Component separation repair of incisional hernia: evolution of practice and review of long-term outcomes in a single center

PURPOSE

To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center.

METHODS

This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients.

RESULTS

89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date.

CONCLUSION

Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.

Exploration of rotational thromboelastometry (ROTEM) to characterize the coagulation profiles of newly diagnosed pediatric leukemia patients

BACKGROUND

Viscoelastic testing has been used in adult hematologic malignancies in conjunction with conventional coagulation tests (CCTs) to predict coagulopathies and tailor blood product replacement. However, there is a paucity of similar pediatric studies.

OBJECTIVES

Analyze and correlate leukemia-associated coagulopathy in newly diagnosed pediatric leukemia patients using CCT's and Rotational Thromboelastometry (ROTEM).

METHODS

Pediatric patients with newly diagnosed acute leukemia underwent testing with ROTEM and CCTs on days 0, 15 and 29 of induction chemotherapy.

RESULTS

Sixty-two patients were enrolled. At presentation, 54.8 % of patients had platelets <50 K/μL, 73 % had prolonged PT, 1.6 % had fibrinogen <150 mg/dL. Fifteen patients (24.2 %) had WHO grade 1 bleeding and two patients (3 %) had WHO grade 4 bleeding. EXTEM/INTEM values at presentation (day 0) reflected hypocoagulability, however FIBTEM revealed hypercoagulability. Patients showed a progressive hypocoagulability in all ROTEM assays by day 15 (day 0 vs day 15, p < 0.001), with improvement by day 29 (day 15 vs day 29, p < 0.001). Day 0 ROTEM parameters were comparable to day 29. Fibrinogen strongly correlated with ROTEM at all three time points (p < 0.0001), along with platelet count with moderate correlations (p < 0.001).

CONCLUSION

Fibrinogen and platelets appear to be the drivers of leukemia associated coagulopathy in the pediatric population, suggesting the utility of using CCTs and ROTEM in this population to better evaluate hemostatic function and guide blood product replacement.

In vitro comparative evaluation of physical and chemical properties of surface enamel after using APF and SDF with or without laser activation

PURPOSE

To evaluate and compare the changes in physical and chemical properties of the enamel surface after application of Silver Diamine Fluoride (SDF), Acidulated Phosphate Fluoride (APF), LASER activated SDF and LASER activated APF.

METHODS

Sample consisted of 72 freshly extracted healthy human premolar teeth, extracted for orthodontic purpose, free from caries, fracture or any anomalies. The selected samples were randomly divided into four groups (n = 18): Group 1 (SDF); Group 2 (APF); Group 3 (LASER activated SDF) and Group 4 (LASER activated APF). All samples were evaluated for values of DIAGNOdent at baseline, after demineralisation and after remineralisation. They were further divided and assessed for colour changes, surface alterations and fluoride content of surface enamel using Spectrophotometer, Scanning Electron Microscopy and Energy Dispersive X-ray Spectrometry respectively. The statistical analysis was done using One-Way ANOVA, Tukey's HSD test, Mann-Whitney U test and Kruskal-Wallis Test.

RESULTS

Highest remineralising potential and maximum colour changes of surface enamel was exhibited by Group 3. Scanning Electron Micrographs of Group 3 and Group 4 exhibited regular globular structures of enamel whereas Group 1 and Group 2 showed irregular globular surface of the enamel at 2000× and 5000× magnification. Maximum fluoride uptake on the surface enamel was seen in Group 4 followed by Group 3.

CONCLUSION

Use of LASER activated topical fluorides helps to achieve superior caries prevention. LASER activated APF can be used as an aesthetic alternative to SDF, as LASER activated APF showed higher uptake of fluoride on the enamel surface without discoloration effect.

Efficacy of spinal manipulations and Schroth exercises on psychological parameters in patients with functional scoliosis: a randomised controlled trial

Functional scoliosis is defined as the reversible and temporary lateral spinal curvature that mainly occurs due to abnormal postural habits that leads to non-structural and compensatory changes in spine. Functional scoliosis can lead to the development of mental health issues, such as stress, anxiety and depression. The purpose of the present study was to evaluate the effects of spinal manipulation techniques and Schroth exercises on psychological parameters in patients with functional scoliosis. The subjects were randomly allocated into experimental (n=31) and control group (n=31). Spinal manipulation techniques and Schroth exercises were given to the patients of experimental group, while only Schroth exercises were given to the patients of control group. Outcome measures were Depression, Anxiety & Stress Score that was examined by using ‘DASS-21 questionnaire’. Treatment was given for four weeks, thrice weekly. After the completion of four weeks, DASS scores were obtained from the participants. Patients were followed up after 2 months and data was collected again. Repeated measures ANOVA were used to compare the mean changes within-group. Independent t-test was used to analyse the mean improvement between-group. Results suggested that there was a statistically significant difference between pre-/post and pre-/follow-up scores of the DASS, but there was statistical non-significant difference between post-/follow-up scores of the DASS. Results also suggested that experimental group showed better improvement compared to the control group. This study concluded that the combine use of spinal manipulation techniques and Schroth exercise protocol can significantly reduce the psychosomatic symptoms in functional scoliosis.

Clinical Trial Registry of India: CTRI/2020/02/023221

T-wave alternans poorly prognostic in primary prophylactic ICD patients: a prospective EU-CERT-ICD study

Background

New methods to identify patients who truly benefit from primary prophylactic implantable cardioverter defibrillation (ICD) are urgently needed. T-wave alternans (TWA) represents a beat-to-beat fluctuation in the morphology of the ST-segment and T-wave. It has been shown to associate with arrhythmogenesis of heart and sudden cardiac death [1]. We hypothised that TWA might associate with benefit from ICD implantation in primary prevention.

