Do future healthcare professionals advocate for pharmacogenomics? A study on medical and health sciences undergraduate students

Pharmacogenomics (PGx) is a rapidly changing field of genomics in which healthcare professionals play an important role in its implementation in the clinical setting, however PGx level of adoption remains low. This study aims to investigate the attitude, self-confidence, level of knowledge, and their impact on health sciences undergraduate students' intentions to adopt PGx in clinical practice using a questionnaire developed based on the Theory of Planned Behavior (TPB). A model was proposed and a questionnaire was developed that was distributed to 467 undergraduate students of all academic years from four different departments of the University of Sharjah (UoS) including medical, dental, nursing, and pharmacy students from September 2022 to November 2022. Descriptive statistics along with factor analysis and regression analysis were conducted. The proposed model had a good internal consistency and fit. Attitude was the factor with the greatest impact on student's intentions followed by self-confidence and barriers. The level of knowledge had a meaningless impact. The majority of students shared a positive attitude and were aware of PGx benefits. Almost 60% of the respondents showed a high level of knowledge, while 50% of them were confident of implementing PGx in their clinical practice. Many students were prone to adopt PGx in their future careers. PGx testing cost and the lack of reimbursement were the most important barriers. Overall, students shared a positive intention and were prone to adopt PGx. In the future, it would be important to investigate the differences between gender, year of studies, and area of studies studies and their impact on students' intentions.

Right-to-Left Intra-cardiac Shunt in a COVID-19 Patient Leading to Stroke and Poor Prognosis: A Case Report and Review of the Literature

Coronavirus disease 2019 (COVID-19) often presents with a wide range of complications, including respiratory distress, acute respiratory distress syndrome (ARDS), and hypercoagulable states with resultant cerebrovascular incidents. Intra- and extra-pulmonological shunts can further complicate patient courses, leading to persistent hypoxemia and paradoxical emboli, resulting in potentially life-threatening consequences, necessitating a comprehensive, multidisciplinary approach to patient care. Here we present the case of a 73-year-old male who experienced severe persistent hypoxemic respiratory failure, superimposed methicillin-resistant Staphylococcus aureus (MRSA) pneumonia, and stroke with a previously undiagnosed patent foramen ovale (PFO) contributing to his clinical presentation.

Predictive factors for docking site procedure in bone transport for large lower extremity segmental defects

BACKGROUND

Segmental bone transport is a common technique for treating large segmental bone defects. However, a docking site procedure is often necessary in segmental bone transport. To date, no prognostic factors for the need of docking site procedure have been reported. Thus, the decision is often made at random, based on the surgeon's subjective judgment and experience. The aim of this study was to identify prognostic factors for the need of docking site operation.

METHODS

Patients with segmental bone transport in lower extremity bone defects were included regardless of age, aetiology, and defect size. We excluded patients undergoing treatments that were not yet completed, and those who discontinued therapy by any reason. The need for docking site operation was modelled with logistical and linear regression as well as univariate analysis of variances (ANOVA). Receiver operating characteristics (ROC) curve analysis was also performed.

RESULTS

Twenty-seven patients from age 12 to 74 years (mean age: 39.07 ± 18.20 years) were included. The mean defect size was 76.39 ± 41.10 mm. The duration of transport (days) showed a significant influence (p = 0.049, 95%CI: 1.00-1.02) on the need for docking site operation. No other significant influences were detected.

CONCLUSION

A link between the duration of transport and the need for docking site operation was detected. Our data showed that if a threshold of about 188 days is exceeded, docking surgery should be considered.

Blockchain-based Supply Chain Traceability for COVID-19 personal protective equipment

The COVID-19 pandemic has severely impacted many industries, in particular the healthcare sector exposing systemic vulnerabilities in emergency preparedness, risk mitigation, and supply chain management. A major challenge during the pandemic was related to the increased demand for Personal Protective Equipment (PPE), resulting in critical shortages for healthcare and frontline workers. This is due to the lack of information visibility combined with the inability to precisely track product movement within the supply chain, requiring a robust traceability solution. Blockchain technology is a distributed ledger that ensures a transparent, safe, and secure exchange of data among supply chain stakeholders. The advantages of adopting blockchain technology to manage and track PPE products in the supply chain include decentralized control, security, traceability, and auditable time-stamped transactions. In this paper, we present a blockchain-based approach using smart contracts to transform PPE supply chain operations. We propose a generic framework using Ethereum smart contracts and decentralized storage systems to automate the processes and information exchange and present detailed algorithms that capture the interactions among supply chain stakeholders. The smart contract code was developed and tested in Remix environment, and the code is made publicly available on Github. We present detailed cost and security analysis incurred by the stakeholders in the supply chain. Adopting a blockchain-based solution for PPE supply chains is economically viable and provides a streamlined, secure, trusted, and transparent mode of communication among various stakeholders.

Floor plants’ leaf shape and Phyllagathis rotundifolia’s soil organic matter in Kuala Keniam Trail, Pahang National Park

Kuala Keniam forest in the Pahang National Park is a part of the oldest and most complex ecosystem in the world with multispecies of plants and structures. Unfortunately, near to none information was documented on the geometrical aspects of leaves. Thus, this study aims to pre-document on the variety of shapes of leaves along the trail and classify them. Photographs of the plants and all site activities were taken and documented by using the digital single-lens reflex (DSLR) and smartphone-digital cameras. Secondly, this study also aims at understanding this one particular herbaceous plant, known as Phyllagathis rotundifolia (tapak sulaiman) which is commonly found along the trail, and traditionally used to relieve gastrointestinal problems and fever. The composition of the soil organic matter of the plant were collected for better understanding of the type of soil needed for mass-cultivation and medical purposes. The Walkley-Black (WB) titration method was used to analyse the soil, where the oxidation of organic matter by potassium dichromate (K2Cr2O7)-sulfuric acid mixture followed by back titration of the excessive dichromate by ferrous ammonium sulphate (Fe (NH4)2(SO4)2.6H2O) were monitored. Findings from the Kuala Keniam trails were documented and analysed. Thirty distinct-leaves have been identified and classified into 10-distinct leaf shape categories. Rich soil contents such as iron, carbon and phosphorous were also detected, thus creating Kuala Keniam as an excellent environment for the growth of beneficial shrubs and herbs

A224 COVID-19 INFECTION IN LIVER TRANSPLANT RECIPIENTS: CLINICAL FEATURES, HOSPITALIZATION, AND MORTALITY FROM A CANADIAN MULTICENTRE COHORT

Background

The COVID-19 pandemic has brought significant challenges to clinicians caring for liver transplant (LT) recipients. Researchers have sought to better understand the risk and clinical outcomes of LT recipients infected with COVID-19 globally, however, there is a paucity of data from within Canada.

Aims

Our multi-center study aims to examine the characteristics and clinical outcomes of LT patients with COVID-19 in Canada.

