Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures

Background

Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures.

Methods

Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes.

Results

Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation.

Conclusion

Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

Shots fired: evaluation of vascular injury, compartment syndrome, and transfusion rates among civilian ballistic orthopaedic fracture patients presenting to two Level I trauma centres

PURPOSE

This study investigates baseline patient demographics and predictors of vascular injury, blood transfusion, and compartment syndrome in patients with orthopaedic fractures secondary to GSWs at two high-volume Level I trauma centres.

METHODS

A retrospective chart review of all GSW-related trauma patients at two Level I trauma centres between July 2019 and September 2021 was conducted. Chi-squared and two-tailed independent t tests were used for data analysis, and logistic regression with odds ratios (OR) determined predictors of primary outcomes.

RESULTS

Among 478 GSW patients, 94 (19.7%) sustained 130 orthopaedic fractures, most commonly at the lower extremity (77.7%). Orthopaedic fracture patients showed significantly higher rates of vascular injury (29.8 vs. 4.7%, p < 0.001), transfusion (27.7 vs. 12.8%, p = 0.006), and compartment syndrome (3.2 vs. 0.3%, p = 0.011) compared to non-orthopaedic injury patients. Univariable analysis identified ankle (OR = 47.50, p < 0.001) and hip/femur fractures (OR = 5.31, p < 0.001) as predictors of vascular injury. Multivariable logistic regression revealed lower extremity vascular injury (OR = 54.69, p = 0.006) and anatomic fracture sites of the humerus (OR = 15.17, p = 0.008), clavicle/scapula (OR = 11.30, p = 0.009), and acetabulum/pelvis (OR = 7.17, p = 0.025) as predictors of blood transfusion. Univariable analysis showed lower extremity vascular injury (OR = 30.14, p = 0.007) as a predictor of compartment syndrome.

CONCLUSION

These findings underscore the importance of diagnosing and managing vascular injuries and compartment syndrome in GSW-related orthopaedic fractures, emphasizing the necessity for targeted transfusion strategies in such cases.

Simultaneous Electrochemical Detection of Dopamine and Uric Acid via Au@Cu-Metal Organic Framework

The incorporation of noble metals with metal-organic frameworks (MOFs) are conducive to the simultaneous electrochemical detection of analytes owing to multiple accessible reaction sites. Herein, Au@Cu-metal organic framework (Au@Cu-MOF) is successfully synthesized and modified as a screen-printed carbon electrode (SPCE), which serves as an excellent electrocatalyst for the oxidation of dopamine (DA) and uric acid (UA). The sensor shows a linear range from 10 μM to 1000 μM, with sensitivity and detection limit of 0.231 μA μM-1  cm-2 and 3.40 μM for DA, and 0.275 μA μM-1  cm-2 and 10.36 μM for UA. Au@Cu-MOF could realize the individual and simultaneous electrochemical sensing of DA and UA, with distinguishable oxidation peak potentials. Moreover, it exhibits reproducibility, repeatability, and stability. Ultimately, the sensor provides an avenue for an ultrasensitive label-free electrochemical detection of DA and UA.

Employability characteristics and their impact on social impact: An exploratory study on women's small social enterprises

This study seeks to understand and explore how women social entrepreneurs select their employees and how this can affect their social impact. This study has two objectives. The first is to explore the most attractive employees' employability characteristics chosen by women entrepreneurs. The second objective was to explore the relationship between employability characteristics and the social impact of the social enterprises. This study used an exploratory quantitative paradigm to reach the study's findings. Multiple correspondence analysis (MCA) explores employability characteristics the women social entrepreneurs select and the relationship between the selected employability characteristics and the social impact of the women's social enterprises. The data were collected using a cross-sectional questionnaire. Data were collected from 382 employees working in 174 female social enterprises. Women social entrepreneurs were found to prefer employees with high interpersonal skills, high ethics, high physical abilities, high abilities to learn, high implicit knowledge, high reliability, and low soft skills. Linking these employability skills to social impact revealed that implicit knowledge and interpersonal skills are the most influential. A paucity of research discusses how women social entrepreneurs recruit their employees. This problem is getting worse when it comes to small social enterprises. This study led to a discussion about employability characteristics in women's social enterprises and their impact on social impact.

A review of zeolitic imidazolate frameworks (ZIFs) as electrochemical sensors for important small biomolecules in human body fluids

Small biomolecules play a critical role in the fundamental processes that sustain life and are essential for the proper functioning of the human body. The detection of small biomolecules has garnered significant interest in various fields, including disease diagnosis and medicine. Electrochemical techniques are commonly employed in the detection of critical biomolecules through the principle of redox reactions. It is also a very convenient, cheap, simple, fast, and accurate measurement method in analytical chemistry. Zeolitic imidazolate frameworks (ZIFs) are a unique type of metal-organic framework (MOF) composed of porous crystals with extended three-dimensional structures. These frameworks are made up of metal ions and imidazolate linkers, which form a highly porous and stable structure. In addition to their many advantages in other applications, ZIFs have emerged as promising candidates for electrochemical sensors. Their large surface area, pore diameter, and stability make them ideal for use in sensing applications, particularly in the detection of small molecules and ions. This review summarizes the critical role of small biomolecules in the human body, the standard features of electrochemical analysis, and the utilization of various types of ZIF materials (including carbon composites, metal-based composites, ZIF polymer materials, and ZIF-derived materials) for the detection of important small biomolecules in human body fluids. Lastly, we provide an overview of the current status, challenges, and future outlook for research on ZIF materials.