Methods

In EU-CERT-ICD study, we prospectively enrolled 2327 primary prophylactic ICD candidates from 15 European countries. A 24-hours Holter-monitoring was taken from all recruited patients at enrolment. TWA was assessed from Holter-monitoring using MMA method with Getemed Cardioday software. To assess the benefit from ICD treatment, we used outcomes all-cause mortality, appropriate shock and survival benefit. We conducted Cox regression model, competing risk regression model and propensity score adjusted Cox regression model. TWA was assessed both as contiguous variable and with cut-off points &lt;47 μV and &lt;60 μV.

Results

Final cohort included 1,734 valid T-wave alternans samples, 1,211 patients with ICD and 523 control patients with conservative treatment, with mean follow-up time 2.3 years. TWA &lt;60 μV predicted lower all-cause mortality in ICD patients in univariate cox regression model (HR 1.484, 95% CI 1.024–2.151, p=0.0374). In multivariate models, TWA did not predict death or appropriate shocks in ICD patients. In addition, TWA did not predict death in control patients. In propensity score adjusted Cox regression model, TWA did not predict ICD benefit.

Conclusion

T-wave alternans is poorly prognostic in primary prophylactic ICD patients. Altough it may predict life-threatening arrhythmias and sudden cardiac death in several patient populations, it cannot be used in assessing benefit from implantable cardioverter defibrillator in primary prevention among patients with ejection fraction ≤35%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community's 7th Framework Program FP7/2007-2013

Adherence and discontinuation of sglt2-inhibitors and glp1-r agonists in patients with type 2 diabetes with and without cardiovascular disease

Background

Sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucacon-like-peptide-1 receptor (GLP-1R) agonists are two novel therapies in type 2 diabetes (T2D) that are recommended in patients with manifestations of cardiovascular disease or high risk of cardiovascular disease due to their cardioprotective benefits. Despite the increasing use of these drugs, there is still limited knowledge on the adherence patterns and the risk of discontinuation, according to the presence or absence of different cardiovascular conditions.

Purpose

To investigate the adherence and estimate the risk of discontinuation of SGLT2 inhibitors and GLP1-R agonists in patients with T2D with and without cardiovascular disease.

Methods

From Danish nationwide registers, we included all individuals &gt;40 years with T2D who redeemed the first prescription of a SGLT2 inhibitor or GLP1-R agonist, between December, 2012 and December, 2018. Patients were divided into subgroups according to the presence or absence of different cardiovascular conditions (heart failure, ischemic heart disease, peripheral artery disease, atrial fibrillation), at the time of inclusion. Adherence over the course of one year after initiation of treatment was estimated by the proportion of days covered (PDC) for each subgroup, and adherence was defined as PDC 80%. The risk of discontinuation was estimated using multivariable cause-specific Cox regression models, and was defined as a break in treatment of 90 days. The Aalen-Johansen estimator was used to account for censoring and competing risks. Patients were followed until date of emigration, death or study end (December 31, 2019).

Results

We included 24,061 patients with T2D who initiated treatment with a SGLT2 inhibitor, and 13,899 patients with T2D who initiated treatment with a GLP1-R agonist, for the first time between December 10, 2012 and December 31, 2018. Median age at inclusion was 62 years (IQR 54–70) and 40% were female. In the analyses, 67% of the patients treated with SGLT2 inhibitors were adherent to therapy throughout the first year, whereas the same proportion of patients, 67%, were adherent to therapy with GLP-1R agonists. Mean PDC was 77% (SD 33) and 79% (31) for patients in therapy with SGLT2 inhibitors and GLP1-R agonists, respectively. No significant difference was observed related to the presence or absence of cardiovascular disease (SGLT2 inhibitor: mean PDC 77 (33) vs. 77 (33), GLP1-R agonist: 78 (32) vs. 79 (31)).

Conclusions

In this nationwide cohort study, we found that patients with T2D who initiated therapy with a SGLT2 inhibitor and those who initiated therapy with a GLP1-R agonist were almost equally adherent to therapy throughout the first year. Adherence in both treatment groups did not differ according to the presence or absence of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

AB1510 INFLAMMATORY MYOSITIS – FINAL ANSWER?

Background

Motor neurone disease may mimic inflammatory myositis. There is an overlap in clinical symptoms (such as muscle weakness, dysphagia and respiratory involvement) which may pose a diagnostic challenge. Careful history, thorough clinical examination and appropriate investigations can help to distinguish between the two. Monitoring the response to treatment is also crucial. We present a case that presented to rheumatology with progressive muscle weakness, she was investigated and treated for inflammatory myositis but was later diagnosed with motor neurone disease.

Objectives

To illustrate the need for thorough clinical assessment and investigations in patients with suspected inflammatory myositis and consider alternative diagnoses as clinical picture evolves.

Methods

A 68 year old lady, presented with 6 months history of progressive proximal muscle weakness. She also reported weakness of grip, affecting activities of daily life. She was finding it difficult to get up from chair. There was no swallowing difficulty, respiratory symptoms and skin rash. She had no weight loss or constitutional symptoms. She did not have any joint pain or features of connective tissue disease. She had history of hypertension. On clinical examination, she did not have any features of connective tissue disease. There was no evidence of joint synovitis or skin rash. Proximal power in upper and lower limbs noted to be 4/5 with intact reflexes. Initial investigations revealed mildly raised CPK at 287 with normal thyroid function and inflammatory markers. Immunological tests including ANA and myositis panel were requested alongside EMG, MRI thighs and CT chest/abdomen/pelvis. Myositis panel was positive for anti-MDA-5 antibodies (in the absence of any skin or respiratory symptoms). There was no evidence of malignancy on CT imaging. MRI thighs revealed fluid in the trochanteric bursae. She was trialled on oral prednisolone in view of her clinical features and positive anti-MDA5 antibody. However, there was no improvement in her symptoms or functional status. EMG revealed widespread neurogenic process affecting upper and lower limbs on both sides, without significant evidence of acute myopathy. The progressive nature of symptoms with the upper motor neurone signs raised the possibility of an evolving anterior horn cell disorder. She was referred to neurology and was subsequently diagnosed to have Motor Neurone Disease. The steroids were rapidly tapered off and stopped.

