Malnutrition in Acutely Unwell Hospitalized Elderly - "The Skeletons Are Still Rattling in the Hospital Closet"

INTRODUCTION

Malnutrition is common in hospitalized patients with prevalence rates of up to 30% in Australian hospitals with adverse consequences for both the patients and health care services. Despite formulation of nutritional screening protocols, not all hospitalized patients get nutritional screening. Real life screening rates of hospitalized elderly patients are unknown.

AIM

The present study explored nutrition screening rate in acutely unwell elderly patients admitted in a large tertiary hospital and how these patients fared depending upon their nutrition status.

METHODS

A prospective cross-sectional study involving 205 general medical patients ≥60years recruited between November 2014 and November 2015. The number of patients who missed nutrition screening were noted and all patients underwent nutritional assessment by a qualified dietitian using PG-SGA and quality of life was measured using EQ-5D 5L. A survival curve was plotted and multivariate cox proportional hazard model was used to adjust for confounders.

RESULTS

Only 99 (49.7%) patients underwent nutritional screening. One hundred and six (53.5%) patients were confirmed as malnourished by PG-SGA. Malnourished patients had significantly longer length of hospital stay and had worse quality of life. Mortality was significantly higher in malnourished patients at one year (23 (21.7%) vs 4 (4.3%); p<0.001) and cox proportional hazard model suggests that malnutrition significantly affects survival even after adjustment for confounders like age, sex, Charlson index and polypharmacy.

CONCLUSION

This study confirms that nutrition screening is still suboptimal in elderly hospitalized patients with adverse consequences and suggests need for review of policies to improve screening practices.

Evaluation of increasing levels of a microbial phytase in phosphorus deficient broiler diets via live broiler performance, tibia bone ash, apparent metabolizable energy, and amino acid digestibility

The objective was to investigate increasing concentrations of an evolved microbial phytase on male broiler performance, tibia bone ash, AME, and amino acid digestibility when fed diets deficient in available phosphorus (aP). Experiment 1 evaluated the effects of phytase during a 21 d battery cage study and Experiment 2 was a 42 d grow-out. Experiment 1 included six treatments; negative control (NC) with an aP level of 0.23% (starter) and 0.19% (grower), two positive controls (PC) consisting of an additional 0.12% and 0.22% aP (PC 1 and PC 2), and the NC supplemented with three levels of phytase (250, 500, and 2,000 U/kg). The NC diet reduced (P < 0.05) FC, BW, and bone ash. Phytase increased (P < 0.05) BW with 2,000 U/kg phytase yielding similar results to the PC2, and improved FCR and increased bone ash was observed at all phytase levels. Amino acid digestibility coefficients were increased (P < 0.05) with phytase at 250 U/kg. Phytase at all rates increased (P < 0.05) AME to levels similar level as PC diets. Linear regression analysis indicated average P equivalency values for BW and bone ash of 0.137, 0.147, and 0.226 for phytase inclusion of 250, 500, and 2000 U/kg, respectively. Experiment 2 included a PC consisting of 0.45%, 0.41%, and 0.38% aP for the starter, grower, and finisher, respectively; NC with reduced aP of 0.17%; and phytase at 500 and 2,000 U/kg. Phytase increased BW (P < 0.05) compared to the NC as 2,000 U/kg phytase resulted in further BW increases compared to the PC (starter and grower). Phytase improved FCR to levels comparable to the PC, with supplementation at 2,000 U/kg resulting in improvements beyond the PC in the starter phase. Amino acid digestibility coefficients were increased with phytase at 2,000 U/kg to levels comparable to that of the PC. These data confirm that the inclusion of phytase improves broiler performance and bone mineralization in aP reduced diets and levels beyond the traditional 500 U/kg can result in further improvements.