Evaluation of Phosphorus Storage and Performance of Broilers Using Phytase Synthetic Enzyme

Phytic acid is a stored form of phosphorus in cereals, 65 to 70% of phosphorus in plant sources is phytate, and broilers are only able to use part of the phosphorus in plant sources. To meet the needs of chickens, it is necessary to use other artificial resources, which not only impose part of the cost of the breeding period because of its presence in the manure but is one of the factors polluting the environment. This study aimed to use different levels of phytase enzyme to reduce dietary phosphorus levels. 600 Ross 308 broilers were used in this experiment with five treatments and six replications, and in each replication, 20 chickens were used in a completely randomized design (CRD). Experimental treatments include 1) basal diet (control) 2) basal diet with 15% less phosphorus 3) basal diet with 15% less phosphorus + 1250 (FTU) phytase enzyme 4) basal diet with 15% less phosphorus + 2500 (FTU) phytase enzyme 5) basal diet with 15% less phosphorus + 5000 (FTU) phytase enzyme. The evaluated traits included weekly feed intake, weekly weight gain, feed conversion ratio, carcass characteristics, ash, calcium, and bone phosphorus. The use of phytase enzyme in different diets had no significant effect on food intake, weight gain, and feed conversion ratio (P>0.05). However, the use of phytase in different diets significantly affected the percentage of Gizzard, Heart, Liver, Proventriculus, and Spleen (P<0.05). The most changes were the increase in the ratio of feed intake and weight gain in the fourth week compared to the third week so that the changes in the ratio of feed intake ranged from 1.85 to 1.91, and this ratio for weight gain also ranged from 3.12 to 3.86 was recorded, and the lowest feed conversion ratio was obtained at the same age. The percentage of raw ash in broiler chickens was significantly increased by adding dietary phytase. The lowest amount of ash, calcium, and phosphorus belonged to the second group (diets with low phosphorus and no enzyme). The difference between the other groups and the control was not significant. Feed intake, weight gain, and feed conversion ratio with the addition of phytase enzyme were not affected by phosphorus reduction and had no significant effect on carcass characteristics. Environmental pollution can be prevented by reducing the level of dietary phosphorus and reducing excreted phosphorus.

Potential Therapeutic Effects of Morin Hydrate in Folic Acid-Induced Acute Kidney Injury

Introduction/Objective

Acute kidney injury (AKI) causes significant morbidity and mortality and, if left unmanaged, can progress to chronic kidney disease. Despite the advances in our understanding of the pathogenesis of AKI, there are no available therapeutics to combat it effectively. Folic acid (FA)-induced AKI is a well established rat model characterized by acute renal injury due to the disturbance of the antioxidant system with subsequent renal fibrosis. Morin hydrate, a well-known bioactive flavonoid, has been proven to alleviate oxidative stress and exhibits anti- inflammatory, anti-apoptotic and neuroprotective activity.

Methods/Case Report

We investigated the potential protective and therapeutic effects of morin hydrate on FA-induced AKI. Thirty-five rats were divided randomly into 5 groups (6 rats/ group) as follows: control group received a vehicle for 10 days, FA group received a vehicle for 10 days with an intraperitoneal (IP) injection of a single dose (SD) of FA (250 mg/kg) on the 7thday, FA-Withdrawal group injected with a SD of FA (250 mg/kg IP) on the 1st day with a vehicle for 10 days, morin-pretreated group received morin hydrate (40 mg/kg orally) for 7 days, followed by a SD of FA (250 mg/kg, i.p), and morin-treated group injected with a SD of FA (250 mg/kg IP), then treated with morin hydrate (40 mg/kg orally) for 7 consecutive days. All animals were sacrificed after 10 days and then, blood samples and kidneys were collected for biochemical and histopathological examination.

Results (if a Case Study enter NA)

FA group showed extensive structural damage in renal tubules and glomeruli with no significant improvement in withdrawal and morin-pretreated groups. Morin treatment significantly attenuated histopathological changes and reduced FA-induced increase in serum creatinine, albumin and urea levels. This therapeutic role of morin was associated with suppression of inflammation, oxidative stress, and apoptosis.

Conclusion

These findings suggest that morin hydrate constitutes a potential natural therapeutic product for treating AKI.

Hydatid cyst excision using Dowling's technique of hydrodissection

BACKGROUND

Neurohydatidosis is a rare zoonotic disease in nonendemic areas and a differential diagnosis of intracerebral cysts workup. Appropriate imaging modalities with serology are required for proper diagnosis. The gold standard surgical intervention is the Dowling-Orlando technique.

