Guidelines for Prehospital Management of Traumatic Brain Injury 3rd Edition: Executive Summary

Prehospital care markedly influences outcome from traumatic brain injury, yet it remains highly variable. The Brain Trauma Foundation's guidelines informing prehospital care, first published in 2002, have sought to identify and disseminate best practices. Many of its recommendations relate to the management of airway, breathing and circulation, and infrastructure for this care. Compliance with the second edition of these guidelines has been associated with significantly improved survival. A working group developed evidence-based recommendations informing assessment, treatment, and transport decision-making relevant to the prehospital care of brain injured patients. A literature search spanning May 2005 to January 2022 supplemented data contained in the 2nd edition. Identified studies were assessed for quality and used to inform evidence-based recommendations. A total of 122 published articles formed the evidentiary base for this guideline update including 5 providing Class I evidence, 35 providing Class II evidence, and 98 providing Class III evidence for the various topics. Forty evidence-based recommendations were generated, 30 of which were strong and 10 of which were weak. In many cases, new evidence allowed guidelines from the 2nd edition to be strengthened. Development of guidelines on some new topics was possible including the prehospital administration of tranexamic acid. A management algorithm is also presented. These guidelines help to identify best practices for prehospital traumatic brain injury care, and they also identify gaps in knowledge which we hope will be addressed before the next edition.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Epigenetic effects of folate and related B vitamins on brain health throughout life: Scientific substantiation and translation of the evidence for health improvement strategies

Suboptimal status of folate and/or interrelated B vitamins (B12 , B6 and riboflavin) can perturb one-carbon metabolism and adversely affect brain development in early life and brain function in later life. Human studies show that maternal folate status during pregnancy is associated with cognitive development in the child, whilst optimal B vitamin status may help to prevent cognitive dysfunction in later life. The biological mechanisms explaining these relationships are not clear but may involve folate-related DNA methylation of epigenetically controlled genes related to brain development and function. A better understanding of the mechanisms linking these B vitamins and the epigenome with brain health at critical stages of the lifecycle is necessary to support evidence-based health improvement strategies. The EpiBrain project, a transnational collaboration involving partners in the United Kingdom, Canada and Spain, is investigating the nutrition-epigenome-brain relationship, particularly focussing on folate-related epigenetic effects in relation to brain health outcomes. We are conducting new epigenetics analysis on bio-banked samples from existing well-characterised cohorts and randomised trials conducted in pregnancy and later life. Dietary, nutrient biomarker and epigenetic data will be linked with brain outcomes in children and older adults. In addition, we will investigate the nutrition-epigenome-brain relationship in B vitamin intervention trial participants using magnetoencephalography, a state-of-the-art neuroimaging modality to assess neuronal functioning. The project outcomes will provide an improved understanding of the role of folate and related B vitamins in brain health, and the epigenetic mechanisms involved. The results are expected to provide scientific substantiation to support nutritional strategies for better brain health across the lifecycle.

The cardioprotective effect of inhibiting SGLT1 in hyperglycemia ischemia reperfusion injury

Background

Diabetes clinical trials have shown SGLT inhibition improves cardiovascular outcomes, yet the mechanism is not fully understood. Hyperglycemia is a common finding in diabetic and non-diabetic patients presenting with ACS and is a powerful predictor of prognosis and mortality. The role of hyperglycemia in ischemia-reperfusion injury (IRI) is not fully understood, and whether the Sodium Glucose Co-Transporter 1 (SGLT1) plays a role in infarct augmentation, before and/or after reperfusion, remains to be elucidated.

Purpose

Investigate if SGLT1 is involved in a glucotoxicity injury during IRI and whether inhibiting SGLT1 with an SGLT1 inhibitor may reduce infarct size.

Method

RT-PCR and in-situ hybridization (RNAScope) combined with Immunofluorescence integrated co detection with different cell marker techniques were used to detect SGLT1 mRNA expression in Sprague-Dawley whole myocardium and isolated primary cardiomyocytes.

An Ex-vivo Langendorff ischemia-reperfusion perfusion model was used to study the effect of high glucose (22mmol) on myocardium at reperfusion. Canagliflozin (CANA) a non-selective SGLT inhibitor (1μmoL/L to block the SGLT1 receptor and SGLT2 and 5nmol/L to block only the SGLT2 receptor) and Mizagliflozin a selective SGLT1 inhibitor (100nmol/L) was introduced following ischemia at two different glucose concentration concentrations at reperfusion and its effect on infarct size measured using triphenyltetrazolium chloride (TTC) staining.

Results

We showed that SGLT1 is homogenously expressed throughout the myocardium and is particularly evident within the vasculature. we demonstrate that hyperglycemia at reperfusion is injurious to myocardium with an increase of myocardial infarction. Our data reveal that glucose exacerbation of injury appears to be mediated via SGLT1. We have also demonstrated that high-glucose mediated injury in the isolated, perfused heart model is abrogated through the administration of a clinically available mixed SGLT2/SGLT1 inhibitor, canagliflozin, at a dose that inhibits both SGLT2 and SGLT1, but by the SGLT2-selective concentration.

