'Look up from the waiting list and see the bigger picture': a qualitative analysis of clinical specialist physiotherapist perspectives on low back pain care in Ireland

INTRODUCTION

Healthcare systems are struggling to deliver high-quality low back pain (LBP) care. In 2012 specialist physiotherapist-led musculoskeletal (MSK) triage services were introduced in Irish hospitals to expedite patient care and alleviate pressure on elective orthopaedic/ rheumatology consultant clinics. Specialist physiotherapists have expertise to inform health service improvement and reform, but their perspectives of LBP healthcare delivery have received scant attention.

OBJECTIVES

To explore specialist physiotherapists' perspectives on LBP care in Ireland, the barriers and facilitators to quality LBP care and the development of MSK interface services in primary care settings.

DESIGN

Cross-sectional observational study using an anonymous electronic survey with thematic framework analysis of response data from open-ended questions.

PARTICIPANTS

Thirty-four clinical specialist physiotherapists in Irish MSK triage services.

RESULTS

Thematic analysis resulted in six overarching themes, grouped into two categories. One category pertained to LBP healthcare in Ireland with the following three themes: 1) Inadequate health services for patients with LBP; 2) Need for defined LBP clinical pathways; 3) Need for a multisectoral approach to spine health. Themes in the second category, pertaining to the development of community-based MSK interface services, were: 4) Concern regarding isolation from secondary care services; 5) Unrealistic expectations of MSK triage; 6) Improved communication and collaboration with primary care services.

CONCLUSION

Specialist physiotherapists have concerns regarding LBP health services and persistence of a biomedical, secondary care-led approach. They advocate for investment in primary care multi-disciplinary teams, enhanced integration across primary and secondary care, development of a national clinical pathway and a multisectoral approach. CONTRIBUTION OF PAPER.

An evaluation of the West of Scotland in-programme Chief Resident role

Background

Postgraduate leadership education is an evolving field. Locally we have an established 'Chief Residency' programme where centres have two to four senior trainees completing leadership duties alongside clinical workload, supported by local directors of medical education. This is twinned with a 4-day central training programme and peer-support network.

Methods

To assess perspectives of the CR role, we adopted a qualitative case-study design using an electronic questionnaire delivered to previous chief residents between 2020 and 2023. Results were analysed using thematic analysis.

Results

Trainees valued involvement within quality improvement and trainee support, demonstrating successful multi-departmental projects. Leadership education was viewed ubiquitously positively but participants felt further work is needed to address role legitimacy locally. A proposed solution was junior doctor leadership teams to address workload and emotional challenges.

Conclusion

This model provides further evidence of the value in investing in trainee leadership positions, demonstrating organisational impact. Future work will research hospital peer leadership teams.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Series: Public engagement with research. Part 4: Maximising the benefits of involving the public in research implementation

This final article in the four-part series focuses on the often neglected yet important role of the public in implementing research in General Practice and Primary Care more broadly. Experience in implementation of findings from research with public engagement in Primary Care has highlighted how partnership working with patients and the public is important in transitioning from 'what we know' from the evidence-base to 'what we do' in practice. Factors related to Primary Care research that make public engagement important are highlighted e.g. implementing complex interventions, implementing interventions that increase health equity, implementing interventions in countries with different primary healthcare system strengths. Involvement of patients and public can enhance the development of modelling and simulation included in studies on systems modelling for improving health services. We draw on the emerging evidence base to describe public engagement in implementation and offer some guiding principles for engaging with the public in the implementation in General Practice and Primary Care in general. Illustrative case studies are included to support others wishing to offer meaningful engagement in implementing research evidence.

Veterinary Students' Sense of Belonging: Growing Community with Small Group Academic Enhancement

A student's sense of belonging to a university is associated with success in academic setting, happiness, and satisfaction. It is therefore unsurprising that universities commonly strive to improve student measures of belonging especially considering its negative correlation with attrition rates. This study documents the implementation and assessment of a new curricular intervention at Ross University School of Veterinary Medicine (RUSVM) and measures associated changes in students' feeling of belonging to the university and accountability for their success. Specifically, small, group, faculty-guided weekly discussion sessions were introduced to the Veterinary Professional Foundation (VPF) course to complement a series of updated didactic only lectures. Voluntary surveys ("belonging to the university scale" [1] and the "personal accountability in education scale" [2]) were utilized to document student attitudes and feelings surrounding these variables. Likert scores from a control group of students who completed the VPF course prior to the curricular change were compared to the intervention group who engaged in the weekly guided discussion sessions via a Wilcoxon test. The intervention group reported significantly improved feelings of belonging to the university (p-values ranging from 0.008 to 0.027). Minimal change was noted between groups associated with accountability. The addition of weekly small group meetings has proven valuable at RUSVM in improving student sense of belonging to the university. Further research is indicated to determine if accountability may be improved over a longer period of monitoring with continued interventions.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >19 0 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.00 0 to 70.48 0, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89).    Conclusions This prospective study found no association between the changes in clinical examination variables and changes in crouch highlighting the likely multi-factorial aetiology of this gait pattern and the need for larger prospective studies. The variability crouch gait progression among the 27 participants highlights the pitfall of group mean values in such a heterogeneous population.

A prospective assessment of gait kinematics and related clinical examination measures in cerebral palsy crouch gait

Background While prospectively assessed crouch gait in cerebral palsy (CP) does not necessarily progress, prospective changes in clinical examination measures have not been reported. This study prospectively examined the association between selected clinical examination variables and change in crouch gait in a cohort with bilateral CP. Methods Inclusion criteria were a diagnosis of ambulant bilateral CP, knee flexion at mid-stance >190 and a minimum of two-years between gait analyses. The change in kinematic variables was assessed using Statistical Parameter Mapping (SPM) and changes in clinical measures using appropriate paired tests. Linear regression examined the association between progression of crouch and clinical examination variables. Results There was no mean change in crouch in 27 participants over 3.29 years. However, there was significant variability within this group. Clinical hamstring tightness (60.000 to 70.480, p<0.01) and external knee rotation during stance (SPM analysis, p<0.001) increased but there was no association between changes in clinical examination variables and changes in crouch (p-values 0.06 - 0.89).    Conclusions The variability crouch gait progression highlights the pitfall of group mean values in such a heterogeneous population.  The lack of association between changes in clinical examination variables and changes in crouch highlights the multi-factorial aetiology of this gait pattern and the need for larger prospective studies.

