Intraoperative scrub nurse turnover in orthopaedic surgery procedures: An opportunity for improved operating room efficiency

BACKGROUND

Scrub nurses play a crucial role in facilitating orthopaedic surgeries, and thus intraoperative scrub nurse turnover may disrupt the workflow of the surgical team and prolong duration of surgery (DOS). The purpose of this study was to quantify the impact of intraoperative scrub nurse turnover on operative time of orthopaedic surgeries lasting less than 3h in duration.

METHODS

Prospectively collected databases from two institutions were retrospectively queried to identify all orthopaedic procedures of maximum mean duration of 180min from March 4th, 2018 to August 31st, 2022. Cases were divided into two groups, those with scrub nurse turnover and those without. Propensity score matching was conducted to match groups by surgeon, hospital, patient age, gender, and ASA classification. Unpaired t-tests were used to compare mean DOS for each surgical procedure. Average treatment effect on treated (ATET) with 95% confidence intervals (CIs) were calculated.

RESULTS

Scrub nurse turnover significantly prolonged DOS for both bone forearm facture open reduction and internal fixation (ORIF) (ATET=21.08, p=0.001), ankle ORIF (ATET=21.26, p<0.001), clavicle ORIF (ATET=16.16, p=0.028), femur intramedullary nail (ATET=11.52, p=0.003), rotator cuff repair (ATET=16.88, p<0.001), partial discectomy (ATET=10.52, p=0.001), total knee arthroplasty (TKA) (ATET=5.69, p<0.001), anterior total hip arthroplasty (THA) (ATET=8.80, p<0.001), lateral THA (ATET=7.02, p<0.001), and uncemented hip hemiarthroplasty (ATET=16.79, p=0.049).

CONCLUSION

Intraoperative scrub nurse turnover significantly prolongs surgical times in orthopaedic surgeries lasting up to 3h in duration. This highlights the importance of developing strategies to prevent intraoperative scrub nurse turnover to improve OR efficiency and decrease healthcare costs.

Impact of Seasonal Changes on Asthma Control in North-Western Nigeria

BACKGROUND

Asthma control is poor worldwide and is often affected by changes in environmental conditions. Effort to determine the cause of this heavy burden on patients and the healthcare system is crucial.

AIM

To determine the role of seasonal changes on asthma control in Sokoto, North-Western Nigeria.

METHODS

One hundred and one (101) patients with physician diagnosed asthma were consecutively recruited after obtaining informed consent. A structured researcher administered questionnaire was used as instrument of data collection and asthma control test questionnaire was also used to assess level of asthma control in each participant. Five items with a 4-week recall were assessed. Data for temperature, humidity, wind and rain was obtained from the Nigerian Meteorological Agency (NIMET), Sokoto. We computed frequency and level of asthma control with seasons of the year and weather variables.

RESULTS

One hundred and one patients comprising 71 females and 30 males with a mean age of 32.14 ± 10.68 years participated in the study. Level of asthma control was found to be poor among the participants with 41(40.6%) having very poorly controlled asthma, 30(29.7%) with not well controlled and 30(24.8%) well controlled asthma respectively. Among patients with very poorly controlled asthma, 22(48.9%) occurred during harmattan season and 14(31.1%) during rainy season. Weather parameters such as humidity shows significant relationship with asthma control (B= -0.504, P= 0.031, 95% CI [-0.012, -0.0253]).

CONCLUSION

The study shows that asthma control is poor among the participants and presentation with poor asthma control is more during harmattan season.

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PURPOSE

Giant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.

METHODS

A retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.

RESULTS

The study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48-150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.

CONCLUSION

Type IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

EVALUATION THE EFFECT OF THE ADDITION OF ZIRCONIUM OXIDE AND TITANIUM DIOXIDE NANOPARTICLES ON SHEAR BOND STRENGTHS OF ORTHODONTIC ADHESIVE: IN-VITRO STUDY

OBJECTIVES

the study aims to assess the shear bond strength of modified- 3M orthodontic adhesive Transbond™ XT with different concentrations of Titanium Dioxide and zirconium oxide nanoparticles. In a retrospective cross-sectional study a hundred sound-extracted human upper premolars were collected. 3M orthodontic adhesive Transbond™ XT was modified by (0,02%, 0.04%, and 0.06% Zirconium Oxide), and (0,02%, 0.04%, and 0.06% Titanium Dioxide) nanoparticles, and (0,02%, 0.04%, and 0.06% Zirconium Oxide and Titanium Dioxide). dentaurum discovery pearl ceramic bracket were bonded to buccal enamel surfaces of the samples of control and nine modified adhesive groups. At 24 h after bonding, shear bond strength was measured. Adhesive remnant index was scored under (10X) magnification power of stereomicroscope after de-bonding. The chemical characteristics of orthodontic adhesive material were explored before and after mixing with Titanium Dioxide and zirconium oxide nanoparticles by using FTIR. (Zirconium Oxide nanoparticles) group and combination (Zirconium Oxide and Titanium Dioxide nanoparticles) had a higher shear bond strength mean value than the control group, 0.06% combination (Zirconium Oxide and Titanium Dioxide nanoparticles) group had the highest mean value. About adhesive remnant index, no significant differences were found among the studying groups. The addition of 0.06% combination (Zirconium Oxide and Titanium Dioxide nanoparticles) had the best performance and improved shear bond strength of 3M orthodontic adhesive Transbond™ XT.

Clinical Profile and Determinants of Loss to Follow-Up in Patients Enrolled in an Urban Antiretroviral Treatment Programme in Northwestern Nigeria

INTRODUCTION

Loss of follow up in patients enrolled on antiretroviral treatment programmes has the potential to reduce their quality of life. We set out to describe the profile and risk factors for loss to follow up in patients enrolled on our programme.

MATERIALS AND METHODS

In this retrospective study, we reviewed the records of patients who were identified as lost to follow up between August 2008 to July 2018. Determinants of loss to follow-up were identified by the use of binary logistic regression with SPSS to compare the data of patients lost to follow-up with randomly selected patients who were still in care.

