WAFER trial: a study protocol for a feasibility randomised controlled trial comparing wide-awake local anaesthesia no tourniquet (WALANT) to general and regional anaesthesia with tourniquet for flexor tendon repair

INTRODUCTION

Flexor tendons are traditionally repaired under either general anaesthesia (GA) or regional anaesthesia (RA), allowing for the use of an arm tourniquet to minimise blood loss and establish a bloodless surgical field. However, the use of tourniquets exposes the patient to certain risks, including skin, muscle and nerve injuries. A recent advancement in anaesthesia delivery involves the use of a wide-awake approach where no sedation nor tourniquets are used (wide-awake local anaesthesia no tourniquet (WALANT)). WALANT uses local anaesthetic with epinephrine to provide pain relief and vasoconstriction, reducing operative bleeding. Several studies revealed potential benefits for WALANT compared with GA or RA. However, there remains a paucity of high-quality evidence to support the use of WALANT. As a result of this uncertainty, the clinical practice varies considerably. We aim to evaluate the feasibility of WALANT as an alternative to GA and RA in patients undergoing surgical repair of flexor tendon injuries. This involves addressing factors such as clinician and patient support for a trial, clinical equipoise, trial recruitment and dropout and the most relevant outcomes measures for a future definitive trial.

METHODS AND ANALYSIS

WAFER is a multicentre, single-blinded, parallel group, randomised controlled trial (RCT) to assess the feasibility of WALANT versus RA and GA. The target population is patients with acute traumatic flexor tendon injuries, across 3 major hand surgery units in England involving a total of 60 participants. Outcome assessors will be blinded. The primary outcome will be the ability to recruit patients into the trial, while secondary outcomes include difference in functional outcome, patient-reported outcome measures, health-related quality of life, cost-effectiveness and complication rates.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the London-City and East Research Ethics Committee (22/PR/1197). Findings will be disseminated through peer-reviewed publication, conferences, patient information websites and social media networks.

TRIAL REGISTRATION NUMBER

ISRCTN identifier: 15052559.

QTc interval in anorexia nervosa: a systematic review and meta-analysis

Background

Patients with anorexia nervosa (AN) are at higher risk of sudden cardiac death. Although the underlying aetiology for this association remains unclear. It may be related to prolongation of the QT interval, which can degenerate into fatal ventricular arrhythmias. However, the presence of prolonged heart rate-corrected QT interval (QTc) in AN remains controversial, and two previous meta-analyses on AN and QTc showed contradictory findings [1,2].

Purpose

In this systematic review and meta-analysis, we aimed to evaluate if AN was associated with changes in the QTc interval and dispersion.

Methods

MEDLINE, EMBASE and COCHRANE databases were systematically searched from inception to January 2021. Random-effects meta-analysis and meta-regression were used. The inclusion criteria were (i) confirmed diagnosis of AN, (ii) measurement of QTc on electrocardiogram and (iii) peer-reviewed articles. The primary endpoint of the study was the duration of the QTc interval calculated using the Bazett (QTcB), Hodges (QTcH), Fridericia (QTcF) and Framingham (QTcFr) formulae. The secondary endpoints were QT dispersion (QTd) and QTc dispersion (QTcd).

Results

The 25 eligible studies included 5687 patients (1862 AN, 3825 control) (Figure 1: PRISMA diagram). The majority of patients were female (96.3%) with a mean age between 14.3 to 31.0 years and mean duration of disease ranging from 9.1 to 129.6 months. The mean BMI ranged from 13.7 to 18.5 kg/m2. Pooled analysis did not show significant prolongation between AN versus control in QTcB (mean difference (MD) MD 4.9ms, 95% CI −3.2, 13.1ms, p=0.23; I2=95%; n=24/25 studies; Figure 2A), QTcH (MD 1.3ms, 95% CI −8.5, 11.2ms, p=0.79; I2=71%; n=3/25 studies), and QTcF (MD 3.1ms, 95% CI −21.6, 27.7ms, p=0.81; I2=97%; n=3/25 studies). Only two studies reporting QTcFr showed a significant prolongation between AN and control (MD 15.9ms, 95% CI 0.0, 31.8ms, p=0.05, I2=65%; n=2/25 studies; Figure 2B). However, QTd and QTcd were significantly greater in AN than control (MD 21.3ms, 95% CI 10.4, 32.3ms, p=0.0001, I2=94%; Figure 2C and MD 16.9ms, 95% CI 4.5, 29.3ms, p=0.007 I2=93%; Figure 2D, respectively).

