Role of probiotics in chronic rhinosinusitis: a systematic review of randomised, controlled trials

OBJECTIVE

This review evaluated the safety profile and efficacy of probiotics in chronic rhinosinusitis and was registered with Prospero (Centre for Reviews and Dissemination number: 42020193529).

METHOD

Literature databases were searched through inception to August 2022. Randomised, controlled trials exploring adjunctive probiotics in adult chronic rhinosinusitis patients were included. From 948 records screened, 4 randomised, controlled trials were included.

RESULTS

Probiotics-associated adverse effects comprised epistaxis and abdominal pain. No reduction in Sino-Nasal Outcome Test values before 4 weeks (p = 0.58) or beyond 8 weeks (p = 0.08) of treatment or reduction of severe symptom frequency (p = 0.75) was observed. Symptom relapse in probiotic-treated patients was significantly lower across all timepoints (p = 0.045). Lower sinusitis relapse risks during treatment (risk ratio = 0.49; p = 0.019) and 8 months post-treatment (risk ratio = 0.56, p = 0.013) were observed. Probiotics demonstrated potential in improving Sino-Nasal Outcome Test symptom subscales, including sleep, psychological and rhinology subscales.

CONCLUSION

The optimal mode of probiotic administration, treatment duration and target patient subgroups requires further study to evaluate the utility of probiotics.

Time for change? Feasibility of introducing micromodules into medical student education: a randomised controlled trial

INTRODUCTION

Didactic lectures have been the foundation of learning for many medical students. However, in recent years, the flipped classroom model has become increasingly popular in medical education. This approach enhances pre-class learning, allowing the limited contact time between clinicians and medical students to be focused on practical issues. This study evaluated the effectiveness and non-inferiority of online micromodule teaching in terms of knowledge transfer concerning specific urology topics.

METHODS

Medical students without prior exposure to the urology subspecialty were enrolled in the study, then randomised to a traditional didactic lecture group or an online micromodule group. Knowledge transfer was assessed by pre-intervention and post-intervention multiple-choice questions and objective structured clinical examinations that involved the acquisition of medical histories from real patients.

RESULTS

In total, 45 medical students were enrolled (22 in the traditional didactic group and 23 in the online micromodule group). In terms of knowledge transfer (assessed by objective structured clinical examinations), the efficacy of online micromodules was comparable to traditional didactic lectures, although the difference was not statistically significant (P=0.823). There were no significant differences in terms of knowledge acquisition, retention, or clinical application between the two groups.

CONCLUSION

In terms of acquiring, retaining, and applying foundational urological knowledge, online micromodules can help medical students to achieve outcomes comparable with the outcomes of didactic lectures. Online micromodules may be a viable alternative to traditional didactic lectures in urology education.

A method for estimating and characterizing explicitly nonlinear dynamic functional network connectivity in resting-state fMRI data

The past 10 years have seen an explosion of approaches that focus on the study of time-resolved change in functional connectivity (FC). FC characterization among networks at a whole-brain level is frequently termed functional network connectivity (FNC). Time-resolved or dynamic functional network connectivity (dFNC) focuses on the estimation of transient, recurring, whole-brain patterns of FNC. While most approaches in this area have attempted to capture dynamic linear correlation, we are particularly interested in whether explicitly nonlinear relationships, above and beyond linear, are present and contain unique information. This study thus proposes an approach to assess explicitly nonlinear dynamic functional network connectivity (EN dFNC) derived from the relationship among independent component analysis time courses. Linear relationships were removed at each time point to evaluate, typically ignored, explicitly nonlinear dFNC using normalized mutual information (NMI). Simulations showed the proposed method estimated explicitly nonlinearity over time, even within relatively short windows of data. We then, applied our approach on 151 schizophrenia patients, and 163 healthy controls fMRI data and found three unique, highly structured, mostly long-range, functional states that also showed significant group differences. In particular, explicitly nonlinear relationships tend to be more widespread than linear ones. Results also highlighted a state with long range connections to the visual domain, which were significantly reduced in schizophrenia. Overall, this work suggests that quantifying EN dFNC may provide a complementary and potentially valuable tool for studying brain function by exposing relevant variation that is typically ignored.