Conclusion

We have shown that SGLT1 is present in the myocardium. Hyperglycemia appears to augment myocardial infarction and inhibition of SGLT1 attenuates this incre

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The government of saudi Arabia

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Survival Outcome with Routine Clinical Use of 82Rb PET/CT Myocardial Blood Flow (MBF) Quantification

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): NIHR Biomedical Research Centre, University College London Hospitals

Background

The prognostic value of 82Rb PET/CT derived myocardial blood flow (MBF) is increasingly recognised in both general and specific cardiovascular populations.

Purpose

This study investigates the prognostic potential of MBF in a large cohort of patients undergoing routine 82Rb PET/CT examination.

Methods

1148 consecutive patients (687 males, mean age 64 +/- 12 years) whom had been referred for 82Rb PET/CT examination in a single centre were included in this study.  All patients completed a stress 82Rb PET/CT with adenosine infusion, paired with a rest study.  Dynamic PET acquisitions were performed in both. Cardiovascular risk factors were documented as per clinical routine. Images were checked for quality and analysed using a proprietary software by an experienced operator to derive MBF parameters.  Overall survival was recorded following the study.

Results

Median follow-up period was 71 +/- 28 months.  Mean survival was 121 (95% CI: 118-124) months. On univariate analysis, global myocardial flow reserve &lt;1.77 was associated with a higher all-cause mortality (p &lt; 0.001). Other parameters including higher age (&gt; =76 years), lower BMI (&lt;21), qualitative abnormality on the myocardial perfusion scan (MPS), low hyperaemic ejection fraction on the gated studies (stress &lt; 37 and rest &lt; 34). Patients being on cardiac glycosides and diuretics were also significant predictor of poor prognosis (p &lt; 0.001) on univariate analysis, presumably reflecting underlying arrhythmia and heart failure. A multivariate Cox regression analysis (step-wise Forward Wald), comprising of the above significant univariate markers, highlighted global myocardial flow reserve (HR: 2.6, 95%CI: 1.8-3.6, p &lt; 0.001), age (HR: 2.8, 95%CI: 2.0-3.9, p &lt; 0.001),, BMI (HR: 2.7, 95%CI: 1.7-4.1, p &lt; 0.001),, ejection fraction (stress - HR: 3.3, 95%CI: 2.3-4.8, p &lt; 0.001), MPS (HR: 1.5, 95%CI: 1.1-2.1, p = 0.024), and patients on diuretics (HR: 1.8, 95%CI: 1.2-2.5, p = 0.003) were independent predictors of overall survival (overall model: p &lt; 0.001)

Discussion

We show that high volume routinely derived MBF in patients undergoing 82Rb PET/CT is a strong predictor of mortality and independent of other risk factors. This has important clinical implication for measuring not only interventional treatment but also measuring the effect of lifestyle and medical strategies.

Socioeconomic Implications of Professional Relationships within Modern Care Delivery Systems

No physician can successfully deliver high-value patient care in the modern-day health care system in isolation. Delivery of effective patient care requires integrated and collaborative systems that depend on dynamic professional relationships among members of the health care team. An overview of the socioeconomic implications of professional relationships within modern care delivery systems and potential employment models is presented.

U.S. Neurosurgical Response to COVID-19: Forging a Path Toward Disaster Preparedness

Introduction

The worldwide COVID-19 pandemic poses challenges to healthcare capacity and infrastructure. The authors discuss the structure and efficacy of the U.S. Navy’s response to COVID-19 and evaluate the utility of this endeavor, with the objective of providing future recommendations for managing worldwide healthcare and medical operational demands from the perspective of Navy Neurosurgery.

Materials and Methods

The authors present an extensive review of topics and objectively highlight the efforts of U.S. Navy Neurosurgery as it pertains to the humanitarian mission during the COVID-19 pandemic.

Results

During the humanitarian mission (March 27, 2020–April 14, 2020), the response of active duty and reserve neurosurgeons in the U.S. Navy was robust. Neurosurgical coverage was present on board the U.S. Navy Ships Mercy and Comfort, with additional neurosurgical deployment to New York City for intensive care unit management and coverage.

Conclusions

The U.S. Navy neurosurgical response to the COVID-19 pandemic was swift and altruistic. Although neurosurgical pathologies were limited among the presenting patients, readiness and manpower continue to be strong influences within the Armed Forces. The COVID-19 response demonstrates that neurosurgical assets can be rapidly mobilized and deployed in support of wartime, domestic, and global humanitarian crises to augment both trauma and critical care capabilities.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P&lt;0.0001). Levels of ADVS-1 was &gt;3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 &gt;15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (&lt;0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

Guideline on the peri-operative management of patients with sickle cell disease: Guideline from the Association of Anaesthetists

Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso-occlusive crises and acute and chronic end-organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri-operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non-sickle-related. Complications may be reduced by meticulous peri-operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo-immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID-19 infection but may have a relatively mild clinical course. Outcomes are determined by pre-existing comorbidities, as for the general population.

