The unrestricted global effort to complete the COOL trial

BACKGROUND

Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.

METHODS

The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.

DISCUSSION

OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.

TRIAL REGISTRATION

National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).

The Utility of Minimally Invasive Surgery in the Emergency Management of Femoral Hernias: A Systematic Review

Background: Femoral hernias are a relatively rare type of hernia but have a high complication rate, with a high proportion either presenting as an emergency or requiring emergency management. Minimal access surgery has been shown to be safe, with good results, in an elective setting, but there is little published evidence of its utility in an emergency. Methods: A systematic review was conducted searching PubMed, OVID, Embase, and Cochrane reviews for ((Femoral hernia) AND (laparoscop* OR minimal access OR robotic)) AND (strangulat* OR obstruct* OR incarcerat*). Results: 286 manuscripts were identified of which 33 were relevant. 24 were individual case reports, 3 case series, 4 cohort studies or case control series, and 2 high level reviews of National registers. Conclusion: Minimal access surgery can avoid an unnecessary laparotomy for the assessment of hernial contents, especially via a TAPP approach. Minimal access repair of femoral hernias as an emergency is feasible and can be done safely with results similar to open surgery but good quality evidence is lacking.

Hernioscopy: A Description of an Adjunct Technique in Emergency Femoral Hernia Surgery

Femoral hernias commonly present as an emergency with a large proportion strangulated or with contents that are threatened. Many surgical options are available including minimally invasive surgery and multiple open approaches. A low approach allows a relatively simple repair of the hernia and has a long-established history of safety with reproducible outcomes and low recurrence rates. It is technically less challenging than a high approach but does not allow easy assessment or management of hernia sac contents. We highlight and describe a technique that can be used when the hernia reduces spontaneously at induction, or when the surgeon cannot be confident that the contents are viable. Hernioscopy is the technique of utilizing a laparoscope inserted via the hernia sac to either examine the abdominal contents or facilitate the safe creation of pneumoperitoneum and further insertion of ports transabdominally when the patient has pelvic adhesions. We describe the operative steps taken to make this a feasible approach and reduce the need for unnecessary laparotomies and the associated morbidity.

P-144 THE ABDOMINAL BINDERS FOLLOWING ABDOMINAL WALL RECONSTRUCTIVE SURGERY: USEFUL OR USELESS? - A META-ANALYSIS

Aim

Despite a recent meta-analysis published in SAGE in 2021 by a group of chinese researchers, which included 10 RCTs, the research committee for this study felt that a substantial volume of recent literature, including 7 RCTs and 3 high value non-RCT newly published articles have not been included in the latest meta-analysis and a new study is required, to understand the clinical usefulness of abdominal binders, following abdominal wall reconstructive surgery. Furthermore, no recent studies looked at the long-term impact of abdominal binders and whether their use prevent hernia recurrence, if applied from the immediate post-op period.

Material & Methods

A thorough review of all medical literature published in english language since year 2000 and to date was carried out, using the following keywords: “hernia”, “hernia repair”, “abdominal wall reconstruction” and “abdominal binder”. 17 randomised control trials and 3 non-RCT studies (systematic reviews and surveys) were included in the study. A total of 5216 patients were included in the 20 studies included. The databases searched were PubMed, Medbase, Jama and Embase.

Results/Conclusions

The use of abdominal binders following abdominal wall surgery suggests a better pain control when compared with non-users group. This contributes to earlier mobilisation and by this preventing secondary post-op complications. There is building evidence that in long term the use of abdominal binders reduces the risk of hernia recurrence and this could be in relation to decreased post-op pain and earlier return to a normal activities in the immediate post-op period.