Methods

We identified a retrospective cohort of adult LT recipients with RT-PCR confirmed COVID-19 from 7 Canadian tertiary care centers between March 2020 and June 2021. Demographic and clinical data were compiled by clinicians within those centers. We identified liver enzyme profile at the time of COVID-19 infection, immunosuppression type and post-infection adjustments, rate of hospitalization, ICU admission, mechanical ventilation, and death.

Results

A total of 49 patients with a history of LT and COVID-19 infection were identified. Twenty nine patients (59%) were male, the median time from LT was 66 months (1, 128) and the median age at COVID-19 infection was 59 years (52, 65). At COVID-19 diagnosis, the median ALT was 37 U/L (21, 41), AST U/L was 34 (20, 37), ALP U/L was 156 (88, 156), Total Bilirubin was 11 umol/L (7, 14), and INR was 1.1 (1.0, 1.1). The majority of patients (92%) were on tacrolimus monotherapy or a combination of tacrolimus and mycophenolate mofetil (MMF); median tacrolimus level at COVID-19 diagnosis was 5.3 ug/L (4.0, 8.1). Immunosuppression was modified in 8 (16%) patients post-infection; either the tacrolimus dose was reduced or MMF was held. One patient developed acute cellular rejection which recovered after re-initiation of the prior regimen. Eighteen patients (37%) required hospitalization, 6 (12%) were treated with dexamethasone, and 3 (6%) required ICU admission and mechanical ventilation. Four patients (8%) died due to complications of COVID-19. On univariate analysis, neither age, sex, co-morbidities nor duration post-transplant were associated with risk of hospitalization.

Conclusions

In our national retrospective study, approximately 40% of patients required hospitalization with a mortality rate of < 10%. Previous studies have shown proximity to LT as an independent factor for mortality with COVID-19; the median time from LT for our patients was 5 years, which may explain the lower mortality rate. Of note, the median tacrolimus levels were much lower in comparison to the target of 8–10 ug/L used in the first year post-transplant. As the landscape of COVID-19 changes with vaccination, evolving treatments, and increasing rates of variant transmission, additional studies are required to continue identifying trends in clinical outcomes.

Funding Agencies

None

Quantitative vestibular function tests in posterior circulation stroke patients: A review

While specific bedside examinations are known to be sensitive in identifying stroke among acute vestibular syndrome patients, complementary quantitative vestibular function testing can be helpful to quantify vestibular loss due to stroke. In contrast to peripheral vestibular dysfunction, diagnosis of central vestibular dysfunction can be challenging for unskilful clinicians. This article presents a comprehensive overview of quantitative vestibular function test findings such as the video head impulse test (vHIT), cervical vestibular evoked myogenic potentials (cVEMPs), ocular vestibular evoked myogenic potentials (oVEMPs), videonystagmography (VNG) and caloric test among stroke patients. Vestibulo-ocular reflex (VOR) gain is usually found normal among posterior inferior cerebellar artery (PICA) stroke patients but varies among anterior inferior cerebellar artery (AICA) stroke patients. Abnormal contralesional posterior semicircular canal VOR gain can be observed due to lesions in the medial longitudinal fasciculus (MLF). AICA and PICA stroke can impair cVEMPs, oVEMPs, and VNG (i.e., smooth pursuit and saccade functions). Strokes, particularly those involving the vestibular nucleus, including both upper, lower brainstem and cerebellum, can result in various abnormalities of smooth pursuit, saccade or calorics testing. The combined evaluations of VNG, vHIT, and VEMPs can be accurately used to complement and quantify bedside vestibular evaluation in diagnosing central vestibular dysfunction. In addition, as most studies were conducted amongst acute vestibular syndrome (AVS) patients, future studies that investigate the prevalence of vestibular dysfunction in recovering stroke patients are required.

Bioaccumulation and biomagnification in elasmobranchs: A concurrent assessment of trophic transfer of trace elements in 12 species from the Indian Ocean

We provided the first multi-species study investigating the presence and organotropism of trace elements in three tissues of 12 elasmobranch species. Shark species showed comparable TE loads, although milk sharks and juvenile scalloped hammerhead sharks exhibited the highest Cd and Hg levels, respectively. Fins accumulated higher levels of Pb, Co, and Cr; muscles higher V, As, and Hg; livers higher Se and Cd levels. The organotropism of TEs calls for cautious when choosing a tissue to be sampled since certain tissues, like fin clips, do not provide reliable surrogate for the internal loads of some TEs. Strong correlations between essential and toxic TEs indicated detoxification mechanisms, while the TMF provided evidence for Hg, As and Se biomagnification along the food-web. Considering the difficulties in assessing elasmobranchs contamination from different areas, the proposed multi-species approach represents a valuable way to estimate the species-specific accumulation and transfer of pollutants in sharks.

Cutibacterium acnes Pneumonia in an Immunocompromised Patient: A Case Report and Review of the Literature

Cutibacterium acnes (C. acnes), known previously as Proprionebacterium acnes, is a common skin and mucous membrane colonizing bacteria. On rare occasions it has been associated with invasive infections in both immunocompetent and immunosuppressed patients. We describe the case of a 55-year-old female with a history of Sjogren's syndrome and psoriatic arthritis on TNF-alpha inhibitor therapy with etanercept. She presented with signs and symptoms of a thoracic infection with pulmonary nodules, hilar adenopathy, and bronchiectasis on thoracic computed tomography. She was diagnosed with C. acnes pneumonia based on culture growth from both endoscopic bronchial ultrasound transbronchial lymph node needle biopsy and navigational bronchoscopy transbronchial lung biopsy. Our patient noticed marked symptom relief and radiographic pulmonary parenchymal improvement with intravenous ceftriaxone provided for a six-week course. This case highlights the potential invasive disease caused by C. acnes, a common skin commensal.

Challenges of delivering reproductive health services to forced displaced populations

Background

Of the 80 million forced displaced persons worldwide, women and children bear greater morbidity and mortality, especially in conflict-affected regions. This is due to disruption in health service provision, breakdown of social institutions and increase in sexual and gender-based violence. Reproductive health (RH) service delivery as part of humanitarian health cluster services is outlined in the Minimum Initial Service Package (MISP). This study explores the challenges of delivering RH services to forced-displaced populations, focussing on field level stakeholders in humanitarian settings.

Methods

Qualitative semi-structured interviews were conducted with stakeholders from non-governmental and United Nations agencies involved in delivering RH services to conflict-affected populations. Additionally, a scoping review, using the Arksey and O'Malley framework, of the literature was also conducted reviewing challenges of delivering RH programmes to women in forced displaced populations. An inductive and deductive thematic approach was used in data analysis.

