Preparing Patients for Body Contouring Surgery and Postoperative Surveillance for Deep Venous Thrombosis

This article highlights the importance of the preoperative evaluation and considerations necessary in preparing patients for body contouring surgery after massive weight loss (MWL). The importance of evaluating such factors as body mass index stabilization, medical comorbidities, nutritional optimization, social factors, deep venous thrombosis prophylaxis, and postoperative surveillance is critically important. Patients undergoing body contouring surgery after MWL are at increased risk of thromboembolic events, and prophylactic measures should be taken to minimize this risk. Overall, a thorough preoperative evaluation is essential to ensure patient safety, optimize surgical outcomes, and address the unique challenges presented by the MWL patient population.

Work-related injuries and attendance at a Canadian regional emergency department

BACKGROUND

Monitoring trends in the burden of illness and injury attributable to work is key in assessing occupational health hazards; however, New Brunswick does not participate in the Canadian National Ambulatory Care Reporting System which itself does not collect details of occupation and industry.

AIMS

We set out to determine the proportion of emergency department attendances that were attributable to a work-related cause. We also wanted to evaluate the recording of occupation in the electronic health record system, and to describe the characteristics of patients with a work-related presentation.

METHODS

A retrospective observational study over a 1-year period was conducted using an administrative database obtained from Canadian Emergency Department Information System. Descriptive statistics are used to present the analysis of categorical and continuous data.

RESULTS

A total of 49 365 patients were included for analysis. Two per cent of patients presented with a self-reported work-related condition. Health care and social assistance, construction, retail trade and manufacturing were the most common industries reported by patients.

CONCLUSIONS

This study found the rate of work-related medical conditions to be substantially less than expected, and that occupation was not captured for any patients presenting to the emergency department with a work-related condition, despite a field being available in the electronic health record registration system. We were able to analyse the industry sectors for work-related presentations. The recording and coding of occupation and industry would significantly benefit occupational epidemiology in emergency medicine as well as potentially improving patient outcomes and health system efficiencies.

Pediatric Cardiology Fellowship Standards for Training in Exercise Medicine and Curriculum Outline

Over the past 2 decades, fundamentals of exercise medicine, including clinical exercise testing, assessment and promotion of physical activity, exercise prescription, and supervised exercise training/rehabilitation programming have demonstrated considerable clinical value in the management of children and adolescents with congenital and acquired heart disease. Although the principles of exercise medicine have become an integral component in pediatric cardiology, there are no standardized training recommendations for exercise physiology during pediatric cardiology fellowship at this time. Thus, the Pediatric Cardiology Exercise Medicine Curriculum Committee (PCEMCC) was formed to establish core and advanced exercise physiology training recommendations for pediatric cardiology trainees. The PCEMCC includes a diverse group of pediatric cardiologists, exercise physiologists, and fellowship program directors. The expert consensus training recommendations are by no means a mandate and are summarized herein, including suggestions for achieving the minimum knowledge and training needed for general pediatric cardiology practice.

POS1158 CHARACTERIZATION OF GOUT IN US PATIENTS UNDERGOING HEMODIALYSIS (HD) AND PERITONEAL DIALYSIS (PD)

Background

Gout is the most common inflammatory arthritis and occurs frequently in patients with renal disease often leading to a significant burden on quality of life and functional status.1,2 Despite the established connection of renal disease with gout, little has been reported on the prevalence, patient characteristics, and associations of gout with other outcomes in the US hemodialysis (HD) and peritoneal dialysis (PD) population.

Objectives

This project used a large end-stage renal disease (ESRD) focused-database, Dialysis Outcomes and Practice Patterns Study (DOPPS), to examine gout in dialysis-dependent patients.

