Preoperative Dehydration Predicts Adverse Events Following Anterior Cervical Discectomy and Fusion

BACKGROUND

Anterior cervical discectomy and fusion (ACDF) is a common procedure for neck arthritis, typically alleviating pain and improving function. Preoperative dehydration has been correlated with postoperative infection, acute renal failure, deep vein thrombosis, and increased hospital length of stay. However, some studies have suggested that preoperative dehydration has a minimal relationship with postoperative outcomes, specifically in arthroplasty and lumbar surgery candidates.

METHODS

Patients who underwent ACDF from 2015 to 2020 as part of the American College of Surgeons National Surgical Quality Improvement Program database were identified. We excluded patients who presented with acute trauma. Dehydration was determined using the accepted definition of preoperative blood urea nitrogen to creatinine ratio greater than 20. Lengths of stay and 30-day postoperative adverse events were compared between dehydrated and nondehydrated cohorts, adjusting for baseline features using standard multivariate regression.

RESULTS

We identified 14,932 patients, and 4206 (28.1%) of whom were preoperatively dehydrated. Dehydrated patients had significantly higher odds of wound, hematological, and pulmonary complications; Clavien-Dindo grade IV, delayed length of stay (>5 days); and a lower likelihood of being discharged home (P < 0.005), even after controlling for demographic features (eg, sex, age, body mass index, race, and ethnicity). Furthermore, linear regression suggested an overall half-day increased length of hospital stay for dehydrated patients (95% CI [0.36, 0.60], P < 0.001).

CONCLUSION

Preoperative dehydration is common among ACDF surgery patients and appears to correlate with an increased risk of postoperative complications and prolonged length of hospital stay. Evaluation of a patient's hydration status from standard preoperative laboratory metrics can be employed for risk stratification, patient counseling, and timing of ACDF surgeries.

LEVEL OF EVIDENCE: 3

Single incision laparoscopy versus conventional multiport laparoscopy for colorectal surgery: a systematic review and meta-analysis

INTRODUCTION

There has been an increase in colorectal cancer resections worldwide and in the UK. Initially conducted as an open procedure, this was replaced with the conventional multiport technique. Laparoscopic colectomy became the standard surgical technique in 1991. With innovation in surgical technology, single incision laparoscopy (SIL) has attracted more attention as the possible next step in colorectal resection. The aim of this review was to compare outcomes between SIL and conventional laparoscopy (CL).

METHODS

A literature search was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. The PubMed®, MEDLINE®, Embase®, Google Scholar™ and Cochrane Library databases were used to extract randomised controlled trials (RCTs) published between January 2000 and May 2021. Statistical analysis was performed with RevMan software.

RESULTS

A total of 11 RCTs were extracted with 1,370 patients (686 SIL, 684 CL). There was no significant difference between SIL and CL for operative time (standardised mean difference [SMD]: 0.01, 95% confidence interval [CI]: -0.19 to 0.22, z=0.11, p=0.91), length of hospital stay (SMD: -0.10, 95% CI: 0.22 to 0.02, z=1.61, p=0.11) or overall complications (odds ratio [OR]: 0.99, 95% CI: 0.75 to 1.30, z=0.09, p=0.93). SIL had a shorter mean incision (SMD: -0.99, 95% CI: -1.35 to -0.62, z=5.25, p<0.00001). Patients undergoing SIL had a higher conversion rate to CL or an open approach (OR: 3.10, 95% CI: 0.95 to 10.14, z=1.87, p=0.06) but this just missed statistical significance.

CONCLUSIONS

SIL can be considered a safe alternative to CL if performed by experienced surgeons.

AMFR dysfunction causes autosomal recessive spastic paraplegia in human that is amenable to statin treatment in a preclinical model

Hereditary spastic paraplegias (HSP) are rare, inherited neurodegenerative or neurodevelopmental disorders that mainly present with lower limb spasticity and muscle weakness due to motor neuron dysfunction. Whole genome sequencing identified bi-allelic truncating variants in AMFR, encoding a RING-H2 finger E3 ubiquitin ligase anchored at the membrane of the endoplasmic reticulum (ER), in two previously genetically unexplained HSP-affected siblings. Subsequently, international collaboration recognized additional HSP-affected individuals with similar bi-allelic truncating AMFR variants, resulting in a cohort of 20 individuals from 8 unrelated, consanguineous families. Variants segregated with a phenotype of mainly pure but also complex HSP consisting of global developmental delay, mild intellectual disability, motor dysfunction, and progressive spasticity. Patient-derived fibroblasts, neural stem cells (NSCs), and in vivo zebrafish modeling were used to investigate pathomechanisms, including initial preclinical therapy assessment. The absence of AMFR disturbs lipid homeostasis, causing lipid droplet accumulation in NSCs and patient-derived fibroblasts which is rescued upon AMFR re-expression. Electron microscopy indicates ER morphology alterations in the absence of AMFR. Similar findings are seen in amfra-/- zebrafish larvae, in addition to altered touch-evoked escape response and defects in motor neuron branching, phenocopying the HSP observed in patients. Interestingly, administration of FDA-approved statins improves touch-evoked escape response and motor neuron branching defects in amfra-/- zebrafish larvae, suggesting potential therapeutic implications. Our genetic and functional studies identify bi-allelic truncating variants in AMFR as a cause of a novel autosomal recessive HSP by altering lipid metabolism, which may potentially be therapeutically modulated using precision medicine with statins.

Phenotypic continuum of NFU1-related disorders

Bi-allelic variants in Iron-Sulfur Cluster Scaffold (NFU1) have previously been associated with multiple mitochondrial dysfunctions syndrome 1 (MMDS1) characterized by early-onset rapidly fatal leukoencephalopathy. We report 19 affected individuals from 10 independent families with ultra-rare bi-allelic NFU1 missense variants associated with a spectrum of early-onset pure to complex hereditary spastic paraplegia (HSP) phenotype with a longer survival (16/19) on one end and neurodevelopmental delay with severe hypotonia (3/19) on the other. Reversible or irreversible neurological decompensation after a febrile illness was common in the cohort, and there were invariable white matter abnormalities on neuroimaging. The study suggests that MMDS1 and HSP could be the two ends of the NFU1-related phenotypic continuum.