Results

Motor neurone disease is an important differential when considering inflammatory myopathy, particularly inclusion body myositis which causes more progressive muscle weakness. It is a neurological disorder characterised by degeneration of neurons. There is no clear cause identified. MND causes both upper and lower motor neurone signs. Symptoms include limb weakness, bulbar weakness that can affect speech and swallowing, muscle twitching and fasciculation. Respiratory weakness may occur. Thorough clinical examination and EMG findings help identify the diagnosis. Imaging may be needed. There is no cure. Management requires an MDT approach, primarily guided by neurology, including physiotherapy, occupational therapy, speech and language therapy and respiratory support.

Conclusion

This lady was initially treated for inflammatory myositis based on her symptoms, mildly raised CK and positive anti-MDA5 antibodies. On review of her clinical progress, we noted poor response to steroids and EMG results pointing at an alternative diagnosis of MND. This case highlights the importance of EMG in the assessment and management of patients with suspected inflammatory myositis as well as the need to closely monitor progress and re-evaluation where needed. Although she had anti-MDA-5 antibodies and mildly raised CK, she did not have any skin disease or other systemic features, inflammatory markers and muscle imaging was normal. Response to steroids was inadequate.

References

[1]Turner MR, Talbot K. Mimics and chameleons in motor neurone disease. Pract Neurol. 2013

[2]Ryan A, Nor AM, Costigan D, et al. Polymyositis Masquerading as Motor Neuron Disease. Arch Neurol. 2003

Disclosure of Interests

None declared

QRS duration as an independent risk factor for appropriate shocks and mortality in patients with prophylactic implantable cardioverter-defibrillator

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community’s 7th Framework Programme FP7/2007-2013

Background

The implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death (SCD) in high-risk heart failure patients. However, improvements in risk stratification are necessary to increase the efficiency of ICD use. We performed an analysis of the retrospective EU-CERT-ICD registry with respect to QRS duration and effects of cardiac resynchronisation therapy (CRT) on outcomes.

Methods/Results

A total of 5033 patients (81% males) from 14 European centres had an ICD implanted for primary prophylaxis. Mean age at the time of ICD implantation was 64±11 years and ischemic cardiomyopathy was the underlying pathology in 65% of patients. CRT was used in 43% of the patients. The median follow-up was 2.7 years (IQR 1.4-4.6 years). Predefined primary endpoints were all-cause mortality, first appropriate and first inappropriate shocks. The effect of covariates on the cumulative primary endpoints were assessed through hazard ratios in the Fine and Gray subdistributional hazard models (accounting for the competing risks) stratified by centres.

Because of resynchronization by the device, the analysis considered a different influence of QRS on outcomes in the CRT-D and the ICD groups. We observed an increase in the cumulative incidence of the first appropriate shock with increasing QRS values for patients implanted with only an ICD (HR 1.12 per 10ms increase, p&lt;0.001). In patients with CRT-D, increasing QRS values related to a (statistically non-significant) decrease in the cumulative incidence of the first appropriate shocks (HR 0.96 per 10ms, p=0.299).

Since a wide QRS is an indication for CRT-D therapy, high QRS values cluster among those patients with implanted CRT-D, while among patients with QRS under 130ms standard ICD implantations are more frequent. This can explain the observed increase in the cumulative incidence of the first appropriate shocks for increasing QRS values up to 130ms in the ICD-group and its decrease for increasing QRS values over 130ms in the CRT-D group.

Regarding all-cause mortality, hazard ratios for age, LVEF, NYHA, ICM, AF, diabetes and sex category agreed with the results obtained in previously published meta-analyses.

Increased QRS values are associated with higher mortality in the ICD group (HR 1.09 per 10ms increase, p&lt;0.001), but not in the CRT-D group (HR 0.99 per 10ms increase, p=0.695).

Conclusion

In our study, we confirmed QRS duration as an independent risk factor for appropriate ICD shocks and all-cause mortality in patients with ICD for primary prophylaxis. However, this was only observed in patients with single- or dual-chamber ICD, while there was no correlation in CRT-D patients. The findings suggest that CRT-D exerts a protective effect regarding the occurrence of first appropriate shock and all-cause mortality for patients with QRS values higher than 130 ms and indication for resynchronization.

3D Finite Element Simulation of Processing of Generalized Newtonian Fluids in Counter-rotating and Tangential TSE and Die Combination

A full three-dimensional finite element analysis of the nonisothermal flow of generalized non-Newtonian fluids in counter-rotating tangential twin screw extruder is presented. Previous studies of the simulation of processing in tangential twin screw extruders have focused solely on the twin screw extruder, whereas here the coupled flow and heat transfer occurring in the integrated geometry of the extruder, connected to a die are considered. The FEM based numerical simulation of the coupled momentum-mass-energy conservation equations allowed the determination of the effects of some of the important system parameters, including the power law index and the staggering angle of the screws, on the pumping and pressurization capability of the extruder and the associated degree of fill in the extruder.