Methods

Gout patients were identified by active prescription (Rx) of (1) colchicine, (2) febuxostat, or (3) allopurinol; or by (4) prior diagnosis of gout from US cohorts of 70,297 HD (DOPPS, 2012-2020) patients and 5117 PD (Peritoneal DOPPS, 2014-2020) patients. Outcomes of HD and PD patients with and without a history of gout were compared with propensity score matching. Outcomes included erythropoietin resistance index (ERI = ESA dose/(hemoglobin*weight), cardiovascular death, all-cause mortality/hospitalization, and baseline patient-reported outcomes (PROs).

Results

Gout prevalence was 13% in HD and 21% in PD and was highest among incident dialysis patients. Of the gout patients identified, the most-commonly used gout-related medications were allopurinol (9-12%), followed by colchicine (2-3%), and then febuxostat (1%, Figure 1). Both HD and PD patients with gout (vs. no gout) were older and more likely male. Gout HD and PD patients had higher BMI and higher prevalence of cardiovascular comorbidities than HD and PD patients without gout. After propensity score matching, mean ERI was 4% higher for gout vs. non-gout patients, while there was minimal evidence of association with clinical outcomes (mortality and hospitalization) or PROs.

Figure 1.

Gout prevalence by dialysis duration in patients undergoing HD and PD. Criteria for gout included gout diagnosis and use of a urate-lowering therapy.

HD, hemodialysis; PD, peritoneal dialysis; mo, months; Rx, prescription; yrs, years. Some patients were included in multiple gout categories.

Conclusion

Gout was common in US HD and PD patients, with a large proportion of these patients treated with drugs indicated for hyperuricemia (allopurinol and febuxostat) and gout flares (colchicine). The true prevalence of gout was likely higher than observed when considering potential under-ascertainment of gout diagnosis history in nephrology/dialysis-focused clinical settings.3 This report provides a snapshot of gout in the US dialysis population and offers opportunities to expand on research to improve awareness and care for patients with gout and ESRD.

References

[1]Singh JA, Strand V. Ann Rheum Dis. 2008;67:1310–6.

[2]Singh JA, Cleveland JD. BMC Neph 2019;20:93.

[3]Roughley M, et al. Arthritis Res Ther. 2018;20(1):243.

Disclosure of Interests

Angelo Karaboyas Grant/research support from: Horizon Therapeutics, Junhui Zhao Grant/research support from: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brad Marder Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Barry Gorlitsky Consultant of: AstraZenica, Davita, Horizon Therapeutics, Jensen Pharmaceuticals, KidneyAide LLC, vinicius domingues Consultant of: Abbvie, Aurinia Pharma, Exagen, Eli Lilly, Roberto Pecoits-Filho Grant/research support from: Horizon Therapeutics, Bruce Robinson Grant/research support from: Horizon Therapeutics

Utilization of Short Tandem Repeat Analysis to Resolve Specimen Mislabeling in the Anatomic Pathology Laboratory

Introduction/Objective

A mislabeled specimen is an example of preanalytical error that can have significant consequences on patient care. These errors can be difficult to detect and resolve. One method to confirm genetic identity is short tandem repeat (STR) analysis, which is utilized in forensic investigations, paternity studies, and post- hematopoietic stem cell transplantation monitoring. Herein we present application of STR analysis to resolve a suspected specimen mislabeling prior to receipt in our anatomic pathology laboratory.

Methods/Case Report

DNA was extracted from paraffin embedded tissues. Chimerism testing was performed by STR analysis using the Globalfiler (ThermoFisher Scientific) and analyzed by Chimermarker (Softgenetics) automated chimerism software.

Results (if a Case Study enter NA)

Colon biopsies were received for a single patient (#1) with two requisition forms. Each specimen (A-F) was labeled with the patient’s name, with specimens A-D noted on first page of requisition and specimens E-F on the second requisition page. After the case was signed out, the lab was contacted looking for biopsy results on another patient (#2) who was seen on the same day as patient #1. Review of all the patients seen in the endoscopy suite on the given date raised suspicion that specimens E-F from the second page of the requisition actually pertained to patient #2. STR analysis performed on specimens confirmed that specimens E-F were genetically distinct from those labelled A-D. Tissue from a subsequent biopsy on patient #2 was analyzed by STR testing, which was identical to STR results performed on specimens E-F.