Switching to or Add-on Peginterferon in Patients on Nucleos(t)ide Analogues for Chronic Hepatitis B: The SWAP RCT

BACKGROUND & AIMS

The optimal therapeutic strategy in nucleoside analogue (NA) experienced chronic hepatitis B (CHB) using peginterferon is still unclear; hence we explored a switch to or add-on peginterferon strategy versus continued NA.

METHODS

We conducted a randomized controlled trial of CHB patients on NA >12 months with HBV DNA(-) randomized to switch or add-on peginterferon-alpha2b (1.5 μg/kg/weekly) for 48 weeks versus continuing NA (controls) (allocation 2:2:1; Clinicaltrial.gov: NCT01928511) in tertiary Singapore hospitals. The primary composite endpoint at week 72 was hepatitis B e antigen (HBeAg) loss or quantitative HBsAg (qHBsAg) >1 log IU/mL reduction, and secondary endpoints were HBsAg loss, HBsAg seroconversion, qHBsAg <200 IU/mL, qHBsAg <100 IU/mL, HBV DNA(-), viral relapse, and safety. Analysis was by intention-to-treat (ITT).

RESULTS

A total of 253 patients (controls 51, switch 103, add-on 99) were randomized. The primary ITT endpoint was achieved in 3.9% of controls, 33.3% of switch, and 26.7% of add-on (P < .0001, switch/add-on versus controls). HBsAg loss occurred in 0% of controls, 7.8% of switch, and 10.1% of add-on (ITT, P < .001, switch/add-on versus controls). HBeAg(+) patients on peginterferon had higher HBeAg loss than controls but poor HBsAg responses, whereas HBeAg(-) patients on peginterferon achieved better HBsAg responses than controls. Reduction in qHBsAg in HBeAg(+) was 0.14 log IU/mL versus 0.51 log IU/mL in HBeAg(-) (P < .0001) in peginterferon-treated patients. Clinical relapse was higher in switch (13.6% overall, 27% in HBeAg(+)) versus 1% add-on and 0% controls. Adverse events were typically interferon-related symptoms, with one death (myocardial infarction unrelated to therapy).

CONCLUSIONS

ITT analysis showed that either peginterferon strategies were superior to NA for the primary endpoint and HBsAg loss, but add-on peginterferon is preferred to switch due to improved safety and similar efficacy. ClincialTrials.gov number: NCT01928511.

Radiotherapy Quality Assurance in the PORTEC-3 (TROG 08.04) Trial

AIMS

Quality assurance in radiotherapy (QART) is essential to ensure the scientific integrity of a clinical trial. This paper reports the findings of the retrospective QART assessment for all centres that participated in PORTEC-3; a randomised controlled trial that compared pelvic radiotherapy with concurrent chemoradiotherapy to the pelvis followed by adjuvant chemotherapy. The trial showed an overall survival benefit for the addition of the chemotherapy in the management of women with high-risk endometrial cancer.

MATERIALS AND METHODS

Clinicians were invited to upload a randomly selected case/s treated at each of the participating sites. Panel reviewers analysed the contours to certify that the target volumes and organ at risk structures were contoured according to guidelines. The results were categorised into acceptable, minor variation, major variation or unevaluable. The radiotherapy plans were dosimetrically evaluated using the well-established Trans-Tasman Radiation Oncology Group (TROG) protocol.

RESULTS

Between August 2010 and January 2018, data from 146 patients of 686 consecutively treated patients were retrospectively reviewed. All 16 Australia and New Zealand and 71 of 77 international centres uploaded data for evaluation. In total, 3514 dosimetric and contour variables were reviewed. Of these, 3136 variables were deemed acceptable (89.2%), with 335 minor (9.6%) and 43 major variations (1.2%). Major contour variations included the clinical target volume vaginal vault, clinical target volume parametria and differential planning target volume vault expansion.

CONCLUSION

The results of the QART assessment confirmed high uniformity and low rates of both minor and major deviations in contouring and dosimetry in all sites. This supports the safe introduction of the PORTEC-3 treatment protocol into routine clinical practice.