360 PROFILING FRAILTY IN A POPULATION OF OLDER FARMERS IN THE WEST OF IRELAND

Background

Identification of different groups at risk of frailty is a key research focus. Farmers frequently have higher prevalence of some health problems; however, they undertake high levels of physical activity which may provide protection against the development of frailty in this cohort. To date, no published research has examined prevalence of frailty levels in older farmers in Ireland. This research aimed to profile frailty levels of older farmers in the west of Ireland, and, establish if there is an association between frailty levels in this group and different farming specific demographics/socioeconomic factors such as; type of farming undertaken, amount of time spent farming outdoors and amount of land owned by farmers

Methods

This cross-sectional study recruited older farmers via livestock marts in the west of Ireland. A questionnaire regarding participants characteristics and farming demographics was provided to participants. This questionnaire also included the Program on Research for Integrating Services for the Maintenance of Autonomy (PRISMA-7) questionnaire and the short 5-question assessment of Fatigue, Resistance, Aerobic capacity, Illnesses, and Loss of weight (FRAIL) questionnaire to assess frailty. Data were analysed using STATA statistical software.

Results

In total, 58 older farmers participated in the study. Results showed found that two participants (3.5%) were ‘frail’, with 27 participants (47%) classified as ‘prefrail’. An association existed between the type of farming undertaken and frailty levels based on the FRAIL scale (p=0.009). No association was found between frailty levels and the amount of land owned by farmers (p=0.34) or the amount of time spent farming outdoors (p=0.18).

Conclusion

A minority of participants in this study were classified as frail. The type of farming undertaken by farmers may have an association with frailty levels. Results should be interpreted with caution secondary to the small sample size and the small geographical scope of recruitment.

186 FRAILTY IN HOSPITALISED OLDER ADULTS AND THEIR SPOUSES: A CROSS-SECTIONAL STUDY

Background

Hospital admissions are a critical time-point for assessing frailty. Frail older adults have high utilisation of healthcare resources and many require on-going care. Often spouses provide this care, however caregiving can lead to increased frailty in the caregiver. A description of frailty and caregiving within marital dyads has not been explored previously, in relation to hospital admissions.

Methods

Aim: To measure the frequency and describe the characteristics of frailty in hospitalised older adults and their spouse. Objectives were to: (1) Describe frailty, physical and cognitive performance in patients and spouses; (2) Determine frailty correlations between dyads; (3) Establish if patients are more likely to have spouses of the same frailty classification; (4) Describe caregiving within the context of frailty. Participants were recruited from geriatric and stroke services from October 2019-March 2020. Fried Frailty Phenotype (FFP) was used to test frailty. Clinical Frailty Scale, Grip Strength, Montreal Cognitive Assessment, Timed Up and Go, Geriatric Depression Scale and self-reported: mobility status, caregiving status, number of falls and number of hospital admissions were also assessed to describe the population.

Results

Data from 27 dyads that participated and consented were analysed using SPSS. A total of 15 patients (55.5%) and four spouses (14.8%) were classified as frail. Of 15 frail patients, four had frail spouses, five had pre-frail spouses and six had robust spouses. No pre-frail or robust patients had frail spouses. Spearman’s Correlational analysis showed no correlation in FFP between patient and spouse (r=0.24, p=0.23). Participants that provided care (44.4%) accounted for 5 patients (frail n=4) and 19 spouses (frail n=4).

Conclusion

Frailty in dyads is heterogeneous. Caregivers are commonly frail and provide care to frail partners. Older adults admitted to hospital should be assessed for frailty. If the patient has a spouse, especially if the patient is frail, their spouse should be assessed for frailty.

119 The Perceptions of Older Patients and their Family or Caregivers Towards Physical Activity and Exercise in Hospital: A Qualitative Study

Background

Between 30-60% of older people experience functional decline after hospitalisation which can be accelerated by inactivity in hospital. Family or caregivers can positively affect activity levels of hospitalised older people. We aimed to explore the perceptions of hospitalised older people and their family or caregivers towards physical activity and exercise during an admission to a Specialist Geriatric Ward in an acute hospital

Methods

A qualitative approach was taken, using semi-structured interviews with eleven patient participants and semi-structured focus groups with four family or caregivers. Thematic analysis was utilised to identify key themes.

Results

Three similar themes emerged from both groups: 1) personal feelings towards exercise or inactivity, 2) the role family/caregivers could play in facilitating exercise and 3) the role of hospital staff, which all impacted on participants’ perceptions towards exercise in hospital.

Personal influences including self-efficacy and appreciation of the importance of exercise resulted in more positive views towards activity. There was an acute awareness among some family of the dangers of inactivity.

Uncertainty existed regarding the role family or caregivers have in increasing patient activity levels. Some patient participants believed family involvement may increase activity levels, while others thought it would compromise their independence.

Both groups identified a need for more patient-specific information regarding activity in hospital. Both groups favoured hospital staff encouraging rather than restricting activity and felt that more doctors encouraging exercise would be helpful. The need for more opportunities for meaningful activity in hospital was highlighted.

Conclusion

Physical activity and exercise were perceived as important during hospital admission. Hospital staff should facilitate and enable increased opportunities for patient activity, and empower family or caregiver involvement in this where appropriate.

