Tertiary lymphoid structures sustain cutaneous B cell activity in hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic skin condition affecting approximately 1% of the US population. HS skin lesions are highly inflammatory and characterized by a large immune infiltrate. While B cells and plasma cells comprise a major component of this immune milieu, the biology and the contribution of these cells in HS pathogenesis are unclear. We aimed to investigate the dynamics and microenvironmental interactions of B cells within cutaneous HS lesions. Combining histological analysis, single-cell RNA sequencing, and spatial transcriptomics profiling of HS lesions, we defined the tissue microenvironment relative to B cell activity within this disease. Our findings identified tertiary lymphoid structures (TLSs) within HS lesions and described organized interactions among T cells, B cells, antigen-presenting cells, and skin stroma. We found evidence that B cells within HS TLSs actively underwent maturation, including participation in germinal center reactions and class switch recombination. Moreover, skin stroma and accumulating T cells were primed to support the formation of TLSs and facilitate B cell recruitment during HS. Our data definitively demonstrated the presence of TLSs in lesional HS skin and point to ongoing cutaneous B cell maturation through class switch recombination and affinity maturation during disease progression in this inflamed nonlymphoid tissue.

Data Requirement for Animal-Derived Wound Care Devices: Limitations of the 510(k) Regulatory Pathway

BACKGROUND

Device classification and preclinical data requirements for animal-derived wound care products were recently reviewed by the FDA. Given the possible performance differences for these products, we evaluated the FDA data requirements as well as the published literature for all animal-derived wound care products ever cleared through the FDA.

STUDY DESIGN

The publicly available online database was queried for all animal-derived wound products; premarket data requirements for each product were recorded. A PubMed search was conducted to determine the number of published clinical studies for each product, and manufacturer websites were accessed to obtain the price for each product.

RESULTS

A total of 132 animal-derived wound products have been cleared by the FDA since the Center for Devices and Radiological Health was established in 1976. Of these, 114 had a publicly available clearance statement online. Preclinical biocompatibility testing was performed in 85 products (74.6%) and referenced in 10 (8.8%). Preclinical animal wound healing testing took place in 17 (14.9%). Only 9 products (7.9%) had clinical safety testing, and no products had clinical effectiveness data. We found no published peer-reviewed clinical data for 97 products (73%). Cost was infrequently available but ranged from $4.79 to $2,178 per unit.

CONCLUSIONS

Although the current pathway is appropriate for efficiently clearing new wound care products, clinical effectiveness is not included in the regulatory review process. Wound care products are primarily evaluated by the FDA for safety and biocompatibility. Thus, any claims of clinical effectiveness require independent validation, which is often lacking.

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

INTRODUCTION

Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.

METHODS

We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.

RESULTS

Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).

CONCLUSIONS

The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

Tertiary Lymphoid Structures Sustain Cutaneous B cell Activity in Hidradenitis Suppurativa

Background

Hidradenitis suppurativa (HS) skin lesions are highly inflammatory and characterized by a large immune infiltrate. While B cells and plasma cells comprise a major component of this immune milieu the biology and contribution of these cells in HS pathogenesis is unclear.

Objective

We aimed to investigate the dynamics and microenvironmental interactions of B cells within cutaneous HS lesions.

Methods

We combined histological analysis, single-cell RNA-sequencing (scRNAseq), and spatial transcriptomic profiling of HS lesions to define the tissue microenvironment relative to B cell activity within this disease.

Results

Our findings identify tertiary lymphoid structures (TLS) within HS lesions and describe organized interactions between T cells, B cells, antigen presenting cells and skin stroma. We find evidence that B cells within HS TLS actively undergo maturation, including participation in germinal center reactions and class switch recombination. Moreover, skin stroma and accumulating T cells are primed to support the formation of TLS and facilitate B cell recruitment during HS.

Conclusion

Our data definitively demonstrate the presence of TLS in lesional HS skin and point to ongoing cutaneous B cell maturation through class switch recombination and affinity maturation during disease progression in this inflamed non-lymphoid tissue.