When upper respiratory tract infections go rogue: A case report of Arcanobacterium haemolyticum Cerebral Abscess

Arcanobacterium haemolyticum is an extremely rare cause of cerebral abscess. We present a unique case of Arcanobacterium haemolyticum sinusitis complicated by preseptal cellulitis and cerebral abscess. The patient initially presented with pharyngitis and then developed sinus congestion, headache and facial pain. Computed tomography and magnetic resonance imaging revealed a right gyrus rectus cerebral abscess and paranasal sinus infection. The patient underwent endoscopic sinus surgery and cultures revealed Arcanobacterium haemolyticum. Repeat imaging revealed maturation and progression of intracranial abscess. The abscess was drained and patient was treated with parenteral and oral antibiotics until complete clinical and radiological remission. This case highlights the importance of recognizing Arcanobacterium haemolyticum as a cause of invasive disease in immunocompetent hosts.

Investigating sodium-glucose co-transporters 1 (SGLT1) in myocardium and its role in hyperglycaemia ischaemia-reperfusion injury

Background

Hyperglycaemia is a common finding in diabetic and non-diabetic patients presenting with ACS, and is a powerful predictor of prognosis and mortality. The role of hyperglycaemia in ischemia-reperfusion injury (IRI) is not fully understood, and whether the Sodium Glucose co-Transporter 1 (SGLT1) plays a role in infarct augmentation, before and/or after reperfusion, remains to be elucidated. However, diabetes clinical trials have shown SGLT inhibition improves cardiovascular outcomes, yet the mechanism is not fully understood.

Purpose

(1) Characterise the expression of SGLT1 in the myocardium, (2) determine the role of high glucose during IRI, (3) whether SGLT1 is involved in a glucotoxicity injury during IRI, and (4) whether inhibiting SGLT1 with an SGLT inhibitor may reduce infarct size.

Methods

RT-PCR and in-situ hybridization (RNAScope) techniques were used to detect SGLT1 mRNA expression in Sprague-Dawley whole myocardium and isolated primary cardiomyocytes. An Ex-vivo Langendorff ischemia-reperfusion perfusion model was used to study the effect of high glucose (22mmol) on the myocardium at reperfusion compared to normoglycaemia (11mmol). The mixed SGLT1&2 inhibitor, Phlorizin was introduced following ischaemia, at reperfusion and its effect on infarct size measured using triphenyltetrazolium chloride (TTC) staining.

Results

RT-PCR found SGLT1 mRNA is expressed in whole myocardium and in individual cardiac chambers. SGLT1 expression was not detected in isolated cardiomyocyte but it is detected in the non-cardiomyocyte population. Cardiomyocytes were found to express mRNA SGLT1 if incubated overnight. RNAscope detected SGLT1 mRNA within intact myocardium: not in the cardiomyocyte, but rather in a perivascular distribution. Importantly, hyperglycaemia (22mmol) at reperfusion increased infarct size (51.80±3.52% vs. 40.80±2.89%; p-value: 0.026) compared to normoglycaemia, and the mixed SGLT inhibitor, Phlorizin, significantly attenuated infarct size (from 64.7±4.2%to 36.6±5.8%; p-value&lt;0.01) when given at reperfusion.

Conclusion

We have shown that SGLT1 is present in the myocardium, but not expressed in cardiomyocytes. The cell type is yet to be determined, but the distribution of SGLT1 is perivascular. Hyperglycaemia appears augment myocardial infarction and inhibition of SGLT1&2 attenuates this increase. We suspect SGLT1 may plays a role in exacerbating the injurious effect of glucotoxicity during ischemia-reperfusion.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation

Education as a contradictory determinant of mental health between migrant and national adulthood

The Social Determinants of Health (SDHs) are well known for their interaction on health outcomes and they can have a stronger impact on migrant health whom have higher probability to live in precarious living and working conditions compared to the hosting population. Migrant health is a public health issue which has to be considered taking into account the SDHs and complementary, including cultural issues is fundamental for addressing health equity in the society as a whole. Recognising this challenge, this study aims to evaluate the interactions between education and mental health of resident population in Italy, including Italians and immigrants.

This study examined the respondents in 2014-17 to the Italian “Progressi delle Aziende Sanitarie per la Salute in Italia” (PASSI) surveillance system. The sample of 118,639 respondents is composed by the residing working adults aged 25-69 with Italian citizenship (n = 112,345) and foreign citizenship (n = 6,294). Looking at SDHs, if for Italians high level of education appears to be a protective factor of mental health in accordance with the international evidence (adjPR: tertiary education 0,87 95%IC 079-0,97), among immigrants higher level of education it is more associated with the presence of depressive symptoms (adjPR: tertiary education: 1.77 95%IC: 1.19-2.63). Longer the length of stay in Italy for PFPM immigrants higher the risk of depressive symptoms: adjPR for 10+ years: 5.1 95%IC: 1.29-4.3.

The data show that high education could represent a risk factor for mental health of immigrants. Considering that health is related to the nature of society as well as to access to technical solutions, multicultural societies require culturally oriented interventions for tackling health inequities. This means developing evidence-based policies in order to tackle health inequalities in the population as a whole, including culturally oriented measures in the larger framework of developing diversity sensitive services.

Key messages

For some groups of population, such as migrants, high education could represent a risk factor for mental health. Developing diverse sensitive policies is needed in order to tackle health inequities in the population as a whole.

