Implementation of a clinical pathway for the surgical treatment of colorectal cancer during the COVID-19 pandemic

AIM

This report summarizes the early experience of implementing elective colorectal cancer surgery during the COVID-19 pandemic.

METHODS

A pathway to minimize the risk of including COVID-19-positive patients for elective surgery was established. Prioritization and additional safety measures were introduced into clinical practice. Minimal invasive surgery was used where appropriate.

RESULTS

Thirty-eight patients were prioritized, and 23 patients underwent surgery (eight colon, 14 rectal and one anal cancer). The minimal invasive surgery rate was 78%. There were no major postoperative complications or patients diagnosed with COVID-19. Histopathological outcomes were similar to normal practice.

CONCLUSION

A safe pathway to offer standard high-quality surgery to colorectal cancer patients during the COVID-19 pandemic is feasible.

Preliminary Investigation to Review If a Glycomacropeptide Compared to L-Amino Acid Protein Substitute Alters the Pre- and Postprandial Amino Acid Profile in Children with Phenylketonuria

In Phenylketonuria (PKU), the peptide structure of the protein substitute (PS), casein glycomacropeptide (CGMP), is supplemented with amino acids (CGMP-AA). CGMP may slow the rate of amino acid (AA) absorption compared with traditional phenylalanine-free amino acids (Phe-free AA), which may improve nitrogen utilization, decrease urea production, and alter insulin response.

AIM

In children with PKU, to compare pre and postprandial AA concentrations when taking one of three PS's: Phe-free AA, CGMP-AA 1 or 2.

METHODS

43 children (24 boys, 19 girls), median age 9 years (range 5-16 years) were studied; 11 took CGMP-AA1, 18 CGMP-AA2, and 14 Phe-free AA. Early morning fasting pre and 2 h postprandial blood samples were collected for quantitative AA on one occasion. A breakfast with allocated 20 g protein equivalent from PS was given post fasting blood sample.

RESULTS

There was a significant increase in postprandial AA for all individual AAs with all three PS. Postprandial AA histidine (p < 0.001), leucine (p < 0.001), and tyrosine (p < 0.001) were higher in CGMP-AA2 than CGMP-AA1, and leucine (p < 0.001), threonine (p < 0.001), and tyrosine (p = 0.003) higher in GCMP-AA2 than Phe-free AA. This was reflective of the AA composition of the three different PS's.

CONCLUSIONS

In PKU, the AA composition of CGMP-AA influences 2 h postprandial AA composition, suggesting that a PS derived from CGMP-AA may be absorbed similarly to Phe-free AA, but this requires further investigation.

Effect of Patient Portal Reminders Sent by a Health Care System on Influenza Vaccination Rates: A Randomized Clinical Trial

Importance

Influenza vaccination rates across the US are low. Because few practices send patient reminders for influenza vaccination, a scalable patient reminder system is needed.

Objective

To evaluate the effect of patient reminders sent via a health care system's electronic health record patient portal on influenza vaccination rates.

Design, Setting, and Participants

This pragmatic, 4-arm randomized clinical trial was performed from October 1, 2018, to March 31, 2019, across the UCLA (University of California, Los Angeles) health care system. A total of 164 205 patients in 52 primary care practices who had used the patient portal within 12 months were included.

Interventions

Patients due for an influenza vaccine were sent a letter via the patient portal of the health care system reminding them about the importance of influenza vaccination, safety of the vaccine, and morbidity associated with influenza. Patients were randomized within primary care practices to 1 of 4 study groups (no reminder [n = 41 070] vs 1 reminder [n = 41 055], 2 reminders [n = 41 046], or 3 reminders [n = 41 034]).

Main Outcomes and Measures

The primary outcome was receipt of 1 or more influenza vaccines as documented in the electronic health record, which was supplemented with influenza vaccination data from external sources (eg, pharmacies). Secondary outcomes were influenza vaccination rates among subgroups and influenza vaccinations self-reported by patients in reply to the portal-based query as having been received elsewhere.

Results

A total of 164 205 patients (mean [SD] age, 46.2 [19.6] years; 95 779 [58.3%] female) were randomly allocated to 1 of the 4 study arms. In the primary analysis across all ages and not including patient self-reported vaccinations in reply to portal reminders, influenza vaccination rates were 37.5% for those receiving no reminders, 38.0% for those receiving 1 reminder (P = .008 vs no reminder), 38.2% for those receiving 2 reminders (P = .03 vs no reminder), and 38.2% for those receiving 3 reminders (P = .02 vs no reminder). In the secondary analysis not including patient self-reported vaccinations, among adults aged 18 to 64 years (vaccination rates: 32.0% in the control group, 32.8% in the 1-reminder group, 32.8% in the 2-reminder group, and 32.8% in the 3-reminder group; P = .001), male patients (vaccination rates: 37.3% vs 38.3%, 38.6%, and 38.8%; P = .001), non-Hispanic patients (vaccination rates: 37.6% vs 38.2%, 38.3%, and 38.2%; P = .004), and those who were not vaccinated in the prior 2 years (vaccination rates: 15.3% vs 15.9%, 16.3%, and 16.1%; P < .001), vaccination rates were higher in the portal reminder groups than in the control group; the findings in these 3 subgroups mirrored the findings in the entire population. When self-reported vaccinations received elsewhere were included, influenza vaccination rates were 1.4 to 2.9 percentage points higher in the portal reminder groups, with a dose-response effect (0 reminders: 15 537 [37.8%]; 1 reminder: 16 097 [39.2%]; 2 reminders: 16 426 [40.0%]; and 3 reminders: 16 714 [40.7%]; P < .001).

Conclusions and Relevance

Generic patient portal reminders were effective in minimally increasing influenza vaccination rates, but more intensive or more targeted patient motivational strategies appear to be needed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03666026.

Special Low Protein Foods in the UK: An Examination of Their Macronutrient Composition in Comparison to Regular Foods

Special low protein foods (SLPFs) are essential in a low phenylalanine diet for treating phenylketonuria (PKU). With little known about their nutritional composition, all SLPFs on UK prescription were studied (n = 146) and compared to equivalent protein-containing foods (n = 190). SLPF nutritional analysis was obtained from suppliers/manufacturers. Comparable information about regular protein-containing foods was obtained from online UK supermarkets. Similar foods were grouped together, with mean nutritional values calculated for each subgroup (n = 40) and percentage differences determined between SLPFs and regular food subgroups. All SLPF subgroups contained 43-100% less protein than regular foods. Sixty-three percent (n = 25/40) of SLPF subgroups contained less total fat with palm oil (25%, n = 36/146) and hydrogenated vegetable oil (23%, n = 33/146) key fat sources. Sixty-eight percent (n = 27/40) of SLPF subgroups contained more carbohydrate, with 72% (n = 105/146) containing added sugar. Key SLPF starch sources were maize/corn (72%; n = 105/146). Seventy-seven percent (n = 113/146) of SLPFs versus 18% (n = 34/190) of regular foods contained added fibre, predominantly hydrocolloids. Nine percent of SLPFs contained phenylalanine > 25 mg/100 g and sources of phenylalanine/protein in their ingredient lists. Stricter nutritional composition regulations for SLPFs are required, identifying maximum upper limits for macronutrients and phenylalanine, and fat and carbohydrate sources that are associated with healthy outcomes.

