Sociodemographic disparities and potential biases in persistent pain estimates: Findings from 5 waves of the Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Pain is a prevalent, debilitating condition among older adults. Much evidence on this topic comes from cohort studies, which may be affected by attrition and measurement bias. Little is known about the impact of these biases on pain estimates for European older adults. Additionally, there is a lack of longitudinal research on pain and sociodemographic disparities in Irish older adults.

METHODS

We analysed data from 8171 participants (aged ≥50 at baseline) across five waves of the Irish Longitudinal Study on Ageing. Longitudinal pain severity and sociodemographic disparities in pain were explored visually and using a latent growth curve model. Using multivariate logistic regression, we examined bias due to attrition at later waves associated with reported pain at Wave 1. Measurement biases due to reporting heterogeneity were assessed by investigating associations between sociodemographic factors and pain-related disability for given pain levels.

RESULTS

Wave 1 severe pain was associated with increased odds of attrition due to death by Wave 5 (AOR: 1.63, 95% CI: 1.20, 2.19). Not having private health insurance was associated with increased odds of pain-related disability at Wave 1, controlling for pain severity (AOR: 1.37, 95% CI: 1.15, 1.64). These results suggested mortality bias and reporting heterogeneity measurement bias, respectively. Sex, education level, and private health insurance status disparities in pain were observed longitudinally.

CONCLUSIONS

Mortality bias and reporting heterogeneity measurement bias must be accounted for to improve older adult pain estimates. There is a need for policymakers to address sociodemographic disparities in older adult pain levels.

SIGNIFICANCE

This study highlights a need to address bias in the estimation of pain in observational studies of older adults. Understanding the sources and extent of these biases is important so that health practices and policies to address pain disparities can be guided by accurate estimates. Women, those with lower educational attainment, and those without private health insurance were found to have the highest pain burden longitudinally, suggesting a need for targeted interventions for these groups in Ireland and internationally.

Anti-tumour necrosis factor-induced skin rashes in inflammatory bowel disease: a systematic review and evidence-based management algorithm

BACKGROUND

Anti-tumour necrosis factor alpha (anti-TNF) agents are a highly effective treatment for inflammatory bowel disease (IBD). Skin lesions, including psoriasiform, eczematous and lupoid eruptions, may paradoxically result from anti-TNF use and cause significant morbidity leading to discontinuation of therapy. There are no consensus guidelines on the management of these lesions.

AIMS

This systematic review considers the existing evidence regarding cutaneous complications of anti-TNF therapy in IBD and the development of an algorithm for management.

METHODS

A systematic review was performed by searching Medline (Pubmed) and Embase for articles published from inception to January 2021. The following search terms were used 'anti-tumour necrosis factor alpha', 'infliximab', 'adalimumab', 'certolizumab', 'golimumab', 'inflammatory bowel disease', 'Crohn disease', 'Ulcerative colitis', 'psoriasis', 'psoriasiform', 'dermatitis', 'lupus', 'skin lesion' and 'skin rash'. Reference lists of relevant studies were reviewed to identify additional suitable studies.

RESULTS

Thirty-four studies were included in the review. Eczema can generally be managed with topical agents and the anti-TNF can be continued, while the development of lupus requires immediate cessation of the anti-TNF and consideration of alternative immunomodulators. Management of psoriasis and psoriasiform lesions may follow a step-wise algorithm where topical treatments will be trialled in less severe cases, with recourse to an alternative anti-TNF or a switch to an alternative class of biological agent.

CONCLUSION

Assessment of anti-TNF skin lesions should be performed in conjunction with a dermatologist and rheumatologist in complex cases. High-quality prospective studies are needed to clarify the validity of these algorithms in the future.

Protective antibody threshold of RTS,S/AS01 malaria vaccine correlates antigen and adjuvant dose in mouse model

Mouse models are useful for the early down-selection of malaria vaccine candidates. The Walter Reed Army Institute of Research has optimized a transgenic Plasmodium berghei sporozoite challenge model to compare the efficacy of Plasmodium falciparum circumsporozoite protein (CSP) vaccines. GSK's RTS,S vaccine formulated in the adjuvant AS01 can protect malaria-naïve individuals against malaria. We report that the RTS,S/AS01 vaccine induces high level sterile protection in our mouse model. Down titration of the antigen at a constant AS01 dose revealed a potent antigen dose-sparing effect and the superiority of RTS,S/AS01 over a soluble CSP antigen. RTS,S-mediated protective immunity was associated with a threshold of major repeat antibody titer. Combined titration of the antigen and adjuvant showed that reducing the adjuvant could improve antibody boosting post-3rd vaccination and reduce the threshold antibody concentration required for protection. Mouse models can provide a pathway for preclinical assessment of strategies to improve CSP vaccines against malaria.

Maternal and peripartum risk factors for acute funisitis among term deliveries complicated by intraamniotic infection

BACKGROUND

Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response and has been associated with adverse neonatal outcomes. Little is known regarding the maternal and intrapartum risk factors associated with the development of acute funisitis among term deliveries complicated by intraamniotic infection.

OBJECTIVE

This study aimed to identify the maternal and intrapartum risk factors associated with developing acute funisitis among term deliveries complicated by intraamniotic infection.

STUDY DESIGN

After institutional review board approval, we conducted a retrospective cohort study of term deliveries affected by clinical intraamniotic infection at a single tertiary center between 2013 and 2017, with placental pathology consistent with histologic chorioamnionitis. The exclusion criteria included intrauterine fetal demise, missing delivery information or placental pathology, and documented congenital fetal abnormalities. Maternal sociodemographic, antepartum, and intrapartum factors were compared among patients with acute funisitis on pathology to those without acute funisitis using bivariate statistics. Regression models were developed to estimate the adjusted odds ratios.

RESULTS

Of 123 patients meeting the inclusion criteria, 75 (61%) had acute funisitis on placental pathology. Compared with placental specimens without acute funisitis, acute funisitis was observed more frequently among patients with maternal BMI ≥30 kg/m2 (58.7% vs 39.6%, P=.04) and labor courses with increased rupture of membrane duration (17.3 vs 9.6 hours, P=.001). Use of fetal scalp electrode was observed less frequently in acute funisitis (5.3% vs 16.7%, P=.04) than cases without acute funisitis. In regression models, maternal BMI ≥30 kg/m2 (adjusted odds ratio, 2.67; 95% confidence interval, 1.21-5.90) and rupture of membrane >18 hours (adjusted odds ratio, 2.48; 95% confidence interval, 1.07-5.75) were significantly associated with acute funisitis. Fetal scalp electrode use (adjusted odds ratio, 0.18; 95% confidence interval, 0.04-0.71) was negatively associated with acute funisitis.

