P6: ANTIPLATELET AND ANTICOAGULANT USE IN RANDOMISED TRIALS OF PATIENTS UNDERGOING ENDOVASCULAR INTERVENTION FOR PERIPHERAL ARTERIAL DISEASE: SYSTEMATIC REVIEW

Introduction

Guideline recommendations for antithrombotic (antiplatelet and anticoagulant) therapy during and after endovascular intervention are patchy and conflicted, in part due to a lack of evidence. The aim of this systematic review was to examine the antithrombotic specifications in randomised trials for peripheral arterial endovascular intervention.

Method

This review was conducted according to PRISMA guidelines. Randomised trials including participants with peripheral arterial disease undergoing endovascular arterial intervention were included. Trial methods were assessed to determine whether an antithrombotic protocol had been specified, its completeness, and the agent(s) prescribed. Antithrombotic protocols were classed as periprocedural (preceding/during intervention), immediate postprocedural (up to 14 days following intervention) and maintenance postprocedural (therapy continuing beyond 14 days). Trials were stratified according to type of intervention.

Result

Ninety-four trials were included. Only 29% of trials had complete periprocedural antithrombotic protocols, and 34% had complete post-procedural protocols. In total, 64 different periprocedural protocols, and 51 separate postprocedural protocols were specified.

Antiplatelet monotherapy and unfractionated heparin were the most common choices of regimen in the periprocedural setting, and dual antiplatelet therapy (55%) was most commonly utilised postprocedure. There is an increasing tendency to use dual antiplatelet therapy with time or for drug-coated technologies.

Conclusion

Randomised trials comparing different types of peripheral endovascular arterial intervention have a high level of heterogeneity in their antithrombotic regimens, and there has been an increasing tendency to use dual antiplatelet therapy over time. Antiplatelet regimes need to be standardised in trials comparing endovascular technologies.

Take-home message

To determine the benefits of any endovascular intervention within a randomised trial, antithrombotic regimens should be standardised to prevent confounding. This systematic review demonstrates a high level of heterogeneity of antithrombotic prescribing in randomised trials of endovascular intervention, and an increasing tendency to utilise dual antiplatelet therapy, despite a lack of evidence of benefit, but an increased risk of harm.

P132 TRAVERSING: Transfer of thoracic Aortic Vascular Emergencies to Regional Specialist Institutes Group

Introduction

The incidence of Acute Aortic Syndrome (AAS) is rising. The Department of Health is considering a supra regional tier of centralisation for complex aortic care. No standardised pathway exists to guide the transfer of patients with AAS, despite increasing evidence from coroners and the Healthcare Safety Investigation Board of delayed transfers and miscommunication costing lives. This study aims to deliver a pathway for the safe transfer of patients with suspected AAS to a specialist aortic centre through multidisciplinary Delphi consensus.

Methods

The researchers will create an interdisciplinary Steering Group to oversee the study, which will identify appropriate stakeholders for inclusion in the Delphi process. A systematic review will be performed to summarise existing evidence and highlight gaps in knowledge where consensus is required. The Steering Group will create, circulate and interpret the Delphi questionnaire. The outcomes will also enable determination of criteria for audit that should become the standard for ensuring a safe and efficient process for patient transfer to a complex aortic centre.

Results

Results will provide inter-disciplinary guidance to healthcare professionals for early management and transfer of patients with suspected AAS, and prevent unnecessary transfer, thereby improving outcomes, ensuring equity of access to specialist aortic care for patients. Results will also provide audit standards through which future improvements can be realised.

Conclusion

This study is reliant upon collaboration between multidisciplinary healthcare providers, qualitative researchers and patients. Its success will streamline emergency pathways in the management of AAS, saving lives and resources, with inbuilt mechanisms for continuous review and improvement.

A systematic review of reporting quality for anaesthetic interventions in randomised controlled trials

Interventions from randomised controlled trials can only be replicated if they are reported in sufficient detail. The results of trials can only be confidently interpreted if the delivery of the intervention was systematic and the protocol adhered to. We systematically reviewed trials of anaesthetic interventions published in 12 journals from January 2016 to September 2019. We assessed the detail with which interventions were reported, using the Consolidated Standards of Reporting Trials statement for non‐pharmacological treatments. We analysed 162 interventions reported by 78 trials in 18,675 participants. Detail sufficiently precise to replicate the intervention was reported for 111 (69%) interventions. Intervention standardisation was reported for 135 (83%) out of the 162 interventions, and protocol adherence was reported for 20 (12%) interventions. Sixty (77%) out of the 78 trials reported the administrative context in which interventions were delivered and 36 (46%) trials detailed the expertise of the practitioners. We conclude that bespoke reporting tools should be developed for anaesthetic interventions and interventions in other areas such as critical care.