P-128 GET THE COMPLEX HERNIA PATIENT THEATRE READY: THE PERI-OPERATIVE OPTIMISATION PATHWAY PROFORMA WE UTILISE

Aim

In modern times, complex abdominal wall herniae are an area of increased sub-specialisation for the surgeon as well as the multidisciplinary team that work together. Recent advances in pre-op optimisation pathways and protocols, several pre- and intra-operative adjuncts available for these complex cases and a multitude of surgical techniques that can be deployed in open or minimally invasive fashion, have made it increasingly difficult for surgical teams to integrate all aspects of care for their patients. We are proposing for presentation our Hospital Pathway-Proforma used for diagnosis, pre-optimisation and peri-operative care in complex ventral and groin hernias.

Material and Method

“In-house” developed pre-optimisation planning proforma taking into consideration all evidence based interventions that can lower a patient's CEDAR score: BMI reducing, smoking cessation, blood sugar control, nutritional optimisation and skin decolonisation, as well as anaesthetic specific tests and interventions aimed at optimising patient's cardiac, respiratory, renal and metabolic status before undergoing complex abdominal wall reconstruction surgery. The proforma details specific diagnostics and intervention at pre-operative clinic visit one and two, then concentrates on pre-operative and intra-operative adjuncts to be used in each individualised case (e.g. Botox, Fasciotens). Finally the post-operative pathway details specific interventions to be taken for an uneventful post-op recovery.

Results and Conclusion

By using the Profoma-Pathway, the work of the complex hernia surgeon, anaesthestist and entire team taking care of CAWR patients became more organised and streamlined. The local pathway is also useful in auditing the local work in major abdominal wall hernia reconstruction patients.

P-121 RETROSPECTIVE REVIEW OF PRACTICE AND OUTCOMES USING A SINGLE BRAND BIOLOGIC MESH AT A DISTRICT GENERAL HOSPITAL

Aim

A retrospective review of all operated hernia patients in which a single brand of Biologic mesh was used, since it's first introduction in our Trust and to date, has been conducted. During last almost 5 years, twelve patients were identified and included. All patients operated with any other type of Biologic mesh and all patients operated with synthetic meshes were excluded, as the aim of the study was to look at the efficiency of a particular product, which was the cheapest biologic mesh at the time of contract with our Hospital.

Material and Methods

Retrospective review of patient's notes and outcomes, including post-op follow-up and long-term follow-up. The study looked at the following criteria: indication of use as per VHWG (ventral hernia working group) classification of the patients, LOS (length of stay) compared with patients operated with synthetic mesh, any post-op complications including SSO/SSI (surgical site occurrence and/or infection) and outcome at follow-up to date, including recurrence, chronic pain or mesh infection.

Results

The biologic mesh studied proved itself as a reliable product and provided a durable repair in the cases where it was used. It was noticed that majority of the cases were emergency presentations for complicated ventral or inguinal hernias, the complexity of the cases compared with elective cases being higher (higher ASA grade patients, non-optimised etc).

Conclusions

The outcome of the study recommends to continue utilising this product, as efficient and financially competitive.

Chest wall deformities and their possible associations with different genetic syndromes

OBJECTIVE

Our primary objective was to identify discrete and syndromic cases of Pectus excavatum (PE) and Pectus carinatum (PC). We also intended to highlight the significance of further genetic exploration in clinically suspected syndromic cases of PC and PE. Pectus excavatum (PE) and Pectus carinatum (PC) are the most common morphological chest wall deformities. Although various hypotheses have been put forth, the pathogenesis of both entities is largely unknown. Clinicians often refer such cases for further genetic evaluation to exclude an associated underlying connective tissue disorder or a syndrome. Additionally, a detailed anamnesis with focused family history and thorough dysmorphological physical examination was done. PE and PC are considered isolated abnormalities if there is the absence of features of other syndromes, eliminating the need for further genetic evaluations. It is believed that the pattern of inheritance of these non-syndromic isolated PE and PC cases with positive family history could be multifactorial in nature. The recurrence risk of such isolated cases is thought to be low. Further diagnostic studies are indicated as PE and PC could be a part of a syndrome. Among the many syndromes, the most common monogenic syndromes associated with PE and PC are Marfan's and Noonan's.