METHOD

We provide a detailed description, with key surgical steps, for total excision of hydatid cysts with intact capsules by hydrodissection. We also describe the relevant surgical anatomy, with indications, limitations, and possible complications.

CONCLUSION

Hydrodissection allows safe resection of hydatid cysts without further damage to the surrounding parenchyma and reduces the risk of cystic wall rupture.

Comparative performances of soluble urokinase plasminogen activator receptor and Mid-regional proADM to predict composite death and new heart failure rehospitalisation in acutely breathless patients

Background

Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. Mid-regional pro-adrenomedullin (MR-proADM) is the stable peptide precursor of adrenomedullin, with concentrations reflective of vasodilation and cardiac remodelling. We compared the prognostic performances of suPAR and MR-proADM for the composite clinical endpoint of death and new heart failure (HF) in patients with undifferentiated breathlessness.

Methods

Patients presenting to hospital with the primary complaint of acute dyspnoea were recruited in New Zealand (n=612) and in Singapore (n=483)]. Baseline plasma measurements were undertaken for suPAR (ViroGates) and MR-proADM (Thermo Scientific). Cardiac biomarker levels of NT-proBNP (Roche) was available on all patients. Statistical assessment was made using SPSS v28 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Prognostic performance of suPAR, MR-proADM and NT-proBNP to predict the composite clinical endpoint of death/new HF at 90-days and 1-yr were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis (Z-scores) and Cox hazard regression analysis (per doubling of biomarker concentrations) after adjustment for traditional risk factors. P-value &lt;0.05 was considered statistically significant.

Results

In the entire acutely breathless cohort [median age: 65 years (IQR: 52.9–76.0), 63.1% males], 343/1095 of patients had the final adjudication of ADHF. suPAR and MR-proADM concentrations were higher with increasing age (Spearmans rho, r&gt;0.46, P&lt;0.0001), lower eGFR (r&gt;0.58, P&lt;0.0001) and in those with ADHF (r&gt;0.40, P&lt;0.0001). During the follow-up period, 122 patients were categorised with death/new HF by 90-days, rising to 281 at 1-year. suPAR and MR-proADM were able to predict death/new HF at 90-days (both ROC-AUC &gt;0.77) and at 1-year (both ROC-AUC ≥0.78) (Table 1). All markers were however less accurate in predicting this endpoint in the presence of ADHF (ROC-AUC &lt;0.71). After adjustment in Cox-regression modelling, suPAR obtained HR &gt;1.35 per doubling of suPAR concentrations (P=0.001) for outcomes at 90-days and at 1-year (Table 2), achieving the highest prognostic performance for this clinical endpoint, followed by NT-proBNP (HR &gt;1.29) (Table 2), whilst MR-proADM was not an independent predictor of death/HF in this cohort. suPAR was also an independent predictor of death/HF for patients with ADHF, obtaining HR &gt;1.35 per doubling of concentrations. Above a cut-off concentration of 3.6 ng/mL, suPAR was associated with a HR of 2.1 (95% CI: 1.55–2.91) for death/HF at 1-year for acutely dyspnoeic patients.

Conclusion

suPAR concentrations is superior than MR-proADM in predicting the clinical end-point of death/HF at 1-year in this cohort. It may aid in risk-stratification strategies for the management of acutely breathless patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Heart Foundation of New ZealandHealth Research Council of New Zealand

A copper-based metal-organic framework decorated with electrodeposited Fe2O3 nanoparticles for electrochemical nitrite sensing

An amperometric nitrite sensor is reported based on a screen-printed carbon electrode (SPCE) modified with copper(II)-benzene-1,4-dicarboxylate (Cu-BDC) frameworks and iron(III) oxide nanoparticles (Fe₂O₃ NPs). First, copper(I) oxide (Cu₂O) nanocubes were synthesized, followed by a solvothermal reaction between Cu₂O and H₂BDC to form square plate-like Cu-BDC frameworks. Then, Fe₂O₃ NPs were electrodeposited on Cu-BDC frameworks using a potentiostatic method. The Fe₂O₃@Cu-BDC nanocomposite benefits from high conductivity and large active surface area, offering excellent electrocatalytic activity for nitrite oxidation. Under optimal amperometric conditions (0.55 V vs. Ag/AgCl), the sensor has a linear range of 1 to 2000 µM with a detection limit of 0.074 µM (S/N = 3) and sensitivity of 220.59 µA mM^-1 cm^-2. The sensor also provides good selectivity and reproducibility (RSD = 1.91%, n = 5). Furthermore, the sensor exhibits long-term stability, retaining 91.4% of its original current after 4 weeks of storage at room temperature. Finally, assessing nitrite in tap and mineral water samples revealed that the Fe₂O₃@Cu-BDC/SPCE has a promising prospect in amperometric nitrite detection.

