Upper gastrointestinal training in the UK and Ireland: a Roux Group Study

INTRODUCTION

Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I.

METHODS

A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability.

RESULTS

A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p<0.001); <3 presentations (<3 vs 3-5, p=0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p<0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage.

CONCLUSIONS

Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

'How I'm feeling today, I probably won't be feeling tomorrow'. Using I-Poems to explore young people's changing emotions during the Covid-19 pandemic - A qualitative, longitudinal study

Background

Relatively little published qualitative research has explored children and young people's (CYP) prolonged or longitudinal experiences of the pandemic, and their emotional responses to such unreserved change to everyday life. As part of a broader, qualitative longitudinal study, this paper explores change and continuity in young people's emotions over time during the Covid-19 pandemic in North East England.

Methods

I-Poems were curated for each of the 26 young people in this study from serial interview transcripts and diary entries, collected over the course of 16 months. Creation of I-Poems require researchers to focus on sentences made by the interviewee that include the word "I," and without changing the order of those sentences, to present them in poetic stanzas.

Findings

Young people's voices and experiences became more poignant and powerful when their 'I' narrative was centralised, silencing the presence of the researcher. Further, presenting the data in this way allowed us to see how the following emotions shifted over time: grief, sadness, frustration, anger, anxiety, joy, pleasure, excitement. We contend that young people experienced significant rupture and change over the course of our 16 month project, with both positive and negative repercussions for their emotional wellbeing.

Conclusions

Large scale (quantitative and qualitative) studies remain much needed to focus on the long-term impacts of the pandemic on young people's social, emotional and cultural lives. Longitudinal and creative qualitative approaches (such as I-Poems) have the potential to centralise participant voice, break down power dynamics, and allow exploration of shifting experiences and emotions over time.

Assessment of groundwater salinity using principal component analysis (PCA): a case study from Mewat (Nuh), Haryana, India

In the present study, principal component analysis (PCA) is used to investigate the processes controlling groundwater salinity in the Mewat (Nuh) district, Haryana, India. Twenty groundwater samples were collected from salinity-affected areas in the March-April months of years 2018 and 2019 and were analyzed for chemical variables pH, EC, Ca²⁺, Mg²⁺, Na⁺, K⁺, [Formula: see text], Cl^-, SO₄^2-, [Formula: see text], TDS, and total hardness. Three principal components were selected based on the eigen value, which explains 79.58% and 85.08% of the total variation in the years 2018 and 2019, respectively. The first principal component (PC-1) is identified with salinity, the second principal component (PC-2) with alkalinity, and the third principal component (PC-3) described the pollution. When the yearly comparison was made, the samples collected in 2019 were found to have an increased salinity compared to 2018, which shows an increased vulnerability to the aquifer of Mewat on account of the decline in rainfall recharge. It was also evident that declining recharge also triggered the recharge from other sources; thus, the impact of pollution is more pronounced in 2019 compared to 2018.

P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Aim

Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites.

Methods

This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures.

Results

The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported.

Conclusion

Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

341 Consenting Practices in Plastic Surgery

Introduction

Informed consent is a vital aspect of safe patient care within any surgical specialty, and if not completed thoroughly, may result in misinformation and patient dissatisfaction.

Traditional paper consent forms are notoriously poorly completed by medical professionals, with common issues ranging from ineligible handwriting, to missing key components of the form.

The aim of this audit was to assess our departments’ compliance with standard trust consent forms and compare adherence to local and national consenting policies.

Method

All elective and emergency plastic surgical procedures carried out over a one-week period from 17/05/2021 to 23/05/2021 were identified using eTrauma and Cerner operative records. In total, 40 procedures were identified. Consent forms were then reviewed and assessed for completion in key areas. 4 procedures were excluded due to the consent form not being available for review, and 1 procedure was excluded due to a cancellation.

Results

The risks and benefits of procedures were generally documented to a high standard. Providing written information to patients, confirmation of consent if the procedure was being performed on a different day, and possible additional procedures were poorly completed throughout. 90% of consent forms screened, failed to include confirmation of the surgical site within the specific section of the form.

Conclusions

Overall, the department demonstrated good compliance with completing trust consent forms. Electronic consent forms would likely address the shortcomings identified in this audit and should be adopted. Continued responsibility from the whole team should be highlighted and maintained to ensure a high standard of consenting.

61 Use of Ketamine Sedation for the Treatment of Minor Plastic Surgery Procedures in the Paediatric Emergency Department

Aim

To determine if ketamine sedation is a safe and cost-effective way of treating paediatric patients presenting with minor injuries, requiring plastic surgery procedures, in the emergency department.

Method

A retrospective cohort study was carried out over a 9-month period in children between ages 18 months and 16 years old, presenting to the paediatric emergency department at Chelsea and Westminster Hospital with minor injuries requiring plastic surgery input. The data collected included previously validated co-primary outcome measures of surgical site infection at 7 days and cosmetic appearance summary score at a minimum of 4 months. Parental satisfaction surveys were completed at 4 months to assess perceived quality of treatment. A cost analysis comparison against procedures completed under general anaesthetic was also undertaken.

