A Multicentric, Retrospective, Real-world Study on Immune-related Adverse Events in Patients with Advanced Non-small Cell Lung Cancers Treated with Pembrolizumab Monotherapy

AIMS

We present 7 years of clinical experience with single-agent pembrolizumab immune checkpoint inhibitor immunotherapy in non-small cell lung cancers (NSCLC) from four UK cancer centres.

MATERIALS AND METHODS

This multi-institutional retrospective cohort study included 226 metastatic NSCLC patients. Outcomes were number and severity of immune-related adverse events (irAEs), median progression-free survival (mPFS) and median overall survival (mOS).

RESULTS

Within our cohort, 119/226 (53%) patients developed irAEs. Of these, 54/119 (45%) experienced irAEs affecting two or more organ systems. The most common irAEs were diarrhoea and rash. The development of an irAE was associated with better mOS (20.7 versus 8.0 months; P < 0.001) and mPFS (12.0 versus 3.9 months; P < 0.001). The development of grade 3/4 toxicities was associated with worse outcomes compared with the development of grade 1/2 toxicities (mOS 6.1 months versus 25.2 months, P < 0.01; mPFS 5.6 months versus 19.3 months, P = 0.01, respectively). Females had a higher proportion of reported grade 3/4 toxicities (13/44 [29.5%] versus 10/74 [13.5%], P = 0.03). Using a multiple Cox regression model, the presence of irAEs was associated with a better overall survival (hazard ratio = 0.42, 95% confidence interval 0.29-0.61; P < 0.01) and better PFS (hazard ratio 0.38, 95% confidence interval 0.27-0.53; P < 0.001).

CONCLUSION

In this multicentre retrospective cohort study, the development of at least one irAE was associated with significantly longer mPFS and mOS; however, more severe grade 3 and 4 irAEs were associated with worse outcomes. Delayed-onset irAEs, after the 3-month timepoint, were associated with better clinical outcomes.

Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series

Introduction

To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy.

Materials and methods

A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score.

Results

Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the six-month follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011).

Conclusion

FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

Anxiolytic potential of resveratrol and rufinamide combination by modulating GABA-ergic transmission: insights from experiments, molecular docking and dynamics simulations

Resveratrol is a polyphenolic phytocompound known to possess anxiolytic-like effects but its impact on central gammaaminobutyric acid (GABA) modulation has never been explored. The purpose of this study was to analyze the anxiolytic-like effects of resveratrol alone and in combination with rufinamide, an antiepileptic drug which has never been studied for its anxiolytic potential. The BALB/c mice were tested in a battery of behavior testing after administration of resveratrol (50 mg/kg) and rufinamide (50 mg/kg) alone and in combination. Moreover, molecular docking studies were also carried out to understand the interaction of resveratrol and rufinamide with GABA aminotransferase, GABA receptor and GABA-A transporter type 1. Resveratrol alone exerted notable anxiolytic-like effects and improved outcomes in few experiments but rufinamide alone did not yield any beneficial outcomes. However, the animal co-administered with resveratrol and rufinamide behaved exceptionally well (p<0.05) and preferred open, illuminated and exposed areas of open field, light/dark and elevated plus maze. Further, these animals showed reduced anxiety towards anxiogenic stimuli i.e. holes and marbles in hole board and marble bury tests, respectively. Resveratrol and rufinamide showed moderate to strong binding affinities with GABA proteins, indicating the potential to treat anxiety-like neurological disorders. Moreover, resveratrol and rufinamide were analyzed using molecular docking to determine their interaction with GABA receptors, transporters, and transaminase. The results suggest that their anxiolytic-like effects may be due to inhibiting GABA reuptake transporter 1 protein, leading to increased synaptic levels of GABA neurotransmitter, as seen in stable molecular dynamics results with the 7SK2 GABA transporter protein.