457 The Effect of Biochemical Adversity of Primary Hyperparathyroidism on Preoperative Imaging (SPECT-CT and US Parathyroids)

Aim

Primary hyperparathyroidism (PHPT) is a common endocrine disorder, with an estimated incidence of 1/500 women and 1/2000 men older than 40 years. Several factors influence the positivity of preoperative scans including serum calcium, PTH and vitamin D levels, and gland size. The aim of our study is to examine the effect of biochemical adversity of primary hyperparathyroidism on preoperative imaging (SPECT-CT and US parathyroids).

Method

Retrospective study of 176 parathyroidectomies (2017-2020) in a tertiary referral centre with biochemistry, SPECT-CT, US parathyroids and histology outcomes being recorded. Failed parathyroidectomies were excluded.

Results

Patients were divided into 4 groups based on the preoperative calcium levels (normocalcemia &lt;2.6, 3.4%; mild 2.60-2.79, 51.1%; moderate 2.80-2.99, 31.2%; severe &gt;3.0 mmol/l, 14.2% of patients). Age (p-0.0297), preoperative vitamin D (p-0.03) and PTH levels (p-0.0001) were different while SPECT-CT positivity (p-0.29) weight of gland (p-0.015) and US positivity (p-0.09) were similar within the subgroups. Looking at the whole group, patients with positive SPECT-CT have a larger weight (p &lt; 0.0001) while preoperative PTH levels was higher for the positive SPECT-CT patients (p-0.0289). No relation was identified between calcium levels and SPECT-CT positivity (p-0.18). No significance between preoperative vitamin D and positivity of US and SPECT-CT within the study group were noted.

Conclusions

Serum PTH levels and weight of the gland are directly correlated with positivity of preoperative imaging. Preoperative calcium and vitamin D levels correlates indirectly with the severity of the disease but did not influence the preoperative imaging positivity.

Perceptions of the use of artificial intelligence in the diagnosis of skin cancer: an outpatient survey

BACKGROUND

Convolutional neural networks (artificial intelligence, AI) are rapidly appearing within the field of dermatology, with diagnostic accuracy matching that of dermatologists. As technologies become available for use by both the health professionals and the general public, their uptake in healthcare will become more acceptable. National Health Service England recognizes the potential of AI for healthcare but emphasizes that patient-centred care should be at the forefront of these technological advancements.

AIM

To obtain opinions of patients on the use of AI in a dermatology setting, when aiding the diagnosis of skin cancers.

METHODS

A cross-sectional 14-point questionnaire was handed out to patients attending dermatology outpatient skin cancer clinics in two UK hospitals, between March and August 2018.

RESULTS

In total, 603 patient questionnaires were completed. Nearly half (47%; n = 282) of respondents were not concerned if AI technology was used by a skin specialist to aid skin cancer diagnosis. However, the majority (81%; n = 491) of respondents, considered it important for a dermatologist to examine and confirm a diagnosis and to be present for discussion of a cancer diagnosis.

CONCLUSION

Although the majority of respondents were not reluctant about the use of AI for skin cancer diagnosis, respondents still considered it important that dermatologists are involved in the diagnosis and/or confirmation of skin cancer. Furthermore, the study results demonstrate that personal interaction with a clinician is important. This is in keeping with proposals that AI be used as an adjunctive technology to increase accuracy of skin cancer diagnoses, but not as a substitute for a dermatologist.

Validation of genetic variants associated with metabolic dysfunction-associated fatty liver disease in an ethnic Chinese population

BACKGROUND

Genetic factors play an important role in the pathogenesis and development of metabolic dysfunction-associated fatty liver disease (MAFLD).

AIM

To study the association of single nucleotide polymorphisms (SNPs), previously identified in Western populations, with the risk of MAFLD in a Singapore Chinese population and their interactions with environmental and medical risk factors.

METHODS

A retrospective case-control study was conducted with 72 MAFLD cases and 72 controls with no hepatic steatosis on computed tomography, magnetic resonance imaging, or controlled attenuation parameter score. Subjects were recruited from two tertiary hospitals. Genetic alleles such as NCAN, GCKR, LYPLAL1, PNPLA3, PPP1R3B, FDFT1, COL13A1, EFCAB4B, PZP, and TM6SF2 were genotyped using the TaqMan^® Predesigned SNP Genotyping Assay.