Results

Eleven key informants (KIs) were interviewed from six conflict-affected countries including Syria, Afghanistan and Libya. Main emerging themes were: 1. Poor awareness of international guidelines (including the MISP) 2. Service provision barriers including lack of human resources 3. Attitudes towards SRH and women's rights 4. Disruption of health services due to COVID-19.

Conclusions

This study has highlighted the main challenges that the humanitarian actors delivering RH programmes in conflict-affected settings face. Implementation of international guidelines remains a key barrier. Key policy recommendations would be to standardise training for all RH providers, prioritise training in the MISP and address cultural attitudes towards RH. Further research exploring the use of WHO's essential medicines for RH and the long-term impact of COVID-19 on forced displaced females needs to be conducted.

Key messages

Providing basic essential reproductive health services to conflict affected populations remains a challenge, including implementation of standardised international guidance through the MISP.

One key policy recommendation would be to prioritise training in MISP for conflict-affected humanitarian settings to ensure it is offered as part of the essential package.

Resting and exercise hemodynamic determinants of daily activity measured by accelerometer in stable heart failure patients

Background

Patient-worn accelerometer is increasingly used in patients with heart failure and reduced ejection fraction (HFrEF) to assess daily activity and and as surrogate endpoint. We examined the association between cardiac physiology and daily activity by patient-worn accelerometer recordings in stable HFrEF patients.

Methods

In this descriptive study, physical average daily accelerometer units (PADA) and total average daily accelerometer unit (TADA) were assessed by a accelerometer recordings. Sixty three stable ambulatory patients with HFrEF, mainly men (92%), mean age 58±10 years, and ejection-fraction 26±4% underwent hemodynamic exercise testing, and accelerometry (Table 1). Patients were divided by PADA in a low and high activity level groups based on counts per minute physical activity.

Results

Patients in the low activity group were older and more frequently treated with diuretics. At rest, the low activity group was characterized by a lower cardiac index (CI) (2.2±0.4 vs. 2.4±0.4 l/min/m2, p=0.01), Stroke volume (SV) (70±19 vs. 81±17 ml, p=0.02) but not pulmonary capillary wedge pressure (PCWP) (12±5 vs. 11±5 mmHg, p=0.3) (Figure 1). Low activity group reached a lower CI (4.8±1.7 vs. 6.6±1.7 l/min/m2, p<0.001) and SV (94±32 vs. 121±29 ml, p<0.001), but not in PCWP (31±12 vs. 27±8 mmHg, p=0.2) or arterial-venous O2 content difference (A-VO2 diff) (13.00±2.32 vs. 12.96±1.65 ml O2/dl, p=0.9) at peak exercise. The attenuated increase was associated with attenuated increase in SV rther than increase in heart rate (42±23 vs. 52±21 bpm, p=0.07). Finally, CI at peak exercise was the only independent variable associated with PADA after adjusting for age, gender, and BMI (p<0.0001). The PADA and TADA were associated to functional assessments using Kansas City Cardiomyopathy Questionnaire, but not with New York Heart Association class or N-terminal pro brain natriuretic peptide (NT-proBNP) (Table 1).

Conclusion

Accelerometer-assessed activity in patients with HFrEF are associated with impairments in LV performance, SV reserve and cardiac output during exercise, to a greater extent than changes in arterial-venous O2 content difference or pulmonary vascular pressures. Accelerometer data may provide information about the functional status that we do not nessecary find in the widely used tools in both research and daily clinical practice.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline and regression analysisFigure 1. Change in PCWP and CI by exercise

Effect of empagliflozin in hfref patients treated with angiotensin receptor neprilysin inhibitor an analysis of EMPIRE HF

Introduction

Inhibition of neprilysin/valsartan (ARNi) or sodium glucose cotransporter 2 (SGLT2) in patients with heart failure (HF) and reduced ejection fraction (HFrEF) has been shown to reduce the risk of Cardiovascular death and hospitalization for HF. Recent trails suggested that SGLT2 reduces the risk for cardiovascular death or hospitalization for HF, regardless of underlying ARNi treatment and that the effect may even be greater in those receiving the combination. Whether there exist an interaction between effect of ARNi and SGLT2 on functional endpoints related to mechanism of action is unknown.

Purpose

This post-hoc analysis of the randomized double-blinded Empire HF trial evaluated the influence of ARNi on the effect of the SGLT2 Empagliflozin on N-terminal prohormone B-type natriuretic peptide (NT-proBNP), pulmonary capillary wedge pressure (PCWP), Left ventricular end-systolic and end-diastolic volumes index; (LVESVI) (LVEDVI), left atrial volume index (LAVI), Left ventricular ejection fraction (LVEF), and Kansas City Cardiomyopathy Questionnaire (KCCQ) HFrEF patients.

Methods

Empire HF trial randomized 190 patients with HFrEF (LVEF ≤40%) to placebo or empagliflozin (10 mg/day), on top of recommended treatment for HFrEF, for 12 weeks of treatment. A total of 58 (31%) received ARNi at baseline and no patients initiated ARNi during study period.

Results

Patients on ARNi were well-treated with a similar baseline characteristic as those who were not treated with ARNi (Table 1). Patients with ARNi had a lower systolic blood pressure (P=0.01), with a higher NT-proBNP (P<0.001) when compared with those not receiving ARNi. When compared to placebo, empagliflozin did not reduce the ratio of change of NT-proBNP with or without ARNi (0.94 [95% CI, 0.75 to 1.19] pg/ml; P=0.62) and (1.02 [95% CI, 0.86 to 1.22] pg/ml; P=0.78), respectively, adjusted (age, atrial fibrillation) interaction P=0.57. Empagliflozin reduced PCWP regardless of ARNi treatment (with ARNi; −4.9 [95% CI, −9.1 to −0.6] mmHg; P=0.02) and (without ARNi; −2.1 [95% CI, −3.8 to −0.4] mmHg; P=0.01), adjusted interaction P=0.20. Overall, empagliflozin was associated with a reduction in LVESVI, LVEDVI, and LAVI volumes, but no effect on LVEF. However, Empagliflozin combined with ARNi at baseline, significantly reduced LVEDVI (−11.2 [95% CI, −21.2 to −1.2] ml/m2; P=0.03), but not without ARNI (−2.9 [95% CI, −8.7 to 2.9] ml/m2; P=0.32), adjusted interaction P=0.13. Treatment-by-subgroup interaction P-values for LVESVI, LAVI, and LVEF analysis were >0.05 (Figure 1). KCCQ total symptom score were significantly increased in those not receiving ARNi (5.4 [95% CI, 1.1 to 9.6]; P=0.013), but not with ARNi (−4.0 [95% CI, −10.3 to 2.3]; P=0.22), adjusted P=0.02.