Results

During the 9-month period of study, 24 minor procedures were performed under ketamine in the paediatric emergency department. There were no serious adverse events recorded. Three cases exceeded the recommended 20-minute maximum procedure duration, but there was no associated adverse outcome. No cases required further procedures under general anaesthesia and there were no cases of surgical site infections at 7 days. Parents reported extremely favourable outcomes using this technique, with an average overall satisfaction score of 9.2 (assessed over a number of parameters, where 10 is complete satisfaction).

Conclusions

Ketamine procedural sedation in the paediatric population is a safe and cost-effective method for the treatment of minor plastic surgery procedures, with low risk for surgical site infection post-operatively, and high parent satisfaction rates

Idiopathic Aneurysms of the Ascending Aorta in the Mouse and Rat

Aneurysms of the ascending aorta, unrelated to xenobiotic administration, are described in 5 rats and 2 mice in nonclinical safety studies conducted at Charles River Laboratories (CRL) sites over the past 10 years. The most prominent microscopic finding was focal dilation with disruption of the wall of the ascending aorta with chronic adventitial inflammation or fibroplasia. The pathogenesis of this finding is unknown. There were no associated macroscopic findings, clinical abnormalities, or vascular lesions elsewhere. The results of a search of historical control data from toxicology studies of 1 day to 72 weeks' duration performed at CRL for aortic findings from 5900 mice and 23,662 rats are also reported. Aortic lesions are uncommon in mice and rats used in nonclinical safety studies, but toxicologic pathologists should be aware that aneurysms of the ascending aorta with fibroplasia and inflammation in the aortic wall and adventitia may occur spontaneously or iatrogenically, as they have the potential to impact interpretation in toxicology studies.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Non-proliferative and Proliferative Lesions of the Non-human Primate (M. fascicularis)

The INHAND (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions Project (www.toxpath.org/inhand.asp) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP) and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative lesions in laboratory animals. The purpose of this publication is to provide a standardized nomenclature for classifying microscopic lesions observed in most tissues and organs from the nonhuman primate used in nonclinical safety studies. Some of the lesions are illustrated by color photomicrographs. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. Relevant infectious and parasitic lesions are included as well. A widely accepted and utilized international harmonization of nomenclature for lesions in laboratory animals will provide a common language among regulatory and scientific research organizations in different countries and increase and enrich international exchanges of information among toxicologists and pathologists.

POS0926 NORMALIZATION OF HIGH SENSITIVITY CRP VERSUS CLINICAL RESPONSE TO IXEKIZUMAB AT WEEK 16 IN PATIENTS WITH RADIOGRAPHIC & NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE COAST STUDIES

Background:

C-reactive protein (CRP), an objective marker of inflammation, can be used to monitor treatment response to biologics in patients with axial spondyloarthritis (axSpA) in addition to evaluating signs & symptoms. CRP is not elevated in all patients with active axSpA questioning its validity as a universal biomarker of response. Ixekizumab (IXE) demonstrated efficacy in axSpA treatment irrespective of baseline (BL) CRP levels. However, response to IXE categorized on CRP change from BL is unknown.

Objectives:

To evaluate response to IXE treatment from BL through week (wk) 16 in patients with axSpA categorized according to change in high sensitivity (hs) CRP.

Methods:

COAST-V (NCT 02696785),-W (NCT02696798), & -X (NCT02757352), were phase 3, multicentre, randomized, controlled trials, investigating the efficacy of IXE 80 mg every 4 & 2 wks in patients with: r-axSpA naïve to biologic disease-modifying antirheumatic drugs (bDMARDs; COAST-V); or who were inadequate responders/intolerant to tumour necrosis factor inhibitors (TNFi; COAST-W); or who fulfilled Assessment of SpondyloArthritis International Society (ASAS) criteria for non-radiographic (nr)axSpA (COAST-X).

This post hoc analysis focuses on approved dosing regimens. Depending on BL and wk 16 hsCRP values, patients were categorised as stable low (hsCRP ≤5 mg/L at BL & ≤5 mg/L at wk 16), normalized (hsCRP >5 mg/L at BL & ≤5 mg/L at wk 16) or elevated (hsCRP >5 mg/L at wk 16, irrespective of BL hsCRP). An absolute cutoff of 5 mg/L was used as the stratification factor in all COAST studies. Data were analyzed by treatment arm. Each trial was analyzed separately.

For hsCRP subgroups, patient demographics & other characteristics at BL, as well as trajectory over time for the endpoints ASAS40 & Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50 are described. Non-responder imputation was used for missing values.

Results:

In all studies at BL, disease activity & MRI SPARCC score were higher in normalized & elevated subgroups compared to the stable low subgroup - a.

In COAST-V, ASAS40 & BASDAI50 response was observed in IXE-treated patients regardless of hsCRP change status by wk 16 vs placebo. The highest ASAS40 & BASDAI50 response rate was reported in patients with normalized hsCRP - b. Similar findings were observed in COAST-W & -X.