Single versus separate implant fixation for concomitant ipsilateral femoral neck and shaft fractures: A systematic review

Concomitant ipsilateral femoral neck and shaft fractures are uncommon, occurring in 1-9% of femoral shaft fractures. While this injury typically occurs in young patients following high-energy trauma, little consensus has been established regarding the optimal fixation approach. A multitude of treatment strategies exist, with limited evidence as to which is more favorable. The aim of this study was to appraise current evidence, comparing management with either one single or separate devices for both fractures. A systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1992 and 2018 comparing the rate of postoperative nonunion, malunion, delayed union, avascular necrosis, infection or reoperation between at least one method of single device fixation and one method of separate device fixation were included. Six non-randomized cohort studies assessing 173 patients were suitable for inclusion, each comparing single device cephalomedullary nail fixation of both fractures with a combination of devices. All patients presented following high-energy trauma, at a median age of 32 years. While low complication rate and favorable outcomes were found across both groups, no significant difference could be inferred between either treatment strategy. This injury continues to occur in the traditionally described patient group, and results in acceptable postoperative outcomes. A paucity of randomized studies limits the ability to recommend a single or separate device treatment approach, and as such prospective, randomized trials with adequately powered sample sizes are required to definitively compare surgical management strategies in this rare but complex injury.

Measurement properties of instruments for assessment of cervical spine function in infants with torticollis: a systematic review

The aim of this study was to systematically review the measurement properties of instruments which assess cervical spine function in infants with torticollis. Electronic searches were performed in MEDLINE, CINAHL, Embase, Web of Science and the Cochrane Library, combining three constructs ('torticollis', 'cervical spine assessment' and 'measurement properties'). Two reviewers independently rated the methodological quality and the quality of measurement properties of identified articles, using both the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist and quality criteria for measurement properties. Five studies, using six instruments, met the inclusion criteria and were analysed. Included instruments were the goniometer, electronic pendular goniometer, protractor, still photography, Muscle Function Scale and a range of motion limitation scale. All studies assessed reliability, and one study also assessed content validity and hypothesis testing. The methodological quality of the studies varied from poor to excellent according to the COSMIN checklist. Two instruments were found to have good measurement properties from high-quality studies: still photography for the assessment of habitual head tilt in supine and the Muscle Function Scale for the assessment of side-flexor muscle function in lateral head righting.Conclusion: This systematic review identified two reliable tools for the assessment of cervical spine function in infants with torticollis. Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in this population. What is known? • A thorough assessment of the infant presenting with torticollis is essential, in order to correctly diagnose, rule out 'red flags' and manage appropriately • Assessment tools need to have robust measurement properties in order to be of value for clinical practice and research What is new? • This systematic review identified two valid and reliable tools for the assessment of cervical spine function in infants with torticollis • Further research is required to assess the measurement properties of tools already described in the literature and to develop further tools for use in infants with torticollis.

The natural history of crouch gait in bilateral cerebral palsy: A systematic review

AIM

To systematically review the natural history of crouch gait in bilateral cerebral palsy (CP) in the absence of surgical intervention and to review any relationship between clinical variables and progression of knee crouch.

METHODS

Relevant literature was identified by searching article databases (PubMed, CINAHL, EMBASE, and Web of Science). Included studies reported on participants with bilateral CP who had 3-dimensional gait analysis on at least two occasions with no surgical interventions between analyses.

RESULTS

Five papers (4 retrospective cohort studies; 1 case report) comprised the final selection. Studies varied in follow-up times and participant numbers. Increased knee flexion over time was reported in the four retrospective studies with two distinct patterns of increasing knee flexion evident. Only the case-study reported improved knee extension between assessments. Four studies demonstrated increased hamstring tightness over time with the biggest increases related to longer follow-up time rather than increase in crouch.

CONCLUSION AND IMPLICATIONS

The existing literature suggests that the natural history of crouch gait is towards increasing knee flexion over time. Future prospective studies of bigger groups are needed to examine the relationship between increasing crouch and clinical variables.

195 EXPRESSION OF MESENCHYMAL STROMAL CELL (MSC) MARKERS IN THE EQUINE ENDOMETRIUM AND IN VITRO INFLUENCE OF STEROID HORMONES ON ENDOMETRIAL-DERIVED MSC

Mesenchymal stromal cell (MSC) are multipotent precursor cells that have been isolated from many tissues, including endometrium in some species. These cells are necessary for tissue homeostasis, which in the cycling equine endometrium is regulated in part by changes in concentration of steroid hormones. The expression of oestrogen and progesterone receptors during the oestrous cycle has been studied before, but MSC gene expression is not reported as well as the effects of steroid hormones on in vitro proliferation of endometrial MSC. This study was designed to investigate the influence of steroid hormones on endometrial MSC proliferation in vitro and to examine mRNA expression of MSC markers (CD29, CD44, CD73, CD90, and CD105) in the healthy equine endometrium during the oestrous cycle. Equine endometrial tissue was collected postmortem (n = 6) and digested using a dissociation medium and mucin-1-bound magnetic beads were utilised to remove epithelial cells from the resulting single-cell solution. The cells were expanded in culture and, at passage 4, incubated with 3 different concentrations of oestradiol and progesterone for 5 days. For the proliferation analysis the Alamar Blue® assay was used according to manufacturer instructions. Endometrial biopsies, for quantitative RT-PCR analysis, were taken from healthy mares (n = 5) on Day 5 and 13 post-ovulation, during oestrus (1 follicle >3.5cm, pronounced uterine oedema), and seasonal anestrous (seasonal anovulation). The ΔCt values were used for statistical analysis using SPSS Statistics 22 (IBM Corp., Armonk, NY). Data for quantitative PCR are presented as gene expression relative to the mean of 18S and GAPDH. No significant differences in proliferation could be detected in the various groups incubated with steroid hormones compared with the controls supplemented with charcoal-stripped fetal bovine serum. Detectable levels of mRNA for all 5 MSC markers analysed were present throughout the oestrous cycle. While the levels of CD73 were consistent, the expression of 3 MSC markers (CD29, CD44, and CD105) was elevated at Day 13. This difference was substantial between Day 13 and oestrus for CD29 (37.6 ± 6.2 and 12.2 ± 3.4; P < 0.01) and CD105 (8.3 ± 0.9 and 4.5 ± 0.6; P < 0.05), and between Day 5 and 13 for CD29 (7.4 ± 2.3 and 37.6 ± 6.2) and CD44 (12.9 ± 1.8 and 4.1 ± 0.3; P < 0.01). In contrast, CD90 expression was higher at oestrus (27.8 ± 3.8) than at Day 5 (6.7 ± 0.9) or 13 (12.0 ± 2.1; P < 0.01). Elevated quantities of MSC marker transcripts during late diestrus might be linked to the preparation of the equine endometrium for the proliferation phase associated with oestrus. However, the in vitro proliferation of endometrial-derived MSC is not influenced by the steroid hormones, although gene expression of steroid hormone receptors is present throughout the oestrous cycle of the mare. In summary, this study shows that the equine endometrium expresses MSC markers, and it does so at variable levels throughout the oestrous cycle; however, cell proliferation in vitro is not influenced by steroid hormones. This information will be useful for future studies aiming to derive endometrial MSC from mares.

