Wildfire-related smoke inhalation worsens cardiovascular risk in sleep disrupted rats

Introduction

As a lifestyle factor, poor sleep status is associated with increased cardiovascular morbidity and mortality and may be influenced by environmental stressors, including air pollution.

Methods

To determine whether exposure to air pollution modified cardiovascular effects of sleep disruption, we evaluated the effects of single or repeated (twice/wk for 4 wks) inhalation exposure to eucalyptus wood smoke (ES; 964 μg/m3 for 1 h), a key wildland fire air pollution source, on mild sleep loss in the form of gentle handling in rats. Blood pressure (BP) radiotelemetry and echocardiography were evaluated along with assessments of lung and systemic inflammation, cardiac and hypothalamic gene expression, and heart rate variability (HRV), a measure of cardiac autonomic tone.

Results and Discussion

GH alone disrupted sleep, as evidenced by active period-like locomotor activity, and increases in BP, heart rate (HR), and hypothalamic expression of the circadian gene Per2. A single bout of sleep disruption and ES, but neither alone, increased HR and BP as rats transitioned into their active period, a period aligned with a critical early morning window for stroke risk in humans. These responses were immediately preceded by reduced HRV, indicating increased cardiac sympathetic tone. In addition, only sleep disrupted rats exposed to ES had increased HR and BP during the final sleep disruption period. These rats also had increased cardiac output and cardiac expression of genes related to adrenergic function, and regulation of vasoconstriction and systemic blood pressure one day after final ES exposure. There was little evidence of lung or systemic inflammation, except for increases in serum LDL cholesterol and alanine aminotransferase. These results suggest that inhaled air pollution increases sleep perturbation-related cardiovascular risk, potentially in part by increased sympathetic activity.

1103 AN EVALUATION OF A GERIATRICIAN-LED ACUTE MEDICAL ADMISSION UNIT AT MORRISTON HOSPITAL, SWANSEA

Introduction

The medical intake at Morriston Hospital is accepted on two units; Rapid Assessment Unit (RAU) and Acute Medical Assessment Unit. Both were acute physician-led until July 2021

Method

(Phase 1). From July 2021, RAU became geriatrician-led (Phase 2). This evaluation concerns the performance of RAU.

Phase 1 (Acute Physician-Led Unit) Between 01/08/2020-30/06/2021, there were 3102 admissions with a median length of stay (LOS) of 2 days on RAU. 37.2% of patients were discharged directly from the unit. (SBUHB data). A detailed analysis of 496 patients consecutively assessed between November 2020–January 2021 showed a median LOS on RAU of 1, 28.8% were discharged directly from RAU. Overall health board (HB) median LOS for the cohort was 7. In over 70 years, median LOS on RAU was 1, overall HB LOS 9.

Phase 2 (Geriatrician-Led Unit) 1237 patients were assessed July-December 2021, with a median LOS of 2 days. 42.8% of patients were discharged from RAU. (SBUHB data). A detailed analysis of 566 patients consecutively assessed between September-November 2021 showed a median LOS on RAU of 2, 41.7% discharged directly from RAU. Overall HB median LOS for the entire cohort was 5. For the > 70 years, median LOS on RAU was 2, overall HB LOS was 7. Patient flow through assessment areas is dependent on the function of downstream medical wards. Mean LOS within medicine at Morriston increased 1.5 days between Phase 1 and Phase 2.

Results

Acute geriatricians have delivered the 72hr LOS standard that SBUHB has set for assessment areas. The unit has achieved a reduction in overall LOS for the cohort of patients evaluated (p<.01), especially for the > 70 years (p=.007).

Conclusion

This data supported a change in practice; RAU has taken a frailty specific intake since January 2022.