A Novel Polypropylene Mesh (T-Line®) for Abdominal Wall Repair: Early Experience at Three Centers in the United States

Mesh suture was initially developed and investigated to overcome suture pull-through in hernia repair. It has a large area compared to standard suture which distributes the load in tissue, reducing stress at the suture/tissue interface and preventing suture from cutting through tissue or the mesh. This report describes our early experience using the new T-line® mesh (Deep Blue Medical Advances, Durham, NC, USA) in patients with incisional and primary ventral hernia repairs. This is a descriptive, retrospective study in 18 patients who underwent abdominal wall repair with T-Line® mesh from November 2020 to November 2021 in three academic centers. T-Line® is a novel moderate-weight macroporous, polypropylene mesh with extensions that are 29 times the cross-sectional area of #0 polypropylene suture. They can be sewn into fascia to anchor the mesh with no need for suture tackers or other devices to fixate the mesh. The median age of the patients was 56.5 years (range 25-83) and the median BMI was 31.7 kg/m2 (range 23.6-51). Twelve patients (66.7%) had primary hernias, and 11 (61.1%) had a recurrent hernia. The median defect area was 117.5 cm2 (range 4-390) and the median mesh area was 449.5 cm2 (range 130-600). The mesh position was onlay in 16 cases (88.9%) and sublay in 2 cases (11.1%). The median operative time was 247 minutes (range 104-395). The median length of stay was six days (range 0-21) with no significant in-hospital complications. One patient had a surgical site infection (5.5%) and two patients developed seromas (11.1%). There were no early hernia recurrences with a median follow-up of 28 days (range 8-307). The T-Line® mesh was shown to be safe and effective for patients with ventral hernia in the short term.

Expert Consensus for Key Features of Operative Reports of Ventral Hernia

BACKGROUND

Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report.

STUDY DESIGN

The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round.

RESULTS

Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus.

CONCLUSION

Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair.

POS1496-HPR HARD TIMES: ADAPTING A FATIGUE MANAGEMENT PROGRAMME IN A PANDEMIC

Background

Fatigue is a symptom of many Rheumatology Conditions (1). Hewlett et al have shown that a Fatigue Management programme (FMP) is effective in reducing fatigue in Rheumatoid Arthritis patients (2). In 2019, a 7-week group-based FMP was developed using a cognitive behavioural approach for Rheumatology patients in NHS Lothian (Scotland). In 2020, due to COVID-19, the in person FMP was adapted for virtual delivery. Referral criteria included Visual Analogue Scale-Fatigue (VAS-F) of ≥6/10 and an inflammatory rheumatic disease diagnosis. The FMP participants recorded Patient Reported Outcome Measures (PROMs) prior to and on completion of the FMP. In August 2021 demand for the FMP far outweighed the capacity of the delivery team and therefore the original 7-week FMP was further adapted to a 4-week programme. This was achieved by focusing on four core elements (i) sleep, (ii) thoughts, emotions and behaviours, (iii) energy conservation, (iv) setbacks.

Objectives

The primary objective was to evaluate whether the 4-week programme produced comparable PROMs results to the 7-week programme. In doing so, the aim was to maintain efficacy of the programme and provide increased capacity by offering more groups in the same timeframe.

Methods

Fatigue Severity Scale (FSS) and VAS-F were selected for comparison between pre and post FMP PROMs results, these being the main indicators of improvement in fatigue management. Fisher’s exact test was used to determine any difference between the PROMs results reported at the end of both programmes. Participants who reported that their PROMs result were the same, worse or who did not respond, were all placed into the category “Other”. The FMP team recorded the average waiting time for those attending each group. The length of the waiting list at any one time was calculated by removing those who were not interested, had been referred elsewhere, or who did not respond to the invitation, from the total number of referrals received by the FMP team.

Results

There was no significant difference in FSS and VAS-F results reported by the participants in both groups at the end of the FMPs as determined by Fisher’s exact test (Table 1). Waiting list times reduced from 24 weeks in August 2021 to 6 weeks in December 2021 as a result of the adaptation of the FMP from a 7-week programme to a 4-week programme (Figure 1).

Table 1.

Reported differences between pre-FMP and post-FMP PROMs.

7 Week FMP (n = 25)4 Week FMP (n = 13)Fischer ExactFSSImproved72%77%p = 1.000Other28%23%VASImproved80%69%p = 0.689Other20%31%Figure 1.