CONCLUSION

In term deliveries with intraamniotic infection and histologic chorioamnionitis, maternal BMI ≥30 kg/m2, and rupture of membrane>18 hours were associated with acute funisitis on placental pathology. As insight into the clinical impact of acute funisitis grows, the ability to predict which pregnancies are at the greatest risk for its development may allow for a tailored approach to predicting neonatal risk for sepsis and related comorbidity.

Lung SPLUNC1 Peptide Derivatives in the Lipid Membrane Headgroup Kill Gram-Negative Planktonic and Biofilm Bacteria

SPLUNC1 (short palate lung and nasal epithelial clone 1) is a multifunctional host defense protein found in human respiratory tract with antimicrobial properties. In this work, we compare the biological activities of four SPLUNC1 antimicrobial peptide (AMP) derivatives using paired clinical isolates of the Gram-negative (G(-)) bacteria Klebsiella pneumoniae, obtained from 11 patients with/without colistin resistance. Secondary structural studies were carried out to study interactions between the AMPs and lipid model membranes (LMMs) utilizing circular dichroism (CD). Two peptides were further characterized using X-ray diffuse scattering (XDS) and neutron reflectivity (NR). A4-153 displayed superior antibacterial activity in both G(-) planktonic cultures and biofilms. NR and XDS revealed that A4-153 (highest activity) is located primarily in membrane headgroups, while A4-198 (lowest activity) is located in hydrophobic interior. CD revealed that A4-153 is helical, while A4-198 has little helical character, demonstrating that helicity and efficacy are correlated in these SPLUNC1 AMPs.

Transumbilical Silicone Breast Augmentation: A Practical Review of an Innovative Technique

ABSTRACT

Transumbilical silicone breast augmentation (TUSBA) is a fairly new and rapidly growing technique of endoscopically assisted placement of silicone breast implants. In comparison, the well-known transumbilical breast augmentation (TUBA) with saline has been described in the literature since 1993 (Planas J. Introduction of breast implants through the abdominal route. Plast Reconstr Surg. 1976;57:431-437). The TUBA procedure has proven to be safe, efficient, and cosmetically sound over the last 29 years (Shiffman MA, Caleel RT, Shumway R, et al. Survey of transumbilical breast augmentation (TUBA). Am J Cosmet Surg. 2011;28:5-11). Augmentation with silicone through the umbilicus is becoming more popular due to several factors: first, because the acceptance of TUBA with saline has been good with positive outcomes and, second, because patients prefer the discrete location and small size of the umbilical scar left behind. Endoscopic guidance is a critical tool for learning and visualization and for reducing complications such as hematoma or misplacement of the implant.Breast augmentation continues to grow in popularity and acceptance, alongside cosmetic procedures in general. This author expects that, as the TUSBA technique becomes more widespread in use, surgeons will benefit from having a practical clinical publication from which to modify their own technique. This publication will present the authors' TUSBA technique and chart review of practice data from May 2021 through November 2022, wherein the TUSBA procedure was performed.Forty women aged 21 to 61 years (mean, 35.13 years) underwent endoscopically assisted TUSBA. All patients had the implants placed in the submuscular pocket. Patient surveys and postoperative visit data were used in the generation of follow-up information. Upon inspection of the chart data at 3, 6, 9, and 12 months, there were no reports of capsular contracture. Transumbilical silicone breast augmentation is a safe and efficient method for silicone implant placement in select patients.

Unglycosylated Soluble SARS-CoV-2 Receptor Binding Domain (RBD) Produced in E. coli Combined with the Army Liposomal Formulation Containing QS21 (ALFQ) Elicits Neutralizing Antibodies against Mismatched Variants

The emergence of novel potentially pandemic pathogens necessitates the rapid manufacture and deployment of effective, stable, and locally manufacturable vaccines on a global scale. In this study, the ability of the Escherichia coli expression system to produce the receptor binding domain (RBD) of the SARS-CoV-2 spike protein was evaluated. The RBD of the original Wuhan-Hu1 variant and of the Alpha and Beta variants of concern (VoC) were expressed in E. coli, and their biochemical and immunological profiles were compared to RBD produced in mammalian cells. The E. coli-produced RBD variants recapitulated the structural character of mammalian-expressed RBD and bound to human angiotensin converting enzyme (ACE2) receptor and a panel of neutralizing SARS-CoV-2 monoclonal antibodies. A pilot vaccination in mice with bacterial RBDs formulated with a novel liposomal adjuvant, Army Liposomal Formulation containing QS21 (ALFQ), induced polyclonal antibodies that inhibited RBD association to ACE2 in vitro and potently neutralized homologous and heterologous SARS-CoV-2 pseudoviruses. Although all vaccines induced neutralization of the non-vaccine Delta variant, only the Beta RBD vaccine produced in E. coli and mammalian cells effectively neutralized the Omicron BA.1 pseudovirus. These outcomes warrant further exploration of E. coli as an expression platform for non-glycosylated, soluble immunogens for future rapid response to emerging pandemic pathogens.

Does acute funisitis predict worse neonatal outcomes among term newborns?

BACKGROUND

Acute funisitis-the histologic diagnosis of inflammation within the umbilical cord-represents a fetal inflammatory response to infection. Although acute funisitis has been associated with an increased risk of adverse outcomes among preterm neonates, there are limited and conflicting data with term deliveries.

OBJECTIVE

This study aimed to evaluate the association between acute funisitis and neonatal morbidity in neonates born at term to pregnant patients with a clinical diagnosis of intraamniotic infection.

STUDY DESIGN

This was a retrospective cohort study of pregnant patients who had clinically diagnosed intraamniotic infection at term, delivered vaginally at a single tertiary institution from 2013 to 2019, and had histologic chorioamnionitis on placental pathology. Patients with intrauterine fetal demise or missing neonatal/placental pathology data were excluded. The primary outcome was a neonatal sepsis composite, defined as culture-positive bacteremia, neutropenia (absolute neutrophil count<3500/μL), or immature-to-total neutrophil ratio>0.2. The secondary outcomes included composite neonatal morbidity, defined as neonatal intensive care unit admission, 5-minute Apgar score <7, bacteremia, endotracheal intubation or need for continuous positive airway pressure, intraventricular hemorrhage (grade 3 or 4), necrotizing enterocolitis (stage 3 or 4), umbilical artery pH<7.1, umbilical artery base excess>12, and neonatal mortality. The components of these composites, neonatal intensive care unit length of stay, and Kaiser early-onset sepsis score were also measured. Neonates with acute funisitis on pathology were compared with those without acute funisitis using bivariate statistics. Regression was used to estimate the relative risk of outcomes.

