Thromboembolic Events During Weightbearing vs Nonweightbearing Accelerated Rehabilitation Protocols for Complete Achilles Tendon Ruptures

Background

Achilles tendon rupture can be treated nonoperatively with functional rehabilitation. However, prolonged immobilization has associated risk of venous thromboembolism (VTE). Early weightbearing may reduce VTE risk, and this was introduced to our rehabilitation protocol. We investigated the prevalence of symptomatic VTE events before and after the introduction of the early weightbearing protocol.

Methods

Adults with ultrasonography-confirmed complete tendo-Achilles ruptures between January 2017 and June 2020 were included. Preprotocol, patients were instructed to not weightbear for 4 weeks. In 2018, immediate weightbearing was introduced to the treatment protocol. All patients in both cohorts were given low-molecular-weight heparin for 4 weeks. Patients with symptomatic VTE events were investigated with duplex ultrasonographic scan or chest computed tomography. Two independent anonymized examiners collected data from electronic records. Rates of symptomatic VTEs were compared.

Results

A total of 296 patients were included. Sixty-nine patients were managed with the nonweightbearing protocol, and 227 patients were managed with the early-weightbearing protocol. Two patients in each group developed deep vein thrombosis and 1 developed pulmonary embolism in the early-weightbearing group. Rates of VTEs were lower in the early-weightbearing group (1.3% vs 2.9%) but did not reach statistical significance (P = .33).

Conclusion

In this cohort we found that symptomatic VTE after nonoperatively treated Achilles tendon rupture was uncommon. We did not demonstrate a reduction in symptomatic VTE between our early weightbearing and nonweightbearing rehabilitation protocols. We believe a larger study may help clarify whether early weightbearing is beneficial in VTE reduction.

Level of Evidence

Level III, retrospective cohort study.

A253 PRIMARY PROPHYLAXIS FOR SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED CIRRHOTIC PATIENTS WITH LOW PROTEIN ASCITES AND RENAL DYSFUNCTION OR LIVER FAILURE: A RETROSPECTIVE REVIEW FROM A TERTIARY CENTRE IN BRITISH COLUMBIA

Background

Spontaneous bacterial peritonitis (SBP) is a severe and often fatal infection that can occur in patients with cirrhosis and ascites. The benefits of primary prophylaxis with antibiotics for SBP have been demonstrated in patients with cirrhosis presenting with gastrointestinal (GI) bleeding; patients hospitalized for other reasons with an ascitic protein less than 10 g/L; and patients with ascitic protein less than 15 g/L with either impaired renal function (serum creatinine greater than 106 µmol/L, BUN greater than 8.9 mmol/L, or serum sodium less than or equal to 130 mEq/L) or liver failure (Child-Pugh score greater than or equal to 9 or bilirubin greater than 50 umol/L).

Purpose

To evaluate the rate of primary prophylaxis in patients discharged from a tertiary care hospital with low protein ascites and impaired renal function or liver failure, and subsequent episodes of SBP, hospitalizations, or deaths.

Method

A retrospective chart review at St. Paul’s Hospital in Vancouver, British Columbia, from November 2019 to August 2021 was conducted. Hospitalized patients with cirrhosis who had an ascitic protein less than 15 g/L and met criteria for either renal dysfunction or liver failure were included in the study. The rate of primary prophylaxis prescribed in eligible patients as well as the subsequent incidence of SBP, hospitalizations, or all-cause mortality were evaluated. Patients were followed up to 12 months after the index paracentesis.

Result(s)

A total of 279 patients with cirrhosis were hospitalized during the study period. 69 patients underwent a diagnostic paracentesis and 41 patients met the inclusion criteria for primary SBP prophylaxis. 28 patients were excluded with most common reasons being ascitic protein above 15 g/L (n=12), no documented ascitic protein concentration (n=9), or index paracentesis met the criteria for the diagnosis of SBP (n=5). Of the patients included, 37 (90.2%) did not receive primary prophylaxis. 8 of these patients (21.6%) developed subsequent SBP. 30 patients (81.1%) were hospitalized at least once in the following 12 months. 18 (48.6%) died during the follow-up period with 1 death attributed to SBP. 4 patients (9.76%) received primary prophylaxis and were prescribed either ciprofloxacin or trimethoprim/sulfamethoxazole. None of these patients developed SBP, however, 3 (75%) were hospitalized and died from other causes.