- Review of average waiting times experienced by each group. In August 2021, the decision was made to trial a 4-week FMP to counter large increases in average waiting times.

Conclusion

A 4-week FMP is as effective at improving the management of fatigue in Rheumatology patients as a 7-week FMP and reduces patient waiting times. More research is required to bolster the evidence base to support this novel approach.

References

[1]Overman, C.L., Kool, M.B., Da Silva, J.A.P. et al. The prevalence of severe fatigue in rheumatic diseases: an international study. Clin Rheumatol35, 409–415 (2016).

[2]Hewlett, S., et al., Group cognitive–behavioural programme to reduce the impact of rheumatoid arthritis fatigue: the RAFT RCT with economic and qualitative evaluations. Health Technology Assessment 23(57), 1-130 (2019).

Disclosure of Interests

Joanne Dobson: None declared, Dervil Dockrell: None declared, Kathryn Berg: None declared, Helen Harris Speakers bureau: Galapagos

Release of individual surgeon data to the public: patients' and surgeons' views

BACKGROUND

Limited surgeon-specific outcomes data are currently released to the public. Existing schemes generally result from the recommendations of public enquiries, addressing breaches to patient safety and malpractice. We found limited evidence in the literature about patients' or orthopaedic surgeons' wishes regarding the release of such data to the public.

METHODS

We surveyed 80 joint replacement patients and 41 orthopaedic surgeons regarding their wishes concerning collection and release of individual surgeon data to the public.

RESULTS

Of 80 patients, 30% (24/80) were aware of data on the NHS-My Choices website, 16% (13/80) had reviewed data prior to operation and 95% (76/80) wanted data concerning surgeons' experience, length of stay and complications including revisions. Patients expected more current monitoring of data than occurs. Of 41 surgeons, 20% (8/41) thought national joint registry (NJR) derived data accurately reflected their NHS work. Surgeons did not think this data improved patient outcomes (34%, 14/41), and that it reduced innovation (61%, 25/41) and training (75%, 31/41) and increased risk of adverse behaviour (61%, 25/41). Surgeons wanted a minimal data set accurately presented and risk adjusted.

CONCLUSION

In the future, it is likely that more individual surgeon data will be released to the public. There needs to be an agreed, accurate minimum dataset collected, reviewed in local clinical governance meetings and published with explanatory notes regarding the interfering variables and what conclusions can be drawn regarding the ability of the surgeon. This process needs to be overseen by an independent body trusted by the public.

O13 BIOLOGIC VERSUS SYNTHETIC MESH IN VENTRAL HERNIA REPAIR: PARTICIPANT-LEVEL ANALYSIS OF TWO RANDOMIZED CONTROLLED TRIALS AT ONE YEAR

Aim

Biologic mesh has been increasingly utilized in complex ventral hernia repair despite limited evidence at low risk of bias supporting its growth. We hypothesized biologic mesh when compared to synthetic mesh would have fewer major complications at one year.

Material and Methods

We performed a participant-level meta-analysis of published randomized controlled trials (RCTs) comparing biologic to synthetic mesh at one year. Primary outcome was major complication (composite of mesh infection, recurrence, reoperation, or death) at one year post-operative. Secondary outcomes included length of index hospital stay, surgical site occurrence, and surgical site infection. Outcomes were assessed using frequentist generalized linear models.

Results

A total of 252 patients from two RCTs were included, 126 patients randomized to the intervention arm of biologic mesh and 126 patients randomized to the control of synthetic mesh. Median follow-up was 15 (12, 27) months. Major complication occurred in 41 (33%) patients randomized to biologic mesh, and 44 (35%) patients randomized to synthetic mesh, (relative risk [RR] 0.91, 95% confidence interval [CI] 0.54-1.55, p-value 0.740). There were 36 total recurrences, 23 (18%) in the biologic arm, and 13 (10%) in the synthetic arm (RR 1.83, 95% CI 0.84-3.99, p-value 0.130). The remainder of outcomes demonstrated no statistically significant differences.

Conclusions

The risk of major complication did not differ between biologic versus synthetic mesh. In patients undergoing ventral hernia repair, there was no clinical benefit with biologic mesh as opposed to synthetic mesh at one year post-operative.