RESULTS

Weight and body mass index (BMI) were 1.2-times higher in patients (70.6 kg, 95% confidence interval [CI]: 57.1-84.1 vs 60.8 kg, 95%CI: 48.5-73.1, P < 0.001 and 26.9 kg, 95%CI: 23-40.8 vs 23.3 kg 95%CI: 19-27.6, P < 0.001 respectively). The prevalence of diabetes mellitus in patients was 40.3% and 20.8% in controls (P = 0.011). Patients had higher mean triglycerides than controls (P < 0.001). PNPLA3 GG was more likely to be associated with MAFLD (43.4% CC vs 69.7% GG, P = 0.017, and 44.8% CG vs 69.7% GG, P = 0.022). In multivariable analysis, hypertriglyceridemia (odds ratio [OR]: 2.04 95%CI: 1.3-3.1, P = 0.001), BMI (OR: 1.2 95%CI: 1.1-1.4, P < 0.001) and PNPLA3 GG (OR: 3.4 95%CI: 1.3-9.2, P = 0.014) were associated with MAFLD (area under the receiver operating characteristic curve of 0.823).

CONCLUSION

Among the Chinese population of Singapore, PNPLA3 homozygous GG allele is a strong predictor of MAFLD, whereas LYPLAL1, GCKR, FDFT1, COL13A1, PZP, and TM6SF2 are not significantly associated. Hypertriglyceridemia, high BMI, and PNPLA3 GG are independent predictors of MAFLD.

Prediction models and questionnaires developed to predict vitamin D status in adults: a systematic review

A systematic review of prediction models/questionnaires developed to identify people with deficient/insufficient vitamin D status shows the potential of self-reported information to estimate vitamin D status. The objective is to identify and compare existing screening tools, developed to identify vitamin D deficiency or insufficiency in adults. A systematic search of literature was conducted using MEDLINE, Scopus, Web of Science and CINAHL databases. Risk of bias and applicability concerns were assessed by quality assessment of diagnostic accuracy studies (QUADAS-2). Data were extracted on socio-demographic, anthropometric, risk factors, serum 25 hydroxyvitamin D [25(OH)D] levels, statistical methods and predictive ability. A total of 12 studies were considered for inclusion for this systematic review after screening of 4851 abstracts and 15 full-text articles. Ten of twelve studies developed prediction models and 2 studies developed questionnaires. The majority of studies had low risk of bias and applicability as assessed by QUADAS-2. All studies included only self-reported predictors of vitamin D status in their final models and development of scores. Sunlight exposure and related factors were important significant contributors to the predictive ability of the models and/or questionnaires. Sensitivity and specificity of the prediction models or questionnaires ranged from 55 to 91% and 35 to 84%, respectively. Six out of twelve studies converted final models to scores associated with vitamin D status. There was no evidence that any of these existing tools have been translated into clinical practice. The prediction models or questionnaires identified in this systematic review were moderately sensitive and specific for identifying people with vitamin D deficiency or insufficiency. The substantial contribution of sunlight exposure to the prediction of vitamin D status highlights the importance of including this information when developing vitamin D screening tools.

AB1126 THE RELIABILITY AND DIAGNOSTIC ACCURACY OF DIGITAL TOMOSYNTHESIS COMPARED WITH CONVENTIONAL RADIOGRAPHY FOR THE INVESTIGATION OF SACROILIITIS

Background:

Conventional radiography remains part of the diagnosis of axial spondyloarthritis and determines qualification for biologic disease modifying anti-rheumatic drugs in many countries. The standard anteroposterior radiograph (XR) incompletely images the complex sacroiliac joint with recognised unacceptably low levels of agreement between readers. Digital tomosynthesis (DTS) uses conventional radiographic projections to create a three-dimensional image and is a potential alternative for the initial radiographic detection and grading of sacroiliitis.

Objectives:

To compare the level of agreement between two radiologists when reporting sacroiliac joint imaging with digital tomosynthesis versus conventional radiography, as well as to compare the diagnostic accuracy of each imaging modality.