Conclusion

In this post hoc analysis the effects on empagliflozin to reduce PCWP and LV volumes were not diminished in patients receiving ARNi, however KCCQ change were diminished in patients receiving ARNi.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This work was supported by the Danish Heart Foundation [grant numbers 17-R116-A7714-22076, 18-R124-A8573-22107]; Steno Diabetes Center Odense, Denmark [grant number 3363] and A.P. Møller Foundation for the Advancement of Medical Science [grant number 17-L-0339]. Table 1. Baseline characteristicsFigure 1. Change in echo variables +/− ARNi

Acute Non-Traumatic Sub-Arachnoid Hemorrhage in a Young Female With Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in patients with type 1 DM. Due to severe acidosis, ketonemia and electrolyte disturbances it can lead to various complications in the body, which can be fatal in some cases. Neurological complications related to DKA include cerebral edema, cerebral infarction, brain herniation, cortical venous thrombosis. It is very rare for DKA to cause subarachnoid hemorrhage (SAH). We present a case 19-year-old female with severe DKA, who developed SAH without any pre-existing aneurysm or other common risk factors. The patient did not have any neurologic deficits and was managed conservatively with the resolution of her symptoms. We have also summarized the existing literature regarding the association of DKA with subarachnoid hemorrhage.

The clinical effectiveness of reconstructing 18F-sodium fluoride PET/CT bone using Bayesian penalized likelihood algorithm for evaluation of metastatic bone disease in obese patients

OBJECTIVE

A new Bayesian penalized likelihood reconstruction algorithm for positron emission tomography (PET) (Q.Clear) is now in clinical use for fludeoxyglucose (FDG) PET/CT. However, experience with non-FDG tracers and in special patient populations is limited. This pilot study aims to compare Q.Clear to standard PET reconstructions for ¹⁸F sodium fluoride (¹⁸F-NaF) PET in obese patients.

METHODS

30 whole body ¹⁸F-NaF PET/CT scans (10 patients with BMI 30-40 Kg/m² and 20 patients with BMI >40 Kg/m²) and a NEMA image quality phantom scans were analyzed using ordered subset expectation maximization (OSEM) and Q.Clear reconstructions methods with B400, 600, 800 and 1000. The images were assessed for overall image quality (IQ), noise level, background soft tissue, and lesion detectability, contrast recovery (CR), background variability (BV) and contrast-to-noise ratio (CNR) for both algorithms.

RESULTS

CNR for clinical cases was higher for Q.Clear than OSEM (p < 0.05). Mean CNR for OSEM was (21.62 ± 8.9), and for Q.Clear B400 (31.82 ± 14.6), B600 (35.54 ± 14.9), B800 (39.81 ± 16.1), and B1000 (40.9 ± 17.8). As the β value increased the CNR increased in all clinical cases. B600 was the preferred β value for reconstruction in obese patients. The phantom study showed Q.Clear reconstructions gave lower CR and lower BV than OSEM. The CNR for all spheres was significantly higher for Q.Clear (independent of β) than OSEM (p < 0.05), suggesting superiority of Q.Clear.

CONCLUSION

This pilot clinical study shows that Q.Clear reconstruction algorithm improves overall IQ of ¹⁸F-NaF PET in obese patients. Our clinical and phantom measurement results demonstrate improved CNR and reduced BV when using Q.Clear. A β value of 600 is preferred for reconstructing ¹⁸F-NaF PET/CT with Q.Clear in obese patients.

ADVANCES IN KNOWLEDGE

¹⁸F-NaF PET/CT is less susceptible to artifacts induced by body habitus. Bayesian penalized likelihood reconstruction with¹⁸F-NaF PET improves overall IQ in obese patients.

HCC-Mark: a simple non-invasive model based on routine parameters for predicting hepatitis C virus related hepatocellular carcinoma

BACKGROUND

Early detection of hepatocellular carcinoma (HCC) is crucial in providing more effective therapies. As routine laboratory variables are readily accessible, this study aimed to develop a simple non-invasive model for predicting hepatocellular cancer.

METHODS

Two groups of patients were recruited: an estimation group (n = 300) and a validation group (n = 625). Each comprised two categories: hepatocellular cancer and liver cirrhosis. Logistic regression analyses and receiver operating characteristic (ROC) curves were used to develop and validate the HCC-Mark model comprising AFP, high-sensitivity C-reactive protein, albumin and platelet count. This model was tested in cancer patients classified by the Barcelona Clinic Liver Cancer (BCLC), Cancer of Liver Italian Program (CLIP) and Okuda systems, and was compared with other non-invasive models for predicting hepatocellular cancer.

RESULTS

HCC-Mark produced a ROC AUC of 0.89 (95% CI 0.85-0.90) for discriminating hepatocellular carcinoma from liver cirrhosis in the estimation group and 0.90 (0.86-0.90) in the validation group (both p < 0.0001). This AUC exceeded all other models, that had AUCs from 0.41 to 0.81. AUCs of HCC-Mark for discriminating patients with a single focal lesion, absent macrovascular invasion, tumour size <2 cm, BCLC (0-A), CLIP (0-1) and Okuda (stage Ι) from cirrhotic patients were 0.88 (0.85-0.90), 0.87 (0.85-0.89), 0.89 (0.85-0.93), 0.87 (0.84-0.89), 0.85 (0.82-0.87) and 0.86 (0.83-0.89), respectively (all p < 0.0001).

CONCLUSION

HCC-Mark is an accurate and validated model for the detection of hepatocellular cancer and certain of its clinical features.

Development of an intraoperative 3D C-arm technique for torsion control of femur fractures: a cadaver study

AIM

This study aims to test the accuracy and feasibility of a measurement of femoral torsion of a 3D C-arm system (Linea aspera method) in a cadaver setting.

MATERIALS AND METHODS

A total of 11 intact femora were used. Schanz screws were inserted in the femoral bone in a parallel manner with the help of a fixed drill sleeve. Femur bones were then fractured in a controlled manner and three different internal and external torsion angles were fixed with the help of a Goniometer. After that, a 3D scan was performed. The 3D data set was analyzed using a radiologic software (Visage 7, Visage Imaging Inc, USA). Measurements were then compared in the two methods with a dependent t test.

RESULTS

Specific measurements for different angles did not show any differences between those two utilities.

CONCLUSION

Intraoperative estimation of femoral antetorsion using a 3D C-Arm system and the Linea aspera method seems to be an accurate and feasible method. Nevertheless, more studies with higher patient numbers, comparison to CT seems to be the next step and can be recommended.

HCC-Mark: a simple non-invasive model based on routine parameters for predicting hepatitis C virus related hepatocellular carcinoma

BACKGROUND

Early detection of hepatocellular carcinoma (HCC) is crucial in providing more effective therapies. As routine laboratory variables are readily accessible, this study aimed to develop a simple non-invasive model for predicting hepatocellular cancer.

