Application of the Banff Human Organ Transplant Panel to kidney transplant biopsies with features suspicious for antibody-mediated rejection

The Banff Classification for Allograft Pathology includes the use of gene expression in the diagnosis of antibody-mediated rejection (AMR) of kidney transplants, but a predictive set of genes for classifying biopsies with 'incomplete' phenotypes has not yet been studied. Here, we developed and assessed a gene score that, when applied to biopsies with features of AMR, would identify cases with a higher risk of allograft loss. To do this, RNA was extracted from a continuous retrospective cohort of 349 biopsies randomized 2:1 to include 220 biopsies in a discovery cohort and 129 biopsies in a validation cohort. The biopsies were divided into three groups: 31 that fulfilled the 2019 Banff Criteria for active AMR, 50 with histological features of AMR but not meeting the full criteria (Suspicious-AMR), and 269 with no features of active AMR (No-AMR). Gene expression analysis using the 770 gene Banff Human Organ Transplant NanoString panel was carried out with LASSO Regression performed to identify a parsimonious set of genes predictive of AMR. We identified a nine gene score that was highly predictive of active AMR (accuracy 0.92 in the validation cohort) and was strongly correlated with histological features of AMR. In biopsies suspicious for AMR, our gene score was strongly associated with risk of allograft loss and independently associated with allograft loss in multivariable analysis. Thus, we show that a gene expression signature in kidney allograft biopsy samples can help classify biopsies with incomplete AMR phenotypes into groups that correlate strongly with histological features and outcomes.

Metabolic Outcomes After Pancreas Transplant Alone From Donation After Circulatory Death Donors-The UK Transplant Registry Analysis

Extrapolating data from early DCD (donation after circulatory death) kidney transplantation, pancreas transplants from DCD grafts were feared to have worse metabolic outcomes. Hence, we aimed to address the question of pancreas transplant alone (PTA) from DCD donors-are our concerns justified? A UK transplant registry analysis of 185 PTA performed between 2005 and 2018 was done. All early graft losses (<3 months) were excluded to allow focus on the metabolic outcomes (HbA₁c, weight gain and incidence of secondary diabetic macrovascular complications). The aim was to compare the metabolic outcomes, rejection rates (including the need for steroids), patient and graft survival between DBD (Donation after brainstem death) and DCD groups. After excluding early graft losses, data from 162 PTA (DBD = 114 and DCD = 48) were analyzed. Body mass index of the donor was less in DCD group (DBD = 23.40 vs. DCD = 22.25, p = 0.006) and the rest of the baseline transplant characteristics were comparable. There were no significant differences in the HbA₁c, weight gain, rejection rate, and incidence of secondary diabetic macrovascular complications post-transplant between DBD and DCD recipients. The 1-, 5-, and 10-year patient and graft survival were similar in both the groups. PTA from DCD donors have equivalent metabolic outcomes and survival (patient/graft) as that of DBD donors.

Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs)

Introduction

There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.

Purpose

We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.

Methods

All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.

Results

Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.

Conclusion

Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Incidence, Risk Factors, and Effect on Allograft Survival of Glomerulonephritis Post-transplantation in a United Kingdom Population: Cohort Study

Background

Post-transplant glomerulonephritis (PTGN) has been associated with inferior long-term allograft survival, and its incidence varies widely in the literature.

Methods

This is a cohort study of 7,623 patients transplanted between 2005 and 2016 at four major transplant UK centres. The diagnosis of glomerulonephritis (GN) in the allograft was extracted from histology reports aided by the use of text-mining software. The incidence of the four most common GN post-transplantation was calculated, and the risk factors for disease and allograft outcomes were analyzed.

Results

In total, 214 patients (2.8%) presented with PTGN. IgA nephropathy (IgAN), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative/mesangiocapillary GN (MPGN/MCGN) were the four most common forms of post-transplant GN. Living donation, HLA DR match, mixed race, and other ethnic minority groups were associated with an increased risk of developing a PTGN. Patients with PTGN showed a similar allograft survival to those without in the first 8 years of post-transplantation, but the results suggest that they do less well after that timepoint. IgAN was associated with the best allograft survival and FSGS with the worst allograft survival.

Conclusions

PTGN has an important impact on long-term allograft survival. Significant challenges can be encountered when attempting to analyze large-scale data involving unstructured or complex data points, and the use of computational analysis can assist.

