Providing environmentally sustainable nephrology care: focus in low- and middle-income countries

Health care on a global scale significantly contributes to carbon emissions, with high-income countries being the primary culprits. Within health care, dialysis plays a significant role as a major source of emissions. Low- and middle-income countries have a high burden of kidney disease and are facing an increasing demand for dialysis. This reality presents multiple opportunities to plan for environmentally sustainable and quality kidney care. By placing a stronger emphasis on primary and secondary prevention of kidney disease and its progression, within the framework of universal health coverage, as well as empowering patients to enhance self-care, we can significantly reduce the need for costly and environmentally detrimental kidney replacement therapy. Mandating the adoption of lean and innovative low-carbon dialysis practices while also promoting the growth of kidney transplantation would enable low- and middle-income countries to take the lead in implementing environmentally friendly nephrology practices and reducing costs, thus optimizing sustainability and the well-being of individuals living with kidney disease.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

POS0462 HYDROXYCHLOROQUINE REDUCES THE TITERS OF ANTI-DOMAIN 1 ANTIBODIES OVER TIME IN PATIENTS WITH PERSISTENTLY POSITIVE ANTIPHOSPHOLIPID ANTIBODIES: RESULTS FROM THE APS ACTION CLINICAL DATABASE AND REPOSITORY (“REGISTRY”)

Background

Data on fluctuation of antibodies directed against domain 1 (anti-D1) of β2-glycoprotein I (β2GPI) are scarce. Patients with antiphospholipid syndrome (APS) and all three criteria tests for antiphospholipid antibodies (aPL) display higher titers of anti-D1, which correlate with anti-β2GPI levels.

Objectives

This project aims at evaluating predictors of the variation of anti-D1 titers over time in a large international cohort of persistently aPL positive patients.

Methods

AntiPhospholipid Syndrome Alliance For Clinical Trials and InternatiOnal Networking (APS ACTION) Registry was created to study the course of persistently aPL-positive patients with or without autoimmune disorders over at least 10 years. Inclusion criteria are positive aPL by Updated Sapporo Criteria tested within one year prior to enrolment. Patients are followed every 12±3 months with clinical data and blood collection. Patients with available blood samples from at least three time points were included in this analysis. Anti-β2GPI and anti-D1 IgG were tested by chemiluminescence (BioFlash, Werfen) at APS ACTION core laboratories. Positive results were defined as >20 CU, according to the manufacturer. Clinical data were retrieved from APS ACTION online database. Anti-D1 titers within the same subject were compared by Friedman’s test. A mixed linear model was built to identify predictors of the fluctuation of anti-D1 antibody titers over time.

Results

In this longitudinal study, 230 patients with anti-D1 tested at 4 time points were included (Table 1). Patients with thrombotic APS had anti-D1 titers significantly higher than those without thrombosis (p=0.022). Among 135 patients with at least one anti-D1 positive result, anti-D1 titers varied significantly over time (Friedman statistics: 508.5, p<0.0001; anti-D1 geometric mean at baseline 189.0; T1 132.3 [-15%]; T2 113.8 [-17%]; T3 109.2 [-6% versus T2, -38% versus T1]). Anti-D1 titers were significantly higher at baseline compared to T3 (p=0.029). In the 4 years of follow-up, 18 new thrombotic events occurred. Patients with double/triple aPL positivity displayed 12.5 fold increase [95%CI 7.4-20.0] in baseline anti-D1 titers. After adjustment for age, gender and number of positive aPL tests, the fluctuation of anti-D1 titers was associated with treatment with hydroxychloroquine (HCQ) at each time-point. In particular, treatment with HCQ, but not those with conventional immunosuppressors, was associated with a 1.3-fold decrease in anti-D1 titers [95%CI 1.1-1.5]. In the same multivariable model, incident vascular events were associated with a 1.5 fold increase of anti-D1 titers. A concomitant diagnosis of systemic lupus erythematosus did not affect the fluctuation of anti-D1 titers.

Table 1.

