Obesity, Sarcopenia and Myosteatosis: Impact on Clinical Outcomes in the Operative Management of Crohn's Disease

BACKGROUND

Obesity, sarcopenia, and myosteatosis in inflammatory bowel disease may confer negative outcomes, but their prevalence and impact among patients with Crohn's disease (CD) have not been systematically studied. The aim of this study was to assess nutritional status and body composition among patients undergoing resectional surgery for CD and determine impact on operative outcomes.

METHODS

Consecutive patients with CD undergoing resection from 2000 to 2018 were studied. Total, subcutaneous, and visceral fat areas and lean tissue area (LTA) and intramuscular adipose tissue (IMAT) were determined preoperatively by computed tomography at L3 using SliceOmatic (Tomovision, Canada). Univariable and multivariable linear, logistic, and Cox proportional hazards regression were performed.

RESULTS

One hundred twenty-four consecutive patients were studied (ileocolonic disease 53%, n = 62, biologic therapy 34.4% n = 43). Mean fat mass was 22.7 kg, with visceral obesity evident in 23.9% (n = 27). Increased fat stores were associated with reduced risk of emergency presentation but increased corticosteroid use (β 9.09, standard error 3.49; P = .011). Mean LBM was 9.9 kg. Sarcopenia and myosteatosis were associated with impaired baseline nutritional markers. Myosteatosis markers IMAT (P = .002) and muscle attenuation (P = .0003) were associated with increased grade of complication. On multivariable analysis, IMAT was independently associated with increased postoperative morbidity (odds ratio [OR], 1.08; 95% confidence interval (CI), 1.01-1.16; P = .037) and comprehensive complications index (P = .029). Measures of adiposity were not associated with overall morbidity; however, increased visceral fat area independently predicted venous thromboembolism (OR, 1.02; 95% CI, 1.00-1.05; P = .028), and TFA was associated with increased wound infection (OR, 1.00; 95% CI, 1.00-1.01; P = .042) on multivariable analysis.

CONCLUSION

Myosteatosis is associated with nutritional impairment and predicts increased overall postoperative morbidity following resection for CD. Despite its association with specific increased postoperative risks, increased adiposity does not increase overall morbidity, reflecting preservation of nutritional status and relatively more quiescent disease phenotype. Impaired muscle mass and function represent an appealing target for patient optimization to improve outcomes in the surgical management of CD.

TRANSPORTATION AND MOOD: THE ROLE OF TRIP CHARACTERISTICS

Safe and affordable transportation has a positive impact on the health and well-being of older adults. What is less understood are which factors influence these outcomes. To examine the impact of trip characteristics on the mood of older adults, residents in three neighborhoods in Franklin County, Ohio (n = 32) were provided tablets and used an app (MyAmble) to document their travel. During a 14-day period, 1,190 trips were recorded; 71% of which were completed by car. Participants reported 72% of the trips improved their mood. Perceived importance of the trip, challenges associated with the trip, and trip destinations to social activities and to employment/education explained 33% of the variance in mood. Challenges associated with the trip was the strongest predictor of impact on mood. Identifying trip characteristics that impact mood provides new insights for the design and implementation of travel interventions for older persons.

Time to expand the circle of care - General practitioners' experiences of managing concussion in the community

New Zealand Rugby (NZR) implemented a concussion management pathway (CMP), aimed at improving management at community level. General Practitioners (GPs) played a large role in the design of this process. The objective of this study was to explore GPs' perceptions of barriers and facilitators of the CMP and rugby-related concussion management in the community. A descriptive qualitative approach using interviews and focus groups was employed. Four themes were derived: i) GPs' existing knowledge and confidence around concussion management; ii) Operational resources: time, remuneration and pathway guidance; iii) Standardising concussion care and iv) Expanding the circle of care - the need for multi-disciplinary healthcare team. These themes described how GP's concussion knowledge, and the efficiency and availability of operational resources affected their experience and ability to fulfil their tasks within the CMP. GPs found NZR's CMP especially valuable, as it provided guidance and structure. Expanding the role of other healthcare providers was seen as critical to reduce the burden on GPs, while also delivering a more holistic experience to improve clinical outcomes. Addressing the identified barriers and expanding the network of care will help to improve the ongoing development of NZR's CMP, while supporting continued engagement with all stakeholders.

The effect of extraction of the lower first permanent molar on the developing third molar in children

Objective:

To find the effect of extraction of the lower first permanent molar in children (aged 8–11 years) on the position and angle of the developing third molar.

Design:

Retrospective radiographic analysis.

Participants:

Two cohorts of participants were identified: an extraction group, who had extraction of one or more first permanent molars aged 8–11 years; and a non-extraction group, who retained all mandibular teeth. Both cohorts previously had panoramic radiographs taken at mean ages of 9.7 years (T1), before extraction, and 12.12 years (T2). In total, there were 61 third molars with an associated extracted first permanent molar and 60 third molars with an associated retained first permanent molar.