Pancreas Transplantation in Black, Asian and Minority Ethnic Patients-Single Centre Experience in the UK

Ethnic disparities in the outcomes after simultaneous pancreas kidney (SPK) transplantation still exist. The influence of ethnicity on the outcomes of pancreas transplantation in the UK has not been reported and hence we aimed to investigate our cohort. A retrospective analysis of all pancreas transplant recipients (n = 171; Caucasians = 118/Black Asian Ethnic Minorities, BAME = 53) from 2006 to 2020 was done. The median follow-up was 80 months. Patient &amp; pancreas graft survival, rejection rate, steroid free maintenance rate, HbA1c, weight gain, and the incidence of secondary diabetic complications post-transplant were compared between the groups. p &lt; 0.003 was considered significant (corrected for multiple hypothesis testing). Immunosuppression consisted of alemtuzumab induction and steroid free maintenance with tacrolimus and mycophenolate mofetil. Pancreas graft &amp; patient survival were equivalent in both the groups. BAME recipients had a higher prevalence of type-2 diabetes mellitus pre-transplant (BAME = 30.19% vs. Caucasians = 0.85%, p &lt; 0.0001), and waited for a similar time to transplantation once waitlisted, although pre-emptive SPK transplantation rate was higher for Caucasian recipients (Caucasians = 78.5% vs. BAME = 0.85%, p &lt; 0.0001). Despite equivalent rejections &amp; steroid usage, BAME recipients gained more weight (BAME = 7.7% vs. Caucasians = 1.8%, p = 0.001), but had similar HbA1c (functioning grafts) at 3-,12-, 36-, and 60-months post-transplant.

1307 Linking Pre-ST Trainees into The Surgical Profession - An Example from OMFS Of A Structured Introduction to The Speciality

Introduction

Inspiration and support are two of the key principles that enthuse junior trainees to pursue a career in surgery. Exposure to Oral and Maxillofacial Surgery (OMFS) is minimal at undergraduate level and can present a challenge for those postgraduate individuals who wish to gain more experience before applying to further training. This has prompted the formation of a support programme comprised of two stages: Taste of OMFS and Mentoring and Support Programme (MSP).

Method

Feedback was captured from OMFS junior trainees and educational supervisors on the existing junior trainee programme. It was concluded that a new programme was required to create a more structured system to help support trainees achieve their goals within OMFS. Taste in OMFS aims to provoke intrigue in the specialty. Individuals who are inspired to experience more can advance on to the MSP which consists of checklists, carefully designed to help the trainee obtain adequate exposure and achieve the recommended requirements for second-degree and specialty training applications.

Results

The new programme was trialed by existing junior trainee programme members over a six-month period. The results were encouraging with positive feedback on the structure of both sections. This, in combination with ideas generated from a focus group has helped create the final version, now published and accessible on the British Association of Oral and Maxillofacial Surgeons website.

Conclusions

We hope to raise awareness of this dynamic programme which can be tailored to each individual, in the hope that more junior trainees pursue a career within OMFS.

Diagnostic application of transcripts associated with antibody-mediated rejection in kidney transplant biopsies

Background

The diagnosis of antibody-mediated rejection (AMR) is reached using the Banff Classification for Allograft Pathology, which now includes gene expression analysis. In this study, we investigate the application of ‘increased expression of thoroughly validated gene transcripts/classifiers strongly associated with AMR’ as diagnostic criteria.

Method

We used quantitative real-time polymerase chain reaction for 10 genes associated with AMR in a retrospective cohort of 297 transplant biopsies, including biopsies that met the full diagnostic criteria for AMR, even without molecular data (AMR, n = 27), biopsies that showed features of AMR, but that would only meet criteria for AMR with increased transcripts [suspicious for AMR (AMRsusp), n = 49] and biopsies that would never meet criteria for AMR (No-AMR, n = 221).

Results

A 10-gene AMR score trained by a receiver-operating characteristic to identify AMR found 16 cases with a high score among the AMRsusp cases (AMRsusp-high) that had significantly worse graft survival than those with a low score (AMRsusp-low; n = 33). In both univariate and multivariate Cox regression analysis, the AMR 10-gene score was significantly associated with an increased hazard ratio (HR) for graft loss (GL) in the AMRsusp group (HR = 1.109, P = 0.004 and HR = 1.138, P = 0.012, respectively), but not in the whole cohort. Net reclassification index and integrated discrimination improvement analyses demonstrated improved risk classification and superior discrimination, respectively, for GL when considering the gene score in addition to histological and serological data, but only in the AMRsusp group, not the whole cohort.

Conclusions

This study provides evidence that a gene score strongly associated with AMR helps identify cases at higher risk of GL in biopsies that are suspicious for AMR but do not meet full criteria.