METHODS

Two groups of patients were recruited: an estimation group (n = 300) and a validation group (n = 625). Each comprised two categories: hepatocellular cancer and liver cirrhosis. Logistic regression analyses and receiver operating characteristic (ROC) curves were used to develop and validate the HCC-Mark model comprising AFP, high-sensitivity C-reactive protein, albumin and platelet count. This model was tested in cancer patients classified by the Barcelona Clinic Liver Cancer (BCLC), Cancer of Liver Italian Program (CLIP) and Okuda systems, and was compared with other non-invasive models for predicting hepatocellular cancer.

RESULTS

HCC-Mark produced a ROC AUC of 0.89 (95% CI 0.85-0.90) for discriminating hepatocellular carcinoma from liver cirrhosis in the estimation group and 0.90 (0.86-0.90) in the validation group (both p < 0.0001). This AUC exceeded all other models, that had AUCs from 0.41 to 0.81. AUCs of HCC-Mark for discriminating patients with a single focal lesion, absent macrovascular invasion, tumour size <2 cm, BCLC (0-A), CLIP (0-1) and Okuda (stage Ι) from cirrhotic patients were 0.88 (0.85-0.90), 0.87 (0.85-0.89), 0.89 (0.85-0.93), 0.87 (0.84-0.89), 0.85 (0.82-0.87) and 0.86 (0.83-0.89), respectively (all p < 0.0001).

CONCLUSION

HCC-Mark is an accurate and validated model for the detection of hepatocellular cancer and certain of its clinical features.

Validated spectrofluorimetric method for determination of mirabegron by utilizing its quenching effect on acetoxymercuric fluorescein reagent

A reliable, sensitive, simple and inexpensive spectrofluorimetric method has been developed for assay of mirabegron in bulk powder and in its tablets. The method depends on the quenching effect of mirabegron on the fluorescence intensity of acetoxymercuric fluorescein (AMF) reagent at ƛem of 520 nm and ƛex of 498 nm. Parameters that may affect the reaction such as pH, AMF solution concentration, temperature, time and diluting solvents were studied and optimized. Under the optimized conditions, the proposed method was applied over the concentration range of 1-5 μg mL^-1 with acceptable linearity (r = 0.9997). The developed method was validated according to ICH guidelines in terms of accuracy, precision, linearity, range, LOD and LOQ. The proposed method was applied to analyze mirabegron in Bladogra® 50 mg tablets with acceptable recovery% of 100.41 and RSD% of 1.72. The results obtained were compared to those obtained by a previously reported TLC method.

P1425 Association between severity of mitral regurgitation and right ventricular function in patients with moderate to severe mitral regurgitation assessed by invasive hemodynamics measurements

Funding Acknowledgements

-

Background

Primary mitral regurgitation (MR) will cause volume overload to the left ventricle (LV) but due to systolic reguritant flow the pulmonary circulation will be affected often leading to post-capillary pulmonary hypertension and thus increased afterload to the right heart. As a consequence right ventricular (RV) dysfunction may be a consequence of MR.

Purpose

To assess the association between RV function assessed with cardiac magnetic resonance imaging (CMRI) and hemodynamics at rest and during exercise in ambulatory patients with primary mitral regurgitation (MR).

Methods

In an observational study, patients with significant primary MR with effective regurgitant orifice ≥0.30 cm2 and LV ejection fraction &gt;60% were examined with right heart catheterization during rest and exercise and CMRI at rest. Patients were examined in semi-supine position (30 degree). From right heart catheterization pulmonary artery systolic pressure (PAPs) was measured, where RV stroke work index (RVSWI = 0.0136*(mean pulmonary artery pressure – right atrial pressure *stroke volume index) and pulmonary artery compliance (PAC= stroke volume / (PAPsystolic – PAPdiastolic)) was calculated. Patients were dichotomized according to effective regurgitant orifice (ERO) (≤0.4 cm2).

Results

The two groups (total n = 46) have same baseline characters with no significant differences. In both groups resting RVEF was normal and no difference in RV stroke volume was seen between the groups at rest or with exercise. However RVSWi was significantly higher in patients with ERO &gt; 0.4, (rest p = 0.0039, exercise p = 0.01), Figure. The increase in RVSWi was driven by increased sPAP and where significantly in ERO &gt; 0.4 at rest at during exercise (rest p = 0.00027, exercise p = 0.0352). At rest PAC was significantly higher in ERO above 0.4, but during exercise no differences was found in the two groups. RVEF at rest measured by CMRI showed no correlation with RVSWi in the two groups (r = 0.11, p = 0.45)

Conclusion

In ambulatory patients with mitral regurgitation above 0.4 cm2, RVSW is associated with an increased right ventricle workload and contractility at rest and during exercise which especially is driven by increased post capillary pressure whereas pulmonary arterial compliance only is mildly affected.

Abstract P1425 Figure. Ventricle function at rest/exercise

The rotational fixator: A new device

Objectives

Malrotation after surgical treatment of femoral shaft fractures is a common problem and often leads to follow-up procedures with uncertain outcome. The aim of this study is the validation of a new device (Rotational Fixator) to perform the correction safely and accurately.

Methods

In an in-vitro study, we tested the Rotational Fixator on 21 corpse bones against a commercially available standard goniometer for measurement inaccuracies. For this purpose, we varied the rotation width from 10 to 30° in inside and outside rotation.

Results

We found a small measurement inaccuracy of 1-2° with increasing rotation. The smallest differences are found at 10° IR with 0.9524° (SD ± 1.0713; p = 0.001) difference and 10° ER with at 0.5952° (SD ± 0.6823; p = 0.001) difference and increase up to 30° (IR 1.6667°, SD ± 1.7121, p < 0.000/ER 1.5000°, SD ± 1.0488, p < 0.000).

Conclusions

The measurement results of the device show a constant deviation from the gold standard but are constant in the measurement error and slightly in relation to the desired correction range, so that a further review of the device and further testing in in vivo studies makes sense.

Levels of evidence

Level 3.

The benefits and challenges of cash transfer programmes in Greece, with a focus on protection

Introduction

This qualitative study evaluates cash transfer programmes (CTPs) in forcibly displaced populations, specifically in Greece. There is a focus on protection, encompassing health, gender, child protection and disability. The Greece Cash Alliance, run by the United Nations High Commissioner for Refugees (UNHCR), currently supports 63,853 individuals with cash via a pre-paid card. This study provides insight into challenges encountered by implementers of cash programmes in Greece, and the potential protection issues faced with the changing climate of the cash programme in Greece.

Methods

A literature review of academic and grey literature and semi-structured key informant interviews with stakeholders including Non-Governmental Organisation and United Nations agency staff were performed. Key informants were identified through purposive sampling. An inductive thematic approach was taken in analysis.

Results

Main emerging themes included the benefits and challenges of CTPs and their role in protection. Challenges included the mobile, heterogenous population and benefits included economic development in Greece and restored choice to beneficiaries. With regards to protection, informants reported a positive impact through allowing refugees to meet their basic needs and prioritise other needs and CTPs providing consistent access to refugees which could allow identification of protection risks. However, protection was not considered in the design of all CTPs.