Methods:

A digital radiographic analysis was carried out on the panoramic radiographs to measure the movement of the third molar, vertically and horizontally, and its angle. The magnification of the T1 and T2 radiographs was calibrated. Reliability of the radiographic analysis was confirmed via intra- and inter-rater reliability tests. The extraction and non-extraction groups were compared via independent sample tests

Results:

The third molar moved significantly more mesial in the extraction group (P < 0.001) and the angle uprighted significantly more than the non-extraction group (P < 0.001). Vertically, the third molar moved inferiorly in both cohorts with no significant difference.

Conclusion:

In the developing dentition, extraction of the lower first permanent molar encouraged mesial movement and uprighting of the developing third molar. This may improve the likelihood of future eruption of the third molar.

Sport concussion assessment in New Zealand high school rugby players: a collaborative approach to the challenges faced in primary care

PRIMARY OBJECTIVE

To describe the collaborative development of a New Zealand Rugby Concussion Assessment (NZRCA) for primary care and to provide normative baseline data from a representative group of high school rugby players.

METHODS

This study, conducted over the 2018 and 2019 community rugby season where players were baseline tested during the pre- or start of season period.

RESULTS

Data were collected from 1428 players (males n = 1121, females n = 307) with a mean age of 15.9 ± 1.4 years. The mean ± SD symptom severity score was 11.3 ± 8.6, the mean number of endorsed symptoms was 8.5 ± 5.3 and the percentage feeling "normal" was 80.2 ± 15.3%. Only 5.3% of players reported no symptoms at baseline. The most common reported were: 'distracted easily' (72.5%), 'forgetful' (68.5%), and 'often tired' (62.6%). None of the participants achieved a perfect score for the SAC50. The majority of participants (89.7%) passed the tandem gait test with a time of 12.2 ± 1.7 seconds. Age, gender, and ethnicity were associated with NZRCA performance; albeit weakly.

CONCLUSION

This study provides normative reference values for high-school rugby players. These data will aid healthcare providers in their identification of suspected concussion in the absence of individualized baselines.

Baseline concussion assessment performance of community-based senior rugby players: a cross-sectional study

OBJECTIVE

To report pre-season baseline concussion assessment performance among senior rugby players and explore associations between assessment performance and player demographics.

DESIGN

A cross-sectional study using the New Zealand Rugby Concussion Assessments (NZRCA), comprising symptom, cognitive and dynamic coordination assessments was conducted in the 2018-2019 season.

METHODS

Players' baseline assessments were characterised using descriptive statistics; effect sizes (ES) and t-tests were used to explore associations between player demographic characteristics and NZRCA performance.

RESULTS

A total of 733 players (11.4% female) aged between 16 and 52 years completed the NZRCA. The median (range) value for symptom severity, endorsed symptoms and "percentage normal" was respectively, 5 (0-40), 5 (0-21) and 90% (30-100%). A perfect standardised assessment of concussion score was achieved by one participant; seven achieved ≥27/30 for immediate recall, and 22 achieved a perfect delayed recall score. Most participants (n = 674, 92%) passed the tandem gait test. Associations between NZRCA performance and gender, concussion history, and Pasifika ethnicity were observed with effect sizes ranging from small (0.18) to large (0.70). Six hundred and twenty-three (85%) participants reported at least one symptom.

CONCLUSIONS

The results from this study could help support decision-making by clinicians, improving the management of concussions in the community setting.

Validation and Update of the Lémann Index to Measure Cumulative Structural Bowel Damage in Crohn's Disease

BACKGROUND & AIMS

The Lémann Index is a tool measuring cumulative structural bowel damage in Crohn's disease (CD). We reported on its validation and updating.

METHODS

This was an international, multicenter, prospective, cross-sectional observational study. At each center, 10 inclusions, stratified by CD duration and location, were planned. For each patient, the digestive tract was divided into 4 organs, upper tract, small bowel, colon/rectum, anus, and subsequently into segments, explored systematically by magnetic resonance imaging and by endoscopies in relation to disease location. For each segment, investigators retrieved information on previous surgical procedures, identified predefined strictures and penetrating lesions of maximal severity (grades 1-3) at each organ investigational method (gastroenterologist and radiologist for magnetic resonance imaging), provided segmental damage evaluation ranging from 0.0 to 10.0 (complete resection). Organ resection-free cumulative damage evaluation was then calculated from the sum of segmental damages. Then investigators provided a 0-10 global damage evaluation from the 4-organ standardized cumulative damage evaluations. Simple linear regressions of investigator damage evaluations on their corresponding Lémann Index were studied, as well as calibration plots. Finally, updated Lémann Index was derived through multiple linear mixed models applied to combined development and validation samples.