Patterns of Locoregional Pancreatic Cancer Recurrence after Total Neoadjuvant Therapy and Implications on Optimal Neoadjuvant Radiation Treatment Volumes

PURPOSE/OBJECTIVE(S)

Neoadjuvant treatment for patients with localized pancreatic adenocarcinoma (PDAC) has improved survival duration. As survival increases, local disease control becomes even more important. We sought to understand the patterns of locoregional recurrence following total neoadjuvant therapy (TNT) and determine the impact of treatment volumes on recurrence.

MATERIALS/METHODS

Patients with PDAC managed with neoadjuvant chemotherapy and chemoradiation (TNT) followed by surgery who developed an isolated locoregional or simultaneously locoregional and distant recurrence were identified. Locoregional recurrences were individually contoured utilizing commercially available software. When available, original neoadjuvant dose distributions were registered to the scans on which the locoregional recurrences were contoured. Recurrences where then classified as in-field (> 95% of prescription dose), marginal (50-95% of prescription dose), or out of field (< 50% of prescription dose). Target volumes were created using four commonly utilized PDAC contouring guidelines to characterize the relationship of the local recurrence to the RT dose distribution.

RESULTS

Of 474 patients treated with TNT and surgery, 80 (17%) patients developed a locoregional recurrence with or without distant recurrence, visible on diagnostic imaging. Of the 80 patients, 56 (70%) had tumors in the pancreatic head; 46 (57.5%) were borderline resectable, 23 (28.8%) locally advanced, and 11 (13.6%) resectable. The most common initial neoadjuvant therapies were FOLFIRINOX (57.5%) and gemcitabine/nab-paclitaxel (18.8%). Chemoradiation included concurrent gemcitabine (47.5%) or 5-fluorouracil (26.3%). RT dose distributions were available for 38 patients; 22 (57.9%) had in-field failures, 9 (23.7%) marginal failures, and 7 (18.4%) out of field failures. Each published contouring atlas covered a relatively low percentage of recurrences, which are summarized in Table 1. Regions at particularly high likelihood of recurrence that were under covered on existing atlases included: aortic-diaphragmic junction, retro-pancreatic duodenal nodal basin, and the region to the right of the superior mesenteric artery (SMA).

CONCLUSION

We present the largest series (to our knowledge) of mapped locoregional recurrences for patients being treated with TNT in PDAC. These recurrences differ substantially from established atlases and highlight anatomical regions of highest priority for RT coverage. A novel visual contouring volume highlighting these regions will be presented which will strive to advance the use of RT in the TNT setting.

Examining the prevalence of obesity in school children through an on-site obesity outpatient clinics survey based on student's lifestyles

OBJECTIVE

The purpose of this study was to identify the prevalence of obesity, overweight, and risk factors in pediatric patients attending outpatient clinics at a public sector hospital in the central province of Saudi Arabia.

SUBJECTS AND METHODS

This cross-sectional study was conducted in Riyadh, the capital of Saudi Arabia, between January 2022 and October 2022. The target population was aged 6-15 years. We conducted on-site obesity assessments utilizing questionnaire-based interviews with patients attending outpatient clinics. Data collection was carried out with the help of parents, where required. Using BMI growth charts for Saudi children and teenagers, the weight, height, and body mass index (BMI) of subjects were computed.

RESULTS

A total of 576 responses with a response rate of 64% were received and included in the study. In the current study, the majority (41.1%) of the patients were aged between 11 and 12 years old, followed by 37.0% of the students aged between 13 and 15 years old, and 21.9% of students aged between 8 and 10 years old. In the current study, 54.2% of the patients had normal weight, 15.6% of patients were underweight, 16.7% of patients were overweight, and 13.5% were obese. In this study, the prevalence of overall obesity was 2.3 times more prevalent in children aged 11 to 12 years (OR=2.30; p=0.03), followed by ~2 times higher levels in children aged 13 to 15 years (OR=2.30; p=0.03). Moreover, 2.11 times higher prevalence of obesity (OR=2.11; p=0.77) in those who regularly took food (especially lunch) from the school cafeteria. A significant ~2.5 high obesity level was recorded for students who consumed fizzy/soft drinks four or more times per week (OR=2.38; p=0.007).