Conclusion

Here we utilized STR testing to resolve a suspected mislabeled specimen, allowing the appropriate diagnosis to be attributed to the correct patient. This is a unique application of a common method, which could be implemented in anatomic pathology laboratories to resolve cases of specimen mix-ups.

Adherence to Adjuvant Endocrine Therapy in Christchurch Women with Early Breast Cancer

AIMS

To assess adherence to adjuvant endocrine therapy by a real-world cohort of women in Christchurch and to determine any associated factors.

MATERIALS AND METHODS

Records were retrieved of all women newly diagnosed with early breast cancer and registered on the Christchurch Breast Cancer Patient Register over 4 years from June 2009. Demographic and pathological factors, dates of starting and stopping endocrine therapies and reported side-effects were collected. The proportion remaining on endocrine therapy was analysed by Kaplan-Meier curve; Cox regression analysis was used to identify independent factors influencing adherence.

RESULTS

Of 1213 women, 1018 (83.9%) had oestrogen receptor-positive tumours, of whom 674 (66.2%) started adjuvant endocrine therapy, including 62 (9.2%) neoadjuvantly. Uptake was 52.4% of those with T1 tumours, 89% with T2 tumours, 93% with T3/T4 tumours, 92.7% with node-positive tumours and 49.7% with node-negative tumours. The initial endocrine therapy was an aromatase inhibitor in 254 (38%) and tamoxifen for 412 (61%). At 1 year, 90% remained adherent, at 2 years 84%, at 3 years 81%, at 4 years 76%, at 4.5 years 71% and at 5 years 50%, with a median duration of 60 months (56-64 months, 95% confidence interval) and a median follow-up of 33 months. Overall, 135 (20%) women stopped treatment for adverse events or poor tolerability. A longer persistence with endocrine therapy was associated with node-positive tumours (hazard ratio 1.38, P = 0.003), but not first hormone used; aromatase inhibitor compared with tamoxifen, P = 0.76.

CONCLUSION

Adjuvant endocrine therapy use fell to 50% by 5 years, limiting possible survival benefits, providing support for efforts to increase compliance.

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study

Background The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT. Methods In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle. Results The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion. Conclusion NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.

Prevalence of cam hip shape morphology: a systematic review

OBJECTIVE

Cam hip shape morphology is a recognised cause of femoroacetabular impingement (FAI) and is associated with hip osteoarthritis. Our aim was to systematically review the available epidemiological evidence assessing the prevalence of cam hip shape morphology in the general population and any studied subgroups including subjects with and without hip pain.

DESIGN

All studies that reported the prevalence of cam morphology, measured by alpha angles, in subjects aged 18 and over, irrespective of study population or presence of hip symptoms were considered for inclusion. We searched AMED, MEDLINE, EMBASE, CINAHL and CENTRAL in October 2015. Two authors independently identified eligible studies and assessed risk of bias. We planned to pool data of studies considered clinically homogenous.

RESULTS

Thirty studies met inclusion criteria. None of the included studies were truly population-based: three included non-representative subgroups of the general population, 19 included differing clinical populations, while eight included professional athletes. All studies were judged to be at high risk of bias. Due to substantial clinical heterogeneity meta analysis was not possible. Across all studies, the prevalence estimates of cam morphology ranged from 5 to 75% of participants affected. We were unable to demonstrate a higher prevalence in selected subgroups such as athletes or those with hip pain.

CONCLUSIONS

There is currently insufficient high quality data to determine the true prevalence of cam morphology in the general population or selected subgroups. Well-designed population-based epidemiological studies that use homogenous case definitions are required to determine the prevalence of cam morphology and its relationship to hip pain.