RESULTS

Of 184 neonates with deliveries complicated by intraamniotic infection, acute funisitis was present in 109 (59%) placental specimens. Composite neonatal sepsis was significantly higher among neonates with acute funisitis (relative risk, 1.85; 95% confidence interval, 1.13-3.03) than in those without acute funisitis. As a marker for sepsis, acute funisitis has a sensitivity of 39.4%, negative predictive value of 47.2%, specificity of 78.7%, and positive predictive value of 72.9%. An immature-to-total neutrophil ratio>0.2 (relative risk, 1.83; 95% confidence interval, 1.09-3.08) was also significantly associated with acute funisitis. Neonatal morbidity composite, intraventricular hemorrhage, necrotizing enterocolitis, neonatal intensive care unit admission, higher Kaiser early-onset sepsis scores, and other examined outcomes were not statistically associated with acute funisitis.

CONCLUSION

In term deliveries complicated by intraamniotic infection, acute funisitis was associated with increased neonatal sepsis. Current approaches for estimating neonatal sepsis risk are limited by their reliance on indirect maternal factors such as maximum maternal temperature and intrapartum antibiotic use. This study suggests that acute funisitis may serve as a marker that could be utilized to augment risk stratification at birth if a protocol for evaluating the umbilical cord in real-time were widely adopted.

Immediate possible adverse event rates in infants treated with oral propranolol for infantile haemangiomas at an Australian urban tertiary hospital between 2016 and 2019

BACKGROUND/OBJECTIVES

Infantile haemangiomas (IH) are common benign tumours of childhood. The current guideline recommended treatment is oral propranolol, the use of which for IH is relatively recent and there are no safety audits in Australian children published. As a result, it is a primarily inpatient initiated treatment. The aim of this study was to examine the short-term complication rates in infants treated with oral propranolol for IH.

METHODS

Retrospective case note review of IH patients initiated on oral propranolol admitted to the day-unit of tertiary metropolitan hospital in an Australia capital city, from January 2016 to December 2019.

RESULTS

Overall, 72 children were included in the study. Mean age at time of admission was 3.8 ± 2 months. Eight patients (11.1%) experienced complications during their initiation admission. Pulmonary complications (oxygen desaturation, wheeze, increased respiratory rate) was the most common type. No children required high-dependency or intensive care unit admission. The children who experienced complications had a mean age of 2.4 ± 1.2 months; t-test of equality of means found a relationship between propranolol-associated complication rate and age (p = 0.007). All other patient or admission characteristics were not associated with complication events (all p > 0.05).

CONCLUSIONS

Propranolol is a safe, effective and well-tolerated treatment in Australian children with IH. This study demonstrates younger infants will most likely benefit from inpatient initiation. More research needs to be done to characterise the risk profile of propranolol initiation for IH.

Risk factors for failure of limb salvage among veterans with foot ulcers

BACKGROUND

There is limited available information to guide early discussions involving limb salvage for patients with non-traumatic foot ulcers. We hypothesized patient, wound and treatment factors identifiable at initial operative treatment would be associated with failure of attempted limb salvage.

METHODS

We retrospectively assessed United States military veterans treated operatively for non-traumatic foot ulcers at a Veteran's Administration (VA) hospital from 2008 to 2018. Cox proportional hazard analysis assessed for independent associations with eventual above ankle amputation.

RESULTS

Limb salvage failed for 52 of 461 patients (11.0%). Univariable associations included initial wound area ≥1 cm (p < .001), immediate TMA (p < .001), diagnosis of PVD (p < .001) or diabetes (p = .005), nonpalpable pulse (p = .006), CKD (p = .023), creatine ≥ 1.5 (p = .004), and HgA1c ≥ 6.2 (p < .001). Independent associations consisted of initial wound area ≥1 cm (HR 6.0, 95% CI 1.4-25.1, p = .014), immediate TMA (HR 3.5, 95% CI 1.9-6.4, p < .001), and PVD (HR 3.5, 95% CI 1.6-7.5, p = .001). When <2 risk factors were present, 99.1% and 96.8% retained their hindfoot at 5 and 10 years, respectively. However, this decreased to 87.3% and 80.1% with two risk factors and fell to 63.3% and 43.3% with three risk factors.

CONCLUSION

Failure of limb salvage was increasingly likely as the number of identified independent risk factors increased. These results may assist in prognostication and shared decision making between patients and providers.

LEVEL OF EVIDENCE

Prognostic, Level III.

Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R): protocol for a pilot randomised controlled study

BACKGROUND

Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18-35 in terms of years lived with disability. Current pharmacological and psychological interventions intervention have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning.

METHODS/DESIGN

The CReSt-R intervention trial is a single center, pilot randomised controlled study based at the National University of Ireland (NUI), Galway. The trial will recruit participants from four clinical sites with assessment and intervention completed by the primary NUI Galway team. The trial will explore the feasibility, acceptability, and effectiveness of a novel psychosocial intervention for early psychosis based on a combined cognitive remediation training and cognitive behavioural therapy approach focused on social recovery. Participants, aged 16-35 within the first 5 years of a diagnosed psychotic disorder, will be recruited from the Children and Adolescent Mental Health Service and the Adult Mental Health Services in the region.

DISCUSSION

Cognitive remediation training (for improving cognition) and social recovery focused cognitive behavioural therapy, have both separately demonstrated effectiveness. This trial will evaluate the feasibility, acceptability, and explore the efficacy of a treatment approach that combines both approaches as part of an integrated, multicomponent intervention.

TRIAL REGISTRATION

Cognitive Remediation & Social Recovery in Early Psychosis (CReSt-R): ClincialTrials.gov Identifier NCT04273685. Trial registered Feb 18th, 2020. Last updated April 14th, 2021.