Abstracts from the 5th International Conference for Healthcare and Medical Students (ICHAMS)

O1: Assessing the protective effect of dexrazoxane against doxorubicin-induced toxicity in HL-1 cardiomyocytes

Yvonne Sweeney, Hugh O’Neill, Garry Duffy

O2: Role of KCNQ1 in epithelial barrier repair

Daniel Creegan, Viviana Bustos, Brian J. Harvey

O3: The suitability of non-small cell lung cancer cytology preparations for the analysis of anaplastic lymphoma kinase gene rearrangements

Alexander Dalphy, Anthony O’Grady, Elaine Kay

O4: Penetrating keratoplasty and descemet’s stripping automated endothelial keratoplasty may lead to deterioration in glaucoma management

Katarzyna Samelska, Justyna Izdebska, Anna Kurowska

O5: The effect of Resolvin D1 on normal and cystic fibrosis human bronchial epithelium

Rena Al-Zubaidy, Magdalena Mroz, Brian Harvey

O6: Validity of clinical assessment compared with plantar fascia thickness on ultrasound for plantar fasciitis: a cross-sectional study

Ryan Fagan, Helen French, Vanessa Cuddy, Jennifer Ashton, Michelle Clarke

P1: Undergraduate medical research in Gulf Cooperation Council (GCC) countries: A descriptive study of students’ views

Zaid Sayedalamin, Mukhtiar Baig, Osama Almutairi, Hassan Allam, Taher F. Halawa, Hazem M. Atta

P2: Positive fluid balance as a prognostic factor in children with sepsis during first 3 hours of resuscitation in intensive care unit

Linda Sirone, Renars Erts, Jana Pavare

P3: Patients on aspirin: Too little or too much?

Louis Richter, Joseph Morris, Irene Oglesby, Eimear Dunne, Dermot Kenny

P4: Beta catenin/TCF4 activation reduces KCNQ1 current in colonic monolayers

Ibrahim Mohammed Mahdi Khayyat, Viviana Bustos Salgado, Brian J. Harvey

P5: Size Matters. Abdominal aortic aneurysm: adherence to surveillance imaging guidelines

Jonavan Tan, Daragh Moneley, Austin Leahy, Patricia Fitzgerald

P6: Endoscopic retrograde cholangiopancreatography in the west of Ireland: Procedural outcomes and peri-procedural complications

Evelyn Fennelly, Grace Harkin, John Lee

P7: The effect of the extracellular redox environment on polyamine-platelet interactions

Erica O’Sullivan, Brian Kirby, Sarah O’Neill

P8: Functionalized gold nanoparticles: preliminary data on in vitro toxicity and comparative photothermal effect

Diana Gonciar, Teodora Mocan, Cristian Matea, Lucian Mocan, Cornel Iancu

P9: Imaging proteasomal inhibition after seizures in the brain: A study into cellular activity in the hippocampus of epileptic transgenic mice

Chloe Doran, Sarah Hoolahan, Tobias Engel

P10: Investigating the ability of the Olfactory epithelial stem cells to differentiate into glial cells by assessing cell morphology and marker expression

Maha Alkhattab, Tijna Alekseeva, William Lackington, Fergal O’Brien

P11: Beaumont Hospital cystic fibrosis service audit and annual report

Nabeehah Moollan, Chloe Doran, Noel Gerry McElvaney, Cedric Gunaratnam

P12: Quick cognitive screening: the 6-item cognitive impairment test and the temporal orientation score

Lorraine Scanlon, Noeleen Brady, Suzanne Timmons

P13: Granular analysis of causes of peritoneal dialysis technique failure in the first six months of therapy

Richard Bresler, Zita Abreu, Stefan Trohonel, Joanne Bargman

P14: Job satisfaction of surgeons working in hajj pilgrimage: a multicenter study

Ahmad A. Mirza, Ahmed Badrek-Amoudi, Rakan H. Aun, Hussam A. Senan, Abdulrahim A. Mirza, Mohammed S. Binsaad, Mian U. Farooq

P15: Investigation of the role of Bok using wild-type, bax-, bok-, and bax/bok-double-deficient mice

Saheli Nandi, Beatrice D’Orsi, Jochen Prehn

P16: Is it possible to predict resistance of an organism to stress based on the level of corticosterone?

Mariia Zharova, Pavel Umrukhin

P17: Investigating the strength model of self-regulation (ego depletion) and medical decision making and error in medical students

Wendy Evans-Uhegbu, Frank Doyle, Hope Kudryashova, Derek Dorris, Anthony Cummins

P18: Does bladder drainage with intermittent catheterisation preserve kidney function in boys with posterior urethral valves?