A survey of UK and Irish surgeons' attitudes, behaviours and barriers to change for environmental sustainability

INTRODUCTION

Surgery is a major contributor to the large environmental impact of healthcare, demanding urgent attention. To date there are no data on the attitudes and behaviours of surgeons towards climate change, or perceived barriers towards sustainable practice.

METHODS

We invited surgeons and surgical trainees in the UK and Ireland to participate in an online survey (developed in accordance with the CHERRIES checklist) conducted between June and November 2020 and disseminated via the Royal College of Surgeons of England, Edinburgh and Ireland, the Association of Surgeons in Training and through local communication.

RESULTS

We received 130 responses, across 14 surgical specialties. The majority of respondents (122/130; 94%) were concerned about the threat of climate change. Most respondents had instigated more sustainable practices in their personal lives (113/130; 87%) and, to a lesser extent, at work (73/130; 56%). Surgeons were willing to make changes to their clinical practice (107/130; 82%), but the main perceived barrier to improving sustainability was a lack of leadership (92/130; 70%). Surgeons welcomed greater leadership and guidance from national bodies (118/130; 91%) and more monitoring and regulation (113/130; 87%).

CONCLUSIONS

The surgeons who responded to our survey are concerned about climate change and willing to engage in efforts to transition to more sustainable practice, but would welcome greater support, guidance and leadership.

MYOD1 c.365G>T, p.L122R Variant Detection by Droplet Digital PCR (ddPCR)

Introduction/Objective

Rhabomyosarcomas (RMS) are a group of skeletal muscle tumors that include embryonal, alveolar, pleomorphic, spindle cell/sclerosing subtypes (SC/SRMS). Spindle cell RMS occurs in both adult and pediatric populations, and is associated with either more aggressive or better clinical outcomes respectively. A recurrent hotspot variant in MYOD1, p.L122R (NM_002478.4 c.365G>T), has been described in SC/SRMS. The classification of this diagnosis is evolving, with VGLL2 and NCOA2 fusions defining the diagnosis in young children, and MYOD1 p.L122R defining the diagnosis in older children. The MYOD1 p.L122R variant seems to be associated with more aggressive disease, and may be increasingly used in risk stratification with intensification of treatment.

Methods/Case Report

A digital droplet PCR (ddPCR) assay was used to detect the MYOD1 p.L122R in DNA samples with RMS. Patients and controls were coded as positive or negative, and tested for association with clinical features and outcome.

Results (if a Case Study enter NA)

Known-positive cohort of samples was limited by the extreme rarity of this tumor. “Known-positive” status was established by confirmation of the variant with an external clinically-validated assay. The six known positive samples were assessed by ddPCR for the presence of MYOD1 L122R. The L122R variant was detected in all six variants for a sensitivity of 100%. DNA and/or TNA obtained from known wild-type FFPE and frozen material was assessed, for a total of nine unique samples (1 synthetic, 8 patient-derived). All 9 samples were wild- type, with no positive droplets detected, for a specificity of 100%.

Conclusion

Our MYOD1 c.365G>T, p.L122R variant detection by droplet digital PCR (ddPCR) assay is a robust, reproducible, specific and sensitive method to detect the MYOD1 hotspot mutation.

976 Traumatic Damage to The Liver Capsule: An Unusual Cause of Small Bowel Obstruction

A 57-year-old man presented to the emergency department with severe abdominal pain. Three months prior to presentation, he had sustained blunt trauma to his right side whilst cycling but had not sought medical attention. On admission, a CT scan showed small bowel obstruction and he underwent an emergency laparotomy. Intraoperatively, a subcapsular liver haematoma was identified, with incarcerated, necrotic small bowel within the liver capsule. The patient underwent deroofing of the haematoma with an omental patch and a small bowel resection with primary anastomosis.

Small bowel obstruction is a common presentation in A&E and is responsible for half of emergency laparotomies in the UK each year. Although hepatic haematomas are also a relatively common complication of blunt trauma to the abdomen, associated bowel herniation into the liver capsule is very unusual. We believe this is the first time such a case of small bowel obstruction has been reported in the literature and we discuss details of operative management and highlight key learning points.