Conclusion

To the best of our knowledge, this is the largest meta-analysis of QTc in AN and the first meta-analysis exploring the significance of QTd and QTcd in AN. AN was not found to be associated with prolongation of QTc calculated using the Bazett, Fridericia and Hodges formulae. However, an association of AN with prolonged QTc was observed in the studies using the Framingham formula. More pronounced dispersion (QTd and QTcd) was also observed in patients with AN.

Funding Acknowledgement

Type of funding sources: None.

Strategic placement of automated external defibrillators (AEDs) for cardiac arrests in public locations and private residences

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We ranked businesses for their ability to fill gaps in the AED landscape.

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23% of OHCAs in public, and 4% in homes, were within 100 m of an existing AED.

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Many businesses can simultaneously improve coverage of arrests in public and homes.

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Rankings were largely robust to the coverage radius used (100 m, 200 m, and 500 m).

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Even if all 5006 business locations hosted AEDs, large gaps in OHCA coverage remain.

Aim

Methods

Results

Conclusion

Sub-organism (acetylcholinesterase activity), population (survival) and chemical concentration responses reinforce mechanisms of antagonism associated with malathion toxicity

Within human modified ecosystems the effects of individual stressors are difficult to establish amid co-occurring biological processes, environmental gradients and other stressors. Coupled examination of several endpoints across different levels of organisation may help elucidate the individual and combined effects of stressors and interactions. Malathion is a commonly used organophosphate pesticide that contaminates freshwaters and has strong negative effects on aquatic biota. However, both other stressors (e.g. increased sediment) and common ecosystem components (e.g. macrophytes and variable pH) can reduce the aqueous concentrations of malathion, reducing its toxic effects. We conducted a fully orthogonal bioassay to examine how pH (at 7 and 7.8) and sorptive processes (across two levels of kaoline clay 0 and 24 g L^-1) affected aqueous malathion concentrations and toxicity in an aquatic invertebrate genus. Survival and acetylcholinesterase activity as a sub-organism response were examined in the mayfly Coloburiscoides spp. (Ephemeroptera; Coluburiscidae). Measured aqueous malathion concentrations decreased with increased pH and in the presence of kaolin clay. Survival declined with increasing malathion concentrations and exposure period. Results further identify that antagonism of malathion toxicity was associated with both pH (alkaline hydrolysis) and effects associated with sediment independent of pH (driven by sorptive processes). However, model predictions varied associated with target and measured concentrations and concentrations examined. Antagonistic effects were most apparent using subset target malathion concentrations because of the dominant effect of malathion at high concentrations. Acetylcholinesterase activity, identified repression occurred across all treatments and did not identify antagonistic interactions, but these results were similar to survival responses at the time points examined (i.e. 120 h). Examination of chemistry, acetylcholinesterase, and survival, affords greater understanding of stressor effects and their interactions. Measured malathion concentrations may underestimate effects on aquatic biota; not because of synergism among stressors, but because of strong effects despite antagonism.

Does care at a cardiac arrest centre improve outcome after out-of-hospital cardiac arrest? - A systematic review

AIM

To perform a systematic review to answer 'In adults with attempted resuscitation after non-traumatic cardiac arrest does care at a specialised cardiac arrest centre (CAC) compared to care in a healthcare facility not designated as a specialised cardiac arrest centre improve patient outcomes?'