RESULTS

A total of 4,250 patients were enrolled on our programme during the study period. Of these, 965 patients were identified as lost to follow-up, giving a loss to follow up rate of 22.7%. Compared to patients still in care, patients who were lost to follow up were significantly male (male, n =395, 56% versus female, n= 310, 44%, p<0.0001), of younger age (33.53+9.05 versus 34.48+9.25 years, p = 0.028), married (married, n = 669, 58.9% versus not married n = 467, 41.1%, p<0.0001) and with evidence of low crude weight at the time of recruitment (58.58+12.12 versus 60.09+14.58 kg, p = 0.018).

CONCLUSION

Our study showed that patients who are young, male, married, recently enrolled, with evidence of the low crude weight, with WHO Clinical Stages III and IV and anaemia at enrolment are commonly lost to follow-up. Clinicians need to target this population to reduce the loss of follow up in patients on antiretroviral therapy.

Comparison of the effect of zinc oxide nanoparticles and extract of Acorus calamus applied topically on surgical wounds inflicted on the skin of rabbits

Antibiotics are used for postsurgical wound healing purposes but unfortunately, resistance against them demands some alternatives for quick recovery. Sepsis of wounds is a challenge for medical as well as veterinary professionals. Nanoparticles have significant advantages in wound treatment and drug resistance reversal. This study was conducted to appreciate emerging alternates of antibiotics like zinc oxide nanoparticles and plant extracts in topical application. Zinc oxide is considered a good wound healer and its nanoparticles are easy to access. So, the efficacies of zinc oxide nanoparticles and sweet flag plant extract ointments were tested to compare modern and traditional therapeutics as sweet flag is considered a pure medicinal plant. Rabbits were selected for this study due to the healing properties of their skin. Wounds were inflicted on the thoracolumbar region and treated for 29 days post-surgically daily with normal saline and the ointment of zinc oxide nanoparticles and sweet flag extract ointment, prepared in a hydrophilic solvent. Wound shrinkage was observed daily and histopathological analysis was made and results were compared. Zinc oxide nanoparticles ointment showed the most satisfactory results for every parameter included in the study. No side effects of its topical application were observed. Healing was normal without any complications. The preparations of zinc oxide nanoparticles may help in the era of antibiotic resistance as topical drugs in the future.

Clinical and exploratory biomarker findings from the MODUL trial (Cohorts 1, 3 and 4) of biomarker-driven maintenance therapy for metastatic colorectal cancer

PURPOSE

MODUL is an adaptable, signal-seeking trial of biomarker-driven maintenance therapy following first-line induction treatment in patients with metastatic colorectal cancer (mCRC). We report findings from Cohorts 1 (BRAF^mut), 3 (human epidermal growth factor 2 [HER2]+) and 4 (HER2‒/high microsatellite instability, HER2‒/microsatellite stable [MSS]/BRAF^wt or HER2‒/MSS/BRAF^mut/RAS^mut).

METHODS

Patients with unresectable, previously untreated mCRC without disease progression following standard induction treatment (5-fluorouracil/leucovorin [5-FU/LV] plus oxaliplatin plus bevacizumab) were randomly assigned to control (fluoropyrimidine plus bevacizumab) or cohort-specific experimental maintenance therapy (Cohort 1: vemurafenib plus cetuximab plus 5-FU/LV; Cohort 3: capecitabine plus trastuzumab plus pertuzumab; Cohort 4: cobimetinib plus atezolizumab). The primary efficacy end-point was progression-free survival (PFS).

RESULTS

Cohorts 1, 3 and 4 did not reach target sample size because of early study closure. In Cohort 1 (n = 60), PFS did not differ between treatment arms (hazard ratio, 0.95; 95% confidence intervals 0.50-1.82; P = 0.872). However, Cohort 1 exploratory biomarker data showed preferential selection for mitogen-activated protein kinase (MAPK) pathway mutations (mainly KRAS, NRAS, MAP2K1 or BRAF) in the experimental arm but not the control arm. In Cohort 3 (n = 5), PFS ranged from 3.6 to 14.7 months versus 4.0 to 5.4 months in the experimental and control arms, respectively. In Cohort 4 (n = 99), PFS was shorter in the experimental arm (hazard ratio, 1.44; 95% confidence intervals 0.90-2.29; P = 0.128).

CONCLUSIONS

Vemurafenib plus cetuximab plus 5-FU/LV warrants further investigation as first-line maintenance treatment for BRAF^mut mCRC. MAPK-pathway emergent genomic alterations may offer novel therapeutic opportunities in BRAF^mut mCRC. Cobimetinib plus atezolizumab had an unfavourable benefit:risk ratio in HER2‒/MSS/BRAF^wt mCRC. New strategies are required to increase the susceptibility of MSS mCRC to immunotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02291289.

Appendiceal diverticulum masquerading as acute appendicitis

Appendiceal diverticula present as rare clinical finding and are most confused with acute appendicitis. A 65-year-old female was presented to our surgical service after 1 day of right lower quadrant abdominal pain and a computed tomography evaluation, read as a diagnosis of acute appendicitis. Due to the location and quality of pain and intraoperative findings acute appendicitis was our preliminary diagnosis. Follow up with histopathology confirmed acute inflammation of an appendiceal diverticulum. With discordance in original diagnosis from final pathological evaluation, we suggest appendiceal diverticula as an important differential to consider in patients of similar clinical presentation. Surgical treatment with appendectomy and final histological diagnosis are essential in the proper treatment of this rare clinical finding.

Who tells the story of burns in low-and-middle income countries? – A bibliometric study

INTRODUCTION

Low- and middle-income countries (LMICs) remain drastically underrepresented in health research, with African countries producing less than 1% of the global output. This work investigates authorship patterns of publications on burns in LMICs. Original research studies addressing burn injuries in LMICs and published between 1st January 2015 and 31st December 2020 were included in the review. Descriptive statistics were performed for country affiliations of authors, World Bank Country Income Groups, WHO group, study-focus and country studied. Of the 458 results, 426 studies met the inclusion criteria. Nearly a quarter of papers on burns in LMICs had both first and senior authors from high-income countries (HICs, n = 95, 24.4%), more than half of the papers had both first and senior authors from upper middle- income countries (upper MICs, n = 222, 57.2%), while less than 1% (n = 3) had first and senior authors exclusively from lower-income countries (LICs). Eleven percent (n = 41/388) of all papers were written without either first nor senior author being from the country studied, and 17 of them (41%) had both first and senior authors from the USA. Twenty-five (6%) of the papers had the first author and not the senior author from the country of focus, while six (2%) had the senior and not the first author from the country of interest. To overcome global health challenges such as burns, locally led research is imperative. The maximum benefit of HIC-LMIC collaborations is achieved when LMICs play an active role in leading the research. When LMICs direct the research being conducted in their country, the harm of inherently inequitable relationships is minimized.

