An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

How reconfiguration of a minor injuries unit has affected service delivery during the COVID-19 pandemic: a retrospective analysis

INTRODUCTION

Redeployment of orthopaedic consultants to a minor injuries unit (MIU) during the COVID-19 pandemic provided a unique opportunity to assess the impact of early senior specialist input on patient management.

METHODS

Patient demographics, diagnosis, location of injury and disposal method were compared between three 7-day periods: during the April 2020 COVID-19 lockdown (period A), one month prior to period A (period B) and one year prior to period A (period C). Orthopaedic consultants staffed the MIU during period A, and emergency nurse practitioners staffed the MIU during periods B and C.

RESULTS

Period A witnessed higher injury severity either due to modified activities or altered healthcare-seeking behaviour during lockdown. For fractures, compared with periods B and C, period A saw a lower rate of referral to fracture clinic (41% vs 100% vs 86%, p<0.001) and higher rate of discharge (38% vs 0% vs 9%, p<0.001). The median time to fracture clinic was also longer (15 days vs 6 days vs 10 days, p<0.001), indicating earlier institution of definitive care. There were no other significant differences between periods with radiology alerts and complaints received remaining largely unchanged.

CONCLUSION

Early senior orthopaedic input in the patient journey from MIU had clear benefits, this being most true for fracture diagnoses. Earlier definitive management planning was observed as lower rates of fracture clinic referral, higher rates of discharge and deferred first fracture clinic reviews. This study highlights the benefits of greater partnership between MIU and orthopaedics. As the pandemic subsides and redeployed staff return to normal duties, a modification of this model could be utilised to ensure this partnership is sustainable.

The importance of right heart function in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure (HF) is a complex clinical syndrome that is a frequent cause of morbidity and mortality. Although half of patients with HF have a preserved ejection fraction (HFpEF), the majority of studies have examined the prognostic impact of left heart parameters instead of the right. We thus evaluated associations of right heart hemodynamics and echocardiographic measures with outcomes in HFpEF subjects.

Purpose

To perform long-term mortality analysis of patients with decompensated HFpEF using strain imaging and right heart catheterization hemodynamics.

Methods

This was a retrospective cross-sectional study which included patients hospitalized for acute heart failure exacerbation as the primary admitting diagnosis based on clinical and laboratory parameters as determined by the primary medical team. Patients included were only those with HFpEF and with available echocardiographic and right heart catheterization (RHC) hemodynamic data done during the index admission. 2D strain analysis software was used to automatically calculate right ventricular free wall strain (RVFWS), fractional area change (FAC), and left ventricular global longitudinal strain (LVGLS). Demographic and clinical parameters were obtained including RHC hemodynamics. The outcome of interest was long term 6-year all-cause mortality. Right and left ventricular echocardiographic strain and hemodynamic parameters were compared between patients with mortality and those who survived using independent T tests and non-parametric methods as appropriate. Multivariable logistic regression was used to identify echocardiographic and hemodynamic factors independently associated with all-cause mortality. Results From a total of 100 patients, 47% were Caucasian and 53% were female. The mean age was 67.4 ± 14.3. There was an 18% long term all cause mortality rate. Of the right sided echocardiographic strain parameters, only RVFWS was statistically significantly lower among those who died (12.0 vs 15.7 p = 0.038). Meanwhile, 4 chamber LVGLS was significantly lower (13.8 vs 15.1 p = 0.016) and mean right atrial (RA) pressure was higher (13.6 vs 10.7 p = 0.076) although this did not reach statistical significance. Looking at echocardiographic strain and hemodynamic parameters as predictors of mortality, after adjusting for age, gender and race accounting for the major differences in these parameters between the survival groups, only RVFWS (OR 1.90, 95% CI 1.12-3.28; p = 0.02) and RA pressure (OR 1.85, 95% CI 1.12-3.28; p = 0.016) remained independently associated with long term all-cause mortality with C statistic of 0.751 for the overall predictive model.