METHODS

The PRISMA guidelines were followed. We searched bibliographic databases (Embase, MEDLINE and the Cochrane Library (CENTRAL)) from inception to 1st August 2018. Randomised controlled trials (RCTs) and non-randomised studies were eligible for inclusion. Two reviewers independently scrutinized studies for relevance, extracted data and assessed quality of studies. Risk of bias of studies and quality of evidence were assessed using ROBINS-I tool and GRADEpro respectively. Primary outcomes were survival to 30 days with favourable neurological outcomes and survival to hospital discharge with favourable neurological outcomes. Secondary outcomes were survival to 30 days, survival to hospital discharge and return of spontaneous circulation (ROSC) post-hospital arrival for patients with ongoing resuscitation. This systematic review was registered in PROSPERO (CRD 42018093369) RESULTS: We included data from 17 observational studies on out-of-hospital cardiac arrest (OHCA) patients in meta-analyses. Overall, the certainty of evidence was very low. Pooling data from only adjusted analyses, care at CAC was not associated with increased likelihood of survival to 30 days with favourable neurological outcome (OR 2.92, 95% CI 0.68-12.48) and survival to 30 days (OR 2.14, 95% CI 0.73-6.29) compared to care at other hospitals. Whereas patients cared for at CACs had improved survival to hospital discharge with favourable neurological outcomes (OR 2.22, 95% CI 1.74-2.84) and survival to hospital discharge (OR 1.85, 95% CI 1.46-2.34).

CONCLUSIONS

Very low certainty of evidence suggests that post-cardiac arrest care at CACs is associated with improved outcomes at hospital discharge. There remains a need for high quality data to fully elucidate the impact of CACs.

Pan-Canadian Framework for Palliative and End-of-Life Care Research

Background and context: Ongoing advances have been made in the conceptualization and operationalization of palliative and end-of-life care (PEOLC) (e.g., palliative approaches to care, early identification of people who would benefit from palliative care). In addition, Canada has been a leader in PEOLC research and continues to have an internationally recognized research community. However, many Canadians continue to experience unnecessary pain and suffering at the end of life and receive care inconsistent with their goals and preferences. Within this context, the Canadian Cancer Research Alliance (CCRA) sought to develop a national research framework to guide Canada's cancer research funders in response to their strategic priority to improve the patient experience and quality of life for all cancer patients. Aim: To develop and implement a national framework and recommendations to enable funders to capitalize on existing research strengths and build capacity to address unmet needs to advance the field and broaden the scope, beyond its historical affiliation with advanced cancer, to include PEOLC for all those living and dying with life-limiting conditions. Strategy/Tactics: The framework's development was informed by multiple approaches, including: a strategic literature review; an analysis of PEOLC research funding in Canada from 2005-13; and an online survey and key informant interviews from the broader stakeholder community. Program/Policy process: A working group of CCRA member representatives and palliative care experts met regularly to provide guidance and feedback to a consultant who synthesized the data and formulated recommendations. In total, > 200 stakeholders (e.g., patients, caregivers, researchers, volunteers, practitioners, decision-makers, and policy-makers) provided input through the survey and interviews. Outcomes: The Pan-Canadian Framework for Palliative and End-of-Life Research was released March 2017. It emphasizes priorities for research funding across three broad themes: 1) Transforming models of care; 2) Patient and family centredness; and 3) Ensuring equity. The identified research priorities are underpinned by four building blocks: capacity building; knowledge, synthesis, exchange, and implementation; data access and standardization; and research network development. What was learned: Successful implementation of the framework's recommendations requires strong leadership from champions within the community. The formation of the Pan-Canadian Palliative Care Research Collaborative led by palliative care clinician-researchers, in response to the identified need for a research network, is an example of an early success resulting from release of the framework. Continued efforts are needed to ensure ongoing uptake of the framework's recommendations. CCRA members have commenced planning to identify next steps for joint action.