A prospective observational study of the association between cabin and outside air temperature, and patient temperature gradient during helicopter transport in New South Wales

The prevalence of hypothermia in patients following helicopter transport varies widely. Low outside air temperature has been identified as a risk factor. Modern helicopters are insulated and have heating; therefore outside temperature may be unimportant if cabin heat is maintained. We sought to describe the association between outside air, cabin and patient temperature, and having the cabin temperature in the thermoneutral zone (18-36°C) in our helicopter-transported patients. We conducted a prospective observational study over one year. Patient temperature was measured on loading and engines off. Cabin and outside air temperature were recorded for the same time periods for each patient, as well as in-flight. Previously identified risk factors were recorded. Complete data was obtained for 133 patients. Patients' temperature increased by a median of 0.15°C (P=0.013). There was no association between outside air temperature or cabin temperature and patient temperature gradient. The best predictor of patient temperature on landing was patient temperature on loading (R2=0.86) and was not improved significantly when other risk factors were added (P=0.63). Thirty-five percent of patients were hypothermic on loading, including those transferred from district hospitals. No patient loaded normothermic became hypothermic when the cabin temperature was in the thermoneutral zone (P=0.04). A large proportion of patients in our sample were hypothermic at the referring hospital. The best predictor of patient temperature on landing is patient temperature on loading. This has implications for studies that fail to account for pre-flight temperature.

Young people's exposure to point-of-sale tobacco products and promotions

OBJECTIVES

Point of sale (POS) displays are one of the most important forms of tobacco marketing still permitted in many countries. Reliable methods for measuring exposure to such displays are needed in order to assess their potential impact, particularly on smoking attitudes and uptake among young people. In this study we use a novel method for evaluating POS exposure based on young people's use of retail outlets and recall of tobacco displays and observational data on the characteristics of displays.

STUDY DESIGN

Observational audit of retail outlets (n = 96) and school-based pupil survey (n = 1482) in four Scottish communities reflecting different levels of social deprivation and urbanisation, conducted in 2013 before legislation to remove POS displays was implemented in supermarkets.

METHODS

Measures were taken of: visibility and placement of tobacco displays; internal and external advertising; display unit size, branding and design; visibility of pack warnings; proximity of tobacco products to products of potential interest to children and young people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco displays. Variation in POS exposure across social and demographic groups was assessed.

RESULTS

Displays were highly visible within outlets and, in over half the stores, from the public footway outside. Tobacco products were displayed in close proximity to products of interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled seeing tobacco displays, with those from deprived areas more likely to recall displays in small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/convenience stores (two of the outlet types most often visited by young people) were examined separately, average tobacco display unit sizes were significantly larger in those outlets in more deprived areas.

CONCLUSIONS

POS displays remain a key vector in most countries for advertising tobacco products, and it is important to develop robust measures of exposure. The data reported in this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting such displays.

Ribociclib plus letrozole in early breast cancer: A presurgical, window-of-opportunity study

OBJECTIVES

Cyclin D-cyclin-dependent kinase (CDK) 4/6-inhibitor of CDK4/6-retinoblastoma (Rb) pathway hyperactivation is associated with hormone receptor-positive (HR+) breast cancer (BC). This study assessed the biological activity of ribociclib (LEE011; CDK4/6 inhibitor) plus letrozole compared with single-agent letrozole in the presurgical setting.

MATERIALS AND METHODS

Postmenopausal women (N = 14) with resectable, HR+, human epidermal growth factor receptor 2-negative (HER2-) early BC were randomized 1:1:1 to receive 2.5 mg/day letrozole alone (Arm 1), or with 400 or 600 mg/day ribociclib (Arm 2 or 3). Circulating tumor DNA and tumor biopsies were collected at baseline and, following 14 days of treatment, prior to or during surgery. The primary objective was to assess antiproliferative response per Ki67 levels in Arms 2 and 3 compared with Arm 1. Additional assessments included safety, pharmacokinetics, and genetic profiling.

RESULTS

Mean decreases in the Ki67-positive cell fraction from baseline were: Arm 1 69% (range 38-100%; n = 2), Arm 2 96% (range 78-100%; n = 6), Arm 3 92% (range 75-100%; n = 3). Decreased phosphorylated Rb levels and CDK4, CDK6, CCND2, CCND3, and CCNE1 gene expression were observed following ribociclib treatment. Ribociclib and letrozole pharmacokinetic parameters were consistent with single-agent data. The ribociclib plus letrozole combination was well tolerated, with no Grade 3/4 adverse events over the treatment.

CONCLUSION

The results suggest absence of a drug-drug interaction between ribociclib and letrozole and indicate ribociclib plus letrozole may reduce Ki67 expression in HR+, HER2- BC (NCT01919229).