Use of diamond sensors for a high-flux, high-rate X-ray pass-through diagnostic

X-ray free-electron lasers (XFELs) deliver pulses of coherent X-rays on the femtosecond time scale, with potentially high repetition rates. While XFELs provide high peak intensities, both the intensity and the centroid of the beam fluctuate strongly on a pulse-to-pulse basis, motivating high-rate beam diagnostics that operate over a large dynamic range. The fast drift velocity, low X-ray absorption and high radiation tolerance properties of chemical vapour deposition diamonds make these crystals a promising candidate material for developing a fast (multi-GHz) pass-through diagnostic for the next generation of XFELs. A new approach to the design of a diamond sensor signal path is presented, along with associated characterization studies performed in the XPP endstation of the LINAC Coherent Light Source (LCLS) at SLAC. Qualitative charge collection profiles (collected charge versus time) are presented and compared with those from a commercially available detector. Quantitative results on the charge collection efficiency and signal collection times are presented over a range of approximately four orders of magnitude in the generated electron-hole plasma density.

O39: THE HISTOPATHOLOGICAL AND MOLECULAR FEATURES OF BREAST CARCINOMA WITH HIGH-GRADE TUMOUR BUDDING

Background

Tumour budding (TB) is an adverse histological feature in many cancers. It is thought to represent epithelial-to-mesenchymal transition, a key step in the metastatic process. The role of TB in breast carcinoma (BC) remains unclear.

Aim

To investigate the relationship between TB and other histological and molecular features of BC.

Method

A systematic search was performed to identify studies that compared features of BC based on the presence or absence of high-grade TB. Dichotomous variables were pooled as odds ratios (OR) using the Cochran–Mantel–Haenszel method. Quality assessment of the included studies was performed using the Newcastle-Ottawa scale (NOS).

Result

Seven studies with a total of 1040 patients (high grade TB n=519, 49.9%; low grade TB n=521, 50.1%) were included. A moderate- to high-risk of bias was noted. The median NOS was 7 (range 6-8). High-grade TB was significantly associated with lymph node involvement (OR 2.28, 95% c.i. 1.74 to 2.98, P&lt;0.001) and lymphovascular invasion (OR 3.08, 95% c.i. 2.13 to 4.47, P&lt;0.001). Regarding molecular subtypes, there was an increased likelihood of high-grade TB in oestrogen- (OR 1.66, 95% c.i. 1.21 to 2.29, P=0.002) and progesterone-receptor positive (OR 1.68, 95% c.i. 1.10 to 2.59, P=0.02) tumours. In contrast triple negative breast cancer had a reduced incidence of high-grade TB (OR 0.46, 95% c.i. 0.30 to 0.72, P=0.0006).

Conclusion

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Take-home message

High-grade TB is enriched in hormone-positive BC and is associated with known adverse prognostic variables. TB may offer new insights into the metastatic processes of luminal BC.

Paediatric Head Injury and Traumatic Brain Injury

Aim To determine prevalence of head injury presenting to paediatric emergency departments (PEDs) and characterise by demographics, triage category, disposition neuroimaging or re-attendance. Methods Presentations in 2014 and 2015, with diagnoses of head injury, intracranial bleed, skull fracture including single or re-attendances within 28 days post head injury to all national PEDs, were analysed. Demographics, triage score, imaging rate, admission, mechanisms and representation rate were recorded. Results Head injury was diagnosed in 13,392 of 224,860 (5.9%), median (IQR) age 3.9 (1.4 - 8.3) years. Regionally 3% of children <5 years attend each year. The total admitted/transferred was 10.8% (n=1460). Neuroimaging rate was 4.3% (n= 570). Falls predominated. Sport accounted for 12.2%. Conclusion One in twenty children PED presentations are head injury, over half in preschool children. A sizeable number were symptomatic reflected by admission, transfer, imaging or re-attendance. Observational management was favoured over imaging reflected in the higher admission versus imaging rate.

Venous thromboembolism prophylaxis in ambulatory cancer patients initiating chemotherapy: A cost-effectiveness analysis

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Background: Venous thromboembolism (VTE) is a major cause of morbidity and mortality among cancer patients. The Apixaban for the Prevention of Venous Thromboembolism in High-Risk Ambulatory Cancer Patients (AVERT) randomized controlled trial concluded that apixaban is a safe and effective option for VTE prophylaxis in high-risk ambulatory cancer patients initiating a new chemotherapy regimen. We performed a cost-effectiveness analysis from a health system perspective to determine if apixaban is a feasible prophylactic strategy for this population. Methods: A decision model was created from a third party payer perspective with a time horizon of 6 months, based on the treatment arms of the AVERT trial: (1) apixaban 2.5 mg twice daily for 6 months during active chemotherapy versus (2) placebo. Rates of VTE (4.2% apixaban vs 10.2% placebo), major bleeding (3.5% vs 1.8%) and clinically relevant nonmajor bleeding (CRNMB) (7.3% vs 5.5%) were modeled from the results of the AVERT trial. Cost estimates for treatments and events were obtained from wholesale drug costs, previously published studies and Medicare reimbursement data, and adjusted for inflation to 2018 dollars. Quality adjusted life years were calculated based on previously published utility values for the health states of advanced cancer, DVT, PE, and major bleeding events. An exploratory analysis was performed comparing prophylactic aspirin to no prophylaxis assuming a VTE rate of 7.2%, major bleeding rate of 3.5%, and CRNMB rate of 7.3%, based on the conservative assumptions that while aspirin may not be as effective at preventing VTE, the rate of clinically significant bleeding events would be similar or greater than that of apixaban. Results: In the base case model, apixaban is more costly and more effective than placebo (ICER = $5,013,190/QALY), and the cost per VTE prevented in the apixaban arm is $33,000. In one-way sensitivity analysis, if the cost of apixaban were reduced by 40% from $3,197 to $1,250 for a 6 month course, this could potentially be a cost-effective prophylaxis strategy with an ICER less than $100,000/QALY. In the alternative analysis, aspirin dominates placebo as it is both more effective and less expensive, and remains cost-effective even when the rate of clinically recognized bleeding with aspirin exceeds 15%. Conclusions: Further investigation into less costly prophylactic options such as generic direct oral anticoagulants (once available) and aspirin is warranted prior to broader implementation of a VTE prophylaxis strategy in this population.