Colony-stimulating factor 3 receptor gene (CSF3R) T618I mutated chronic myelomonocytic leukemia: A proliferative subtype with a distinct mutational profile

Introduction/Objective

Chronic myelomonocytic leukemia (CMML) is a myeloid neoplasm characterized by sustained monocytosis, ranging from cytopenia with a dysplastic subtype to leukocytosis with a proliferative subtype, with a typical mutational profile involving TET2, ASXL1, and SRSF2. Mutation in colony-stimulating factor 3 receptor gene (CSF3R) is commonly associated with chronic neutrophilic leukemia (CNL) but exceedingly rare in CMML, particularly CSF3R T618I (~10 cases described, ~30 cases of CSF3R non-T618I mutations). We report a case of CSF3R T618I mutated CMML and compare the clinicopathologic features to reported CMML cases with and without CSF3R T618I mutations.

Methods/Case Report

A 27-year-old woman presented for evaluation of leukocytosis, sustained monocytosis, and anemia. Peripheral blood (PB) revealed leukocytosis (white cell count 35x109/L), left-shifted and dysplastic neutrophils (myelocytes and metamyelocytes, 5%), absolute and relative monocytosis (7x109/L, 29%), anemia (Hgb 4.3 g/dL), and thrombocytopenia. Bone marrow aspirate and core biopsy demonstrated a hypercellular marrow with increased myeloblasts (~3%, immunophenotypically aberrant by flow cytometry), increased myelomonocytic cells, and multilineage dysplasia, including ring sideroblasts and hypolobated megakaryocytes. Cytogenetic and molecular studies revealed a normal karyotype and mutations in CSF3R T618I, ASXL1, SETBP1, BCORL1, KRAS, and PTPN11. Despite the presence of a CSF3R T618I mutation, CMML was diagnosed given marked monocytosis, left- shifted neutrophils in PB, multilineage dysplasia, and immunophenotypically aberrant myeloblasts.

Results (if a Case Study enter NA)

NA

Conclusion

Our case demonstrates clinicopathological features similar to those of reported CSF3R T618I mutated CMML, i.e., a proliferative subtype and less likely to have co-occurring mutations in TET2 or SRSF2, which is distinct from CSF3R non-T618I mutated CMML; the latter often has a dysplastic subtype and mutational profile of frequent TET2 and SRSF2 mutations, similar to CSF3R unmutated CMML. While additional cases with this unusual mutation need to be studied to arrive at a more definitive conclusion, the CSF3R T618I mutation seems to define a unique proliferative subtype CMML with a distinct mutational profile.

861 Bone Protection in Neck of Femur Patients in A DGH Without A Fracture Liaison Service

Introduction

In England and Wales, there are approximately 75,000 proximal femoral fractures per year. Bone protection is vital in these patients and is a key recommendation of NICE guidelines (CG124) for multidisciplinary approach in hip fracture management.

Method

Data were collected retrospectively using clinical portal, admission records and medication charts. The data were inputted into the FRAX calculator to calculate a patient’s risk of developing an osteoporotic fracture; depending on their risk they would be appropriate for bone protection or require a DEXA scan for further assessment. As certain data criteria were not available for the FRAX calculation, risk calculation was underscored i.e., if parental hip fracture status was not known.

Results

A total of 59 patients were audited between July and October 2019. Of those patients, 25 were calculated as high risk, however, only 6 patients had adequate bone protection. 19 patients were deemed intermediate risk and would benefit from a DEXA scan for further assessment. Of those 19 patients, only 8 had adequate bone protection. DEXA scan was only requested for 2 of the patients who were intermediate/high risk. In the year following, 4 patients have had another fracture, with 3 of those patients not on any bone protection medication and had a high risk FRAX calculation.

Conclusions

Following a local meeting; a proforma has been piloted to identify patients at risk and requiring bone protection. With the help of a dedicated orthopaedic pharmacist and nurse practitioners, continuity of care can be achieved to aid a patient’s long-term wellbeing.

O59: USE OF DEXTRAN 40 FOLLOWING PANCREAS TRANSPLANT MAY REDUCE EARLY INFLAMMATION AND SIGNIFICANT BLEEDING COMPARED TO A HEPARIN-BASED PROTOCOL

Introduction

Dextran 40 (D40) is a synthetic colloid with anticoagulant properties, which is commonly used instead of heparin following pancreas transplantation, however there is a lack of evidence over which is more effective. Graft thrombosis and pancreatitis, which may be mediated through micro or macrothrombosis within the graft, remain significant complications following pancreas transplantation. We hypothesised that D40 reduces inflammation through its antithrombotic pro-microcirculatory effects. We aimed to evaluate D40 compared to a heparin-based protocol by comparing post-operative complications and post-transplant levels of inflammation.

Method

Data were collected retrospectively for pancreas transplant patients between December 2009 and August 2018 – 26 patients had been treated with the pre-Dextran protocol and 37 had received D40. Post-operative complications and inflammatory markers (WCC, CRP and amylase) on post-operative days 1, 2, 3 and 7 were compared between the two groups. Potential confounders were also recorded.

Result

Patients in the D40 group had similar thrombosis rates but were less likely to have had substantial post-operative bleeding compared to the heparin-based protocol. The group who received D40 had significantly lower CRP and WCC on days 2, 3 and 7. The differences on days 3 and 7 remained when the results were adjusted for the significant confounders - cold ischaemic time and donor age.