Influence of environmental variability and Emiliania huxleyi ecotypes on alkenone-derived temperature reconstructions in the subantarctic Southern Ocean

Long-chain unsaturated alkenones produced by haptophyte algae are widely used as paleotemperature indicators. The unsaturation relationship to temperature is linear at mid-latitudes, however, non-linear responses detected in subpolar regions of both hemispheres have suggested complicating factors in these environments. To assess the influence of biotic and abiotic factors in alkenone production and preservation in the Subantarctic Zone, alkenone fluxes were quantified in three vertically-moored sediment traps deployed at the SOTS observatory (140°E, 47°S) during a year. Alkenone fluxes were compared with coccolithophore assemblages, satellite measurements and surface-water properties obtained by sensors at SOTS. Alkenone-based temperature reconstructions generally mirrored the seasonal variations of SSTs, except for late winter when significant deviations were observed (3-10 °C). Annual flux-weighted averages in the 3800 m trap returned alkenone-derived temperatures ~1.5 °C warmer than those derived from the 1000 m trap, a distortion attributed to surface production and signal preservation during its transit through the water column. Notably, changes in the relative abundance of E. huxleyi var. huxleyi were positively correlated with temperature deviations between the alkenone-derived temperatures and in situ SSTs (r = 0.6 and 0.7 at 1000 and 2000 m, respectively), while E. huxleyi var. aurorae, displayed an opposite trend. Our results suggest that E. huxleyi var. aurorae produces a higher proportion of C_37:3 relative to C_37:2 compared to its counterparts. Therefore, the dominance of var. aurorae south of the Subtropical Front could be at least partially responsible for the less accurate alkenone-based SST reconstructions in the Southern Ocean using global calibrations. However, the observed correlations were largely influenced by the samples collected during winter, a period characterized by low particle fluxes and slow sinking rates. Thus, it is likely that other factors such as selective degradation of the most unsaturated alkenones could also account for the deviations of the alkenone paleothermometer.

Important marine areas for the conservation of northern rockhopper penguins within the Tristan da Cunha Exclusive Economic Zone

The designation of Marine Protected Areas has become an important approach to conserving marine ecosystems that relies on robust information on the spatial distribution of biodiversity. We used GPS tracking data to identify marine Important Bird and Biodiversity Areas (IBAs) for the Endangered northern rockhopper penguin Eudyptes moseleyi within the Exclusive Economic Zone (EEZ) of Tristan da Cunha in the South Atlantic. Penguins were tracked throughout their breeding season from 3 of the 4 main islands in the Tristan da Cunha group. Foraging trips remained largely within the EEZ, with the exception of those from Gough Island during the incubation stage. We found substantial variability in trip duration and foraging range among breeding stages and islands, consistent use of areas among years and spatial segregation of the areas used by neighbouring islands. For colonies with no or insufficient tracking data, we defined marine IBAs based on the mean maximum foraging range and merged the areas identified to propose IBAs around the Tristan da Cunha archipelago and Gough Island. The 2 proposed marine IBAs encompass 2% of Tristan da Cunha’s EEZ, and are used by all northern rockhopper penguins breeding in the Tristan da Cunha group, representing ~90% of the global population. Currently, one of the main threats to northern rockhopper penguins within the Tristan da Cunha EEZ is marine pollution from shipping, and the risk of this would be reduced by declaring waters within 50 nautical miles of the coast as ‘areas to be avoided’.

Application rates to surgical residency programs in Canada

PURPOSE

The purpose of this study is to identify if the previously reported declining interest in surgery amongst medical students persists, and also to provide more descriptive analysis of trends by surgical specialty and medical school. Our hypothesis is that the previously reported decreasing interest in surgery remains constant for some surgical disciplines.

METHODS

The Canadian Resident Matching Service and the Association of Faculties of Medicine of Canada provided data for this study. Several metrics of interest in surgery, including overall application trends, applications by discipline, and rankings by school of graduation were evaluated. Descriptive statistics and linear regression modeling were used.

RESULTS

Between 2007 and 2017 the number of non-surgical residency positions and Canadian medical graduates increased significantly. However, the number of surgical residency positions and applications to surgical programs did not change significantly. The number of rankings to orthopedic and vascular surgery decreased significantly. Likewise, applicants to general, orthopedic, plastic, otolaryngology, and vascular surgery decreased significantly. Vascular surgery saw a significant decrease in first choice rankings. Total rankings to surgical programs increased significantly at McGill, with no significant change at other Canadian institutions.