POS0714 POOLED SAFETY ANALYSIS OF BARICITINIB IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: RESULTS FROM THREE RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, CLINICAL TRIALS

Background

Baricitinib (BARI), an oral selective inhibitor of Janus kinase 1 and 2 approved for the treatment of rheumatoid arthritis and atopic dermatitis, has been evaluated in clinical studies in patients with systemic lupus erythematosus (SLE).

Objectives

To assess the safety profile of BARI in patients with SLE.

Methods

Patients with SLE receiving stable background therapy were randomised 1:1:1 to BARI 2-mg, 4-mg, or placebo (PBO) once daily in one 24-week, phase 2 (NCT02708095) and two 52-week, phase 3, PBO controlled studies (NCT03616912 and NCT03616964).

Results

A total of 1,849 patients were included in this pooled analysis, representing 1,463.5 patient years of exposure (PYE). The incidence rates per 100 PYR at risk (IR/100 PYR) for serious adverse events (SAEs) were 9.5, 14.7, and 14.1 respectively for PBO, BARI 2-mg, and BARI 4-mg. There were no clinically meaningful differences between treatment groups for discontinuations due to AEs or death (Table 1).

Table 1.

Overview of safety measures of baricitinib in patients with SLE

Safety measurePBOBARI 2-mgBARI 4-mgPooled-BARIN=614N=621N=614N=1235PYE=488.1PYE=494.0PYE=481.4PYE=975.4n(%)n(%)n(%)n(%)PYRPYRPYRPYR[IR; 95%CI][IR; 95%CI][IR; 95%CI][IR; 95%CI]SAEs45 (7.3)70 (11.3)*65 (10.6)*135 (10.9)*473.2476.6461.9938.5[9.5; 6.9, 12.7][14.7; 11.5, 18.6][14.1; 10.9, 17.9][14.4; 12.1, 17.0]Discontinuation of study drug due to AE48 (7.8)58 (9.3)57 (9.3)115 (9.3)485.3492.3480.6973.0[9.9; 7.3, 13.1][11.8; 8.9, 15.2][11.9; 9.0, 15.4][11.8; 9.8, 14.2]Death4 (0.7)1 (0.2)4 (0.7)5 (0.4)488.2494.0481.5975.5[0.8; 0.2, 2.1][0.2; 0.0, 1.1][0.8; 0.2, 2.1][0.5; 0.2, 1.2]Serious infections12 (2.0)22 (3.5)28 (4.6)*50 (4.0)*484.3487.2472.5959.7[2.5; 1.3, 4.3][4.5; 2.8, 6.8][5.9; 3.9, 8.6][5.2; 3.9, 6.9]Herpes Zoster18 (2.9)17 (2.7)29 (4.7)46 (3.7)481.1486.5468.6955.1[3.7; 2.2, 5.9][3.5; 2.0, 5.6][6.2; 4.1, 8.9][4.8; 3.5, 6.4]VTEs#6 (1.2)3 (0.6)1 (0.2)4 (0.4)444.0450.2438.1888.3[1.4; 0.5, 2.9][0.7; 0.1, 1.9][0.2; 0.0, 1.3][0.5; 0.1, 1.2]MACE#01 (0.2)3 (0.6)4 (0.4)443.9450.1438.1888.3[0.0; NA, 0.8][0.2; 0.0, 1.2][0.7; 0.1, 2.0][0.5; 0.1, 1.2]Malignancy excluding NMSC2 (0.3)3 (0.5)2 (0.3)5 (0.4)488.0494.1481.4975.5[0.4; 0.0, 1.5][0.6; 0.1, 1.8][0.4; 0.1, 1.5][0.5; 0.2, 1.2]NMSC2 (0.3)000*486.7494.0481.4975.4[0.4; 0.0, 1.5][0.0; NA, 0.7][0.0; NA, 0.8][0.0; NA, 0.4]

Data are n (%) patients PYR [IR; 95% CI]. #Phase 2 study data not included. AE=adverse event; CI=confidence interval; MACE=major adverse cardiac event; NMSC=non-melanoma skin cancers; VTE=venous thrombotic event (includes deep vein thrombosis and pulmonary embolism); IR=incidence rate (100 times the number of patients reporting an adverse event divided by the event-specific exposure to treatment); N=number of patients in the analysis population; n=number of patients in the specified category; PYE=patient-year of exposure; PYR=patient years at risk; SAE=serious adverse event. *p≤0.05 vs placebo.

The IR/100 PYR for serious infections were 2.5, 4.5, and 5.9 respectively for PBO, BARI 2-mg, and BARI 4-mg. The risk of Herpes Zoster was higher in BARI 4-mg (4.7%) vs PBO (2.9%) (Table 1).

The IR/100 PYR for positively adjudicated venous thrombotic events (VTEs) were 1.4, 0.7, and 0.2 respectively for PBO, BARI 2-mg, and BARI 4-mg. The IR/100 PYR for positively adjudicated major adverse cardiac event (MACE) was numerically higher in BARI 2-mg (0.2) and BARI 4-mg (0.7) vs PBO (0.0), however the pooled-BARI IR/PYR (0.5) was within the range of background disease (1). No increased risk for malignancies was observed.

Conclusion

The safety profile of BARI in SLE patients was consistent with the known BARI safety profile. There was no increased risk of VTE in BARI treatment groups.

References

[1]Barbhaiya M, Feldman CH, et al. Arthritis Rheumatol. 2017;69(9):1823-31.