RESULTS

In 15 centers, 134 patients were included. Correlation coefficients between investigator damage evaluations and Lémann Indexes were >0.80. When analyzing data in 272 patients from both samples and 27 centers, the unbiased correlation estimates were 0.89, 0,97, 0,94, 0.81, and 0.91 for the 4 organs and globally, and stable when applied to one sample or the other.

CONCLUSIONS

The updated Lémann Index is a well-established index to assess cumulative bowel damage in CD that can be used in epidemiological studies and disease modification trials.

Care of the adult cancer patient at the end of life: ESMO Clinical Practice Guidelines

•This ESMO Clinical Practice Guideline provides key recommendations for end-of-life care for patients with advanced cancer. •It details care that is focused on comfort, quality of life and approaching death of patients with advanced cancer. •All recommendations were compiled by a multidisciplinary group of experts. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

Expansion of cognitive testing for off-field concussion screening in elite rugby players: A cohort study

OBJECTIVES

Current off-field concussion screening instruments have sub-optimal accuracy and additional testing domains may be necessary to detect the full spectrum of concussion presentations. This study aimed to determine if additional cognitive tests add utility to off-field screening for sport-related concussion.

DESIGN

Reproducibility and diagnostic accuracy cohort studies were performed in the 2017 and 2018 seasons of the Super Rugby competition, conducted in Argentina, Australia, Japan, New Zealand, and South Africa.

METHODS

Abridged versions of Stroop (score, time), Spatial Memory (score, failed trials), and Trail Making Trial-B (time, errors) cognitive tests, modified for off-field use, were examined. Players performed baseline testing prior to each season. Cases undergoing off-field screening as part of the World Rugby Head Injury Assessment Process underwent evaluation with the same cognitive tests during competition matches. Agreement between repeated pre-season baseline measurements, and the diagnostic accuracy of off-field testing against a clinical reference standard of concussion, was evaluated.

RESULTS

Data were available for repeated preseason baseline testing in 644 players, and 100 cases undergoing off-field concussion screening. There was little individual agreement across pre-season baseline assessments for all tests (Lin's correlation and Gwets AC1 coefficients ranging between 0.2 and 0.3). There was significantly worse performance for the time taken to complete the modified Stroop Test in concussed players undergoing off-field screening, compared to non-concussed players (median time 21.1 v 18.4 s, p < 0.01; area under the receiver operating characteristic curve 0.7 (95% CI 0.5-0.8)). Other cognitive measures did not discriminate between injured and un-injured players, with no-statistically significant differences in distribution medians (p = 0.6-0.9) and AUROC values close to 0.5.

CONCLUSIONS

The time taken to perform a modified Stroop Test may provide additional diagnostic accuracy if added to current off-field concussion screening tools. Abridged Spatial Memory and Trail Making Trial-B tests did not discriminate between concussed and non-concussed players.

1461. Impact of the Ampicillin/Sulbactam Shortage on Antibiotic Prescribing and Clinical Outcomes for Adult Inpatients with Aspiration Pneumonia

Background

Ampicillin/sulbactam is a recommended first-line agent for the treatment of aspiration pneumonia. Due to the ampicillin/sulbactam shortage, beginning in March 2019, alternative therapies, such as ceftriaxone plus metronidazole, have been utilized more frequently. The objective of this study is to examine clinical outcomes in adult inpatients treated with either ampicillin/sulbactam or ceftriaxone/metronidazole for aspiration pneumonia.

Methods

An electronic health record report identified patients ≥18 years of age that received ampicillin/sulbactam (pre-March 2019) or ceftriaxone/metronidazole (post-March 2019) with the indication of aspiration pneumonia. The primary objective was to describe 30-day all-cause readmission rates for patients that received ampicillin/sulbactam compared to ceftriaxone/metronidazole. The secondary objectives included hospital length of stay (LOS), 30-day all-cause mortality, C.difficile infection (CDI) within 3 months, and total antibiotic costs.

Results

A total of 86 patients (50 received ampicillin/sulbactam and 36 received ceftriaxone/ metronidazole) were included. Demographics were similar between groups. There was no significant difference in 30-day all-cause readmission rates (30% vs 19%, p=0.322). The ampicillin/sulbactam group, however, was found to have a significantly higher rate of 30-day all-cause mortality (12% vs 0%, p=0.038). Additionally, total duration of therapy was found to be significantly shorter in the ampicillin/sulbactam group (5 vs 7 days, p=0.002) with reduced overall cost of therapy($130 vs $235, p< 0.001). No differences were observed in hospital LOS or CDI within 3 months.

Conclusion

No difference was observed in 30-day all-cause readmissions in patients receiving ampicillin/sulbactam compared to ceftriaxone/metronidazole for the treatment of aspiration pneumonia. Further analyses are recommended to evaluate the impact on 30-day all-cause mortality.