Patterns of short saphenous vein incompetence

The significance of short saphenous vein (SSV) reflux is an under-explored territory in chronic venous disease (CVD). We have examined the origin and significance of SSV reflux in primary and secondary CVD. While the natural history of SSV incompetence remains uncertain, its prevalence has been shown to approximate 3.5%, rising with progressing clinical venous insufficiency, and bears an association with lateral malleolar venous ulceration. The most common pattern of reflux extends throughout the SSV Patterns of incompetence in recurrent disease are highly variable, but SSV reflux may itself pose a risk for recurrence, in part due to the complex anatomy of the saphenopopliteal system. Further studies are required to delineate the impact of SSV reflux in secondary venous disease and deep venous incompetence.

DREB1/CBF transcription factors: their structure, function and role in abiotic stress tolerance in plants

Drought, high salinity and low temperature are major abiotic stresses that influence survival, productivity and geographical distribution of many important crops across the globe. Plants respond to these environmental challenges via physiological, cellular and molecular processes, which results in adjusted metabolic and structural alterations. The dehydration-responsiveelement-binding (DREB) protein / C-repeat binding factors (CBFs) belong to APETALA2 (AP2) family transcription factors that bind to DRE/CRT cis-element and regulate the expression of stress-responsive genes. DREB1/CBF genes, therefore, play an important role in increasing stress tolerance in plants and their deployment using transgenic technology seems to be a potential alternative in management of abiotic stresses in crop plants. This review is mainly focussed on the structural characteristics as well as transcriptional regulation of gene expression in response to various abiotic stresses, with particular emphasis on the role of DREB1/CBF regulon in stress-responsive gene expression. The recent progress related to genetic engineering of DREB1/CBF transcription factors in various crops and model plants is also summarized.

Assessment of tracheal intubating conditions in children using remifentanil and propofol without muscle relaxant

BACKGROUND

Tracheal intubation in children can be achieved by deep inhalational anaesthesia or an intravenous anaesthetic and a muscle relaxant, suxamethonium being widely used despite several side-effects. Studies have shown that oral intubation can be facilitated safely and effectively in children after induction of anaesthesia with propofol and alfentanil without a muscle relaxant. Remifentanil is a new, ultra-short acting, selective mu-receptor agonist that is 20-30 times more potent than alfentanil. This clinical study was designed to assess whether combination of propofol and remifentanil could be used without a muscle relaxant to facilitate tracheal intubation in children.

METHODS

Forty children (5-10 years) admitted for adenotonsillectomy were randomly allocated to one of two groups to receive remifentanil 2 microg.kg(-1) (Gp I) or remifentanil 3 microg.kg(-1) (Gp II) before the induction of anaesthesia with i.v. propofol 3 mg.kg(-1). No neuromuscular blocking agent was administered. Intubating conditions were assessed using a four-point scoring system based on ease of laryngoscopy, jaw relaxation, position of vocal cords, degree of coughing and limb movement. Mean arterial pressure (MAP) and heart rate (HR) measured noninvasively before induction of anaesthesia to 5 min after intubation (seven time points).

RESULTS

Tracheal intubation was successful in all patients without requiring neuromuscular blocking agent. Intubating conditions were clinically acceptable in 10 of 20 patients (50%) in Gp I compared with 18 of 20 patients (90%) in Gp II (P < 0.05). MAP and HR decreased in both groups after induction of anaesthesia (P < 0.01). Both HR and MAP were significantly lower in Gp II compared with Gp I after tracheal intubation (P < 0.01). No patient in the present study developed bradycardia or hypotension.

CONCLUSIONS

We conclude that remifentanil (3 microg.kg(-1)), administered before propofol (3 mg.kg(-1)) provides acceptable tracheal intubating conditions in children, and completely inhibited the increase in HR and MAP associated with intubation.

Effect of protein malnutrition on the weight and serum albumin of albino rats

BACKGROUND

Protein Malnutrition is one of the major mortality factors in the children of Pakistan. Not only do the children suffer from infections (because of low resistance secondary to malnutrition), but they also lose weight significantly. The two spectra of the diseases are Kwashiorkor and Marasmus. We conducted this study on laboratory animals to assess the weight change and correlated it with the extent of malnutrition by studying and estimating the serum albumin levels as well.

METHODS

40 male albino rats of 2 weeks age were used for the experiment. They were divided into Control and Experimental groups containing equal number of animals. The experimental group was subjected to protein malnutrition for 3 to 6 weeks. They were killed with the paired control animals. The parameters of the two groups were compared for statistical analysis.

RESULTS

The results showed significant change in the weights of the experimental animals right from the first week of malnutrition while the change in serum albumin level became significant after prolonged malnutrition.

CONCLUSION

Protein malnutrition is reflected from the decrease in the serum albumin levels of the animals and their weights are also decreased significantly.