Methods:

229 consecutive patients that had radiography and digital tomosynthesis performed at Footscray Hospital, Melbourne, Australia were included. Two blinded radiologists independently re-reported all images according to the modified New York criteria, or listed an alternative diagnosis. An overall assessment of each image as inflammatory sacroiliitis, normal or non-inflammatory disease was also recorded. Demographic and clinical data were extracted from medical records. Agreement between and within readers was evaluated using kappa (κ) statistic. Diagnostic accuracy was calculated by comparing each reader’s overall assessment against 2 reference standard comparators: most recent rheumatologist diagnosis and fulfillment of ASAS criteria at any time point.

Results:

The intra-reader agreement of reader 1 was almost perfect for the left, right and overall sacroiliac joint assessments (κ 0.77 - 0.94), with DTS outperforming XR. Reader 2 agreement was mostly moderate (κ 0.39 - 0.69), with DTS and XR better on the left and right sacroiliac joint respectively, but XR having better overall assessment. The inter-reader agreement of DTS for all patients was moderate and better than XR as shown in the Table. When excluding non-spondyloarthritis patients, inter-reader agreement improved (κ 0.50 to 0.58) but there was no significant difference between DTS and XR. Using reader 1, the sensitivity of DTS (64.8 - 66.7%) was better than XR (54.9 - 60.7%) but low, in keeping with what is known about radiographic sacroiliitis and axial spondyloarthritis. The specificity of XR (78.5 – 80.3%) was better than DTS (72.3 – 73.1%). There were no significant differences when fulfillment of modified New York Criteria was used as a reader’s positive test.

Table.

Inter-rater reliability between the readers

All patients(N=229)*Inflammatory sacroiliitis & normal patients (N=164)**Inflammatory sacroiliitis patients (N=92)**XR Right0.360.520.56DTS Right0.390.500.51XR Left0.340.550.56DTS Left0.420.550.58XR Overall0.40DTS Overall0.45

*Non-weighted kappa statistic

**Weighted kappa statistic

Conclusion:

DTS demonstrated moderate reliability for assessment of sacroiliitis, marginally better than conventional radiography. Overall levels of agreement for both imaging modalities were however lower than radiography in previous studies, with several possible contributing factors. A prospective study in a selected spondyloarthritis cohort may better determine any benefit of DTS.

References:

[1]Christiansen AA, Hendricks O, Kuettel D, Horslev-Petersen K, Jurik AG, Nielsen S, et al. Limited Reliability of Radiographic Assessment of Sacroiliac Joints in Patients with Suspected Early Spondyloarthritis. The Journal of rheumatology. 2017;44(1):70-7.

[2]van Tubergen A, Heuft-Dorenbosch L, Schulpen G, Landewe R, Wijers R, van der Heijde D, et al. Radiographic assessment of sacroiliitis by radiologists and rheumatologists: does training improve quality? Annals of the rheumatic diseases. 2003;62(6):519-25.

Disclosure of Interests:

None declared

Risk factors for ribavirin treatment failure in Asian organ transplant recipients with chronic hepatitis E infection

BACKGROUND

Hepatitis E virus (HEV) infection is a cause of chronic hepatitis in immunosuppressed patients. Sustained virologic response rates to a 12-wk course of ribavirin therapy were reported to be > 70% in the West. This study describes the outcome of HEV treatment in a transplant center in Singapore.

AIM

To study the outcome of ribavirin treatment in a series of chronic HEV patients, and the cause of treatment failure.

METHODS

We studied all of the transplant recipients who were diagnosed with HEV infection between 2012 to 2015. The outcome of therapy and virologic relapse are monitored for three years after the end of therapy.

RESULTS

Ten transplant recipients (4 liver, 5 kidney, and 1 bone marrow transplantation) with positive HEV RNA were studied. Nine patients received at least 12 wk of ribavirin therapy, and the remaining patient resolved after reducing immunosuppression therapy. Two subjects had prolonged viremia that lasted more than one year, despite continuous ribavirin therapy. Four ribavirin-treated patients (44.4%) had HEV RNA relapse after achieving a virologic response by the end of treatment. The overall failure rate is 66.7%. Being a kidney transplant recipient is the strongest risk factor for not achieving an initial sustained virologic response (0/5 treated, Chi-Square test, P < 0.05). The most common side effect of ribavirin is anemia (100%) (haemoglobin reduction of 3-6.2 g/dL). Seven patients required either a blood transfusion or erythropoietin therapy.