Conclusion

D40 appears to be as effective as IV heparin at preventing graft thrombosis following pancreas transplant, and to confer a reduced risk of bleeding. It may also reduce post-operative inflammatory processes, leading to reduced graft pancreatitis.

Take-home message

Using Dextran 40 as an anticoagulant after pancreas transplantation is as effective as IV heparin at preventing graft thromboses and has a reduced risk of bleeding.

O67: PERFUSATE GLUCOSE REFLECTS TISSUE GLYCOGENATION DURING LIVER PERFUSION

Introduction

Normothermic machine perfusion (NMP) is a method of organ preservation that aims to replicate the physiological environment, achieved by perfusing the livers with a blood-based perfusate at physiological inflow pressures and temperature. NMP also permits viability assessment through evaluation of the perfusate flow rates through the portal vein and hepatic artery. In addition to this, biochemical assessment and perfusate gas analysis can be performed to provide insights into the metabolic activity of the liver.

Method

Discarded human liver grafts (n=6), were perfused for 24 hours. Core biopsies and perfusate samples were taken from each liver at 5 distinct time intervals over 24 hours. Core biopsies were fixed and stained with periodic acid-Schiff and analysed with Leica software to provide a quantitative estimate of the hepatocellular glycogen content.

Result

Hepatic glycogen concentration rose during the first hour, followed by a steady decline thereafter until the end of perfusion. Contrary to our initial hypothesis that glucose concentration within the circuit would show an inverse relationship to glycogen stores in the liver cells, we found that glucose concentration closely followed the same trend.

Conclusion

Change in hepatocyte glycogen content provides an important insight into the synthetic function of a liver destined for transplant. Our research suggests that glucose concentration can be used as a surrogate marker for the synthetic function of a liver on NMP and provides valuable information on the glycogen-synthesising capability of the hepatocytes. In future, this could potentially aid the decision-making process with regards to liver graft transplant viability.

Take-home message

Perfusate glucose concentration could provide an insight into the viability of liver transplants

GSK3β: A plausible molecular target in the cytokinemodulating effect of exogenous insulin in a murine model of malarial infection

Malaria is a life-threatening disease caused by the Plasmodium sp. parasite. Infection results in heightened pro-inflammatory response which contributes to the pathophysiology of the disease. To mitigate the overwhelming cytokine response, host-directed therapy is a plausible approach. Glycogen synthase kinase-3β (GSK3β), a serine/threonine kinase plays a pivotal role in the regulation of inflammatory response during pathogenic infections. The present study was conducted to investigate the chemo-suppressive and cytokine-modulating effects of insulin administration in malaria-infected mice and the involvement of GSK3β. Intraperitoneal administrations of 0.3 and 0.5 U/kg body weight insulin each for four consecutive days into Plasmodium berghei NK65 (PbN)-infected mice resulted in chemo-suppression exceeding 60% and improved median survival time of infected mice (20.5 days and 19 days respectively compared to 15.5 days for non-treated control). Western analysis revealed that pGSK3β (Ser9) intensity in brain samples from insulin-treated (0.3 and 0.5 U/kg body weight) infected mice each were 0.6 and 2.2 times respectively than that in control. In liver samples, pGSK3β (Ser9) intensity from insulin-treated infected mice were significantly higher (4.8 and 16.1 fold for 0.3 and 0.5 U/kg bw respectively) than that in control. Insulin administration decreased both brain and liver pNF-κB p65 (Ser536) intensities (to 0.8 and 0.6 times for 0.3 U/kg bw insulin; and to 0.2 and 0.1 times for 0.5 U/kg bw insulin respectively compared to control). Insulin treatment (0.5 U/kg bw) also significantly decreased the serum levels of pro-inflammatory cytokines (TNF-α (3.3 times) and IFN-γ (4.9 times)) whilst significantly increasing the levels of anti-inflammatory cytokines (IL-4 (4.9 fold) and IL-10 (2.1 fold)) in PbN-infected mice. Results from this study demonstrated that the cytokinemodulating effects of insulin at least in part involve inhibition of GSK3β and consequent inhibition of the activation of NF-κB p65 suggesting insulin as a potential adjunctive therapeutic for malaria.

Prognostic performance of soluble urokinase plasminogen activator receptor for 1-year mortality in Asian and Western patients with acute breathlessness

Background

Soluble urokinase plasminogen activator receptor (suPAR) is a pleotropic receptor, capable of orchestrating plaque vulnerability and vascular immune dysfunction. We have previously reported on the prognostic ability of suPAR in cardiovascular disease (CVD). However the performance of suPAR to predict death in an Asian population with undifferentiated breathlessness has not been described.