Vraag & Antwoord

- Intestinaal microbioom/dysbiose-index bij chronische darmproblemen bij kleine huisdieren - Effect of anemia on performance and immune response in piglets - Behandeling van FIP bij katten

Assessment of land use cover changes, carbon sequestration and carbon stock in dry temperate forests of Chilas watershed, Gilgit-Baltistan

Abstract Land use and land cover change are affecting the global environment and ecosystems of the different biospheres. Monitoring, reporting and verification (MRV) of these changes is of utmost importance as they often results in several global environmental consequences such as land degradation, mass erosion, habitat deterioration as well as micro and macro climate of the regions. The advance technologies like remote sensing (RS) and geographical information system (GIS) are helpful in determining/ identifying these changes. In the current study area, changes in carbon stocks, notably in forest areas, are resulting in considerable dynamics of carbon stocks as a result of climate change and carbon sequestration. This study was carried out in the Diamer district of the Gilgit Baltistan (GB) Pakistan to investigate the change in cover change/land use change (particularly Forest Land use) as well as carbon sequestration potential of the forests in the district during almost last 25years. The land cover, temporal Landsat data (level 1, LIT) were downloaded from the USGS EROS (2016), for 1979-1989, 1990-2000 and 2001-2012. Change in land uses, particularly forest cover was investigated using GIS techniques. Forest inventory was carried out using random sampling techniques. A standard plot of size 0.1 ha (n=80) was laid out to determine the tree density, volume, biomass and C stocks. Simulation of C stocks was accomplished by application of the CO2FIX model with the data input from inventory. Results showed a decrease in both forest and snow cover in the region from 1979-2012. Similarly decrease was seen in tree volume, tree Biomass, dynamics of C Stocks and decrease was in occur tree density respectively. It is recommended we need further more like project such as BTAP (Billion Tree Afforestation Project) and green Pakistan project to increase the forest cover, to control on land use change, protect forest ecosystem and to protect snow cover.

Lung ultrasound could reduce X-ray after major lung resection

OBJECTIVES

This study evaluated the role of ultrasound in postoperative care after major lung resection.

BACKGROUND

High accuracy of lung ultrasound imaging was proved in various medical fields. The experience with ultrasound after thoracic surgery is limited.

METHODS

Patients scheduled for major lung resection were consecutively included in a prospective study comparing two modalities of imaging examinations, namely those employing ultrasound and X-ray in the diagnoses of pneumothorax and pleural effusion. Two examinations were performed. One after recovery from anaesthesia, the second before chest tube removal.

RESULTS

Forty-eight patients underwent 87 examinations. X-ray and ultrasound examinations showed substantial and fair agreements for pneumothorax (Cohen's kappa coefficients 0.775 and 0.397) and slight and substantial agreements for pleural effusion (Cohen's kappa coefficients 0.036 and 0.611). The sensitivity bounds for pneumothorax were 45.5-58.5 % at the first and 29.7-59.4 % at the second examination. Sensitivity bounds for pleural effusion were 0-86.2 % at the first and 32.6-36.9 % at the second examination. Except for two cases of pneumothorax being missed by X-ray imaging, the rest of mismatches were clinically irrelevant conditions with no impact on clinical decision and patient's outcome.

CONCLUSION

The use of ultrasound can reduce the number of X-ray examinations and thus lower the radiation exposure after major lung resections (Tab. 4, Ref. 30).

The Haleem-Marks-Botchu classification: a novel CT-based classification for intracanal rib head penetration

PURPOSE

Intracanal rib head penetration is a well-known entity in dystrophic scoliotic curves in neurofibromatosis type 1. There is potential for spinal cord injury if this is not recognised and managed appropriately. No current CT-based classification system is currently in use to quantify rib head penetration. This article aims to propose and evaluate a novel CT-based classification for rib head penetration primarily for neurofibromatosis but which can also be utilised in other conditions of rib head penetration.

MATERIALS AND METHODS

The grading was developed as four grades: normal rib head (RH) position-Grade 0, subluxed extracanal RH position-Grade 1, RH at pedicle-Grade 2, intracanal RH-Grade 3. Grade 3 was further classified depending on the head position in the canal divided into thirds. Rib head penetration into proximal third (from ipsilateral side)-Grade 3A, into the middle third-Grade 3B and into the distal third-Grade 3C. Seventy-five axial CT images of Neurofibromatosis Type 1 patients in the paediatric age group were reviewed by a radiologist and a spinal surgeon independently to assess interobserver and intraobserver agreement of the novel CT classification. Agreement analysis was performed using the weighted Kappa statistic.

RESULTS

There was substantial interobserver correlation with mean Kappa score (k = 0.8, 95% CI 0.7-0.9) and near perfect intraobserver Kappa of 1.0 (95% CI 0.9-1.0) and 0.9 (95% CI 0.9-1.0) for the two readers.

CONCLUSION

The novel CT-based classification quantifies rib head penetration which aids in management planning.

1576 Safeguarding Tools in Paediatric Burns

Introduction

When assessing paediatric patients presenting with burns, non-accidental injury always has to be considered. In our department, local policy dictates that all patients aged 18 or below should have a child safeguarding tool completed on initial clerking.

Method

A retrospective audit of all paediatric burns seen over one month was performed. Primary outcome measures included completion of a safeguarding tool and documentation of referral outcome. These results were presented locally and implementing changes were carried out. This was then re-audited over a further monthly period.

Results

Initial data collection showed a safeguarding tool completion rate of 69% and referral outcome documentation rate of 50% (n = 16). Implement changes included dissemination of initial audit results to the department, changing the layout of our clerking proformas and introducing posters in the unit which provided more information on risk assessing paediatric patients. The re-audit results showed a safeguarding tool completion rate of 100% and a referral outcome documentation rate of 100% (n = 14).

Conclusions

There was a significant improvement in both the safeguarding tool completion and referral outcome documentation rates following our interventions. Simple measures just such education and strategic adjustments of clerking proformas have been shown to be effective measures for increasing documental compliance of child safeguarding tools.

1013 Dupuytren’s Contracture Treatment with XIAPEX Injection: Reviewing A Single Surgeon's Experience

Aim

To review a single surgeon's experience for the treatment of Dupuytren's disease with XIAPEX injection and the clinical outcomes as measured by a URAM score.