Disclosure of Interests

Thomas Dörner Speakers bureau: Eli Lilly and Company and Roche, Consultant of: AbbVie, Celgene, Eli Lilly and Company, Janssen, Novartis, Roche, Samsung and UCB, Grant/research support from: Chugai, Janssen, Novartis and Sanofi, Yoshiya Tanaka Speakers bureau: Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Consultant of: Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie, Grant/research support from: Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, Marta Mosca Speakers bureau: Eli Lilly, GSK, Astra Zeneca, Consultant of: Eli Lilly, GSK, Astra Zeneca, Ian N. Bruce Speakers bureau: GSK, Astra Zeneca, UCB, Consultant of: Eli Lilly, GSK, UCB, BMS, Merck Serono, Astra Zeneca, IL-TOO, Aurinia, Grant/research support from: GSK, Janssen, Mario Cardiel Speakers bureau: Eli Lilly, Pfizer, Abbvie, Consultant of: Eli Lilly, Pfizer, Grant/research support from: Pfizer, Gilead, Roche, Janssen, Eric F. Morand Speakers bureau: AstraZeneca, Eli Lilly, Novartis, Consultant of: Amgen, AstraZeneca, Asahi Kasei, Biogen, BristolMyersSquibb, Capella, Eli Lilly, EMD Serono, Genentech, GlaxoSmithKline, Janssen, Neovacs, Sanofi, Servier, UCB, Wolf, Grant/research support from: Janssen, AstraZeneca, BristolMyersSquibb, Eli Lilly, EMD Serono, GlaxoSmithKline, Michelle A Petri Consultant of: Eli Lilly, Grant/research support from: Eli Lilly, Maria Silk Shareholder of: Eli Lilly, Employee of: Eli Lilly, christina dickson Shareholder of: Eli Lilly, Employee of: Eli Lilly, Gabriella Meszaros Shareholder of: Eli Lilly, Employee of: Eli Lilly, Maher Issa Shareholder of: Eli Lilly, Employee of: Eli Lilly, Lu Zhang Shareholder of: Eli Lilly, Employee of: Eli Lilly, Daniel J. Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono and Pfizer

Hand hygiene practices for prevention of health care-associated infections associated with admitted infectious patients in the emergency department: a systematic review

Background

In most high-income countries, emergency departments (ED) represent the principal point of access forcer by critically ill or injured patients. Unlike inpatient units, ED healthcare workers (ED HCWs) have demonstrated relative lack of adherence to hand hygiene (HH) guidelines, commonly citing frequency of intervention and high rates of admission, which reflect severity of cases encountered.

Aim

Assessment of studies on hand hygiene compliance (HHC) by ED HCWs conducted between 2010 and 2020, seeking to estimate HHC rates and intervention strategies utilised to improve HHC in EDs.

Methods

Searches conducted in Web of Science, EBSCO HOST (CINHAL & Medline), PubMed, Embase, and Cochrane for full studies published between 2010 and 2020 on the topic of HHC in the ED.

Results

One hundred twenty-nine eligible articles were identified of which 79 were excluded. Fifty-one underwent full-text screening before 20 studies were deemed relevant. Of the eligible studies, fifteen (75%) had, as the primary outcome, HHC according to the WHO-recommended 5-moments. Twelve studies (60%) implemented multimodal or single intervention strategies. Eight studies were ambiguous regarding the nature of the approach adopted. In the nine observational studies where HHC was documented, an overall post-intervention median HHC rate of 45% (range 8–89.7%).

Conclusion

Multimodal approaches appear to have enhanced HHC moderately among ED HCWs. Elevated complexity associated with critically ill patients, and ED overcrowding, are contributing factors to relatively low compliance rates observed. Strategies to improve HHC rates may need to acknowledge, and cater for, the context of an unpredictable environment.

42 The Accuracy of the Multi-Slice Detector CT scan (MDCT) in Staging Borderline Respectable Periampullary Carcinoma

Aim

Assess MDCT accuracy in staging cancers periampullary cancers.

Method

Periampullary malignancies are highly aggressive with poor outcomes. Surgery is the only curative option. It is crucial to define the patients who can advantage from a Whipple’s resection and who can avoid. RCT investigated randomly 28 patients over 15 months. The patients were sub-divided into 2 groups. Group A, we relied mainly on the MDCT for preoperative staging, while in Group B staging laparoscopy was added before the abdominal exploration. Sensitivity of the MDCT and its accuracy were 100% in defining the signs of irresectability. For borderline staging, the accuracy of the scan was 62.5% and 71%, in groups A and B. The Overall accuracy of MDCT was 75%. It decreased to 68.1% for borderline lesions. The addition of staging laparoscopy to the diagnostic work up, increased the accuracy to 92.5%. The camera test was able to see occult findings which were missed in the images. Liver Mets and malignant peritoneal fluid were localized in 18% and 9% respectively. 3 cases in group A and one in group B underwent unnecessary laparotomy. Thus, the false negative incidences were 21% and 7% in group A and B, with overall incidence 14.2%.

Conclusion

MDCT is highly sensitive and specific with high stage periampullary cancers. These parameters drop in border tumours with reduced accuracy in detecting the degree of vascular abutment and distant-occult findings. Addition of other adjuncts to decrease the rate of un-indicated laparotomy.

52 Evaluating the Outcomes of Anal Squamous Cell Carcinoma with Curative Intent- a 10-Year Experience

Background

Our 10-year experience in treating anal squamous cell carcinoma (ASCC) with curative intent.

Method

Clinical and pathological data were analysed between January 2011 and December 2019. All patients underwent the standard workup and treated accordingly. Patients were followed up according to the network protocol. The outcome measures were clinicopathological characteristics, treatment modalities, response, recurrence, disease-free and overall survival.