Jemma Doheny-Shanley, Mark Woodward, Wesley Hayes

P19: Investigating the role of Stonin 2, a Clathrin Mediated Endocytosis adaptor protein, in altered hippocampal synaptic transmission characterized in schizophrenia

Marina Yostos, David Cotter, Melanie Focking

P20: Predicting complications after colon resection

Samantha Stancu, Florin Iordache, Bogdan A. Popescu

P21: Knowledge, attitude and practice of the methods of primary and secondary prevention of cervical cancer among NYSC members in Lagos state, Nigeria

Muhammad-Mujtaba A. Akanmu, Alero A. Robert, Ezekiel O. Oridota

P22: Incidental glucose and lipid metabolisms disorders among office workers: a cross sectional study

Ahmad A. Mirza, Ali K. Alzahrani, Omar Alfarhan, Essam Nour Eldin

P23: Differentiating clinically significant spinal injuries; a review of emergency department presentations

Bronagh MacManus, Owen Keane, Patrick Hillery, James Lee, Hugh O’Reilly, Niamh Collins

P24: Pattern of renal colic occurrence due to urinary stones during Ramadan and other months of the year at King Abdulaziz Medical City, Riyadh, KSA

Ibrahim Abu saq, Abdullah Al Mufarrih, Muath Jaafari, Abdullah Al Mahayni, Amen Bawazir, Sultan Alkhateeb

P25: Proteomic analysis reveals novel AIB1 co-factors that may contribute to acquired endocrine resistance in breast cancer

Amenah Dhannoon, Damir Vareslija, Arnold Hill, Leonie Young

P26: Improving sedation practice in general ICU in Beaumont Hospital

Declan Donoghue, Criona Walsh, Aileen McCabe, John Pope, Saturnino Pasco, Caroline Fallon, Don Solanki, Fiona Kiernan, Sinead Galvin, Jquan Mucvimicc, Johanna Mulvihill

P27: Diagnosis and control of hypertension as indicators of the level of awareness among relatives of medical students

Ahmad A. Mirza, Soha A. Elmosry

P28: Evaluation of the antitumor potential from extracts of endemic plants of Brazilian caatinga against melanoma and hepatocarcinoma

Lorenza Andres Ameida De Souza, Yuri de Oliveira, Diego Menezes, Alene Vanessa Santos

P29: The role of Chromogranin A as a biomarker in drug resistant neuroblastoma

Ahmad Zaki Asraf, Raymond Stallings, Olga Piskareva, Ross Conlon

P30: Membrane sweep at term gestation in CUMH; a case-control study

Siún Sweeney-Landers, Cathy Burke

P31: Study of the variability of glucose levels in patients with diabetes undergoing continuous glucose monitoring

Paraic Behan, Seamus Sreenan

P32: Inflammatory cytokine response to decreased plasma alpha-1 antitrypsin levels in individuals with the MZ genotype

Ahmed Organjee, Tatsiana Crosbie-Staunton, Emer Reeves, Noel McElvaney

P33: Analysing the role of SRC-1 in breast cancer stem cell formation and activity

Crystal Mieres, Leonie Young, Sara Charmsaz

P34: Screening Streptococcus pneumoniae isolates for virulence genes

Aya Al-Jalamdeh, Mary Corcoran, Martha McElligott, Niall Stevens, Hilary Humphreys

P35: Assessment of the relevance of admission clerking criteria taught to medical students at King Abdulaziz University to real hospital practice

Rashid Barnawi, Abdulaziz Ghurab, Sultan Alfaer, Hassan Balubaid, Kamal Hanbazazah, Mohammed Bukhari

P36: Pattern of emergency department visits during Hajj period

Mohammed Alsakkaf, Ahmad Mirza, Amrallah Mohammed

P37: Anti-Dengue activity of Aspergillus terreus (sulochrin); An in vitro study

Anastasia Pratanata, Maria Nathania, Tsabita Annisa, Beti Dewi

P38: The comorbidome in alpha-1 antitrypsin deficiency

Kuok Zhen Lee, Tomas P. Carroll, Laura Fee, Noel G. McElvaney

P39: MLO-Y4 cells behave more like osteocytes in response to mechanical stimulation when cultured in 3D

Rachel C. White, Robert T Brady, Fergal O’Brien

Neonatal-perinatal medicine fellow procedural experience and competency determination: results of a national survey

OBJECTIVE

Ensuring that neonatal-perinatal medicine (NPM) fellows attain competency in performing neonatal procedures is a requirement of training-competent neonatologists.

STUDY DESIGN

A survey of NPM fellows was performed to determine the procedural experience of current fellows, investigate techniques used to track procedural experience and examine the methods programs use to verify procedural competency.

RESULTS

One hundred and sixty-three fellows in 57 accredited training programs responded to the survey. Reported number of procedures provide contemporary normative data on procedural experience during training. The majority of fellows reported using an online reporting system to track experience. The most common technique to verify procedural competency was supervised practice until an arbitrary number of procedures had been performed.

CONCLUSIONS

NPM fellow procedural experience increases significantly for most, but not all, procedures duration training. We speculate that supplemental simulation training for rare neonatal procedures would help ensure the competency of graduating NPM fellows. Experience alone is insufficient to verify competency. Further work on the accurate tracking of experience and verification of procedural competency is needed.

Necessary but not sufficient? Engaging young people in the development of an avatar-based online intervention designed to provide psychosocial support to young people affected by their own or a family member's cancer diagnosis

Objective

This study discusses the challenges and successes of engaging young people in a project aimed at developing an online counselling intervention for young people affected by cancer.

Context

For younger people with a diagnosis of cancer or who are caring for someone with cancer, the psychosocial consequences can create significant challenges for their social and educational development. Whilst young people have been shown to be reluctant to make use of traditional face‐to‐face counselling, research is beginning to suggest that effective therapeutic relationships can be formed with young people online.

Design

The first phase of the study involved working with a ‘Young Persons’ Panel’ of healthy school pupils and university students to develop and pilot an online counselling intervention and study materials in preparation for a pilot evaluation of the intervention.