CONCLUSIONS

Saudi Arabia still has a high rate of overweight and obesity among children of school-going age, which is a significant public health issue. To properly address and control this issue, policies at the national, local, and individual levels must be implemented. Notably, there was also a high prevalence of being underweight, and this issue needs to be brought up as well.

Evaluation of potential ecological risk assessment of toxic metal (lead) in contaminated meadows in the vicinity of suburban city: soil vs forages vs livestock

Heavy metal toxicity is becoming an increasing concern for environmental, human and animal health. The current research analyzed the lead (Pb) contamination in the food chain under three different irrigation sources (ground, canal, and wastewater). Soil, plant and animal samples were collected from the Jhang district of Pakistan and processed with an atomic absorption spectrophotometer. Lead concentration varied in the samples as: 5.22-10.73 mg/kg in soil, 2.46-10.34 mg/kg in forages and 0.736-2.45 mg/kg in animal samples. The observed lead concentration in forage and animal blood samples was higher than the standard limits. The pollution load index (0.640-1.32) in soil showed that lead contamination mainly took place at the wastewater irrigating sites. Bio-concentration factor values (0.313-1.15) were lower than one in all samples except Zea mays, showing that lead metal was actively taken up by Zea mays tissues from the soil. Enrichment factor values ranged from 0.849-3.12, showing a moderate level of lead enrichment. Daily intake and health risk index varied between 0.004-0.020 mg/kg/day and 0.906-4.99, respectively. All the samples showed maximum lead concentration at the wastewater irrigating site compared to the ground or canal water application sites. These results recommended that consistent application of wastewater for forage irrigation must be avoided to prevent health hazards associated with lead in the animal and human food chain. Government must implement adequate strategies to protect the animal and human health from the harms of toxic heavy metals.

Effect of telephone-monitored home-based cardiac rehabilitation exercise on functional capacity and quality of life in heart failure patients in a lower-middle-income country

Funding Acknowledgements

Type of funding sources: None.

Introduction

Chronic heart failure (CHF) prevails as one of the major cardiovascular diseases in lower-middle-income countries (LMICs) like Bangladesh. Home-Based Cardiac Rehabilitation (HBCR) is a cost-effective method of secondary prevention of chronic heart failure which, if provided, might not only improve the health status of the patients but might also reduce the financial and hospitalization burden on the health care system of these countries. The study aims to assess the scope and benefits of HBCR in such low resource settings.

Purpose

The study evaluates the effect of telephone-monitored HBCR exercise programme in improving the functional capacity and quality of life (QoL) in patients of CHF with reduced ejection fraction due to ischemic heart disease (IHD).

Method

This self-controlled interventional study was conducted from August 2019 to July 2020 at a heart failure clinic, a tertiary healthcare centre in Bangladesh. A total of 115 patients of CHF with ejection fraction &lt;40% and in NYHA class II and III were included in the study according to selection criteria. The functional capacity of the patients was evaluated by NYHA classification and 6-minute walk test. The quality of life of the patients was evaluated by Minnesota Living with Heart Failure Questionnaire (MLHFQ). All patients were advised to perform HBCR exercise as per recommended guideline and were telephone-monitored 2-weekly. After the 3-months study period, the participants were divided into compliant and partial compliant groups based on their adherence to the guideline. Repeat evaluation of patients' condition was carried out. Results were then compared within the groups and data was analyzed through appropriate statistical methods.