Table 1.

Baseline Patient demographics & other characteristics - ITT population, per CRP subgroup

COAST-V(r-axSpA, bDMARD naive)COAST-W(r-axSpA, inadequate responders /intolerant to TNFi)COAST-X(non-radiographic axSpA, bDMARD naïve)Stable low (n=79)Norma-lized (n=80)Elevated (n=98)Stable low(n=58)Norma-lized (n=34)Elevated (n=126)Stable low (n=78)Norma-lized(n=40)Elevated (n=81)ParameterAge (years)43.7 (12.1)38.9 (10.9)42.7 (12.0)50.4 (13.3)46.1 (13.8)45.7 (12.5)44.0 (12.8)37.2 (14.6)38.7 (12.8)Male gender, n (%)63 (79.7)71.0 (88.8)78 (79.6)39.0 (67.2)30 (88.2)109 (86.5)35 (44.9)23 (57.5)34 (42)Duration of symptoms since axSpA onset (years)17.5 (11.2)14.4 (9.3)16.1 (9.9)21.7 (12.9)16.8 (11.6)18.9 (10.9)12.1 (9.9)10.3 (9.7)9.5 (9.0)HLA-B27 positive, n (%)69 (87.3)75.0 (93.8)89 (90.8)31.0 (91.2)101 (80.2)101 (80.2)48 (61.5)31 (77.5)67 (82.7)BASDAI Total Score6.5 (1.4)6.7 (1.5)7.0 (1.1)7.4 (1.5)7.3 (1.3)7.4 (1.3)6.9 (1.5)7.1 (1.6)7.2 (1.5)ASDAS Total Score3.1 (0.5)3.9 (0.6)4.2 (0.7)3.5 (0.6)4.3 (0.6)4.4 (0.8)3.2 (0.6)4.2 (0.8)4.2 (0.9)Spinal Pain due to AS7.0 (1.5)7.0 (1.5)7.5 (1.3)7.8 (1.5)7.7 (1.5)7.9 (1.4)7.2 (1.7)7.5 (1.7)7.5 (1.6)Patients with peripheral articular manifestations (>=1 TJC or >=1 SJC)47 (59.5)40 (50)62 (63.3)43 (74.1)24 (70.6)86 (68.3)56 (71.8)33 (82.5)66 (81.5)MRI Spine SPARCC ScoreMRI SIJ SPARCC ScoreMRI SPARCC Score6.7 (11.2)21.8 (27.3)20.7 (25.7)1.2 (2.3)7.0 (7.6)10.4 (17.0)5.2 (6.6)6.1 (8.2)6.2 (10.5)

Conclusion:

IXE reduced clinical disease activity in patients with axSpA irrespective of hsCRP change from BL to wk 16. Improvement in hsCRP level was associated with overall response rates.

Acknowledgements:

The authors would like to acknowledge Philana Fernandes, an employee of Eli Lilly and Company, for her for writing and editorial support.

Disclosure of Interests:

Helena Marzo-Ortega Consultant of: Celgene, Janssen, Eli Lilly, Novartis, Pfizer, UCB, Grant/research support from: Janssen, Novartis, Xavier Juanola: None declared, Tadashi Okano Speakers bureau: Asahi Kasei, Astellas, Abbvie, Ayumi, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Janssen, Mitsubishi Tanabe, Novartis, Ono, Pfizer, Sanofi and Takeda, Grant/research support from: Asahi Kasei, Abbvie, Chugai, Eisai, Yves Schymura Employee of: Eli Lilly, Andrew Bradley Shareholder of: Eli Lilly, Employee of: Eli Lilly, Jens Gerwien Shareholder of: Eli Lilly, Employee of: Eli Lilly, Brigitte Monsberger Shareholder of: Eli Lilly, Employee of: Eli Lilly, Soyi Liu Leage Employee of: Eli Lilly, Daniel Aletaha Speakers bureau: Abbvie, Amgen, Celgene, Lilly, Medac, Merck, Novartis, Pfizer, Roche, Sandoz, Sanofi/Genzyme, Grant/research support from: Abbvie, Lilly, Novartis, Roche, Mikkel Østergaard Speakers bureau: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis

450 Retrospective Analysis of Surgical Clerk-Ins Within the Acute Receiving Unit: A Quality Improvement Project

Introduction

Accurate patient documentation at the ARU is vital to patient safety and ensuring smooth handovers to secondary care services. Because the nature of surgical treatment requires frequent patient handovers, and this increases the risk of miscommunication, we aimed to assess the quality of surgical clerk-ins and identify areas for improvement.

Method

Emergency admissions at the Dumfries Galloway Royal Infirmary were audited, looking at documentation quality under various clerk-in sections. Data was analysed before presentation to clinical governance.

Results

When 46 patient clerk-ins were examined, venous thromboembolism (VTE) prophylaxis plans were performed in only 24% of admissions - less than 1 in 4 patients.