Genetic counseling referrals after next generation sequencing testing

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Background: Next generation sequencing (NGS) testing of tumor tissue or blood is performed to identify ‘actionable’ mutations that might guide patient care. NGS testing might incidentally identify germline mutations associated with cancer syndromes. No distinction is made between germline and somatic alterations on NGS reports, thus confirmatory germline testing is required. In this quality improvement (QI) initiative, we evaluated the frequency of referrals to genetic counseling (GC) for patients with potentially heritable germline mutations identified through NGS testing. Methods: We generated a list of high-risk mutations (HRMs) which merit GC referral based on NCCN guidelines. NGS test results for 3,400 consecutive patients with solid tumor malignancies were reviewed by the molecular tumor board from 1/2014-9/2019 and were screened for pathogenic HRMs. Basic demographic, oncologic, and GC data were retrospectively abstracted for each patient. The outcomes of interest were the frequency of HRMs identified through NGS testing, the proportion of patients subsequently referred to GC, and the proportion of patients ultimately diagnosed with a hereditary cancer syndrome. Results: 472 individual patients (14%) had NGS testing with one or more HRM identified; 465 patients were evaluable which corresponded to 519 HRMs that were included in the analysis (Table). Malignancies included were gastrointestinal 199 (42.8%), lung 83 (17.8%), genitourinary/renal 56 (12.0%), breast 49 (10.5%), gynecologic 35 (7.5%), and other 43 (9.2%). 75 (16.1%) patients had germline testing prior to NGS testing. Of those patients without prior germline genetic testing, 62 (15.9%) were referred to GC, and 19 (4.9%) patients were diagnosed with a hereditary cancer syndrome. Conclusions: Tumor NGS testing identifies HRMs that may represent an undiagnosed heritable germline mutation. Providers ordering NGS tests should review results for HRMs, refer to GC when appropriate, and offer confirmatory germline testing for patients and their families. [Table: see text]

Evaluation of VIDAS® Listeria species Xpress (LSX) Immunoassay Method for the Detection of Listeria species in Foods: Collaborative Study

In a multilaboratory study, the effectiveness of an alternative method for rapid screening of Listeria species compared to traditional reference methods was demonstrated in a variety of food products. A collaborative study was conducted to compare the VIDAS® Listeria species Xpress (LSX) method and the standard cultural methods for the detection of Listeria species in foods. Six food types were tested: vanilla ice cream, cheddar cheese, raw ground beef, frozen green beans, deli turkey, and cooked shrimp. Each food, inoculated with a different Listeria strain at two levels and uninoculated test portions, was analyzed by each method. A total of 15 laboratories representing government and industry participated. In this study 1134 tests were analyzed in the statistical analysis. There were 490 positives by the VIDAS LSX method using the sample boiling step, 483 positives by the VIDAS LSX method using the Heat and Go system, and 439 positives by the standard culture methods. Overall, the Chi-square result for the VIDAS LSX method with boiling for all foods was 7.25, indicating a significant statistical difference between the VIDAS method and the standard methods at the 5% confidence. For the VIDAS LSX method with the Heat and Go system, the Chi-square result for all foods was 5.37, indicating a significant statistical difference between the VIDAS LSX assay with the Heat and Go system and the standard methods at the 5% level of significance. In both cases, the VIDAS method was more sensitive than the standard methods. The LSX method detects Listeria species in foods with negative or presumptive positive results in a minimum of 30 h compared to at least 5 days for the cultural methods. Based on the results of this collaborative study, it is recommended that the VIDAS LSX method be adopted as an AOAC Official MethodSM for the detection of Listeria species in dairy products, vegetables, seafood, raw meats and poultry, and processed meats and poultry.

Characteristics of Mycobacterium bovis infected herds tested with the interferon-gamma assay

The IFN-γ (interferon gamma) assay is used in Ireland as an ancillary diagnostic test to the single intradermal comparative tuberculin test (SICTT) to maximise the detection of Mycobacterium bovis infected animals (bTB) in cattle herds. Understanding the relationships between herd and animal risk factors and IFN-γ test results is critical to enable the development and evaluation of policy measures on how best to use the test. In this study, we set out to characterise Irish herds with IFN-γ test positive animals in terms of herd size, number of SICTT reactors and number of IFN-γ positive tests, and to evaluate the IFN-γ test in terms of the test cut-off values. The results showed that larger herds with more SICTT reactors were likely to have more IFN-γ positives in the herd, and herds with an IFN-γ test positive animal that was also positive for bTB lesions at post-mortem had higher numbers of IFN-γ positive animals in the herd. Raising the cut-off values for the IFN-γ test only marginally decreased the combined sensitivity of the IFN-γ and the SICTT for diagnosis of bTB lesioned animals. The analysis has provided valuable information on the performance of the IFN-γ test as it is used under current bTB infection levels in Ireland.

Can Early Changes in Vital signs Predict Duration of Antibiotic Therapy in Suspected Neonatal Sepsis?

Aims Suspected sepsis remains a leading causes of Neonatal Intensive Care Unit admission, with infants often receiving 48-72 hours of empirical antibiotic therapy. Early in treatment it is difficult to predict infants who will require prolonged antibiotic therapy. Our aim was to assess if vital sign measurements in the initial period of treatment can predict those neonates requiring prolonged antibiotic therapy in term and late-preterm infants. Methods Data was retrospectively collected over 1 year on neonates admitted to our institute for antibiotics. Infants were classified as standard (<48hours duration) or prolonged (>48hours duration) antibiotic therapy. Results Respiratory rate on admission and 12 hours after initiation of therapy correlated significantly with duration of antibiotic therapy and infants requiring prolonged therapy were more likely to have one or more abnormal vital signs 12 hours after initiation of treatment (p<0.05). Conclusion Respiratory rate shows a weak positive correlation with antibiotic duration. Infants requiring prolonged therapy were more likely to have abnormal vital signs 12 hours after initiating antibiotic therapy. Changes in vital signs maybe useful in detecting infants who will require prolonged antibiotic therapy.

Meconium Ileus in Two Irish Newborns: The Presenting Feature of Cystic Fibrosis

Introduction Meconium Ileus (MI) is the presenting feature of CF in approximately 10-15% of cases. This report outlines the clinical presentation, imaging and management of two neonates with MI and subsequent diagnosis of Cystic Fibrosis (CF). Methods A retrospective chart review was performed to evaluate the clinical course of two neonates with MI. Results Case 1 and 2 presented clinically with signs of abdominal obstruction. Subsequent laparotomies confirmed MI. MI is strongly associated with CF and CF is the most common genetically inherited disease in Ireland. Genetic testing was positive for a homozygous ∆ F508 mutation in both case 1 and 2, securing a diagnosis of MI secondary to CF. Conclusion Our cases highlight that all infants born in Ireland with MI should be considered as CF positive until proven otherwise.