CONCLUSIONS

The findings of this study suggest that while the number of applicants to surgical residency positions has been consistent, it is not keeping pace with the growing number of both CMGs and non-surgical residency positions. Furthermore, by using other measures of medical student interest in surgical specialties, such as the total number of rankings to a specialty through the residency matching process, the total number of applicants applying to a surgical discipline and the total number of first choice ranks that each surgical discipline received, we have demonstrated that there is a possible declining interest in some surgical discipline.

The future is here! Pediatric surgery and the move to the royal college of physicians and surgeons of Canada's competence by design

This interactive session was held at the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) in preparation for the transition of Pediatric Surgery training in Canada to Competency by Design (a CBME-based model of residency training developed by the Royal College of Physicians and Surgeons of Canada).

Predictors for surgical intervention and surgical outcomes in neonates with cystic fibrosis

BACKGROUND/PURPOSE

To identify prenatal and perinatal predictors of surgery and describe surgical findings/outcomes of neonates with Meconium Ileus (MI) secondary to Cystic Fibrosis (CF).

METHODS

Potential risk factors (prenatal bowel echogenicity, CF genotype, birthweight, prematurity and sex) for MI and surgery were examined in a retrospective cohort of neonates with CF presenting to a tertiary center between 1997 and 2015. Following univariable analysis, predictors of MI and surgery were determined using multivariable logistic regression. For surgical patients, detailed operative findings and outcomes were examined.

RESULTS

MI was diagnosed in 26/120 (21.7%) neonates with CF and 19/26 (73.0%) required surgery. Prematurity was significantly associated with increased risk of MI and operative intervention (p-value 0.022 and p-value 0.016 respectively); lower birthweight was associated with operative intervention (p-value 0.039); genotype and echogenic bowel were associated with neither. Surgical data were available for 17/19 patients; median age at surgery was 2 days (IQR1-3), 4/17 had an atresia and 6/17 received an ostomy. Median NICU and hospital stays were 34.5 and 70 days while median time on TPN and time to ostomy reversal were 28.5 and 97 days, respectively.

CONCLUSIONS

In patients with CF, prematurity and lower birthweight were identified as risk factors for meconium ileus and need for surgery. Specific genotypes and echogenic bowel were not predictors of either.

LEVEL OF EVIDENCE

Level III.

The Efficacy of Budesonide and Beclomethasone Dipropionate, Delivered via a Pressurized Metered Dose Inhaler, in the Treatment of Perennial Rhinitis: A Randomized, Double-Blind, Crossover Study

A total of 28 adult patients (19 women, nine men; mean age 28.5 years, range 15–63 years) with a diagnosis of perennial allergic and nonallergic rhinitis (mean duration of symptoms 4.0 years, range 1–20 years) were recruited into this randomized, double-blind, crossover study. Eighteen patients (64%) were atopic for common allergens. The efficacy of budesonide nasal aerosol (Rhinocort®) and beclomethasone dipropionate (BDP; Beconase®) was compared using nominal doses of 200 μg (b.i.d.) for each drug administered every morning and evening. Following a 2-week run-in period, patients were randomly-divided into two groups and treated for 4 weeks with either BDP or budesonide. After the crossover, patients then received the second drug for the remaining 4 weeks of the trial. Response to the treatment regimens was assessed by subjective symptom scoring and nasal peak expiratory flow rate (PEF) measurements. Budesonide and BDP reduced all nasal symptom scores and improved nasal PEF compared to the run-in period. During budesonide therapy, significantly less sleep disturbance, lower evening and morning nasal blockage scores, and greater nasal PEF values in the evening were recorded than for BDP. Following crossover, patients who were treated with budesonide in the second part of the trial demonstrated significantly improved nasal blockage scores and evening nasal PEF in contrast to those who received BDP during the latter part of the study. The number of adverse events reported during the trial was equal for both drugs and those noted tended to be mild. In conclusion, although the symptoms of perennial rhinitis were well controlled by both budesonide and BDP, the predominant symptom of nasal blockage was managed more effectively with budesonide.