Comparing out-of-hours and in-hours patient documentation, much higher omission rates were identified in the out-of-hours documentation: in systemic enquiry (42 vs 100%) and family history (31% vs 66%).

Conclusions

These results brought to attention the effect of hospital admission timing on patient documentation quality, and the lack of VTE prophylaxis planning. In surgery, these plans are key to minimising risk of avoidable thromboembolic complications.

A departmental meeting was convened to stress the importance of accurate and comprehensive clerk-ins to ARU doctors. Future audits could explore the factors influencing documentation quality for out-of-hours admissions, and ways to address these issues.

Nonproliferative and Proliferative Lesions of the Rat and Mouse Hematolymphoid System

The INHAND Project (International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice) is a joint initiative of the Societies of Toxicologic Pathology from Europe (ESTP), Great Britain (BSTP), Japan (JSTP), and North America (STP) to develop an internationally accepted nomenclature for proliferative and nonproliferative changes in rats and mice. The purpose of this publication is to provide a standardized nomenclature for classifying changes observed in the hematolymphoid organs, including the bone marrow, thymus, spleen, lymph nodes, mucosa-associated lymphoid tissues, and other lymphoid tissues (serosa-associated lymphoid clusters and tertiary lymphoid structures) with color photomicrographs illustrating examples of the lesions. Sources of material included histopathology databases from government, academia, and industrial laboratories throughout the world. Content includes spontaneous lesions as well as lesions induced by exposure to test materials. The nomenclature for these organs is divided into 3 terminologies: descriptive, conventional, and enhanced. Three terms are listed for each diagnosis. The rationale for this approach and guidance for its application to toxicologic pathology are described in detail below.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

International Regulatory Guiding Documents and Best Practice Recommendations on Peripheral Nervous System (PNS) Histopathologic Evaluation in Good Laboratory Practice (GLP)-Compliant Animal Toxicity Studies

Assessment of the peripheral nervous system (PNS) tissues during animal toxicity studies generally is included within guiding documents issued by regulatory agencies of individual nations (eg, US Environmental Protection Agency, US Food and Drug Administration) and multinational federations (eg, European Medicines Agency) as well as international cooperative efforts (eg, International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use, Organisation for Economic Co-operation and Development). The present list of major regulatory guiding documents categorizes recommendations from around the world for sampling and processing PNS tissues (nerves and ganglia) for general animal toxicity studies (ie, where neurotoxicity is not expected) and specialized neurotoxicity studies (ie, where neurotoxicity is anticipated or known to occur). In general, regulatory guidelines call for collection of one or more sensorimotor nerves (usually the sciatic trunk and its branches), though details vary among agencies. Regulatory guiding documents represent a “starting point,” after which additional PNS samples and/or special methods may be implemented at the applicant’s discretion. Best practice recommendations for PNS sampling and processing in animal toxicity studies endorsed by multiple global societies of toxicologic pathology encompass and expand on existing regulatory guidelines.

Health assessments and screening tools for adults experiencing homelessness: a systematic review

Background

Homelessness is increasing globally. It results in poorer physical and mental health than age matched people living in permanent housing. Better information on the health needs of people experiencing homelessness is needed to inform effective resourcing, planning and service delivery by government and care organisations.

The aim of this review was to identify assessment tools that are valid, reliable and appropriate to measure the health status of people who are homeless.

Methods

Data sources: A systematic literature search was conducted in PubMed (and Medline), PsychInfo, Scopus, CINAHL and ERIC from database inception until September 2018. Key words used were homeless, homelessness, homeless persons, vagrancy, health status, health, health issues, health assessment and health screening. The protocol was registered with PROSPERO. The National Health and Medical Research Council of Australia (NHMRC) hierarchy of evidence was applied; methodological quality of included articles was assessed using the McMaster critical appraisal tools and psychometric properties of the tools were appraised using the International Centre for Allied Health Evidence Ready Reckoner.

Results

Diverse tools and measures (N = 71) were administered within, and across the reviewed studies (N = 37), with the main focus being on general health, oral health and nutrition. Eleven assessment tools in 13 studies had evidence of appropriate psychometric testing for the target population in domains of quality of life and health status, injury, substance use, mental health, psychological and cognitive function. Methodological quality of articles and tools were assessed as moderate to good. No validated tools were identified to assess oral health, chronic conditions, anthropometry, demography, nutrition, continence, functional decline and frailty, or vision and hearing. However, assessments of physical constructs (such as oral health, anthropometry, vision and hearing) could be applied to homeless people on a presumption of validity, because the constructs would be measured with clinical indicators in the same manner as people living in permanent dwellings.

Conclusions

This review highlighted the need to develop consistent and comprehensive health assessment tools validated with, and tailored for, adults experiencing homelessness.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7234-y) contains supplementary material, which is available to authorized users.