Results

Significant improvement of NYHA class (p&lt;0.05), and 6-minute walk test distance (6MWTD) (1102.01±215.90 feet vs 1243.30±217.86 feet; p&lt;0.001) were noticed after the rehabilitation programme. Improvement of total MLHFQ score was also observed (35.53±14 vs 28.22±12.84; p&lt;0.001) at 3-months follow up. The functional capacity and quality of life of the patients in both the compliant and partially compliant groups showed significant improvement after the rehabilitation programme (p&lt;0.001); though no difference was found in the indicators when compared between compliant vs partially compliant groups after rehabilitation except for 6MWTD (1302.86±219.61 feet vs 1230.71±212.284 feet, p&lt;0.001).

Conclusion

From the results, it can be concluded that any amount of routine exercise tends to improve quality of life and symptoms in patients of chronic heart failure with reduced ejection fraction. However, to achieve the best effect in functional capacity and overall health status, the addition of a structured exercise programme like HBCR can be beneficial for proper rehabilitation in low resource settings. Further validation of the results is recommended through randomized control trials in larger study groups.

Knowledge and awareness levels of diabetes mellitus risk factors among nondiabetic visitors of primary health care centers: a multicenter study

OBJECTIVE

People with a high risk of developing Type 2 Diabetes Mellitus are primarily due to lifestyle factors and can be reduced by implementing awareness programs. Therefore, this study evaluates the diabetic awareness level, risk factors, and lifestyle behaviors among nondiabetic participants.

PATIENTS AND METHODS

This is a cross-sectional study conducted among 538 nondiabetic participants based on American Diabetic Association (ADA) parameters via face-to-face interview. The sample was collected from five different primary health care centers from November 2019 to February 2020. The target population was nondiabetic with age ≥18 years and participants with other serious chronic illnesses, pregnant women, or unable to communicate effectively were excluded.

RESULTS

A total of 538 participants without diabetes data were analyzed, of which 363 (67.5%) were males. Good, moderate, and insufficient knowledge of Type 2 Diabetes Mellitus awareness was 34.6%, 52.4%, and 13.0%, respectively. The knowledge level in females' participants was significantly less than the males (OR=2.4; p=0.0005). About 44% had diabetic risk, and the prevalence of diabetes risk was significantly high in males (OR=1.7), obesity (OR=2.9), overweight (OR=2.3), and high blood pressure (OR= 2.2) (all p < 0.05). The risk of diabetes was increased in those participants who consumed more bakery items (p < 0.05). The diabetes risk score was negatively associated with diabetes awareness levels (r= -0.29, p= 0.063).

CONCLUSIONS

The risk of diabetes in the general population can be prevented by proactive public health awareness campaigns, particularly among elderly age group, with lower educational level, physically inactive, and obese.

Mortality and readmission in non-ischemic compared with ischemic cardiomyopathies after implantable cardioverter-defibrillator implantation

Background/Introduction

Uncertainty remains regarding the benefit of primary prevention ICDs overall in contemporary practice, and particularly in those with NICM compared with ICM.

Purpose

To evaluate the contemporary risk of death and readmission following following implantable cardioverter-defibrillator (ICD) implantation in patients with non-ischemic cardiomyopathies (NICM) compared with ischemic cardiomyopathies (ICM) in a large nationally representative cohort in the United States.

Methods

We used data from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ICD Registry linked with Medicare claims from April 1, 2010 to December 31, 2013 to establish a cohort of NICM and ICM patients with a left ventricular ejection fraction ≤35% who received a de novo, primary prevention ICD. We compared mortality, all-cause readmission, and heart failure readmission using Kaplan-Meier curves and Cox proportional hazard regressions models. We also evaluated temporal trends in mortality.

Results

Among 31,044 NICM and 68,458 ICM patients with a median follow up of 2.4 years, one-year mortality was significantly higher in ICM patients (12.3%) compared with NICM (7.9%, p&lt;0.001). The higher mortality in ICM patients remained significant after adjustment for covariates (hazard ratio (HR) 1.40; 95% confidence interval (CI) 1.36 to 1.45), and was consistent in subgroup analyses. These findings were consistent across the duration of the study. ICM patients were also significantly more likely to be readmitted for all causes (adjusted HR 1.15, CI 1.12 to 1.18) and for heart failure (adjusted HR 1.25, CI 1.21 to 1.31).