Kidney transplantation and patients who decline SARS-CoV-2 vaccination: an ethical framework

The COVID-19 pandemic has had a major impact on kidney transplantation and on patients with end-stage kidney disease. Transplantation activity has been substantially reduced, and kidney transplant recipients have suffered increased mortality. The introduction of vaccines against SARS-CoV-2 has offered considerable hope that it may be possible to protect patients from the risks associated with SARS-CoV-2 infection, and that more patients may once again have access to kidney transplantation.

Informing the Risk of Kidney Transplantation Versus Remaining on the Waitlist in the Coronavirus Disease 2019 Era

INTRODUCTION

There are limited data pertaining to comparative outcomes of remaining on dialysis versus kidney transplantation as the threat of coronavirus disease 2019 (COVID-19) remains. In this study we delineate the differential risks involved using serologic methods to help define exposure rates.

METHODS

From a cohort of 1433 patients with end-stage kidney disease (ESKD), we analyzed COVID-19 infection rates and outcomes in 299 waitlist patients compared with 237 transplant recipients within their first year post-transplant. Patients were followed over a 68-day period from the time our transplant program closed due to COVID-19.

RESULTS

The overall mortality rates in waitlist and transplant populations were equivalent (P = 0.69). However, COVID-19 infection was more commonly diagnosed in the waitlist patients (P = 0.001), who were more likely to be tested by reverse transcriptase polymerase chain reaction (P = 0.0004). Once infection was confirmed, mortality risk was higher in the transplant patients (P = 0.015). The seroprevalence in dialysis and transplant patients with undetected infection was 18.3% and 4.6%, respectively (P = 0.0001). After adjusting for potential screening bias, the relative risk of death after a diagnosis of COVID-19 remained higher in transplant recipients (hazard ratio = 3.36 [95% confidence interval = 1.19-9.50], P = 0.022).

CONCLUSIONS

Although COVID-19 infection was more common in the waitlist patients, a higher COVID-19‒associated mortality rate was seen in the transplant recipients, resulting in comparable overall mortality rates.

The UK Mentoring and Support Programme (MSP) for those considering a career in Oral and Maxillofacial Surgery (OMFS). A review of a 'Register Interest in OMFS' website and the MSP as two key resources created by the British Association of Oral and Maxillofacial Surgeons to promote recruitment and retention (2008-2020)

In 2008, to create a rapid route for information transfer in relation training and recruitment for OMFS trainees, the British Association of Oral and Maxillofacial Surgeons (BAOMS) created a website to "Register Your Interest in OMFS" (RYIO). From 2011 a Mentoring and Support Programme (MSP) was created to provide focussed guidance for trainees aiming for specialty training. This paper reviews the effectiveness and cost of these programmes. Between 2008 and 2020, 1744 individuals used RYIO on 2715 occasions. Of these registrations, 1772 were by dentists, 193 dental students, 589 doctors and 161 medical students. 2354 were from UK and Ireland and 351 from the rest of the world. 188 registrants subsequently became UK OMFS trainees or specialists. All registrants valued the information provided. In response to RYIO trainee feedback the new 'Taste of OMFS 2020' programme was created. The MSP was originally called the Junior Trainee Programme (JTP). The MSP scheme provides a layer of mentorship/support which runs parallel to the medical/dental training post or period of study. Of 180 members of MSP, 72 have obtained specialty training posts in OMFS. There are 88 current members. Full information is available on the BAOMS website www.baoms.org.uk. Reviewing both programmes, participant feedback is excellent with tangible results whilst cost effectiveness is high.

Administration of intravenous iron and tranexamic acid in the management of postoperative iron deficiency anaemia following free flap reconstruction: re-audit

Following free tissue transfer, intravenous iron (IVI) has a role in reducing the rates of blood transfusion and more rapidly restoring haemoglobin (Hb) levels. Anaemia has a detrimental effect on survival, postoperative complications, fatigue, and health-related quality of life, therefore early correction is recommended. The aim of this re-audit is to assess the use of IVI, of tranexamic acid intraoperatively, and of perioperative blood transfusions. A total of 148 consecutive patients who underwent ablative surgery and free flap reconstruction between May 2018 and September 2019 were audited. The median (IQR) age was 66 (59,72) years and 36% were female. For two-thirds, surgery was for cancer located in the oral cavity and two-thirds of the free flaps were soft tissue. Tranexamic acid (TXA) was used intraoperatively for 30%, red blood cells (RBC) were transfused for 20% and 55 patients (37%) received IV iron. This compares with 4%, 26%, and 0, respectively, in the initial audit. Those having IVI were more likely (56%) to have had a composite flap, a lower postoperative haemoglobin and lower discharge Hb. The Hb between four and twelve weeks' follow up, known for 40, was a median (IQR) of 122 (104,138). There were no adverse reactions to IV iron. Although it is straightforward to administer IVI postoperatively, this re-audit demonstrates that it can be a challenge to embed change in protocols. Through raised awareness of the benefits of IVI, lack of adverse events and clarification of selection criteria, it is hoped that rates of IVI use will increase.