Results

117 patients followed up over the 10-year. 26 patients treated palliatively, 11 patients with adenocarcinoma, 1 melanoma, 1 Paget disease and 1 carcinoid tumour were excluded. Median age was 65 (38–90) years with male to female ratio of 1:1.9. 3 patients were HIV+ve and 52% of the patients had AIN of varying degree of dysplasia. AJCC stages were I (16), II (18), IIIA (19), IIIB (9) and IV (15). 88.3%% of the patients had radical chemoradiotherapy while 9 patients with tumour ≤2cm underwent wide local excision. 81.8% of the patients treated with radical chemoradiotherapy had complete response while (5/77) had partial response.4 patients with incomplete response underwent salvage APER. Recurrence rate was 13%.

The overall mean survival time was 99.82 (95% CI 88.87–110.77) months with 5-year survival rate 78.0%. Overall recurrence rate was 13.0%. Mean disease-free survival time in 77 patients was 111.82 (95% CI 102.38–121;26) months. 75.3% of the patients were alive at the end of the study with an overall mortality rate was 24.7% and disease-specific mortality was 15.6%.

Conclusions

Recurrent anal SCC occurred in 1 in 10 after radical chemo-radiotherapy with disease-specific mortality of 26%.

127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit

Background

Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking.

Method

A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded.

Results

Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively.

Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients).

Conclusions

Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

302 Metastatic: Benign Lymph Node Ratio (LNR) and Lymph Node Yield (LNY) as Predictors of Survival in Resected Colorectal Cancer (CRC)

Background

Lymphadenectomy is central to tumor prognosis. 12 LNY during CRC resection is a standard of good oncological resection, but 30–50 percent of resections do not achieve this. LNR was suggested to be a more accurate predictive factor.

Aim

To examine the prognostic significance of LNY and LNR on survival in patients with non-metastatic CRC.

Method

A retrospective study on patients with CRC treated at a DGH from January 2015 to February 2017. Outcome measures were Disease-Free (DFS) and Overall Survival (OS).

Results

265 cases were identified. The mean age was (71.4±11.3) years with a median follow-up of 56 (range 0–72) months. Median LNY was 18 (range 0–66) nodes. 74.9% of the cases have&gt; 12 LNY and only 25.1% of the cases have &lt; 12 LN yielded in the specimen; however, 76.4% have LNR of 0-&lt;0.25. Increasing LNR was associated with poorer OS and

DFS (p-value 0.0001). An LNR of (0.75–1) was associated with a very poor prognosis (p-value 0.0001); it showed 30 and 33 months less in median OS and DFS retrospectively than LNR

(0-&lt;0.25). LNY did not show any statistically significant predictive factor in survival.

Multivariate analysis showed OS and DFS are affected (R2 = 27.3% and 26.1% retrospectively) mainly by LNR. It did not show statistical significance with the other variables, including TNM, LNY, and Dukes' stages.

Conclusions

Increasing LNR was a marker of poor survival; however, LNY was not a statistically significant predictive factor. LNR is better in predicting survival than TNM and Dukes' staging.

Vascular inflammation in patients with obstructive sleep apnoea and coronary artery disease shown on coronary computed tomography angiography attenuation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obstructive sleep apnoea (OSA) is associated with increased plaque burden in coronary artery disease (CAD), but the role of vascular inflammation in this relationship is unclear. Coronary computed tomography angiography (CTA) enables surrogate assessment of systemic inflammation via subcutaneous adipose tissue attenuation (ScAT-a), and of coronary inflammation via epicardial adipose tissue volume and attenuation (EAT-v and EAT-a) and pericoronary adipose tissue attenuation (PCAT-a).

Purpose

To investigate whether vascular inflammation is increased in patients with severe OSA and high plaque burden.

Methods

Patients with clinically indicated polysomnography and coronary CTA were included. Severe OSA was classified as apnoea/hypopnoea index (AHI) &gt;30. High plaque burden was defined as a CT-Leaman score (CT-LeSc) &gt;8.3. Patients with both severe OSA and high plaque burden were defined as ‘Group 1’, all other patients were classified as ‘Group 2’. ScAT-a, EAT-a, EAT-v and PCAT-a were assessed on semi-automated software.

Results

A total of 91 patients were studied (59.3 ± 11.1 years). Severe OSA was associated with high plaque burden (p = 0.02). AHI correlated with CT-LeSc (r = 0.24, p = 0.023). Group 1 had lower EAT-a and PCAT-a compared to Group 2 (EAT-a: -87.6 vs. -84.0 HU, p = 0.01; PCAT-a: -90.4 vs. -83.4 HU, p &lt; 0.01). However, among patients without high plaque burden, EAT-a was increased in patients with severe OSA versus mild-moderate OSA (-80.3 vs. -84.0 HU, p = 0.020). On multivariable analysis, EAT-a independently associated with severe OSA and high plaque burden (p &lt; 0.02), and PCAT-a associated with severe OSA and high plaque burden, and hypertension (all p &lt; 0.01).

Conclusions

EAT attenuation is decreased in patients with severe OSA and high plaque burden but increased in patients with severe OSA and low plaque burden. These divergent results suggest coronary inflammation may be increased in OSA independent of CAD, but larger studies are required to validate these findings.

Implication of folate deficiency in CYP2U1 loss of function

Hereditary spastic paraplegias are heterogeneous neurodegenerative disorders. Understanding of their pathogenic mechanisms remains sparse, and therapeutic options are lacking. We characterized a mouse model lacking the Cyp2u1 gene, loss of which is known to be involved in a complex form of these diseases in humans. We showed that this model partially recapitulated the clinical and biochemical phenotypes of patients. Using electron microscopy, lipidomic, and proteomic studies, we identified vitamin B2 as a substrate of the CYP2U1 enzyme, as well as coenzyme Q, neopterin, and IFN-α levels as putative biomarkers in mice and fluids obtained from the largest series of CYP2U1-mutated patients reported so far. We also confirmed brain calcifications as a potential biomarker in patients. Our results suggest that CYP2U1 deficiency disrupts mitochondrial function and impacts proper neurodevelopment, which could be prevented by folate supplementation in our mouse model, followed by a neurodegenerative process altering multiple neuronal and extraneuronal tissues.