Genetic Consequences of the Transatlantic Slave Trade in the Americas

According to historical records of transatlantic slavery, traders forcibly deported an estimated 12.5 million people from ports along the Atlantic coastline of Africa between the 16th and 19th centuries, with global impacts reaching to the present day, more than a century and a half after slavery's abolition. Such records have fueled a broad understanding of the forced migration from Africa to the Americas yet remain underexplored in concert with genetic data. Here, we analyzed genotype array data from 50,281 research participants, which-combined with historical shipping documents-illustrate that the current genetic landscape of the Americas is largely concordant with expectations derived from documentation of slave voyages. For instance, genetic connections between people in slave trading regions of Africa and disembarkation regions of the Americas generally mirror the proportion of individuals forcibly moved between those regions. While some discordances can be explained by additional records of deportations within the Americas, other discordances yield insights into variable survival rates and timing of arrival of enslaved people from specific regions of Africa. Furthermore, the greater contribution of African women to the gene pool compared to African men varies across the Americas, consistent with literature documenting regional differences in slavery practices. This investigation of the transatlantic slave trade, which is broad in scope in terms of both datasets and analyses, establishes genetic links between individuals in the Americas and populations across Atlantic Africa, yielding a more comprehensive understanding of the African roots of peoples of the Americas.

6 Perioperative Urinary Catheterisation in Hip Fracture Patients

Introduction

There are currently no national guidelines, in the UK, advising when to catheterize hip fracture patients and when to trial without a catheter (TWOC). We audited the practice in a UK teaching hospital where there is a consultants’ consensus that all patients should be catheterized on the day of admission (or day of surgery; which is usually within 36 hours of admission) and TWOC as soon as possible within 72 hours postoperatively. We also correlated delays in TWOC with urinary tract infection (UTI) rates.

Methods

Audit of consecutive hip fracture patients who had undergone surgery. Patients who had long term indwelling urinary catheter were excluded. Data collected include: demographics and date and time of admission, catheterisation, operation and TWOC, also duration of catheter post operatively, reason if TWOC delayed and whether the patient had a UTI.

Results

43 patients were included; 30 males and 13 females with a mean age of 82.9 and 83.9 years respectively. Urinary catheters were inserted in 100% of patients preoperatively. Overall 23% of patients had a UTI. There were more UTIs with prolonged catheterization. The results are summarised in the table. The reason for delaying a TWOC was not documented in any of patients’ notes.

Discussion

The low rate of TWOC within 72 hours can be attributed to:Lack of clear guidelinesReluctance to have a TWOC for older patients with poor postoperative mobility with concerns regarding inability to reach the toilet timely.Reluctance to have a TWOC for those who did not open their bowels postoperatively.Time and resources pressure.

Conclusion and recommendations

National guidelines for urinary catheterisation in hip fracture patients are needed meanwhile Orthopaedic Department guidelines will improve the care in these patients. Patients should have a urinary catheter “passport” documenting the date of insertion, expected date of TWOC and the reasons for delaying TWOC. It is important to educate the team about the importance of TWOC as early as possible and improve communication.

Analysis of Factors and Conditions Influencing Military Neurosurgery Recruitment and Retention

INTRODUCTION

The Defense Health Agency has shifted focus of military medicine to operational readiness. As such, neurosurgery remains a critical wartime specialty. We investigate the factors impacting recruitment and retention of military neurosurgeons.

METHODS

Survey of military neurosurgeons was performed via the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Retention and recruitment were queried.

RESULTS

93/119 (78.2%) current or previously affiliated military neurosurgeons would recommend service as a military neurosurgeon to a colleague. Those who felt a sense of patriotism were 4.3 times more likely to recommend military service (P = 0.027, CI 1.19-16.82). Those who developed a sense of camaraderie showed a trend to recommending military neurosurgery (P = 0.058, CI 0.95-9.78). Those with a current military obligation were.28 times (P = 0.02, CI 0.09-0.85) as likely to recommend service. Military physicians who felt a need for reform to increase salary were 2.5 times less likely to be retained.

DISCUSSION

Service in the US military is a positive experience with camaraderie, patriotism, and unique military experiences predictive of recruitment. Meanwhile, focus on pay discrepancy can result in lost retention. These factors should be explored regarding recruitment and retention of military neurosurgeons.

Association of time to craniectomy with survival in patients with severe combat-related brain injury

OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.

Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review

BACKGROUND

There is substantial variation in how menopausal vasomotor symptoms are reported and measured among intervention studies. This has prevented meaningful comparisons between treatments and limited data synthesis.

OBJECTIVES

To review systematically the outcome reporting and measures used to assess menopausal vasomotor symptoms from randomised controlled trials of treatments.

SEARCH STRATEGY

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to May 2018.

SELECTION CRITERIA

Randomised controlled trials with a primary outcome of menopausal vasomotor symptoms in women and a sample size of at least 20 women per study arm.

DATA COLLECTION AND ANALYSIS

Data about study characteristics, primary vasomotor-related outcomes and methods of measuring them.