479 Climate Change and Environmental Sustainability: A Survey of The Behaviours, Attitudes and Current Practice of Surgeons in The UK And Ireland

Background

The operating theatre is resource intensive and surgery is a major contributor to the environmental impact of healthcare. Our survey aims to explore the behaviours and attitudes of surgeons towards climate change and understand the barriers towards sustainable practice.

Method

We invited surgeons and surgical trainees to take part in a voluntary online survey between June- October 2020 and disseminated this via the Royal College of Surgeons of England, Edinburgh, and Ireland, ASIT, and to surgeons locally.

Results

We received 116 responses from 14 different surgical specialties, across all grades. The majority (107/116 respondees) said that they were concerned about climate change. This concern had led to change in surgeons’ personal lives (98/116) and professional lives (63/116). Most respondees agreed that surgeons have a responsibility to be aware of the environmental impact of surgical services (101/116). Surgeons were generally not aware of any environmental training or education in the workplace and felt efforts towards improving surgical sustainability in their workplace were minimal. Surgeons would welcome more national guidance (103/116) and would welcome more regulation and monitoring (93/116).

Conclusions

Our results indicate that surgeons are concerned about climate change and they are willing to engage in efforts to transition to more sustainable practice.

234 Remote Surgical Teaching During COVID-19: Early Feedback from Students and Teachers

Background

On the 23rd March 2020 the government issued a nationwide lockdown in response to COVID-19. Using Microsoft Teams software, Brighton and Sussex Medical School transitioned to remote surgical teaching. We discuss the early feedback from students and tutors.

Method

All students (N = 40) and tutors (N = 7) were invited to complete an online feedback survey.

Results

Twenty students responded. Nine preferred remote teaching. The teaching was described as either good (10/20) or excellent (10/20). Small group teaching, lectures and student lead seminar sessions all received positive feedback. Students preferred sessions that were interactive. One hour was optimal (17/20). There was no consensus over class size. 15/20 (75%) would like remote teaching to continue after the pandemic.

All tutors responded. There was a preference towards shorter sessions: 45 minutes (2/7) one hour (5/7). Tutors found virtual sessions less interactive (6/7). All tutors would like remote teaching to continue after the pandemic. Three suggested extending teaching to remote surgical ward rounds.

Concern was raised by both students and tutors regarding the absence of practical skills.

Conclusions

The value of remote teaching has been highlighted by COVID-19. Our feedback recommends a transition towards blended learning; using the convenience of remote teaching to help augment traditional medical school teaching.

292 Publication of Individual Surgeon Outcomes Data: The Wishes of Orthopaedic Patients and Their Surgeons

Background

The Paterson report recommended increased release of individual surgeon data to the public. There is limited evidence in the literature about patients’ or orthopaedic surgeons’ wishes regarding release of such data to the public.

Method

We surveyed 80 joint replacement patients and 41 orthopaedic surgeons to determine their wishes regarding collection and release of individual surgeon data to the public.

Results

Patients expected more current monitoring of data than actually occurs. Of the patients, 95% wanted data to be available describing surgeon experience, length of stay and complications. Regarding currently available data, 50% of patients who were aware of it were likely to view it on the internet.

Surgeons were aware of the data available, but 80% did not think it was accurate. Surgeons did not think this data improved standards, that it negatively affected innovation (61%) and training (76%) and led to risk averse behaviour (61%). Surgeons wanted a minimal data set accurately presented and risk adjusted.

Conclusions

We recommend an agreed minimum dataset of good quality data is collected and discussed in clinical governance sessions. It can then be released to the public with explanatory notes.

342 Rib Fracture Scoring at The Royal Sussex County Hospital, A Major Trauma Centre

Introduction

In April 2017, The Royal Sussex County Hospital introduced rib fracture scoring to help guide the management of rib fractures.

Rib fracture score = (number of fractures x number of sides) + age score1

In this study, we audit our adherence to the scoring system and compare our management of chest trauma before and after its implementation.

Method

All admissions with rib fractures between 1/10/2016- 28/02/2017 (N = 35) and 1/10/2019- 31/01/2020 (N = 41) were recorded. Electronic and written notes were used to retrospectively record multidisciplinary care involvement, analgesics, chest infection and death.

