the new modes with ESR and Kerr score.

Results:

In total, 64 (70.3%) cases showed active disease. Higher levels of ESR and CRP, and lower interleukin (IL)-2R levels, were observed in active cases. 18F-FDG-PET/CT parameters, including SUVmean, SUVratio1, SUVratio2, sum of SUVmean, and sum of SUVmax, were significantly higher in active disease groups. The C index threshold of ESR to indicate active disease was 0.78 (95% CI: 0.69-0.88). The new activity assessment model combining ESR, sum of SUVmean, and IL-2R showed significant improvement in C index over the ESR method (0.96 vs. 0.78, P < 0.01; NRI 1.63, P < 0.01; and IDI 0.48, P < 0.01). The new model also demonstrated modest superiority to Kerr score assessment (0.96 vs. 0.87, P = 0.03; NRI 1.19, P < 0.01; and IDI 0.33 P < 0.01).

Conclusion:

A novel 18F-FDG-PET/CT-based method that involves combining the sum of SUVmean with ESR score and IL-2R levels demonstrated superiority in identifying active TA compared to conventional methods.

References:

[1]Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, et al. Takayasu arteritis. Ann Intern Med 1994;120:919-29.

[2]Hoffman GS, Ahmed AE. Surrogate markers of disease activity in patients with Takayasu arteritis. A preliminary report from The International Network for the Study of the Systemic Vasculitides (INSSYS). Int J Cardiol 1998;66 Suppl 1:S191-4; discussion S195.

[3]Misra R, Danda D, Rajappa SM, Ghosh A, Gupta R, Mahendranath KM, et al. Development and initial validation of the Indian Takayasu Clinical Activity Score (ITAS2010). Rheumatology (Oxford) 2013;52:1795-801.

[4]Bardi M, Diamantopoulos AP. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice summary. Radiol Med 2019;124:965-972.

[5]Spick C, Herrmann K, Czernin J. 18F-FDG PET/CT and PET/MRI Perform Equally Well in Cancer: Evidence from Studies on More Than 2,300 Patients. J Nucl Med 2016;57:420-30.

Disclosure of Interests:

None declared

POS0816 PROGNOSTIC FACTORS FOR AGGRAVATED VASCULAR DAMAGE IN TAKAYASU ARTERITIS

Background:

Takayasu arteritis is a rare disease characterized by inflammation in the aorta and its branches. Some patients were discovered to suffer the aggravated vascular damage (AVD), monitored by imaging techniques, even with the effective anti-inflammation treatment. But the general characteristics and the related prognostic factors of AVD in TA were unclear yet.

Objectives:

We aimed to describe the characteristics of the AVD and identify its prognostic factors in TA.

Methods:

From the living East China Takayasu arteritis cohort, patients who underwent at least two magnetic resonance angiography (MRA) examinations at Zhongshan Hospital from April 2009 to April 2019 were enrolled as the derivation cohort to explore the prognostic factors of AVD in MRA. An independent group of patients from May 2019 to July 2020 comprising the validation cohort were used to validate the nomogram formed by these prognostic factors.

Results:

Among 235 enrolled patients, 69 patients (29.3%) suffered AVD with the median follow-up of 14 months. The limb arteries were the most vulnerable and the aggravated vascular stenosis were the most commonly seen in AVD. Patients with AVD were younger, had higher complement 4 levels at baseline, and lower disease remission rate at 6 months. Multivariate cox regression analysis revealed that younger age (HR: 0.25-0.42, 95%CI: 0.09-0.91), higher CRP levels (HR = 2.57, 95%CI: 1.51–4.36) at baseline, and lower remission rate at 6 months (HR = 0.36, 95%CI: 0.21–0.64) were significant predictors. In the validation cohort of 65 patients, 19 cases had AVD. The predictive nomogram based on these factors achieved C-indices of 0.745 and 0.641 in the derivation and validation cohort respectively.

Conclusion:

Totally, 29.3% of patients suffered AVD, among which the aggravated vascular stenosis and limb arteries involvement were most commonly seen. Younger age, higher CRP at baseline, and lower disease remission rate at 6 months were prognostic factors for AVD.