Disclosures

All Authors: No reported disclosures

Using Community-Based Research Strategies in Age-Friendly Communities to Solve Mobility Challenges

Aging is linked to an increased risk of disability. Disabilities that limit major life activities such as seeing, walking, and motor skills impact a person’s ability to drive a car. Low utilization of alternative transportation by older adults may put them at risk for social isolation. The purpose of this paper is to illustrate how community-based participatory research (CBPR) was used to engage older residents in the development of alternative transportation options in a metropolitan county in the Midwestern U.S. Older residents worked as co-investigators to develop, use and evaluate alternative transportation options including walking, biking, fixed route busing, senior circulator, ride sharing, and transit training. Data were collected through mapping the built environment, an electronic daily transportation diary app called “MyAmble” on tablets, walk audits and focus groups. CBPR approaches led by interdisciplinary teams resulted in community engagement and more equitable strategies for transportation planning and utilization.

Square peg round hole - Time to customise a concussion assessment tools for primary care: The New Zealand experience? A call for a GP-SCAT

In rugby union concussions are a player welfare concern, particularly in the community game where there is often minimal sideline medical support. New Zealand Rugby (NZR) has three primary goals around the management of concussions in the community game: (1) players with a suspected concussion are removed from the game or training; (2) players are referred into primary care for a diagnosis by a general practitioner(GPs) (doctor in primary care); (3) prior to returning to contact training that they are medically cleared by a doctor. Given their role in the diagnosis and medical clearance of players with a concussion, GPs are a key stakeholder in the concussion management pathway. Thus to ensure that players are safely returning to play, NZR acknowledged the need to better support and engage with GPs. This editorial is an opportunity for NZR to share our experience working collaboratively with GPs in New Zealand to support the diagnosis and medical clearance of players following a rugby-related concussion.

Injury Risk in New Zealand Rugby Union: A Nationwide Study of Injury Insurance Claims from 2005 to 2017

Objectives

The Accident Compensation Corporation is a compulsory, 24-h, no-fault personal injury insurance scheme in New Zealand. The purpose of this large-scale retrospective cohort study was to use Accident Compensation Corporation records to provide information about rugby injury epidemiology in New Zealand, with a focus on describing differences in risk by age and gender.

Methods

A total of 635,657 rugby injury claims were made to the Accident Compensation Corporation for players aged 5–40 years over the period 2005–2017. Information about player numbers and estimates of player exposure was obtained from New Zealand Rugby, the administrative organisation for rugby in New Zealand.

Results

Over three quarters of claims (76%) were for soft-tissue injuries, with 11% resulting from fractures or dislocations, 6.7% from lacerations, 3.1% from concussions and 2.0% from dental injuries. Body regions injured included shoulder (14%), knee (14%), wrist/hand (13%), neck/spine (13%), head/face (12%), leg (11%) and ankle (10%). The probability of a player making at least one injury claim in a season (expressed as a percentage) was calculated under the assumption that the incidence of claims follows a Poisson distribution. Players aged 5–6 years had a probability of making at least one claim per season of 1.0%, compared to 8.3% for players aged 7–12 years, 35% for age 13–17 years, 53% for age 18–20 years, 57% for age 21–30 years and 47% for age 31–40 years. The overall probability of making at least one claim per season across all age groups was 29%. The relative claim rate for adults (players aged 18 years and over) was 3.92 (90% confidence interval 3.90–3.94) times that of children. Ten percent of players were female, and they sustained 6% of the injuries. Overall, the relative claim rate for female players was 0.57 times that of male players (90% confidence interval 0.56–0.58). The relative claim rate of female to male players tended to increase with age. There were very few female players aged over 30 years; however, those who did play had higher claim rates than male players of the same age group (1.49; 90% confidence interval 1.45–1.53).

Conclusions

Injuries resulting from rugby are distributed across the body, and most of the claims are for soft-tissue injuries. Rates of injury increase rapidly through the teenage years until the early 20 s; for male players they then decrease until the mid-30 s. For female players, the injury rate does not decrease as players move into their 30 s. Combining Accident Compensation Corporation injury claim data with national player registration data provides useful information about the risks faced by New Zealand’s community rugby players, and the insights derived are used in the development of rugby injury prevention programme content.

Electronic supplementary material

The online version of this article (10.1007/s40279-019-01176-9) contains supplementary material, which is available to authorized users.