Results

The pre-intervention cohort had an average age of 55.1 years and rib score of 8.8. The post intervention cohort had an average age of 67.2 years and score of 11.3. Following implementation, 45% of patients had a rib score recorded. Post-intervention, anaesthetic involvement increased by 34.5% and 15.4% more patients received a regional block. Inpatient nights fell from 11.2 to 10.1, mortality rate from 7% to 4% but the incidence of chest infection remained similar.

Conclusions

The implementation of a rib fracture scoring system has led to greater multidisciplinary care and higher levels of pain management. A larger study is required to assess patient outcome given the change in sample population over time.

291 Pre-Operative Venepuncture: An Audit of The Trauma and Orthopaedic Department at The Royal Sussex County Hospital, Brighton

Background

NICE recommends that patients undergoing intermediate or minor elective surgery do not need routine coagulation or transfusion blood testing unless they are ASA 3+ or taking anticoagulation mediation, where testing may be considered. Currently there is no guidance for trauma patients.

Method

We identified all patients that underwent intermediate or minor trauma and orthopaedic surgery within a three-month period from December 2019- February 2020 at the RSCH. We excluded major trauma patients, patients taking anticoagulants and patients with complex admission or past medical history. Computer records were used to identify pre-operative investigations and admission history.

Results

843 patients met our inclusion criteria. In total, 92 clotting studies and 200 transfusion samples were taken preoperatively. The majority of tests were for patients undergoing ankle 130/292 (45%) or Tibia/Fibula 54/292 (18%) procedures. This equates to approximately 1168 blood tests per year. Based on the lab cost of £15.97 for a transfusion sample and £18 for a coagulation sample, this is a cost of approximately £19,616 each year on blood testing that is not indicated.

Discussion

We hope that by presenting these results we will help reduce the unnecessary time and financial burden of routine venipuncture in departments undertaking intermediate and minor surgery.

Immunopathogenesis of hidradenitis suppurativa and response to anti-TNF-α therapy

Hidradenitis suppurativa (HS) is a highly prevalent, morbid inflammatory skin disease with limited treatment options. The major cell types and inflammatory pathways in skin of patients with HS are poorly understood, and which patients will respond to TNF-α blockade is currently unknown. We discovered that clinically and histologically healthy appearing skin (i.e., nonlesional skin) is dysfunctional in patients with HS with a relative loss of immune regulatory pathways. HS skin lesions were characterized by quantitative and qualitative dysfunction of type 2 conventional dendritic cells, relatively reduced regulatory T cells, an influx of memory B cells, and a plasma cell/plasmablast infiltrate predominantly in end-stage fibrotic skin. At the molecular level, there was a relative bias toward the IL-1 pathway and type 1 T cell responses when compared with both healthy skin and psoriatic patient skin. Anti–TNF-α therapy markedly attenuated B cell activation with minimal effect on other inflammatory pathways. Finally, we identified an immune activation signature in skin before anti–TNF-α treatment that correlated with subsequent lack of response to this modality. Our results reveal the fundamental immunopathogenesis of HS and provide a molecular foundation for future studies focused on stratifying patients based on likelihood of clinical response to TNF-α blockade.

Hidradenitis suppurativa lesions are characterized by alterations in cDC2s, relatively reduced Tregs, an influx of memory B cells and plasma cells, and biases towards IL1 pathway activation and type 1 T cell responses.

Does insurance protect individuals from catastrophic payments for surgical care? An analysis of Ghana's National Health Insurance Scheme at Korle-Bu teaching Hospital

BACKGROUND

According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.

METHODS

We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income.

RESULTS

Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05).

CONCLUSION

This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.

TRIAL REGISTRATION

Registered at www.clinical trials.gov identifier NCT03604458.