Technical considerations when designing a gene expression panel for renal transplant diagnosis

Gene expression analysis is emerging as a new diagnostic tool in transplant pathology, in particular for the diagnosis of antibody-mediated rejection. Diagnostic gene expression panels are defined on the basis of their pathophysiological relevance, but also need to be tested for their robustness across different preservatives and analysis platforms. The aim of this study is the investigate the effect of tissue sampling and preservation on candidate genes included in a renal transplant diagnostic panel. Using the NanoString platform, we compared the expression of 219 genes in 51 samples, split for formalin-fixation and paraffin-embedding (FFPE) and RNAlater preservation (RNAlater). We found that overall, gene expression significantly correlated between FFPE and RNAlater samples. However, at the individual gene level, 46 of the 219 genes did not correlate across the 51 matched FFPE and RNAlater samples. Comparing gene expression results using NanoString and qRT-PCR for 18 genes in the same pool of RNA (RNAlater), we found a significant correlation in 17/18 genes. Our study indicates that, in samples from the same routine diagnostic renal transplant biopsy procedure split for FFPE and RNAlater, 21% of 219 genes of potential biological significance do not correlate in expression. Whether this is due to fixatives or tissue sampling, selection of gene panels for routine diagnosis should take this information into consideration.

Molecular assessment of antibody-mediated rejection in human pancreas allograft biopsies

Pancreas transplant longevity is limited by immune rejection, which is diagnosed by graft biopsy using the Banff Classification. The histological criteria for antibody-mediated rejection (AMR) are poorly reproducible and inconsistently associated with outcome. We hypothesized that a 34-gene set associated with antibody-mediated rejection in other solid organ transplants could improve diagnosis in pancreas grafts. The AMR 34-gene set, comprising endothelial, natural killer cell and inflammatory genes, was quantified using the NanoString platform in 52 formalin-fixed, paraffin-embedded pancreas transplant biopsies from 41 patients: 15 with pure AMR or mixed rejection, 22 with T cell-mediated rejection/borderline and 15 without rejection. The AMR 34-gene set was significantly increased in pure AMR and mixed rejection (P = .001) vs no rejection. The gene set predicted histological AMR with an area under the receiver operating characteristic curve (ROC AUC) of 0.714 (P = .004). The AMR 34-gene set was the only biopsy feature significantly predictive of allograft failure in univariate analysis (P = .048). Adding gene expression to DSA and histology increased ROC AUC for the prediction of failure from 0.736 to 0.770, but this difference did not meet statistical significance. In conclusion, assessment of transcripts has the potential to improve diagnosis and outcome prediction in pancreas graft biopsies.

Epidemiology of COVID-19 in an Urban Dialysis Center

BACKGROUND

During the coronavirus disease 2019 (COVID-19) epidemic, many countries have instituted population-wide measures for social distancing. The requirement of patients on dialysis for regular treatment in settings typically not conducive to social distancing may increase their vulnerability to COVID-19.

METHODS

Over a 6-week period, we recorded new COVID-19 infections and outcomes for all adult patients receiving dialysis in a large dialysis center. Rapidly introduced control measures included a two-stage routine screening process at dialysis entry (temperature and symptom check, with possible cases segregated within the unit and tested for SARS-CoV-2), isolated dialysis in a separate unit for patients with infection, and universal precautions that included masks for dialysis nursing staff.

RESULTS

Of 1530 patients (median age 66 years; 58.2% men) receiving dialysis, 300 (19.6%) developed COVID-19 infection, creating a large demand for isolated outpatient dialysis and inpatient beds. An analysis that included 1219 patients attending satellite dialysis clinics found that older age was a risk factor for infection. COVID-19 infection was substantially more likely to occur among patients on in-center dialysis compared with those dialyzing at home. We observed clustering in specific units and on specific shifts, with possible implications for aspects of service design, and high rates of nursing staff illness. A predictive epidemic model estimated a reproduction number of 2.2; cumulative cases deviated favorably from the model from the fourth week, suggesting that the implemented measures controlled transmission.

CONCLUSIONS

The COVID-19 epidemic affected a large proportion of patients at this dialysis center, creating service pressures exacerbated by nursing staff illness. Details of the control strategy and characteristics of this epidemic may be useful for dialysis providers and other institutions providing patient care.