The Extraction from the Blood of Phosphate Compounds by Canine Bone

Uptake by bone of 99mTc-labeled pyrophosphate (PPj) and ethane-1-hydroxy-1,1-diphosphonate (EHDP) involves passage through capillaries in the Haversian system, extracellular fluid space, and membrane of osteoblasts before adsorption onto available apatite surfaces. Passage through capillaries was studied by the outflow-dilution technique in a canine tibia model in mongrel dogs. slCr-labeled albumin (nondiffusible reference tracer), sucrose (diffusible reference tracer), PPi, and EHDP were injected into the isolated nutrient tibial artery. Blood was collected from the ipsilateral femoral vein every 15 sec for 2 min. Emax, the apparent extraction at the time of the peaks of the dilution curves, is influenced little by back diffusion; for PP, Emax (mean ± SD) = 0.42 ± 0.08 (N = 4); for EHDP, Emax = 0.27 ± 0.05 (N - 10). Net extraction (apparent fractional retention by (pone at 2 min) was 0.36 ± 0.1 for PP. Emax for 8sSr chloride and 18F sodium in our laboratory is 0.69 ± 0.11 (N = 14) and 0.70 ± 0.008 (N = 9), respectively. Permeabilities (P) were calculated by PS = -Fs loge (1-Emax), where Fs = plasma flow and S = capillary surface; the ratio of P for EHDP to P for sucrose was 0.71 which is similar to the ratio of diffusion coefficients, 0.78. The data suggest that EHDP and probably also PPj pass through the capillaries by passive diffusion. As expected, the extraction through capillary walls for EHDP and PPj was lower than that for 8SSr and 18F because of their larger molecular size.

Appendectomy versus non-operative treatment for acute uncomplicated appendicitis in children: study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

BACKGROUND

Appendectomy is considered the gold standard treatment for acute appendicitis. Recently the need for surgery has been challenged in both adults and children. In children there is growing clinician, patient and parental interest in non-operative treatment of acute appendicitis with antibiotics as opposed to surgery. To date no multicentre randomised controlled trials that are appropriately powered to determine efficacy of non-operative treatment (antibiotics) for acute appendicitis in children compared with surgery (appendectomy) have been performed.

METHODS

Multicentre, international, randomised controlled trial with a non-inferiority design. Children (age 5-16 years) with a clinical and/or radiological diagnosis of acute uncomplicated appendicitis will be randomised (1:1 ratio) to receive either laparoscopic appendectomy or treatment with intravenous (minimum 12 hours) followed by oral antibiotics (total course 10 days). Allocation to groups will be stratified by gender, duration of symptoms (> or <48 hours) and centre. Children in both treatment groups will follow a standardised treatment pathway. Primary outcome is treatment failure defined as additional intervention related to appendicitis requiring general anaesthesia within 1 year of randomisation (including recurrent appendicitis) or negative appendectomy. Important secondary outcomes will be reported and a cost-effectiveness analysis will be performed. The primary outcome will be analysed on a non-inferiority basis using a 20% non-inferiority margin. Planned sample size is 978 children.

DISCUSSION

The APPY trial will be the first multicentre randomised trial comparing non-operative treatment with appendectomy for acute uncomplicated appendicitis in children. The results of this trial have the potential to revolutionise the treatment of this common gastrointestinal emergency. The randomised design will limit the effect of bias on outcomes seen in other studies.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov: NCT02687464. Registered on Jan 13th 2016.

The impact of using silver alloy urinary catheters in reducing the incidence of urinary tract infections in the critical care setting

prospective study was undertaken on three critical care units to establish the efficacy of using a silver alloy urinary catheter in reducing the incidence of nosocomial urinary tract infections.

Some 188 patients participated in the evaluation (94 in each group). A urine sample was obtained post insertion and every three days while on the critical care unit to detect bacteriuria. The infection rate was 12.65 in the standard group and 11.32 in the silver alloy group per 1000 catheter days respectively. The mean duration of catheterisation was 16 days (inter-quartile range 13). Gram positive cocci were responsible for 24.5% of the bacteriuria, Gram negatives 64.5% and yeasts accounted for 11%. Based on these results, routine use of silver alloy catheters cannot be justified for all patients, but may be suited to high-risk female patients.