Conclusions

The risks of mortality and hospital readmission after primary prevention ICD implantation were significantly higher in patients with ICM compared with NICM, and these findings were consistent across all patient subgroups tested and over the duration of the study.

Funding Acknowledgement

Type of funding source: None

Twenty Years of Military Prehospital Care in the Eastern Sovereign Base Area, Cyprus

INTRODUCTION

The Medical Reception Station (MRS) in Dhekelia provides a prehospital emergency care (PHEC) service for the Eastern Sovereign Base Area and surrounding Cypriot towns. This service has been evaluated previously but some important aspects of care have not yet been measured. The primary aim of this study was to undertake the most comprehensive service evaluation of the demand for the PHEC service at MRS Dhekelia over a 12-month period. The secondary aim of this study was to compare findings in 2018 to those in 1995-1998 and 2013-2016.

METHODS

All calls to the PHEC team between 01/07/2017 and 30/06/2018 were reviewed and compared with previously reported data from 1995 to 1998 and 2013 to 2016. Data were collected from the occurrence book, the logbook used by the PHEC team to record the details of each call.

RESULTS

There were 164 calls to the PHEC service during the current study period. The number of activations has decreased since the 2013-2016 period but remains greater than 1995-1998. In every month there was a call to a scene where more than one casualty was present, with the highest number being nine patients at one call. More calls were received during the day (55%). There were more calls because of trauma than medical complaints (55% vs 45%). Trauma calls have reduced over 20 years. The frequency of neurological and psychiatric complaints has increased over 20 years.

CONCLUSIONS

The PHEC service at MRS Dhekelia is frequently used. The team consistently face with scenes with more than one casualty. Trauma is becoming less frequent but psychiatric and neurological complaints are increasingly common. These findings are important for training and service provision.

Transcatheter Aortic Valve Implantation (TAVI): First Case in Bangladesh

We came across an 81 years old male with symptomatic severe aortic stenosis. He was hypertensive and had history of CABG 9 years back. Due to his advanced age and co morbidities, he was at high surgical risk. He underwent transcatheter aortic valve implantation in our centre (United Hospital Ltd) in July 2017 and no complications occurred during or in the peri-procedural period. He had good functional and haemodynamic results at 3 months follow-up.

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery

Background

The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems.

Methods

We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest).

Results

A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications.

Conclusions

Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.

Post-exposure prophylaxis vaccination rate and risk factors of human rabies in mainland China: a meta-analysis

Rabies is one of the major public health problems in China, and the mortality rate of rabies remains the highest among all notifiable infectious diseases. A meta-analysis was conducted to investigate the post-exposure prophylaxis (PEP) vaccination rate and risk factors for human rabies in mainland China. The PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodical and Wanfang databases were searched for articles on rabies vaccination status (published between 2007 and 2017). In total, 10 174 human rabies cases from 136 studies were included in this meta-analysis. Approximately 97.2% (95% confidence interval (CI) 95.1-98.7%) of rabies cases occurred in rural areas and 72.6% (95% CI 70.0-75.1%) occurred in farmers. Overall, the vaccination rate in the reported human rabies cases was 15.4% (95% CI 13.7-17.4%). However, among vaccinated individuals, 85.5% (95% CI 79.8%-83.4%) did not complete the vaccination regimen. In a subgroup analysis, the PEP vaccination rate in the eastern region (18.8%, 95% CI 15.9-22.1%) was higher than that in the western region (13.3%, 95% CI 11.1-15.8%) and this rate decreased after 2007. Approximately 68.9% (95% CI 63.6-73.8%) of rabies cases experienced category-III exposures, but their PEP vaccination rate was 27.0% (95% CI 14.4-44.9%) and only 6.1% (95% CI 4.4-8.4%) received rabies immunoglobulin. Together, these results suggested that the PEP vaccination rate among human rabies cases was low in mainland China. Therefore, standardised treatment and vaccination programs of dog bites need to be further strengthened, particularly in rural areas.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Preoperative heart rate and myocardial injury after non-cardiac surgery: results of a predefined secondary analysis of the VISION study

Background

Increased baseline heart rate is associated with cardiovascular risk and all-cause mortality in the general population. We hypothesized that elevated preoperative heart rate increases the risk of myocardial injury after non-cardiac surgery (MINS).