Variance components for bovine tuberculosis infection and multi-breed genome-wide association analysis using imputed whole genome sequence data

Bovine tuberculosis (bTB) is an infectious disease of cattle generally caused by Mycobacterium bovis, a bacterium that can elicit disease humans. Since the 1950s, the objective of the national bTB eradication program in Republic of Ireland was the biological extinction of bTB; that purpose has yet to be achieved. Objectives of the present study were to develop the statistical methodology and variance components to undertake routine genetic evaluations for resistance to bTB; also of interest was the detection of regions of the bovine genome putatively associated with bTB infection in dairy and beef breeds. The novelty of the present study, in terms of research on bTB infection, was the use of beef breeds in the genome-wide association and the utilization of imputed whole genome sequence data. Phenotypic bTB data on 781,270 animals together with imputed whole genome sequence data on 7,346 of these animals' sires were available. Linear mixed models were used to quantify variance components for bTB and EBVs were validated. Within-breed and multi-breed genome-wide associations were undertaken using a single-SNP regression approach. The estimated genetic standard deviation (0.09), heritability (0.12), and repeatability (0.30) substantiate that genetic selection help to eradicate bTB. The multi-breed genome-wide association analysis identified 38 SNPs and 64 QTL regions associated with bTB infection; two QTL regions (both on BTA23) identified in the multi-breed analysis overlapped with the within-breed analyses of Charolais, Limousin, and Holstein-Friesian. Results from the association analysis, coupled with previous studies, suggest bTB is controlled by an infinitely large number of loci, each having a small effect. The methodology and results from the present study will be used to develop national genetic evaluations for bTB in the Republic of Ireland. In addition, results can also be used to help uncover the biological architecture underlying resistance to bTB infection in cattle.

Rapamycin as a potential treatment for succinate dehydrogenase deficiency

Drosophila melanogaster is a powerful model to study mitochondrial respiratory chain defects, particularly succinate dehydrogenase (SDH) deficiency. Mutations in sdh genes cause degenerative disorders and often lead to death. Therapies for such pathologies are based on a combination of vitamins and dietary supplements, and are rarely effective. In Drosophila, mutations in several of the genes encoding SDH resemble the pathology of SDH deficiency in humans, enabling the Drosophila model to be used in finding treatments for this condition. Here we show that exposure to the drug rapamycin improves the survival of sdh mutant strains, the activity of SDH and the impaired climbing associated with sdh mutations. However, the production of reactive oxygen species, the oxygen consumption of isolated mitochondria and the resistance to hyperoxia were minimally affected. Our results contribute to the current research seeking a treatment for mitochondrial disease.

Transcriptional subtyping and CD8 immunohistochemistry identifies poor prognosis stage II/III colorectal cancer patients who benefit from adjuvant chemotherapy

Purpose

Transcriptomic profiling of colorectal cancer (CRC) has led to the identification of four consensus molecular subtypes (CMS1 to 4) that have prognostic value in stage II and III disease. More recently, the Colorectal Cancer Intrinsic Subtypes (CRIS) classification system has helped to define the biology specific to the epithelial component of colorectal tumors; however, the clinical value of these classification systems in the prediction of response to standard-of-care adjuvant chemotherapy remains unknown.

Patients and Methods

Using samples from four European sites, we assembled a novel cohort of patients with stage II and III CRC (n = 156 samples) and performed transcriptomic profiling and targeted sequencing and generated a tissue microarray to enable integrated multiomics analyses. We also accessed data from two published cohorts of patients with stage II and III CRC: GSE39582 and GSE14333 (n = 479 and n = 185 samples, respectively).

Results

The epithelial-rich CMS2 subtype of CRC benefitted significantly from treatment with adjuvant chemotherapy in both stage II and III disease (P = .02 and P < .001, respectively), whereas the CMS3 subtype significantly benefitted in stage III only (P = .001). After CRIS substratification of CMS2, we observed that only the CRIS-C subtype significantly benefitted from treatment with adjuvant chemotherapy in stage II and III disease (P = .0081 and P < .001, respectively), whereas the CRIS-D subtype significantly benefitted in stage III only (P = .0034). We also observed that CRIS-C patients with low levels of CD8⁺ tumor-infiltrating lymphocytes were most at risk for relapse in both stage II and III disease (log-rank P = .0031; hazard ratio, 12.18 [95% CI, 1.51 to 98.58]).

Conclusion

Patient stratification using a combination of transcriptional subtyping and CD8 immunohistochemistry analyses is capable of identifying patients with poor prognostic stage II and III disease who benefit from adjuvant standard-of-care chemotherapy. These findings are particularly relevant for patients with stage II disease, where the overall benefit of adjuvant chemotherapy is marginal.

THE IMPACT OF DIGITAL TECHNOLOGY ON DOSE REDUCTION IN PAEDIATRIC CARDIAC CATHETERISATION WITHIN A LARGE METROPOLITAN CHILDREN'S HOSPITAL

This study examines the kerma-area product (PKA) levels from paediatric cardiac catheterisations at a major Children's Hospital over three different time periods in order to gain an understanding of the causation of dose variations over time and to present a model for dose reduction. A retrospective review of 1245 paediatric procedural records was undertaken. This cohort consisted of patients that were catheterised over a period from November 2007 to July 2009, October 2009 to November 2011 and January 2016 to December 2016. The age distribution was from newborn to 18 years. Archived (PKA) readings were retrieved and analysed. The 75th percentile PKA values for the specific age categories over time periods (1, 2, 3) were 0-30 days-(5.47, 1.37, 1.37) Gy cm2; 1-12 months-(6.42, 2.03, 1.06) Gy cm2; 1-3 years-(11.25, 3.20, 1.25) Gy cm2; 3-5 years-(12.65, 3.72, 2.88) Gy cm2; 5-10 years-(12.80, 8.53, 3.52) Gy cm2; 10-15 years-(27.92, 10.85, 2.97) Gy cm2; >15 years-(29.09, 27.81, 11.65) Gy cm2. Using newer imaging technologies, optimising dose reduction strategies and regular dose auditing can transform radiation dose delivery for paediatric x-ray examinations. Our centre provides a template for dose reduction success worldwide.