1073 Synchronous Cholecystitis and Appendicitis: A Case Report Highlighting Learning Points on Medical Imaging and Consent

Laparoscopic appendicectomy and laparoscopic cholecystectomy are separately two of the most common emergency surgical procedures carried out in the UK. Only a small number of synchronous presentations of acute appendicitis and acute cholecystitis have been reported in surgical literature and this rare co-existent pathology gives rise to several valuable learning points with regards to laparoscopy, medical imaging interpretation and the consent process.

Our case report involves a 58-year-old female patient presenting with both RUQ and RIF pain and positive Murphy’s sign on clinical examination. US scan demonstrated several gallstones within a thin-walled gallbladder. Subsequent CT scan reported acute appendicitis which was treated definitively with laparoscopic surgery. Intraoperatively a perforated gangrenous gallbladder containing multiple calculi was discovered, and the decision was made to perform a double procedure of laparoscopic appendicectomy and cholecystectomy. Histopathology confirmed synchronous pathology of appendicitis with faecolith and calculus cholecystitis.

This case demonstrates the importance of considering multiple pathologies when assessing a patient with ambiguous and migratory abdominal pain. It reinforces the importance of diagnostic laparoscopy to rule out multiple pathologies. This acts as a cautionary case against over-reliance on medical imaging and reminds surgeons of their obligation to maintain competence in CT interpretation plus correlation of imaging with clinical assessment of the patient. Readers should also be reminded that the consent process for surgical interventions should be undertaken meticulously in patients with ambiguous abdominal pain.

833 An Interesting Association Between Recurrent Acute Pancreatitis and Myotonic Dystrophy, A Case Report

Myotonic Dystrophy(MD) is an autosomal dominant genetic condition affecting the musculoskeletal system. Recurrent acute pancreatitis(RAP) is a frequent presentation in the emergency surgical scenario with two or more episodes of established acute pancreatitis separated by a minimum of 3 month periods. We report here a case of a patient presenting with a background of Myotonic Dystrophy with a third episode of RAP. Diagnostic work up led to the discovery of microlithiasis as a possible cause of pancreatitis in our patient. Literature review reports two other case reports detailing a potential association between MD and pancreatitis at the time of writing. This could be due to disturbances of the pancreatobiliary system, resulting from the sphincter of Oddi dysfunction (SOD) and gallbladder myotonia as MD affects the smooth and striated muscle of the gastrointestinal tract. In our case report, we highlight the importance of understanding how MD is a rare cause for a common surgical emergency presentation clinicians should be aware of.

Performance of the APACHE II and SOFA Scores in Diabetic Ketoacidosis

Accurate prediction of severity and mortality in diabetic ketoacidosis (DKA) is important for allocation of resources. The APACHE II and SOFA scores are used to predict mortality in critically ill patients, however neither has been tested exclusively in DKA. We sought to determine if these scoring systems can accurately predict mortality in patients with DKA. This was an observational study of patients presenting to an urban tertiary care center with a diagnosis of DKA. Adult patients (age ≥ 18 years) with glucose > 250 mg/dL, bicarbonate ≤ 20 mEg/L, an anion gap ≥ 16 mEg/L, pH ≤ 7.30, and urine ketones were included. Predicted mortality based upon APACHE II and SOFA scores were compared to observed mortality. A total of 50 patients were included. There was no observed mortality in our population. The median APACHE II score was 10 (IQR: 6, 15) which predicted a mortality of 15% and the median SOFA score was 1 (IQR: 0, 2) which predicted a mortality of 0%. In summary, we found the APACHE II illness severity score does not accurately predict mortality in a population of patients with DKA, while the SOFA score appears to predict mortality in the same population.

645 An EGS-Led Service for Acute Appendicitis Enhances Surgical Training Whilst Improving Outcomes for Patients: Results of A 6-Month Audit

Introduction

Appendicitis is common &treatment by appendectomy is usually undertaken. Variations in diagnostics &imaging are accompanied by high negative appendectomy rates (NAR) of around 20%. This study evaluated the outcomes of appendectomy in a dedicated Surgical Emergency Unit.

Method

All patients undergoing emergency appendectomy between 1stSept 2019&29thFeb 2020 were identified. Demographics, clinical findings, pre-operative investigations, intra-operative findings &post-operative outcomes were recorded.

Results

There were 192 patients (102 [53.1%] female;90 [46.9%] male). Median age was 36 years(range 8-80)with 25 below 14.Some 58.3% underwent imaging (ultrasound 33.5%; CT 32.5%).

Laparoscopic appendectomy (LA) was performed in 84.4% of cases with 11.4% open; conversion from laparoscopic to open was only 4.2%. Some 56% paediatric patients had open appendectomy & 44% laparoscopic with no conversions. Trainees were the sole or first operators in 63% of cases.

NAR was just 5.7%. Some 21(10.9%) patients were readmitted within 30 days of which 8 had a collection; all were treated conservatively.

Conclusions

Accurate clinical diagnosis & selective use of imaging in a dedicated EGS unit optimizes outcomes for appendectomy with low NAR & low complication rates. Appendectomy is effectively undertaken by trainees. LA is safely performed in children.