Demographic and Clinical Characteristics of 230 APS ACTION Registry Patients with anti-D1 tested ≥3 time points during the follow-up

Anti-D1 pos samplesAnti-D1 neg samplesp-valueOverall sample(n=135)(n=95)(n=230)Age [years] mean (SD)42.3 (11.8)48.8 (13.0)0.000145.0 (12.7)%Female (n)71.9 (97)65.3 (62)0.35869.1 (159)Associated systemic autoimmune disease39.3 (53)44.2 (42)0.53941.3 (95)aPL without APS19.3 (26)34.7 (33)0.01025.7 (59)Thrombotic APS54.1 (73)53.7 (51)53.9 (124)Obstetric APS11.9 (16)5.3 (5)9.1 (21)Thrombotic/+obstetric APS14.8 (20)6.3 (6)11.3 (26)aCL IgG89.5 (119/133)25.5 (24/94)<0.000163.0 (143/227)aCL, IgM36.1 (48/133)27.7 (26/94)0.23432.6 (74/227)Anti-2GPI, IgG93.2 (124/133)39.4 (37/94)<0.000170.9 (161/227)Anti-2GPI, IgM34.6 (46/133)21.3 (20/94)0.04329.1 (66/227)LA82.8 (82/99)59.5 (44/74)0.00172.8 (126/173)

Conclusion

Treatment with HCQ and vascular events during follow-up were identified as significant predictors of the fluctuation of anti-D1 antibody titers over time.

Disclosure of Interests

None declared.

Robust but weak winter atmospheric circulation response to future Arctic sea ice loss

The possibility that Arctic sea ice loss weakens mid-latitude westerlies, promoting more severe cold winters, has sparked more than a decade of scientific debate, with apparent support from observations but inconclusive modelling evidence. Here we show that sixteen models contributing to the Polar Amplification Model Intercomparison Project simulate a weakening of mid-latitude westerlies in response to projected Arctic sea ice loss. We develop an emergent constraint based on eddy feedback, which is 1.2 to 3 times too weak in the models, suggesting that the real-world weakening lies towards the higher end of the model simulations. Still, the modelled response to Arctic sea ice loss is weak: the North Atlantic Oscillation response is similar in magnitude and offsets the projected response to increased greenhouse gases, but would only account for around 10% of variations in individual years. We further find that relationships between Arctic sea ice and atmospheric circulation have weakened recently in observations and are no longer inconsistent with those in models.

Core surgical field camps: a new deanery-based model for enhancing advanced skills in core surgical trainees through simulation

Hands-on wet lab simulation training is a vital part of modern surgical training. Since 2010, surgical 'boot camps' have been run by many UK deaneries to teach core surgical trainees basic entry level skills. Training in advanced skills often requires attendance at national fee-paying courses. In the Wessex Deanery, multiple, free of charge, core surgical 'field camps' were developed to provide more advanced level teaching in the particular specialty preference of each core surgical trainee. After the COVID-19 pandemic, national hands-on courses will be challenging to provide and deanery-based advanced skills training may be the way forward for craft-based specialties. The experiences over 2 years of delivering the Wessex core surgical field camps are shared, giving a guide and advice for other trainers on how to run a field camp.

Developing a comprehensive database with sensitive health information: A profile of people living with HIV in Newfoundland and Labrador, Canada

Introduction

Developing a comprehensive cohort of people living with HIV (PLHIV) to help improve healthcare has long been the vision of researchers, clinicians and decision makers. The development of this kind of database is challenging and requires strict adherence to privacy and confidentiality policies. We explored procedures, activities and events in database development.

Objectives

To understand processes of developing a database with sensitive health information in Newfoundland and Labrador (NL), and to investigate procedures and activities to develop the database within its environmental context.

Methods

A narrative case study was used to explain the challenges and procedures involved in developing a database for our population. The development of the PLHIV cohort in NL is provided as an example to demonstrate the complexity of the process. We linked three datasets that included patient-level data for PLHIV: 1. laboratory data; 2. HIV clinic data; 3. health administrative data, which allowed for the creation of a large database containing many variables describing the PLHIV cohort in the province.