Risk factors for renal disease and diabetes in remote Australia - findings from The Western Desert Kidney Health Project

INTRODUCTION

The Western Desert Kidney Health Project (WDKHP) aimed to determine the prevalence of type 2 diabetes (T2DM), kidney disease and associated risk factors in Aboriginal and non-Aboriginal people in a remote area of Western Australia.

METHODS

The project, featuring whole-of-community cross-sectional surveys and health assessments using point-of-care testing, was conducted in five small towns and six remote Aboriginal communities in the Goldfields of Western Australia between 2010 and 2014. Initial health assessments were completed by 597 adults (424 Aboriginal) and 502 children (393 Aboriginal). This included almost 80% of the Aboriginal population. All non-Aboriginal people residing in the six remote Aboriginal communities participated.

RESULTS

Risk factors for renal disease and T2DM were present in participants of all ages, including children as young as 2 years. There was no significant difference between Aboriginal and non-Aboriginal children. Aboriginal and non-Aboriginal adult participants had twice the burden of T2DM than the standard Australian population. More than 12% of all children had elevated albumin-creatinine ratio (ACR). Adults had markers of kidney disease at higher rates than expected: 51% of Aboriginal adults and 27% of non-Aboriginal adults had at least one marker of kidney disease (haematuria, proteinuria or elevated ACR). Aboriginal women were the highest risk group (32% T2DM, 40% elevated ACR). Haematuria and low urine pH were common findings, 21% of people had haematuria (greater than trace) and 71% had urine pH of 6 or less; there was no difference in this finding between Aboriginal and non-Aboriginal people.

CONCLUSION

The WDKHP found higher than expected rates of risk factors for T2DM and renal disease compared with Australian Bureau of Statistics rates for Australian Aboriginal and non-Aboriginal adults and children, with Aboriginal women the highest risk group. The rates for non-Aboriginal participants were higher than expected, suggesting exposures in common might be more important than ethnicity.The high prevalence of aciduria and haematuria found in both Aboriginal and non-Aboriginal participants in this study suggests that factors contributing to a chronic metabolic acidosis and inflammation or irritation of the urinary tract need to be explored. Drinking water quality in this remote area is known to be poor and may be an important contributing factor. Many of the contributing factors are potentially modifiable - such as water quality, food supply, exercise opportunities and living conditions - offering scope for interventions to reduce the risk and burden of these diseases.

Abstract IA26: Breast tumor microenvironment in black women: A distinct signature of CD8+ T-cell exhaustion

Background: Blacks tend to have a stronger inflammatory immune response than Whites. We hypothesized that racial differences in host immunity also manifest in the tumor microenvironment (TME), constituting part of a distinct tumor biology underlying more aggressive breast cancer and higher mortality in Black women.

Patients and Methods: Pathologic and gene expression profiling approaches were used for comprehensively characterizing infiltrating immune cells in breast TME from 1,315 patients from the Women’s Circle of Health Study (WCHS). Racial differences in tumor immune phenotypes were compared, with results validated in data from The Cancer Genome Atlas (TCGA). Prognostic associations of immune phenotypes were assessed in WCHS, TCGA and Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) cohorts.

Results: We found marked and consistent differences in tumor immune responses between Black and White patients. Not only did tumors from Blacks display a stronger overall immune presence, but the composition and quality of immune infiltrates differed, independent of tumor subtypes. Black patients had a stronger humoral immunity response, and further, a more exhausted CD8+ T-cell profile featuring the coexpression of PD-1, LAG3, and CTLA4. A signature indicating a higher ratio of exhausted CD8+ T cells to total CD8+ T cells (ExCD8-r) was consistently associated with poorer survival, particularly among hormone receptor-positive patients. Combinations of the absolute fraction of CD8+ T cells and ExCD8-r signature identified the CD8-low/ExCD8-r-high subgroup, the most prevalent among Blacks, as having the worst survival.

Conclusions: Our findings of a distinct exhausted CD8+ T-cell signature in Black breast cancer patients indicates an immunobiologic basis for their more aggressive disease, and also a rationale for the use of immune checkpoint inhibitors targeting the exhaustion phenotype.

Citation Format: Song Yao, Ting-Yuan Cheng, Ahmed Elkhanany, Li Yan, Angela Omilian, Scott I. Abrams, Sharon Evans, Chi-Chen Hong, Qianya Qi, Warren Davis, Song Liu, Elisa V. Bandera, Kunle Odunsi, Kazuaki Takabe, Thaer Khoury, Christine B. Ambrosone. Breast tumor microenvironment in black women: A distinct signature of CD8+ T-cell exhaustion [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr IA26.

Natural Protein Tolerance and Metabolic Control in Patients with Hereditary Tyrosinaemia Type 1

In a longitudinal retrospective study, we aimed to assess natural protein (NP) tolerance and metabolic control in a cohort of 20 Hereditary Tyrosinaemia type I (HTI) patients. Their median age was 12 years ([3.2-17.7 years], n = 11 female, n = 8 Caucasian, n = 8 Asian origin, n = 2 Arabic and n = 2 Indian). All were on nitisinone (NTBC) with a median dose of 0.7 g/kg/day (range 0.4-1.5 g/kg/day) and were prescribed a tyrosine (Tyr)/phenylalanine (Phe)-restricted diet supplemented with Tyr/Phe-free L-amino acids. Data were collected on clinical signs at presentation, medical history, annual dietary prescriptions, and blood Phe and Tyr levels from diagnosis until transition to the adult service (aged 16-18 years) or liver transplantation (if it preceded transition). The median age of diagnosis was 2 months (range: 0 to 24 months), with n = 1 diagnosed by newborn screening, n = 3 following phenylketonuria (PKU) screening and n = 7 by sibling screening. Five patients were transplanted (median age 6.3 years), and one died due to liver cancer. The median follow-up was 10 years (3-16 years), and daily prescribed NP intake increased from a median of 5 to 24 g/day. Lifetime median blood Tyr (370 µmol/L, range 280-420 µmol/L) and Phe (50 µmol/L, 45-70 µmol/L) were maintained within the target recommended ranges. This cohort of HTI patients were able to increase the daily NP intake with age while maintaining good metabolic control. Extra NP may improve lifelong adherence to the diet.