MAIN RESULTS

The search identified 5591 studies, 214 of which were included. Forty-nine different primary reported outcomes were identified for vasomotor symptoms and 16 different tools had been used to measure these outcomes. The most commonly reported outcomes were frequency (97/214), severity (116/214), and intensity (28/114) of vasomotor symptoms or a composite of these outcomes (68/214). There was little consistency in how the frequency and severity/intensity of vasomotor symptoms were defined.

CONCLUSIONS

There is substantial variation in how menopausal vasomotor symptoms have been reported and measured in treatment trials. Future studies should include standardised outcome measures which reflect the priorities of patients, clinicians, and researchers. This is most effectively achieved through the development of a Core Outcome Set. This systematic review is the first step towards development of a Core Outcome Set for menopausal vasomotor symptoms.

TWEETABLE SUMMARY

Menopausal hot flushes and night sweats have been reported in 49 different ways in clinical research. A core outcome set is urgently required.

A future for all to INHERIT: taking integrated action on the environment, health and equity

Key messages

The urgent need to address the environmental crisis presents an opportunity to simultaneously manage closely related societal challenges linked to health and equity. Public health actors can play a key role by bringing together the sectors, evidence and examples to instigate change, around the common interest of promoting human, which depends on planetary, health.

Policies for tackling health inequities in migrants in an irregular situation: learning from Italy

Issue

With increasing of numbers of people moving in Europe and around the world, the health of migrants has become a key global public-health issue. Migrants in an irregular situation (MIS) represent an important part of the migration phenomenon, whether they have become irregular by entering a country without authorisation or by overstaying a visa, including whose applied unsuccessfully for asylum.

Description of the problem

Overstaying of visas is not unusual in EU countries and during 2015 and 2016 in particular, many countries experienced a large number of unauthorised entrants. Health policies for MIS are increasingly a matter of concern. Using the 2015 Migrant Integration Policy Index Health strand (MIPEX HS) it is possible to conduct an analysis of health policies, focusing on access to health services by MIS.

Results

Among the 34 European countries covered by the MIPEX HS, Italy’s overall score of 65 is exceeded only by Switzerland (70) and Norway (67). Averaging the indicators of access for MIS, Italy obtains the highest score (83), followed by Denmark, France, the Netherlands, Romania, Spain, Sweden and Switzerland with 67. Its score for legal entitlements to health care is 75 (the same as Sweden), while reporting of MIS to the immigration authorities is prohibited and there are no sanctions against helping them. However, legislation introduced by the new government in 2018 has restricted some of their rights.

Lessons

Current migration to Europe requires dealing with short-term health needs as well as strengthening public health and health systems in the long term. This presentation will discuss the lessons that can be learned from the comparative analysis of health policies for MIS using the MIPEX HS.

Key messages

Affordable health care is a human right, which should not be denied to any migrant. Policy analysis plays a key role in identifying interventions for promoting health equity.

The impact of the reserve military neurosurgeon: practice, community, and service

OBJECTIVEPapers from 2002 to 2017 have highlighted consistent unique socioeconomic challenges and opportunities facing military neurosurgeons. Here, the authors focus on the reserve military neurosurgeon who carries the dual mission of both civilian and military responsibilities.METHODSSurvey solicitation of current active duty and reserve military neurosurgeons was performed in conjunction with the AANS/CNS Joint Committee of Military Neurosurgeons and the Council of State Neurosurgical Societies. Demographic, qualitative, and quantitative data points were compared between reserve and active duty military neurosurgeons. Civilian neurosurgical provider data were taken from the 2016 NERVES (Neurosurgery Executives Resource Value and Education Society) Socio-Economic Survey. Economic modeling was done to forecast the impact of deployment or mobilization on the reserve neurosurgeon, neurosurgery practice, and the community.RESULTSSeventy-five percent (12/16) of current reserve neurosurgeons reported that they are satisfied with their military service. Reserve neurosurgeons make significant contributions to the military's neurosurgical capabilities, with 75% (12/16) having been deployed during their career. No statistically significant demographic differences were found between those serving on active duty and those in the reserve service. However, those who served in the reserves were more likely to desire opportunities for improvement in the military workflow requirements compared with their active duty counterparts (p = 0.04); 92.9% (13/14) of current reserve neurosurgeons desired more flexible military drill programs specific to the needs of practicing physicians. The risk of reserve deployment is also borne by the practices, hospitals, and communities in which the neurosurgeon serves in civilian practice. This can result in fewer new patient encounters, decreased collections, decreased work relative value unit generation, increased operating costs per neurosurgeon, and intangible limitations on practice development. However, through modeling, the authors have illustrated that reserve physicians joining a larger group practice can significantly mitigate this risk. What remains astonishing is that 91.7% of those reserve neurosurgeons who were deployed noted the experience to be rewarding despite seeing a 20% reduction in income, on average, during the fiscal year of a 6-month deployment.CONCLUSIONSReserve neurosurgeons are satisfied with their military service while making substantial contributions to the military's neurosurgical capabilities, with the overwhelming majority of current military reservists having been deployed or mobilized during their reserve commitments. Through the authors' modeling, the impact of deployment on the military neurosurgeon, neurosurgeon's practice, and the local community can be significantly mitigated by a larger practice environment.