Method

Retrospective review of patient notes, clinical photography and URAM scores for patients who underwent the procedure between August 2013 and October 2016.

Results

33 patients underwent the procedure. 25 patients completed pre and post URAM scores. Average pre procedure score was 19.4 and avergae post procedure score was 3.28 a difference of 16.12 (clinically important change for URAM score is 2.9). Average pre procedure MCPJ contracture was 46.67 degrees and average post procedure contracture was 3.3 degrees. Average pre procedure PIPJ contracture was 66.8 degrees and average post procedure contracture was 8.2 degrees. Where both MCPJ and PIPJ affected of the same digit average pre procedure MCPJ and PIPJ contracture was 60 degrees. The post procedure contracture was 0 degrees in the MCPJ and 29.7 degrees in the PIPJ. 1 patient underwent surgery for progressive disease.

Conclusions

XIAPEX injection has shown a clinically significant result in the treatment of Dupuytren's disease. There were minimal complications and only 1 patient needed further surgery. However, a small sample size thus conclusions have to be cautious.

1632 Improving Excision Margins in Skin Oncology

Aim

There are 152,000 new non-melanoma skin cancer (NMSC) cases in the UK every year, and excision and reconstruction of basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) form a significant part of the clinical workload in plastic surgery. In this quality improvement project, we aimed to identify and improve our unit’s compliance of guidelines for excision margins for NMSCs.

Method

A retrospective audit was undertaken in June 2020 to determine compliance with British Association of Dermatology and local guidelines on excision margins for NMSCs. A repeat audit was undertaken in October 2020 following quality improvement interventions.

Results

The first audit cycle examined 66 lesions in total. Guidelines were met in 53% (BCCs) and 50% (SCCs) of lesions. 12% of lesions had unclear documentation of margins. 16 lesions had margins that were too small as according to the risk factors present. These findings were presented to the department, and a new operative note template specifically designed for skin oncology was launched. Key audit findings were displayed along with the guidelines on posters. A repeat cycle was undertaken in October 2020, which examined 52 lesions. Significant improvement was seen with 100% documentation, and excision margin guideline compliance rate of 71% (BCCs) and 79% (SCCs).

Conclusions

Adequate excision margins in skin oncology is vital to ensure complete excision and to minimise the risk of recurrence. Our project demonstrates significant improvement in excision margin compliance through the launch of a specific operative note template and information posters.

Conventional oxygen therapy versus CPAP as a ceiling of care in ward-based patients with COVID-19: a multi-centre cohort evaluation

BACKGROUND

Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV.

METHODS

This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale ≤ 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1^st March to May 31^st, and from 1^st September to 31^st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO₂ ≥0_.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering.

FINDINGS

Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it.

INTERPRETATION

No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting.

FUNDING

L Pearmain is supported by the MRC (MR/R00191X/1). TW Felton is supported by the NIHR Manchester Biomedical Research Centre.

Development, Characterization, and Evaluation of SLN-Loaded Thermoresponsive Hydrogel System of Topotecan as Biological Macromolecule for Colorectal Delivery

BACKGROUND

Chemotherapeutic drugs cause severe toxicities if administered unprotected, without proper targeting, and controlled release. In this study, we developed topotecan- (TPT-) loaded solid lipid nanoparticles (SLNs) for their chemotherapeutic effect against colorectal cancer. The TPT-SLNs were further incorporated into a thermoresponsive hydrogel system (TRHS) (TPT-SLNs-TRHS) to ensure control release and reduce toxicity of the drug. Microemulsion technique and cold method were, respectively, used to develop TPT-SLNs and TPT-SLNs-TRHS. Particle size, polydispersive index (PDI), and incorporation efficiency (IE) of the TPT-SLNs were determined. Similarly, gelation time, gel strength, and bioadhesive force studies of the TPT-SLNs-TRHS were performed. Additionally, in vitro release and pharmacokinetic and antitumour evaluations of the formulation were done.

RESULTS

TPT-SLNs have uniformly distributed particles with mean size in nanorange (174 nm) and IE of ~90%. TPT-SLNs-TRHS demonstrated suitable gelation properties upon administration into the rat's rectum. Moreover, drug release was exhibited in a control manner over an extended period of time for the incorporated TPT. Pharmacokinetic studies showed enhanced bioavailability of the TPT with improved plasma concentration and AUC. Further, it showed significantly enhanced antitumour effect in tumour-bearing mice as compared to the test formulations.

CONCLUSION

It can be concluded that SLNs incorporated in TRHS could be a potential source of the antitumour drug delivery with better control of the drug release and no toxicity.

Multisystem inflammatory syndrome in children (MIS-C) and the prothrombotic state: Coagulation profiles and rotational thromboelastometry in a MIS-C cohort

BACKGROUND

Adults infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have had high rates of thrombosis. A novel condition in children infected with SARS-CoV-2, multisystem inflammatory syndrome in children (MIS-C), has limited data on their prothrombotic state or need for thromboprophylaxis.

OBJECTIVES

We aimed to analyze the prothrombotic state using coagulation profiles, rotational thromboelastometry (ROTEM) parameters and clinical outcomes, to determine if this could aid in risk stratification for thromboprophylaxis.

METHODS

This analysis included patients (<21 years of age) with a diagnosis of MIS-C (n = 40) and controls (presenting with suspicion of MIS-C but later ruled out; n = 26).