Oral 11β-HSD1 inhibitor AZD4017 improves wound healing and skin integrity in adults with type 2 diabetes mellitus: a pilot randomized controlled trial

BACKGROUND

Chronic wounds (e.g. diabetic foot ulcers) reduce the quality of life, yet treatments remain limited. Glucocorticoids (activated by the enzyme 11β-hydroxysteroid dehydrogenase type 1, 11β-HSD1) impair wound healing.

OBJECTIVES

Efficacy, safety, and feasibility of 11β-HSD1 inhibition for skin function and wound healing.

DESIGN

Investigator-initiated, double-blind, randomized, placebo-controlled, parallel-group phase 2b pilot trial.

METHODS

Single-center secondary care setting. Adults with type 2 diabetes mellitus without foot ulcers were administered 400 mg oral 11β-HSD1 inhibitor AZD4017 (n = 14) or placebo (n = 14) bi-daily for 35 days. Participants underwent 3-mm full-thickness punch skin biopsies at baseline and on day 28; wound healing was monitored after 2 and 7 days. Computer-generated 1:1 randomization was pharmacy-administered. Analysis was descriptive and focused on CI estimation. Of the 36 participants screened, 28 were randomized.

RESULTS

Exploratory proof-of-concept efficacy analysis suggested AZD4017 did not inhibit 24-h ex vivoskin 11β-HSD1 activity (primary outcome; difference in percentage conversion per 24 h 1.1% (90% CI: -3.4 to 5.5) but reduced systemic 11β-HSD1 activity by 87% (69-104%). Wound diameter was 34% (7-63%) smaller with AZD4017 at day 2, and 48% (12-85%) smaller after repeat wounding at day 30. AZD4017 improved epidermal integrity but modestly impaired barrier function. Minimal adverse events were comparable to placebo. Recruitment rate, retention, and data completeness were 2.9/month, 27/28, and 95.3%, respectively.

CONCLUSION

A phase 2 trial is feasible, and preliminary proof-of-concept data suggests AZD4017 warrants further investigation in conditions of delayed healing, for example in diabetic foot ulcers.

SIGNIFICANCE STATEMENT

Stress hormone activation by the enzyme 11β-HSD type 1 impairs skin function (e.g. integrity) and delays wound healing in animal models of diabetes, but effects in human skin were previously unknown. Skin function was evaluated in response to treatment with a 11β-HSD type 1 inhibitor (AZD4017), or placebo, in people with type 2 diabetes. Importantly, AZD4017 was safe and well tolerated. This first-in-human randomized, controlled, clinical trial found novel evidence that 11β-HSD type 1 regulates skin function in humans, including improved wound healing, epidermal integrity, and increased water loss. Results warrant further studies in conditions of impaired wound healing, for example, diabetic foot ulcers to evaluate 11β-HSD type 1 as a novel therapeutic target forchronic wounds.

Genetic and phenotypic characteristics of Clostridium (Clostridioides) difficile from canine, bovine, and pediatric populations

Objectives:

Carriage of Clostridioides difficile by different species of animals has led to speculation that animals could represent a reservoir of this pathogen for human infections. The objective of this study was to compare C. difficile isolates from humans, dogs, and cattle from a restricted geographic area.

Methods:

C. difficile isolates from 36 dogs and 15 dairy calves underwent whole genome sequencing, and phenotypic assays assessing growth and virulence were performed. Genomes of animal-derived isolates were compared to 29 genomes of isolates from a pediatric population as well as 44 reference genomes.

Results:

Growth rates and relative cytotoxicity of isolates were significantly higher and lower, respectively, in bovine-derived isolates compared to pediatric- and canine-derived isolates. Analysis of core genes showed clustering by host species, though in a few cases, human strains co-clustered with canine or bovine strains, suggesting possible interspecies transmission. Geographic differences (e.g., farm, litter) were small compared to differences between species. In an analysis of accessory genes, the total number of genes in each genome varied between host species, with 6.7% of functional orthologs differentially present/absent between host species and bovine-derived strains having the lowest number of genes. Canine-derived isolates were most likely to be non-toxigenic and more likely to carry phages. A targeted study of episomes identified in local pediatric strains showed sharing of a methicillin-resistance plasmid with dogs, and historic sharing of a wide range of episomes across hosts. Bovine-derived isolates harbored the widest variety of antibiotic-resistance genes, followed by canine

Conclusions:

While C. difficile isolates mostly clustered by host species, occasional co-clustering of canine and pediatric-derived isolates suggests the possibility of interspecies transmission. The presence of a pool of resistance genes in animal-derived isolates with the potential to appear in humans given sufficient pressure from antibiotic use warrants concern.

1158 Summarising the Reporting of Study Outcomes in Robotic Oesophagectomy: A Systematic Review

Introduction

There is an increasing adoption of robotic oesophagectomy in place of standard techniques for oesophageal cancer resection. This is potentially due to its perceived technical benefits and improved short-term outcomes. Consistency in outcome selection, definition and reporting between studies is required for effective evidence synthesis and prevention of research waste. The aim of this review is to perform an in-depth analysis of outcome reporting in robotic oesophagectomy.

Method

Systematic searches were conducted using key words for robotic surgery and oesophageal cancer, from inception to February 2020. Studies reporting any outcome for robotic oesophagectomy were included. Outcomes in each study were recorded verbatim and categorised into twelve domains. Outcomes were independently categorised by two reviewers. Where reported, the follow-up period was also recorded.

Results

Of 954 abstracts screened, 226 full texts were reviewed and 102 included. Only one study was a RCT. A total of 1422 outcomes were reported. Each study had a median of 14 reported outcomes (range 1-25). Outcomes related to complications (n = 578, 99 studies), technical/operative factors (n = 290, 90 studies), and pathology (e.g., resection margin) (n = 197, 83 studies) were reported most frequently. No single outcome, or outcome domain was reported in all studies. No studies used a core outcome set for reporting. Forty-five studies stated a follow-up period, ranging from &lt;1 month to 58 months.