Methods

We performed a secondary analysis of a prospective international cohort study of patients aged ≥45 yr undergoing non-cardiac surgery. Preoperative heart rate was defined as the last measurement before induction of anaesthesia. The sample was divided into deciles by heart rate. Multivariable logistic regression models were used to determine relationships between preoperative heart rate and MINS (determined by serum troponin concentration), myocardial infarction (MI), and death within 30 days of surgery. Separate models were used to test the relationship between these outcomes and predefined binary heart rate thresholds.

Results

Patients with missing outcomes or heart rate data were excluded from respective analyses. Of 15 087 patients, 1197 (7.9%) sustained MINS, 454 of 16 007 patients (2.8%) sustained MI, and 315 of 16 037 patients (2.0%) died. The highest heart rate decile (>96 beats min⁻¹) was independently associated with MINS {odds ratio (OR) 1.48 [1.23–1.77]; P<0.01}, MI (OR 1.71 [1.34–2.18]; P<0.01), and mortality (OR 3.16 [2.45–4.07]; P<0.01). The lowest decile (<60 beats min⁻¹) was independently associated with reduced mortality (OR 0.50 [0.29–0.88]; P=0.02), but not MINS or MI. The predefined binary thresholds were also associated with MINS, but more weakly than the highest heart rate decile.

Conclusions

Preoperative heart rate >96 beats min⁻¹ is associated with MINS, MI, and mortality after non-cardiac surgery. This association persists after accounting for potential confounding factors.

Clinical trial registration

NCT00512109.

Evidence-based dentistry can effectively be taught to dental care professional students - A mixed methods study

BACKGROUND

Little research exists in the teaching of evidence-based dentistry (EBD) to students in the fields of dental hygiene, dental nursing and orthodontic therapy. This study aims to analyse the effect of a 1-day EBD programme on knowledge and confidence whilst also gaining insight into students' experience of the intervention.

METHOD

A mixed methods study was utilised with explanatory sequential design. The population consisted of dental hygiene (DH), dental nursing (DN) and orthodontic therapy (OT) students (N = 44). The intervention consisted of a 1-day active learning EBD programme, delivered via group projects and lectures. In the initial quantitative phase, a standardised questionnaire pre- and post -intervention measured changes in confidence for all participants, whilst change in knowledge was measured for DH and OT students only. Following this, focus groups were scheduled for all members of each discipline 3 months post-intervention for DN and 2 months post-intervention for DH and OT students. Semi-structured focus group schedules were drawn up, and groups organised according to the outcomes of quantitative data analysis. Qualitative results were analysed using a deductive adaptation of Burnard's thematic content analysis.

RESULTS

Forty-two students took part (94.45%) in this study. Median knowledge scores increased from zero to two of five (P < .001), whilst median confidence score doubled from four to eight of eight (P < .001). Results of thematic content analysis were coincident with quantitative results; however, it also provided constructive feedback regarding design and content of the course.

CONCLUSIONS

A 1-day bespoke programme in EBD increased students' confidence and knowledge in EBD skills. However, the findings further suggest that two successive half-day training sessions instead of one full-day training, tied in with coursework that requires the application of the acquired skills, may increase the learning experience further.

Faecal calprotectin effectively excludes inflammatory bowel disease in 789 symptomatic young adults with/without alarm symptoms: a prospective UK primary care cohort study

BACKGROUND

Primary care faecal calprotectin testing distinguishes inflammatory bowel disease (IBD) from functional gut disorder in young patients presenting with abdominal symptoms; however, previous evaluations have excluded patients with alarm symptoms.