Predicting Post-Discharge Outcome

The ability of members of the multidisciplinary team and of elderly patients themselves to predict how patients will cope at home influences the successful outcome of discharge from hospital. Following the introduction of structured assessment of the physical, psychological and social function of patients on an acute elderly care unit, a study was undertaken to compare the predictive ability of the primary nurse, the patient and the occupational therapist.

Overall, results suggested a high level of accuracy of predictions. There was a trend for the occupational therapist to predict more accurately (83.6%) than the patient (80.7%) or the primary nurse (72.5%). Where the predictions were incorrect, the patients erred on the side of optimism (78% optimistic) whereas the nurses were more pessimistic (69% pessimistic). Further studies to look at the reliability of outcome predictions by health professionals and the patients themselves would be useful in the overall management of the discharge of elderly people from hospital.

Individualisation of time-motion analysis: a method comparison and case report series

This study compared the intensity distribution of time-motion analysis data, when speed zones were categorized by different methods. 12 U18 players undertook a routine battery of laboratory- and field-based assessments to determine their running speed corresponding to the respiratory compensation threshold (RCT), maximal aerobic speed (MAS), maximal oxygen consumption (vV˙O2max) and maximal sprint speed (MSS). Players match-demands were tracked using 5 Hz GPS units in 22 fixtures (50 eligible match observations). The percentage of total distance covered running at high-speed (%HSR), very-high speed (%VHSR) and sprinting were determined using the following speed thresholds: (1) arbitrary; (2) individualised (IND) using RCT, vV˙O2max and MSS; (3) individualised via MAS per se; (4) individualised via MSS per se; and (5) individualised using MAS and MSS as measures of locomotor capacities (LOCO). Using MSS in isolation resulted in 61% and 39% of player's % HSR and % VHSR, respectively, being incorrectly interpreted, when compared to the IND technique. Estimating the RCT from fractional values of MAS resulted in erroneous interpretations of % HSR in 50% of cases. The present results suggest that practitioners and researchers should avoid using singular fitness characteristics to individualise the intensity distribution of time-motion analysis data. A combination of players' anaerobic threshold, MAS, and MSS characteristics are recommended to individualise player-tracking data.

Short term benefits of post-operative oral dietary supplements in surgical patients

The present study was undertaken to investigate the short term clinical efficacy of oral dietary supplements administered post-operatively to patients undergoing predetermined moderate to severe gastrointestinal surgery. Trial end points for comparison included effects of oral dietary supplements on nutritional intake, nutritional status and incidence of serious complications. 54 patients who were scheduled to undergo predetermined moderate to major gastrointestinal surgical procedures entered the study. They were randomly assigned to receive a normal ward diet post-operatively or the same diet supplemented ad libitum by an oral nutritional sip feed. The study period was defined as commencing from the day patients were adjudged to be capable of ingesting 'free fluids' to the day of hospital discharge. 40 patients (20 in each group) completed the study. The mean daily energy intake (KCal/day) assessed from 7 day food diaries was significantly higher in the treatment group (1833 +/- SEM 99) than in the control group (1108 +/- 56, p < 0.0001). This increase occurred not only as a consequence of energy intake from the oral dietary supplements (470 +/- 30) but also because more energy was consumed from the ward diet by the treatment than the control patients (1353 +/- 92 vs 1108 +/- 56, p < 0.02). The mean daily protein intake g/day in the treatment group (66.0 +/- 3.4) was also greater than in the control group (52.9 +/- 29 p < 0.0001). This difference was due solely to the intake in protein from the oral dietary supplements (15.7 +/- 1.0), protein intake from the ward diet being similar in the treatment (50.1 +/- 3.2) and control (52.9 +/- 29) groups. Patients in the treatment group maintained their pre-operative weight where as control patients had lostsignificant amount of their pre-operative weight by study day 3 (4.5 +/- 12 kg and by discharge (4.7 +/- 1.2 kg, p < 0.02). Pre-operative muscle function as evidenced by grip strength dynamometry decreased to a greater extent in the control than treatment group patients by study day 3 (14.6 +/- 2.2 KPa vs 2.8 +/- 2.4 < 0.03) and by discharge (10.4 +/- 3.1 KPa vs 0.10 +/- 1.9 p < 0.03). The incidence of serious infections (pneumonia, wound infection) was significantly higher in the control group (10) than in the treatment group (3, p < 0.02). It is concluded that the prescription of oral dietary supplements on an ad libitum basis to post-operative patients undergoing moderate to major gastrointestinal surgery results in clinically significant short term benefits.

Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia

INTRODUCTION

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of paediatric traumatic OHCA.

METHODS

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings.

RESULTS

Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n=64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5-13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae; 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%).

CONCLUSIONS

Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.

Paediatric hanging associated out of hospital cardiac arrest in Melbourne, Australia: characteristics and outcomes

INTRODUCTION

Hanging is a rare but devastating cause of out of hospital cardiac arrest (OHCA). The characteristics and outcomes of hanging associated OHCA in the paediatric age group are described.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was searched for patients aged less than 18 years where the precipitant cause of OHCA was hanging. Results were cross checked with the coronial database.

RESULTS

During the years 2000-2009, there were 680 paediatric cardiac arrests of which 53 (7.8%) were precipitated by hanging with an incidence of 4.4 per million paediatric patients (<18 years) per year. Median age was 16 (IQR 14-17) years and 58.5% were males. Five were unintentional hangings; median age 3 (IQR 2-4) years. The youngest deliberate hanging associated OHCA was aged 10 years. Most hangings occurred in a house (85%) and bystander cardiopulmonary resuscitation (CPR) was performed in 30%. Asystole was the most common initial cardiac arrest rhythm seen in 50 cases (94%) while three patients had pulseless electrical activity. The emergency medical services (EMS) attempted resuscitation in 18 patients (34%), inserting an endotracheal tube in 13 patients. The majority (n=41) were not transported; seven patients were transported with return of spontaneous circulation (ROSC) and five patients were transported with ongoing CPR. Victims who had bystander CPR were more likely to have EMS attempted resuscitation (p<0.001). Only patients who had received bystander CPR achieved ROSC (p<0.001). Three patients survived to hospital discharge; two survivors suffered severe neurological injury (Cerebral Performance Category Scale 3-4).

CONCLUSION

Non-intentional hanging is rare but deliberate hanging with suicidal intent represents a significant proportion of OHCAs in patients under 18&emsp14;years of age. A focus on prevention is key, as outcomes are poor, with survivors likely to suffer a severe neurological insult.

Influence of pharmacogenetics on response and toxicity in breast cancer patients treated with doxorubicin and cyclophosphamide

Background:

Doxorubicin and cyclophosphamide (AC) therapy is an effective treatment for early-stage breast cancer. Doxorubicin is a substrate for ABCB1 and SLC22A16 transporters. Cyclophosphamide is a prodrug that requires oxidation to 4-hydroxycyclophosphamide, which yields a cytotoxic alkylating agent. The initial oxidation is catalysed by cytochrome P450 enzymes including CYP2B6, CYP2C9, CYP2C19 and CYP3A5. Polymorphic variants of the genes coding for these enzymes and transporters have been identified, which may influence the systemic pharmacology of the two drugs. It is not known whether this genetic variation has an impact on the efficacy or toxicity of AC therapy.

Methods:

Germ line DNA samples from 230 patients with breast cancer on AC therapy were genotyped for the following SNPs: ABCB1 C1236T, G2677T/A and C3435T, SLC22A16 A146G, T312C, T755C and T1226C, CYP2B6^*2, ^*8, ^*9, ^*3, ^*4 and ^*5, CYP2C9^*2 and ^*3, CYP3A5^*3 and CYP2C19^*2. Clinical data on survival, toxicity, demographics and pathology were collated.