PATIENTS AND METHODS

After obtaining the consent, we compiled a database of the patients who presented with chest wall deformities during the period 2017-2019. We selected 70 cases with PC and PE deformities to identify the discrete and syndromic PC and PE cases. During the study, we perused the cytogenetic and/or molecular analyses, that had been conducted to confirm the clinically suspected syndromic cases. We also scrutinized for the presence of PC and PE cases that are associated with the rare syndrome (s).

RESULTS

Various genetic abnormalities were identified in 28 (40%) of the 70 cases that had been diagnosed with chest wall abnormalities. Along with PE and PC, other thoracic wall abnormalities were also identified, such as the broad chest, bell-shaped thorax, and elongated or enlarged thorax. One case of a rare genetic disorder of Morquio syndrome associated with PC was also identified. Novel (previously unpublished) genomic variants are reported here.

CONCLUSIONS

It is important to delve deeper when encountering cases of PE and PC by conducting a further genetic exploration of such cases to identify syndromic associations that cause other structural and functional disorders, diagnosis of which might be missed during the early developmental period. Early identification of such disorders may help us correcting the defects, slowing the progression of disease processes, and preparing better to deal with the potential outcome.

Deficiency of Vitamin D, a Major Risk Factor for SARS-CoV-2 Severity

BACKGROUND

The SARS-CoV-2 outbreak started in March 2020 with more than 120,552,261 cases at present and having caused over 2,667,248 deaths worldwide at the time this paper was written. The clinical signs of SARS-CoV-2 infection are especially evident in the respiratory and cardiovascular systems. Patients can be asymptomatic or present mild respiratory symptoms to severe acute lung injury leading to multiorgan failure and death. The study aims to assess the levels of serum 25-hydroxyvitamin D (25-(OH)-D) in 20 hospitalized patients infected with SARS-CoV-2 and 20 deceased people and to analyze the influence of vitamin D status on the severity of their disease.

METHODS

The present study was conducted on 40 patients who tested positive for SARS-CoV-2 infection. They were divided into two groups: 20 patients admitted to the "Victor Babes" Hospital of Infectious Diseases and 20 postmortem cases autopsied at the Institute of Legal Medicine Timisoara, Romania. During the autopsy, blood and bronchial fluid samples were collected for the laboratory. Automate Viral RNA extraction was performed on the Maxwell 48 RSC Extraction System (Promega, USA) using the Maxwell RSC Viral Total Nucleic Acid Purification kit (Promega, USA). After RNA extraction, the samples were amplified on a 7500 real-time PCR (Applied Biosystems, USA) using the genesig® Real-Time PCR Assay 2G (Primer Design, UK).

RESULTS

The living and deceased patients selected for the research presented decreased vitamin D levels, which are associated with increased levels of D-dimers, C reactive protein (CRP), and interleukin-6 (IL-6). These patients had a severe form of the SARS-CoV-2 disease, which led to death.

CONCLUSIONS

We conclude that deficiency of vitamin D in patients infected with SARS-CoV-2 presents a major risk factor related to the evolution and severity of the disease.

PROLACTIN LEVEL IN PATIENTS WITH FIRST EPISODE SCHIZOPHRENIA TREATED FOR ONE YEAR WITH ATYPICAL ANTIPSYCHOTICS

CONTEXT

Atypical antipsychotics (AAs) are the first-line treatments for schizophrenia, schizoaffective disorder and bipolar disorder. However, they are now extensively utilized as off label in a myriad of diseases despite their frequently serious metabolic side-effects and hyperprolactinemia.

OBJECTIVE

The purpose of our study was to observe long-term (one year) prolactin level change in first episode schizophrenia patients treated with one of the four AAs: olanzapine, quetiapine, amisulpride, ziprasidone.