Intervention

An avatar‐based virtual reality counselling world was created where young people can create their own avatar and receive counselling over the Internet from a qualified counsellor via an avatar in a virtual reality world.

Findings

The process of engaging young people in the C:EVOLVE project enabled a unique intervention to be developed and demonstrated positive developmental opportunities. However, despite the rigorous approach to the development of the intervention, initial attempts within the pilot evaluation phase of the study showed difficulties recruiting to the study, and this phase of the study has currently ceased whilst further exploratory work takes place.

Conclusion

This study has demonstrated the complexities of intervention development and evaluation research targeted at young people and the challenges created when attempting to bring clinical practice and research evaluation together.

Effect of flip-flops on lower limb kinematics during walking: a cross-sectional study using three-dimensional gait analysis

BACKGROUND

Flip-flops are a popular footwear choice in warm weather however their minimalist design offers little support to the foot.

AIM

To investigate the effect of flip-flops on lower limb gait kinematics in healthy adults, to measure adherence between the flip-flop and foot, and to assess the effect on toe clearance in swing.

METHODS

Fifteen healthy adults (8 male, mean age 27 years) completed a three-dimensional gait analysis assessment using Codamotion. Kinematic and lower limb temporal-spatial data were captured using the Modified Helen Hayes marker set with additional markers on the hallux and flip-flop sole.

RESULTS

Compared to barefoot walking, there were no differences in temporal-spatial parameters walking with flip-flops. There was an increase in peak knee flexion in swing (mean difference 4.6°, 95 % confidence interval (CI) [-5.8°, -3.4°], p < 0.001) and peak ankle dorsiflexion at terminal swing (mean difference 2°, 95 % CI [-3°, -1°], p = 0.001). Other kinematic parameters were unchanged. Peak separation between foot and flip-flop was 8.8 cm (SD 1.48), occurring at pre-swing. Minimum toe clearance of the hallux in barefoot walking measured 4.2 cm (SD 0.8). Minimum clearance of the flip-flop was 1.6 cm (SD 0.56).

CONCLUSIONS

Healthy adults adapted well to flip-flops. However, separation of the flip-flop from the foot led to increased knee flexion and ankle dorsiflexion in swing, probably to ensure that the flip-flop did not contact the ground and to maximise adherence to the foot. Minimum clearance of the flip-flop was low compared to barefoot clearance. This may increase the risk of tripping over uneven ground.

224 CHARACTERIZATION OF EQUINE ENDOMETRIAL-DERIVED MESENCHYMAL STROMAL CELLS

Equine mesenchymal stromal cells (MSC) are mainly harvested from bone marrow and adipose tissue, requiring surgical procedures. Although human endometrium is known to harbor mesenchymal precursor cells, the presence of MSC in equine endometrium, a dynamic tissue, has not been investigated. This study reports for the first time the culture and characterisation of MSC from equine endometrium compared with equine bone marrow (BM)-derived MSC. Samples of equine endometrium (n = 6) and BM (n = 3) were collected postmortem. Endometrial tissue was digested using a dissociation medium containing collagenase I and DNase type I, and CD227 (mucin-1)-bound magnetic beads were utilised to separate epithelial (CD227+) from stromal (CD227–) cell fractions. Red blood cells from BM samples were excluded using a density gradient. All cell fractions were cultured in DMEM/F-12 containing 10% fetal bovine serum. After expansion, colony-forming unit (CFU) assay at passage 2, trilineage differentiation (adipogenic, chondrogenic, osteogenic), and flow cytometry analysis at passage 3/4 were performed for CD227– fractions and BM-MSC. Descriptive statistical analysis and 2-tailed t-test was performed with IBM SPSS Statistics 22 (SPSS Inc./IBM, Chicago, IL, USA). Both isolated cell fractions were plastic adherent and grew well under standard MSC culture conditions, although endometrial CD227– cells attached quicker to culture plasticware than did BM-MSC. The CFU assay at passage 2 showed no significant difference in cloning efficiency (CE) between BM-MSC (20.78 ± 2.86%) and CD227– (24.89 ± 3.04%) cell lines (P = 0.36). Flow cytometry showed the expression of MSC markers (CD29, CD44, CD90, CD105) and perivascular markers (CD146, NG2) but almost no expression of haematopoietic markers (CD34, CD45) in both cell lines (Table 1). No statistically relevant difference was seen except for the higher expression of NG2 in BM-MSC (P = 0.054). Trilineage differentiation was successfully induced in both cell lines. In conclusion, we showed the presence of putative MSC in equine endometrium. We successfully isolated and cultured these cells, which display comparable characteristics in MSC criteria as well-established BM-derived MSC. These endometrial-derived MSC may provide a convenient source for veterinary regenerative therapies in equine reproduction. Table 1.Flow cytometry marker expression (mean ± standard error) at passage 4

Electrical resistivity tomography as monitoring tool for unsaturated zone transport: an example of preferential transport of deicing chemicals

Non-invasive spatially resolved monitoring techniques may hold the key to observe heterogeneous flow and transport behavior of contaminants in soils. In this study, time-lapse electrical resistivity tomography (ERT) was employed during an infiltration experiment with deicing chemical in a small field lysimeter. Deicing chemicals like potassium formate, which frequently impact soils on airport sites, were infiltrated during snow melt. Chemical composition of seepage water and the electrical response was recorded over the spring period 2010. Time-lapse electrical resistivity tomographs are able to show the infiltration of the melt water loaded with ionic constituents of deicing chemicals and their degradation product hydrogen carbonate. The tomographs indicate early breakthrough behavior in parts of the profile. Groundtruthing with pore fluid conductivity and water content variations shows disagreement between expected and observed bulk conductivity. This was attributed to the different sampling volume of traditional methods and ERT due to a considerable fraction of immobile water in the soil. The results show that ERT can be used as a soil monitoring tool on airport sites if assisted by common soil monitoring techniques.