Methods

Patients presenting to hospital with the primary complaint of breathlessness were recruited according to identical criteria in New Zealand [(NZ), n=612] and in Singapore (n=483)]. Baseline measurements of suPAR plasma concentrations were undertaken with a CE-marked ELISA (ViroGates). NT-proBNP, hsTnT (both Roche) and standard biochemistry analytes were also measured. Statistical assessment was made using SPSS v25 (IBM), with all biomarkers treated as continuous variables and presented as median [interquartile range (IQR)]. Group comparisons were made by Mann-Whitney U test. Prognostic performance of suPAR, NT-proBNP and hsTnT for 1-yr mortality prediction was assessed using receiver operator curve (ROC) area under the curve (AUC) analysis (Z-scores) and Cox hazard regression analysis (log-values). P-value &lt;0.05 was considered significant.

Results

The adjudicated diagnosis of ADHF was more common in NZ than in Singapore (37 vs. 25%, P&lt;0.0001) in concordance with the higher median age (16 yrs older) of NZ patients and poorer kidney function. Diabetes was however more prevalent amongst Singaporean patients. There were a total of 143 deaths [NZ, n=113 (18%); Singapore, n=30 (6%)] within 1 year from hospital admission. In both cohorts, median suPAR concentrations were higher in those who died vs those who survived (P&lt;0.0001) (Figure). For the Singapore cohort, suPAR (AUC=0.85) discriminated 1-yr mortality better than hs-TnT (AUC=0.78) and NT-proBNP (AUC=0.79). For the NZ cohort, suPAR (AUC=0.71) was similar to hs-TnT (AUC=0.73) and NT-proBNP (AUC=0.69) for 1-yr death prediction. In the combined cohort, after the adjustment of conventional risk factors, suPAR (P=0.007) was the superior biomarker for 1-year death prediction in the subgroup of ADHF patients only (n=51/343). suPAR concentrations above a cut-off value of 3.1 ng/mL, were associated with hazard ratios of 7.4 (95% CI:1.6–17.4) (P=0.009) for Singapore patients and 2.8 (95% CI:1.5–5.3) (P=0.001) for NZ patients for death within 1 year.

Conclusion

This is a first report confirming the strong prognostic ability of suPAR in mortality prediction for acutely breathless patients in an Asian population despite the presence of several demographic and clinical differences compared to a Western population. The inclusion of suPAR may add value to risk stratification models in acutely dyspnoeic patients.

suPAR concentrations in 1-yr outcomes

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Health Research Council of New Zealand, National Heart Foundation of New Zealand

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Implant cut-out following cephalomedullary nailing of intertrochanteric femur fractures: Are helical blades to blame?

INTRODUCTION

Implant cut-out remains a common cause of cephalomedullary nail (CMN) failure and patient morbidity following surgical treatment of intertrochanteric femur fractures. Recent studies have suggested an increased rate of CMN cut-out with helical blades as opposed to lag screws. We compared rates of overall cut-out between helical blades and lag screws and used bivariate and multivariate analysis to determine the role of proximal fixation method among other variables on risk for cut-out. Subgroup analysis was performed on the basis of failure mechanism; superior migration (Fig. 2) versus medial perforation (Fig. 3).

METHODS

Three-hundred and thirteen patient charts were retrospectively reviewed over an 8-year period; 245 patients were treated with helical blades and 68 with lag screws. Radiographs were reviewed for fracture pattern, Tip-Apex Distance (TAD), Parker's Ratio (PR) and reduction quality. Rate of implant cut-out was compared between groups and multiple logistic regression was used to analyze the ability of several independent variables to predict implant cut-out.

RESULTS

Twenty cut-outs occurred; 15 with helical blades and 5 with lag screws. No difference in the rate of cut-out was observed between the two groups (p = 0.45). Poor fracture reduction was found to be a significant predictor of implant failure via bivariate and multiple logistic regression analysis (p = <0.01, OR 23.573). Helical blade fixation, fracture instability, TAD ≥ 25, and PR ≥ 0.45 were not predictive of implant cut-out during multivariate analysis. Similarly, patient smoking status and surgeon trauma fellowship training did not significantly increase the odds of implant cut-out. Failure by medial perforation occurred in 12 instances, all involving helical blades. Failure by superior migration occurred at a significantly higher rate with lag screws than helical blades (p = 0.02).

CONCLUSION

CMN cutout is likely multifactorial. A direct association between helical blade fixation and implant cut-out was not observed in our study. Amongst modifiable risk factors for implant failure, poorer fracture reduction was predictive of failure by cut-out. Subgroup analysis highlights differing modes of failure between lag screws and helical blades which warrants further investigation. Ideal TAD during helical blade fixation remains unknown.

ABO-Incompatible Kidney Transplantation: Low Rates of Infectious Complications and Excellent Patient Survival

BACKGROUND

A significant gap exists between demand and supply of organs for patients with end-stage renal disease. To increase the donor pool, kidney transplantation is performed across ABO- and HLA-incompatible barriers. ABO-incompatible kidney transplant (ABOi-KT) recipients are at increased risk of antibody-mediated rejection, infection, and mortality. Hypogammaglobulinemia secondary to immunosuppression is highly prevalent after solid organ transplantation, and intravenous immunoglobulin (IVIG) has been reported to reduce the risks of infections in various settings. We use high-dose IVIG in ABOi-KT recipients perioperatively. We aimed to determine the rate of infectious complications along with graft and patient survival in our ABOi-KT recipients.