Results

We developed a de-identified cohort of 251 PLHIV that contained 178 variables. Our case study showed database development is an iterative process. The main challenges were ensuring patient privacy and data confidentiality are not compromised and working with multi-custodian data. These challenges were addressed by establishing a data governance team.

Conclusions

It is important that policy be implemented to merge siloed data sources in order to provide researchers with accurate and complete data that is required to conduct sound and precise research with maximum benefits for treatment and policy-making to improve health outcomes.

41 Using Patient Centred Care to Redesign Integrated Discharge Services in Derby

Background

Discharge to Assess as outlined by the Department of Health was adopted in Derby in 2016. Previously the discharge pathways to community settings from the acute trust were complex. Challenges included: Operating from a traditional residential care home.No integration of community health staff and social care teams leading to delays in treatment and decision making as well as multiple referrals and hand-overs and no joint communication which was confusing for patients.Stakeholder anticipation of 6 weeks length of stay.Limited responsiveness to capacity demand within planned and unplanned community physiotherapy.Changing the culture and mind-set of staff.Different health and social care processes and procedures, IT systems, working patterns, contracts and pay scales.

Methods

A new service model, joint processes and standard operating procedures was developed with the patient at the centre of the design. Trusted assessment and information sharing reduce multiple assessments and hand overs, ensuring a smoother and improved patient experience.

Outcomes

Triage of patients from the Integrated Discharge Hub to the appropriate pathway, early discharge planning, board rounds and MDT's and timely assessments combined with an enablement ethos have increased the flow of patients through the service, decreased care package hours and increased capacity through reducing both length of stay and delayed transfers of care. The health and social care teams are now delivering fully integrated care and undertaking joint training. This has led to a reduction in treatment times from 20 days to 12 days, reductions in DTOC to average of 8 days per month and improved access to community based routine therapy from 85% of referrals being seen by 6 weeks 2017-18 to 99% in 2018-19.

Conclusions

The integrated service delivers more for less resulting in significant savings in the healthcare and social care system while maintaining quality standards and outcomes.

B-66 The Effect of Bilingualism on Boston Naming Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

The Boston Naming Test (BNT) is a lexical-retrieval task. It has been documented that those with a history of traumatic brain injury (TBI) have reduced performance on the BNT. Bilingualism is also known to impact BNT performances. We examined the relationship of TBI and bilingualism/monolingualism on BNT performances.

Method

The sample (N = 95) consisted of 36 healthy controls (19 bilingual; 17 monolingual), 32 acute TBI participants (12 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. All participants passed performance validity testing. A 3X2 ANOVA was conducted to determine the effect of TBI and bilingualism/monolingualism on BNT performance.

Results

A main effect was found for group (i.e., control, 6 month TBI, and 12 month TBI), p < .001, ηp² = .21. Pairwise comparisons revealed that acute TBI participants performed worse than the control and chronic TBI groups. A main effect for bilingualism/ monolingualism was found, p < .001, ηp² = .14; monolinguals performed better on the BNT. No interactions were found between TBI and bilingualism/monolingualism.

Conclusions

BNT performance improves overtime in TBI and the pattern of improvement post-TBI is not statistically different between bilingual/monolingual groups. Relative to monolinguals, bilingual participants demonstrated worse BNT performance.

B-71 The Effect of Bilingualism on Verbal and Design Fluency Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) impacts neurocognitive function. Language is also known to influence test performances. We examined the relationship between TBI and monolingualism/bilingualism on verbal and design fluency tests.

Method

The sample (N = 74) consisted of 33 healthy controls (18 bilingual; 15 monolingual), 15 acute TBI participants (6 bilingual; 9 monolingual), and 26 chronic TBI participants (15 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. The Delis-Kaplan Executive Function System Letter Fluency (DKEFS-LF), Category Fluency (DKEFS-CF), Category Switching Fluency (DKEFS-CSF), and global verbal fluency composite (DKEFS-GVF) scores assessed verbal fluency; DKEFS fill-dots (DKEFS-FD), empty dots (DFEFS-ED), dot switching (DKEFS-DS), and global design fluency composite (DKEFS-GDF) scores assessed design fluency; and global verbal and non-verbal fluency composite (DKEFS-GF) assessed overall fluency. 3X2 ANOVAs were conducted to evaluate the effect of monolingualism/bilingualism on fluency performance in TBI and controls.