Toxicologic Pathology Forum*: Opinion on Considerations for the Use of Whole Slide Images in GLP Pathology Peer Review

Whole slide imaging (WSI) technology has advanced to a point where it has replaced the glass slide as the primary means of pathology evaluation within many areas of medical pathology. The deployment of WSI in the field of toxicologic pathology has been delayed by a lack of clarity around the degree of validation required for its use on Good Laboratory Practice (GLP) studies. The current opinion piece attempts to provide a high-level overview of WSI technology to include basic methodology, advantages and disadvantages over a conventional microscope, validation status of WSI scanners, and perceived concerns over regulatory acceptance for the use of WSI for (GLP) peer review in the field of toxicologic pathology. Observations are based on the extensive use by AstraZeneca of WSI for the peer review of non-GLP studies conducted at Charles River facilities and represent the experiences of the authors.

[Box: see text]

Aging phenotype(s) in kidneys of diabetic mice are p66ShcA dependent

The p66ShcA protein controls cellular responses to oxidative stress, senescence, and apoptosis. Here, we test the hypothesis that aging phenotype(s) commonly associated with the broad category of chronic kidney disease are accelerated in diabetic kidneys and linked to the p66ShcA locus. At the organ level, tissue stem cells antagonize senescent phenotypes by replacing old dysfunctional cells. Using established methods, we isolated a highly purified population of stem cell antigen-1-positive mesenchymal stem cells (Sca-1⁺ MSCs) from kidneys of wild-type (WT) and p66 knockout (p66 KO) mice. Cells were plated in culture medium containing normal glucose (NG) or high glucose (HG). Reactive oxygen species (ROS) metabolism was substantially increased in WT MSCs in HG medium in association with increased cell death by apoptosis and acquisition of the senescent phenotype. DNA microarray analysis detected striking differences in the expression profiles of WT and p66 KO-MSCs in HG medium. Unexpectedly, the analysis for p66 KO-MSCs revealed upregulation of Wnt genes implicated in self-renewal and differentiation. To test the in vivo consequences of constitutive p66 expression in diabetic kidneys, we crossed the Akita diabetic mouse with the p66KO mouse. Homozygous mutation at the p66 locus delays or prevents aging phenotype(s) in the kidney that may be precursors to diabetic nephropathy.

Multiple traumatisation and subsequent psychopathology in people with intellectual disabilities and DSM-5 PTSD: a preliminary study

BACKGROUND

Individuals with intellectual disability (ID) are at greater risk of exposure to traumatic life events compared with the non-ID population. Yet no study to date has examined the role of multiple traumatisation and subsequent psychopathology in people with ID. The aim of this study was to explore the association between multiple traumatisation and subsequent mental health.

METHODS

A preliminary cross-sectional study involving 33 participants with DSM-5 post-traumatic stress disorder completed self-report questionnaires on exposure to traumatic life events and post-traumatic stress disorder symptoms, anxiety, depression and general distress.

RESULTS

A proportion of 42.4% of the sample reported multiple traumatisation, including exposure to life events in both childhood and adulthood. Those who reported exposure to life events in childhood and adulthood reported significantly higher risk of harm, depression and general psychological distress compared with those who reported exposure to life events only in adulthood.

CONCLUSIONS

Preliminary results indicate that more severe psychopathology is associated with multiple traumatisation in childhood and adulthood compared with trauma experienced solely in adulthood.

Historical control background incidence of spontaneous pituitary gland lesions of Han-Wistar and Sprague-Dawley rats and CD-1 mice used in 104-week carcinogenicity studies

The aim of this study was to determine the range and incidences of spontaneous microscopic lesions of the pituitary gland in control Han-Wistar and Sprague-Dawley rats and CD-1 mice from 104-week carcinogenicity studies carried out between 1998 and 2010 at Charles River Edinburgh. In both strains of rats and in CD-1 mice, non-proliferative lesions of the pituitary gland were generally uncommon, excluding cysts/pseudocysts (6.42% in Han-Wistar rats, 5.85% in Sprague-Dawley rats, and 2.08% in CD-1 mice). Primary proliferative lesions were most frequently found in the pars distalis of the pituitary gland. Adenomas and carcinomas of the pars distalis were more common in Sprague-Dawley rats (49.33% and 2.85%, respectively) than in Han-Wistar rats (27.29% and 0.21%, respectively), and adenomas in both strains of rats and CD-1 mice exhibited a marked sex predisposition, with females more commonly affected.

Spontaneous and Dosing Route–related Lung Lesions in Beagle Dogs from Oral Gavage and Inhalation Toxicity Studies

This study was conducted to characterize lung microscopic lesions in control beagle dogs from inhalation and oral gavage toxicity studies, to determine differences associated with the route of administration, and to discuss distinguishing features from compound-induced lung lesions. Samples from 138 control dogs from oral gavage studies and 124 control dogs from inhalation (vehicle control) studies were evaluated microscopically. There was no significant sex-related difference in the incidence of all lesions. Perivascular mononuclear cell infiltration, centriacinar mixed cell infiltration, bronchopneumonia, subpleural septal fibrosis, and alveolar macrophage accumulation were the most common lesions. Aspiration pneumonia was more common in dogs from gavage studies, suggesting reflux after gavage dosing or accidental administration of test formulation as possible causes. Centriacinar mixed cell infiltration was more common in dogs from inhalation studies, suggesting mild irritation by the vehicles used. Vascular lesions, which included pulmonary arteriopathy and smooth muscle mineralization, were observed in a few animals. Some of the spontaneous lesions are similar to lesions induced by test compounds. Compared to spontaneous lesions, compound-induced lesions tend to be multifocal or diffuse, follow a pattern of distribution (e.g., centriacinar, perivascular, and interstitial), show a dose response in the incidence and severity, and may show cell-specific toxicity.