3-Year Survival and Neurodevelopmental Outcomes in Extremely Premature Neonates: A 15-Year Odyssey

BACKGROUND: For neonates born at limits of viability, CPS recommends resuscitation decisions should occur after detailed discussion with parents, utilizing best available data on survival and neuro-developmental morbidities. There are emerging studies reporting such outcomes beyond 18-24 months. However, there is a notably wide variation in survival and rates of long term morbidity reported in the literature for infants born before 26 weeks of gestation. Centre specific survival rates among actively resuscitated extremely premature neonates and accurate developmental outcome data that truly reflects functional abilities are crucial for both parents and healthcare providers.

OBJECTIVES: Assess mortality, neuro-developmental outcomes at 3 years of age and correlate with risk factors predictive of adverse developmental outcomes in neonates born between 23+0-26+6 weeks of gestation at a tertiary care center in Ontario, Canada

DESIGN/METHODS: This was a retrospective analysis at a Level 3 center focusing on neonates born at 23+0 to 26+ 6 weeks gestation between January 2000 to December 2014. Data was extracted from Neonatal-Perinatal Database and Developmental Clinic Database. Clinical assessment of motor impairment (GMFCS), sensory impairment(blind or deaf) and a well validated tool Child Development Inventory were used to assess developmental outcomes at 3 yrs of age. Comparative analysis of possible risk factors, extracted from the NICU database , for adverse outcomes were analyzed using multivariate regression.

RESULTS: Survival rate among actively treated neonates were 25%, 60.4% and 77.5% at 23, 24 and 25 weeks respectively. 3 year survival rates with no major motor or neuro-sensory impairment were 40% among survivors born at 23 weeks, 47.2% among those born at 24 weeks, 55.6% and 68.6% among those born at 25 and 26 weeks respectively. Those born at 23 weeks had a significantly higher risk of having CP compared to the risk at 26 weeks [OR 9.04 {CI 1.96-41.67}]. Presence of IVH [OR 2.50 {CI 1.20-5.21}] and CSF infections [OR 5.71 {CI 1.03-31.56}] were identified as significant risk factors for adverse motor outcomes. Female neonates across all gestational age groups had significantly lower C P, speech delay and significantly better CDI scores. CDI profile analysis showed that at 3 years, nearly 80% of neonates born between 24-26 weeks have normal General Development Score, while only 40% of neonates born at 23 weeks had normal General Development Score at 3 years.

CONCLUSION: Being born at 23 week increased risk of cerebral palsy when compared to risk of birth at 26 weeks. CSF infection and IVH were found to be significant risk factors for adverse motor outcomes. The functional abilities as per the CDI Profiles were remarkably similar among survivors born at 24, 25,26 weeks of gestation.