References:

[1]M. Bredemeier, C.M. Rocha, M.V. Barbosa, E.H. Pitrez. One-year clinical and radiological evolution of a patient with refractory Takayasu’s arteritis under treatment with tocilizumab. Clin Exp Rheumatol 2012; 30 (Suppl. 70): S98-S100.

Disclosure of Interests:

None declared

A novel 12-gene signature as independent prognostic model in stage IA and IB lung squamous cell carcinoma patients

BACKGROUND

There is currently no formal consensus on the administration of adjuvant chemotherapy to stage I lung squamous cell carcinoma (LUSC) patients despite the poor prognosis. The side effects of adjuvant chemotherapy need to be balanced against the risk of tumour recurrence. Prognostic markers are thus needed to identify those at higher risks and recommend individualised treatment regimens.

METHODS

Clinical and sequencing data of stage I patients were retrieved from the Lung Squamous Cell Carcinoma project of the Cancer Genome Atlas (TCGA) and three tissue microarray datasets. In a novel K-resample gene selection algorithm, gene-wise Cox proportional hazard regressions were repeated for 50 iterations with random resamples from the TCGA training dataset. The top 200 genes with the best predictive power for survival were chosen to undergo an L1-penalised Cox regression for further gene selection.

RESULTS

A total of 602 samples of LUSC were included, of which 42.2% came from female patients, 45.3% were stage IA cancer. From an initial pool of 11,212 genes in the TCGA training dataset, a final set of 12 genes were selected to construct the multivariate Cox prognostic model. Among the 12 selected genes, 5 genes, STAU1, ADGRF1, ATF7IP2, MALL and KRT23, were adverse prognostic factors for patients, while seven genes, NDUFB1, CNPY2, ZNF394, PIN4, FZD8, NBPF26 and EPYC, were positive prognostic factors. An equation for risk score was thus constructed from the final multivariate Cox model. The model performance was tested in the sequestered TCGA testing dataset and validated in external tissue microarray datasets (GSE4573, GSE31210 and GSE50081), demonstrating its efficacy in stratifying patients into high- and low-risk groups with significant survival difference both in the whole set (including stage IA and IB) and in the stage IA only subgroup of each set. The prognostic power remains significant after adjusting for standard clinical factors. When benchmarked against other prominent gene-signature based prognostic models, the model outperformed the rest in the TCGA testing dataset and in predicting long-term risk at eight years in all three validation datasets.

CONCLUSION

The 12-gene prognostic model may serve as a useful complementary clinical risk-stratification tool for stage I and especially stage IA lung squamous cell carcinoma patients to guide clinical decision making.

Impairment of testes development in Yangzhou ganders by augmentation of leptin receptor signaling

The aim of this study was to determine the cellular and molecular mechanisms of leptin (LEP) and the leptin receptor (LEPR) in testicular development of prepubertal ganders. In an in vivo animal experiment, active immunization against LEPR severely depressed prepubertal testicular development by significantly reducing testicular weights at 200 and 227 days of age. The number of elongated spermatids in the seminiferous tubules was also significantly decreased by immunization with LEPR at ages of 200 and 227 days. Inhibition of testicular development by LEPR immunization was associated with decreases in LHR, StAR, 3β-HSD, CYP11A1, CYP17A1, and PRLR mRNA expression levels in testicular tissue, which resulted in a significant decrease in testosterone synthesis. In the in vitro experiments, the addition of LEP combined with anti-LEPR antibodies strengthened LEPR signal transduction, and inhibited significantly testosterone production in cultured Leydig cells isolated from prepubertal gander testes. The mRNA expression of LHR, StAR, 3β-HSD, CYP11A1, CYP17A1 also decreased significantly after treatment with LEP combined with anti-LEPR antibodies in cultured Leydig cells. These results suggest that anti-LEPR antibodies strengthen LEPR signaling transduction in the presence of LEP, and immunization against LEPR inhibited testes development and testosterone secretion in prepubertal ganders.