Clarifying the role of belief-motive explanations in multi-stakeholder realist evaluation

In realist evaluation, where researchers aim to make program theories explicit, they can encounter competing explanations as to how programs work. Managing explanatory tensions from different sources of evidence in multi-stakeholder projects can challenge external evaluators, especially when access to pertinent data, like client records, is mediated by program stakeholders. In this article, we consider two central questions: how can program stakeholder motives shape a realist evaluation project; and how might realist evaluators respond to stakeholders' belief-motive explanations, including those about program effectiveness, based on factors such as supererogatory commitment or trying together in good faith? Drawing on our realist evaluation of a service reform initiative involving multiple agencies, we describe stakeholder motives at key phases, highlighting a need for tactics and skills that help to manage explanatory tensions. In conclusion, the relevance of stakeholders' belief-motive explanations ('we believe the program works') in realist evaluation is clarified and discussed.

Anterior translation of the tibia in relation to femur in mucoid degeneration of ACL - An observational study

Background

Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) are a well-known pathological entity.We have encountered several patients with MD of the ACL, found to have a anterior translation of tibia a exceeding 5 mm with an intact ACL. We studied this cohort and investigated the likely cause of this.

Methods

A retrospective search of our department's radiology system to identify all patients referred from the knee orthopaedic clinic for MR imaging over a span of 10 years. All patients had MD within the substance of the ACL and an intact ACL. We evaluated the degree of anterior translation of the tibia (ATT) in relation to the femur in mucoid degeneration of ACL.

Results

We identified 464 consecutive cases. The mean age was 52 years. There was a male predominance of 261 to 203 female. The average PTF measurement was 2.4 mm with a range of 0-20mm. Of the 464 cases, 3 397 patients had an insignificant ATT of < 5 mm. (0mm. 67. 67 67 patients had a ATT >5 mm. Of them, 32.8% had a ATT of 6 mm, 53.7% had a ATT range between 7 and 9 mm, with the remaining 13.4% above 9 mm in length.

Conclusion

It is essential to look for other secondary signs of ACL tears and not only focus on ATT as well as correlate this with clinical findings.

Dietary practices in methylmalonic acidaemia: a European survey

Background The dietary management of methylmalonic acidaemia (MMA) is a low-protein diet providing sufficient energy to avoid catabolism and to limit production of methylmalonic acid. The goal is to achieve normal growth, good nutritional status and the maintenance of metabolic stability. Aim To describe the dietary management of patients with MMA across Europe. Methods A cross-sectional questionnaire was sent to European colleagues managing inherited metabolic disorders (IMDs) (n=53) with 27 questions about the nutritional management of organic acidaemias. Data were analysed by different age ranges (0-6 months; 7-12 months; 1-10 years; 11-16 years; >16 years). Results Questionnaires were returned from 53 centres. Twenty-five centres cared for 80 patients with MMA vitamin B12 responsive (MMAB12r) and 43 centres managed 215 patients with MMA vitamin B12 non-responsive (MMAB12nr). For MMAB12r patients, 44% of centres (n=11/25) prescribed natural protein below the World Health Organization/Food and Agriculture Organization/United Nations University (WHO/FAO/UNU) 2007 safe levels of protein intake in at least one age range. Precursor-free amino acids (PFAA) were prescribed by 40% of centres (10/25) caring for 36% (29/80) of all the patients. For MMAB12nr patients, 72% of centres (n=31/43) prescribed natural protein below the safe levels of protein intake (WHO/FAO/UNU 2007) in at least one age range. PFAA were prescribed by 77% of centres (n=33/43) managing 81% (n=174/215) of patients. In MMAB12nr patients, 90 (42%) required tube feeding: 25 via a nasogastric tube and 65 via a gastrostomy. Conclusions A high percentage of centres used PFAA in MMA patients together with a protein prescription that provided less than the safe levels of natural protein intake. However, there was inconsistent practices across Europe. Long-term efficacy studies are needed to study patient outcome when using PFAA with different severities of natural protein restrictions in patients with MMA to guide future practice.

Mealtime Anxiety and Coping Behaviour in Parents and Children During Weaning in PKU: A Case-Control Study

Solid food introduction may create anxiety for parents of children with phenylketonuria (PKU) due to the burden associated with protein substitute (PS) administration and natural protein restriction. In a longitudinal, prospective study, 20 mothers of children with PKU and 20 non-PKU control mothers completed 4 questionnaires (mealtime emotions, feed-time, Beck’s anxiety inventory and the coping health inventory for parents), examining parent/child mealtime emotions, anxiety, stress and coping strategies at child ages: weaning start, 8 months (m), 12 m, 15 m, 18 m and 24 m. Overall, mothers of children with PKU cope well with solid food introduction when applying a low-phenylalanine diet, with comparable low levels of stress and anxiety reported in both PKU and non-PKU groups. However, mothers of children with PKU reported peak scores in anxiety for emotive/cognitive symptoms at a child age of 15 m, and higher use of coping strategies at 15 m and 24 m (p < 0.05) of age. Generally, there was a trend that maternal anxiety regarding child rejection of PS increased with time, peaking between 12–24 m. In PKU, a child age of 12–18 m is identified as a key period when mothers feel most anxious/stressed with feeding, coinciding with raised blood phenylalanine levels probably associated with teething, illness and developing independence. Health professionals should be conscious of this vulnerable period and be prepared to offer more directional support as required.

Investigation of paediatric PKU breath malodour, comparing glycomacropeptide with phenylalanine free L-amino acid supplements

In clinical practice, caregivers of children with phenylketonuria (PKU) report that their children have breath malodour. This might be linked to the regular consumption of low phenylalanine (Phe)/Phe-free protein substitutes (PS), which are an essential component of a low-Phe diet. Oral malodour can negatively affect interpersonal communication, lead to bullying, low self-esteem and social isolation. In this longitudinal cross-over study, exhaled volatile organic compounds (VOCs) were measured using gas chromatography-ion mobility spectrometry. 40 children (20 PKU, 20 controls) were recruited. Subjects with PKU took either L-Amino Acid (L-AA) or Casein Glycomacropeptide (CGMP-AA) exclusively for 1 week, in a randomised order. On the seventh day, seven exhaled breath samples were collected over a 10 h period. Subjects then transferred to the other PS for a week and on day seven, provided seven further breath samples. All subjects had a standardised menu using low-Phe food alternatives and all food intake was measured and recorded. In the PKU group, the aim was to collect samples 30 min after consuming PS. In 3 subjects, breath was collected 5 min post-PS consumption. Fasted L-AA and CGMP-AA breath samples contained a similar number of VOC peaks (10-12) as controls. Longitudinal breath testing results demonstrate that there was no significant difference in the number of exhaled VOCs, comparing L-AA or CGMP-AA with controls, or between PS (12-18 VOC peaks). Breath analysed immediately after consumption of PS (n = 3) showed an immediate increase in the number of VOC peaks (25-30), but these were no longer detectable at 30 min post-consumption. This suggests PS have a transient effect on exhaled breath. Measurements taken 30 min after consuming L-AA or CGMP-AA were not significantly different to controls. This indicates that timing food and drinks with PS consumption may be a potential solution for carers to reduce or eliminate unpleasant PS-related breath odours.