Human genome meeting 2016 : Houston, TX, USA. 28 February - 2 March 2016

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Majumder P21 Epigenetic mechanisms of carcinogensis by hereditary breast cancer genes J. J. Gruber, N. Jaeger, M. Snyder P22 RNA direct: a novel RNA enrichment strategy applied to transcripts associated with solid tumors K. Patel, S. Bowman, T. Davis, D. Kraushaar, A. Emerman, S. Russello, N. Henig, C. Hendrickson P23 RNA sequencing identifies gene mutations for neuroblastoma K. Zhang P24 Participation of SFRP1 in the modulation of TMPRSS2-ERG fusion gene in prostate cancer cell lines M. Rodriguez-Dorantes, C. D. Cruz-Hernandez, C. D. P. Garcia-Tobilla, S. Solorzano-Rosales P25 Targeted Methylation Sequencing of Prostate Cancer N. Jäger, J. Chen, R. Haile, M. Hitchins, J. D. Brooks, M. Snyder P26 Mutant TPMT alleles in children with acute lymphoblastic leukemia from México City and Yucatán, Mexico S. Jiménez-Morales, M. Ramírez, J. Nuñez, V. Bekker, Y. Leal, E. Jiménez, A. Medina, A. Hidalgo, J. Mejía P28 Genetic modifiers of Alström syndrome J. Naggert, G. B. Collin, K. DeMauro, R. Hanusek, P. M. Nishina P31 Association of genomic variants with the occurrence of angiotensin-converting-enzyme inhibitor (ACEI)-induced coughing among Filipinos E. M. Cutiongco De La Paz, R. Sy, J. Nevado, P. Reganit, L. Santos, J. D. Magno, F. E. Punzalan , D. Ona , E. Llanes, R. L. Santos-Cortes , R. Tiongco, J. Aherrera, L. Abrahan, P. Pagauitan-Alan; Philippine Cardiogenomics Study Group P32 The use of “humanized” mouse models to validate disease association of a de novo GARS variant and to test a novel gene therapy strategy for Charcot-Marie-Tooth disease type 2D K. H. Morelli, J. S. Domire, N. Pyne, S. Harper, R. Burgess P34 Molecular regulation of chondrogenic human induced pluripotent stem cells M. A. Gari, A. Dallol, H. Alsehli, A. Gari, M. Gari, A. Abuzenadah P35 Molecular profiling of hematologic malignancies: implementation of a variant assessment algorithm for next generation sequencing data analysis and clinical reporting M. Thomas, M. Sukhai, S. Garg, M. Misyura, T. Zhang, A. Schuh, T. Stockley, S. Kamel-Reid P36 Accessing genomic evidence for clinical variants at NCBI S. Sherry, C. Xiao, D. Slotta, K. Rodarmer, M. Feolo, M. Kimelman, G. Godynskiy, C. O’Sullivan, E. Yaschenko P37 NGS-SWIFT: a cloud-based variant analysis framework using control-accessed sequencing data from DBGAP/SRA C. Xiao, E. Yaschenko, S. Sherry P38 Computational assessment of drug induced hepatotoxicity through gene expression profiling C. Rangel-Escareño, H. Rueda-Zarate P40 Flowr: robust and efficient pipelines using a simple language-agnostic approach;ultraseq; fast modular pipeline for somatic variation calling using flowr S. Seth, S. Amin, X. Song, X. Mao, H. Sun, R. G. Verhaak, A. Futreal, J. Zhang P41 Applying “Big data” technologies to the rapid analysis of heterogenous large cohort data S. J. Whiite, T. Chiang, A. English, J. Farek, Z. Kahn, W. Salerno, N. Veeraraghavan, E. Boerwinkle, R. Gibbs P42 FANTOM5 web resource for the large-scale genome-wide transcription start site activity profiles of wide-range of mammalian cells T. Kasukawa, M. Lizio, J. Harshbarger, S. Hisashi, J. Severin, A. Imad, S. Sahin, T. C. Freeman, K. Baillie, A. Sandelin, P. Carninci, A. R. R. Forrest, H. Kawaji, The FANTOM Consortium P43 Rapid and scalable typing of structural variants for disease cohorts W. Salerno, A. English, S. N. Shekar, A. Mangubat, J. Bruestle, E. Boerwinkle, R. A. Gibbs P44 Polymorphism of glutathione S-transferases and sulphotransferases genes in an Arab population A. H. Salem, M. Ali, A. Ibrahim, M. Ibrahim P46 Genetic divergence of CYP3A5*3 pharmacogenomic marker for native and admixed Mexican populations J. C. Fernandez-Lopez, V. Bonifaz-Peña, C. Rangel-Escareño, A. Hidalgo-Miranda, A. V. Contreras P47 Whole exome sequence meta-analysis of 13 white blood cell, red blood cell, and platelet traits L. Polfus, CHARGE and NHLBI Exome Sequence Project Working Groups P48 Association of adipoq gene with type 2 diabetes and related phenotypes in african american men and women: The jackson heart study S. Davis, R. Xu, S. Gebeab, P Riestra, A Gaye, R. Khan, J. Wilson, A. Bidulescu P49 Common variants in casr gene are associated with serum calcium levels in koreans S. H. Jung, N. Vinayagamoorthy, S. H. Yim, Y. J. Chung P50 Inference of multiple-wave population admixture by modeling decay of linkage disequilibrium with multiple exponential functions Y. Zhou, S. Xu P51 A Bayesian framework for generalized linear mixed models in genome-wide association studies X. Wang, V. Philip, G. Carter P52 Targeted sequencing approach for the identification of the genetic causes of hereditary hearing impairment A. A. Abuzenadah, M. Gari, R. Turki, A. Dallol P53 Identification of enhancer sequences by ATAC-seq open chromatin profiling A. Uyar, A. Kaygun, S. Zaman, E. Marquez, J. George, D. Ucar P54 Direct enrichment for the rapid preparation of targeted NGS libraries C. L. Hendrickson, A. Emerman, D. Kraushaar, S. Bowman, N. Henig, T. Davis, S. Russello, K. Patel P56 Performance of the Agilent D5000 and High Sensitivity D5000 ScreenTape assays for the Agilent 4200 Tapestation System R. Nitsche, L. Prieto-Lafuente P57 ClinVar: a multi-source archive for variant interpretation M. Landrum, J. Lee, W. Rubinstein, D. Maglott P59 Association of functional variants and protein physical interactions of human MUTY homolog linked with familial adenomatous polyposis and colorectal cancer syndrome Z. Abduljaleel, W. Khan, F. A. Al-Allaf, M. Athar , M. M. Taher, N. Shahzad P60 Modification of the microbiom constitution in the gut using chicken IgY antibodies resulted in a reduction of acute graft-versus-host disease after experimental bone marrow transplantation A. Bouazzaoui, E. Huber, A. Dan, F. A. Al-Allaf, W. Herr, G. Sprotte, J. Köstler, A. Hiergeist, A. Gessner, R. Andreesen, E. Holler P61 Compound heterozygous mutation in the LDLR gene in Saudi patients suffering severe hypercholesterolemia F. Al-Allaf, A. Alashwal, Z. Abduljaleel, M. Taher, A. Bouazzaoui, H. Abalkhail, A. Al-Allaf, R. Bamardadh, M. Athar