What they know and who they are telling: Concussion knowledge and disclosure behaviour in New Zealand adolescent rugby union players

The purpose of this study was to survey high school rugby players from a range of ethnic, geographic and socioeconomic backgrounds in New Zealand (NZ) to gain an understanding of concussion knowledge, awareness of NZ Rugby's (NZR) guidelines and attitudes towards reporting behaviours. Male and female high school rugby players (n= 416) from across NZ were surveyed. The findings indicated that 69% of players had sustained a suspected concussion, and 31% had received a medical diagnosis of concussion. 63% of players indicated they were aware of NZR's guidelines. Māori and Pasifika players were less likely to be aware of the guidelines compared to NZ European, Adjusted OR 0.5, p = 0.03. Guideline awareness was significantly higher for those from high decile schools when compared to low (Unadjusted OR 1.63, p = 0.04); however, when ethnicity and school locations were controlled for this became non-significant (Adjusted OR= 1.3, p=0.37). The coach was the key individual for the provision of concussion information and disclosure of symptoms for players. The findings of this study will inform the development and delivery of NZR's community concussion initiative and how these examined factors influence a high school player's concussion knowledge and reporting behaviour.

Methodology and Implementation of a Randomized Controlled Trial (RCT) for Early Post-concussion Rehabilitation: The Active Rehab Study

Background: Sports-related concussion (SRC) is a complex injury with heterogeneous presentation and management. There are few studies that provide guidance on the most effective and feasible strategies for recovery and return to sports participation. Furthermore, there have been no randomized studies of the feasibility, safety, and efficacy of early rehabilitation strategies across multiple sports and age groups. This international cluster-randomized pragmatic trial evaluates the effectiveness of early multi-dimensional rehabilitation integrated with the current return to sport strategy vs. the current return to sport strategy alone.

Methods: The study is a cluster-randomized pragmatic trial enrolling male and female athletes from 28 sites. The sites span three countries, and include multiple sports, levels of play (high school, college, and professional), and levels of contact. The two study arms are Enhanced Graded Exertion (EGE) and Multidimensional Rehabilitation (MDR). The EGE arm follows the current return to sport strategy and the MDR arm integrates early, MDR strategies in the context of the current return to sport strategy. Each arm employs a post-injury protocol that applies to all athletes from that site in the event they sustain a concussion during their study enrollment. Participants are enrolled at pre-season baseline. Assessment timepoints include pre-season baseline, time of injury (concussion), 24–48 h post-injury, asymptomatic, and 1-month post-injury. Symptoms and activity levels are tracked post injury through the return to play process and beyond. Injury and recovery characteristics are obtained for all participants. Primary endpoints include time to medical clearance for full return to sport and time to become asymptomatic. Secondary endpoints include symptom, neurocognitive, mental status, balance, convergence insufficiency, psychological distress, and quality of life trajectories post-injury.

Discussion: Outputs from the trial are expected to inform both research and clinical practice in post-concussion rehabilitation across all levels of sport and extend beyond civilian medicine to care for military personnel.

Ethics and Dissemination: The study is approved by the data coordinating center Institutional Review Board and registered at clinicaltrials.gov. Dissemination will include peer-reviewed publications, presentation to patients and public groups, as well as dissemination in other healthcare and public venues of interest.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02988596

Trial Funding: National Football League.

BUILDING SAFE ROUTES TO AGE IN PLACE THROUGH PARTNERSHIPS WITH AGE-FRIENDLY COMMUNITIES

Participation in active transportation by older persons has been associated with higher quality of life and longevity. Efforts across the United States to increase active transportation (walking, biking and fixed route transportation) by older adults have lacked meaningful input by older adults, are non-theoretical and have had inconclusive results. This paper describes the findings from Phase 1 of the Safe Routes to Age in Place project, a collaboration between Age-Friendly Franklin County, The Ohio State University (OSU) and the University of Texas-Arlington (UT-A), funded by the Ohio Department of Transportation. The aim of the study is to increase the options and safe utilization of active transportation by older persons in three pilot neighborhoods in Franklin County, Ohio utilizing community-based participatory action research strategies with a customized data collection app, MyAmble. The purpose of Phase 1 was to engage city and regional planning students, government officials and older adults to identify “hot spots” in the three pilot neighborhoods. Heat mapping of community data including locations of densely-populated vulnerable older adults, fixed transportation routes, bus stop signage and benches, shared bike stations, bike routes, paratransit routes and pedestrian crash data was completed. Maps were used to identify areas of focus and discussions with municipal leaders and older adult residents further refined target areas to be used in the second phase of the study. Older residents completed walk audits using the MyAmble app and identified issues with sidewalks, crosswalk timers and bus stops. Implications related to age-friendly communities and active transportation are offered.