130The effect of parity on exercise physiology in women with heart failure with preserved ejection fraction

Introduction

Women are overrepresented amongst patients with HFpEF, however the underpinning mechanism for this asymmetric distribution is unclear. Pregnancy has been demonstrated to contribute to cardiovascular risk, and represents a potential gender specific risk factor for HFpEF.

Purpose

To investigate the relationship between parity and severity of HFpEF on invasive haemodynamic and echocardiographic studies.

Methods

Patients referred for investigation of dyspnoea with exercise right heart catheterisation from 2008–19 were included and classified as HFpEF with an ejection fraction (EF) ≥50% and a resting PCWP ≥15mmHg or exercise PCWP ≥25mmHg. All patients underwent detailed haemodynamic and echocardiographic assessment, and an obstetric history including socioeconomic data were obtained using a questionnaire.

Results

58 women were included, and categorised as having either 0–2 births, or ≥3 births, dividing the cohort equally. Women with ≥3 births achieved a lower peak exercise workload than those with 0–2 births (46 [31–68] vs. 38 [24–51] W, p=0.04). Women with ≥3 births had a greater rise in pulmonary capillary wedge pressure indexed to workload with exercise (0.5 [0.3–0.8] vs. 0.3 [0.2–0.5] mmHg/W, p=0.03), paralleled by a greater rise in right atrial pressure (10 [8–12] vs. 7 [3–11] mmHg, p=0.01), pictured. Pulmonary vascular resistance was also higher in women with ≥3 births (1.9 [1.6–2.4] vs. 1.6 [1.4–1.9] mmHg/L/min rest, p=0.046, and 1.9 [2.4–2.4] vs. 1.4 [1–1.8] mmHg/L/min exercise, p=0.024). Left ventricular ejection fraction was lower at rest (60 [57–61] vs. 63 [60–66] %, p=0.008) and during exercise (65 [62–67] vs. 68 [66–70] %, p=0.038) in women with higher parity. Otherwise, echocardiographic parameters did not differ according to parity. There were no significant differences between parity groups in baseline characteristics, including age, body mass index, systemic blood pressure, natriuretic peptides or dyspnea class. Similarly, comorbidities and socioeconomic status did not differ.

Conclusion(s)

Higher parity is associated with impairments in multiple physiologic parameters of HFpEF severity in women, including diastolic reserve, pulmonary vascular resistance, and systolic function. This may indicate a role for pregnancy in the development of HFpEF, and suggests that multiparous women should be targeted for intensification of preventative measures for HFpEF.

P2608Impact of sub-clinical systolic dysfunction on exercise hemodynamics in HFpEF: time to integrate diastolic and systolic indices

Background

A potential role for subclinical systolic impairment as a contributor to the pathophysiology and outcomes of heart failure with preserved ejection fraction (HFpEF) has been proposed recently. However, the precise relationship of indices of systolic dysfunction with exercise hemodynamics in HFpEF is not known. In this study, we characterize the relationship between left ventricular mechanical function assessed by strain imaging with the key hemodynamic features of HFpEF at rest and during exercise.

Methods

Simultaneous echocardiography and exercise right heart catheterization was performed in 90 subjects (68 HFpEF, 22 control) referred for assessment of dyspnea. HFpEF was defined as left ventricular ejection fraction (LVEF) ≥50% with a pulmonary capillary wedge pressure (PCWP) ≥15mmHg at rest and/or ≥25mmHg at maximal exertion. Measures of left ventricular strain were taken using speckle tracking and analyzed together with natriuretic peptides and rest and exercise hemodynamics.

Results

At rest, HFpEF patients had impaired GLS compared to NCD subjects (−18.4±2.5 vs −21.2±3.5%, p≤0.001. Ejection fraction was similar (62±6 vs 61±6%, p=0.81). With worsening global longitudinal strain, patients with HFpEF displayed a worse cardiac index at both rest and exercise (p<0.001 for both), but similar filling pressure (p=0.85). The tertile with the worst strain had the highest level of natriuretic peptide. The association of strain with peak cardiac index was independent of LVEF, BNP, age, LAVI, LVMI, and systolic blood pressure.

Conclusions

Despite a preserved ejection fraction, a proportion of patients with HFpEF display impaired GLS, which correlates with a worse cardiac output. Impaired GLS was not associated with higher filling pressures at rest or exercise.

Acknowledgement/Funding

National Heart Foundation of Australia

Physeal-preserving endoprosthetic replacement with short segment fixation in children with bone sarcomas

AIMS

The aim of this study was to report the results of custom-made endoprostheses with extracortical plates plus or minus a short, intramedullary stem aimed at preserving the physis after resection of bone sarcomas in children.

PATIENTS AND METHODS

Between 2007 and 2017, 18 children aged less than 16 years old who underwent resection of bone sarcomas, leaving ≤ 5 cm of bone from the physis, and reconstruction with a custom-made endoprosthesis were reviewed. Median follow-up was 67 months (interquartile range 45 to 91). The tumours were located in the femur in 11 patients, proximal humerus in six, and proximal tibia in one.

RESULTS

The five-year overall survival rate was 78%. No patient developed local recurrence. The five-year implant survival rate was 79%. In all, 11 patients (61%) developed a complication. Seven patients (39%) required further surgery to treat the complications. Implant failures occurred in three patients (17%) including one patient with aseptic loosening and two patients with implant or periprosthetic fracture. The preserved physis continued to grow at mean 3.3 cm (0 to 14). The mean Musculoskeletal Society score was 88% (67% to 97%).

CONCLUSION

Custom-made endoprostheses that aim to preserve the physis are a safe and effective option for preserving physeal growth, limb length, and joint function with an acceptable rate of complications. Cite this article: Bone Joint J 2019;101-B:1144-1150.

A-04 Evaluating Race-Related Differences in Performance of Two App-based Cognitive Tasks

Objective

Increased participation of African Americans (AA) in Alzheimer’s disease (AD) clinical research is a national priority given their increased risk for developing AD. Removal of logistical barriers, such as time and travel costs, may increase AA participation. We developed two racially unbiased smartphone applications to assess cognition adapted from traditional tasks, the computerized Flanker test and paper-based Symbol Digit Modalities Test (SDMT). This study evaluated baseline performance and construct validity of the tasks in Non-Hispanic White (NHW) and AA participants.

Method

A sample of AA (n = 47) and NHW (n = 50) cognitively normal, middle-age and older adults (Mage = 60.73, SDage = 7.65) completed an in-clinic visit that included traditional assessments, as well as two app-based measures, Arrows and Number Match. Racial differences in group performance were evaluated with independent samples t-tests. Construct validity was assessed through inter-version correlations between traditional and app-based measures.