Diet Liberalisation in Older Australians Decreases Frailty without Increasing the Risk of Developing Chronic Disease

BACKGROUND

Successful ageing relies on the prevention of frailty and chronic disease, many of which have a strong link with diet. Despite evidence suggesting diet is important in the management of frailty, there is little evidence investigating the impact of a liberal diet on the prevention of frailty and development of chronic diseases in the elderly.

OBJECTIVES

To determine the impact of a liberal diet on the development of frailty and whether this affects the incidence of obesity, diabetes, hypertension and hyperlipidaemia.

DESIGN

Secondary data analysis of the Australian Longitudinal Study of Ageing, 1992 to 2000.

SETTING

Random selection of older adults from the South Australian electoral roll.

PARTICIPANTS

1298 older Australians (629 women, 669 men), mean age 77 years.

MEASUREMENTS

A validated food frequency questionnaire was used to measure the dietary exposure; liberal diet defined as: energy >10% estimated requirements; sodium >1600mg; total fat >35% energy; saturated fat >10%; refined sugar >10%; fibre <38g males and <28g females. Frailty was determined using the Fried phenotype in combination with Cesari's biological definition of frailty. Chronic disease outcomes were measured by medication usage and obesity defined as BMI >30kg/m². Binary logistic regression was performed using participants free of chronic disease at baseline to determine the impact of each dietary exposure independently, and combined, on the development of frailty and the incidence of chronic disease over the subsequent eight years.

RESULTS

Incidence of frailty after 8 years of follow up was 14%. The incidence of diabetes after 8 years of follow up was 5.3%, hypertension 39%, hyperlipidaemia 15% and obesity 6%. A liberal energy intake adjusted for age and sex, significantly reduced the risk of developing frailty eight years post baseline (OR 0.48, 95% CI 0.30, 0.77). After adjustment for age, sex and body weight, a liberal saturated fat intake (>10% of energy) increased the risk of hyperlipidaemia (OR 2.11, 95% CI 1.27, 3.54). A liberal intake of sodium, total fat, refined sugar and fibre did not increase the risk of diabetes, hypertension, hyperlipidaemia or obesity.

CONCLUSIONS

This study suggests that a liberal intake of energy may decrease the risk of developing frailty in the elderly without increasing the risk of developing obesity, diabetes, hypertension or hyperlipidaemia. Caution should remain however in the prescription of diets high in saturated fat as the link established with hyperlipidaemia in young adults appears to be consistent in the elderly. Further research is required to explore the optimal sources of energy for a liberalised diet and the effect of a liberalised diet on other diet related health conditions.

OC-13 - Safe and effective use of direct oral anticoagulants (DOAC) versus conventional anticoagulation for the treatment of cancer-related venous thromboembolism

INTRODUCTION

Cancer is a risk factor for the development of venous thromboembolism (VTE). The standard of care for the treatment of cancer-related VTE is a low molecular weight heparin (LMWH) formulation. The treatment for these events can be painful, lengthy, and expensive. The development of DOAC has created new options for the treatment of VTE. Data from a recent systematic review suggested that the safety and effectiveness of DOAC in patients with cancer is equivalent to that of traditional therapies. If equivalent to LMWH, the use of DOAC in the treatment of cancer-related VTE would reduce the risk of VTE recurrence while giving patients freedom from subcutaneous injections.