Results

The groups (control and TBI groups) differed for DKEFS-LF, p = .048, ηp² = .09, DKEFS-CF, p = .000, ηp² = .21, DKEFS-GVF, p = .004, ηp² = .15, DKEFS-ED, p = .008, ηp² = .13, DKEFS-GF, p = .001, ηp² = .20, with controls outperforming TBI groups on the DKEFS-CF, DKEFS-GVF, and DKEFS-GF. Furthermore, controls outperformed acute TBI participants on the DKEFS-LF and DKEFS-ED. Main effects were found for bilingualism/monolingualism on DKEFS-CF, p = .035, ηp² = .06, with bilinguals outperforming monolinguals. No interactions were found.

Conclusion

The TBI group had poor verbal and design fluency in contrast controls. Unexpectedly, bilinguals outperformed monolinguals on a task of verbal category fluency. Revealing that in the present study bilinguals have better semantic verbal fluency abilities.

A-01 Age of Immigration and Test Performance for Immigrant Spanish-speakers on Córdoba Naming Test

Objective

This study examines the correlation between age of immigration for Spanish speakers in the USA and their performance on the Córdoba Naming Test (CNT), a confrontation naming test designed to be multicultural. We predicted that those who immigrated at a later age, whom we expect to have more years of education in their native language, will perform better on the CNT.

Method

The study used the CNT with a sample of 44 Spanish-speakers from the United States. We worked with participants with no prior history of medical complications, such as damage to the central nervous system, drug use, or excessive alcohol use. 21 male and 23 female participants were recruited. The age of participants ranged from 20 to 89 years old and education ranged from 0 to 22 years of schooling (either in the United States or in their native country). The variables of focus are the age of immigration into the United States (when participants migrated into the US) and their test performance on the CNT (total score of correct responses).

Results

Our results indicate a statistically significant positive correlation between age of immigration and performance on the CNT, (r(44)) = .357, p = .019). Conclusions: The overall trend of the data suggested that older age at immigration was indeed associated with better performance on the CNT, thus highlighting the importance of language and acculturation issues when being assessed with neuropsychological or cognitive testing.

Conclusions

The overall trend of the data suggested that older age at immigration was indeed associated with better performance on the CNT, thus highlighting the importance of language and acculturation issues when being assessed with neuropsychological or cognitive testing.

B-69 The Effect of Bilingualism on Symbol Digit Modalities Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) survivors exhibit cognitive deficits. Language factors can also influence neurocognitive performance. We examined the effects of TBI and bilingualism/monolingualism on a test of attention and cognitive speed (i.e., Symbol Digit Modalities Test; SDMT).

Method

The sample (N = 98) consisted of 37 controls (19 bilingual; 18 monolingual), 34 acute TBI participants (12 bilingual; 22 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury; chronic TBI participants were tested 12 months or more post-injury. All participants passed performance validity testing. 3X2 ANOVAs were conducted to determine the effect of TBI and language on SDMT written and oral performance.

Results

A main effect was found between groups (control and TBI groups) on SDMT written, p < .001, ηp² = .19 and SDMT oral p < .001, ηp² = .16. Pairwise comparisons revealed a difference between the control group and TBI groups, with TBI groups performing worse. A main effect for bilingualism/monolingualism was not found; interaction effects emerged between TBI and bilingualism/monolingualism on SDMT written, p < .05, ηp² = .07 and SDMT oral p < .05, ηp² = .07.

Conclusion

TBI groups performed worse than controls on the SDMT. Relative to monolinguals with TBI, our findings suggest better cognitive recovery of verbal attention and cognitive speed in bilingual TBI participants.

B-68 The Effect of Bilingualism on Stroop Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) affects neurocognition. Speaking multiple languages can also influence cognitive test performances. We examined the relationship between TBI and monolingualism/bilingualism on a task of attention and response inhibition (Stroop Color Word Test; SCWT).