Conclusions

Due to the multi-sectoral nature of the response, there is no standard integration of protection into cash programmes. Cash programming offers unique, regular contact with beneficiaries and chances to identify protection risks that are not always utilised due to minimal staff training in protection. Cash assistance in Greece allows people to meet their basic needs and gives people space and funds to prioritise other needs such as health and education, inherently improving their protection status.

Key messages

With cash assistance growing in popularity in humanitarian programming, consideration of protection is important as it can improve the health, safety and dignity of beneficiaries. In Greece the cash programme was only designed to meet basic needs but broader effects on protection were seen.

Syndromic infectious disease surveillance of refugees in Greece: a mixed methods analysis

Background

An estimated 1,174,140 refugees have migrated into Greece, a main entry point for refugees into Europe, since 2014. Their infectious disease profile is monitored by a national-level ad-hoc syndromic surveillance system in refugee-migrant reception centres. The utility of this system is explored to contribute evidence to and improve syndromic surveillance in European refugee responses.

Methods

Proportional morbidities, numbers of cases and signals, cases above expected numbers, of 14 syndromes are collated from weekly reports between 2016-2019, graphed and analysed in the context of the humanitarian response. Semi-structured key informant interviews are conducted and thematically analysed.

Results

Between 20.06.2016 and 17.02.2019, 36358 cases and 116 signals occurred. Public health responses resulted and there were no significant outbreaks. On average 5% of all consultations in centres were on infectious syndromes. Respiratory infections with fever (57%), gastroenteritis (22%), suspected scabies (13%) and rashes with fever (5%) were most commonly reported. Every week, between 68-100% of 25-58 participating centres completed reporting adequately. 6 informants reported on their syndromic system user experience. The system’s benefits, providing information and safeguarding refugees, outweighed harms. Data was timely and complete, but likely under-reported for common conditions. Poor living conditions and inter-agency coordination complicated reporting and public health responses.

Conclusions

Infectious burdens and trends were provided by the system and allowed for timely responses. Data quality was adequate. The system was valuable and feasible to informants. The set-up of the humanitarian response, inadequate ownership and poor coordination of authorities reduced the system’s utility.

Key messages

Syndromic surveillance is useful for monitoring refugee infectious health. Structural barriers need to be resolved to improve systems’ data and user experience.

Mastoid Reconstruction With Platelet-Rich Plasma and Bone Pate After Canal Wall Down Mastoidectomy: A Preliminary Report

OBJECTIVES

Mastoid reconstruction principle had been described to overcome problems of chronic discharging cavity. Different materials were used; nonbiologic materials seem to be less preferred. Platelet-rich plasma (PRP) could promote the regeneration of mineralized tissues. In this work, the authors present a simple and easy technique for mastoid reconstruction with PRP and cortical bone pate.

METHODS

The study design is a case series. Patients had mastoid reconstruction after canal wall down mastoidectomy using PRP and cortical bone pate.

RESULTS

This study included 21 patients: 9 males, and 12 females. Sixteen patients had left side disease. All surgical procedures were conducted smoothly within 90 to 135 minutes with no stressful events had been reported. At 12 to 16 months of follow-up, external canal stenosis and mastoid fistulas were not reported. Good healing of the tympanic membrane was seen in 18 patients. No radiological signs suggestive of recurrence were detected and the reconstructed mastoid cavity was smooth and well aerated. Residual tympanic membrane perforations were detected in 3 patients.

CONCLUSION

Autologous materials (PRP and bone pate pate) after canal wall down mastoidectomy appear to be a reliable and effective choice for mastoid reconstruction.

Safety and Efficacy of Dolutegravir Plus Rilpivirine in Treatment-Experienced HIV-Infected Patients: The DORIVIR Study

Objectives:

To analyze the efficacy and safety of dolutegravir/rilpivirine (DTG/RPV) in HIV-infected patients who switched from any other antiretroviral therapy (ART).

Methods:

Open-label, multicenter study including patients who switched to DTG/RPV between February 2015 and February 2016. Efficacy (HIV RNA <50 copies/mL), adverse events, and metabolic changes at 24 weeks were analyzed.

Results:

A total of 104 participants were included, who switched for the following reasons: toxicity/intolerance (42.3%), convenience (27.8%), and drug interactions (17.3%). Prior regimens are protease inhibitor (56.7%), integrase strand transfer inhibitor (26.9%), and non-nucleoside reverse transcriptase inhibitor (16.3%). Efficacy at 24 weeks was 88.4% (intention to treat) and 96.8% (per protocol). Triglyceride levels were reduced, on average, by 12.7% and a mean decrease of 9.0% in the glomerular filtration rate was observed as well (P values of .003 and .002, respectively), whereas total cholesterol, HDL cholesterol, LDL cholesterol, creatinine, and glutamic-pyruvic transaminase remained unchanged. No patient discontinued due to adverse events.

Conclusions:

Dolutegravir/RPV is effective and safe in long-term HIV-infected patients under any prior ART. Toxicity, convenience, and interactions were the main reasons for changing. At 24 weeks, the lipid profile improved with a decrease in triglycerides.

Disparity in oesophageal cancer management in South Africa: a comparison between two tertiary centres with special focus on the palliation of dysphagia

BACKGROUND

For most patients with oesophageal cancer worldwide, palliation of dysphagia is the goal which is most commonly achieved with self-expanding metal stents (SEMS). The aim of this study was to assess the profile and management of oesophageal cancer patients at Frere Hospital in the Eastern Cape, and compare this to a similar cohort from Groote Schuur Hospital (GSH) in the Western Cape Province.

METHOD

This study is a retrospective comparative cohort which reviewed all patients diagnosed with oesophageal cancer by the Frere Hospital and GSH endoscopy units from January to December 2015. Independent prospective electronic databases for the two hospitals were merged for comparative analysis.

RESULTS

During the study period, 346 and 108 patients were diagnosed with oesophageal cancer at Frere Hospital and GSH respectively. The rate of curative intended intervention was similarly low, with 3% of cases at Frere Hospital undergoing oesophagectomy or definitive radiotherapy as compared to 5% at GSH (p=0.48). In terms of palliation, significantly more patients received palliative oncological therapy at GSH as compared to Frere Hospital (21% vs 8%, p < 0.001). At Frere Hospital, 281 patients (81%) were treated primarily with serial dilatations. At GSH, 9 patients received a single dilatation, all as a bridge to radiotherapy or stenting. At Frere Hospital, 28 patients (8%) were stented, as compared to GHS where 69 patients (64%) were managed with a stent (p < 0.001).

CONCLUSION

This study shows significant differences in the oncological and endoscopic palliation of patients between the two institutions, highlighting a gross disparity in healthcare provision between them. The reasons for these disparities should be investigated and equipoise addressed by national health policy makers.