AIM

Our primary aim was to determine the rate of VTE recurrence in patients on anticoagulation. Secondary aims were determination of the rate of anticoagulant-associated clinically relevant bleeding and VTE recurrence-free survival.

MATERIALS AND METHODS

We performed retrospective analysis (2014-2015) of the electronic medical records (EMR) of adult patients with cancer-related VTE treated with anticoagulation. We selected 122 patients for our final analysis according to the inclusion criteria. Demographic, laboratory, cancer diagnosis, and VTE diagnosis data were collected. We documented VTE recurrence as well as clinically relevant bleeding. Non-parametric statistical procedures were used to determine differences in variables associated with this study among the anticoagulant class groups, with a test significance level of 0.05.

RESULTS

Among 122 patients, 89 (73%) were treated with LMWH, 26 (21%) were treated with DOAC, and 7 (6%) were treated with warfarin. The majority of VTE occurred in patients with advanced disease. The most common index event was pulmonary embolism (49%) followed by catheter-associated deep venous thrombosis (DVT) (24%). Recurrence of VTE occurred in 7.7% of patients receiving DOAC and 7.9% of patients receiving LMWH (P=NS). Major bleeding occurred more often with the use of DOAC (11.5%) than with LMWH (10.1%), but non-major bleeding was more common in patients receiving LMWH (9.0% versus 7.7%). These differences were not statistically significant. There was no mortality attributed to bleeding complications. The VTE recurrence-free survival rates were not statistically different among LMWH versus DOAC (Figure 1).

CONCLUSIONS

Recurrence of cancer-associated VTE is not uncommon, and the treatment of VTE has significant hemorrhagic risks. Our analysis suggests that there is no significant difference in the rate of VTE recurrence and anticoagulant-related bleeding when using oral DOACs versus LMWH. Further studies are needed to compare the safety and effectiveness of these methods of anticoagulation.

Experimental Transmission of Bighorn Sheep Sinus Tumors to Bighorn Sheep (Ovis canadensis canadensis) and Domestic Sheep

Bighorn sheep sinus tumors are a recently described disease affecting the paranasal sinuses of Rocky Mountain bighorn sheep (Ovis canadensis canadensis). Several features of this disease suggest an infectious cause, although a specific etiologic agent has not been identified. To test the hypothesis that bighorn sheep sinus tumors are caused by an infectious agent, we inoculated 4 bighorn sheep lambs and 4 domestic sheep lambs intranasally with a cell-free filtrate derived from a naturally occurring bighorn sheep sinus tumor; we held 1 individual of each species as a control. Within 18 months after inoculation, all 4 inoculated domestic sheep (100%) and 1 of the 4 inoculated bighorn sheep (25%) developed tumors within the ethmoid sinuses or nasal conchae, with features similar to naturally occurring bighorn sheep sinus tumors. Neither of the uninoculated sheep developed tumors. Histologically, the experimentally transmitted tumors were composed of stellate to spindle cells embedded within a myxoid matrix, with marked bone production. Tumor cells stained positively with vimentin, S100, alpha smooth muscle actin, and osteocalcin, suggesting origin from a multipotent mesenchymal cell. A periosteal origin for these tumors is suspected. Immunohistochemical staining for the envelope protein of JSRV (with cross-reactivity to ENTV) was equivocal, and PCR assays specific for these agents were negative.

Tuberculosis in Rhinoceros: An Underrecognized Threat?

Historical evidence of tuberculosis (TB) affecting primarily captive rhinoceroses dates back almost two centuries. Although the causative Mycobacterium tuberculosis complex (MTC) species has not been determined in many cases, especially for those that occurred before bacterial culture techniques were available, the spectrum of documented reports illustrates the importance of TB as cause of morbidity and mortality in different rhinoceros species across continents. In more recent years, sporadic suspected or confirmed cases of TB caused by Mycobacterium bovis (M. bovis) have been reported in semi-free or free-ranging rhinoceroses in South Africa. However, the true risk TB may pose to the health and conservation of rhinoceros populations in the country's large conservation areas where M. bovis is endemic, which is unknown. Underlying the current knowledge gap is the lack of diagnostic tools available to detect infection in living animals. As documented in other wildlife species, TB could establish itself in a rhinoceros population but remain unrecognized for decades with detrimental implications for wildlife conservation at large and should such animals be moved to uninfected areas or facilities. This paper reviews the current state of knowledge regarding TB in rhinoceros including critical gaps that need to be addressed to effectively assess the threat that this disease may present to rhinoceros.