Method

The sample (N = 96) consisted of 37 healthy controls (19 bilingual; 18 monolingual), 32 acute TBI participants (12 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. The SCWT included the word (SCWT-W), color (SCWT-C), and color-word interference (SCWT-I) conditions. All participants passed performance validity testing. 3X2 ANOVAs were conducted to examine the relationship between TBI and monolingualism/bilingualism on SCWT performances.

Results

Group effects (control and TBI groups) were found for all Stroop measures. We found main effects of TBI on SCWT-W, p = .013, ηp² = .09, SCWT-C, p = .001, ηp² = .14, and SCWT-I, p = .022, ηp² = .08, with the controls outperforming acute TBI survivors on SCWT-I, chronic TBI survivors on SCWT-W, and both TBI groups on SCWT-C. We also observed main effects of language for SCWT-C, p = .012, ηp² = .07, and SCWT-I, p = .003, ηp² = .09, with the monolinguals outperforming bilinguals on SCWT-C and SCWT-I. However, no significant interactions between TBI and language were found.

Conclusion

As expected, the control group outperformed TBI survivors on the SCWT. Monolinguals outperformed bilinguals on all Stroop measures except SCWT-W condition. Our findings seem to suggest that monolingual speakers may have better attention and response inhibition abilities that resulted in better SCWT performance.

B-67 The Effect of Bilingualism on Executive Functioning Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) survivors often exhibit problems with executive function (EF). Language use can also impact EF test performances. We examined the effects of TBI and bilingualism/monolingualism on several EF tests.

Method

The sample (N = 94) consisted of 37 healthy controls (19 bilingual; 18 monolingual), 30 acute TBI participants (10 bilingual; 20 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. Stroop Color-Word (SCW), Delis-Kaplan Executive Function System Letter Fluency (DKEFS-LF), Trail Making Test part B (TMT-B) and a EF global composite (EF-GC) were used to assess EF. All participants passed performance validity testing. 3X2 ANOVAs were conducted to determine the effect of TBI and bilingualism/monolingualism on EF performances.

Results

Main effects were found between groups (control and TBI groups) on SCW, p = .046, ηp² = .07, TMT-B, p = .042, ηp² = .07, and EF-GC, p = .005, ηp² = .13; the 6-month TBI group performed worse than controls on TMT-B and EF-GC. Main effects were found for bilingualism/ monolingualism on SCW, p = .012, ηp² = .07, and TMT-B, p = .034, ηp² = .05; monolingual participants performed better than bilingual participants. No significant interactions between TBI and language were found.

Conclusion

The TBI group underperformed on SCW, TMT-B, and EF-GC compared to controls; relative to monolinguals, bilinguals underperformed on the SCW and TMT-B only. In conclusion, our findings seem to suggest that monolinguals have better cognitive flexibility compared to bilinguals that result in better EF performances.

B-70 The Effect of Bilingualism on Trail Making Test Performance in Traumatic Brain Injury Survivors and Healthy Adults

Objective

Traumatic brain injury (TBI) is associated with a number of cognitive deficits. Language factors also impact neurocognitive performance. We examined the effects of TBI and bilingualism/monolingualism on a test of attention and executive functioning (Trail Making Test; TMT).

Method

The sample (N = 96) consisted of 36 healthy controls (19 bilingual; 17 monolingual), 34 acute TBI participants (12 bilingual; 21 monolingual), and 27 chronic TBI participants (16 bilingual; 11 monolingual). Acute TBI participants were tested 6 months post-injury and chronic TBI participants were tested 12 months or more post-injury. 3X2 ANOVAs were conducted to determine the effect of TBI and bilingualism/monolingualism on TMT part A and B.

Results

Main effects were found between groups (i.e., control and TBI groups) on TMT A, p < .001, ηp² = .17 and TMT B, p < .05, ηp² = .09. Pairwise comparisons revealed a difference only between the control group and the 6-month TBI group, with the latter performing worse. Main effects were found for bilingualism/monolingualism on TMT A, p < .05, ηp² = .04 and TMT B, p < .05, ηp² = .05; monolingual participants performed better than bilingual participants. No interactions emerged.