Loss of PHLDA1 has a protective role in OGD/R-injured neurons via regulation of the GSK-3β/Nrf2 pathway

Pleckstrin homology-like domain, family A, member 1 (PHLDA1) is a multifunctional protein that plays a role in diverse pathological conditions. However, whether PHLDA1 participates in cerebral ischemia-reperfusion injury has not been reported. The goals of the present work were to assess the possible relationship between PHLDA1 and cerebral ischemia-reperfusion injury. Hippocampal neurons were subjected to oxygen-glucose deprivation/reoxygenation (OGD/R) to simulate cerebral ischemia-reperfusion injury in vitro, which led to significant increases in the expression of PHLDA1. Cellular functional studies showed that the knockdown of PHLDA1 produced a protective role in OGD/R-injured neurons via the down-regulation of neuronal apoptosis, oxidative stress and proinflammatory cytokine release. On the contrary, the overexpression of PHLDA1 rendered neurons more vulnerable to OGD/R injury. In-depth research revealed that the inhibition of PHLDA1 resulted in the enhancement of nuclear factor erythroid 2 like 2 (Nrf2) signaling in OGD/R-injured neurons. The reactivation of glycogen synthase kinase 3β (GSK-3β) abolished the PHLDA1-inhibition-mediated activation of Nrf2 signaling. Moreover, the restraint of Nrf2 signaling diminished the PHLDA1-knockdown-induced neuroprotective effects in OGD/R-injured neurons. In summary, the data of our work show that the loss of PHLDA1 protects against OGD/R injury via potentiating Nrf2 signaling via the regulation of GSK-3β. This work underscores a potential role of PHLDA1 in cerebral ischemia-reperfusion injury and proposes PHLDA1 as an attractive target for the development of neuroprotective therapy.

Epidemiological features of coronavirus disease 2019 in children: a meta-analysis

OBJECTIVE

Many studies have been published recently on the characteristics of the clinical manifestations of COVID-19 in children. The quality scores of literature are different, and the incidence of clinical manifestations and laboratory tests results vary greatly. Therefore, a systematic retrospective meta-analysis is needed to determine the incidence of the clinical manifestations of COVID-19 in children.

MATERIALS AND METHODS

Data from databases, such as PubMed, Web of science, EMBASE, Johns Hopkins University, and Chinese databases were analysed from January 31, 2020 to October 20, 2020. High-quality articles were selected for analysis based on a quality standard score. A meta-analysis of random effects was used to determine the prevalence of comorbidities and subgroup meta-analysis to examine the changes in the estimated prevalence in different subgroups.

RESULTS

Seventy-one articles involving 11,671 children were included in the study. The incidence of fever, respiratory symptoms, gastrointestinal symptoms, asymptomatic patients, nervous system symptoms, and chest tightness was 55.8%, 56.8%, 14.4%, 21.1%, 6.7%, and 6.1%, respectively. The incidence of multisystem inflammatory syndrome was 6.2%. Laboratory examination results showed that lymphocytes decreased in 12% and leukocytes decreased in 8.8% of patients, whereas white blood cells increased in 7.8% of patients. Imaging showed abnormalities in 66.5%, and ground-glass opacities were observed in 36.9% patients. Epidemiological history was present in 85.2% cases; severe disease rate was 3.33%. The mortality rate was 0.28%.

CONCLUSIONS

The clinical symptoms of COVID-19 in children are mild, and laboratory indicators and imaging manifestations are atypical. While screening children for COVID-19, in addition to assessing patients for symptoms as the first step of screening, the epidemiological history of patients should be obtained.

[Cystic echinococcosis of the waist and hip: a case report]

A patient with cystic echinococcosis was presented with primary lesions in the waist and hip. The case was misdiagnosed as subcutaneous abscess at initial diagnosis, and then definitively diagnosed as echinococcosis by means of imaging examinations and anti-Echinococcus antibody test. This case was reported with aims to improve the awareness of cystic echinococcosis among clinical physicians to avoid and reduce the misdiagnosis and missing diagnosis.