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

Background

The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal.

Methods

We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item.

Results

From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure.

Conclusion

This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting.

P333Late mortality after pharmaco-invasive PCI for STEMI

Background

Worldwide, and in Australia, a large proportion of patients with ST-segment elevation myocardial infarction (STEMI) are unable to undergo timely primary percutaneous coronary intervention (PCI), and so are transferred for PCI after receiving fibrinolytic therapy (so-called pharmaco-invasive PCI).

Methods

Our Hospital, the primary PCI centre for Southwest Sydney, Australia receives patients for both primary PCI and transferred post- fibrinolytic therapy for rescue or prognostic PCI. Associations were determined between late outcomes (bleeding according to Bleeding Academic Research Consortium (BARC) criteria and mortality) and reperfusion strategy, either primary PCI, or pharmaco-invasive PCI, in patients undergoing PCI for STEMI during hospitalization.

Results

Among 2083 consecutive patients (80% male) with STEMI who underwent PCI (1076 [52%] primary PCI and 1007 [48%] pharmaco-invasive PCI), mortality at 3 years was 8.7%,11.1% after primary PCI and 6.2% after pharmaco-invasive PCI (9.4% after rescue PCI and 4.6% after prognostic PCI); p<0.001 (Figure). Rates of type 2–5 BARC bleeding post-PCI were 35% after primary PCI and 24% after pharmaco-invasive PCI (42% after rescue PCI and 15% after prognostic PCI); p<0.001. while the rate of major bleeding type 3b-5 were 5% after primary PCI and 3% after pharmaco-invasive PCI (8% after rescue PCI and 1% after prognostic PCI); p=0.112.The independent predictors of 3 year mortality were, pre-PCI cardiogenic shock HR=0.25 [95% CI: 0.16–0.39], p<0.001), age (HR=1.05 [95% CI: 1.03–1.06], p<0.001), TIMI 3 flow post-PCI (HR=5.25 [95% CI: 2.51–11.00], p≤0.001), eGFR<60mL/min/1.73m2 (HR=2.90 [95% CI: 1.93–4.34], p≤0.001), post PCI bleeding (HR=2.17 [95% CI: 1.53–3.08], p≤0.001), anterior infarction (HR=1.76 [95% CI: 1.23–2.51], p=0.002), and female gender (HR=1.56 [95% CI: 1.07–2.27], p=0.022); and primary PCI (HR=1.6 [95% CI: 1.18–2.19; p=0.003]. On multi-variable analysis, age, cardiogenic shock presentation, rescue PCI, intra-aortic balloon pump, Pre-procedural anaemia, (all p<0.001) and eGFR<60mL/min/1.73m2 (p=0.006) were associated with bleeding.

Figure 1. Late survival after primary & PI PCI

Conclusion

Among patients with STEMI who underwent pharmaco-invasive PCI had lower mortality rates than to those who had primary PCI, though procedural selection criteria may have been different; bleeding rates were similar. Among suitable patients pharmaco-invasive PCI should be evaluated in large clinical trials.

PodCast: A rural and regional service model for podiatrist-led total contact casting

PROBLEM

Diabetes-related foot disease causes significant health system costs and is a leading cause of morbidity and disproportionately affects rural populations. Total contact casts or instant total contact casts are gold standard for management of foot ulcerations resulting from diabetes-related foot disease. The aim of this study was to evaluate the impact of a podiatrist-led casting service model within a rural and regional setting.

DESIGN

The implementation of the service model was evaluated over a 12-month period using a quality improvement approach, informed by multiple methods. Quantitative and qualitative methods were used.

SETTING

An outpatient high-risk foot clinic and community-based podiatry services within a large regional health service. The location was central Victoria, servicing rural communities within the Loddon Mallee region.

KEY MEASURES FOR IMPROVEMENT

Patient-related data included information relating to demographics, diabetes and foot pathologies. Service-related data included occasions of service, locations and the number and type of casts applied.

STRATEGIES FOR CHANGE

Upskilling podiatrists to provide the service in a safe, supportive and sustainable manner and ensuring the podiatrist-led casting service model was sufficiently adaptable for patients to access at the rural sites.

EFFECTS OF CHANGE

Increased access to total contact casts and instant total contact casts, comparable wound healing times to other studies and the model was able to be sustained.

LESSONS LEARNT

Podiatrist-led casting resulted in increased utilisation of total contact casts and instant total contact casts. The increased use of instant total contact casts in particular may help address the lack of uptake of this treatment for people with diabetes-related foot disease, thereby improving rural health outcomes.