Conclusion

Relative to monolinguals, bilingual participants demonstrated worse attention and executive functioning performances 6 months post-TBI; however, 12 months post-TBI, the difference was negligible.

Observation of two types of charge-density-wave orders in superconducting La2-xSrxCuO4

The discovery of charge- and spin-density-wave (CDW/SDW) orders in superconducting cuprates has altered our perspective on the nature of high-temperature superconductivity (SC). However, it has proven difficult to fully elucidate the relationship between the density wave orders and SC. Here, using resonant soft X-ray scattering, we study the archetypal cuprate La_2-xSr_xCuO₄ (LSCO) over a broad doping range. We reveal the existence of two types of CDW orders in LSCO, namely CDW stripe order and CDW short-range order (SRO). While the CDW-SRO is suppressed by SC, it is partially transformed into the CDW stripe order with developing SDW stripe order near the superconducting T_c. These findings indicate that the stripe orders and SC are inhomogeneously distributed in the superconducting CuO₂ planes of LSCO. This further suggests a new perspective on the putative pair-density-wave order that coexists with SC, SDW, and CDW orders.

To fully elucidate the relationship between density wave orders and superconductivity in high-T_c cuprates remains difficult. Here, the authors reveal two types of charge-density-wave orders and their intertwined relationship with spin-density-wave order and superconductivity in La_2-xSr_xCuO_4.

Analysis of 11 years of clinical negligence claims in esophagogastric cancer in England

In the National Health Service (NHS), clinical negligence claims and associated compensations are constantly rising. The aim of this study is to identify the size, trends, and causes of litigations claims in relation to esophagogastric (EG) cancer in the NHS. Data requests were submitted to the NHS Litigation Authority (NHSLA) for the period of January 2003 to December 2013. Data were reviewed, categorized clinically, and analyzed in terms of causes and costs behind claims. In this time period, there were 163 claims identified from the NHSLA database. Ninety-five (58.3%) claims were successful with a pay out of £6.25 million. An increasing overall claim frequency and success rate were found over the last few years. Majority of the claims were from gastric cancer 84 (88.4%). The commonest cause of complaint in successful claims was delay or failure in diagnosis (21.1%) and treatment (17.9%). There were only 10.5% successful intraoperative claims, of which 50% were due to unnecessary or additional procedures. The frequency and success rates of malpractice claims in EG cancer are rising. The failure or delay in diagnosing and treatment in EG malignancy are the common cause for successful litigation claims. The findings further reinforce the need to improve early diagnosis.

Vitamin D supplementation during pregnancy and infancy reduces aeroallergen sensitization: a randomized controlled trial

BACKGROUND

Vitamin D has immune-modulating effects. We determined whether vitamin D supplementation during pregnancy and infancy prevents aeroallergen sensitization and primary care respiratory illness presentations.

METHODS

A randomized, double-blind, placebo-controlled parallel-group trial. We assigned pregnant women, from 27-week gestation to birth, and then their infants, from birth to 6 months, to placebo or one of two dosages of daily oral vitamin D. Woman/infant pairs were randomized to: placebo/placebo, 1000 IU/400 IU or 2000 IU/800 IU. When the children were 18 months old, we measured serum-specific IgE antibodies and identified acute primary care visits described by the doctor to be due to a cold, otitis media, an upper respiratory infection, croup, asthma, bronchitis, bronchiolitis, a wheezy lower respiratory infection or fever and cough.

RESULTS

Specific IgE was measured on 185 of 260 (71%) enrolled children. The proportion of children sensitized differed by study group for four mite antigens: Dermatophagoides farinae (Der-f1, Der-f2) and Dermatophagoides pteronyssinus (Der-p1, Der-p2). With results presented for placebo, lower dose, and higher dose vitamin D, respectively (all P < 0.05): Der-f1 (18%, 10%, 2%), Der-f2 (14%, 3%, 2%), Der-p1 (19%, 14%, 3%) and Der-p2 (12%, 2%, 3%). There were study group differences in the proportion of children with primary care visits described by the doctor as being for asthma (11%, 0%, 4%, P = 0.002), but not for the other respiratory diagnoses.