CONCLUSION

The sustained virologic response rate of 12-wk ribavirin therapy for HEV infection in this Asian series was lower than expected. Kidney transplant recipients had a higher rate of treatment failure due to higher immunosuppression requirements and adverse effects.

Outcomes of transperineal and transrectal ultrasound-guided prostate biopsy

OBJECTIVE

To compare the clinical outcomes and pathological findings of transperineal ultrasound-guided prostate biopsy (TPUSPB) and transrectal ultrasound-guided prostate biopsy (TRUSPB) in a secondary referral hospital.

METHODS

This was a retrospective study of 100 TPUSPBs and 100 TRUSPBs performed in our centre. Pre-biopsy patient parameters (eg, patient age, clinical staging, serum prostate-specific antigen [PSA] level, prostate size, and PSA density), as well as pathological results and 30-day complication and readmission rates, were retrieved from the patients' medical records and compared between the two groups.

RESULTS

One hundred TPUSPBs performed from January 2018 to May 2018 and 100 TRUSPBs performed from January 2016 to April 2016 were included for analysis. Mean age did not significantly differ between the groups. The TPUSPB group had a higher mean PSA level, smaller prostate size, and higher PSA density, compared with the TRUSPB group. The overall prostate cancer detection rate was similar between the TPUSPB and TRUSPB groups (35% vs 25%, P=0.123). There were no significant differences between the groups in prostate cancer detection rates after stratification according to PSA density and clinical staging. With respect to complications, no patients developed fever in the TPUSPB group, while 4% of patients in the TRUSPB group had fever and required at least 1-week admission for intravenous antibiotic administration.

CONCLUSION

For prostate biopsy, TPUSPB is safer, with no infection complications, and has similar prostate cancer detection rate compared with TRUSPB.

Spontaneous spinal epidural haematomas in children

PURPOSE

To understand the typical presentation, risk factors, location and size, treatment, neurological recovery and survival of spontaneous spinal epidural haematomas (SSEH) in children.

METHODS

A systematic review of the English literature from 1 January 1960 to 1 March 2018 was performed on children aged 18 years and younger. Individual patient data were extracted and collated. Outcome measures were mode of presentation, risk factors, initial neurological findings, initial presumed diagnosis, diagnostic investigations, site and size of the SSEH, treatment, neurological recovery and survival.

RESULTS

Thirty-one publications and 36 patients were reviewed. All age groups were affected. 83% of patients did not have a known risk factor. Back pain was reported in 61% and neurological dysfunction in 97% of patients, although not all articles defined these parameters. Initially 28% of patients were suspected of having an alternative diagnosis. All patients had an MRI and/or CT scan confirming the diagnosis. The cervical-thoracic region was most commonly affected, and the average haematoma size extended across 6.3 vertebral levels. Surgical decompression was performed in 72% of patients. Neurological function improved in 83% of patients. Two patients died as a consequence of their SSEH.

CONCLUSIONS

SSEHs affect all paediatric age groups and typically present with neurological dysfunction and/or back pain. The initial diagnosis is incorrect in up to 28% of cases, but cross-sectional spinal imaging is diagnostic. Most SSEHs are located in the cervico-thoracic region and affect multiple spinal levels. The treatment depends on whether the patient has a bleeding disorder and their neurological status. These slides can be retrieved under Electronic Supplementary Material.

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.

Factors associated with the orthopaedic surgeon's decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1905 patients

OBJECTIVE

To determine factors associated with orthopaedic surgeons' decision to recommend total joint replacement (TJR) in people with knee and hip osteoarthritis (OA).

DESIGN

Cross-sectional study in eleven countries. For consecutive outpatients with definite hip or knee OA consulting an orthopaedic surgeon, the surgeon's indication of TJR was collected, as well as patients' characteristics including comorbidities and social situation, OA symptom duration, pain, stiffness and function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), joint-specific quality of life, Osteoarthritis Research Society International (OARSI) joint space narrowing (JSN) radiographic grade (0-4), and surgeons' characteristics. Univariable and multivariable logistic regressions were performed to identify factors associated with the indication of TJR, adjusted by country.