Validity of screening tools for dementia and mild cognitive impairment among the elderly in primary health care: a systematic review

OBJECTIVES

This systematic review aims to provide updated and comprehensive evidence on the validity and feasibility of screening tools for mild cognitive impairment (MCI) and dementia among the elderly at primary healthcare level.

STUDY DESIGN

A review of articles was performed.

METHODS

A search strategy was used by using electronic bibliographic databases including PubMed, Embase and CENTRAL for published studies and reference list of published studies. The articles were exported to a bibliographic database for further screening process. Two reviewers worked independently to screen results and extract data from the included studies. Any discrepancies were resolved and confirmed by the consensus of all authors.

RESULTS

There were three screening approaches for detecting MCI and dementia - screening by a healthcare provider, screening by a self-administered questionnaire and caretaker informant screening. Montreal Cognitive Assessment (MoCA) was the most common and preferable tool for MCI screening (sensitivity [Sn]: 81-97%; specificity [Sp]: 60-86%), whereas Addenbrooke's Cognitive Examination (ACE) was the preferable tool for dementia screening (Sn: 79-100%; Sp: 86%).

CONCLUSION

This systematic review found that there are three screening approaches for detecting early dementia and MCI at primary health care. ACE and MoCA are recommended tools for screening of dementia and MCI, respectively.

Comparative plasma phenylalanine and glutamate profiles in scalded rats treated with Mebo or Copper (I) Nicotinate Complex

The time profile of total proteins and albumin in line with two amino acids, Phe and Glu, are of great importance due to their indicative value of the healing and/or deterioration of burn wounds. In this experiment, rats exposed to scalding that produced a second-degree burn were divided into four groups: control, placebo, MEBO ointment, and copper (I) nicotinate complex ointment (an antioxidant anti-inflammatory) for four weeks. The three treatments showed noticeable similarities in the Phe profiles, with a slight drop 24 hours post burn, a peak elevation by the second week, and a slight, insignificant decline by the third week, with the placebo group showing highest values over normal (P< 0.05). In the Glu profile, large differences were observed: two set profiles, one representing MEBO and copper (I) nicotinate showed one peak in the second week, and the other representing placebo showed two peaks in the first and third weeks. Albumin and total protein time profiles showed the same trend throughout the whole experiment, and are in line with a reformed metabolic state parallel to wound closure. These results reveal that MEBO and copper nicotinate have comparable effects on wound healing in scald burns, and that plasma Glu profile is a better systemic indicator reflecting the regularity and steadiness of the healing process in MEBO and copper complex treatment.

Menopause Awareness, Symptoms Assessment and Menqol Among Bahrain Women

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Clinicopathological Criteria and Prognostic Factors in Gastric Adenocarcinoma in Kuwait

Background: Gastric cancer is the 5th most common cancer in the world and 2nd leading cause of cancer deaths. It has marked geographic incidence variation. Most common in Japan, China, other East Asian countries, Eastern Europe and South America. There is sharp decrease in incidence in western countries over the past 60 years but incidence of GE junction and proximal gastric tumors is increasing. In state of Kuwait in 2012 ASR was 2.6/100,000 population (similar to other Gulf countries; apart from Oman). There are many known risk factors including eating smoked and salted food and H. pylori infection. Aim: The aim of this study is to analyze gastric cancer diagnosed cases from 2009 to 2015 in Kuwait and to analyze clinicopathological criteria and prognostic factors. Methods: A total of 145 adult patients with newly diagnosed gastric cancers were treated and followed-up at Kuwait Cancer Control Center (KCCC) between 2009-2015. Patients' data were examined retrospectively. In all cases: age, performance status, sex, ethnicity, smoking and dietary habit, tumor site, pathology, staging and type of treatment were identified. Survival analysis was done using Kaplan-Meier, and comparison was done using long-rank test. Results: The median age at diagnosis was 54 (29-94). Men represented 63.5%. 75.2% had adenocarcinoma, 14.5% gastric lymphoma, 6.2% GIST, 3.4% carcinoid and 1 case squamous cell carcinoma. For gastric adenocarcinoma, 22 were metastatic (20.2%). In spite of composing almost 25% of country population and expected high incidence in their home countries, only 19.5% of patients were Asian with known habit of spicy food intake. 31% of patients were smokers. Performance at diagnosis was ECOG 0-1 in majority. Median follow-up was 45 months (1-89) and median overall survival was 34 months (0.5-89). Almost half of tumors were poorly differentiated with signet-ring feature in 36.8%. 12.6% presented with clinically advanced tumor but after surgery the number upstaged to be 25.9% (Stage III). Tumor epicenter localization was almost equivalent with 43 (49.4%) localized proximally and 44 (50.6%) distally. Surgery was the main treatment in majority (85.1%) while radiation was used in 58.6% and chemotherapy in 74.4% (adjuvant, neoadjuvant or concomitant). 22 patients failed; 7 locoregionally, 15 had distant metastasis while 2 patients failed both locally and distantly. Close surgical margins, and proximal localization were poor prognostic factors. Age and ethnicity had no impact on outcomes in our cohort. Conclusion: Gastric adenocarcinoma in Kuwait has similar profile to that documented worldwide and regionally (apart from Oman). Proximal tumors represent a challenge and has poorer prognosis that may need more intensification of treatment. Current (neo)adjuvant treatment seem to be effective in our population. Molecular profiling and studies are needed for further understanding of this potentially curable disease.

Motivations for Current E-Cigarette Use Among Adult Smokers in Malaysia

Background: Recommendations from WHO regarding the comprehensive ban on tobacco advertisements, promotions and scholarships (TAPS) have recently caused tobacco companies in shifting their market strategies to focus on promoting unregulated devices such as electronic cigarettes (ECs) and vapes. Aim: This study aims to explore the motivations of EC use among dual users and its associations with sociodemographic factors and smoking related characteristics under different regulatory environments in Malaysia. Methods: A total of 5823 dual users was collected using a multistage sampling study design. Data collection was conducted through intercept face-to-face interviews within 3 waves; wave 1 (May-September 2016), wave 2 (December 2016 - April 2017) and wave 3 (May-August 2017). The samples were drawn from 5 streets randomly (two in hotspot and three in nonhotspot locations) within stratified urban and rural areas in 14 states of Malaysia. Every fifth person passing an interview station in each street was approached. All statistical tests were conducted using PASW 18. Results: The top four self-reported motivations of using EC by dual users included “tasted better than conventional cigarettes” (85.1%), “to reduce the number of cigarettes smoked” (72.9%), “to quit smoking” (63.5%) and “increase price of cigarette taxes” (62.9%). Based on a multivariate analysis, respondents from states that have no current restrictions toward the sale and usage of ECs and who use ECs less than weekly (Adj.OR=2.54; 95% CI=1.93-3.34), weekly (Adj.OR=2.22; 95% CI=1.72-2.85) and daily users (Adj.OR= 1.77; 95% CI=1.36-2.31) were more likely to use ECs due to its better taste as compared with those who use ECs less than once a month. In states that have banned the sales and usage of ECs, there was a significant association between daily users of ECs and the four primary motivations. It was found that an increasing amount of cigarettes smoked per day (Adj.OR=2.46; 95% CI=1.59-3.81) had significantly influenced smokers in these states to more likely use ECs due to the increase price of cigarette tax. Conclusion: This study was conducted to show associations between smoking characteristics, EC use and self-reported motivations under different regulatory environments in Malaysia. Frequency of EC use was significantly associated with these self-reported motivations. Further research should be conducted to monitor EC use by Malaysians as well as to contribute to the formulation of EC policy in Malaysia.