Correction to: A decade of progress in critical care echocardiography: a narrative review

The original version of this article unfortunately contained a mistake.

Causes and risk factors for acute dialysis initiation among patients with end-stage kidney disease-a large retrospective observational cohort study

Background

Patients who require acute initiation of dialysis have higher mortality rates when compared with patients with planned starts. Our primary objective was to explore the reasons and risk factors for acute initiation of renal replacement therapy (RRT) among patients with end-stage kidney disease (ESKD). Our secondary objective was to determine the difference in glomerular filtration rate (GFR) change in the year preceding RRT between elective and acute dialysis starts.

Methods

We conducted a single-centre retrospective observational study. ESKD patients either started dialysis electively (planned starters) or acutely and were known to renal services for >90 (unplanned starters) or <90 days (urgent starters).

Results

In all, 825 consecutive patients initiated dialysis between January 2013 and December 2015. Of these, 410 (49.7%) patients had a planned start. A total of 415 (50.3%) patients had an acute start on dialysis: 244 (58.8%) unplanned and 171 (41.2%) urgent. The reasons for acute dialysis initiation included acute illness (58%) and unexplained decline to ESKD (33%). Cardiovascular disease [n = 30 (22%)] and sepsis [n = 65 (48%)] accounted for the majority of acute systemic illness. Age and premorbid cardiovascular disease were independent risk factors for acute systemic illness among unplanned starts, whereas autoimmune disease accounted for the majority of urgent starts. The rate of decline in GFR was greater in the month preceding RRT among acute dialysis starters compared with planned starters (P < 0.001).

Conclusions

Cardiovascular disease and advancing age were independent risk factors for emergency dialysis initiation among patients known to renal services for >3 months. The rapid and often unpredictable loss of renal function in the context of acute systemic illness poses a challenge to averting emergency dialysis start.

The surface eroding thermocouple for fast heat flux measurement in DIII-D

A novel type of surface eroding thermocouple (SETC) has been tested and demonstrated in the small angle slot (SAS) divertor of DIII-D for fast local heat flux measurements. The thermojunction of the SETC is formed between two thin (10 μm) ribbons, which are filed over to create microfiber junctions. These thermocouples are able to be exposed directly to the plasma at surface temperatures exceeding 2000 °C and are capable of sub-10 ms time resolution. Before installation in SAS, the SETCs were exposed in the lower DIII-D divertor during L-mode and H-mode discharges, from which results are presented. In preliminary tests, SETCs proved to be a qualified diagnostic to accurately measure both the intra-edge localized mode (ELM) and inter-ELM heat flux during H-mode shots with high frequency ELMs (hundreds of Hz) and to resolve heat flux profiles during strike point sweeps. The heat fluxes measured by using SETCs are consistent with the heat fluxes measured by using IR cameras and Langmuir probes. These new diagnostic capabilities will complement the existing IR camera measurements and will be of particularly significant value to measure surface heat flux in the SAS divertor or other regions where the IR camera lacks line of sight.

Long- and short-term outcomes in renal allografts with deceased donors: A large recipient and donor genome-wide association study

Improvements in immunosuppression have modified short-term survival of deceased-donor allografts, but not their rate of long-term failure. Mismatches between donor and recipient HLA play an important role in the acute and chronic allogeneic immune response against the graft. Perfect matching at clinically relevant HLA loci does not obviate the need for immunosuppression, suggesting that additional genetic variation plays a critical role in both short- and long-term graft outcomes. By combining patient data and samples from supranational cohorts across the United Kingdom and European Union, we performed the first large-scale genome-wide association study analyzing both donor and recipient DNA in 2094 complete renal transplant-pairs with replication in 5866 complete pairs. We studied deceased-donor grafts allocated on the basis of preferential HLA matching, which provided some control for HLA genetic effects. No strong donor or recipient genetic effects contributing to long- or short-term allograft survival were found outside the HLA region. We discuss the implications for future research and clinical application.

Development of a stochastic agent-based model to evaluate surveillance strategies for detection of emergent porcine reproductive and respiratory syndrome strains

Background

The objective of the current study was to develop a stochastic agent-based model using empirical data from Ontario (Canada) swine sites in order to evaluate different surveillance strategies for detection of emerging porcine reproductive and respiratory syndrome virus (PRRSV) strains at the regional level. Four strategies were evaluated, including (i) random sampling of fixed numbers of swine sites monthly; (ii) risk-based sampling of fixed numbers, specifically of breeding sites (high-consequence sites); (iii) risk-based sampling of fixed numbers of low biosecurity sites (high-risk); and (iv) risk-based sampling of breeding sites that are characterized as low biosecurity sites (high-risk/high-consequence). The model simulated transmission of a hypothetical emerging PRRSV strain between swine sites through three important industry networks (production system, truck and feed networks) while considering sites’ underlying immunity due to past or recent exposure to heterologous PRRSV strains, as well as demographic, geographic and biosecurity-related PRRS risk factors. Outcomes of interest included surveillance system sensitivity and time to detection of the three first cases over a period of approximately three years.