Individual placement and support (IPS) for patients with offending histories: the IPSOH feasibility cluster randomised trial protocol

INTRODUCTION

People with involvement in forensic psychiatric services face many obstacles to employment, arising from their offending, as well as their mental health problems. This study aims to assess the feasibility of conducting a randomised controlled trial (RCT) to evaluate the effectiveness of individual placement and support (IPS), in improving employment rates and associated psychosocial outcomes in forensic psychiatric populations. IPS has been found consistently to achieve employment rates above 50% in psychiatric patients without a history of involvement in criminal justice services.

METHODS/DESIGN

This is a single-centre feasibility cluster RCT. Clusters will be defined according to clinical services in the community forensic services of Nottinghamshire Healthcare NHS Foundation Trust (NHCT). IPS will be implemented into 2 of the randomly assigned intervention clusters in the community forensic services of NHCT. A feasibility cluster RCT will estimate the parameters required to design a full RCT. The primary outcome is the proportion of people in open employment at 12-month follow-up. Secondary outcome measures will include employment, educational activities, psychosocial and economic outcomes, as well as reoffending rates. Outcome measures will be recorded at baseline, 6 months and 12 months. In accordance with the UK Medical Research Council guidelines on the evaluation of complex interventions, a process evaluation will be carried out; qualitative interviews with patients and staff will explore general views of IPS as well as barriers and facilitators to implementation. Fidelity reviews will assess the extent to which the services follow the principles of IPS prior, during and at the end of the trial.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the East Midlands Research Ethics Committee-Nottingham 1 (REC reference number 15/EM/0253). Final and interim reports will be prepared for project funders, the study sponsor and clinical research network. Findings will be disseminated through peer-reviewed journals, conferences and event presentations.

TRIAL REGISTRATION NUMBER

NCT02442193; Pre-results.

Charting the territory: symptoms and functional assessment in children with progressive, non-curable conditions

BACKGROUND

Children with progressive, non-curable genetic, metabolic, or neurological conditions require specialised care to enhance their quality of life. Prevention and relief of physical symptoms for these children needs to begin at diagnosis, yet, little is known about their patterns of symptoms and functional abilities.

AIM

To describe these children's symptoms, as well as how the children's condition affects them physically.

DESIGN

Cross-sectional, baseline results from an observational, longitudinal study, Charting the Territory, that followed 275 children and their families.

SETTING/PARTICIPANTS

Seven tertiary care children's hospitals in Canada, 2 in the USA. Families were eligible based on the child's condition. A total of 275 children from 258 families participated.

RESULTS

The 3 most common symptoms in these children were pain, sleep problems, and feeding difficulties; on average, they had 3.2 symptoms of concern. There was a pattern of under-reporting of children's symptoms for clinicians compared with parents. Regardless of use of associated medications, pain, feeding and constipation symptoms were often frequent and distressing. Children with a G/J tube had a higher total number of symptoms, and respiratory problems, pain, feeding difficulties and constipation were more likely to occur. They also tended to have frequent and distressing symptoms, and to need extensive mobility modifications which, in turn, were associated with higher numbers of symptoms.

CONCLUSIONS

These children experience multiple symptoms that have been previously documented individually, but not collectively. Effective interventions are needed to reduce their symptom burden. Future longitudinal analyses will examine which disease-modifying interventions improve, or do not improve, symptom burden.

Loop versus divided colostomy for the management of anorectal malformations

PURPOSE

The purpose of this study was to compare the clinical outcomes of loop and divided colostomies in patients with anorectal malformations (ARM).

METHODS

We performed a retrospective cohort study reviewing the medical records of all patients with ARM managed with diverting colostomies between 2000 and 2010 at our institution. Independent variables and outcomes of stoma complications were analyzed by parametric measures and logistic regression.

RESULTS

One hundred forty-four patients managed with a colostomy for ARM were evaluated (37.5% females, 50.7% loop, 49.3% divided). The incidence of patients with loop and divided colostomies who developed stoma-related complications was 31.5 and 15.5%, respectively (p=0.031). The incidence of prolapse was 17.8 and 2.8%, respectively (p=0.005). Multivariable-logistic regression controlling for other significant independent variables found loop colostomies to be positively associated with the development of a stoma complication (OR 3.13, 95%CI (1.09, 8.96), p=0.033). When individual complications were evaluated, it was only stoma prolapse that was more likely in patients with loop colostomies (OR 8.75, 95%CI (1.74, 44.16), p=0.009).