CONCLUSIONS

Vitamin D supplementation during pregnancy and infancy reduces the proportion of children sensitized to mites at age 18 months. Preliminary data indicate a possible effect on primary care visits where asthma is diagnosed.

A protocol for management of blood loss in surgical treatment of peritoneal malignancy by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND AND AIMS

The treatment of peritoneal malignancies with cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to be associated with massive surgical blood loss. Maintaining high fibrinogen levels throughout surgery may reduce blood loss in these patients. The primary aim of the study was to see if Tranexamic Acid (TXA) and cryoprecipitate reduced surgical blood loss and hence red cell transfusions. A comparison was made with a cohort of patients treated with fresh frozen plasma (FFP) alone. The secondary aim was to measure the effect of both protocols on coagulation parameters and the incidence of arterial or venous thrombosis.

METHOD

We used prospectively collected data from 201 patients who had complete CRS with HIPEC for peritoneal malignancy using different protocols during two discrete 12-month time periods.

RESULTS

The new transfusion protocol led to a higher average fibrinogen level intra-operatively and post-operatively, with a significant reduction in average RBC, FFP and platelet transfusion intra-operatively per patient from 4·2 to 1·8 units, 6·2 to 0·2 units and 0·1 to 0 units, respectively. No significant difference in PT or APTT was seen between patients treated with the standard and new protocols. Venous thrombosis occurred in seven patients treated with the standard protocol and five with the new protocol. A single case of arterial thrombosis was seen in both groups.

CONCLUSION

Patients treated with upfront TXA and cryoprecipitate during CRS required less RBC transfusion than those treated with the standard protocol of early FFP.

The impacts of larval density and protease inhibition on feeding in medicinal larvae of the greenbottle fly Lucilia sericata

Larval therapy, the therapeutic use of blowfly larvae to treat chronic wounds, is primarily used in debridement. There are, however, gaps in current knowledge of the optimal clinical application of the therapy and mechanisms of action in the debridement process. Using an artificial assay, two studies were undertaken to investigate these aspects of larval debridement by Lucilia sericata Meigen (Diptera: Calliphoridae); the first studied the effects of the density of larvae on tissue digestion and larval mass, and the second considered the effects on the same parameters of incorporating protease inhibitors into the feeding substrate. The total mass of tissue digested increased with larval density until saturation was observed at 5.0-7.5 larvae/cm(2) . This range was considered optimal as lower doses resulted in the removal of less tissue and higher doses offered no additional tissue removal and appeared to exacerbate competition for feeding. In the second study, increased protease inhibitor concentration led to significant decreases in tissue digestion and larval mass, suggesting that serine proteases, particularly trypsin, may play major roles in larval digestion. Such information is important in elucidating the main constituents that make up larval digestive products and may be significant in the development of new therapies.

Effect of Collaterals on Clinical Presentation, Baseline Imaging, Complications, and Outcome in Acute Stroke

BACKGROUND AND PURPOSE

Good CTA collaterals independently predict good outcome in acute ischemic stroke. Our aim was to evaluate the role of collateral circulation and its added benefit over CTP-derived total ischemic volume as a predictor of baseline NIHSS score, total ischemic volume, hemorrhagic transformation, final infarct size, and a modified Rankin Scale score >2.

MATERIALS AND METHODS

This was a retrospective study of 395 patients with stroke dichotomized by recanalization (recanalization positive/recanalization negative) and collateral status. Clot burden score was quantified on baseline CTA. Total ischemic volumes were derived from thresholded CTP maps. Final infarct size was assessed on follow-up CT/MRI. We performed uni-/multivariate analyses for each outcome, adjusting for rtPA status, using general linear (continuous variables) and logistic (binary variables) regression. Model comparison with collateral score and total ischemic volume was performed using the F or likelihood ratio test.