Human preferences for heelwork positions during UK competitive obedience

Competitive obedience (CO) is a canine discipline judged on a dog and handlers ability to undertake obedience exercises at different levels. Currently, there is limited research focusing on competitive obedience. Despite this, regulations regarding heelwork positions have recently been released causing discussion and controversy within the UK CO community. A hyperextended neck position is often apparent during heelwork tests of obedience, yet there is no research stating why this is a common training technique or expectation. This study investigated human preferences for heelwork positions and identified possible reasons for training such positions. Participants (n=251) of an online survey stated their CO experience, whether they trained for a high head position and reasons for training high head positions. Participants were required to rank 12 heelwork positions from 1; most preferred to 12; least preferred, followed by a statement of justification for preference one. Of participants, 70% did not train for high heads and ‘focus’ was reported the most common theme for training this position. The top three themes for preferences included: natural, good head positioning, and focus. Overall, image ranking was varied and differences in preferences were noted between experience groups. A raised head position was apparent in preference one but was not an extreme position. Study findings demonstrated variation in rankings yet responses mostly mirrored current CO regulations and guidelines; a positive outcome for welfare of CO dogs. Preference results highlighted minimal concerning factors regarding canine health and welfare. These results must be used to further extend CO research; particularly for further creation of an appropriate model for heelwork positioning.

Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review

BACKGROUND

Approximately 150 million people suffer from financial catastrophe annually because of out-of-pocket expenditures (OOPEs) on health. Although the National Health Insurance Scheme (NHIS) of Ghana was designed to promote universal health coverage, OOPEs as a proportion of total health expenditures remains elevated at 26%, exceeding the WHO's recommendations of less than 15-20%. To determine whether enrollment in the NHIS reduces the likelihood of OOPEs and catastrophic health expenditures (CHEs) in Ghana, we undertook a systematic review of the published literature.

METHODS

We searched for quantitative articles published in English between January 1, 2003 and August 22, 2017 in PubMed, Google Scholar, Economic Literature, Global Health, PAIS International, and African Index Medicus. Two independent authors (J.S.O. & S.E.) reviewed the articles for inclusion, extracted the data, and conducted a quality assessment of the studies. We accepted the World Health Organization definition of catastrophic health expenditures which is out of pocket payments for health care which exceeds 20% of annual house hold income, 10% of household expenditures, or 40% of subsistence expenditures (total household expenditures net food expenditures).

RESULTS

Of the 1094 articles initially identified, 7 were eligible for inclusion. These were cross-sectional household studies published between 2008 and 2016 in Ghana. They demonstrated that the uninsured paid 1.4 to 10 times more in out-of-pocket payments (OOPs) and were more likely to incur CHEs than the insured. Yet, 6 to 18% of insured households made catastrophic payments for healthcare and all studies reported insured members making OOPs for medicines.

CONCLUSION

Evidence suggests that the national health insurance scheme of Ghana over the last 14 years has made some impact on reducing OOPEs, and yet healthcare costs remain catastrophic for a large proportion of insured households in Ghana. Future studies need to explore reasons for the persistence of OOPs for medicines and services that are covered under the scheme.

An examination of neck angle in obedience dogs whilst completing competition heelwork

Dog obedience competition is an understudied area of canine kinematic research. Consequently, little is understood about the potential welfare considerations of competing in such disciplines. This study examined correlations between the dog’s head position and judges’ scores during an obedience heelwork test. Dartfish was used to analyse head and neck positions of obedience dogs whilst completing a heelwork test in competition. The study found no correlation between judges scores and the apparent head and neck angle of the dogs during heelwork. There was also no correlation between head and neck position of the dogs and the time taken to complete the heelwork test. Study findings demonstrate that more acute hyperextension of the dog’s neck during heelwork is not being selected for by judges. Thus, more research is needed to examine where the desire for apparent hyperextension is originating from and indeed the welfare implications of such positions.

Appendicitis within Morgagni Hernia and simultaneous Paraesophageal Hernia

BACKGROUND

Morgagni hernia is a congenital diaphragmatic defect that rarely presents with symptomatic findings in adults. The presence of one diaphragmatic defect may decrease the occurrence of a separate diaphragmatic defect. Appendicitis may be a unique presentation of incarcerated bowel in a Morgagni defect.

CASE PRESENTATION

Review of recent literature and presentation of a patient with Morgagni defect. Only five cases of simultaneous Morgagni hernia and paraesophageal hernia have been described in the English-language literature since 1958. Here, we report the first case of acute appendicitis within an incarcerated right Morgagni hernia in a 76-year-old patient who also had a paraesophageal hernia.