Does exposure to cigarette brands increase the likelihood of adolescent e-cigarette use? A cross-sectional study

OBJECTIVE

To examine the relationship between tobacco cigarette brand recognition, and e-cigarette use in adolescents.

DESIGN

Cross-sectional observational study.

SETTING

High schools in Scotland.

PARTICIPANTS

Questionnaires were administered to pupils in Secondary 2 (S2 mean age: 14.0 years) and Secondary 4 (S4 mean age: 15.9 years) across 4 communities in Scotland. An 86% response rate with a total sample of 1404 pupils was achieved.

MAIN OUTCOME MEASURES

Self-reported previous use of e-cigarettes and self-reported intention to try e-cigarettes in the next 6 months.

RESULTS

75% (1029/1377) of respondents had heard of e-cigarettes (69.5% S2, 81.1% S4), and of these, 17.3% (10.6% S2, 24.3% S4 n=1020) had ever tried an e-cigarette. 6.8% (3.7% S2, 10.0% S4 n=1019) reported that they intended to try an e-cigarette in the next 6 months. Recognition of more cigarette brands was associated with greater probability of previous e-cigarette use (OR 1.20, 99% CI 1.05 to 1.38) as was having a best friend who smoked (OR 3.17, 99% CI 1.42 to 7.09). Intention to try e-cigarettes was related to higher cigarette brand recognition (OR 1.41, 99% CI 1.07 to 1.87), hanging around in the street or park more than once a week (OR 3.78, 99% CI 1.93 to 7.39) and living in areas of high tobacco retail density (OR 1.20, 99% CI 1.08 to 1.34). Never having smoked was a protective factor for both future intention to try, and past e-cigarette use (OR 0.07, 99% CI 0.02 to 0.25; and OR 0.10, 99% CI 0.07 to 0.16, respectively).

CONCLUSIONS

Higher cigarette brand recognition was associated with increased probability of previous use and of intention to use e-cigarettes. The impact of tobacco control measures such as restricting point-of-sale displays on the uptake of e-cigarettes in young people should be evaluated.

Dehydrated human amnion/chorion membrane treatment of venous leg ulcers: correlation between 4-week and 24-week outcomes

OBJECTIVE

To evaluate correct correlation between an intermediate rate of wound reduction (40% wound area reduction after 4-weeks treatment) and complete healing at 24 weeks in patients with a venous leg ulcer (VLU).

METHOD

A retrospective follow-up study of patients completing a multicenter randomised controlled trial (RCT) comparing the number of patients achieving at least 40% healing of their VLU within 4-weeks of treatment with either dehydrated human amnion/chorion membrane (dHACM) allograft or multilayer compression only was conducted. Outcomes assessed were rates of complete healing within 24 weeks of enrolment and days to healing. Data were divided into two groups based on status at RCT completion (healed at least 40% yes or no). Correct correlation with status at 4 weeks and complete healing within 24 weeks was determined. Clinical characteristics were also compared for patients with and without correct correlation between 4-week and 24-week status.

RESULTS

We identified 55 patients at 5 study sites. Some 47 without complete healing during the initial study were eligible. As three patients were lost to follow-up we evaluated 44 records. Of these, 20 (45.4%) had reduced wound size of ≥40% and 24 (55%) had <40% reduction during the initial study. Complete healing occurred in 16/20 (80%) of the ≥40% group at a mean of 46 days, p=0.0027 and 8/24 (33.3%) of the <40% group at a mean of 103.6 days, p=0.0023. Overall, correct correlation of status at 4 weeks and ultimate healing status of VLU occurred in 32/44 patients (73%).

CONCLUSION

These results confirm that the intermediate outcome used in our initial study is a viable predictor of ultimate VLU healing.