Conclusion(s)

The rate of primary prophylaxis for SBP in hospitalized patients with low protein ascites and impaired renal function or liver failure at our institution is low. The guarded prognosis in this subset of patients is also demonstrated. Further studies are needed to assess the root causes for the lack of primary prophylaxis given.

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Disclosure of Interest

None Declared

A9 INTESTINAL ORGANOID TRANSPLANTATION REVERSED THE INTESTINAL EPITHELIUM DAMAGE IN EXPERIMENTAL NECROTIZING ENTEROCOLITIS

NOT PUBLISHED AT AUTHOR’S REQUEST

Effects of different vitamin A supplies on performance and the risk of ketosis in transition cows

This experiment investigated the effects of feeding low and high supplies of vitamin A (VA) during the transition period on plasma metabolites, prevalence of ketosis, and early milk production. In a randomized complete block design, 42 prefresh Holstein cows and 21 heifers were blocked by parity and calving date and assigned to 1 of 3 dietary treatments (n = 21 per treatment unless noted): CON, a transition diet with supplemental VA (75,000 IU/d) to meet the requirement; LVA, a transition diet with no supplemental VA; or HVA, a transition diet receiving supplemental VA (187,500 IU/d) 2.5 times greater than the requirement. Experimental periods were prepartum (-14 d prepartum), postpartum (1 to 30 d in milk), and carryover period (31 to 58 d in milk; common lactating diet with adequate VA was fed). Differences in dry matter intake in the pre- and postpartum periods and milk yield were not detected among treatment. Milk fat, protein, and lactose yields were similar among treatments and not affected by VA. Somatic cell count increased linearly with increasing VA. Body weight and body condition score decreased postpartum, but no VA effect was observed. Plasma retinol concentrations (n = 10 per treatment) decreased at d 2 postpartum and increased as lactation progressed, but the concentrations were unaffected by treatment. Plasma β-carotene (n = 10 per treatment) had a treatment by time interaction and its concentration decreased after parturition and remained low for 2 wk. Plasma fatty acids and β-hydroxybutyrate did not differ among treatments. Milk retinol concentration and yield (n = 10 per treatment) increased as VA supply increased. Segmented neutrophils (%) decreased, and lymphocytes (%) increased in blood with increasing VA supply. In conclusion, providing different supplies of VA did not affect production, mobilization of body fat, and risk of ketosis; however, excessive VA supply may have negatively affected the immune response, in part contributing to increased milk somatic cell counts during early lactation.

Association between anaemia and hospital readmissions in patients undergoing major surgery requiring postoperative intensive care

Anaemia is a common sequela of surgery, although its relationship with patient recovery is unclear. The goal of this investigation was to assess the associations between haemoglobin concentrations at the time of hospital discharge following major surgery and early post-hospitalisation outcomes, with a primary outcome of 30 day unanticipated hospital readmissions. This investigation includes data from two independent population-based observational cohorts of adult surgical patients (aged ≥ 18 years) requiring postoperative intensive care unit admission between 1 January 2010 and 31 December 2019 in hospitals in Olmsted County, Minnesota, and between 1 July 2010 and 30 June 2017 in the Kaiser Permanente Northern California integrated healthcare system, California. Cox proportional hazards models assessed the associations between discharge haemoglobin concentrations (per 10 g.l-1 ) and outcomes, with prespecified multivariable adjustment. A total of 3260 patients were included from Olmsted County hospitals and 29,452 from Kaiser Permanente Northern California. In adjusted analyses, each 10 g.l-1 decrease in haemoglobin at hospital discharge was associated with a 9% (hazard ratio 1.09, 95%CI 1.02-1.18; p = 0.014) and 8% increase (hazard ratio 1.08, 95%CI 1.06-1.11; p < 0.001) in the hazard for readmission within 30 days in Olmsted County and Kaiser Permanente Northern California, respectively. In a sensitivity analysis exploring relationships across varying levels of pre-operative anaemia severity, these associations remained consistent, with lower discharge haemoglobin concentrations associated with higher readmissions irrespective of pre-operative anaemia severity. Anaemia at hospital discharge in surgical patients requiring postoperative intensive care is associated with increased rates of hospital readmission in two large independent cohorts. Future studies are necessary to evaluate strategies to prevent and/or treat anaemia in these patients for the improvement of post-hospitalisation outcomes.