Conclusions

There is significant heterogeneity in the selection and reporting of outcomes in robotic oesophagectomy. This calls for the use of a core outcome set to allow standardisation and transparency of outcome reporting.

Effects on egg production and quality of supplementing drinking water with calcium and magnesium

This study was conducted to appraise the effects on egg quality and production performance of laying hens when drinking water was supplemented with calcium (Ca) and magnesium (Mg). A total of 384 (64-week-old) Hy-line Brown laying hens were assigned at random to four treatments, which consisted of CON: unsupplemented drinking water; T1: drinking water + 2 mg/L Ca + 250 mg/L Mg; T2: drinking water + 4 mg/L Ca + 510 mg/L Mg /10 L; and T3: drinking water + 5 mg/L Ca and 760 mg/L Mg. The experiment lasted six weeks. Water intake increased linearly in week 1 with the rising levels of Ca and Mg in the drinking water. Increasing the Ca and Mg levels improved eggshell strength (week 2 (P =0.01), week 5 (P =0.01), and week 6 (P = 0.03), and eggshell thickness (week 6) (P =0.02) and reduced the rate at which eggs were broken (week 4) (P =0.01). The supplemental Ca and Mg did not affect egg production, egg weight, Haugh unit, albumen height, eggshell colour, and yolk colour compared with CON. Nor did they influence the Haugh unit and albumen height after storing for 1, 5, 10 and 15 days. In conclusion, adding Ca and Mg to the drinking water increased the thickness and strength of the eggshells.

Characteristics and long-term outcomes of patients with reduced ejection fraction referred for adenosine stress perfusion cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Adenosine stress perfusion has been shown to be of minimal incremental benefit in distinguishing between ischaemic and non-ischaemic aetiology of severe left ventricular systolic dysfunction (LVSD) over and above that obtained from Cardiac Magnetic Resonance (CMR) with Late Gadolinium Enhancement (LGE). Stress CMR has, however, been shown to be effective in risk-stratifying LVSD patients, with ischaemia being an independent predictor of cardiovascular death or myocardial infarction (MI) and associated with higher rates of further intervention.

Purpose

Evaluate real world data from a single tertiary UK cardiac MRI centre to determine the characteristics and long-term clinical outcomes of patients with LVSD referred for stress CMR. 

Methods

As part of an ongoing registry, all consenting patients with Ejection Fraction (EF) ≤40% and a completed adenosine stress perfusion CMR between January 2015 and December 2019 were included with prospective baseline data collection. All-cause mortality and cardiac hospitalisation, coronary angiography/revascularisation was determined from electronic hospital records. Outcomes were compared between the inducible ischaemia vs. no ischaemia groups, and LGE present vs. no LGE groups using chi square. 

Results

The sample included 86 patients. The mean EF was 32 ± 6%. Median follow up was 3.8 years (range 41-2222 days). The indications for CMR were: 30 (35%) assess ischaemia, 35 (41%) assess LVSD aetiology and 21 (24%) LVSD assess viability. 

Inducible ischemia was present in 30 (35%) patients and absent in 56 (65%).  Patient characteristics and outcomes are shown in Table 1. Baseline characteristics were similar between the groups but there was a higher rate of hypertension and ischaemic heart disease in the ischaemia group. There was a non-significant difference in combined mortality and cardiac hospitalisation rates between the groups (40% vs. 27% p = 0.20). 

LGE was present in 69 (80%) patients (28 with ischaemia; 41 without) and absent in 17 (20%, 2 with ischaemia, 15 without). The event rate was 23 (33%) vs. 4 (24%) between LGE vs. No LGE groups (p = 0.44). Of the 15 patients (17%) with no LGE or ischaemia; 2 died and 1 was hospitalised, there were no MI"s and no Percutaneous Coronary Intervention (PCI).

The lack of statistical difference in event rates between ischaemia and no ischaemia groups may be due to our relatively small sample size or could reflect the effectiveness of contemporary disease modifying treatment for Heart Failure with reduced EF.

Conclusion

This real-world data supports published findings that in patients with LVSD and no LGE on CMR, ischaemia is very uncommon and stress CMR is unlikely to increase diagnostic yield. Conversely, if stress CMR is performed and ischaemia is absent, incidence of subsequent angiography and revascularisation is very low, which is reassuring in clinical practice.  In those patients without ischaemia and LGE, likelihood of MI is low.

Exploratory biomarker findings from cohort 2 of MODUL: An adaptable, phase 2, signal-seeking trial of fluoropyrimidine + bevacizumab ± atezolizumab maintenance therapy for BRAFwt metastatic colorectal cancer