Results

There were no statistically significant differences between races on any metric of overall performance: Number Match (t(84) = 1.912, p = .06, 95% CI [-.130, 6.672]), Arrows average reaction time (RT) for incongruent trials (t(93) = -1.496, p = .14, 95% CI [-278.94, 39.27]), average RT for congruent trials (t(93) = -1.751, p = .083, 95% CI [-356.64, 22.44]), or average RT across all trials (t(93) = -1.691, p = .09, 95% CI [-298.21, 23.89]). The overall sample demonstrated small to moderate statistically significant inter-version correlations, from r = 0.39 to r = 0.55, ps < .01, with Number Match and SDMT showing a stronger association than Arrows and Flanker.

Conclusions

Preliminary data suggest no performance differences between races. Future research will evaluate the tasks’ ability to discriminate between clinical populations.

Chondroblastoma in pelvis and extremities- a signle centre study of 177 cases

Introduction

Chondroblastoma is a rare benign bone tumour that usually occurs in children and young adults. They are cartilaginous tumours arising in the epiphysis or apophysis of a long bone. The tumour is classified as benign, although rare cases of pulmonary metastases have been reported. The aims of this study were to describe clinical, radiographic characteristics of chondroblastoma; to analyse the local recurrence rate and complications associated with surgery.

Material and methods

This retrospective study included 177 patients, who had been diagnosed with a chondroblastoma in extremity between 1990 and 2015.

Results

The most common site was proximal tibia 20%, followed by proximal humerus 19%, proximal femur 18%, distal femur 16% and foot 15%. One patient has died of the disease and one patient is alive after being operated for lung metastases. There was local recurrence in 25/177 (14%) patients. The median time to local recurrence was 10 months (range 3–158 months). The most common site for local recurrence was proximal tibia (22.2%). The proximal femur was the location in 32/178 (18%) of the cases. 18/32 (56%) were in the greater trochanter and 14/32 (44%) in the femoral head. The mean age was lower in tumours located in femoral head when compared to the greater trochanter; 19.5 years and 13.9 years respectively (p = =0.004). Tumours located in greater trochanter were all curetted without further complications. Local recurrence was seen more often in femoral head tumours, though without statistical significance; 3/14 (21%) and none, respectively (p = =0.073).

Conclusions

Chondroblastoma is a rare benign to intermediate grade bone tumour with a potential to metastasise. Femoral head chondroblastoma is rare, presenting 4.5% of all chondroblastoma cases. Around 50% of the chondroblastoma in femoral head. occur in patients with open growth plates.

Combining hippocampal volume metrics to better understand Alzheimer's disease progression in at-risk individuals

To date nearly all clinical trials of Alzheimer’s disease (AD) therapies have failed. These failures are, at least in part, attributable to poor endpoint choice and to inadequate recruitment criteria. Recently, focus has shifted to targeting at-risk populations in the preclinical stages of AD thus improved predictive markers for identifying individuals likely to progress to AD are crucial to help inform the sample of individuals to be recruited into clinical trials. We focus on hippocampal volume (HV) and assess the added benefit of combining HV and rate of hippocampal atrophy over time in relation to disease progression. Following the cross-validation of previously published estimates of the predictive value of HV, we consider a series of combinations of HV metrics and show that a combination of HV and rate of hippocampal atrophy characterises disease progression better than either measure individually. Furthermore, we demonstrate that the risk of disease progression associated with HV metrics does not differ significantly between clinical states. HV and rate of hippocampal atrophy should therefore be used in tandem when describing AD progression in at-risk individuals. Analyses also suggest that the effects of HV metrics are constant across the continuum of the early stages of the disease.

Home delivery service of low protein foods in inherited metabolic disorders: Does it help?

Background

In the UK, the customary method of obtaining special low protein (LP) foods was by dispensing through a pharmacist (until 2010) for patients with inherited metabolic disorders (IMD) requiring LP diets. Recently, different home delivery services have been introduced to support patient access of low protein foods, but the effectiveness of these services is unclear.

Aim

A prospective, longitudinal, observational study to examine the effectiveness and safety of patient home delivery services for LP foods over 12 months in IMD patients requiring a LP diet.

Methods

IMD patients/caregivers had the choice of 2 home delivery services (Homeward® and Vitaflo at Home®) as well as access to primary care pharmacy services. Both home delivery services provided a limited range of LP foods. Over a 12-month period, a member of the IMD dietetic team conducted 4 home visits to IMD patients on LP diets using home delivery services for low protein foods. At each visit, caregivers completed a questionnaire consisting of 20 multiple choice and open questions about their prescription experience with special LP foods. The researchers also completed stock checks, assessed 'use by dates' and adequacy of home storage for LP foods.

Results

In total, 58 patients participated in this study. Over 12 months, 95% (n = 55/58) of caregivers used their local pharmacy, 93% (n = 54/58) Homeward® and 78% (n = 45/58) Vitaflo at Home® to access LP foods. Two home delivery services were used by 41 (71%) caregivers and the remaining 17 (29%) only used one of the home delivery service companies. Each patient only stored a median of 6 (range 0-22) different LP foods at home. Overall, 45% (n = 26/58) of caregivers reported problems with their GP prescriptions. 30% (n = 16/53) of caregivers received at least one incorrect prescription when using their pharmacy (e.g. gluten-free foods instead of LP, incorrect product or incorrect product amount), 6% errors (n = 3/53) with Homeward® and 2% (n = 1/48) with Vitaflo at Home®. 49% (n = 26/53) of caregivers said they experienced delayed receipt of LP foods from their pharmacy, compared with 11% (n = 6/55) from Homeward® and 8% (n = 4/48) Vitaflo at Home®.

Conclusions

Although home delivery services for special LP foods are associated with less errors and delay compared with pharmacies, inaccuracies and inefficiencies still occur and the overall system is complex. We suggest a new, simpler, less fragmented system whereby metabolic dietitians prescribe LP foods. This is likely to result in less burden on NHS resources and ensure a better treatment delivered to IMD patients.

Growth, Protein and Energy Intake in Children with PKU Taking a Weaning Protein Substitute in the First Two Years of Life: A Case-Control Study

Growth issues have been observed in young children with phenylketonuria (PKU), but studies are conflicting. In infancy, there is an increasing trend to introduce a second-stage semi-solid weaning protein substitute (WPS) but there is concern that this may not meet energy requirements. In this longitudinal, prospective study, 20 children with PKU transitioning to a WPS, and 20 non-PKU controls were observed monthly from weaning commencement (4–6 months) to 12 m and at 15, 18 and 24 months of age for: weight, length, head circumference, body mass index (BMI), energy and macronutrient intake. Growth parameters were within normal range at all ages in both groups with no significant difference in mean z-scores except for accelerated length in the PKU group. No child with PKU had z-scores < −2 for any growth parameter at age 2 years. Total protein and energy intake in both groups were similar at all ages; however, from 12–24 months in the PKU group, the percentage of energy intake from carbohydrate increased (60%) but from fat decreased (25%) and inversely for controls (48% and 36%). In PKU, use of low volume WPS meets Phe-free protein requirements, facilitates transition to solid foods and supports normal growth. Further longitudinal study of growth, body composition and energy/nutrient intakes in early childhood are required to identify any changing trends.