Results:

A lower incidence of dose delay, indicative of less toxicity, was seen in carriers of the SLC22A16 A146G, T312C, T755C variants. In contrast, a higher incidence of dose delay was seen in carriers of the SLC22A16 1226C, CYP2B6^*2 and CYP2B6^*5 alleles. The ABCB1 2677A, CYP2B6^*2, CYP 2B6^*8, CYP 2B6^*9, CYP 2B6^*4 alleles were associated with a worse outcome.

Conclusion:

Variant alleles in the ABCB1, SLC22A16 and CYP2B6 genes are associated with response to AC therapy in the treatment of breast cancer.

Should we be 'pushing meds'? The implications of pharmacogenomics

Medication continues to be the most widely prescribed treatment in the NHS for mental health problems. It has been known for many years that individuals differ in the way they respond to a given pharmaceutical therapy, and one reason for this lies in the genetic variation between individuals. This paper recognizes the impact that pharmacogenomics and pharmacogenetics are having in the field of mental health. Variants in genes that code for the drug metabolizing enzymes in the liver have been found to influence the way in which these enzymes handle psychotropic medication. Individuals can be classified as poor, moderate or extensive metabolizers when standard regimes are used, and this can lead to huge differences in therapeutic effect and toxicity. There are now genotyping tests available which provide information on the individual's ability to metabolize psychotropic medication. One author provides an account of the effects of medication on her son's physical and psychological well-being. Genotyping provided evidence for his poor metabolism of psychotropic medication, and his life is now changing as he is being very gradually weaned off this medication. This emerging field of work has implications for the way in which practitioners consider medication adherence.

Ureteral spindle cell sarcoma in a dog

A five-year-old, female spayed Labrador retriever was presented for further investigation of an intra-abdominal mass. Abdominal exploration showed a large mass arising from the right ureter and a ureteronephrectomy was performed. Histopathology of the ureteral mass was consistent with a spindle cell sarcoma. The patient recovered well, but five months later was diagnosed with another tumour, this time in her left abdominal wall. The owners decided not to pursue further treatment and euthanasia was performed a month later.

[Infant bronchiolitis point of care by physicians in the Ile-de-France bronchiolitis network]

OBJECTIVE

The Ile-de-France bronchiolitis network assessment gave us the opportunity to carry out a survey regarding the customary handling of acute bronchiolitis by physicians involved in this network. The aim of this study was to retrieve results relating to season 2003-2004 and to compare them with the September 2000 French consensus conference recommendations.

METHODS

The practitioners engaged using a special form subsequently transmitted to network joint committee collected the clinical and therapeutic data of the patients included in the Network. We analysed 342 exploitable forms.

RESULTS

Analysis of the physicians medications for patients classified as bronchiolitis showed that their behavior was on the whole keeping with the official recommendations. The nearly systematic prescription of specific respiratory physiotherapy (increase in expiratory flow) satisfies the expectations of the French consensus conference. Likewise, treatments such as bronchodilator or corticoids that are not recommended were prescribed only in approximately 1/4 of cases. Abstention from all medical treatment was found in only 41% of cases classified as bronchiolitis. However, in considering only the first episode of acute bronchiolitis, this rate increased to 54,3%. Short-acting bronchodilator usage may appear legitimate as a therapeutic test of reversibility. In our study, 1/3 of patients with bronchiolitis treated by bronchodilator underwent a second episode and 80% of them were older than 6 months.

CONCLUSION

Analysis of the practices of physicians participating in the Bronchiolite Ile-de-France Network proves very positive in light of the comparison with studies prior and subsequent to the consensus conference. In recognition of this, it is necessary to consider the importance of the network's training programs. Beyond the need to go on with the diffusion of the recommendations, it seems desirable to extend them to clinical situations not yet considered, especially recurrent bronchiolitis and infant asthma. Finally, this type of study should be repeated in order to measure the future evolution of medical practices, as well as extended to a larger scope than the Ile-de-France bronchiolitis Network.