3570

Background: MODUL is an adaptable, phase 2, signal-seeking trial testing novel agents as first-line therapy for predefined subgroups of patients with metastatic colorectal cancer (mCRC). Previously reported findings demonstrated that adding atezolizumab to fluoropyrimidine (FP)/bevacizumab as first-line maintenance treatment after induction with FOLFOX + bevacizumab did not improve efficacy outcomes in BRAFwt mCRC. Given these efficacy results, exploratory assessments on tumour samples were conducted to provide insights into factors that might affect efficacy of maintenance treatment and provide guidance on appropriate therapeutic strategies for BRAFwt mCRC. Methods: In patients with BRAFwt tumours (Cohort 2), experimental treatment was FP/bevacizumab + atezolizumab. Primary efficacy endpoint: progression-free survival (PFS). Overall survival (OS) was a secondary endpoint. Archival tissue samples from 104 patients were analysed by immunohistochemistry (IHC) at HistoGeneX (PD-L1; CD8/GrB/FoxP3). SP142 antibody was used for PD-L1 IHC analysis, which evaluated PD-L1low (IC 0–1) vs PD-L1high (IC > 1) in correlation with PFS and OS in the control and experimental arms. CD8/GrB/FoxP3 triplex staining was also performed to evaluate potential correlations with efficacy. Results: 445 patients with BRAFwt mCRC were randomised (2:1 ratio) to maintenance treatment in Cohort 2. Archival samples from 104 patients were analysed: FP/bevacizumab + atezolizumab (n = 82); FP/bevacizumab (n = 22). The biomarker evaluable population (BEP) for PD-L1 was n = 81 for FP/bevacizumab + atezolizumab [PD-L1low n = 35 (43%); PD-L1high n = 46 (57%)] and n = 22 for FP/bevacizumab [PD-L1low n = 16 (72%); PD-L1high n = 6 (28%)]. The BEP for CD8/GrB was n = 50 for FP/bevacizumab + atezolizumab and n = 16 for FP/bevacizumab. No difference in PFS or OS was observed in the FP/bevacizumab + atezolizumab vs FP/bevacizumab arms for PD-L1high [PFS: HR = 1.5 (95% CI 0.45−4.8), p = 0.51; OS: HR = 1.3 (95% CI 0.38−4.1), p = 0.71] or PD-L1low [PFS: HR = 0.92 (95% CI 0.47−1.8), p = 0.81; OS: HR = 0.78 (95% CI 0.4−1.5), p = 0.48]. Similar results were observed with CD8/GrBhigh [PFS: HR = 0.73 (95% CI 0.27−2.0), p = 0.55; OS: HR = 0.66 (95% CI 0.24−1.8), p = 0.44], CD8/GrBlow [PFS: HR = 1.0 (95% CI 0.42–2.5), p = 0.96; OS: HR = 0.73 (95% CI 0.3–1.8), p = 0.5], FoxP3high [PFS: HR = 0.97 (95% CI 0.37−2.5), p = 0.95; OS: HR = 0.95 (95% CI 0.36−2.5), p = 0.91] and FoxP3low [PFS: HR = 0.73 (95% CI 0.29−1.9), p = 0.53; OS: HR = 0.5 (95% CI 0.19−1.3), p = 0.18]. Conclusions: These findings suggest that PD-L1, CD8/GrB and FoxP3 might not be predictive biomarkers in BRAFwt mCRC. Further analyses are needed to further evaluate potential predictive and prognostic factors of response in this setting. Clinical trial information: NCT02291289.

Managing breast gangrene during the COVID-19 pandemic

At the onset of the COVID-19 crisis, a 63-year-old woman with multiple life-limiting comorbidities was referred with a necrotic infected left breast mass on a background of breast cancer treated with conservation surgery and radiotherapy 22 years previously. The clinical diagnosis was locally advanced breast cancer, but four separate biopsies were non-diagnostic. Deteriorating renal function and incipient sepsis and endocarditis resulted in urgent salvage mastectomy during the peak of the COVID19 pandemic. The final diagnosis was infected ischaemic/infarcted breast (wet gangrene) secondary to vascular insufficiency related to diabetes, cardiac revascularisation surgery and breast radiotherapy.

Intravenous immunoglobulin and intravenous methylprednisolone as optimal induction treatment in chronic inflammatory demyelinating polyradiculoneuropathy: protocol of an international, randomised, double-blind, placebo-controlled trial (OPTIC)

Background

International guidelines recommend either intravenous immunoglobulin (IVIg) or corticosteroids as first-line treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). IVIg treatment usually leads to rapid improvement and is generally safe, but does not seem to lead to long-term remissions. Corticosteroids act more slowly and are associated with more side effects, but may induce long-term remissions. The hypothesis of this study is that combined IVIg and corticosteroid induction treatment will lead to more frequent long-term remissions than IVIg treatment alone.

Methods

An international, randomised, double-blind, placebo-controlled trial, in adults with ‘probable’ or ‘definite’ CIDP according to the EFNS/PNS 2010 criteria. Three groups of patients are included: (1) treatment naïve, (2) known CIDP patients with a relapse after > 1 year without treatment, and (3) patients with CIDP who improved within 3 months after a single course of IVIg, who subsequently deteriorate at any interval without having received additional treatment. Patients are randomised to receive 7 courses of IVIg and 1000 mg intravenous methylprednisolone (IVMP) (in sodium chloride 0.9%) or IVIg and placebo (sodium chloride 0.9%), every 3 weeks for 18 weeks. IVIg treatment consists of a loading dose of 2 g/kg (over 3–5 days) followed by 6 courses of IVIg 1/g/kg (over 1–2 days). The primary outcome is remission at 1 year, defined as improvement in disability from baseline, sustained between week 18 and week 52 without further treatment. Secondary outcomes include changes in disability, impairment, pain, fatigue, quality of life, care use and costs and (long-term) safety.

Discussion

In case of superiority of the combined treatment, patients will experience the advantages of two proven efficacious treatments, namely rapid improvement due to IVIg and long-term remission due to corticosteroids. Long-term remission would reduce the need for maintenance IVIg treatment and may decrease health care costs. Additionally, we expect that the combined treatment leads to a higher proportion of patients with improvement as some patients who do not respond to IVIg will respond to corticosteroids. Risks of short and long-term additional adverse events of the combined treatment need to be assessed.

Trial registration

ISRCTN registry ISRCTN15893334. Prospectively registered on 12 February 2018.

Severe preeclampsia is associated with postpartum diastolic dysfunction and non-dipping blood pressure profile pattern

Background

Left ventricular diastolic dysfunction and non-dipping profile, detected by ambulatory blood pressure monitoring (ABPM), are two features recorded to be associated with sustained hypertension. Both are predictors of an increased cardiovascular morbidity later in life. Complete normalization of blood pressure (BP) in preeclampsia is detected over a variable period of time.

Methods

A prospective cohort study was conducted in a tertiary university hospital including normotensive women with a history of preeclampsia in the current pregnancy enrolled within the first week postpartum. All cases were subjected to 24 h-ABPM and 2D trans-thoracic echocardiography three months post postpartum concomitantly with a clinical evaluation. Chi2-test was used to compare the qualitative data while student t-test was used to compare the quantitative data. Multivariate regression analysis was used for prediction of non-dippers and diastolic dysfunction in our cohort.