Adult Advanced Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations for advanced life support includes updates on multiple advanced life support topics addressed with 3 different types of reviews. Topics were prioritized on the basis of both recent interest within the resuscitation community and the amount of new evidence available since any previous review. Systematic reviews addressed higher-priority topics, and included double-sequential defibrillation, intravenous versus intraosseous route for drug administration during cardiac arrest, point-of-care echocardiography for intra-arrest prognostication, cardiac arrest caused by pulmonary embolism, postresuscitation oxygenation and ventilation, prophylactic antibiotics after resuscitation, postresuscitation seizure prophylaxis and treatment, and neuroprognostication. New or updated treatment recommendations on these topics are presented. Scoping reviews were conducted for anticipatory charging and monitoring of physiological parameters during cardiopulmonary resuscitation. Topics for which systematic reviews and new Consensuses on Science With Treatment Recommendations were completed since 2015 are also summarized here. All remaining topics reviewed were addressed with evidence updates to identify any new evidence and to help determine which topics should be the highest priority for systematic reviews in the next 1 to 2 years.

Pooled safety analysis of baricitinib in adult patients with atopic dermatitis from 8 randomized clinical trials

BACKGROUND

Janus kinase (JAK) inhibition is a new mode of action in atopic dermatitis (AD); clarity about drug class safety considerations in the context of AD is important. Baricitinib, an oral, reversible, selective inhibitor of JAK1/JAK2, is in late-stage development for adult patients with moderate-to-severe AD.

OBJECTIVE

To report pooled safety data for baricitinib in patients with moderate-to-severe AD in the clinical development program including long-term extension (LTE) studies.

METHODS

This analysis included patient-level safety data from six double-blinded, randomized, placebo-controlled studies (one phase 2 and five phase 3), one double-blinded, randomized, LTE study and one open-label LTE study, reported in three data sets: placebo-controlled, 2-mg - 4-mg extended and All-bari AD. Safety outcomes include treatment-emergent adverse events, adverse events of special interest and abnormal laboratory changes. Proportions of patients with events and incidence rates were calculated.

RESULTS

Data were collected for 2531 patients who were given baricitinib for 2247 patient-years (median duration 310 days). The frequency of serious infections, opportunistic infections and conjunctival disorders was low and similar between treatment groups in the placebo-controlled period. The most common serious infections were eczema herpeticum [n = 11, incidence rates (IR) = 0.5], cellulitis (n = 6, IR = 0.3) and pneumonia (n = 3, IR = 0.1). There were four opportunistic infections (IR = 0.2). No malignancies, gastrointestinal perforations, positively adjudicated cardiovascular events or tuberculosis were reported in the placebo-controlled period in baricitinib-treated patients. Frequency of herpes simplex was higher in the 4-mg group (6.1%) vs. the 2-mg (3.6%) and placebo group (2.7%); IRs in the extended data set (2-mg IR = 9.6; 4-mg IR = 14.5) were lower vs. the placebo-controlled data set (2-mg IR = 12.4; 4-mg IR = 21.3). In the All-bari AD data set, there were two positively adjudicated major adverse cardiovascular events (2-mg group): two venous thrombosis events (4-mg group) and one death.

CONCLUSION

This integrated safety analysis in patients with moderate-to-severe AD confirms the established safety profile of baricitinib.

The Lebanese left ventricular assist device experience, a success story despite the odds

BACKGROUND AND AIM

Heart failure is still a leading cause of mortality and morbidity. Assist devices are reserved for advanced heart failure patients with no other therapeutic options. We aim in this paper to describe the characteristics and outcome of Lebanese left ventricular assist device (LVAD) patients.

RESULTS

From 2010 till December 2019, 78 patients were implanted with assist devices at the Beirut cardiac Institute, 82 pumps were used. To the most recent follow up after 10 years, 26 patients died (34%). 24 patients of 35 (68%) survived more than 5 years. Seven patients only (9%) died during one month of surgery. One year mortality was 19% (15 patients). The leading cause of early mortality was infection, whereas cerebrovascular accidents CVA were the leading cause of late mortality. Pump thrombosis occurred in 12% of the cases. The most serious long term complication was haemorrhagic CVA. Only seven patients (9%) received heart transplantation, with a mean time on support prior to transplantation of 1303 ± 213 days.

CONCLUSION

In this manuscript we reported the characteristics and outcome of the largest population of LVAD patients in Lebanon. The survival rate was 81% at one year. These findings were comparable to the international registries except for rates of heart transplantation. More efforts should be made to encourage organ donation in Lebanon.

Biallelic variants in ADARB1, encoding a dsRNA-specific adenosine deaminase, cause a severe developmental and epileptic encephalopathy

BACKGROUND

Adenosine-to-inosine RNA editing is a co-transcriptional/post-transcriptional modification of double-stranded RNA, catalysed by one of two active adenosine deaminases acting on RNA (ADARs), ADAR1 and ADAR2. ADARB1 encodes the enzyme ADAR2 that is highly expressed in the brain and essential to modulate the function of glutamate and serotonin receptors. Impaired ADAR2 editing causes early onset progressive epilepsy and premature death in mice. In humans, ADAR2 dysfunction has been very recently linked to a neurodevelopmental disorder with microcephaly and epilepsy in four unrelated subjects.

METHODS

We studied three children from two consanguineous families with severe developmental and epileptic encephalopathy (DEE) through detailed physical and instrumental examinations. Exome sequencing (ES) was used to identify ADARB1 mutations as the underlying genetic cause and in vitro assays with transiently transfected cells were performed to ascertain the impact on ADAR2 enzymatic activity and splicing.

RESULTS

All patients showed global developmental delay, intractable early infantile-onset seizures, microcephaly, severe-to-profound intellectual disability, axial hypotonia and progressive appendicular spasticity. ES revealed the novel missense c.1889G>A, p.(Arg630Gln) and deletion c.1245_1247+1 del, p.(Leu415PhefsTer14) variants in ADARB1 (NM_015833.4). The p.(Leu415PhefsTer14) variant leads to incorrect splicing resulting in frameshift with a premature stop codon and loss of enzyme function. In vitro RNA editing assays showed that the p.(Arg630Gln) variant resulted in a severe impairment of ADAR2 enzymatic activity.