RESULTS

In total, 1905 patients were included: mean age was 66.5 (standard deviation [SD], 10.8) years, 1082 (58.0%) were women, mean OA symptom duration was 5.0 (SD 7.0) years. TJR was recommended in 561/1127 (49.8%) knee OA and 542/778 (69.7%) hip OA patients. In multivariable analysis on 516 patients with complete data, the variables associated with TJR indication were radiographic grade (Odds Ratio, OR for one grade increase, for knee and hip OA, respectively: 2.90, 95% confidence interval [1.69-4.97] and 3.30 [2.17-5.03]) and WOMAC total score (OR for 10 points increase: 1.65 [1.32-2.06] and 1.38 [1.15-1.66], respectively). After excluding radiographic grade from the analyses, on 1265 patients, greater WOMAC total score was the main predictor for knee and hip OA; older age was also significant for knee OA.

CONCLUSION

Radiographic severity and patient-reported pain and function play a major role in surgeons' recommendation for TJR.

SIRveNIB: Selective Internal Radiation Therapy Versus Sorafenib in Asia-Pacific Patients With Hepatocellular Carcinoma

Purpose Selective internal radiation therapy or radioembolization (RE) shows efficacy in unresectable hepatocellular carcinoma (HCC) limited to the liver. This study compared the safety and efficacy of RE and sorafenib in patients with locally advanced HCC. Patients and Methods SIRveNIB (selective internal radiation therapy v sorafenib), an open-label, investigator-initiated, phase III trial, compared yttrium-90 (⁹⁰Y) resin microspheres RE with sorafenib 800 mg/d in patients with locally advanced HCC in a two-tailed study designed for superiority/detriment. Patients were randomly assigned 1:1 and stratified by center and presence of portal vein thrombosis. Primary end point was overall survival (OS). Efficacy analyses were performed in the intention-to-treat population and safety analyses in the treated population. Results A total of 360 patients were randomly assigned (RE, 182; sorafenib, 178) from 11 countries in the Asia-Pacific region. In the RE and sorafenib groups, 28.6% and 9.0%, respectively, failed to receive assigned therapy without significant cross-over to either group. Median OS was 8.8 and 10.0 months with RE and sorafenib, respectively (hazard ratio, 1.1; 95% CI, 0.9 to 1.4; P = .36). A total of 1,468 treatment-emergent adverse events (AEs) were reported (RE, 437; sorafenib, 1,031). Significantly fewer patients in the RE than sorafenib group had grade ≥ 3 AEs (36 of 130 [27.7%]) v 82 of 162 [50.6%]; P < .001). The most common grade ≥ 3 AEs were ascites (five of 130 [3.8%] v four of 162 [2.5%] patients), abdominal pain (three [2.3%] v two [1.2%] patients), anemia (zero v four [2.5%] patients), and radiation hepatitis (two [1.5%] v zero [0%] patients). Fewer patients in the RE group (27 of 130 [20.8%]) than in the sorafenib group (57 of 162 [35.2%]) had serious AEs. Conclusion In patients with locally advanced HCC, OS did not differ significantly between RE and sorafenib. The improved toxicity profile of RE may inform treatment choice in selected patients.

Giant cell aortitis leading to Stanford type B and type A aortic dissection

This report provides a rare histological example and the appropriate management of spontaneous aortic dissection secondary to giant cell arteritis.

Acute-on-chronic liver failure in a multi-ethnic Asian city: A comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions

AIM

To explore the applicability of the Asia-Pacific Association for the Study of the Liver (APASL) and European Association for the Study of the Liver (EASL) guidelines for acute-on-chronic liver failure (ACLF) in profiling patients and determining the outcome.

METHODS

Patients admitted to a tertiary hospital in Singapore with acute decompensation of liver disease from January 2004 to July 2014 are screened for ACLF according to the APASL and EASL criteria. The patients’ data (including basic demographics, information about existing chronic liver disease, information about the acute decompensation, relevant laboratory values during admission, treatment, and outcome) are retrospectively analyzed to determine the background, precipitating factors and outcome.