RESULTS

MIS-C patients had higher levels of inflammatory markers including D-dimer (p < .0001), compared with controls, along with evidence of hypercoagulability on ROTEM with elevated evaluation of fibrinogen activity (FIBTEM) maximum clot firmness (MCF) (p < .05). For MIS-C patients with D-dimers >1000 ng/ml, there was a significant correlation of FIBTEM MCF (p < .0001) with a mean value of 37.4 (standard deviation 5.1). D-dimer >2144 ng/ml was predictive of intensive care unit admission (area under the curve [AUC] 0.80; 95% confidence interval, 0.60-0.99; p < .01; sensitivity: 82%, specificity: 75%), and elevated FIBTEM MCF (AUC 1 for >2500 ng/ml). MIS-C patients (50%) received enoxaparin thromboprophylaxis (in addition to aspirin) with significant improvement in their inflammatory and ROTEM parameters upon outpatient follow-up; none developed symptomatic thrombosis.

CONCLUSIONS

Despite an observed prothrombotic state, none of the MIS-C patients (on aspirin alone or in combination with enoxaparin) developed symptomatic thrombosis. ROTEM, in addition to coagulation profiles, may be helpful to tailor thromboprophylaxis in critically ill MIS-C patients.

Quality of life and well-being of population at the end of third phase of lockdown in india against the COVID-19 pandemic

Background. On March 24, 2020, a nationwide Lockdown for 21 days was ordered by the Government of India which was then extended till May 31, 2020. Researchers have predicted lockdown is a necessary step to prevent COVID-19 spread. However, others have also stated that it could cause serious damage to the economic, mental, social, and physical well-being of the people. Objective. The aim of the study is to evaluate the impact of lockdown on the quality of life and well-being of the Indians. Methods. It is a cross sectional prospective web-based questionnaire study. A link (https://forms.gle/pX25VuahP5NxT88QA) was created. Total 426 responses were received via that link and the data was included in the statistical analysis. Results. Our study revealed that during the lockdown 61.5% of the respondents were performing physical activities lesser than before. More than half responded they had a reduced financial satisfaction. Most answers on emotional well-being and social-family wellbeing were also positive, but some responses showed disturbing too, like 22% felt anxious and nervous over half of the days. It was found in the study that physical, financial, emotional, mental, social and family wellbeing were disturbed during the lockdown and quality of life was also hampered. Conclusion. Though, may be Nationwide Lockdown was the most required action at that point of time to prevent virus spread, but our study revealed that uncertainty regarding its cure and management guidelines like lockdown and social distancing has badly affected quality of life and wellbeing of the population.

Prescription understanding among out-patients in government and private hospitals: A cross-sectional study in Lahore, Pakistan

INTRODUCTION

Like many other countries, Pakistan's healthcare system is divided into the public and the private sector. According to some studies and the mindset of many Pakistani people, private hospitals provide better services than government hospitals.

PURPOSE

The paucity of research studies compelled us to compare the understanding of prescription among outpatients of the government and private hospitals since the understanding of prescription by the patient is an important patient care indicator according to WHO.

METHOD

A cross sectional study was conducted by virtue of convenience sampling. The study included 365 patients; 182 from the government sector and 183 from the private sector. The study was conducted over a period of 3 months. A structured questionnaire was prepared to gather data that was analyzed using SPSS Version 22.0.

RESULTS

Patients from both government and private hospitals got no counseling while only 45.9% of the government hospital patients and 65.9% of private hospital patients were satisfied with the counseling they received. Our study concluded that the role of a pharmacist must be extended besides dispensing only, in counseling and educating patients to reduce the burden on the physicians and hospitals as well.

CONCLUSION

It was concluded that although the patients of private hospitals scored somewhat better at answering the questions than the government hospital patients but they failed to hit the benchmark. Their slightly better results were attributed to higher education levels and better socioeconomic status rather than better services of the hospital.

Quantitative analysis of myocardial metabolic heterogeneity is superior to visual assessment for the detection of active cardiac sarcoidosis by F-18 FDG PET-CT imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial inflammation may occur in the context of a multisystem disease such as sarcoidosis, adversely affecting prognosis. A definitive diagnosis of cardiac sarcoidosis (CS) is essential to implementing life-saving treatment but this is complicated by the invasive nature of endomyocardial biopsy (EMB) and its low accuracy. Positron emission tomography (PET) assists in diagnosis, which relies on visual interpretation of myocardial F-18 FDG uptake. The value of quantitative analysis and its application to clinical practice remain uncertain.

Purpose

To investigate the power of quantitative F-18 FDG PET-CT imaging analysis for detecting CS in patients with suspected disease.

Methods

All patients underwent F-18 FDG PET-CT after a 24-hour low-carbohydrate diet and 15-hour fasting as part of their diagnostic work-up for suspected cardiac inflammation. Cardiovascular magnetic resonance acted as gatekeeper to PET-CT in 8 of every 10 scans. Myocardial F-18 FDG uptake was assessed qualitatively and quantitatively using both manually drawn regions of interest and automatic polar maps to measure global and segmental standardised F-18 FDG uptake values (SUV).  The coefficient of variation (CoV) was calculated to determine uptake heterogeneity. To confirm diagnosis, follow-up data regarding disease progression, further testing and treatment were collected. To allow for sufficient follow-up time, the first 40 consecutive patients from a prospective registry (n= 214; Sep 2017-Jun 2020) were included.

Results

A comprehensive clinical picture was obtained successfully in 37 patients (median [IQR], 17 [13.5] months) and a final diagnosis of CS reached in 7 (disease prevalence, 19%). EMB was performed in 2 patients only while 3 underwent PPM/ICD implantation. Significant predictors of CS were fulfilment of Japanese Ministry of Health and Welfare criteria (Wald, 6.44; p = 0.01) and left ventricular dysfunction (Wald 6.72; p = 0.01). Qualitative F-18 FDG PET-CT had a high negative (95%) but low positive (45%) predictive value for CS (sensitivity, 83%; specificity, 77%). F-18 FDG SUV CoV was the strongest imaging predictor (Wald, 6.77; p = 0.009) and was significantly higher in CS than non-CS (CoV median [quartiles], 0.26 [0.21, 0.36] and 0.12 [0.11, 0.14] respectively; p = 0.004). As per ROC curve analysis (AUC, 0.84), a CoV threshold of 0.20 was highly specific (93%) and sensitive (86%) for CS.