CONCLUSION

In conclusion, these data support the pathogenic role of biallelic ADARB1 variants as the cause of a distinctive form of DEE, reinforcing the importance of RNA editing in brain function and development.

A predictive survival model for patients with head and neck squamous cell carcinoma treated with immune check point inhibitors

BACKGROUND

ICIs have expanded treatment options for HNSCC. A minority of the patients respond to these expensive treatments.

PATIENTS AND METHODS

This is a single institutional retrospective review on 121 unresectable or metastatic HNSCC patients treated with ICIs. We predicted that inflammatory markers available through routine blood work, in addition to clinical characteristics may divide patients into groups more or less likely to respond to these agents. Here we develop and internally validate our nomogram to predict survival in patients treated with ICIs.

Familial Jejunal Atresia with ‘Apple-Peel’ Variant1

We report two siblings who had jejunal atresia which we believe to be familial. The parents of these siblings were first cousins. The first child had jejunal atresia with mesenteric agenesis and ‘apple-peel’ configuration; the second child had jejunal atresia with a V-shaped mesenteric defect. Other reported cases of familial atresia of the small intestine are reviewed.

Chronic anterior shoulder instability with significant Hill-Sachs lesion: Arthroscopic Bankart with remplissage versus open Latarjet procedure

BACKGROUND

The objective of this study was to compare short-term shoulder stability after arthroscopic Bankart repair with remplissage versus the open Latarjet procedure in patients who had chronic anterior shoulder instability with a significant Hill-Sachs lesion.

HYPOTHESIS

The dislocation recurrence rate is higher after Bankart repair with remplissage than after open Latarjet.

PATIENTS AND METHODS

An observational non-randomised retrospective cohort study was conducted at two surgical centres in patients treated for chronic anterior shoulder instability with a significant Hill-Sachs defect between January 2009 and July 2014. The study compared 43 patients managed by arthroscopic Bankart repair and remplissage and 43 patients managed with open Latarjet. The two groups were matched on age at surgery and on follow-up duration. All patients were evaluated by independent observers based on a questionnaire including recurrences, range of motion, and functional outcomes (Shoulder Subjective Value [SSV], Walch-Duplay score, and Rowe score).

RESULTS

Mean follow-up was 47.3 months (range, 24-67 months). The recurrence rate at last follow-up was not significantly different between the two groups (9.3% versus 11.2%; P=0.67). The Bankart group had significantly greater loss of external rotation and a significantly higher proportion of patients with residual pain (21% versus 9%, P=0.023). The SSV, Walch-Duplay score, and Rowe score values were similar between groups.

DISCUSSION

In patients who had chronic anterior shoulder instability with a significant Hill-Sachs lesion, arthroscopic Bankart repair with remplissage and open Latarjet were reliable and safe procedures associated with low and similar recurrence rates. However, loss of external rotation and residual pain were significantly more common with the combined Bankart-remplissage procedure.

LEVEL OF EVIDENCE

III; comparative retrospective study.

Alternative approaches in formulating floating hollow tablets via sublimation technique; a platform tailored drug release profile

The aim of this study was to formulate floating hollow tablets of salbutamol sulphate with a platform tailored drug release profile to attain a controllable drug release. Eight formulations (F1-F8) were prepared using sublimation technique. L-menthol was directly compressed as sublimable core followed by compression coating of hydroxypropylmethyl cellulose (HPMC-K15M) or polyethylene oxide (PEO-WSR301) as release retarding polymer coat. Tablets were then subjected to heat to allow sublimation of the core. The effect of polymer type and that of different drug coat/core distribution on swelling and drug release profile was studied. FTIR and DSC revealed the absence of any drug-excipients interaction. Tablets showed a hollow morphology, resulting in low density tablets that floated for over 24 hours without lag time. Moreover, different drug coat/core distribution resulted in controllable release profiles. Based on these results, an optimum drug release behavior was recorded for HPMC-based hollow tablets consisting of 2:1 drug coat/core distribution ratio (F4), revealing a zero order drug release for over 14 hours. Furthermore, F4 showed no changes in drug content, floating properties and drug release profile upon exposure to accelerated stability conditions.

PYCR2 Mutations cause a lethal syndrome of microcephaly and failure to thrive

OBJECTIVE

A study was undertaken to characterize the clinical features of the newly described hypomyelinating leukodystrophy type 10 with microcephaly. This is an autosomal recessive disorder mapped to chromosome 1q42.12 due to mutations in the PYCR2 gene, encoding an enzyme involved in proline synthesis in mitochondria.

METHODS

From several international clinics, 11 consanguineous families were identified with PYCR2 mutations by whole exome or targeted sequencing, with detailed clinical and radiological phenotyping. Selective mutations from patients were tested for effect on protein function.

RESULTS

The characteristic clinical presentation of patients with PYCR2 mutations included failure to thrive, microcephaly, craniofacial dysmorphism, progressive psychomotor disability, hyperkinetic movements, and axial hypotonia with variable appendicular spasticity. Patients did not survive beyond the first decade of life. Brain magnetic resonance imaging showed global brain atrophy and white matter T2 hyperintensities. Routine serum metabolic profiles were unremarkable. Both nonsense and missense mutations were identified, which impaired protein multimerization.

INTERPRETATION

PYCR2-related syndrome represents a clinically recognizable condition in which PYCR2 mutations lead to protein dysfunction, not detectable on routine biochemical assessments. Mutations predict a poor outcome, probably as a result of impaired mitochondrial function. Ann Neurol 2016;80:59-70.