A conserved Toll-like receptor-to-NF-κB signaling pathway in the endangered coral Orbicella faveolata

Herein, we characterize the Toll-like receptor (TLR)-to-NF-κB innate immune pathway of Orbicella faveolata (Of), which is an ecologically important, disease-susceptible, reef-building coral. As compared to human TLRs, the intracellular TIR domain of Of-TLR is most similar to TLR4, and it can interact in vitro with the human TLR4 adapter MYD88. Treatment of O. faveolata tissue with lipopolysaccharide, a ligand for mammalian TLR4, resulted in gene expression changes consistent with NF-κB pathway mobilization. Biochemical and cell-based assays revealed that Of-NF-κB resembles the mammalian non-canonical NF-κB protein p100 in that C-terminal truncation results in translocation of Of-NF-κB to the nucleus and increases its DNA-binding and transcriptional activation activities. Moreover, human IκB kinase (IKK) and Of-IKK can both phosphorylate conserved residues in Of-NF-κB in vitro and induce C-terminal processing of Of-NF-κB in vivo. These results are the first characterization of TLR-to-NF-κB signaling proteins in an endangered coral, and suggest that these corals have conserved innate immune pathways.

Effectiveness of the Healthy Lifestyles Programme (HeLP) to prevent obesity in UK primary-school children: a cluster randomised controlled trial

Background

Although childhood overweight and obesity prevalence has increased substantially worldwide in the past three decades, scarce evidence exists for effective preventive strategies. We aimed to establish whether a school-based intervention for children aged 9-10 years would prevent excessive weight gain after 24 months.

Methods

This pragmatic cluster randomised controlled trial of the Healthy Lifestyles Programme (HeLP), a school-based obesity prevention intervention, was done in 32 schools in southwest England. All state-run primary and junior schools in Devon and Plymouth (UK) with enough pupils for at least one year-5 class were eligible. Schools were assigned (1:1) using a computer-generated sequence to either intervention or control, stratified by the number of year-5 classes (one vs more than one) and the proportion of children eligible for free school meals (<19% [the national average] vs ≥19%). HeLP was delivered to year-5 children (ages 9-10 years) over 1 year, and included dynamic and interactive activities such as physical activity workshops, education sessions delivered by teachers with short homework tasks, drama sessions, and setting goals to modify behaviour (with parental support and one-to-one discussions with HeLP coordinators). The primary outcome was change in body-mass index (BMI) standard deviation score (SDS) between baseline and 24 months, analysed in children with BMI data available for both timepoints. This study is registered with the International Standard Randomised Controlled Trial register, number ISRCTN15811706, and the trial status is complete.

Findings

Between March 21, 2012, and Sept 30, 2013, 32 eligible schools with 1324 children were recruited, of which 16 schools (676 children) were randomly assigned to the HeLP intervention and 16 schools (648 children) to control. All schools that began the trial completed the intervention, and 1244 children (628 in intervention group and 616 in control group) had BMI data at both baseline and 24 months for the primary outcome analysis. Mean BMI SDS was 0·32 (SD 1·16) at baseline and 0·35 (1·25) at 24 months in the intervention group, and 0·18 (1·14) at baseline and 0·22 (1·22) at 24 months in the control group. With adjustment for school-level clustering, baseline BMI scores, sex, cohort, and number of year-5 classes and socioeconomic status of each school, the mean difference in BMI SDS score (intervention-control) at 24 months was -0·02 (95% CI -0·09 to 0·05), p=0·57. One parent reported an adverse event related to their child's eating and activity behaviours, but agreed for the child to continue trial participation after discussion with the chief investigator.

Interpretation

Despite a theoretically informed and extensively piloted intervention that achieved high levels of engagement, follow-up, and fidelity of delivery, we found no effect of the intervention on preventing overweight or obesity. Although schools are an ideal setting in which to deliver population-based interventions, school-based interventions might not be sufficiently intense to affect both the school and the family environment, and hence the weight status of children. Future research should focus on more upstream determinants of obesity and use whole-systems approaches.

Funding

UK National Institute for Health Research, Public Health Research Programme.

Cluster randomised controlled trial and economic and process evaluation to determine the effectiveness and cost-effectiveness of a novel intervention [Healthy Lifestyles Programme (HeLP)] to prevent obesity in school children

Background

Approximately one-third of children in England leave primary school overweight or obese. There is little evidence of effective obesity prevention programmes for children in this age group.

Objective

To determine the effectiveness and cost-effectiveness of a school-based healthy lifestyles programme in preventing obesity in children aged 9–10 years.

Design

A cluster randomised controlled trial with an economic and process evaluation.

Setting

Thirty-two primary schools in south-west England.

Participants

Children in Year 5 (aged 9–10 years) at recruitment and in Year 7 (aged 11–12 years) at 24 months’ post-baseline follow-up.

Intervention

The Healthy Lifestyles Programme (HeLP) ran during the spring and summer terms of Year 5 into the autumn term of Year 6 and included four phases: (1) building a receptive environment, (2) a drama-based healthy lifestyles week, (3) one-to-one goal setting and (4) reinforcement activities.

Main outcome measures

The primary outcome measure was body mass index (BMI) standard deviation score (SDS) at 24 months post baseline measures (12 months post intervention). The secondary outcomes comprised waist circumference SDS, percentage body fat SDS, proportion of children overweight and obese at 18 and 24 months, accelerometer-assessed physical activity and food intake at 18 months, and cost-effectiveness.

Results

We recruited 32 schools and 1324 children. We had a rate of 94% follow-up for the primary outcome. No difference in BMI SDS was found at 24 months [mean difference –0.02, 95% confidence interval (CI) –0.09 to 0.05] or at 18 months (mean difference –0.02, 95% CI –0.08 to 0.05) between children in the intervention schools and children in the control schools. No difference was found between the intervention and control groups in waist circumference SDS, percentage body fat SDS or physical activity levels. Self-reported dietary behaviours showed that, at 18 months, children in the intervention schools consumed fewer energy-dense snacks and had fewer negative food markers than children in the control schools. The intervention effect on negative food markers was fully mediated by ‘knowledge’ and three composite variables: ‘confidence and motivation’, ‘family approval/behaviours and child attitudes’ and ‘behaviours and strategies’. The intervention effect on energy-dense snacks was partially mediated by ‘knowledge’ and the same composite variables apart from ‘behaviours and strategies’. The cost of implementing the intervention was approximately £210 per child. The intervention was not cost-effective compared with control. The programme was delivered with high fidelity, and it engaged children, schools and families across the socioeconomic spectrum.

Limitations

The rate of response to the parent questionnaire in the process evaluation was low. Although the schools in the HeLP study included a range of levels of socioeconomic deprivation, class sizes and rural and urban settings, the number of children for whom English was an additional language was considerably lower than the national average.