Results on the Spin-Dependent Scattering of Weakly Interacting Massive Particles on Nucleons from the Run 3 Data of the LUX Experiment

We present experimental constraints on the spin-dependent WIMP (weakly interacting massive particle)-nucleon elastic cross sections from LUX data acquired in 2013. LUX is a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility (Lead, South Dakota), which is designed to observe the recoil signature of galactic WIMPs scattering from xenon nuclei. A profile likelihood ratio analysis of 1.4×10^{4}  kg day of fiducial exposure allows 90% C.L. upper limits to be set on the WIMP-neutron (WIMP-proton) cross section of σ_{n}=9.4×10^{-41}  cm^{2} (σ_{p}=2.9×10^{-39}  cm^{2}) at 33  GeV/c^{2}. The spin-dependent WIMP-neutron limit is the most sensitive constraint to date.

Improved Limits on Scattering of Weakly Interacting Massive Particles from Reanalysis of 2013 LUX Data

We present constraints on weakly interacting massive particles (WIMP)-nucleus scattering from the 2013 data of the Large Underground Xenon dark matter experiment, including 1.4×10^{4}  kg day of search exposure. This new analysis incorporates several advances: single-photon calibration at the scintillation wavelength, improved event-reconstruction algorithms, a revised background model including events originating on the detector walls in an enlarged fiducial volume, and new calibrations from decays of an injected tritium β source and from kinematically constrained nuclear recoils down to 1.1 keV. Sensitivity, especially to low-mass WIMPs, is enhanced compared to our previous results which modeled the signal only above a 3 keV minimum energy. Under standard dark matter halo assumptions and in the mass range above 4  GeV c^{-2}, these new results give the most stringent direct limits on the spin-independent WIMP-nucleon cross section. The 90% C.L. upper limit has a minimum of 0.6 zb at 33  GeV c^{-2} WIMP mass.

Historical control background incidence of spontaneous thyroid and parathyroid glands lesions of rats and CD-1 mice used in 104-week carcinogenicity studies

The incidence and range of spontaneous thyroid and parathyroid glands findings were determined in control Han-Wistar and Sprague-Dawley rats, and CD-1 mice from 104-week carcinogenicity studies carried out between 1998 and 2010 at Charles River Edinburgh. In both strains of rats and in CD-1 mice, non-proliferative lesions of the thyroid or parathyroid glands were generally uncommon apart from some findings in CD-1 mice such as ultimobranchial duct/cyst (5.72%), follicular distension/dilatation (3.84%), and cystic follicles (3.53%). In Han-Wistar rats, thyroid proliferative lesions were slightly more frequent in males than in females, but in Sprague-Dawley rats, they were of similar incidence in both sexes. The most common findings overall in Han-Wistar and Sprague-Dawley rats were C-cell hyperplasia (48.11% and 36.56%, respectively) and adenoma (10.87% and 9.52%, respectively), follicular cell hyperplasia (4.21% and 0.91%, respectively) and adenoma (4.32% and 1.36%, respectively). Secondary neoplastic lesions either in thyroid or parathyroid gland were poorly represented.

Effect of Wood Biochar in Manure-Applied Sand Columns on Leachate Quality

Agricultural operations can pose a threat to the quality of nearby water sources particularly from nitrogen (N) and phosphorus (P) losses following land application of manure. Biochar application to soils has the potential to ameliorate degraded soils and reduce nutrient leaching to groundwater. The effects of amending sand soil columns with hybrid poplar biochar ( spp.) made by a slow-pyrolysis process at 450°C at varying rates (0, 1, 2, and 5% by weight) with repeated dairy manure applications over a 56-wk period was examined to evaluate the impact to leachate water quality. Increasing levels of biochar decreased cumulative levels of total N (TN) by 21 to 59%, nitrate (NO-N) by 17 to 46%, and ammonia (NH-N + NH-N) by 46 to 90% in leachate but increased cumulative leaching of total P (TP). Overall leachate pH was increased and peak levels of 5-d biological oxygen demand (BOD) in leachate after manure application were decreased with increasing levels of biochar amendment. The results from this study indicate that biochar amendments could be effective in reducing nitrogen leaching from soils, though further study is needed to determine practical application in a field setting.