METHODS

We included all adult patients who underwent ABOi-KT from the year 2007 to 2016. Patients received rituximab, plasma exchange, and IVIG (2 g/kg body weight). Thymoglobulin and intravenous methylprednisolone were used as induction treatment. Oral prednisone, mycophenolate mofetil, and tacrolimus were used as maintenance therapy.

RESULTS

A total of 77 ABOi-KTs were performed, and the recipients were followed up for a median of 1557 days. Two patients were diagnosed as having BK nephropathy. No patients were diagnosed as having pneumocystis infection, cytomegalovirus disease, herpes simplex, varicella zoster, or fungal infection. One-year graft and patient survival was 94.8% and 100%, respectively.

CONCLUSIONS

In our series of ABOi-KTs, we observed a low risk of infectious complications and excellent patient survival. High-dose IVIG might have reduced infections.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Image Possibilities of the Peripheral Nerve Tumor Using Magnetic Resonance Imaging - Case Report

Magnetic resonance imaging (MRI) plays a crucial role in the diagnosis and morphological analysis of peripheral nerve tumours (PNTs). In recent years, a number of novel MRI sequences such as MR neurography (MRN), diffusion tensor imaging (DTI) or MR tractography (MRT) have emerged extending the range of conventional MRI techniques. These advanced sequences are able to provide detailed information concerning PNTs structure, including the course and function of individual neural fascicles. This data can then be utilized in tailoring a suitable surgical procedure, reducing the risks of postoperative neurological deficit. The following case report of a median nerve tumour demonstrates the range and practicality of current MRI techniques. With continuing advancement and perfection of these MRI techniques, we can expect their integration into standard diagnostic protocols of PNTs.

Prevalence of physical activity and sedentary-related behaviors among adolescents: data from the Qatar National School Survey

OBJECTIVES

To investigate the prevalence of physical activity (PA) and sedentary behaviors among adolescents in Qatar by selected demographic characteristics.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 5862 students (2938 boys and 2924 girls) in the age group 12-17 years were included in the analyses. PA and sedentary-related measures were obtained from the self-reported survey questions.

RESULTS

Only 35.4% of students were performing 60 min of PA ≥3 days/week. The proportion of students with >2 hr screentime ranged from 43% to 57% (weekdays) and 50% to 62.5% (weekends). Girls had less odds of being physically active than the boys (odds ratio [OR] = 0.61, P < 0.001). Qatari students were less likely to be physically active than non-Qataris (OR = 0.79, P < 0.001). Age was inversely correlated with PA ([r = -0.113, P < 0.001 for participation with sports team] and [r = -0.139, P < 0.001 for school physical education classes]). Participation in sports teams positively correlated with 60 min of PA number of days in a week (r = 0.317, P < 0.001).

CONCLUSIONS

The study describes insufficient PA among youth as a public health issue of concern in the State of Qatar that requires multipronged health promotion initiatives.

From ICU to Emergency Department: 9-Year Experience with Non-Invasive Ventilation for COPD

Introduction

Non-invasive ventilation (NIV) has been shown to be beneficial for chronic obstructive pulmonary disease (COPD) patients with persistent respiratory acidosis during acute exacerbations. This clinical study described the experience of implementing an NIV program in the emergency department for COPD patients.

Methods

In the pre-implementation phase, patients who presented to the emergency department were transferred to the intensive care unit for NIV. Following the NIV program, patients had NIV commenced in the emergency department. We reported the change in hospital outcomes pre and post-implementation.

Results

A total of 153 patients received NIV, 34 in the pre-implementation phase and 119 patients in the post-implementation phase. The mean pH was 7.22±0.07 and the Acute Physiology and Chronic Health Evaluation (APACHE) II score was 18.9±4. Hospital mortality was lower in the post-implementation phase (1.7% versus 11.8%; p=0.008). The median door-to-NIV time was shorter in the post-implementation phase (64 minutes; interquartile range [IQR] 35-113) versus (457 minutes; IQR 143-1320).

Conclusions

NIV program in the emergency department is feasible and is associated with better hospital outcomes in patients with COPD. (Hong Kong j.emerg.med. 2014;21:140-147)

Biglycan and Decorin Expression and Distribution in Palatal Adhesion

Previous studies demonstrated that chondroitin sulfate proteoglycans (CSPGs) on apical surfaces of palatal medial edge epithelial (MEE) cells were necessary for palatal adhesion. In this study, we identified 2 proteoglycans, biglycan and decorin, that were expressed in the palatal shelves prior to adhesion. In addition, we established that these proteoglycans were dependent on transforming growth factor β (TGFβ) signaling. Laser capture microdissection was used to collect selected palatal epithelial cells from embryonic mouse embryos at various palate development stages. The expression of specific messenger RNA (mRNA) for biglycan and decorin was determined with quantitative real-time polymerase chain reaction. The TGFβrI kinase inhibitor (SB431542) was used in palatal organ cultures to determine if blocking TFGβ signaling changed biglycan and decorin distribution. Immunohistochemistry of both biglycan and decorin revealed expression on the apical and lateral surfaces of MEE cells. Biglycan protein and mRNA levels peaked as the palatal shelves adhered. Decorin was less abundant on the apical epithelial surface and also had reduced mRNA levels compared to biglycan. Their proteins were not expressed on MEE cells of palates treated with SB431542, an inhibitor of TGFβ signaling. The temporal expression of biglycan and decorin on the apical surface of MEE, combined with the evidence that these proteins were regulated through the TGFβ pathway, indicated that they may be important for adhesion.