Results

Hundred twenty eight women were included in the study. Their mean age was 28.6±5.1 years and the mean basal BP was 123.1±6.4/74.6±5.9 mm Hg. Out of the studied women, 90 (70.3%) women were dippers and 38 (29.7%) women were non-dippers. It was noticed that diastolic dysfunction was presented in 28 (73.7%) of non-dippers while none of dippers had diastolic dysfunction. Women with severe preeclampsia had higher frequency of non-dipper (35.5% vs. 24.2%; P=0.02) and diastolic dysfunction (29% vs. 15%; P=0.01) in comparison to those women with mild preeclampsia. Severe preeclampsia and previous history of preeclampsia were significant predictors for non-dipping status (OR=1.1, 95% CI: 0.05–10.56 and 1.4, 95% CI: 0.30–4.26 respectively, R2 = 0.7; P&lt;0.001). They were also predictors for diastolic dysfunction in our studied population (OR = 1.6, 95% CI: 1.1–2.2 and 1.3, 95% CI: 1.2–2.2 respectively, R2 = 0.6; P&lt;0.05).

Conclusion

Women with a history of preeclampsia have the risk for developing cardiovascular events later in life. The severity and recurrence of preeclampsia were significant predictors for both non-dipping profile and diastolic dysfunction.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Orman Heart Hospital-Assiut University; Women Health Hospital-Assiut University

Impact of acute kidney injury on in-hospital outcomes among patients hospitalized with acute heart failure: a propensity score matched analysis

Background

Acute kidney injury (AKI) is frequently present in patients admitted for acute heart failure (AHF). Several studies have evaluated the mortality risk and have concluded poor prognosis in any patient with AKI admitted for AHF. For the most part, the additional morbidity and mortality burden in AHF patients with AKI has been attributed to the concomitant comorbidities, and/or interventions.

Purpose

We sought to determine the impact of acute kidney injury (AKI) on in-hospital outcomes in patients presenting with acute heart failure (AHF). We identified isolated AKI patients after excluding other concomitant diagnoses and procedures, which may contribute to an increased risk of mortality and morbidity.

Methods

Data from the National Inpatient Sample (2012- 14) were used to identify patients with the principal diagnosis of AHF and the concomitant secondary diagnosis of AKI. Propensity score matching was performed on 30 baseline variables to identify a matched cohort. The outcome of interest was in-hospital mortality. We further evaluated in-hospital procedures and complications.

Results

Of 1,470,450 patients admitted with AHF, 24.3% had AKI. After propensity matching a matched cohort of 356,940 patients was identified. In this matched group, the AKI group had significantly higher in-hospital mortality (3.8% vs 1.7%, p&lt;0.001). Complications such as sepsis and cardiac arrest were higher in the AKI group. Similarly, in-hospital procedures including CABG, mechanical ventilation and IABP were performed more in the AKI group. AHF patients with AKI had longer in-hospital stay of ∼1.7 days.

Conclusions

In a propensity score-matched cohort of AHF with and without AKI, the risk of in-hospital mortality was &gt;2-fold in the AKI group. Healthcare utilization and burden of complications were higher in the AKI group.

Funding Acknowledgement

Type of funding source: None

Best practice recommendations: ENT consultations during the COVID-19 pandemic

These best practice recommendations for ENT consultations during the COVID-19 pandemic have been drawn up because ENT examinations and treatments are at risk of contamination by the SARS-Cov-2 virus in certain instances. Thus, ENT specialists are among the professionals who are most exposed to this infection. During the pandemic, insofar as an asymptomatic patient may be infected and contagious, the same precautions must be employed whether the patient is ill with, suspected of having, or without any clinical evidence of COVID-19 infection. According to the scientific data available, the examinations and procedures potentially exposing to projections/aerosolizations of organic material of human origin are considered to be at risk of staff contamination. For ENT examinations and procedures without exposure to such projections/aerosolizations, the professional is advised to a long sleeve clean outfit, a surgical mask and gloves in case of contact with the patient's mucosa. ENT examinations and procedures with exposure to these projections/aerosolizations require the so-called "airborne", "contact", and "droplets" additional precautions: FFP2/N95 respiratory protection device, eye protection, disposable headwear and long sleeve overgown.

Diagnostic utility of additional whole-chest CT as part of an acute abdominal pain CT imaging pathway during the COVID-19 pandemic

AIM

To evaluate the diagnostic utility of additional whole-chest computed tomography (CT) in identifying otherwise unheralded COVID-19 lung disease as part of an acute abdominal pain CT imaging pathway in response to the COVID-19 pandemic.

MATERIALS AND METHODS

Consecutive patients (n=172) who underwent additional whole-chest CT via a COVID-19 acute abdominal pain CT imaging pathway between 27 March and 3 May 2020 were evaluated in this retrospective single-centre study. Chest CT examinations were graded as non-COVID-19, indeterminate for, or classic/probable for COVID-19. CT examinations in the latter two categories were further divided into one of three anatomical distributions (lung base, limited chest [below carina], whole chest [above carina]) based on location of findings. Reverse transcriptase-polymerase chain reaction (RT-PCR) results and clinical features of COVID-19 were assessed to determine if COVID-19 was clinically suspected at the time of CT referral.

RESULTS

Twenty-seven of the 172 (15.7%) patients had CT features potentially indicative of COVID-19 pneumonia, 6/27 (3.5%) demonstrating a classic/probable pattern and 21/27 (12.2%) demonstrating an indeterminate pattern. After correlation with clinical features and RT-PCR 8/172 (4.7%) were defined as COVID-19 positive, of which only 1/172 (0.6%) was clinically unsuspected of COVID-19 at the time of CT referral. All COVID-19 positive cases could be identified on review of the lung base alone.

CONCLUSION

Whole-chest CT as part of an acute abdominal pain CT imaging pathway has a very low diagnostic yield for our cohort of patients. All COVID-19-positive patients in our cohort were identified on review of the lung bases on the abdominal CT and this offers an alternative imaging approach in this patient group.

Elevated plasma and synovial fluid interleukin-8 and interleukin-18 may be associated with the pathogenesis of knee osteoarthritis

PURPOSE

Osteoarthritis (OA) of the knee is a multifactorial degenerative disease typically defined as the 'wear and tear' of articular joint cartilage. However, recent studies suggest that OA is a disease arising from chronic low-grade inflammation. We conducted a study to investigate the relationship between chronic inflammatory mediators present in both the systemic peripheral blood system and localised inflammation in synovial fluid (SF) of OA and non-OA knees; and subsequently made direct comparative analyses to understand the mechanisms that may underpin the processes involved in OA.