Bone marrow spontaneous lesions in rodents from nonclinical 104-week carcinogenicity studies

The authors performed a retrospective study to determine the incidences and range of spontaneous lesions in the bone marrow (sternum and femur) of control mice and rats. Data was collected from 2186 mice (Crl:CD-1(ICR)BR), and 2347 rats (Han Wistar and CD(SD) rats) from the control dose groups of 104-week carcinogenicity studies carried out between 2005 and 2014. The incidence of spontaneous lesions in the bone marrow was higher in mice than in rats, and in both species non-neoplastic lesions were more common than neoplastic lesions. In mice, the most common non-neoplastic lesions in the bone marrow were increased cellularity, pigmented macrophages, and decreased cellularity, and the most common neoplastic lesions were malignant lymphoma, granulocytic leukemia and histiocytic sarcoma. There were occasional sex and site differences (sternum marrow vs femur marrow) in the incidence of a few bone marrow lesions in mice. In rats, the most common non-neoplastic lesions were increased cellularity and stromal fibrosis, and the most common neoplastic lesion was malignant lymphoma. In rats, no sex predilection in the incidence of bone marrow lesions was apparent, and there were no significant site differences in the incidence of lesions. To the best knowledge of the authors, there are no recent reports on spontaneous pathological findings in bone marrow of rodents, and we believe that these results will facilitate the interpretation of background findings and/or their increased incidence in carcinogenicity studies.

Immunophenotype of Spontaneous Hematolymphoid Tumors Occurring in Young and Aging Female CD-1 Mice. [Corrected]

A few reports indicated the incidence of hematolymphoid neoplasms in old CD-1 mice, but the cellular lineage of CD-1 mouse neoplasms has not been published. In this study, immunohistochemistry (IHC) was used to characterize the cellular lineage of spontaneous hematolymphoid neoplasms arising in 24 young female CD-1 mice used as health-monitoring sentinels and 32 aging female CD-1 mice used as controls in 80-week carcinogenesis studies. Lymphoblastic lymphomas of T-cell and B-cell lineage were common in mice aged 12 months or less, whereas a wide range of non-lymphoblastic B-cell lymphomas and lymphoblastic B-cell lymphomas were common in mice >12-mo-old. Renal hyaline droplets positive for lysozyme were observed in aged mice with a histiocytic-associated large B-cell lymphoma (HA-BCL) and a myeloid leukemia. Endogenous ecotropic mouse leukemia virus (MuLV) genes have been recovered from CD-1 mice, but MuLV protein expression has not been previously demonstrated. We reported for the first time the expression of a MuLV protein p30 by IHC in lymphomas and some normal tissues of both young and aging CD-1 mice. This report should help to differentiate spontaneous lymphomas and leukemias in CD-1 mice from those induced by chemicals and other methods.

Adrenal Gland Background Findings in CD-1 (Crl:CD-1(ICR)BR) Mice from 104-week Carcinogenicity Studies

The authors performed a retrospective study to determine the incidences of spontaneous findings in the adrenal glands of control CD-1 mice. Data were collected from 2,163 mice from control dose groups in 104-week carcinogenicity studies carried out between 2000 and 2010. Adrenal gland nonproliferative lesions were more common in males than in females. In males, the most common nonproliferative lesions were cortical hypertrophy, cortical atrophy, pigment deposition/pigmentation, cysts, and extramedullary hematopoiesis. In females, the most common nonproliferative lesions were pigment deposition/pigmentation, extramedullary hematopoiesis, and cortical atrophy. Proliferative lesions were more common in females than in males. In both sexes, the most common proliferative lesions were subcapsular cell hyperplasia, focal cortical hyperplasia, and subcapsular cell tumor. Pheochromocytomas were uncommon in both sexes, with a slightly higher incidence in females, and the benign type was more frequent than the malignant type. Lymphoma was the most common metastatic tumor in both males and females, followed by histiocytic sarcoma and erythroid/myeloid leukemia. To the best knowledge of the authors, there are no recent reports on spontaneous pathological findings in the adrenal glands of CD-1 mice, and these results will facilitate the interpretation of background findings in carcinogenicity studies.

Spontaneous necrotizing sialometaplasia of the submandibular salivary gland in a Beagle dog

A single mass was found on the left submandibular salivary gland at necropsy of a 15-month-old male commercially bred laboratory Beagle dog from a control dose group from a repeat toxicity study. Microscopically, the mass was composed of a well-demarcated area of coagulative necrosis surrounded and separated from the normal salivary gland tissue by a thick fibrovascular capsule. Necrosis was admixed with areas of hemorrhage, fibrin, edema, fibrinoid necrosis of the vascular tunica media, and thrombosis of small and large vessels. Within the necrotic tissue, there was marked ductal hyperplasia, and squamous metaplasia of duct and acinar epithelium. The mass was diagnosed as necrotizing sialometaplasia of the submandibular gland. Hyperplastic ductal elements and squamous metaplasia can be mistaken microscopically with squamous cell carcinoma. Therefore, pathologists should be aware of this lesion as to avoid errors in the diagnosis of this benign pathologic condition.