Results

Surveillance system sensitivities were low and time to detection of three first cases was long across all examined scenarios.

Conclusion

Traditional modes of implementing high-risk and high-consequence risk-based surveillance based on site’s static characteristics do not appear to substantially improve surveillance system sensitivity. Novel strategies need to be developed and considered for rapid detection of this and other emerging swine infectious diseases. None of the four strategies compared herein appeared optimal for early detection of an emerging PPRSV strain at the regional level considering model assumptions, the underlying population of interest, and absence of other forms of surveillance.

Outcome of Halo Immobilisation of 104 Cases of Cervical Spine Injury

Study design: Retrospective review Objectives: To present and discuss the outcome of halo jacket immobilisation of cervical spine injuries. Setting: National Spinal Injuries Unit in a Scottish University teaching Hospital. Methods: Retrospective review of case-notes and radiographs of all patients treated with halo jacket both as primary means of immobilisation or as adjunct to surgical stabilisation between 1992–1999 and followed up at a weekly halo clinic. Results: Out of a total one hundred and four patients with cervical spine injury, eighty-six were treated with Halo jacket as primary means of cervical immobilisation. Halo was used as adjunct to surgical stabilisation for the rest. There were nine cases of true failure. This is a failure rate of 10% for primary halo immobilisation. Of the nine patients who had failure of bony healing, four had fibrous healing, three had surgery to stabilise spine, two were subsequently lost to follow-up. The highest incidence of recurrence of subluxation occurred in patients with fracture/subluxation with a healing rate of 85%. Patients with ankylosing spondylitis did well. Odontoid fractures had 18% failure rate. The commonest complication was loss of reduction, followed by pin-site infection. Conclusion: Halo is an effective non-surgical treatment for the injured cervical spine at both upper and lower levels.

Evaluation of a two rubber band technique for finger ring removal

INTRODUCTION

Rings are required to be removed from a finger in many clinical situations. Rings that are difficult to remove is a problem encountered frequently. Many techniques have been reported for this problem. This study looks at the effectiveness of a single technique for removing difficult rings from fingers.

METHODS

A two rubber band technique was used in this study of 69 difficult to remove rings. Success of the technique and time to removal were recorded.

RESULTS

Difficult rings were removed in 92.5% of cases, in a mean time of 10.7 seconds. No fingers or rings suffered damage during the study.

CONCLUSIONS

This two rubber band technique is a rapid, safe and effective method for removing rings that cannot be removed easily.

Evidence of horsemanship and dogmanship and their application in veterinary contexts

This review collates peer-reviewed evidence for desirable attributes for those who work with dogs and horses. It is written with a particular focus on the veterinary profession. Although veterinarians and veterinary nurses (VNs) occupy variable roles when interacting with their patients, several behavioural attributes emerge as helpful across the range of such roles. In light of recent research on the value of considering animals' arousal and affective state as predictors of behaviour and welfare, best practice in human-horse and human-dog-interactions is outlined. The attributes of affiliation, safety and positive reinforcement seem to contribute greatly to the development and maintenance of moderate arousal and positive affect in animals. The information in this review article is offered in an attempt to show why veterinary professionals with good horsemanship are likely to remain safe, and to introduce the concept of dogmanship. In the light of the peer-reviewed evidence assembled here, it is arguable that veterinary teams, comprising both veterinarians and VNs, can become scholars in these areas. The benefits of this approach for practitioner safety, animal welfare and client satisfaction are likely to be significant.

Immunotherapy following relapse of acute leukaemia after T-cell-replete allogeneic peripheral blood progenitor cell transplantation: importance of new onset chronic graft-versus-host disease

INTRODUCTION

To further define the relative impact of immunotherapy and subsequent development of graft-versus-host disease (GVHD) on survival in patients with relapsed acute leukaemia postallogeneic hematopoietic stem cell transplant (SCT), we performed a single-centre retrospective analysis of 32 actively treated patients between 2003 and 2011.