Military Neurosurgery Socioeconomic Data: Benefits, Challenges, and Opportunities

Military conflict and neurosurgery date back to antiquity. Neurosurgery's development is intimately linked with Harvey Cushing's military experience. Previous papers highlighted unique opportunities and socioeconomic challenges facing military neurosurgeons. Here, we provide objective data from military neurosurgeons surrounding these issues.Internet survey responses were solicited from current, separated, and retired military neurosurgeons regarding workforce issues and their perception of military neurosurgery.A total of 80.9% (98/121) of respondents enjoyed their military experience, 63.6% (77/121) were very pleased with their service; 97.4% (114/117) enjoyed treating military patients, and 78.2% (93/119) would recommend military service. Positives included feelings of patriotism (87.4%), development of camaraderie (71.4%), and deployment experience (93.8%).However, 76.5% of respondents noted concerns regarding military and civilian pay disparity. 37.5% were overwhelmed with administrative responsibilities, and over 50% desired higher case volume.Multivariate analysis showed those who failed to develop a sense of camaraderie were more likely to be dissatisfied (P = .02). Those still currently serving trended towards dissatisfaction (P = .08), and current military neurosurgeons were only 0.29 times as likely to recommend military service to another neurosurgeon as compared to those who were retired or separated (P < .024).Service as a military neurosurgeon is an overwhelmingly positive experience but opportunities exist for mechanisms to increase operative case load, reduce administrative responsibilities, and reduce military-civilian income disparity. Addressing these issues is important as current military neurosurgeons were more likely to be dissatisfied with their military experience and less likely to recommend military service to another neurosurgeon.

Benefits and risks of adjuvant treatment with zoledronic acid in stage II/III breast cancer. 10 years follow-up of the AZURE randomized clinical trial (BIG 01/04)

Adjuvant bisphosphonates improve disease outcomes in postmenopausal early breast cancer (EBC) but the long-term effects are poorly described. The AZURE trial (ISRCTN79831382) was designed to determine whether adjuvant zoledronic acid (ZOL) improves disease outcomes in EBC. Previous analyses showed no effect on overall outcomes but identified benefits in postmenopausal women. Here we present the long-term risks and benefits of adjuvant ZOL with 10-years follow-up.

Patients and methods

3360 patients with stage II/III breast cancer were included in an academic, international, phase III, randomized, open label trial. Patients were followed up on a regular schedule until 10 years. Patients were randomized on a 1:1 basis to standard adjuvant systemic therapy +/− intravenous ZOL 4 mg every 3–4 weeks x6, and then at reduced frequency to complete 5 years treatment. The primary outcome was disease free survival (DFS). Secondary outcomes included invasive DFS (IDFS), overall survival (OS), sites of recurrence, skeletal morbidity and treatment outcomes according to primary tumor amplification of the transcription factor, MAF. Pre-planned subgroup analyses focused on interactions between menopausal status and treatment effects.

Results

With a median follow up of 117 months [IQR 70.4–120.4), DFS and IDFS were similar in both arms (HR_DFS= 0.94, 95%CI = 0.84–1.06, p = 0.340; HR_IDFS= 0.91, 95%CI = 0.82–1.02, p = 0.116). However, outcomes remain improved with ZOL in postmenopausal women (HR_DFS= 0.82, 95%CI = 0.67–1.00; HR_IDFS= 0.78, 95%CI = 0.64–0.94). In the 79% of tested women with a MAF FISH negative tumor, ZOL improved IDFS (HR_IDFS= 0.75, 95%CI = 0.58–0.97) and OS HR_OS= 0.69, 95%CI = 0.50–0.94), irrespective of menopause. ZOL did not improve disease outcomes in MAF FISH + tumors. Bone metastases as a first DFS recurrence (B_DFS) were reduced with ZOL (HR_B-DFS= 0.76, 95%CI = 0.63–0.92, p = 0.005). ZOL reduced skeletal morbidity with fewer fractures and skeletal events after disease recurrence. 30 cases of osteonecrosis of the jaw in the ZOL arm (1.8%) have occurred.

Conclusions

Disease benefits with adjuvant ZOL in postmenopausal early breast cancer persist at 10 years of follow-up. The biomarker MAF identified a patient subgroup that derived benefit from ZOL irrespective of menopausal status.

Inhibition of apoptosis exacerbates fatigue-damage tendon injuries in an in vivo rat model

Tendinopathy is a common and progressive musculoskeletal disease. Increased apoptosis is an end-stage tendinopathy manifestation, but its contribution to the pathology of the disease is unknown. A previously established in vivo model of fatigue damage accumulation shows that increased apoptosis is correlated with the severity of induced tendon damage, even in early onset of the disease, supporting its implication in the pathogenesis of the disease. Consequently, this study aimed to determine: (1) whether apoptosis could be inhibited after fatigue damage and (2) whether its inhibition could lead to remodeling of the extracellular matrix (ECM) and pericellular matrix (PCM), to ultimately improve the mechanical properties of fatigue-damaged tendons. The working hypothesis was that, despite the low vascular nature of the tendon, apoptosis would be inhibited, prompting increased production of matrix proteins and restoring tendon mechanical properties. Rats received 2 or 5 d of systemic pan-caspase inhibitor (Q-VD-OPh) or dimethyl sulfoxide (DMSO) carrier control injections starting immediately prior to fatigue loading and were sacrificed at days 7 and 14 post-fatigue-loading. Systemic pan-caspase inhibition for 2 d led to a surprising increase in apoptosis, but inhibition for 5 d increased the population of live cells that could repair the fatigue damage. Further analysis of the 5 d group showed that effective inhibition led to an increased population of cells producing ECM and PCM proteins, although typically in conjunction with oxidative stress markers. Ultimately, inhibition of apoptosis led to further deterioration in mechanical properties of fatigue-damaged tendons.