Invited review: overview of new traits and phenotyping strategies in dairy cattle with a focus on functional traits

For several decades, breeding goals in dairy cattle focussed on increased milk production. However, many functional traits have negative genetic correlations with milk yield, and reductions in genetic merit for health and fitness have been observed. Herd management has been challenged to compensate for these effects and to balance fertility, udder health and metabolic diseases against increased production to maximize profit without compromising welfare. Functional traits, such as direct information on cow health, have also become more important because of growing concern about animal well-being and consumer demands for healthy and natural products. There are major concerns about the impact of drugs used in veterinary medicine on the spread of antibiotic-resistant strains of bacteria that can negatively impact human health. Sustainability and efficiency are also increasingly important because of the growing competition for high-quality, plant-based sources of energy and protein. Disruptions to global environments because of climate change may encourage yet more emphasis on these traits. To be successful, it is vital that there be a balance between the effort required for data recording and subsequent benefits. The motivation of farmers and other stakeholders involved in documentation and recording is essential to ensure good data quality. To keep labour costs reasonable, existing data sources should be used as much as possible. Examples include the use of milk composition data to provide additional information about the metabolic status or energy balance of the animals. Recent advances in the use of mid-infrared spectroscopy to measure milk have shown considerable promise, and may provide cost-effective alternative phenotypes for difficult or expensive-to-measure traits, such as feed efficiency. There are other valuable data sources in countries that have compulsory documentation of veterinary treatments and drug use. Additional sources of data outside of the farm include, for example, slaughter houses (meat composition and quality) and veterinary labs (specific pathogens, viral loads). At the farm level, many data are available from automated and semi-automated milking and management systems. Electronic devices measuring physiological status or activity parameters can be used to predict events such as oestrus, and also behavioural traits. Challenges concerning the predictive biology of indicator traits or standardization need to be solved. To develop effective selection programmes for new traits, the development of large databases is necessary so that high-reliability breeding values can be estimated. For expensive-to-record traits, extensive phenotyping in combination with genotyping of females is a possibility.

International Harmonization of Nomenclature and Diagnostic Criteria (INHAND): Progress to Date and Future Plans

The International Harmonization of Nomenclature and Diagnostic Criteria for Lesions in Rats and Mice proposal (INHAND) has been operational since 2005. A Global Editorial Steering Committee manages the overall objectives of the project, and the development of harmonized terminology for each organ system is the responsibility of the Organ Working Groups, drawing upon experts from North America, Europe, and Japan. Great progress has been made with 9 systems published to date--respiratory, hepatobiliary, urinary, central/peripheral nervous systems, male reproductive and mammary, zymbals, clitoral, and preputial glands in Toxicologic Pathology and the integument and soft tissue and female reproductive in the Journal of Toxicologic Pathology as supplements and on a Web site--www.goReni.org. INHAND nomenclature guides offer diagnostic criteria and guidelines for recording lesions observed in rodent toxicity and carcinogenicity studies. The guides provide representative photomicrographs of morphologic changes, information regarding pathogenesis, and key references. The purpose of this brief communication is to provide an update on the progress of INHAND.

Post-operative bilateral adrenal haemorrhage: A case report

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An unusual complication of intra-abdominal sepsis.

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A demonstration of diagnostic difficulty in the post-operative patient.

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A variation from the normal electrolyte profile observed in adrenal insufficiency.

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Highlights the clinical importance of a high index of suspicion for further investigation of ‘on-ward’ electrolyte abnormalities.

INTRODUCTION

Bilateral adrenal haemorrhage is a rare, but serious, illness carrying an estimated 15% mortality.^1,2 The majority of cases occur in patients with acute, stressful illness, however the exact mechanism underlying adrenal haemorrhage remains unclear. This medical emergency carries significant diagnostic difficulty⁴ with non-specific clinical symptoms and variations in electrolyte abnormalities. Timely treatment is important as it prevents both the acute and long-term sequelae of adrenal failure.

PRESENTATION OF CASE

This report describes a medical emergency in a surgical patient following emergency surgery for intra-abdominal sepsis. The patient reported non-specific symptoms of confusion, mild pyrexia and vague abdominal pain during the post-operative phase, with subtle electrolyte abnormalities and a low serum cortisol suggestive of adrenal crisis. Timely medical treatment, with intravenous hydrocortisone and intensive monitoring, and appropriate medical follow-up with addition of long-term fludrocortisone resulted in a satisfactory outcome.

DISCUSSION

This report describes a potentially life-threatening complication of intra-abdominal sepsis with adrenal crisis secondary to bilateral adrenal haemorrhage. In particular, this case highlights the diagnostic difficulty in such surgical patients due to vague symptoms and, in this case, the presence of a presentation variant with acute hyponatraemia and normal potassium.

CONCLUSION

This case highlights the importance of awareness of both the symptoms and signs and variation in electrolyte profile when assessing surgical patients post-operatively. In addition, this case highlights the benefit of early recognition and initiation of treatment and the importance of follow-up as long-term medical management is often required to prevent further relapse.