METHODS

20-Plex proteins were quantified using Human Magnetic Luminex® assay (R&D Systems, USA) from plasma and SF of OA (n = 14) and non-OA (n = 14) patients. Ingenuity Pathway Analysis (IPA) software was used to predict the relationship and possible interaction of molecules pertaining to OA.

RESULTS

There were significant differences in plasma level for matrix metalloproteinase (MMP)-3, interleukin (IL)-27, IL-8, IL-4, tumour necrosis factor-alpha, MMP-1, IL-15, IL-21, IL-10, and IL-1 beta between the groups, as well as significant differences in SF level for IL-15, IL-8, vascular endothelial growth factor (VEGF), MMP-1, and IL-18. Our predictive OA model demonstrated that toll-like receptor (TLR) 2, macrophage migration inhibitory factor (MIF), TLR4 and IL-1 were the main regulators of IL-1B, IL-4, IL-8, IL-10, IL-15, IL-21, IL-27, MMP-1 and MMP-3 in the plasma system; whilst IL-1B, TLR4, IL-1, and basigin (BSG) were the regulators of IL-4, IL-8, IL-10, IL-15, IL-18, IL-21, IL-27, MMP-1, and MMP-3 in the SF system.

CONCLUSION

The elevated plasma IL-8 and SF IL-18 may be associated with the pathogenesis of OA via the activation of MMP-3.

Hepatoprotective Effects of Suberoylanilide Hydroxamic Acid (A Histone Deacetylase Inhibitor) in Immunological Liver Injury in Rats

One of the main reasons for the development of chronic liver disease is autoimmune hepatitis (AIH).  There is no clear etiological factor for AIH occurrence and no drug has been approved for its treatment. Vorinostat, a Histone deacetylase inhibitor (HDACi) has been shown to reduce inflammation. Our aim was to explore the therapeutic potential of vorinostat in a rat model of AIH induced by Concanavalin A (Con A). The rats were randomly divided into 4 groups; control group, con A (20 mg/kg/iv/wk) group, vorinostat (15 mg/kg/day p.o) group and Con A with vorinostat group. Blood and liver samples were collected at the end of the fourth and eighth weeks for biochemical and histopathological examinations. Results revealed that administration of Con A elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) liver enzymes, which were reduced to 52.8% and to 61.8% respectively on simultaneous administration of Vorinostat as compare to Con A group.  Furthermore, Vorinostat reduced fibrosis and diminished apoptosis as deduced by the decrease in the hepatic hydroxyproline content of the liver and tumor necrosis factor-alpha levels. Relative gene expression analysis of interleukin 1b and transforming growth factor beta were significantly decreased in groups treated with vorinostat. Histopathological analysis showed that administration of vorinostat significantly restored the well organized structure of the liver, decreased initial inflammation produced by Con A, reduced liver fibrosis and mitigated hepatic stellate cell’s activities. In conclusion, administration of vorinostat in Con A model of autoimmune hepatitis, significantly decreased liver inflammation and fibrosis. So vorinostat might show a novel therapeutic approach for management of autoimmune hepatitis and its obstacles.

P1817Assessment of carotid stiffness indices in patients with ischemic stroke

Background

Arterial stiffness is considered as an emerging new important risk factor for stoke development. Measuring carotid stiffness is easy and non-invasive and thus can be widely applicable.

Purpose

To evaluate the carotid stiffness indices in patients with ischemic stroke compared to normal healthy subjects.

Methods

Included in this study are 60 patients (group 1) with ischemic stroke and 60 healthy control subjects (group 2). Participants were exposed to routine clinical examination and Duplex assessment of both carotid arteries. A specific wall tracking system was used for the semiautomatic calculation of the carotid stiffness indices, which included; compliance coefficient (CC), distensibility coefficient (DC), carotid pulse wave velocity (PWV) and carotid intima media thickness (IMT). Results from both carotid arteries were averaged and data from group 1 patients were compared to group 2 subjects.

Results

The mean age was (60.1±6.9 years) in group 1 compared to (60.1±6.6 years) in group 2 (p=0.9). A significant difference was found between both groups in all carotid stiffness indices; including average CC (0.64±0.29 vs 0.82±0.36 m2/kpa, p=0.004); average DC (11.69±5.42 vs 18.61±11.87 1/kpa, p<0.001); average PWV (16.5±0.6 vs 12.5±3.7 m/s, p<0.001) and average IMT (0.78±0.13 vs 0.68±0.18 mm, p=0.001). Only the carotid PWV was found to be a predictor of vascular stroke (p=0.001)

Conclusion

Patients with vascular stroke have higher carotid stiffness indices than age matched control subjects. Measuring carotid stiffness indices in patients who have atherosclerotic risk factors may help predict those at risk of vascular stroke and thus guide a tighter and a more efficient risk factors control.

Road Map to Setting Up a Palliative Care Service in a Tertiary Center Gynecologic Oncology Unit in Egypt

Background and context: Developing countries struggle with high cancer mortality and low resources. Cancer patients experience pain and physical symptoms in addition to psychological, social and spiritual worries that increase as the patients' conditions progress. Palliative care (PC) primary goal is to help people live as well as they can for the duration of their illness, with the finest physical and emotional well-being possible despite complex problems. However, there are considerable barriers to PC service implementation in developing countries. Aim: Our goal is to set up a PC service and integrate it as a standard of care for gynecologic cancer patients managed at Assiut University Hospitals, Egypt. The objective of this study is to investigate the tools needed to integrate a PC service in any oncology service in developing countries. Strategy/Tactics: A capacity building and local provision PC development framework was laid. Strategies included expanding the gynecologic oncology unit, assessment of PC knowledge among health providers and medical students, assembling a multidisciplinary PC team, overseas PC training, establishing international links, providing essential medicine and addressing PC education. Program/Policy process: The gynecologic oncology unit capacity was expanded to accommodate long term admissions. PC knowledge among physicians, clinical nurse practitioners (CNPs) and medical students in Assiut University Hospitals was assessed using the modified Palliative Care Knowledge Test (PCKT). A multidisciplinary team that will deliver the PC service to our gynecologic cancer patients was assembled based on motivation and individual expertise in the aspects of PC from relevant departments as clinical oncology, surgery, pain and anesthesiology, psychiatry, physical therapy and rehabilitation and nutrition. The hospital leadership worked with the pharmacists to increase opioids quota and facilitate dispensing measures. The PC team leader engaged in a certified online PC course and arranged overseas training with the reputable Palliative Medicine Division at University of Cape Town well known for its legacy in delivering PC education. Outcomes: Ninety two physicians, 14 CNPs and 116 medical students completed the PCKT. The PCKT was composed of 20 questions and each correct answer was given 1 point. The overall total correct score was 7.41 ± 2.48 (Fig 1). Poor knowledge about PC was a strong indicator to acknowledge the gap in PC postgraduate training and undergraduate education. What was learned: Integration of a PC service for cancer patients in Egypt is feasible in spite of local resources constraints. A PC multidisciplinary team can be assembled from skilled specialists. Modifications of undergraduate and postgraduate curricula to include PC is crucial. Our model can be transferred to other low resource settings.