Proteomics profiling reveals signaling pathways associated with major adverse cardiovascular events in patients with hypertrophic cardiomyopathy

Background

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy affecting 1 in 200–500 people in the US. It is characterized by a diverse clinical course, and only a subset of patients with HCM experience major adverse cardiovascular events (MACE) such as arrhythmias (e.g., ventricular tachycardia/fibrillation [VT/VF], atrial fibrillation [AF]), stroke, and heart failure. However, the molecular mechanisms underlying the presence of MACE in HCM are still not well understood.

Purpose

Our aim was to reveal signaling pathways associated with prior MACE in patients with HCM by applying plasma proteomics profiling.

Methods

We conducted a multicenter case-control study of patients with HCM comparing those with and without a prior history of MACE. We performed plasma proteomics profiling of 5032 proteins. We defined prior MACE as a composite outcome of sustained VT/VF, AF, stroke/transient ischemic attack, left ventricular ejection fraction ≤50%, New York Heart Association functional class ≥2 symptoms, resuscitated cardiac arrest, or appropriate implantable cardioverter defibrillator therapy. We applied the random forest method to derive a proteomics-based discrimination model developed in patients enrolled at one institution (training set) and externally validated the model on patients enrolled at another institution (test set). We then performed pathway analysis of proteins differentially regulated in patients with prior MACE. Pathways with a false discovery rate (FDR) &lt;0.05 with at least 5 associated proteins were declared positive.

Results

A total of 396 patients were included, with 278 in the training set and 118 in the test set. In this cohort, 251 (63%) patients had prior MACE (171 in the training set and 80 in the test set). Using the proteomics-based model derived from the training set, the area under the receiver operating characteristic curve was 0.81 (95% CI 0.73–0.88) in the test set (Figure 1). There were 632 differentially expressed proteins (univariable p&lt;0.05). Pathway analysis identified significantly dysregulated pathways in patients with prior MACE (Figure 2). This included both pathways known to be associated with MACE (e.g., TGF-β [FDR=0.03]) and novel pathways (e.g., Ras-MAPK [FDR=0.01] and its upstream PI3K-Akt [FDR=7.7x10–7] pathways). Pathways involved in cellular metabolism/proliferation (e.g., HIF 1 [FDR=0.01] and Wnt [FDR=0.04] pathways) and inflammation (e.g., complement and coagulation cascades [FDR=2.7x10–21], cytokine-cytokine receptor interaction [FDR=8.1x10–16]) were also significantly dysregulated.

Conclusions

Our study in patients with HCM reveals that those with a prior history of MACE have a distinctive plasma proteomics profile. We further identified both previously known and novel pathways dysregulated in this subset with a more severe form of HCM. Our findings may aid in development of targeted therapies for the prevention of MACE in HCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): R01 HL157216

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Atypical clinical presentations are common in TIA and minor stroke patients with DWI-MRI confirmed ischaemia

Background and Aims

Current diagnostic criteria for TIA/minor stroke disqualify several atypical clinical presentations, but pre-date DWI-MRI use. We investigated the proportion of DWI-positive patients with atypical presentations, identifying clinical factors predicting DWI positivity.

Methods

We retrospectively reviewed consecutive patients with suspected TIA/minor stroke (NIHSS<5) undergoing MRI at our comprehensive stroke centre from March 2020-February 2021. We identified pre- dictors of DWI positivity using logistic regression.