RESULTS

A total of 458 liver patients is analyzed, and 78 patients with ACLF are identified. Sixty-three patients (80.8%) meet the APASL criteria, 64 patients (82.1%) meet the EASL criteria, and 49 patients (62.8%) fulfilled both criteria. The most common causes of acute liver injury are bacterial infections (59.0%), hepatitis B flare (29.5%), and variceal bleeding (24.4%). The common aetiologies of the underlying chronic disease included hepatitis B (43.6%), alcoholic (20.5%) and cryptogenic (11.5%) liver disease. The overall mortality rate is 61.5%. Increased age, the number of organ failures (as per CLIF-SOFA score), peak creatinine, INR, and amylase levels are associated with increased mortality or the need for liver transplantation. 14.3% of patients undergo liver transplantation with a 100% 1-year survival rate.

CONCLUSION

Both APASL and EASL criteria have identified ACLF patients with high three-month mortality, but those who fulfill APASL criteria alone have a better survival.

Diversity in fall characteristics hampers effective prevention: the precipitants, the environment, the fall and the injury

Falls among the elderly are common and characteristics may differ between injurious and non-injurious falls. Among 887 older Australian women followed for 1.6 years, 32% fell annually. Only 8.5% resulted in fracture and/or hospital admission. The characteristics of those falls are indistinguishable from those not coming to medical attention.

INTRODUCTION

The precipitants and environment of all falls occurring among a large cohort of older Caucasian women were categorised by injury status to determine if the characteristics differed between injurious and non-injurious falls.

METHODS

Among 887 Australian women (70+ years), falls were ascertained using monthly postcard calendars and a questionnaire was administered for each fall. Hospital admissions and fractures were independently confirmed.

RESULTS

All falls were reported for a mean observation time of 577 (IQR 546-607) days per participant, equating to a total 1400 person-years. Thirty-two percent fell at least once per year. The most common features of a fall were that the faller was walking (61%) at home (61%) during the day (88%) and lost balance (32%). Only 12% of all falls occurred at night. Despite no difference in the type of injury between day and night, the likelihood of being hospitalised from a fall at night was 4.5 times greater than that of a daytime fall with adjustment for injury type and participant age (OR 4.5, 95% CI 2.1, 9.5; p < 0.001). Of all falls, approximately one third were associated with no injury to the faller (31%), one third reported a single injury (37%) and one third reported more than one injury (32%). In 95% of falls, the faller was not admitted to hospital. Only 5% of falls resulted in fracture(s).

CONCLUSIONS

Our findings demonstrate the significant diversity of precipitants and environment where falls commonly occur among older community-dwelling women. Falls resulting in fracture and/or hospital admission collectively represent 8.5% of all falls and their characteristics are indistinguishable from falls not coming to medical attention and incurring no apparent cost to the health system.

Spinal infections in older people: an analysis of demographics, presenting features, microbiology and outcomes

BACKGROUND

Clinical features of infection can become more atypical as we age. Spinal infections can be insidious, and timely diagnosis and treatment are essential to prevent adverse outcomes.

AIMS

To explore differences in presentation and outcomes between younger and older patients with bacterial spinal infections.

METHODS

Clinical, microbiological and radiological information was collected for patients with spinal infections (spondylodiscitis, vertebral osteomyelitis, septic discitis, facet joint septic arthritis and spinal epidural abscess) at a single metropolitan hospital between January 2008 and January 2015. Patients were excluded if they were under 18 years of age or if clinical and imaging findings were inconsistent with the diagnosis. Presenting features, investigations and outcomes were compared for patients ≥65 (older) or <65 (younger) years old.

RESULTS

Of 53 identified patients, 34 (64%) were classified as older, with more males in both older (65%) and younger (79%) groups. Older patients presented later (median symptom duration 13 vs 4 days, P = 0.016). Back pain was nearly ubiquitous. Older patients presented less commonly with fevers (38 vs 63%) and rigors (24 vs 42%) but more commonly with hypotension (18 vs 5%), delirium (24 vs 11%), higher median inflammatory marker levels and variable microbiological findings, although these differences were not statistically significant. They had longer median lengths of stay (24 vs 14 days) and a higher likelihood of death or failure of medical treatment (HR 9.34, P = 0.031). Radicular pain was associated with poor outcome (HR 3.29, P = 0.046).

CONCLUSION

Older patients with spinal infections present later, with higher inflammatory markers and fewer typical infective symptoms and signs; these may contribute to poorer outcomes. A low threshold for promptly investigating older patients with new or worsening back pain should be set.