[Figure: see text]

The effect of acetazolamide on intra-ocular pressure after Trendelenburg positioning - a randomised double-blind crossover trial in volunteers

Recent evidence suggests Trendelenburg positioning can produce a significant rise in intra-ocular pressure. Peri-operative vision loss in patients undergoing laparoscopic colorectal surgery has been reported with the rise in intra-ocular pressure suggested as a possible factor. Acetazolamide decreases intra-ocular pressure by reducing the formation of aqueous humour, so we aimed to investigate if it could attenuate the intra-ocular pressure rise that can occur in the Trendelenburg position. Nine healthy volunteers were recruited and randomly assigned to a double-blind crossover comparison of placebo or acetazolamide with a minimal 4 days' washout period before the second study day. One and a half hours after taking the medication, volunteers lay head-down at 17° for 4 h. Intraocular pressure measurements were repeated in both eyes every 30 min over a 4-h period. There were two males and seven female volunteers, with a mean (SD) age of 54.3 (18.5) years. The mean (SD) increase in intra-ocular pressure following 4 h in the Trendelenburg position was 3.17 (4.63) mmHg after the placebo, and 0.02 (4.01) mmHg (p = 0.02) after acetazolamide. We have shown than acetazolamide can attenuate the rise that occurs in intra-ocular pressure when in the Trendelenburg position.

Role of early endoscopic evaluation in decreasing morbidity, mortality, and cost after caustic ingestion: a retrospective nationwide database analysis

Caustic substance ingestion (CSI) is a serious medical problem with potentially devastating short- and long-term consequences. Early upper gastrointestinal endoscopy (EaEn) is recommended to evaluate the extent of injury and guide management but there has been controversy about the timing. There is no nationwide study evaluating adherence to EaEn and outcomes following CSI.Nationwide Inpatient Sample database 2003-2011 was used to identify all-age, nonreferral, urgent/emergent admissions with E-International Classification of Diseases Ninth Revision codes for CSI. We evaluated the association of undergoing late endoscopy (LaEn, >48 hours since admission) with poor clinical (death or systemic complications) and economic (cost for admission and length of stay above the 75th percentile) outcomes after controlling for other demographic and clinical factors using a multivariate analysis.We identified 21,682 patients with a median age of 37 years, 51% males, 43% Caucasians, with suicidal ingestion reported in 40%. Endoscopy was performed in 6011 patients (37%). The majority had EaEn (43% within 24, and 40% within 24-48 hours), whereas 17% had LaEn.Compared to EaEn group, the LaEn group was associated with a three-fold increase (OR = 2.7, P < 0.001) in the risk for poor clinical outcome: a fourfold increase (OR = 4.6, P < 0.001) in high cost admissions, and a fivefold increase (OR = 4.9, P < 0.001) in prolonged hospitalization. There was no significant difference in clinical outcomes based on endoscopy within 24, and 24-48 hours of admission.In this retrospective nationwide database analysis, undergoing LaEn was associated with both negative clinical and economic outcomes. More studies are needed to further examine the reasons for delaying endoscopy and subsequent management pathways based on the endoscopic findings. Early endoscopic evaluation could potentially improve the clinical outcomes and reduce costs of these admissions.

High-dose oral colecalciferol loading in obesity: impact of body mass index and its utility prior to bariatric surgery to treat vitamin D deficiency

Obesity is associated with lower vitamin D levels compared with normal weight subjects, and if levels are not replaced prior to bariatric surgery, this can increase fracture risk as bone density typically falls post-operatively. We analysed the effect of body mass index (BMI) on vitamin D levels in response to 300 000 IU of colecalciferol in patients with vitamin D deficiency (<30 nmol L^-1 ). Patients were grouped according to their BMI as normal weight (20-24.9 kg m^-2 ), overweight (25-29.9 kg m^-2 ), obese class I (30-34.9 kg m^-2 ) and obese class II and above (>35 kg m^-2 ). The records were retrospectively analysed to investigate the effects of BMI on vitamin D (total 25-hydroxy vitamin D [25(OH)D]), serum Ca²⁺ and parathyroid hormone (PTH) levels at 6, 12, 26 and 52 weeks compared with baseline. Compared with normal weight subjects, overweight and obese patients achieved lower mean peak total 25(OH)D levels (6 weeks post-loading), which was most significant in the class II and above group (mean total 25(OH)D levels 96.5 ± 24.2 nmol L^-1 and 72.42 ± 24.9 nmol L^-1 , respectively; P = 0.003). By 26 weeks, total 25(OH)D levels fell in all groups; however, there was now a significant difference between the normal weight subjects and all other groups (mean total 25(OH)D levels 84.1 ± 23.7 nmol L^-1 ; 58 ± 20 nmol L^-1 , P = 0.0002; 62.65 ± 19.2 nmol L^-1 , P = 0.005; 59.2 ± 21 nmol L^-1 , P = 0.005, respectively). Far fewer patients in the overweight and obese groups maintained levels above the recommended level of 75 nmol L^-1 52 weeks post-loading (93%; 20%, P = 0.0003; 23%, P = 0.01; and 14%, P = 0.001, respectively). Alternative regimes for the treatment of vitamin D deficiency are needed in overweight and obese patients, especially those in whom bariatric surgery is planned.