AIMS

We sought to evaluate the diagnostic accuracy of calprotectin to distinguish IBD from functional gut disorder in young adults in whom general practitioners (GPs) suspected IBD; including patients reporting gastrointestinal alarm symptoms. We hypothesised that calprotectin would reduce secondary care referrals and healthcare costs.

METHODS

We undertook a prospective cohort study of 789 young adults (18-46 years old) presenting with gastrointestinal symptoms to 49 local general practices that had undergone calprotectin testing (1053 tests: between Jan 2014 and May 2016) because of suspected IBD. We considered calprotectin levels of ≥100 μg/g positive. Primary and secondary care records over 12 months from the point of calprotectin testing were used as the reference standard.

RESULTS

Overall, 39% (308/789) patients reported gastrointestinal alarm symptoms and 6% (50/789) tested patients were diagnosed with IBD. The positive and negative predictive values of calprotectin testing for distinguishing IBD from functional gut disorder in patients with gastrointestinal alarm symptoms were 50% (95% CI 36%-64%) and 98% (96%-100%): and in patients without gastrointestinal alarm symptoms were 27% (16%-41%) and 99% (98%-100%), respectively. We estimate savings of 279 referrals and £160 per patient.

CONCLUSIONS

Calprotectin testing of young adults with suspected IBD in primary care accurately distinguishes IBD from functional gut disorder, even in patients with gastrointestinal alarm symptoms and reduces secondary care referrals and diagnostic healthcare costs.

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

BACKGROUND

The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool.

METHODS

Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals.

RESULTS

We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32-0.77); P<0.01], but no difference in complication rates [OR 1.02 (0.88-1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62-0.92); P<0.01; I²=87%] and reduced complication rates [OR 0.73 (0.61-0.88); P<0.01; I²=89%).

CONCLUSIONS

Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

Rate of active Helicobacter pylori infection among symptomatic patients of Pakistan

Only few epidemiological studies have examined the rate of active H. pylori infection in the symptomatic population in Pakistan. This retrospective study presents the laboratory data collected during the past 13 years (2002 to 2015) from 2315 symptomatic patients referred to the BreathMAT Lab, Nuclear Medicine, Oncology and Radiotherapy Institute, Islamabad for the diagnosis of active H. pylori infection using the ¹³C Urea Breath Test. Rate of infection and its association with gender and age were evaluated. The overall rate of active H. pylori infection was 49.5% and there was no association of this rate of infection with gender. An increase in rate of infection was observed with increasing age with significant difference (p < 0.05). The patients that tested negative for this infection might be having symptoms due to stress and indiscriminate use of non-steroidal antiinflammatory drugs (NSAIDs) in this community. The fact that half of the symptomatic patients were negative needs to be highlighted and further suggests that symptomatic patients should be tested by the ¹³C UBT before prescribing antibiotic treatment for H. pylori eradication. In addition, there is a need to educate this community about the harmful and side effects of self medication and overuse of NSAIDs.

Exclusive enteral nutrition provides an effective bridge to safer interval elective surgery for adults with Crohn's disease

BACKGROUND

Few studies have reported the systematic use of exclusive enteral nutrition in the perioperative setting.

AIM

To test the hypothesis that exclusive enteral nutrition provides a safe and effective bridge to surgery and reduces post-operative complications, in adult patients with Crohn's disease requiring urgent surgery for stricturing or penetrating complications.

METHODS

Patients treated with exclusive enteral nutrition prior to surgery were each matched with two control patients for disease behaviour, type of surgery, age at diagnosis and disease duration. Data on disease phenotype, nutritional status, operative course and post-operative complications were obtained.