Gene Expression Meta-Analysis of Potential Metastatic Breast Cancer Markers

Background:

Breast cancer metastasis is a highly prevalent cause of death for European females. DNA microarray analysis has established that primary tumors, which remain localized, differ in gene expression from those that metastasize. Cross-analysis of these studies allow to revile the differences that may be used as predictive in the disease prognosis and therapy.

Objective:

The aim of the project was to validate suggested prognostic and therapeutic markers using meta-analysis of data on gene expression in metastatic and primary breast cancer tumors.

Method:

Data on relative gene expression values from 12 studies on primary breast cancer and breast cancer metastasis were retrieved from Genevestigator (Nebion) database. The results of the data meta-analysis were compared with results of literature mining for suggested metastatic breast cancer markers and vectors and consistency of their reported differential expression.

Results:

Our analysis suggested that transcriptional expression of the COX2 gene is significantly downregulated in metastatic tissue compared to normal breast tissue, but is not downregulated in primary tumors compared with normal breast tissue and may be used as a differential marker in metastatic breast cancer diagnostics. RRM2 gene expression decreases in metastases when compared to primary breast cancer and could be suggested as a marker to trace breast cancer evolution. Our study also supports MMP1, VCAM1, FZD3, VEGFC, FOXM1 and MUC1 as breast cancer onset markers, as these genes demonstrate significant differential expression in breast neoplasms compared with normal breast tissue.

Conclusion:

COX2 and RRM2 are suggested to be prominent markers for breast cancer metastasis. The crosstalk between upstream regulators of genes differentially expressed in primary breast tumors and metastasis also suggests pathways involving p53, ER1, ERB-B2, TNF and WNT, as the most promising regulators that may be considered for new complex drug therapeutic interventions in breast cancer metastatic progression.

Abattoir surveillance of Sarcocystis spp., Cysticercosis ovis and Echinococcus granulosus in Tasmanian slaughter sheep, 2007-2013

OBJECTIVE

To estimate the prevalence of macroscopic Sarcocystis spp., Cysticercus ovis and Echinococcus granulosus recorded at routine postmortem inspection of Tasmanian slaughter sheep during 2007 to 2013.

METHODS

A retrospective analysis of routine postmortem meat inspection data maintained on 352,325 Tasmanian adult slaughter sheep inspected across nine abattoirs in Tasmania, Victoria and South Australia as part of the National Sheep Health Monitoring Project (NSHMP).

RESULTS

During the period 1 September 2007 to 30 June 2013, the estimated prevalence of macroscopic Sarcocystis spp. was 14.3%, C. ovis was 3.2% and E. granulosus was 0.01%. Mean Sarcocystis spp. line prevalence ranged from 0% to 33.5%. Significant between-abattoir differences in the level of sarcosporidiosis (P < 0.001) and C. ovis were found (P < 0.001). Overall, very low levels of hydatidosis were recorded throughout the surveillance period. Predicted within-line prevalence of macroscopic sarcocysts in animals coming from a known/recorded local government area (LGA) (P < 0.001) was lower than that of lines where the LGA was unknown or not recorded. A higher prevalence of sarcocystosis was recorded in lines of sheep aged ≥ 2 years compared with those < 2 years (P < 0.001).

CONCLUSION

Reasons for the significant between-abattoir differences in recorded levels of ovine sarcosporidiosis and cysticercosis remain unknown, but may represent sampling bias, with subsets of slaughter sheep going to abattoirs with different tiers or access to markets. Further investigation into apparent differences, including epidemiological studies of properties with high lesion prevalence, comparing meat inspector diagnostic sensitivity, assessing the effect of line speed and tiers and market access in different abattoirs, may be useful.

Adjuvant zoledronic acid reduces fractures in breast cancer patients; an AZURE (BIG 01/04) study