Are We Missing Something Pertinent? A Bias Analysis of Unmeasured Confounding in the Firearm-Suicide Literature

Despite the magnitude and consistency of risk estimates in the peer-reviewed literature linking firearm availability and suicide, inferring causality has been questioned on the theoretical basis that existing studies may have failed to account for the possibility that members of households with firearms differ from members of households without firearms in important ways related to suicide risk. The current bias analysis directly addresses this concern by describing the salient characteristics that such an unmeasured confounder would need to possess in order to yield the associations between firearm availability and suicide observed in the literature when, in fact, the causal effect is null. Four US studies, published between 1992 and 2003, met our eligibility criteria. We find that any such unmeasured confounder would need to possess an untenable combination of characteristics, such as being not only 1) as potent a suicide risk factor as the psychiatric disorders most tightly linked to suicide (e.g., major depressive and substance use disorders) but also 2) an order of magnitude more imbalanced across households with versus without firearms than is any known risk factor. No such confounder has been found or even suggested. The current study strongly suggests that unmeasured confounding alone is unlikely to explain the association between firearms and suicide.

Inverse relationship between body mass index and mortality in older nursing home residents: a meta-analysis of 19,538 elderly subjects

Body mass index (BMI) and mortality in old adults from the general population have been related in a U-shaped or J-shaped curve. However, limited information is available for elderly nursing home populations, particularly about specific cause of death. A systematic PubMed/EMBASE/CINAHL/SCOPUS search until 31 May 2014 without language restrictions was conducted. As no published study reported mortality in standard BMI groups (<18.5, 18.5-24.9, 25-29.9, ≥30 kg/m(2)), the most adjusted hazard ratios (HRs) according to a pre-defined list of covariates were obtained from authors and pooled by random-effect model across each BMI category. Out of 342 hits, 20 studies including 19,538 older nursing home residents with 5,223 deaths during a median of 2 years of follow-up were meta-analysed. Compared with normal weight, all-cause mortality HRs were 1.41 (95% CI = 1.26-1.58) for underweight, 0.85 (95% CI = 0.73-0.99) for overweight and 0.74 (95% CI = 0.57-0.96) for obesity. Underweight was a risk factor for higher mortality caused by infections (HR = 1.65 [95% CI = 1.13-2.40]). RR results corroborated primary HR results, with additionally lower infection-related mortality in overweight and obese than in normal-weight individuals. Like in the general population, underweight is a risk factor for mortality in old nursing home residents. However, uniquely, not only overweight but also obesity is protective, which has relevant nutritional goal implications in this population/setting.

Intratympanic Contrast in the Evaluation of Menière Disease: Understanding the Limits

BACKGROUND AND PURPOSE

Studies describing endolymphatic hydrops in Menière disease after off-label intratympanic gadolinium-based contrast have been limited by long acquisition times. We aimed to demonstrate the feasibility of post-intratympanic imaging on a 3T MR imaging system within a clinically tolerable acquisition time and to address potential pitfalls in acquisition or interpretation.

MATERIALS AND METHODS

FDA Investigational New Drug 115,342 and institutional review board approval were obtained for intratympanic injection of 8-fold diluted Gd-DTPA into the more symptomatic ear of 6 adults with Menière disease. 3T MR imaging was performed using a 3-inch surface coil before and up to 28 hours after injection using FLAIR to define the nonenhancing endolymphatic space within the enhancing perilymph. Variable FLAIR TI images were used to determine the impact of fluid-suppression on interpretation. Image quality was assessed for perilymphatic and extralabyrinthine contrast enhancement, definition of endolymphatic anatomy, and other anatomic variants or pathologic findings.

RESULTS

The surface coil afforded 0.375 × 0.375 mm in-plane FLAIR resolution in <4 minutes 30 seconds, sufficient to perceive the nonenhancing spiral lamina, interscalar septa, and endolymphatic structures. Coronal views highlighted a potential interpretation pitfall of vestibular endolymphatic distention overestimation due to partial volume averaging. Varying FLAIR TI resulted in visible changes in the perception of the cochlear endolymphatic space. CSF enhancement was detectable at the internal auditory canal fundus on the injected side in half of the patients, which may confound interpretation.

CONCLUSIONS

Using a surface coil preserves high resolution within a clinically acceptable acquisition time. Pitfalls remain regarding the interpretation of these images and optimizing protocols across platforms in the absence of a clear internal reference for standardization.