International consensus statement on injury surveillance in cricket: a 2016 update

Cricket was the first sport to publish recommended methods for injury surveillance in 2005. Since then, there have been changes to the nature of both cricket and injury surveillance. Researchers representing the major cricket playing nations met to propose changes to the previous recommendations, with an agreed voting block of 14. It was decided that 10 of 14 votes (70%) were required to add a new definition element and 11 of 14 (80%) were required to amend a previous definition. In addition to the previously agreed 'Match time-loss' injury, definitions of 'General time-loss', 'Medical presentation', 'Player-reported' and 'Imaging-abnormality' injuries are now provided. Further, new injury incidence units of match injuries per 1000 player days, and annual injuries per 100 players per year are recommended. There was a shift towards recommending a greater number of possible definitions, due to differing contexts and foci of cricket research (eg, professional vs amateur; injury surveillance systems vs specific injury category studies). It is recommended that researchers use and report as many of the definitions as possible to assist both comparisons between studies within cricket and with those from other sports.

Right ventricular assessment at cardiac MRI: initial clinical experience utilizing an IS-SENSE reconstruction

Cardiac MR is considered the gold standard in assessing RV function. The purpose of this study is to evaluate the clinical utility of an investigational iterative reconstruction algorithm in the quantitative assessment of RV function. This technique has the potential to improve the clinical utility of CMR in the evaluation of RV pathologies, particularly in patients with dyspnea, by shortening acquisition times without adversely influencing imaging performance. Segmented cine images were acquired on 9 healthy volunteers and 29 patients without documented RV pathologies using conventional GRAPPA acquisition with factor 2 acceleration (GRAPPA 2), a spatio-temporal TSENSE acquisition with factor 4 acceleration (TSENSE 4), and iteratively reconstructed Sparse SENSE acquisition with factor 4 acceleration (IS-SENSE 4). 14 subjects were re-analyzed and intraclass correlation coefficients (ICC) were calculated and Bland-Altman plots generated to assess agreement. Two independent reviewers qualitatively scored images. Comparison of acquisition techniques was performed using univariate analysis of variance (ANOVA). Differences in RV EF, BSA-indexed ESV (ESVi), BSA-indexed EDV (EDVi), and BSA-indexed SV (SVi) were shown to be statistically insignificant via ANOVA testing. R(2) values for linear regression of TSENSE 4 and IS-SENSE 4 versus GRAPPA 2 were 0.34 and 0.72 for RV-EF, and 0.61 and 0.76 for RV-EDVi. ICC values for intraobserver and interobserver quantification yielded excellent agreement, and Bland-Altman plots assessing agreement were generated as well. Qualitative review yielded small, but statistically significant differences in image quality and noise between TSENSE 4 and IS-SENSE 4. All three techniques were rated nearly artifact free. Segmented imaging acquisitions with IS-SENSE reconstruction and an acceleration factor of 4 accurately and reliably quantitates RV systolic function parameters, while maintaining image quality. TSENSE-4 accelerated acquisitions showed poorer correlation to standard imaging, and inferior interobserver and intraobserver agreement. IS-SENSE has the potential to shorten cine acquisition times by 50 %, improving imaging options in patients with intermittent arrhythmias or difficulties with breath holding.

Four-dimensional flow magnetic resonance imaging-based characterization of aortic morphometry and haemodynamics: impact of age, aortic diameter, and valve morphology

AIMS

Four-dimensional (4D) flow magnetic resonance imaging (MRI) was employed for the simultaneous assessment of morphometry and flow parameters along the thoracic aorta to investigate associations between flow, age, aorta diameter, and aortic valve morphology.

METHODS AND RESULTS

One hundred and sixty-five subjects, 65 controls, 50 patients with bicuspid aortic valve (BAV), and 50 patients with a dilated aorta, and a tricuspid aortic valve (TAV) underwent 4D flow MRI. Following 3D segmentation of the aorta, a vessel centreline was calculated and used to extract aorta diameter, peak systolic velocity, and normalized systolic flow displacement. Validation of 4D flow MRI-based morphometric measurements compared with manual diameter measurements from standard contrast-enhanced MR angiography in 20 controls showed good agreement (mean difference = 0.4 mm, limits of agreement = ±1.31 mm) except at the sinus of valsalva. BAV showed significant differences in average peak velocity (PV; P < 0.016) compared with TAV and controls between the left ventricle outflow tract to sino-tubular junction (BAV: 1.3 ± 0.3 m/s; TAV: 1.2 ± 0.2 m/s; controls: 1.0 ± 0.1 m/s) and the ascending aorta for average normalized flow displacement (BAV: 0.11 ± 0.02; TAV: 0.09 ± 0.02; controls: 0.06 ± 0.01, P < 0.016) despite similar average aortic dimensions for BAV (37 ± 1 mm) and TAV (39 ± 1 mm). Multivariate linear regression showed a significant correlation of maximal aortic diameter to age, PV, and normalized flow displacement (R(2) = 0.413, P < 0.001).

CONCLUSION

A single acquisition of 4D flow MRI characterized local morphological and haemodynamic differences between groups along the aorta. BAV showed altered haemodynamics when compared with TAV in spite of having similar aorta dimensions. Maximal aorta diameter was associated with age, PV, and normalized flow displacement.