The fracture impact of adjuvant bisphosphonates in breast cancer is not defined with most trials reporting changes in bone mineral density as a surrogate. The AZURE trial (ISRCTN79831382) evaluated the impact of adjuvant zoledronic acid (ZOL) on fractures. The AZURE trial is an academic, multi-centre, randomised phase III study evaluating the addition of ZOL 4 mg to standard therapy (neo/adjuvant chemotherapy and/or endocrine therapy) for 5 years (administered by intravenous (iv) infusion every 3-4 weeks for 6 doses, then 3 monthly × 8 and 6 monthly × 5) in patients with stage II/III early breast cancer. Fracture data collected as part of skeletal-related adverse event reporting were analysed after a median of 84.2 months of follow-up and 966 disease-free survival (DFS) events. We assessed number of fractures, time-to-first fracture and the incidence of fractures before and after disease recurrence. Two hundred forty-four patients reported ≥1 fracture, 140 (8.3%) in the control arm (171 fractures) and 104 (6.2%) in the ZOL arm (120 fractures). Of the 291 fractures reported, 207 fractures occurred in the absence of recurrence (control 111, ZOL 96), 80 after recurrence (control 59, ZOL 21). The 5-year fracture rate was reduced from 5.9% (95%CI 4.8, 7.1%; control) to 3.8% (95%CI 2.9, 4.7%) with ZOL. ZOL significantly increased time-to-first fracture (HR 0.69, 95%CI 0.53-0.90; P = 0.0053) but the majority of fracture prevention benefit occurred after a DFS event (HR 0.3; 95%CI 0.17, 0.53; P < 0.001). Fracture benefits from ZOL were similar across menopausal sub-groups. In conclusion, adjuvant ZOL reduced the risk of clinical fractures, the majority of this protection occurred after disease recurrence.

Pregnancy in Diabetes: challenges and opportunities for improving pregnancy outcomes

Our aim was to review the data from the National Pregnancy in Diabetes (NPID) audit, and to identify the challenges and opportunities for improving pregnancy outcomes in women with diabetes. We reviewed three years of NPID data and relevant diabetes and obstetric literature, and found that there has been little change in pregnancy preparation or outcomes over the past 3 years, with substantial clinic-to clinic variations in care. Women with Type 2 diabetes remain less likely to take 5 mg preconception folic acid (22.8% vs. 41.8%; P < 0.05), and more likely to take potentially harmful medications (statin and/or ACE inhibitor 13.0% vs. 1.8%; P < 0.05) than women with Type 1 diabetes. However, women with Type 1 diabetes are less likely to achieve the recommended glucose control target of HbA_1c < 48 mmol/mol (6.5%) (14.9% vs. 38.1%; P < 0.05). The following opportunities for improvement were identified. First, the need to integrate reproductive health into the diabetes care plans of all women with diabetes aged 15-50 years. Second, to develop more innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings. Third, to integrate insulin pump, continuous glucose monitoring and automated insulin delivery technologies into the pre-pregnancy and antenatal care of women with Type 1 diabetes. Fourth, to improve postnatal care with personalized approaches targeting women with previous pregnancy loss, congenital anomaly and perinatal mortality. A nationwide commitment to delivering integrated reproductive and diabetes healthcare interventions is needed to improve the health outcomes of women with diabetes.

Prevalence and disease associations in feline thrombocytopenia: a retrospective study of 194 cases

OBJECTIVES

To assess the prevalence of thrombocytopenia in a referral population of cats in the UK, to identify disease processes associated with thrombocytopenia and to assess the proportion of thrombocytopenic cats that tested positive for feline leukaemia virus or feline immunodeficiency virus.

MATERIALS AND METHODS

Retrospective analysis of medical records at a UK referral hospital. Cats were grouped by mechanism of thrombocytopenia and disease process (where known).

RESULTS

Prevalence of thrombocytopenia was 5·9%. The most common disease processes associated with thrombocytopenia were haematological or infectious disease and neoplasia; 11% of thrombocytopenic cats tested were positive for feline leukaemia virus, which is lower than reported previously. Cats presenting with unexplained haemorrhage had significantly lower platelet counts than other thrombocytopenic cats. Primary immune-mediated thrombocytopenia was less commonly diagnosed than in dogs and associated with the most severe platelet depletion in this study.

CLINICAL SIGNIFICANCE

Thrombocytopenia in cats may be more prevalent than previously reported and severe thrombocytopenia may be associated with spontaneous haemorrhage. Severe thrombocytopenia in cats appears less commonly immune-mediated than in dogs. Thrombocytopenia did not appear to be associated with retroviral infections.

A pilot study comparing the effect of orally administered esomeprazole and omeprazole on gastric fluid pH in horses

AIMS To compare the efficacy of an enteric coated esomeprazole paste with an enteric coated omeprazole paste to increase gastric pH after oral administration in horses. METHODS Nine adult Standardbred horses were randomly assigned to three groups, each containing three horses, for a study comprising three phases of 10 days, with an 18-day washout period between each phase. In each phase, three horses received either 0.5 mg/kg esomeprazole, 1 mg/kg omeprazole or a placebo, as an oral paste, once daily for 10 days (Days 0-9). Over the course of study all horses received all three treatments. Gastric fluid samples were collected using a gastroscope on Days 1, 3, 5, 8 and 10, with food and water withheld for 16 hours prior to collection of samples. The pH of all samples was measured immediately after collection. RESULTS Mean pH (3.38; SD 1.75) of the gastric fluid samples in the horses that received the placebo was lower than in the horses that received esomeprazole (6.28; SD 1.75) or omeprazole (6.13; SD 1.75) (p<0.001). There was no difference in the mean pH between horses receiving esomeprazole and those receiving omeprazole (p=0.56). CONCLUSIONS AND CLINICAL RELEVANCE Under these study conditions, esomeprazole paste was equally as effective as omeprazole paste in increasing gastric pH in horses. Enteric coated esomeprazole, may be a therapeutic alternative to omeprazole for the prevention of gastric ulcers in horses.