CONCLUSION

This case illustrates that there is no role for watchful waiting in the management of Morgagni Defects when diagnosed in adult patients.

Solitary Large Intestinal Diverticulitis in Leatherback Turtles (Dermochelys coriacea)

Leatherback sea turtles are globally distributed and endangered throughout their range. There are limited data available on disease in this species. Initial observations of solitary large intestinal diverticulitis in multiple leatherbacks led to a multi-institutional review of cases. Of 31 subadult and adult turtles for which complete records were available, all had a single exudate-filled diverticulum, as large as 9.0 cm in diameter, arising from the large intestine immediately distal to the ileocecal junction. All lesions were chronic and characterized by ongoing inflammation, numerous intralesional bacteria, marked attenuation of the muscularis, ulceration, and secondary mucosal changes. In three cases, Morganella morganii was isolated from lesions. Diverticulitis was unrelated to the cause of death in all cases, although risk of perforation and other complications are possible.

Aliphatic/aromatic systems under irradiation: influence of the irradiation temperature and of the molecular organization

With the aim of understanding the electronic excitation, charge or reactive species transfers occurring during irradiation, we studied the role of the aromatic content on ethylene/styrene random copolymers (PES) and on cyclohexane/benzene glasses (amorphous organic solids). Radiation-induced modifications were monitored in situ, at the molecular level, using Fourier transform infrared spectroscopy (FTIR). Irradiations were performed under a vacuum, and thanks to in situ measurements, oxidation was avoided. We followed both the C═C bond creation in the aliphatic moiety and the destruction of the aromatic moiety. The influence of the irradiation temperature was investigated by irradiating samples at room temperature and at 11 K. At such a low temperature, long-range migration hardly occurs and its influence is considerably reduced or could even vanish. Therefore, low temperature irradiation gives insight on the relative influence of reactive species transport and electronic excitation and charge transport. We found that the effect of lowering the PES irradiation temperature from room temperature to 11 K is small, indicating a minor role for the reactive species transport. Moreover, the two chosen systems allow the examination of the relative magnitude of intra- and intermolecular transfers. We demonstrate that, under conditions where reactive species are almost frozen, intermolecular transfers are very efficient.

International variation in physicians' attitudes towards prophylactic mastectomy - comparison between France, Germany, the Netherlands and the United Kingdom

PURPOSE

Prophylactic mastectomy (PM) has proven to be the most effective method to reduce the risk of breast cancer in high-risk women. The present study aimed to present and compare the attitudes towards PM among physicians in France, Germany, the Netherlands and the United Kingdom (UK).

PATIENTS AND METHODS

An international sample of 1196 general practitioners (GPs) and 927 breast surgeons (BS) were surveyed using a mailed questionnaire.

RESULTS

Only 30% of the French and 27% of the German GPs were of opinion that PM should be an option for an unaffected female BRCA1/2 mutation carrier, as compared to 85% and 92% of the GPs in the Netherlands and UK, respectively. Similarly, 78% of the French and 66% of the German BS reported a positive attitude towards PM, as compared to 100% and 97% of the BS in the Netherlands and UK, respectively. In the whole sample of GPs, a positive attitude towards PM was associated with country of residence, being female, and having more knowledge of breast/ovarian cancer genetics, while among BS there was a positive association with country of residence and having more knowledge of breast/ovarian cancer genetics as well, and, in addition, with a higher number of newly diagnosed breast cancer patients last year.

CONCLUSION

These results demonstrated the international variations in the attitude towards PM among physicians. This might reflect that different policies are adopted to prevent breast cancer in women at-risk.

Familial breast cancer: is it time to move from a reactive to a proactive role?

In 2004 the NICE guidelines on familial breast cancer advised Health Care Professionals that they should not actively seek to identify women with a family history of breast cancer. We have carried out a review of the evidence base and a large scale questionnaire survey of health professionals in four European countries. There is overwhelming support amongst GPs and surgeons against the premise that that health care professionals should not be proactive in identifying patients at risk of familial breast cancer. This that suggest the time is right to overturn the NICE decision.