DESIGN

This study is an analysis of the prolactin level associated with the atypical antipsychotics used in European First Episode Schizophrenia Trial (EUFEST) study.

SUBJECTS AND METHODS

Seventy-three first episode schizophrenia patients from the 113 patients, randomized to one of the four AAs treatment arms. Prolactin level was obtained at baseline, 6 and 12 months for all the four AAs. Analyses have been done for each antipsychotic separately for each sex.

RESULTS

For the male patients neither of the four antipsychotics have been associated with a statistically significant increase of prolactin level in the entire study (p>0.05). In case of the female patients, treatment with olanzapine (p=.021) and ziprasidone (p=.005) has been associated with a decrease of prolactin level in one year compared with baseline.

CONCLUSIONS

In both men and women, the administration of these four AAs is not associated with the increase of prolactin levels, moreover, in women's case, there is a reduction of prolactin values at administration of Olanzapine and Ziprasidone. These results are optimistic, suggesting that long term administration of these antipsychotics is safe regarding prolactin level.

WEIGHT GAIN AND ANTIPSYCHOTICS. DATA FROM EUFEST STUDY

Context

Schizophrenia is a chronic disease most frequently necessitating lifelong antipsychotic treatment. Selecting which antipsychotic is to be prescribed in an individual schizophrenia patient represents an important clinical decision that need to take into account efficacy and side effects.

Objective

Evaluating weight gain related with one year antipsychotic treatment in antipsychotic naive first-episode schizophrenia patients.

Design

This study is an analysis of weight gain associated with typical or atypical antipsychotics used in European First Episode Schizophrenia Trial (EUFEST) study.

Subjects and Methods

113 first episode naïve antipsychotic schizophrenia patients included in EUFEST - Romanian cohort, who were randomized to one of the 5 treatment arms. Weight was obtained at baseline, 3, 6, 9 and 12 months for the 5 antipsychotics (typical-Haloperidol; atypical-Olanzapine, Amisulpride, Ziprasidone, Quetiapine).

Results

There are no statistically significant differences between groups treated with typical or atypical antipsychotics or between any individual antipsychotics concerning weight gain during the study. Weight gain was the highest in the first 3 months (57.49%) for all the studied neuroleptics. At the end of the study, the less increase was observed with ziprasidone (3.87 kg) and the highest with olanzapine (9.83 kg).

Conclusion

Increase in weight has taken place for each individual neuroleptic, but also as a group (all neuroleptics) in the first three months (57.49%). Therefore, we should address the issue of weight gain with great care, especially in first period of antipsychotic administration, in order to fast deploy intervention tailored to maintain pre-treatment weight.

The Correlations of Suicide Attempts in Major Depressive Disorder

Objective:

We have pursued the association between clinical and socio-demographic characteristics and the suicide attempts at inpatients with major depressive disorder.

Method:

We ran an historical case control study to analyse the individual characteristics associated with suicide attempts in the depression inpatients admitted into the 9th Department of the Clinical Psychiatric Hospital “Al. Obregia” between 01 January 2007 - 01 January 2008. A total of 168 subjects with major depressive disorder (MDD) were included in the study. The patients were separated into two subgroups: “S” - the group with suicide attempt as reason of the present admission into hospital and the comparative group “C” - those without a suicidal attempt at the present admission (used as control group). The two groups were compared with respect to the individual characteristics, following their possible association with the suicidal attempts risk. We used the chi-square (x2) statistic for categorical variables.

Results:

Our findings suggest that the most robust predictors of suicide attempts in depression are the younger age of the depression onset, previous psychiatric hospitalizations, low socio-economic status, “single” marital status (widowed/divorced), with no children, heredocolateral history of suicidal attempts and the comorbidity with the problematic alcohol consumption.

Conclusion:

The risk factors associated with the suicidal attempts are useful for the screening, finding, prediction and prophylaxis of suicide attempts in major depression.