CONCLUSION

Because of the higher incidence of prolapse, loop colostomies were found to be associated with a higher total incidence of complications than divided stomas. The development of other complications, including urinary tract infections (UTIs) and megarectum, were independent of the type of colostomy performed.

CyberKnife for prostate cancer: Is it cost-effective?

87

Background: The study assessed the cost-effectiveness of CyberKnife (CK) compared to surgery and radiation therapy for the treatment of prostate cancer (PC) from a third-party and societal perspective.

Methods: For patients > 65 yrs with localized PC, a Markov model compared treatment with CK, intensity modulated radiation therapy (IMRT), surgery or proton therapy (PT). Following treatment, patients were at risk of long-term toxicity: genitourinary (GU); gastrointestinal (GI); and sexual dysfunction (SD). Long-term toxicity was defined as adverse events >grade 2 on Radiation Therapy Oncology Group scale occurring at least 12 months following treatment. Markov states included all possible combinations of GI, GU, and SD long-term toxicities, no toxicity, and death. During each year patients remained in the same Markov state or died. Costs and utilities were assigned using published sources. Toxicity probabilities were derived using meta-analytical techniques to pool results from multiple studies. It was assumed that long-term disease control would not differ across treatments. The model projected expected lifetime costs and quality adjusted life years (QALYs) for each treatment and incremental cost-effectiveness of CK vs comparators as cost per QALY gained. Costs from societal perspective included lost productivity. Extensive sensitivity analyses were conducted.

Results: Surgery was the least expensive treatment option followed by CK. CK patients had higher expected QALYs (8.11) than other treatment options (7.72- 8.06). From a payer perspective, total lifetime costs were $25,904, $22,295, $38,915, and $58,100 for CK, surgery, IMRT and PT, respectively. Incremental cost per QALY gained for CK versus Surgery was $9,200/QALY. Compared to IMRT and PT, CK was less costly and resulted in higher QALYs (dominance). At a threshold of $50,000/QALY, CK was cost effective in 86%, 79%, and 91% of simulations compared to surgery, IMRT, and PT, respectively. From a societal perspective, CK costs $4,200/QALY compared to surgery and remained dominant vs IMRT and PT. Results were most sensitive to costs of surgery and CK.

Conclusions: Initial CK costs are higher than surgery, but CK patients have better quality of life. CK patients have lower lifetime costs and higher QALYs than IMRT and PT patients.

[Table: see text]

Pediatric antifungal therapy. Part I: focus on febrile neutropenia, invasive aspergillosis, combination antifungal therapy and invasive candidiasis in immunocompromised pediatric patients

The number of available antifungal agents has significantly increased in recent years. These agents are starting to take over niches that were previously occupied by conventional amphotericin B. For many of these agents, pediatric data from randomized trials are generally lacking and clinicians are faced with extrapolating from data generated in adult patients. This notwithstanding, this report summarizes recommendations that define the roles of newer antifungal agents in the treatment of selected scenarios among immunocompromised pediatric patients. The report includes the outcome of a Canadian conference on the use of antifungal agents in children, supplemented by literature reviews and incorporating information from existing national or international guidelines, where appropriate. The focus of the report is on febrile neutropenia, invasive aspergillosis, combination antifungal therapy and selected aspects of the management of invasive candidiasis.

Pediatric antifungal therapy. Part II: neonatal infections

The management of neonatal fungal infections poses several challenges, including the fact that the choices of available agents are limited, given the paucity of data relating to the use of newer antifungal agents in the group of infants. The information summarized herein represents in part the consensus of a group of clinicians involved in the care of neonates at risk of and with fungal infections. The document addresses the prophylaxis and treatment of fungal infections in neonates. It highlights the role of current and emerging antifungal agents, including the lipid amphotericin B products, echinocandins and triazoles.