Conclusion

In a referring population with a low prevalence of cardiac sarcoidosis, F-18 FDG PET-CT imaging is sensitive for the detection of myocardial inflammation with active disease unlikely in patients with a negative scan. Quantitative evaluation of metabolic heterogeneity within the myocardium provides a strong, independent marker of active disease and should be considered alongside visual assessment.

The Haleem-Botchu classification: a novel CT-based classification for lumbar foraminal stenosis

PURPOSE

No clinical CT-based classification system is currently in use for lumbar foraminal stenosis. MRI scanners are not easily available, are expensive and may be contraindicated in an increasing number of patients. This study aimed to propose and evaluate the reproducibility of a novel CT-based classification for lumbar foraminal stenosis.

MATERIALS AND METHODS

The grading was developed as four grades: normal foramen-Grade 0, anteroposterior (AP)/superoinferior (SI) (single plane) fat compression-Grade 1, both AP/SI compression (two planes) without distortion of nerve root-Grade 2 and Grade 2 with distortion of nerve root-Grade 3. A total of 800 lumbar foramen of a cohort of 100 random patients over the age of 60 who had undergone both CT and MRI scans were reviewed by two radiologists independently to assess agreement of the novel CT classification against the MRI-based grading system of Lee et al. Interobserver(n = 400) and intraobserver agreement(n = 160) was also evaluated. Agreement analysis was performed using the weighted kappa statistic.

RESULTS

A total of 100 patients (M:F = 45:55) with a mean age of 68.5 years (range 60-83 years were included in the study. The duration between CT and MRI scans was 98 days (range 0-540, SD-108). There was good correlation between CT and MRI with kappa scores (k = 0.81) and intraobserver kappa of 0.89 and 0.98 for the two readers.

CONCLUSION

The novel CT-based classification correlates well with the MRI grading system and can safely and accurately replace it where required.

Orbital exenteration and reconstruction in a tertiary UK institution: a 5-year experience

PURPOSE

Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach.

METHODS

We performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed.

RESULTS

27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects.

CONCLUSIONS

A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

PRIMARY LARYNGEAL ASPERGILLOSIS IN AN IMMUNOCOMPETENT PATIENT

Background. Aspergillus is an inherently ubiquitous, weakly pathogenic fungus causing opportunistic infections. It is very rarely localized in the larynx, although laryngeal Aspergillosis may develop in the immunocompromised patients including those with leukaemia and severe aplastic anaemia. Objective. The aim of the research was to explore the primary laryngeal Aspergillosis in an immunocompetent patient thru a case report. Methods. A case report of primary laryngeal Aspergillosis in an immunocompetent patient is presented. Results. A male patient of 40 years old, presenting with chronic worsening hoarseness, was found to have a smooth, white spheroid submucosal growth on left vocal cord with preserved bilateral cord movements on videostroboscopy. Histopathological examination of vocal cord growth revealed squamous epithelium containing septate hyphae with acute angle dichotomous branching pattern consistent with Aspergillus. Voice improved after a four-week course of oral itraconazole 200 mg/day. Post therapy follow up of 24 months was unremarkable. Conclusions. Primary laryngeal Aspergillosis develops in the immunocompetent patients. Iatrogenic, vocal abuse, occupation and lifestyle factors may be contributory. Optimal diagnosis and management mandates a high index of suspicion.

Intraprocedural complications of uterine fibroid embolisation and their impact on long-term clinical outcome

OBJECTIVES

Authors evaluate the impact of intraprocedural complications on successful technical realisation and long-term clinical outcome of the uterine fibroid embolisation.

BACKGROUND

The uterine artery embolisation (UAE) has become an accepted treatment method for uterine fibroids. In general, the unilateral embolisation is considered to be insufficient due to poor clinical effect.

METHODS

Overall, 165 uterine artery embolisations were analysed (retrospectively-prospectively) in 163 female patients. Intraprocedural complications and their impact on the possibility to perform bilateral embolisationwere evaluated. In patients with unscheduled unilateral embolisation, short-term as well as long-term clinical effects were observed with mean follow-up period of 41 months.

RESULTS

The bilateral uterine artery embolisation was possible in 95.7 % (95 %, CI 91.3-99.4 %) procedures. The unilateral embolisation was reported in 7 procedures (4.3 %, CI 1.2-8.3 %) and reasons were following: resistant arterial spasm in 4 patients (2.5 %, CI 0.7 %-5.3 %) and impossible catheterisation due to unfavourable anatomic situation in 3 patients (1.8 %, CI 0.3-4.1 %). Other complications, such as dissection and perforation, did not affect the successful technical realisation. The long-term clinical effect of unscheduled unilateral embolisation was reported in 5 patients.

CONCLUSION

The results of our series of unscheduled unilateral uterine fibroid embolisation had high long-term clinical success rate. In way of unscheduled unilateral embolisation, we recommend MRI follow-up and reintervention only in way of persistence or recurrence of symptoms with concurrent MRI finding of residual fibroids(Tab. 5, Fig. 3, Ref. 12).