Conclusion

Among patients with HFpEF admitted for acute heart failure exacerbation, baseline RVFWS and RA hemodynamic pressure measurements were independently associated with long term all-cause mortality. This suggests that right heart diagnostic parameters may hold more prognostic utility in HFpEF. Abstract Figure.  Abstract Figure.

A200 VEDOLIZUMAB IS AN EFFECTIVE TREATMENT OPTION FOR NON INFLAMMATORY BOWEL DISEASE RELATED ENTEROPATHY

Background

Vedolizumab is an α4β7 integrin antagonist which inhibits intestinal T-cell translocation by blocking integrin interactions with mucosal vascular addressin cell adhesion molecule 1, reducing lymphocyte mediated inflammation. Its gut selective mode of action and safety profile have lead to reports of off-label use of vedolizumab for non-IBD related inflammatory intestinal disorders.

Aims

We conducted a literature review to assess clinical, endoscopic and histologic improvement in patients treated with Vedolizumab for non-IBD enteropathies refractory to conventional therapy.

Methods

EMBASE, Medline, Clinicaltrials.gov and Cochrane CENTRAL were searched on September 12, 2019 for case studies, case series and cohort studies without language restriction yielding 356 studies with 164 duplicates, 74 non-applicable studies, leaving 118 studies. After full text review, 98 studies were excluded, leaving 20 included studies.

Results

65% of patients (51/79) achieved clinical response. 40.5% (15/37) of patients experienced endoscopic improvement and 33% (17/51) of patients experienced histologic improvement. The duration of treatment varied from patients receiving only induction doses to up to 70 months for maintenance therapy. There were four reported cases of withdrawal due to adverse events from Vedolizumab.

Conclusions

In a treatment refractory population, over 60% of patients reported to have a clinical response and one-third endoscopic/histologic response, indicating that Vedolizumab is a viable option for patients with refractory non-IBD enteropathy.

Funding Agencies

None

A234 CLINICAL, ENDOSCOPIC AND HISTOLOGICAL IMPROVEMENT IN COMMON VARIABLE IMMUNODEFICIENCY DISEASE ASSOCIATED ENTEROPATHY WITH VEDOLIZUMAB

Background

Common variable immune deficiency (CVID) can be associated with autoimmune manifestations including enteric inflammation and diarrhea. Systemic immunosuppression used in patients with inflammatory bowel disease (IBD) may be associated with increased risk of infection in CVID.

Aims

We report a patient with CVID associated intestinal enteropathy who underwent clinical, endoscopic and histological improvement after treatment with vedolizumab (IgG1 monoclonal antibody to α4β7 integrin), as well as a concurrent systematic review (SR) of the literature.

Methods

Case report and systematic literature review. We searched EMBASE, Medline, Cochrane CENTRAL, clinialtrials.gov, and the International Clinical Trials Registry Platform without language restriction using key words to identify patients with CVID associated enteropathy treated with vedolizumab. Clinical, endoscopic and histological outcomes were extracted and safety data.

Results

A 32-year-old male presented with weight loss, anemia and hypoalbuminemia on a background of chronic diarrhea and recurrent sinus infections. Serology and genetic testing was not consistent with celiac disease. Pan-endoscopy showed complete villous atrophy in the duodenum and biopsies showed and intraepithelial lymphocytosis (IEL) in the duodenum and terminal ileum. CT abdomen showed pan-enteritis with extensive mesenteric lymphadenopathy which were reactive on lymph node excision, as well as bronchiectasis. Pneumococcal vaccination challenge to assess humoral response confirmed CVID. After suboptimal response with steroids and mercaptopurine, treatment was initiated with vedolizumab 300mg IV at weeks 0, 2, and 6, then 8 weekly. This led to normalization of stool frequency, weight gain as well as endoscopic and histological resolution within 6 months of treatment. The SR yielded 101 studies of which 3 case series were identified reporting a total of 7 patients with CVID. In 5 cases there was clinical improvement, 4 reported endoscopic improvement and 3 patients had histologic improvement. No safety concerns associated with vedolizumab were reported.