The Effect of Glycomacropeptide versus Amino Acids on Phenylalanine and Tyrosine Variability over 24 Hours in Children with PKU: A Randomized Controlled Trial

Introduction: In phenylketonuria (PKU), evidence suggests that casein glycomacropeptide supplemented with rate-limiting amino acids (CGMP-AA) is associated with better protein utilisation and less blood phenylalanine (Phe) variability. Aim: To study the impact of CGMP-AA on blood Phe variability using 3 different dietary regimens in children with PKU. Methods: This was a 6-week randomised controlled cross-over study comparing CGMP-AA vs. Phe-free l-amino acids (l-AA) assessing blood Phe and tyrosine (Tyr) variability over 24 h in 19 children (7 boys) with PKU, with a median age of 10 years (6–16). Subjects were randomised to 3 dietary regimens: (1) R1, CGMP-AA and usual dietary Phe (CGMP + Phe); (2) R2, CGMP-AA − Phe content of CGMP-AA from usual diet (CGMP − Phe); and (3) R3, l-AA and usual dietary Phe. Each regimen was administered for 14 days. Over the last 48 h on days 13 and 14, blood spots were collected every 4 h at 08 h, 12 h, 16 h, 20 h, 24 h, and 04 h. Isocaloric intake and the same meal plan and protein substitute dosage at standardised times were maintained when blood spots were collected. Results: Eighteen children completed the study. Median Phe concentrations over 24 h for each group were (range) R1, 290 (30–580), R2, 220 (10–670), R3, 165 (10–640) μmol/L. R1 vs. R2 and R1 vs. R3 p < 0.0001; R2 vs. R3 p = 0.0009. There was a significant difference in median Phe at each time point between R1 vs. R2, p = 0.0027 and R1 vs. R3, p < 0.0001, but not between any time points for R2 vs. R3. Tyr was significantly higher in both R1 and R2 [70 (20–240 μmol/L] compared to R3 [60 (10–200) μmol/L]. In children < 12 years, blood Phe remained in the target range (120–360 μmol/L), over 24 h, for 75% of the time in R1, 72% in R2 and 64% in R3; for children aged ≥ 12 years, blood Phe was in target range (120–600 μmol/L) in R1 and R2 for 100% of the time, but 64% in R3. Conclusions: The residual Phe in CGMP-AA increased blood Phe concentration in children. CGMP-AA appears to give less blood Phe variability compared to l-AA, but this effect may be masked by the increased blood Phe concentrations associated with its Phe contribution. Reducing dietary Phe intake to compensate for CGMP-AA Phe content may help.

Glycomacropeptide: long-term use and impact on blood phenylalanine, growth and nutritional status in children with PKU

Abstract

In phenylketonuria, casein glycomacropeptide (CGMP) requires modification with the addition of some essential and semi essential amino acids to ensure suitability as a protein substitute. The optimal amount and ratio of additional amino acids is undefined.

Aim

A longitudinal, parallel, controlled study over 12 months evaluating a CGMP (CGMP-AA2) formulation compared with phenylalanine-free L-amino acid supplements (L-AA) on blood Phe, Tyr, Phe:Tyr ratio, biochemical nutritional status and growth in children with PKU. The CGMP-AA2 contained 36 mg Phe per 20 g protein equivalent.

Methods

Children with PKU, with a median age of 9.2 y (5-16y) were divided into 2 groups: 29 were given CGMP-AA2, 19 remained on Phe-free L-AA. The CGMP-AA2 formula gradually replaced L-AA, providing blood Phe concentrations were maintained within target range. Median blood Phe, Tyr, Phe:Tyr ratio and anthropometry, were compared within and between the two groups at baseline, 26 and 52 weeks. Nutritional biochemistry was studied at baseline and 26 weeks only.

Results

At the end of 52 weeks only 48% of subjects were able to completely use CGMP-AA2 as their single source of protein substitute. At 52 weeks CGMP-AA2 provided a median of 75% (30–100) of the total protein substitute with the remainder being given as L-AA. Within the CGMP-AA2 group, blood Phe increased significantly between baseline and 52 weeks: [baseline to 26 weeks; baseline Phe 270 μmol/L (170–430); 26 weeks, Phe 300 μmol/L (125–485) p = 0.06; baseline to 52 weeks: baseline, Phe 270 μmol/L (170–430), 52 weeks Phe 300 μmol/L (200–490), p < 0.001)]. However, there were no differences between the CGMP-AA2 and L-AA group for Phe, Tyr, Phe:Tyr ratio or anthropometry at any of the three measured time points. Within the CGMP-AA2 group only weight (p = 0.0001) and BMI z scores (p = 0.0001) increased significantly between baseline to 52 weeks. Whole blood and plasma selenium were significantly higher (whole blood selenium [p = 0.0002]; plasma selenium [p = 0.0007]) at 26 weeks in the CGMP-AA2 group compared L-AA. No differences were observed within the L-AA group for any of the nutritional markers.

Conclusions

CGMP-AA increases blood Phe concentrations and so it can only be used partly to contribute to protein substitute in some children with PKU. CGMP-AA should be carefully introduced in children with PKU and close monitoring of blood Phe control is essential.

Electronic supplementary material

The online version of this article (10.1186/s13023-019-1011-y) contains supplementary material, which is available to authorized users.

Development of national consensus statements on food labelling interpretation and protein allocation in a low phenylalanine diet for PKU

BACKGROUND

In the treatment of phenylketonuria (PKU), there was disparity between UK dietitians regarding interpretation of how different foods should be allocated in a low phenylalanine diet (allowed without measurement, not allowed, or allowed as part of phenylalanine exchanges). This led to variable advice being given to patients.

METHODOLOGY

In 2015, British Inherited Metabolic Disease Group (BIMDG) dietitians (n = 70) were sent a multiple-choice questionnaire on the interpretation of protein from food-labels and the allocation of different foods. Based on majority responses, 16 statements were developed. Over 18-months, using Delphi methodology, these statements were systematically reviewed and refined with a facilitator recording discussion until a clear majority was attained for each statement. In Phase 2 and 3 a further 7 statements were added.

RESULTS

The statements incorporated controversial dietary topics including: a practical 'scale' for guiding calculation of protein from food-labels; a general definition for exchange-free foods; and guidance for specific foods. Responses were divided into paediatric and adult groups. Initially, there was majority consensus (≥86%) by paediatric dietitians (n = 29) for 14 of 16 statements; a further 2 structured discussions were required for 2 statements, with a final majority consensus of 72% (n = 26/36) and 64% (n = 16/25). In adult practice, 75% of dietitians agreed with all initial statements for adult patients and 40% advocated separate maternal-PKU guidelines. In Phase 2, 5 of 6 statements were agreed by ≥76% of respondents with one statement requiring a further round of discussion resulting in 2 agreed statements with a consensus of ≥71% by dietitians in both paediatric and adult practice. In Phase 3 one statement was added to elaborate further on an initial statement, and this received 94% acceptance by respondents. Statements were endorsed by the UK National Society for PKU.