Effectiveness of conventional versus virtual reality based vestibular rehabilitation in the treatment of dizziness, gait and balance impairment in adults with unilateral peripheral vestibular loss: a randomised controlled trial

Background

Unilateral peripheral vestibular loss results in gait and balance impairment, dizziness and oscillopsia. Vestibular rehabilitation benefits patients but optimal treatment remains unkown. Virtual reality is an emerging tool in rehabilitation and provides opportunities to improve both outcomes and patient satisfaction with treatment. The Nintendo Wii Fit Plus^® (NWFP) is a low cost virtual reality system that challenges balance and provides visual and auditory feedback. It may augment the motor learning that is required to improve balance and gait, but no trials to date have investigated efficacy.

Methods/Design

In a single (assessor) blind, two centre randomised controlled superiority trial, 80 patients with unilateral peripheral vestibular loss will be randomised to either conventional or virtual reality based (NWFP) vestibular rehabilitation for 6 weeks. The primary outcome measure is gait speed (measured with three dimensional gait analysis). Secondary outcomes include computerised posturography, dynamic visual acuity, and validated questionnaires on dizziness, confidence and anxiety/depression. Outcome will be assessed post treatment (8 weeks) and at 6 months.

Discussion

Advances in the gaming industry have allowed mass production of highly sophisticated low cost virtual reality systems that incorporate technology previously not accessible to most therapists and patients. Importantly, they are not confined to rehabilitation departments, can be used at home and provide an accurate record of adherence to exercise. The benefits of providing augmented feedback, increasing intensity of exercise and accurately measuring adherence may improve conventional vestibular rehabilitation but efficacy must first be demonstrated.

Trial registration

Clinical trials.gov identifier: NCT01442623

Relapse rate following azathioprine withdrawal in maintaining remission for Crohn's disease: a meta-analysis

BACKGROUND

The duration of use of azathioprine (Aza) and 6-mercaptopurine (6-MP) for maintaining remission for Crohn's disease is debatable.

AIM

To examine whether Aza/6-MP can be safely withdrawn in patients with Crohn's disease who have been in remission.

METHODS

The following databases were searched: MEDLINE (1950-September 2010), EMBASE (1980-September 2010), CINHAL (1981-September 2010), PubMed (1950-September 2010), and the Cochrane Central Register of Controlled Trials (CENTRAL). Randomised controlled and cohort studies comparing azathioprine continuation versus placebo or no treatment were eligible for inclusion. Primary outcomes were relapse rate after discontinuation of Aza/6-MP at 6, 12, and 18 months, and 5 and 10 years.

RESULTS

Five studies, with 256 patients and 168 controls, met the inclusion criteria. Stopping azathioprine/6-MP was found to significantly increase the risk of relapse at 6, 12, and 18 months with pooled odds ratios of 0.22 (95% CI 0.09-0.53), 0.25 (95% CI 0.11-0.56), and 0.35 (95% CI 0.21-0.6), respectively. Two trials examined relapse rate at 5 years with pooled OR 0.53 (95% CI 0.13-2.21). No trials looking at relapse rates beyond 5 years were identified.

CONCLUSIONS

There is a clear benefit of continuing Aza/6-MP for at least 18 months to maintain remission for Crohn's disease patients who established remission. There is not enough evidence to provide clear guidance on whether or not to continue Aza/6-MP treatment beyond 18 months. Well-designed randomised controlled trials addressing this issue are needed.

The effect of the scale of horizontal subsurface flow constructed wetlands on flow and transport parameters

Horizontal subsurface flow constructed wetlands have proven their efficiency in treating wastewater and removing the pollutants of concern. Treatment efficiency depends on the wastewater residence time, which is a function of the hydraulic loading and the physical conditions of the constructed filter system, which can be described with effective parameters such as: hydraulic conductivity, porosity, dispersivity etc. Because spatial variability is often scale dependent, these effective parameters may be affected by the scale of the system being studied. In this paper the results of tracer experiments in constructed filters using saturated horizontal flow at three scales (small and medium lab scales and full-scale system) using the same filter media is reported. Light-weight aggregate (filter media termed Filtralite-P) was used at all scales. Increasing the scale was associated with increasing dispersivity, meanwhile hydraulic conductivity experienced dramatic reduction and variation by increasing the examined scale. Observed changes in the hydraulic parameters indicate that heterogeneity at different scales should be taken into account when the performance of LWA filters are evaluated from small-scale experiments.

Experiential learning as service for others

Experiential learning provides an avenue for educating oneself, others, and communities and can lead to involvement in efforts designed to change social systems and improve conditions that affect a nation as a whole. This article provides an overview of experiential learning related to service and presents an example of one nurse's efforts to contribute to her community through the MERCI: Medical Equipment Recovery of Clean Inventory program at the University of Virginia Health System, Charlottesville.

Ascites resistance of progeny from broiler breeders selected for two generations using chronic unilateral pulmonary artery occlusion

Broilers that survived unilateral pulmonary artery occlusion and lived to maturity comprised the first generation (GEN1) of an ascites-resistant line. Progeny from the GEN1 line previously were shown to tolerate fast growth and cool temperatures with a 50% lower incidence of ascites than chicks from the breeder pullet line serving as the base population for the resistant line. In the present study, progeny from the GEN1 line were subjected to unilateral pulmonary artery occlusion, and survivors were reared to breeding age to serve as the parent stock for the second generation (GEN2) ascites-resistant line. In two experiments (EXP1 and 2), chicks were reared separately by sex but were mixed by line within environmental chambers, where they were grown as rapidly as possible and exposed to cool (14 C) temperatures from 17 to 49 d of age. In EXP1, the ascites incidences in the base population, GEN1, and GEN2 lines, respectively, were 31% (48/157), 15% (8/52), and 4% (3/69) for males and 10% (13/128), 11% (5/46), and 3% (1/36) for females. In EXP2, the ascites incidences in the base and GEN2 lines, respectively, were 44% (71/163) and 6% (7/110) for males and 12% (19/155) and 0% (0/92) for females. The final BW for nonascitic broilers did not differ across lines in EXP1. In EXP2, the final BW was lighter for nonascitic GEN2 males (2,915+/-43 g) and females (2,382+/-17 g) than for nonascitic base population males (3,088+/-42 g) and females (2,493+/-22), respectively. Right:total ventricular weight ratios were higher for ascitic than nonascitic broilers, confirming the primary role for pulmonary hypertension in the pathogenesis of ascites. These experiments demonstrate ongoing improvement in the ascites resistance of progeny from broiler breeders that, for two consecutive generations, have survived the rigorous selection pressure imposed by unilateral pulmonary artery occlusion.