An unusual cause of food-induced anaphylaxis in mothers

BACKGROUND

Galacto-oligosaccharides (GOS) are prebiotics added to commercial milk formula of infants and mothers. In recent years, cases of allergy related to GOS in atopic children have been reported in the South East Asian region.

CASE PRESENTATIONS

We describe a series of pregnant (n = 4) and lactating mothers (n = 2) who developed anaphylactic reactions after consumption of maternal milk formula containing GOS. All six subjects had pre-existing atopy and a positive skin prick test to GOS and 5/5 of the subjects who were tested had positive basophil activation tests to GOS. All of the mothers and their babies had normal neonatal outcomes after the reactions.

CONCLUSIONS

The supplementation of GOS into milk and beverages in the Asian region should take into account the rare chance of allergenicity of GOS in the atopic population.

Cadmium Sulphide-Reduced Graphene Oxide-Modified Photoelectrode-Based Photoelectrochemical Sensing Platform for Copper(II) Ions

A photoelectrochemical (PEC) sensor with excellent sensitivity and detection toward copper (II) ions (Cu²⁺) was developed using a cadmium sulphide-reduced graphene oxide (CdS-rGO) nanocomposite on an indium tin oxide (ITO) surface, with triethanolamine (TEA) used as the sacrificial electron donor. The CdS nanoparticles were initially synthesized via the aerosol-assisted chemical vapor deposition (AACVD) method using cadmium acetate and thiourea as the precursors to Cd²⁺ and S^2-, respectively. Graphene oxide (GO) was then dip-coated onto the CdS electrode and sintered under an argon gas flow (50 mL/min) for the reduction process. The nanostructured CdS was adhered securely to the ITO by a continuous network of rGO that also acted as an avenue to intensify the transfer of electrons from the conduction band of CdS. The photoelectrochemical results indicated that the ITO/CdS-rGO photoelectrode could facilitate broad UV-visible light absorption, which would lead to a higher and steady-state photocurrent response in the presence of TEA in 0.1 M KCl. The photocurrent decreased with an increase in the concentration of Cu²⁺ ions. The photoelectrode response for Cu²⁺ ion detection had a linear range of 0.5–120 μM, with a limit of detection (LoD) of 16 nM. The proposed PEC sensor displayed ultra-sensitivity and good selectivity toward Cu²⁺ ion detection.

Is arterial base deficit still a useful prognostic marker in trauma? A systematic review

BACKGROUND

Arterial base deficit (BD) has been widely used in trauma patients since 1960. However, trauma management has also evolved significantly in the last 2 decades. The first objective of this study was to systematically review the literature on the relationship between arterial BD as a prognostic marker for trauma outcomes (mortality, significant injuries, and major complications) in the acute setting. The second objective was to evaluate arterial BD as a prognosis marker, specifically, in the elderly and in patients with positive blood alcohol levels.

METHODS

MEDLINE, EMBASE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched from January 1, 1990, to August 6, 2015. Bibliographies of articles were also hand searched for relevant citations.

RESULTS

Thirty-four studies were included in this review. The studies consistently showed that a higher arterial BD was associated with increased mortality, significant injuries, and major complications. The threshold BD value of 6 mmol/L was also useful in discriminating for poorer outcomes. The presence of alcohol did not affect the ability of arterial BD to discriminate between major and minor injuries. Elderly patients had higher mortality in all arterial BD categories compared to the younger age group.

CONCLUSIONS

Despite the advances in trauma care in the last 2 decades, arterial BD remains a useful prognostic marker in trauma patients, even in elderly patients and in patients who had consumed alcohol. The threshold BD value of 6 mmol/L was useful to prognosticate poorer outcomes.

Primary Lymphoma of Bone Complicating Total Knee Arthroplasty: An Unexpected Mode of Prosthesis Failure: A Case Report

CASE

Primary lymphoma of bone is a rare musculoskeletal malignancy that typically arises in long bones. Few cases of bone lymphoma occurring alongside orthopaedic implants have been reported in the literature. We describe the complex case of a seventy-eight-year-old woman who developed diffuse large B-cell lymphoma of the proximal part of the tibia five years after a successful total knee arthroplasty.

CONCLUSION

Several studies have suggested a link between orthopaedic implants and genomic instability, although true carcinogenesis remains questionable. Lymphoma complicating joint arthroplasty poses a unique problem for orthopaedic physicians due to diagnostic challenges and the unique implications of disease and treatment-related complications.