CONCLUSIONS

The BIMDG dietitians group have developed consensus dietetic statements that aim to harmonise dietary advice given to patients with PKU across the UK, but monitoring of statement adherence by health professionals and patients is required.

Isolated primary bone tumours of the lesser trochanter: Demographics, diagnosis and management

Primary bone tumours arising from the lesser trochanter (LT) are rare and the literature describing them is sparse. In this paper, we describe the largest series of LT tumours describing the demographics, diagnosis and management.

METHODS

A retrospective search of prospectively maintained radiology and oncology databases was performed to identify bone tumours of the LT diagnosed between 2007 and 2018. Metastatic lesions were excluded. All cases were re-reviewed by a senior Radiologist and all case of isolated tumours of the LT were included.

RESULTS

23 cases of isolated LT tumours were identified. There were 15 males and 8 females. Mean age of our cohort was 32 (14-63) years. Most (n = 19, 82.6%) cases had classic radiological (Radiographic, MR Imaging and CT) features and therefore did not undergo biopsy. 4 patients had equivocal radiological investigations that required biopsy to confirm the diagnosis. MR imaging was the most commonly used imaging modality for diagnosis (n = 17, 73.9%)There was a broad range of tumour subtypes, and osteochondroma (n = 17, 73.9%) the most frequently diagnosed. Surgical excision was performed in 4 patients (all osteochondromas) and 4 patients underwent therapeutic radiological guided hip injections for symptomatic relief. The remaining cases were managed conservatively and where they were identified incidentally, no intervention was required.

CONCLUSION

We report the largest case series of isolated primary bone tumours of the LT. All isolated primary bone tumours of LT are benign. Osteochondroma is the most common. The diagnosis can be made with on radiological investigations in most patients.

Weaning practices in phenylketonuria vary between health professionals in Europe

Background

In phenylketonuria (PKU), weaning is considered more challenging when compared to feeding healthy infants. The primary aim of weaning is to gradually replace natural protein from breast milk or standard infant formula with solids containing equivalent phenylalanine (Phe). In addition, a Phe-free second stage L-amino acid supplement is usually recommended from around 6 months to replace Phe-free infant formula. Our aim was to assess different weaning approaches used by health professionals across Europe.

Methods

A cross sectional questionnaire (survey monkey®) composed of 31 multiple and single choice questions was sent to European colleagues caring for inherited metabolic disorders (IMD). Centres were grouped into geographical regions for analysis.

Results

Weaning started at 17–26 weeks in 85% (n = 81/95) of centres, >26 weeks in 12% (n = 11/95) and < 17 weeks in 3% (n = 3/95). Infant's showing an interest in solid foods, and their age, were important determinant factors influencing weaning commencement. 51% (n = 48/95) of centres introduced Phe containing foods at 17–26 weeks and 48% (n = 46/95) at >26 weeks. First solids were mainly low Phe vegetables (59%, n = 56/95) and fruit (34%, n = 32/95).

A Phe exchange system to allocate dietary Phe was used by 52% (n = 49/95) of centres predominantly from Northern and Southern Europe and 48% (n = 46/95) calculated most Phe containing food sources (all centres in Eastern Europe and the majority from Germany and Austria). Some centres used a combination of both methods.

A second stage Phe-free L-amino acid supplement containing a higher protein equivalent was introduced by 41% (n = 39/95) of centres at infant age 26–36 weeks (mainly from Germany, Austria, Northern and Eastern Europe) and 37% (n = 35/95) at infant age > 1y mainly from Southern Europe. 53% (n = 50/95) of centres recommended a second stage Phe-free L-amino acid supplement in a spoonable or semi-solid form.

Conclusions

Weaning strategies vary throughout European PKU centres. There is evidence to suggest that different infant weaning strategies may influence longer term adherence to the PKU diet or acceptance of Phe-free L-amino acid supplements; rendering prospective long-term studies important. It is essential to identify an effective weaning strategy that reduces caregiver burden but is associated with acceptable dietary adherence and optimal infant feeding development.

Low-radiation and high image quality coronary computed tomography angiography in “real-world” unselected patients

AIM

To determine the radiation dose and image quality in coronary computed tomography angiography (CCTA) using state-of-the-art dose reduction methods in unselected “real world” patients.

METHODS

In this single-centre study, consecutive patients in sinus rhythm underwent CCTA for suspected coronary artery disease (CAD) using a 320-row detector CT scanner. All patients underwent the standard CT acquisition protocol at our institute (Morriston Hospital) a combination of dose saving advances including prospective electrocardiogram-gating, automated tube current modulation, tube voltage reduction, heart rate reduction, and the most recent novel adaptive iterative dose reconstruction 3D (AIDR3D) algorithm. The cohort comprised real-world patients for routine CCTA who were not selected on age, body mass index, or heart rate. Subjective image quality was graded on a 4-point scale (4 = excellent, 1 = non-diagnostic).

RESULTS

A total of 543 patients were included in the study with a mean body weight of 81 ± 18 kg and a pre-scan mean heart rate of 70 ± 11 beats per minute (bpm). When indicated, patients received rate-limiting medication with an oral beta-blocker followed by additional intravenous beta-blocker to achieve a heart rate below 65 bpm. The median effective radiation dose was 0.88 mSv (IQR, 0.6-1.4 mSv) derived from a Dose Length Product of 61.45 mGy.cm (IQR, 42.86-100.00 mGy.cm). This also includes what we believe to be the lowest ever-reported radiation dose for a routine clinical CCTA (0.18 mSv). The mean image quality (± SD) was 3.65 ± 0.61, with a subjective image quality score of 3 (“good”) or above for 93% of patient CCTAs.

CONCLUSION

Combining a low-dose scan protocol and AIDR3D with a 320-detector row CT scanner can provide high quality images at exceptionally low radiation dose in unselected patients being investigated for CAD.

Computed tomography colonography: a new threat to the spleen?

We present a rare and previously undocumented potential complication of computed tomography (CT) colonography. CT colonography is a commonly performed investigation with a relatively low risk of complications. While splenic injury is a well-documented complication after colonoscopy, it has never been reported following CT colonography. A 64-year-old man presented with severe abdominal pain four hours after CT colonography. CT of his abdomen and pelvis revealed appearances consistent with intra-abdominal bleeding secondary to splenic injury. The patient immediately underwent an emergency laparotomy and splenectomy, revealing a grade III splenic capsular tear. Histological evaluation of splenic tissue showed normal morphology with no evidence of malignancy. While the aetiology of the patient's splenic injury remains uncertain, normal histopathology and the chronology of events represents an almost certain link to CT colonography.