Breeding criteria and willingness to pay for improved Azawak zebu sires in Niger

Abstract. In Niger, the growth in local demand for milk and meat makes it necessary to consider genetic improvement of the indigenous cattle. At the Toukounous breeding station, the Azawak zebu has undergone over 50 years of line breeding for milk and meat production traits. To understand the adoption potential of improved Azawak sires in Niger, this study proposes to estimate the values that cattle keepers ascribe to different breeding criteria. In a first participatory stage, the breeding criteria used by cattle keepers were first listed and their relative importance was semi-quantified in three different production zones: pastoral, rural sedentary and peri-urban sedentary. The willingness to pay (WTP) for chosen breeding criteria have then been estimated through stated preference methods with 150 breeders. From participatory surveys, the most important attributes in sire choice were reproductive performance, feeding requirements and docility. The criteria considered for conjoint analysis (CA) were feeding requirements, docility, meat or dairy type, reproductive performance, coat color and tail length. The WTP was EUR 149 for low feed requirements, EUR 139 for docility and EUR 132 for a long tail. The meat and dairy type of the sire were less important in the decision-making.

Effect of bovine colostrum intake on growth, reproductive parameters and survival in red kids

The aim of this study is to evaluate the efficacy of frozen Azawak colostrum supplementation on body weight (BW), average daily gain (ADG), reproductive parameters (mean age at first parturition, fertility, fecundity, prolificacy) and mortality rate among red kids. The study was conducted at the goat farm secondary centre of Maradi in Niger from September 2010 to September 2011. The control animals (n = 20) were left with their mother, while the treatment animals (n = 20) received in addition 50 ml/animal/day of bovine colostrum at birth and 15 ml/animal/day from d2 to d15. Weight was measured weekly from birth to d365. Mortalities were also recorded over the same period. For reproductive parameters, observations began at weaning (d197). Growth rate was higher (p < 0.001) in supplemented animal, and the treatment effects on ADG were observed up to 150 day after the end of supplementation. A similar long-lasting trend was also observed in relation to the mortality rate (25% for ColG vs. 55% for ConG; p = 0.05). The age at first kidding tended to be lower in the treated group (13.8 ± 0.7 vs. 14.1 ± 0.8 month; p < 0.1). In conclusion, mild bovine colostrum supplementation induces a long-lasting positive impact on growth rate and to a lower extent on reproduction parameters and survival rate.

Epidemiology of hip fractures in Lebanon: a nationwide survey

INTRODUCTION

Hip fractures are a reliable indicator of osteoporosis. Despite their importance, few studies have assessed their epidemiology in Lebanon and the Middle East.

HYPOTHESES

Hip fracture incidence rates in Lebanon approximate those of Northern countries, and show the same characteristics, particularly the exponential increase with age, higher incidence in women, and a recent trend of rate leveling in women but not in men.

MATERIALS AND METHODS

A national database of hip fracture cases admitted to hospitals in Lebanon in 2007 was created. Crude and age-adjusted incidence rates were calculated at 5-year intervals for individuals over age 50. These rates were also standardized to the 2000 United States population, and compared to those of other countries. Projected incidence rates in Lebanon in 2020 and 2050 were also calculated.

RESULTS

A total of 1199 patients were included in the study. The crude annual incidence rate in individuals over 50 was 147 per 100,000 individuals, 132 per 100,000 males and 160 per 100,000 females, with a female-to-male ratio of 1.2. The age-standardized annual incidence rates (per 100,000) were 180 in males and 256 in females. Assuming unchanged healthcare parameters, the projected crude incidence rates for people over 50 are expected to reach 174 and 284 per 100,000 in 2020 and 2050 respectively.

CONCLUSIONS

Lebanese hip fracture rates are lower than Northern countries, but show many similar characteristics such as an exponential increase with age, a higher incidence in women, and clues of a leveling of rates in women but not in men. Numbers are expected to increase substantially in the coming decades.

LEVEL OF EVIDENCE

Level IV. Epidemiological study.

Profound microcephaly, primordial dwarfism with developmental brain malformations: a new syndrome

We describe two sibs with a lethal form of profound congenital microcephaly, intrauterine and postnatal growth retardation, subtle skeletal changes, and poorly developed brain. The sibs had striking absent cranial vault with sloping of the forehead, large beaked nose, relatively large ears, and mandibular micro-retrognathia. Brain magnetic resonance imaging (MRI) revealed extremely simplified gyral pattern, large interhemispheric cyst and agenesis of corpus callosum, abnormally shaped hippocampus, and proportionately affected cerebellum and brainstem. In addition, fundus examination showed foveal hypoplasia with optic nerve atrophy. No abnormalities of the internal organs were found. This profound form of microcephaly was identified at 17 weeks gestation by ultrasound and fetal brain MRI helped in characterizing the developmental brain malformations in the second sib. Molecular analysis excluded mutations in potentially related genes such as RNU4ATAC, SLC25A19, and ASPM. These clinical and imaging findings are unlike that of any recognized severe forms of microcephaly which is believed to be a new microcephalic primordial dwarfism (MPD) with developmental brain malformations with most probably autosomal recessive inheritance based on consanguinity and similarly affected male and female sibs.

Expanding the phenotypic and mutational spectrum in microcephalic osteodysplastic primordial dwarfism type I

Mutations in the RNU4ATAC gene cause microcephalic osteodysplastic primordial dwarfism type I. It encodes U4atac, a small nuclear RNA that is a component of the minor spliceosome. Six distinct mutations in 30 patients diagnosed as microcephalic osteodysplastic primordial dwarfism type I have been described. We report on three additional patients from two unrelated families presenting with a milder phenotype of microcephalic osteodysplastic primordial dwarfism type I and metopic synostosis. Patient 1 had two novel heterozygous mutations in the 3' prime stem-loop, g.66G > C and g.124G > A while Patients 2 and 3 had a homozygous mutation g.55G > A in the 5' prime stem-loop. Although they manifested the known spectrum of clinical features of microcephalic osteodysplastic primordial dwarfism type I, they lacked evidence of severe developmental delay and neurological symptoms. These findings expand the mutational and phenotypic spectrum of this syndrome.