High-throughput oncogene mutation profiling shows demographic differences in BRAF mutation rates among melanoma patients

Because of advances in targeted therapies, the clinical evaluation of cutaneous melanoma is increasingly based on a combination of traditional histopathology and molecular pathology. Therefore, it is necessary to expand our knowledge of the molecular events that accompany the development and progression of melanoma to optimize clinical management. The central objective of this study was to increase our knowledge of the mutational events that complement melanoma progression. High-throughput genotyping was adapted to query 159 known single nucleotide mutations in 33 cancer-related genes across two melanoma cohorts from Ireland (n=94) and Belgium (n=60). Results were correlated with various clinicopathological characteristics. A total of 23 mutations in 12 genes were identified, that is--BRAF, NRAS, MET, PHLPP2, PIK3R1, IDH1, KIT, STK11, CTNNB1, JAK2, ALK, and GNAS. Unexpectedly, we discovered significant differences in BRAF, MET, and PIK3R1 mutations between the cohorts. That is, cases from Ireland showed significantly lower (P<0.001) BRAF(V600E) mutation rates (19%) compared with the mutation frequency observed in Belgian patients (43%). Moreover, MET mutations were detected in 12% of Irish cases, whereas none of the Belgian patients harbored these mutations, and Irish patients significantly more often (P=0.027) had PIK3R1-mutant (33%) melanoma versus 17% of Belgian cases. The low incidence of BRAF(V600E)(-) mutant melanoma among Irish patients was confirmed in five independent Irish cohorts, and in total, only 165 of 689 (24%) Irish cases carried mutant BRAF(V600E). Together, our data show that melanoma-driving mutations vary by demographic area, which has important implications for the clinical management of this disease.

Imaging of gunshot injuries in a west Dublin teaching hospital--a ten year review

There has been an increase in gun-related crime in Ireland over the last decade to gangland violence, especially in west Dublin. This places a burden on hospital services not previously encountered. The aim of this study was to examine the demographics of gunshot: injuries presenting to a Dublin teaching hospital, and the impact on radiology over a ten year period. A total of 65 gunshot injuries were seen. Mortality for high velocity wounds was much higher (10/23, 43%) than for low-velocity shotgun injuries (2/34, 6%).

First-in-man demonstration of a fully implanted myoelectric sensors system to control an advanced electromechanical prosthetic hand

BACKGROUND

Advanced motorized prosthetic devices are currently controlled by EMG signals generated by residual muscles and recorded by surface electrodes on the skin. These surface recordings are often inconsistent and unreliable, leading to high prosthetic abandonment rates for individuals with upper limb amputation. Surface electrodes are limited because of poor skin contact, socket rotation, residual limb sweating, and their ability to only record signals from superficial muscles, whose function frequently does not relate to the intended prosthetic function. More sophisticated prosthetic devices require a stable and reliable interface between the user and robotic hand to improve upper limb prosthetic function.

NEW METHOD

Implantable Myoelectric Sensors (IMES(®)) are small electrodes intended to detect and wirelessly transmit EMG signals to an electromechanical prosthetic hand via an electro-magnetic coil built into the prosthetic socket. This system is designed to simultaneously capture EMG signals from multiple residual limb muscles, allowing the natural control of multiple degrees of freedom simultaneously.

RESULTS

We report the status of the first FDA-approved clinical trial of the IMES(®) System. This study is currently in progress, limiting reporting to only preliminary results.

COMPARISON WITH EXISTING METHODS

Our first subject has reported the ability to accomplish a greater variety and complexity of tasks in his everyday life compared to what could be achieved with his previous myoelectric prosthesis.

CONCLUSION

The interim results of this study indicate the feasibility of utilizing IMES(®) technology to reliably sense and wirelessly transmit EMG signals from residual muscles to intuitively control a three degree-of-freedom prosthetic arm.

Abstract B147: P-Rex1 is required for efficient melanoma metastasis

Background: P-Rex1 is a Rac-specific Rho GTPase guanine nucleotide exchange factor that has recently been implicated in cancer for the first time. As Rac has a central role in control of cell motility, we assessed the role of P-Rex1 in melanoma, a cancer where metastasis is the major cause of death. This was the first evaluation of P-Rex1 in a genetically modified animal model of cancer. We also investigated the function of P-Rex1 in melanoblasts, as the molecular pathways that drive their developmental migration are believed to underpin the movement of metastatic melanoma cells.

Methods: P-Rex1−/− mice were crossed to mice carrying the DCT-lacZ transgene, a melanoblast reporter line, and a Tyr::NrasQ61K/°; INK4a−/− metastatic melanoma mouse model. Allograft tail vein (TV) injections were performed to further assess the endogenous function of P-Rex1 in metastasis. Panels of human melanoma cell lines and tissue were investigated with microarray, tissue culture, and immunohistochemical techniques.