Early feeding practices in infants with phenylketonuria across Europe

Background

In infants with phenylketonuria (PKU), dietary management is based on lowering and titrating phenylalanine (Phe) intake from breast milk or standard infant formula in combination with a Phe-free infant formula in order to maintain blood Phe levels within target range. Professionals use different methods to feed infants with PKU and our survey aimed to document practices across Europe.

Methods

We sent a cross sectional, survey monkey® questionnaire to European health professionals working in IMD. It contained 31 open and multiple-choice questions. The results were analysed according to different geographical regions.

Results

Ninety-five centres from 21 countries responded. Over 60% of centres commenced diet in infants by age 10 days, with 58% of centres implementing newborn screening by day 3 post birth. At diagnosis, infant hospital admission occurred in 61% of metabolic centres, mainly in Eastern, Western and Southern Europe. Breastfeeding fell sharply following diagnosis with only 30% of women still breast feeding at 6 months.

53% of centres gave pre-measured Phe-free infant formula before each breast feed and 23% alternated breast feeds with Phe-free infant formula. With standard infant formula feeds, measured amounts were followed by Phe-free infant formula to satiety in 37% of centres (n = 35/95), whereas 44% (n = 42/95) advised mixing both formulas together. Weaning commenced between 17 and 26 weeks in 85% centres, ≥26 weeks in 12% and < 17 weeks in 3%.

Discussion

This is the largest European survey completed on PKU infant feeding practices. It is evident that practices varied widely across Europe, and the practicalities of infant feeding in PKU received little focus in the PKU European Guidelines (2017). There are few reports comparing different feeding techniques with blood Phe control, Phe fluctuations and growth. Controlled prospective studies are necessary to assess how different infant feeding practices may influence longer term feeding development.

A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising

Background

It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images.

Methods

Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05.

Results

Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality.

Conclusions

Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

•

Diffuse bruises may be measured on conventional & cross polarized imaging.

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Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo.

•

Measurements of bruises using infrared imaging may be smaller than other modalities.

First measurements of remaining shell areal density on the OMEGA laser using the Diagnostic for Areal Density (DAD)

A glass Cherenkov detector, called the Diagnostic for Areal Density (DAD), has been built and implemented at the OMEGA laser facility for measuring fusion gammas above 430 keV, from which remaining shell ⟨ρR⟩ _abl can be determined. A proof-of-principle experiment is discussed, where signals from a surrogate gas Cherenkov detector are compared with reported values from the wedge range filter and charged particle spectrometer and found to correlate strongly. The design of the more compact port-based DAD diagnostic and results from the commissioning shots are then presented. Once absolutely calibrated, the DAD will be capable of reporting remaining shell ⟨ρR⟩ _abl for plastic and glass capsules within minutes of a shot and with potentially higher precision than existing techniques.

Vascularized fibular epiphyseal transfer for proximal humeral reconstruction in children with a primary sarcoma of bone

Aims

Preserving growth following limb-salvage surgery of the upper limb in children remains a challenge. Vascularized autografts may provide rapid biological incorporation with the potential for growth and longevity. In this study, we aimed to describe the outcomes following proximal humeral reconstruction with a vascularized fibular epiphyseal transfer in children with a primary sarcoma of bone. We also aimed to quantify the hypertrophy of the graft and the annual growth, and to determine the functional outcomes of the neoglenofibular joint.

Patients and Methods

We retrospectively analyzed 11 patients who underwent this procedure for a primary bone tumour of the proximal humerus between 2004 and 2015. Six had Ewing’s sarcoma and five had osteosarcoma. Their mean age at the time of surgery was five years (two to eight). The mean follow-up was 5.2 years (1 to 12.2).

Results

The overall survival at five and ten years was 91% (confidence interval (CI) 95% 75% to 100%). At the time of the final review, ten patients were alive. One with local recurrence and metastasis died one-year post-operatively. Complications included seven fractures, four transient nerve palsies, and two patients developed avascular necrosis of the graft. All the fractures presented within the first postoperative year and united with conservative management. One patient had two further operations for a slipped fibular epiphysis of the autograft, and a hemi-epiphysiodesis for lateral tibial physeal arrest. Hypertrophy and axial growth were evident in nine patients who did not have avascular necrosis of the graft. The mean hypertrophy index was 65% (55% to 82%), and the mean growth was 4.6 mm per annum (2.4 to 7.6) in these nine grafts. At final follow-up, the mean modified functional Musculoskeletal Tumour Society score was 77% (63% to 83%) and the mean Toronto Extremity Salvage Score (TESS) was 84% (65% to 94%).

Conclusion

Vascularized fibular epiphyseal transfer preserves function and growth in young children following excision of the proximal humerus for a malignant bone tumour. Function compares favourably to other limb-salvage procedures in children. Longer term analysis is required to determine if this technique proves to be durable into adulthood. Cite this article: Bone Joint J 2018;100-B:535–41.

The safety of Lipistart, a medium-chain triglyceride based formula, in the dietary treatment of long-chain fatty acid disorders: a phase I study

BACKGROUND

Children with long-chain fatty acid β-oxidation disorders (LCFAOD) presenting with clinical symptoms are treated with a specialist infant formula, with medium chain triglyceride (MCT) mainly replacing long chain triglyceride (LCT). It is essential that the safety and efficacy of any new specialist formula designed for LCFAOD be tested in infants and children.

METHODS

In an open-label, 21-day, phase I trial, we studied the safety of a new MCT-based formula (feed 1) in six well-controlled children (three male), aged 7-13 years (median 9 years) with LCFAOD (very long chain acyl CoA dehydrogenase deficiency [VLCADD], n=2; long chain 3-hydroxyacyl CoA dehydrogenase deficiency [LCHADD], n=2; carnitine acyl carnitine translocase deficiency [CACTD], n=2). Feed 1 (Lipistart; Vitaflo) contained 30% energy from MCT, 7.5% LCT and 3% linoleic acid and it was compared with a conventional MCT feed (Monogen; Nutricia) (feed 2) containing 17% energy from MCT, 3% LCT and 1.1% linoleic acid. Subjects consumed feed 2 for 7 days then feed 1 for 7 days and finally resumed feed 2 for 7 days. Vital signs, blood biochemistry, ECG, weight, height, food/feed intake and symptoms were monitored.

RESULTS

Five subjects completed the study. Their median daily volume of both feeds was 720 mL (range 500-1900 mL/day). Feed 1 was associated with minimal changes in tolerance, free fatty acids (FFA), acylcarnitines, 3-hydroxybutyrate (3-HB), creatine kinase (CK), blood glucose, liver enzymes and no change in an electrocardiogram (ECG). No child complained of muscle pain or symptoms associated with LCFAOD on either feed.

CONCLUSIONS

This is the first safety trial reported of an MCT formula specifically designed for infants and children with LCFAOD. In this short-term study, it appeared safe and well tolerated in this challenging group.