Results

Of 1615 patients, 442 DWI-positive, 39% had atypical presentations including 20% with progres- sive symptom onset. Atypical symptoms common in DWI-positive patients included headache(17%), unsteadiness(15%), positive sensory symptoms(11%), presyncope(10%), confusion(9%) and vertigo(8%). Symptoms independently associated with DWI-positivity included weakness(OR 1.30, 95% CI 1.01-1.67), dysarthria(OR 2.06, CI 1.56-2.70), and ataxia (OR 3.75, CI 2.27-6.20). Fluctuating symptoms(22%) predicted DWI positivity(OR 1.37, CI 1.00-1.81), but sudden onset(80%) did not (OR 1.05, CI 0.80-1.38). Risk factors associated with DWI positivity included increasing age(OR 1.01/year, CI 1.01-1.02), hypertension (OR 1.70, CI 1.30-2.22), diabetes(OR 1.44, CI 1.07-1.93), and smoking(OR 1.68, CI 1.19-2.39). DWI-positive patients had significantly more risk factors (mean 2.65 vs 1.95 p=<0.001).

Conclusions

Over one-third with DWI-confirmed TIA/minor stroke present atypically. The value of atypical symptoms in excluding ischaemia, particularly in patients with vascular risk factors, appears limited.

Effects of corn distillers grains with yeast bodies and manipulation of dietary cation and anion difference on production, nutrient digestibility, and gas emissions from manure in lactating cows

In a randomized complete block design, 40 lactating Holstein cows (average 98 d in milk and 41 kg/d of milk yield) were randomly assigned to 1 of 4 diets: (1) containing soybean meal as the major protein supplement (CON diet); (2) CON diet with high-protein dried corn distillers grains at 20% on a dry matter (DM) basis by replacing mainly soybean meal (DG diet); (3) DG diet except that high-protein dried corn distillers grains with yeast bodies (extracted after corn ethanol production) was used (DGY diet); or (4) DG diet supplemented with sodium bicarbonate and potassium carbonate to elevate the dietary cation and anion difference (DCAD; DG-DCAD diet). The DCAD of CON, DG, DGY, and DG-DCAD were 185, 62, 67, and 187 mEq/kg of DM, respectively. The experiment began with a 10-d covariate period and then cows were fed the experimental diets for 5 wk (2-wk diet adaptation and 3-wk data collection periods). Dry matter intake and milk yield were measured daily, and spot urine and fecal samples were collected in the last week of the experiment to measure nutrient digestibility; N, S, and P utilization and excretion; and in vitro NH₃ and H₂S emissions from manure. All data were analyzed using the MIXED procedure of SAS (random effect: block; fixed effects: diets, repeated week, and interactions). During data collection, DM intake was not different among treatment groups, but milk yield tended to be lower (42.4 vs. 39.9 kg/d) for DG, DGY, and DG-DCAD versus CON, which could have been caused by decreases in organic matter and neutral detergent fiber digestibility. Milk protein yield tended to be lower (1.33 vs. 1.24 kg/d) for DG, DGY, and DG-DCAD versus CON. Milk fat yield was lower (1.26 vs. 1.55 kg/d) for DG and DGY versus CON, but that for DG-DCAD (1.43 kg/d) did not differ from CON. Similarly, energy-corrected milk was lower (38.0 vs. 43.3 kg/d) for cows on DG and DGY versus those on CON, but it did not differ between DG-DCAD (40.7 kg/d) and CON. Urinary and fecal N excretion were greater for DG, DGY, and DG-DCAD compared with CON due to greater dietary crude protein content and N intake. However, NH₃ emissions did not differ across treatments. Intakes of dietary P and S were greater for DG, DGY, and DG-DCAD, resulting in greater excretion of those in manure and greater H₂S emissions from manure compared with CON. These data suggest that the negative effects of feeding distillers grains on production of lactating cows can be partly explained by a decrease in nutrient digestibility (milk yield) and excessive anion load (milk fat). The milk fat response to DG-DCAD suggests that milk fat depression observed with a diet with high content of distillers grains can be partially alleviated by supplementation of cations. In the current study, we observed no beneficial effects of DG containing yeast bodies.