Results: P-Rex1−/− mice have a melanoblast migration defect during development (p=0.01), evidenced by a white belly. They were resistant to metastasis when crossed to the Tyr::NrasQ61K/°; INK4a−/− murine model of melanoma (1/30 mice with metastases vs 13/30 in control cohort; p=0.001). When melanocytes derived from this model were TV-injected into immune-competent allografts, endogenous P-Rex1 was found to facilitate metastatic incidence, growth, and organ spread following the intravasation stage of the metastatic cascade (p=0.02). Mechanistically, this was associated with P-Rex1 driving invasion in a Rac-dependent manner. In humans, P-Rex1 was elevated in the great majority of melanoma cell lines, with mRNA levels above the median statistically associated with metastasic propensity (p=0.005). Tissue immunohistochemistry revealed an association between tumor progression and P-Rex1 expression.

Conclusions: P-Rex1 is a key component of melanoma progression, invasion and metastatic signaling, supporting the value of pharmacological inhibition of P-Rex1 activation of Rac for treatment of metastatic or high risk primary melanomas.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr B147.

Functional and prognostic relevance of the homeobox protein MSX2 in malignant melanoma

Background:

The homeobox containing transcription factor MSX2 is a key regulator of embryonic development and has been implicated to have a role in breast and pancreatic cancer.

Methods:

Using a selection of two- and three-dimensional in vitro assays and tissue microarrays (TMAs), the clinical and functional relevance of MSX2 in malignant melanoma was explored. A doxycyline-inducible over-expression system was applied to study the relevance of MSX2 in vitro. For TMA construction, tumour material from 218 melanoma patients was used.

Results:

Ectopic expression of MSX2 resulted in the induction of apoptosis and reduced the invasive capacity of melanoma cells in three-dimensional culture. MSX2 over-expression was shown to affect several signalling pathways associated with cell invasion and survival. Downregulation of N-Cadherin, induction of p21 and inhibition of both BCL2 and Survivin were observed. Cytoplasmic MSX2 expression was found to correlate significantly with increased recurrence-free survival (P=0.008). Nuclear expression of MSX2 did not result in significant survival correlations, suggesting that the beneficial effect of MSX2 may be independent of its DNA binding activity.

Conclusions:

MSX2 may be an important regulator of melanoma cell invasion and survival. Cytoplasmic expression of the protein was identified as biomarker for good prognosis in malignant melanoma patients.

Metastasis to the adrenal gland: the emerging role of laparoscopic surgery

BACKGROUND

It is unclear whether resection of clinically isolated metastasis to the adrenal gland improves survival. Also, the role of laparoscopic adrenalectomy (LA) for metastasis is controversial. This study aimed to (1) identify patients who are most likely to have prolonged survival after resection of adrenal metastasis and (2) compare oncological outcomes of LA and open adrenalectomy (OA).

METHODS

A retrospective review of 41 patients, who underwent either OA or LA for metastasis to the adrenal gland during 1997-2002 at a single institution, was conducted.

RESULTS

There were 20 women and 21 men, with a median age of 59 years. The most common disease was non-small-cell lung carcinoma (n = 23), followed by renal cell carcinoma (n = 6). With a median follow-up of 16 months, the overall five-year actuarial survival was 29% (median, 28 months). Four patients were actually alive at four years after adrenalectomy. Disease-free interval (DFI) > 6 months was the only significant predictor of improved survival. LA was performed for 11 patients. There was no difference in the incidence of positive resection-margins or survival between patients with OA or LA.

CONCLUSIONS

Adrenalectomy for metastasis, with intent to prolong survival, should be offered to patients with favorable tumor biology, such as those with significant DFI. The oncological outcome from LA appears similar to that from OA.

Needs assessment for hospital-based home care services

Careful needs assessment is a prerequisite to addressing issues of health care program effectiveness and program planning from a population-based perspective. Home care program evaluation literature is lacking in examples of strategies for such assessment. A nurse-screening of admissions was conducted at an acute care general hospital to estimate need for hospital-based home care (HBHC) services among the 2,613 patients discharged from medical and surgical services over a 5-month period. After careful delineation of inclusion and exclusion criteria for identifying HBHC patients and participant-observer training, the nurse's judgments on patient appropriateness for HBHC care were shown to agree reliably with those of the HBHC staff (k = + .45). In the study hospital under current conditions, an estimated 64% of discharged patients appropriate for home care do not receive these services. A comparison of the incidence according to service of HBHC-appropriate patients and patient-referral rates to HBHC suggests that one service over-refers (neurology), but most under-refer. Screening nurse salary expenditures constitute the major costs of this approach to home care needs assessment, which is recommended only for addressing major, infrequent programmatic policy issues.