Broiler breeder survivors of chronic unilateral pulmonary artery occlusion produce progeny resistant to pulmonary hypertension syndrome (ascites) induced by cool temperatures

Chronic occlusion of one pulmonary artery triggers a high incidence of pulmonary hypertension syndrome (PHS, ascites) in broilers. In the present study, the left pulmonary artery was chronically occluded in 295 male and 255 female chicks pedigreed from 18 sire families, leading to PHS in 74% of the males and 45% of the females. Survivors were reared to breeding age and served as parents for the resulting PHS-resistant chicks (Resistant), whereas control chicks were produced from the base population for this line (Base). In two experiments, male and female Resistant and Base chicks were reared separately by sex but mixed by group within environmental chambers, where they were exposed to cool (14 C) temperatures. In both experiments, the incidence of PHS was at least 50% lower in the Resistant males and females than in the Base males and females, respectively. When compared within a sex, the Base and Resistant broilers surviving to the end of both experiments did not differ in final body weight or body weight gain, nor did their right:total ventricular weight (RV:TV) ratios differ. These results demonstrate that broiler breeders capable of thriving after having their entire cardiac output forced to flow through one lung, subsequently produced male and female progeny with substantially improved resistance to the onset of PHS induced by fast growth and exposure to cool environmental temperatures. Fast growth and cool temperatures are primary triggers for PHS under most conditions of commercial broiler growout. In both experiments, final necropsies revealed higher RV:TV ratios in ascitic than in nonascitic broilers, whereas normalizing the left ventricle plus septum weight for differences in body weight generated similar values for ascitic and nonascitic males or females, respectively. These results support a primary role for pulmonary hypertension but not cardiomyopathy in the pathogenesis of ascites triggered by cool temperatures in both the Base and Resistant populations.

Chronic unilateral occlusion of an extrapulmonary primary bronchus induces pulmonary hypertension syndrome (ascites) in male and female broilers

Previously, it was demonstrated that acute (4 min) and chronic (12 d) occlusion of an extrapulmonary primary bronchus triggers pulmonary hypertension but not pulmonary hypertension syndrome (PHS, ascites) in broilers. The present study was conducted to determine whether a more prolonged period of bronchus occlusion causes PHS similar to that induced by clamping one pulmonary artery. Male and female broiler chicks, 14 to 18 d old, were anesthetized, the thoracic inlet was opened, and a silver clip was positioned to fully obstruct the left extrapulmonary primary bronchus (BRONCHUS CLAMP group) or the left pulmonary artery (PA-CLAMP group). Sham-operated chicks were anesthetized and the thoracic inlet was opened; however, neither the pulmonary artery nor the bronchus was clamped (SHAM group). An electrocardiogram (ECG) was obtained whenever clinical ascites became apparent in individual broilers, or prior to the final necropsy for broilers surviving to the end (Day 36) of the experiment. The right:total ventricular weight ratio (RV:TV) was evaluated as an index of pulmonary arterial pressure. Early post-surgical mortality (up to 21 d of age) was higher in the PA-CLAMP group (27% for males and females combined) than in the BRONCHUS CLAMP (10%) and SHAM (2%) groups. Cumulative ascites mortality (Days 22 to 36) also was higher in the PA-CLAMP group (86% for males, 77% for females) than in the BRONCHUS CLAMP (69% for males, 41% for females) and SHAM (23% for males, 0% for females) groups. Ascitic birds in all treatment groups had higher RV:TV ratios and more negative ECG Lead II S-wave amplitudes than nonascitic birds, reflecting the right ventricular hypertrophy and generalized ventricular dilation typically associated with PHS. These results demonstrate that unilateral bronchus occlusion is an effective experimental model for triggering ascites at a lower incidence than that obtained by occluding one pulmonary artery. Following the onset of pulmonary hypertension, the pathophysiological progression leading to ascites appears to be similar for broilers with either unilateral bronchus or pulmonary artery occlusion.

The relationship of right ventricular hypertrophy, right ventricular failure, and ascites to weight gain in broiler and roaster chickens

Nine hundred twenty-five male progeny from 50 sire families of a commercial sire line were weighed at 14, 28, and 47 days and scored for right ventricular hypertrophydilation at 48 days. Broilers with marked hypertrophy of the right ventricle at processing (298 of 925) were significantly heavier than their more normal contemporaries at 14 and 28 days of age. These results suggest that rapidly growing broilers are more susceptible to increased pulmonary arterial pressure resulting in right ventricular hypertrophy, right ventricular failure, and ascites than slower-growing broilers. Thirty-five (3.5% of 997) broilers died from right ventricular failure and ascites, and 14 (1.5% of 925) has ascites at processing. Two hundred fifty-nine sibs were kept on full feed to 16 weeks of age. Between 7 and 16 weeks, 68 (26.3%) of these cockerels died from right ventricular failure and ascites and a further 27 (10.4%) had marked right ventricular hypertrophy-dilation when processed at 16 weeks. Thus most of the 298 broilers classified as having marked right ventricular hypertrophy at 7 weeks would likely have died from right ventricular failure and ascites if they had been kept on full feed until 16 weeks.