Conclusions

HeLP is not effective or cost-effective in preventing overweight or obesity in children aged 9–10 years.

Future work

Our very high levels of follow-up and fidelity of intervention delivery lead us to conclude that it is unlikely that school-based programmes targeting a single age group can ever be sufficiently intense to affect weight status. New approaches are needed that affect the school, the family and the wider environment to prevent childhood obesity.

Trial registration

Current Controlled Trials ISRCTN15811706.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

Intervention fidelity in the definitive cluster randomised controlled trial of the Healthy Lifestyles Programme (HeLP) trial: findings from the process evaluation

Background

The Healthy Lifestyles Programme (HeLP) was a novel school-located intervention for 9–10 year olds, designed to prevent obesity by changing patterns of child behaviour through the creation of supportive school and home environments using dynamic and creative delivery methods. This paper reports on both the quantitative and qualitative data regarding the implementation of the HeLP intervention in the definitive cluster randomised controlled trial, which was part of the wider process evaluation.

Methods

Mixed methods were used to collect data on intervention uptake, fidelity of delivery in terms of content and quality of delivery of the intervention, as well as school and child engagement with the programme. Data were collected using registers of attendance, observations and checklists, field notes, focus groups with children and semi-structured interviews with teachers. Qualitative data were analysed thematically and quantitative data were summarized using descriptive statistics.

Results

All 16 intervention schools received a complete or near complete programme (94–100%), which was delivered in the spirit in which it had been designed. Of the 676 children in the intervention schools, over 90% of children participated in each phase of HeLP; 92% of children across the socio-economic spectrum were deemed to be engaged with HeLP and qualitative data revealed a high level of enjoyment by all children, particularly to the interactive drama workshops. Further evidence of child engagment with the programme was demonstrated by children’s clear understanding of programme messages around marketing, moderation and food labelling. Thirteen of the intervention schools were deemed to be fully engaged with HeLP and qualitative data revealed a high level of teacher ‘buy in’, due to the programme’s compatability with the National Curriculum, level of teacher support and use of innovative and creative delivery methods by external drama practitioners.

Conclusion

Our trial shows that it is possible to successfully scale up complex school-based interventions, engage schools and children across the socio-economic spectrum and deliver an intervention as designed. As programme integrity was maintained throughout the HeLP trial, across all intervention schools, we can be confident that the trial findings are a true reflection of the effectiveness of the intervention, enabling policy recommendations to be made.

Trial registration

ISRCTN15811706.

Electronic supplementary material

The online version of this article (10.1186/s12966-017-0616-6) contains supplementary material, which is available to authorized users.

Cumulative Effective and Individual Organ Dose Levels in Paediatric Patients Undergoing Multiple Catheterisations for Congenital Heart Disease

This study examines the cumulative radiation dose levels received by a group of children who underwent multiple cardiac catheterisation procedures during the investigation and management of congenital heart disease (CHD). The purpose is to calculate cumulative doses, identify higher dose individuals, outline the inconsistencies with risk assessment and encourage the establishment of dose databases in order to facilitate the longitudinal research necessary to better understand health risks. A retrospective review of patient records for 117 paediatric patients who have undergone two or more cardiac catheterisations for the investigation of CHD was undertaken. This cohort consisted of patients who were catheterised over a period from September 2002 to August 2014. The age distribution was from newborn to 17 y. Archived kerma-area product (PKA) and fluoroscopy time (T) readings were retrieved and analysed. Cumulative effective and individual organ doses were determined. The cumulative PKA levels ranged from 1.8 to 651.2 Gycm2, whilst cumulative effective dose levels varied from 2 to 259 mSv. The cumulative fluoroscopy time was shown to vary from 8.1 to 193.5 min. Median cumulative organ doses ranged from 3 to 94 mGy. Cumulative effective dose levels are highly variable but may exceed 250 mSv. Individual organ and effective dose measurements remain useful for comparison purposes between institutions although current methodologies used for determining lifetime risks are inadequate.

Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer

BACKGROUND

The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection.

METHODS

A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins.

RESULTS

Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263).

CONCLUSION

Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.

Prophylactic Ureteric Stents in Renal Transplant Recipients: A Multicenter Randomized Controlled Trial of Early Versus Late Removal

Prophylactic ureteric stenting in renal transplantation reduces major urological complications; however, morbidity is related to the indwelling duration of a stent. We aimed to determine the optimal duration for stents in this clinical setting. Patients (aged 2-75 years) from six UK hospitals who were undergoing renal transplantation were recruited and randomly assigned to either early stent removal at 5 days (without cystoscopy) or late removal at 6 weeks after transplantation (with cystoscopy). The primary outcome was a composite of stent-related complications defined as pain, visible hematuria, migration, fragmentation, and urinary tract infections (UTIs) within 3 mo of transplantation. Between May 2010 and Nov 2013, we randomly assigned 227 participants, with 205 included in the final analysis of the primary outcome. Stent-related complications were significantly higher in the late versus early stent removal groups (36 of 126 [28.6%] vs. 6 of 79 [7.6%]; p < 0.001). The majority of stent complications consisted of UTIs, with an incidence of 31 of 126 (24.6%) in the late group compared with 6 of 79 (7.6%) in the early group (p = 0.004). We found early stent removal on day 5 significantly reduced stent-related complications and improved quality of life in the first 3 mo after transplantation (ISRCTN09184595).

The use of a micropore particle technology in the treatment of acute wounds

OBJECTIVE

A clinical audit was performed to evaluate whether Acapsil micropore particle technology (MPPT) powder could improve the management of acute wounds to heal by secondary intention.

METHOD

Wounds, which could be characterised as sloughy, wet and probably infected, normally managed by debridement followed by negative pressure wound therapy (NPWT), were included in the evaluation. The MPPT powder was applied topically to the wound surface either once daily or on alternate days, with each wound receiving a total of two to five applications. Most patients had NPWT after the MPPT powder treatment had finished to assist healing.

RESULTS

The study included nine patients with dehisced surgical wounds and one with a category IV pressure ulcer (PU). The wounds were generally covered in slough, exudate and showing signs of local infection. The topical MPPT powder rapidly desloughed the wounds, controlled exudate levels, promoted granulation and was well tolerated. All wounds proceeded towards closure.

CONCLUSION

Comparison of the present data with MPPT powder to standard treatment suggests that the speed of healing using MPPT was improved. Further examination is required to determine if this reduces dressing changes, nursing time, and financial cost.