Abstract P5-07-05: Obesity, adipose inflammation, and race in patients with early stage breast cancer

Background: Elevated body mass index (BMI) is associated with increased risk of estrogen receptor-positive postmenopausal breast cancer. Mechanistically, most individuals with elevated BMI have breast white adipose tissue inflammation (WATi) which confers increased breast cancer risk, particularly in those with existing benign breast disease. Individuals with WATi have elevated in-breast expression of aromatase and several systemic changes that increase breast cancer risk, including hyperinsulinemia and higher levels of C-reactive protein. However, women with normal BMI but high levels of body fat are also likely to harbor WATi and are at increased risk of postmenopausal breast cancer. The accuracy of BMI for assessing adiposity and predicting obesity-related disorders, including cancer, varies across race and ethnicity. Whether the association between BMI and WATi varies by race is unknown. Here we aimed to characterize relationships among breast WATi and clinicopathologic features in a racially diverse cohort undergoing mastectomy for breast cancer treatment.

Methods: Non-tumorous breast tissue and fasting blood were collected from women undergoing mastectomy for breast cancer treatment or prevention at a single center serving a racially diverse patient population. Breast WATi was detected by the presence of crown-like structures in the breast (CLS-B), which are composed of a dead/dying adipocyte surrounded by CD68+ macrophages. Clinicopathologic data were abstracted from electronic medical records. Associations among categorical variables were examined using Fisher's exact test. Relationships between continuous variables were examined using the Spearman correlation.

Results: As of May 18, 2018 62 patients have been accrued; median age 55 (range 32 to 84). Self-reported race distribution was: 36 (58%) Asian, 5 African American (8%), 20 (32%) Caucasian, and 1 (2%) unknown. Breast tissue has been analyzed for WATi in 60 cases thus far. Clinicopathologic features stratified by the presence or absence of breast WATi are presented in. Breast WAT inflammation was associated with obesity (P=0.02) and a trend to association was observed with dyslipidemia (P&lt;0.09).

VariableBreast WATi Absent (n=25)Breast WATi Present (n=35)Age, years  Median (range)51 (32 to 71)59 (36 to 80)BMI, kg/m2  Median (range)22.5 (18.1 to 35.3)28.0 (19.2 to 38.9)BMI Category  Underweight1 (4%)0 (0%)Normal16 (64%)10 (29%)Overweight5 (20%)18 (51%)Obese3 (12%)7 (20%)Race, n (%)  Asian15 (60%)19 (54%)African American2 (8%)3 (9%)Caucasian8 (32%)12 (34%)Unknown0 (0%)1 (3%)Menopausal Status, n (%)  Pre10 (40%)12 (34%)Post15 (60%)23 (66%)Hypertension, n (%)7 (28%)16 (46%)Diabetes mellitus, n (%)0 (0%)5 (14%)Dyslipidemia, n (%)1 (4%)11 (31%)

Conclusions: Breast adipose inflammation is associated with elevated BMI and possibly metabolic syndrome disorders in a racially diverse population. These findings are consistent with observations from predominantly Caucasian cohorts. Race-specific characteristics will also be examined. Study accrual is ongoing and updated results will be presented.

Citation Format: Iyengar NM, Siegel B, Malik M, Giri DD, Tsai J, Hughes M, Adam A, Williams S, Zhou XK, Rodgers W, Ginter P, Patel A, Yong F, Cherian A, August P, Dannenberg AJ. Obesity, adipose inflammation, and race in patients with early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-07-05.

HEMOPHAGOCYTOSIS SECONDARY TO PHARYNGEAL ABSCESS IN AN IMMUNOCOMPETENT PATIENT (case report)

Background. Hemophagocytosis is a rare, potentially fatal disorder, comprising pancytopenia, liver dysfunction, hepatosplenomegaly, hypertriglyceridemia, and hyperferritinemia presenting as fever, lympha­denopathy and skin rashes. Objective. To attract the clinicians’ attention to a problem of hemophagocytosis in Critical Care management.Methods. Hemophagocytosis secondary to pharyngeal abscess in a 58 year old male is being reported.Results. A 58-year-old immunocompetent patient presenting with hemophagocytosis secondary to pharyngeal abscess, was managed on ventilator and inotropic support, when he developed heathcare-associated urinary tract infection by Escherichia coli and ventilator-associated pneumonia by Acinetobacter baumanii. He developed neutropenic septic shock and multi-organ dysfunction and went through a downhill course leading to demise.Conclusions. Hemophagocytosis remains a sinister entity in modern intensive care despite astute clinical management. Secondary superinfections with opportunistic multidrug resistant pathogens are difficult to treat. A high index of clinical suspicion, aggressive diagnosis and prompt treatment for hemophagocytosis and polymicrobial opportunistic superinfections with multidrug-resistant healthcare-associated pathogens needs to be addressed upfront.

The impact of geriatric focused nurse assessment and intervention in the emergency department: A systematic review

BACKGROUND

Nursing assessment of elderly patients is imperative in Emergency Departments (ED) while providing interventions that increase independence facilitating discharge to primary healthcare.

AIMS

To systematically review the impact of geriatric focused nurse assessment and intervention in the ED on hospital utilisation in terms of admission rate, ED revisits and length of hospital stay (LOHS).

METHODS

Search strategy used following databases; Cochrane, Medline, CINAHL, Embase, Scopus and Web of Knowledge; And terms; geriatric nurse assessment, nurse discharge planning, geriatric nurse specialist, nurse intervention, emergency department, accident and emergency, patient outcomes, discharge, admissions, readmissions, hospital utilization, hospitalization, length of stay/hospital stay.

RESULTS

Nine studies were included: seven RCTs and two prospective pre/post-intervention designed studies. Geriatric focused nursing assessment and interventions did not have a statistical impact on hospitalization, readmissions, LOHS and ED revisits. Risk screening and comprehensive geriatric assessment extending into primary care may reduce readmission rates but not affect hospitalization. An increase in ED visits in the intervention group at 30 days post-intervention was noted.

CONCLUSION

Inconsistencies in assessment and interventions for the older person in ED are apparent. Further research evaluating a standardised risk assessment tool and innovative interventions extending into primary healthcare is required.