Self-Reported of Awareness, Trial and Current Use of Electronic Cigarettes (ECS) Among of Adult Smokers in Malaysia

Background: In many parts of the world, E-cigarette (EC) devices are becoming popular and an increasing trend in its usage especially among young people and adult smokers. Aim: To examine the self-reported awareness, trial and current use of ECs among current smokers and to determine the predictors associated with the outcomes. Methods: A total of 40,000 current smokers aged 18 years and above were recruited through intercept face-to-face interview in wave 1 (May-September 2016), wave 2 (December 2016-April 2017) and wave 3 (May-August 2017). The samples were drawn from 5 streets randomly (two in hotspot and three in nonhotspot) within stratified urban and rural areas in 14 states of Malaysia. Respondents were recruited using systematic sampling. Every fifth person passing an interview station in each street was approached. Descriptive analysis and multivariate logistic regression were applied by using PASW 18. Results: Overall, 93% were aware of ECs, 19.9% were ECs trials and 14.6% were current users. Multivariate logistic regression shows that those states with no ban of ECs sales were more likely and significantly associated with these outcomes compared with those in states that this device has already been banned. Those who believe that ECs are “less harmful” (AOR=6.28; 95% CI=5.79-6.81, P < 0.001; AOR=4.84; 95% CI=4.12-5.69, P < 0.001) and “equally harmful” (AOR=2.06; 95% CI=1.91-2.22, P < 0.001; AOR=2.25; 95% CI=1.93-2.62, P < 0.001) were significantly associated with EC trials and current use of ECs respectively. In addition, intention to quit smoking (AOR=2.91; 95% CI=2.72-3.13) was also directly associated with EC trials. Conclusion: Awareness, trials and current use of ECs are likely due to the banning regulation implemented in specific states and strong belief that ECs is less harmful to health. Hence, this should be considered in the formulation of ECs policy in Malaysia.

In vivo heterotopic culturing of prefabricated tendon grafts with mechanical stimulation in a sheep model

BACKGROUND

The goal of this study is to investigate the biomechanical and histological properties of in vivo heterotopically prefabricated cruciate ligament replacement grafts with and without mechanical stimulation. The clinical goal is to heterotopically prefabricate a bone-tendon-bone graft for anterior cruciate ligament reconstruction, which allows rapid ingrowth and early full weight bearing.

METHODS

In a sheep model, eight quadriceps tendon grafts were harvested and introduced into culture chambers at their proximal and distal ends. In group S, four tendon-chamber constructs were mechanically stimulated by direct attachment to the quadriceps tendon and patella. In group NS, the same constructs were cultured without proximal attachment. All sheep were sacrificed six weeks postoperatively and the constructs were examined biomechanically and histologically. The healthy contralateral ACL and quadriceps tendon were used as controls.

RESULTS

Macroscopically, no obvious ossification could be observed at the ends of the tendon-chamber constructs six weeks postoperatively. Histologically, the tendon tissue from the mechanically stimulated constructs revealed higher counts of cells and capillaries. However, there was less regular cell distribution and collagen fiber orientation compared to the control group. In addition, osteoblasts and osteogenesis were observed in the prefabricated constructs both with and without mechanical stimulation. Biomechanically, there were no significant differences in stiffness, elongation and ultimate failure load between the groups.

CONCLUSION

In vivo heterotopic culture of prefabricated tendon grafts may have the potential to stimulate osteoblasts and induce osteogenesis. Future studies with longer follow-up and modifications of the surgical technique and culture conditions are desirable.

[Shoulder dislocations in elderly patients]

In contrast to shoulder dislocations in younger patients, anterior shoulder dislocation in the elderly is often associated with concomitant injuries to the rotator cuff and fractures. There is also frequent involvement of the brachial plexus or peripheral nerves. After closed reduction and a short period of immobilization, physiotherapy should be performed to restore mobility and strength. The evaluation of the rotator cuff is essential for further treatment decisions. The majority of patients are classically treated conservatively. Elderly patients with accompanying rotator cuff lesions and failed conservative therapy can benefit from a surgical intervention. Reconstructive interventions of the rotator cuff should be principally considered; however, some individuals may benefit from a reverse prosthesis in this elderly subgroup of patients. The challenge for the treating surgeon is to exactly define the structural injury of the shoulder (which may include pre-existing lesions) and to select the optimal treatment option.

Two-stage late reconstruction with a fresh large osteochondral shell allograft transplantation (FLOCSAT) for a large ostechondral defect in a non-union after a lateral tibia plateau fracture 2-year follow up

This is the description of a 58-year-old female patient presenting 8 months after a horse riding accident with significant pain and inability to walk independently. Imaging revealed a large osseous defect of the lateral tibia plateau which was not united posteriorly. The patient refused knee replacement and we developed a patient specific two-step procedure for her. Step 1: Filling of the defect with a large cortico-cancellous autograft from the posterior iliac crest; step 2: Transplantation of a fresh large osteochondral shell allograft (FLOCSAT). The postoperative protocol included continuous passive motion (CPM), partial weight bearing for three months, and physiotherapy. Based on the concept of immuno-privileged cartilage tissue, the patient did not get any immuno-suppressive therapy. Pain-, activity of daily living, Lysholm and Tegner scores were evaluated before defect filling surgery with autograft, before allograft transplantation, and at 12 and 24 months after allograft transplantation. There were no complications. Radiographic analyses with plain films and CT scans revealed solid osseous integration within 3 month. The patient regained excellent functionality in both, activities of daily living and sports (back to horse riding, trampolin jumping). Knee arthroscopy after 1year showed excellent condition of the lateral meniscus and the cartilage of the lateral tibia plateau. Chimerism/DNA analysis of a cartilage biopsy showed, that at 1year 32% of the donor cells have been already replaced by the patient's own cells. To our knowledge, this is the first case of a patient who sustained such a large defect during a tibia plateau fracture, and got successfully treated with a fresh large osteochondral shell allograft transplantation in a two-step procedure.