METHODS

A total of 13 patients were identified who were treated actively with cessation of immunosuppression ± Fludarabine, Cytarabine, G-CSF (FLAG) induction, but no donor leucocyte infusion (DLI) (non-DLI group) and 19 patients received the same step-wise therapy plus G-CSF mobilized DLI (G-DLI group).

RESULTS

Groups were not statistically different with regards to baseline characteristics; however, the G-DLI group contained more sibling donors as opposed to unrelated donors than the non-DLI group. With a median follow-up of 47 months, the median overall survival (OS) of the non-DLI and G-DLI groups was not statistically different (8 months vs. 9 months, respectively, P = 0.5). Survival at 3 years was <10% in both groups. Univariate analysis identified response to FLAG, and new onset chronic GVHD as the only factors associated with improved OS.

CONCLUSION

Second donor stem cell infusions are unwarranted in the treatment of relapse after allogeneic SCT and therapeutic strategies should focus on cytoreduction followed by immune modulation with the aim of invoking chronic GVHD.

Acupuncture for treatment of arthralgia secondary to aromatase inhibitor therapy in women with early breast cancer: pilot study

BACKGROUND

Aromatase inhibitors (AIs) are recommended as adjuvant hormone treatment for postmenopausal women with early breast cancer. A substantial proportion of women taking AIs experience joint pain and stiffness. Studies have suggested that acupuncture may be effective in treating joint pain.

OBJECTIVE

A pilot study was conducted to evaluate the feasibility, safety and efficacy of using acupuncture to treat AI-induced arthralgia.

METHODS

A total of 32 patients were randomised to receive either sham or real electroacupuncture (EA) twice weekly for 6 weeks. Outcomes of joint pain, stiffness and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), overall pain severity and interference with the BPI-SF and quality of life (QOL) with the Functional Assessment of Cancer Therapy-General (FACT-G) instrument. Hand strength was assessed by a grip test, and a serum marker of inflammation (C reactive protein (CRP)) was also measured. All assessments were performed at baseline, 6 weeks and 12 weeks, except for blood samples at baseline and 6 weeks only.

RESULTS

No serious adverse events were reported during or after acupuncture treatments. There were no significant differences in outcome measures. However, positive trends were observed in stiffness and physical function at week 12 in favour of real EA.

CONCLUSIONS

Findings suggest that acupuncture is feasible and safe in patients with breast cancer with joint pain caused by AI. A larger study with adequately powered to confirm these results and detect clinically relevant effects is needed.

Prevention of knot slippage with the use of cyanoacrylate glue: a mechanical study

PURPOSE

To assess the effect of cyanoacrylate glue on knot slippage and strength in vitro.

METHODS

Ethibond 3/0 was tested using a tensile tester. A single drop of cyanoacrylate glue was applied to the knots. Seven knot configurations (10 samples each) were tested: (1) a surgeon's knot (S) plus 4 square throws (+4) without glue (control group), (2) S plus one square throw (+1) without glue, (3) S+1 with glue, (4) S with glue, (5) S+1 wet posttie without glue, (6) S+1 wet pre-tie without glue, and (7) S+1 wet pre-tie with glue. Wet sutures were immersed in normal saline for 24 hours prior to knot tying. Wet pre- and post-tie sutures were immersed for one minute prior to knot tying and tensile testing, respectively. Outcome measures were the mode of failure (knot slippage or suture snapping) and the ultimate tensile strength.

RESULTS

All knots without glue failed owing to knot slippage, except for the controls, whereas all knots with glue failed owing to suture snapping. The ultimate tensile strength was significantly higher in knots with glue and controls than in knots without glue. The ultimate tensile strength did not differ significantly between S+4 without glue and S with glue (p=0.48), indicating that glue could reinforce knots and reduce the number of throws needed. Wet suture is protective against failure (p<0.01).

CONCLUSION

Cyanocrylate glue may have clinical applications for flexor tendon repairs for which a reduced knot size is advantageous.

Renal allograft recipients fail to increase interferon-γ during invasive fungal diseases

Invasive fungal diseases are a major cause of death in renal allograft recipients. We previously reported that adjunctive recombinant human interferon-γ therapy has clinical utility for invasive fungal diseases after renal transplantation. We have now developed a rapid peripheral blood-based quantitative real-time PCR assay that enables accurate profiling of cytokine imbalances. Our preliminary studies in renal transplant patients with invasive fungal diseases suggest that they fail to mount an adequate interferon-γ response to the fungal infection. In addition, they have reduced IL-10 and increased TNF-α when compared to stable renal transplant patients. These preliminary cytokine profiling-based observations provide a possible explanation for the therapeutic benefit of adjunctive human interferon-γ therapy in renal allograft recipients with invasive fungal diseases.