RESULTS

Collateral presence independently and inversely predicted all outcomes except hemorrhagic transformation in patients who were recanalization negative and mRS >2 in patients who were recanalization positive. The greatest collateral benefit occurred in patients who were recanalization negative, contributing 16.5% and 19.2% of the variability for final infarct size and mRS >2. The collateral score model is superior to the total ischemic volume for mRS >2 prediction, but a combination of total ischemic volume and collateral score is superior for mRS >2 and final infarct prediction (24% and 28% variability, respectively). In patients who were recanalization positive, a model including collateral score and total ischemic volume was superior to that of total ischemic volume for hemorrhagic transformation and final infarct prediction but was muted compared with patients who were recanalization negative (11.3% and 16.9% variability).

CONCLUSIONS

Collateral circulation is an independent predictor of all outcomes, but the magnitude of significance varies, greater in patients who were recanalization negative versus recanalization positive. Total ischemic volume assessment is complementary to collateral score in many cases.

Addiction-related genes in gambling disorders: new insights from parallel human and pre-clinical models

Neurobiological research supports the characterization of disordered gambling (DG) as a behavioral addiction. Recently, an animal model of gambling behavior was developed (rat gambling task, rGT), expanding the available tools to investigate DG neurobiology. We investigated whether rGT performance and associated risk gene expression in the rat's brain could provide cross-translational understanding of the neuromolecular mechanisms of addiction in DG. We genotyped tagSNPs (single-nucleotide polymorphisms) in 38 addiction-related genes in 400 DG and 345 non-DG subjects. Genes with P<0.1 in the human association analyses were selected to be investigated in the animal arm to determine whether their mRNA expression in rats was associated with the rat's performance on the rGT. In humans, DG was significantly associated with tagSNPs in DRD3 (rs167771) and CAMK2D (rs3815072). Our results suggest that age and gender might moderate the association between CAMK2D and DG. Moderation effects could not be investigated due to sample power. In the animal arm, only the association between rGT performance and Drd3 expression remained significant after Bonferroni correction for 59 brain regions. As male rats were used, gender effects could not be investigated. Our results corroborate previous findings reporting the involvement of DRD3 receptor in addictions. To our knowledge, the use of human genetics, pre-clinical models and gene expression as a cross-translation paradigm has not previously been attempted in the field of addictions. The cross-validation of human findings in animal models is crucial for improving the translation of basic research into clinical treatments, which could accelerate neurobiological and pharmacological investigations in addictions.

A multidisciplinary team approach minimises prophylactic mastectomy rates

BACKGROUND

Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making.

METHODS

We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded.

RESULTS

Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%).

DISCUSSION

MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Nimbolide targets BCL2 and induces apoptosis in preclinical models of Waldenströms macroglobulinemia

Neem leaf extract (NLE) has medicinal properties, which have been attributed to its limonoid content. We identified the NLE tetranorterpenoid, nimbolide, as being the key limonoid responsible for the cytotoxicity of NLE in various preclinical models of human B-lymphocyte cancer. Of the models tested, Waldenströms macroglobulinemia (WM) cells were most sensitive to nimbolide, undergoing significant mitochondrial mediated apoptosis. Notably, nimbolide toxicity was also observed in drug-resistant (bortezomib or ibrutinib) WM cells. To identify putative targets of nimbolide, relevant in WM, we used chemoinformatics-based approaches comprised of virtual in silico screening, molecular modeling and target–ligand reverse docking. In silico analysis revealed the antiapoptotic protein BCL2 was the preferential binding partner of nimbolide. The significance of this finding was further tested in vitro in RS4;11 (BCL2-dependent) tumor cells, in which nimbolide induced significantly more apoptosis compared with BCL2 mutated (Jurkat BCL2^Ser70-Ala) cells. Lastly, intraperitoneal administration of nimbolide in WM tumor xenografted mice, significantly reduced tumor growth and IgM secretion in vivo, while modulating the expression of several proteins as seen on immunohistochemistry. Overall, our data demonstrate that nimbolide is highly active in WM cells, as well as other B-cell cancers, and engages BCL2 to exert its cytotoxic activity.