Conclusions

Vedolizumab, a selective leucocyte inhibitor to the gut, was able to induce either clinical, endoscopic or histological improvement in 8 published cases in the worldwide literature. Prospective studies are needed to determine whether this treatment could be included in the therapeutic armamentarium for this orphan indication.

Funding Agencies

None

Transcriptome analysis reveals a classical interferon signature induced by IFNλ4 in human primary cells

The IFNL4 gene is negatively associated with spontaneous and treatment-induced clearance of hepatitis C virus infection. The activity of IFNλ4 has an important causal role in the pathogenesis, but the molecular details are not fully understood. One possible reason for the detrimental effect of IFNλ4 could be a tissue-specific regulation of an unknown subset of genes. To address both tissue and subtype specificity in the interferon response, we treated primary human hepatocytes and airway epithelial cells with IFNα, IFNλ3 or IFNλ4 and assessed interferon mediated gene regulation using transcriptome sequencing. Our data show a surprisingly similar response to all three subtypes of interferon. We also addressed the tissue specificity of the response, and identified a subset of tissue-specific genes. However, the interferon response is robust in both tissues with the majority of the identified genes being regulated in hepatocytes as well as airway epithelial cells. Thus we provide an in-depth analysis of the liver interferon response seen over an array of interferon subtypes and compare it to the response in the lung epithelium.

Body mass index, waist circumference, hip circumference, waist-hip-ratio and waist-height-ratio: which is the better discriminator of prevalent screen-detected diabetes in a Cameroonian population?

BACKGROUND

The link between measures of adiposity and prevalent screen-detected diabetes (SDM) in Africa has been less well investigated. We assessed and compared the strength of association and discriminatory capability of measures of adiposity including body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip-ratio (WHR) and waist-height-ratio (WHtR) for prevalent SDM risk in a sub-Saharan African population.

METHODS

Participants were 8663 adults free of diagnosed type 2 diabetes, who took part in the nationally representative Cameroon Burden of Diabetes (CAMBoD) 2006 survey. Logistic regression models were used to compute the odd ratio (OR) and 95% confidence interval (95%CI) for a standard deviation (SD) higher level of BMI (7.3), WC (12.5), HC (11.7), WHR (0.19) and WHtR (0.08) with prevalent SDM risk. Assessment and comparison of discrimination used C-statistic and relative integrated discrimination improvement (RIDI, %).

RESULTS

The adjusted OR and 95%CI for prevalent SDM with each SD higher adipometric variable were: 1.05 (0.98-1.13) for BMI, 1.30 (1.16-1.46) for WC, 1.18 (1.05-1.34) for HC, 1.05 (1.00-1.16) for WHR and 1.26 (1.11-1.39) for WHtR. C-statistic comparisons and RIDI analyses showed a trend toward a significant superiority of WC over other adipometric variables in multivariable models. Combining adiposity variables did not improve discrimination beyond multivariable models with WC alone.

CONCLUSION

WC was the best predictors and to some extent WHtR of prevalent SDM in this population, while BMI and WHR were less effective.

Crystal structure of picolinic acid hydrazide, C6H7N3O

C6H7N3O, monoclinic, C12/c1 (no. 15), a = 19.222(2) Å, b = 3.8987(4) Å, c = 18.115(2) Å, β = 107.095(2)°, V = 1297.6 Å3, Z = 8, Rgt(F) = 0.038, wRref(F2) = 0.122, T = 293 K.

Synthesis and structure determination of some oxadiazole-2-thione and triazole-3-thione galactosides

The syntheses of 5-pyridyl-3(beta-D-galactopyranosyl)-1,3,4-oxadiazole-2-thiones 3a-3c and 5-pyridyl-2(beta-D-galactopyranosyl)-4-benzyl-1,2, 4-triazole-3-thiones 6a-6c are reported. The existence of N-galactosides--not S-galactosides--was proven by IR and 15N NMR spectroscopy. The structures of the final products and the intermediates were elucidated by IR, 1H, 13C and 15N NMR spectroscopy and mass spectrometry.