RESULTS

Twenty-five per cent [13/51] patients treated with exclusive enteral nutrition avoided surgery. Exclusive enteral nutrition had no effect on pre-operative weight, but it significantly reduced serum CRP [median at baseline 36 (interquartile range, IQR: 13-91] vs. pre-operation 8 (4-31) mg/L, P = 0.02]. The median (IQR) length of surgery was shorter in patients pre-optimised with exclusive enteral nutrition than controls [3.0 (2.5-3.5) vs. 3.5 (3.0-4.0) hours respectively, P < 0.001]. Multivariable logistic regression analysis confirmed that going straight-to-surgery compared exclusive enteral nutrition pre-optimisation was associated with a ninefold increase in the incidence of post-operative abscess and/or anastomotic leak [OR 9.1; 95% CI (1.2-71.2), P = 0.04].

CONCLUSIONS

Exclusive enteral nutrition frequently down-stages the need for surgery in patients presenting with stricturing or penetrating complications of Crohn's disease; it is associated with a reduction in systemic inflammation, operative times and the incidence of post-operative abscess or anastomotic leak. Further trials are needed to elucidate how exclusive enteral nutrition may improve operative outcomes.

Ethical issues and best practice in clinically based genomic research: Exeter Stakeholders Meeting Report

Current guidelines on consenting individuals to participate in genomic research are diverse. This creates problems for participants and also for researchers, particularly for clinicians who provide both clinical care and research to their patients. A group of 14 stakeholders met on 7 October 2015 in Exeter to discuss the ethical issues and the best practice arising in clinically based genomic research, with particular emphasis on the issue of returning results to study participants/patients in light of research findings affecting research and clinical practices. The group was deliberately multidisciplinary to ensure that a diversity of views was represented. This report outlines the main ethical issues, areas of best practice and principles underlying ethical clinically based genomic research discussed during the meeting. The main point emerging from the discussion is that ethical principles, rather than being formulaic, should guide researchers/clinicians to identify who the main stakeholders are to consult with for a specific project and to incorporate their voices/views strategically throughout the lifecycle of each project. We believe that the mix of principles and practical guidelines outlined in this report can contribute to current debates on how to conduct ethical clinically based genomic research.

Ferric maltol therapy for iron deficiency anaemia in patients with inflammatory bowel disease: long-term extension data from a Phase 3 study

BACKGROUND

Ferric maltol was effective and well-tolerated in iron deficiency anaemia patients with inflammatory bowel disease during a 12-week placebo-controlled trial.

AIM

To perform a Phase 3 extension study evaluating long-term efficacy and safety with ferric maltol in inflammatory bowel disease patients in whom oral ferrous therapies had failed to correct iron deficiency anaemia.

METHODS

After 12 weeks of randomised, double-blind treatment, patients with iron deficiency anaemia and mild-to-moderate ulcerative colitis or Crohn's disease received open-label ferric maltol 30 mg b.d. for 52 weeks.

RESULTS

111 patients completed randomised treatment and 97 entered the open-label ferric maltol extension. In patients randomised to ferric maltol ('continued'; n = 50), mean ± s.d. haemoglobin increased by 3.07 ± 1.46 g/dL between baseline and Week 64. In patients randomised to placebo ('switch'; n = 47), haemoglobin increased by 2.19 ± 1.61 g/dL. Normal haemoglobin was achieved in high proportions of both continued and switch patients (89% and 83% at Week 64, respectively). Serum ferritin increased from 8.9 μg/L (baseline) to 26.0 μg/L (Week 12) in ferric maltol-treated patients, and to 57.4 μg/L amongst all patients at Week 64. In total, 80% of patients reported ≥1 adverse event by Week 64. Adverse events considered related to ferric maltol were recorded in 27/111 (24%) patients: 8/18 discontinuations due to adverse events were treatment-related. One patient was withdrawn due to increased ulcerative colitis activity.

CONCLUSIONS

Normal haemoglobin was observed in ≥80% of patients from weeks 20-64 of long-term ferric maltol treatment, with concomitant increases in iron storage parameters. Ferric maltol was well-tolerated throughout this 64-week study.