Age-related changes in blood lymphocyte subsets of Saudi Arabian healthy children

The age-related changes in absolute and percentage values of lymphocyte subsets in the peripheral blood of healthy children of different ages (1 month to 13 years) were studied by flow cytometry. The absolute and percentage values for most lymphocyte subpopulations differed substantially with age. Comparisons among age groups from infants through adults revealed progressive declines in the absolute numbers of leukocytes, total lymphocytes, and T, B, and natural killer (NK) cells. The percentages of T cells increased with age. Within the T-lymphocyte population, the CD8(+) subset increased but the CD4(+) subset decreased, resulting in a declining CD4(+)/CD8(+) ratio. The percentage of B cells declined, but that of NK cells remained unchanged. The percentage of HLA-DR+ T cells increased over time, but their number changed inconsistently. Our findings confirm and extend earlier reports on age-related changes in lymphocyte subpopulations. These data should be useful in the interpretation of disease-related changes, as well as therapy-dependent alterations, in lymphocyte subsets in children of different age groups.

Breastfeeding practices in urban Riyadh

Three hundred and forty-seven mother-infant pairs attending a well baby clinic in a University Hospital in Riyadh were interviewed on the type of feeding given to their infants. The objective was to assess the latest trend of infant feeding practices in an urban population and to compare present trends and their significance with previous reports. Results showed that 32.4 per cent of infants at 3 months and 22.1 per cent of infants at 6 months were exclusively breastfed; 18.2, 48.4, and 65.4 per cent were exclusively bottle fed at 3 months, 6 months, and 1 year respectively. Weaning foods were added between 3 and 6 months to a very high percentage of infants. Insufficient breast milk and refusal of breast by the infant were among the most common reasons for introduction of bottle feeds.

The spectrum of child abuse presenting to a university hospital in Riyadh

BACKGROUND

Child abuse is prevalent worldwide, although it is often underreported. we describe the pattern of child abuse and neglect presenting to the emergency room of our hospital, the sociocultural changes which brought this about, and suggest ways to deal with this emotionally sensitive issue.

PATIENTS AND METHODS

Thirteen cases of child abuse and neglect were seen in the emergency room of King Khalid University Hospital over a period of one year from July 1996 to June 1997. There were four cases of non-accidental injury, three of which had serious injury. There were three cases of sexual abuse, four cases of neglect, resulting in the death of one child and severe emaciation in another. There was one suspected case of Munchausen syndrome by proxy, and one case of child labor with neglect.

CONCLUSION

Public awareness of the problem of child abuse has increased, and recent media reports reflect the significance accorded to the issue. As more information is obtained on this subject and policies and guidelines are set in place, efforts at reporting and preventing physical and psychological trauma will gather momentum.

Lymphocyte subset reference ranges in healthy Saudi Arabian children

In an attempt to establish the reference ranges for lymphocyte subsets in children, the distribution of lymphocyte population-bearing surface markers such as CD3 (T cells), CD19 (B cells), CD4 (T helper/inducer cells), CD8 (T suppressor/cytotoxic cells), and CD16 and/or CD56 on CD3- cells (NK cells) has been studied among healthy Saudi Arabian infants and children. Normal adult blood donors were used for comparison. Anticoagulated peripheral blood was stained with monoclonal antibodies and the lymphocytes were analyzed by flow cytometry for the expression of the above markers. Absolute and percentage values for most lymphocyte populations differed substantially not only between children and adults but also among children from different age groups. Absolute numbers of all the lymphocyte subsets decreased with age from 1 month to 13 years; the median value declined from 4.1 to 1.9 (T cells), 1.6 to 0.6 (B cells), 0.5 to 0.3 (NK cells), 2.7 to 1.0 (CD4+ T cells) and 1.5 to 0.8 x 10(3) cells/mm3 (CD8+ T cells). HLA-DR+ T cell counts changed significantly from 0.3 to 0.2 x 10 (3) cells/mm3 during the same age period. In contrast, the lymphocyte percentage increased in all the subsets except B cells and CD4+ T cells with time. The percentage values increased from 66 to 74 (T cells), 8 to 11 (NK cells), 23 to 39 (CD8+ T cells) and 4 to 9 (HLA-DR+ T cells). The values changed from 24 to 12 and 46 to 39 for B cells and CD4+ T cells, respectively, with age from 1 month to 13 years. The variations in CD4+ and CD8+ T cells resulted in a decrease in CD4+/CD8+ ratio from 2.0 to 1.1 with age. These data should be useful as reference values for lymphocyte subsets in various diseases of infants and children.

Rectal tear causing prolapsed ileum after closed abdominal injury

A case of prolapsed ileum through a tear in the rectal wall, passing through a tear in the rectal wall, passing through the anal canal, after a blunt injury to the abdomen in a child is presented. The cause and management of the condition are discussed.