Elevated lipoprotein(a) increases risk of subsequent major adverse cardiovascular events (MACE) and coronary revascularisation in incident ASCVD patients: A cohort study from the UK Biobank

BACKGROUND AND AIMS

Elevated lipoprotein(a) [Lp(a)] is a genetic driver for atherosclerotic cardiovascular disease (ASCVD). We aimed to provide novel insights into the associated risk of elevated versus normal Lp(a) levels on major adverse cardiovascular events (MACE) in an incident ASCVD cohort.

METHODS

This was an observational cohort study of incident ASCVD patients. MACE counts and incidence rates (IRs) per 100-person-years were reported for patients with normal (<65 nmol/L) and elevated (>150 nmol/L) Lp(a) within the first year after incident ASCVD diagnosis and overall follow-up. Cox proportional hazard models quantified the risk of MACE associated with a 100 nmol/L increase in Lp(a).

RESULTS

The study cohort included 32,537 incident ASCVD patients; 5204 with elevated and 22,257 with normal Lp(a). Of those with elevated Lp(a), 41.2% had a subsequent MACE, versus 35.61% with normal Lp(a). Within the first year of follow-up, the IRs of composite MACE and coronary revascularisation were significantly higher (p < 0.001) in patients with elevated versus normal Lp(a) (IR difference 6.79 and 4.66). This trend was also observed in the overall follow-up (median 4.7 years). Using time to first subsequent MACE, a 100 nmol/L increase in Lp(a) was associated with an 8.0% increased risk of composite MACE, and 18.6% increased risk of coronary revascularisation during the overall follow-up period.

CONCLUSIONS

The association of elevated Lp(a) with increased risk of subsequent MACE and coronary revascularisation highlights a population who may benefit from earlier and more targeted intervention for cardiovascular risk including Lp(a), particularly within the first year after ASCVD diagnosis. Proactive Lp(a) testing as part of routine clinical practice can help identify and better manage these higher-risk individuals.

Alterations and Preservations: Practices and Perspectives of Speech-Language Pathologists Regarding the Intervention of Thickened Liquids for Swallowing Problems

PURPOSE

The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives.

METHOD

An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives.

RESULTS

The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL.

CONCLUSIONS

The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24317110.

Burden of lipoprotein(a) for patients with atherosclerotic cardiovascular disease: A retrospective analysis from the United States

BACKGROUND: Lipoprotein(a) (Lp(a)) is an inherited, independent, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). OBJECTIVE: To assess the burden of elevated Lp(a) for patients with ASCVD in a real-world setting in the United States. METHODS: This retrospective cohort study assessed US patients with available Lp(a) measurement and established ASCVD using Optum's Clinformatics Data Mart database (2007-2020). Index date was defined as the first diagnosis of an ASCVD event. Patient demographics, medications, health care resource utilization (HCRU), and occurrence of cardiovascular events were assessed for patients with elevated (≥150 nmol/L) vs normal (≥65 nmol/L) Lp(a) levels, within the first year of index date. HCRU was characterized by inpatient hospitalization, inpatient length of stay (LOS), outpatient visits, and emergency department (ED) visits. All comparative analyses of patients with elevated (≥150 nmol/L) vs normal (≥65 nmol/L) Lp(a) levels within the first year of index date were adjusted for age, sex, baseline statin use, and diabetes. RESULTS: 8,372 patients with ASCVD and Lp(a) measurement in nmol/L were included in this study. Patient demographics and baseline clinical characteristics were similar among those with normal and elevated Lp(a). However, the proportion of patients receiving statins and β-blockers at baseline were significantly higher in the elevated vs normal Lp(a) group (54.76% vs 42.91%, P < 0.0001, and 30.92% vs 27.32%, P = 0.0183, respectively). At 1 year of follow-up, the rates per 100 person-years for ASCVD-related inpatient hospitalizations, outpatient hospitalizations, and ED visits were higher among patients with elevated Lp(a) compared with normal Lp(a) (13.33 vs 9.46, 89.08 vs 85.10, and 2.89 vs 2.29, respectively). The mean LOS per ASCVD-related hospitalization was 7.21 days in the elevated and 6.26 days in the normal Lp(a) group (P = 0.3462). During the 1-year post-index follow-up period, 15% of patients in the elevated Lp(a) group required revascularization compared with 10% of patients in the normal Lp(a) group (P = 0.0002). The odds of composite myocardial infarction, ischemic stroke, and revascularization occurrence of events within the first year of index was significantly higher in the elevated Lp(a) group compared with the normal Lp(a) group (1.46; 95% CI = 1.20-1.77; P < 0.05). CONCLUSIONS: HCRU within the first year of ASCVD diagnosis is substantial among patients with ASCVD and elevated Lp(a). Relatively higher rates of inpatient hospitalizations, increased LOS per hospitalization, and requirement of revascularization procedures within the first year of ASCVD index diagnosis were observed in patients with elevated Lp(a) compared with normal Lp(a) levels. Lp(a) testing in routine clinical practice could help in identification of high-risk patients with ASCVD and play an important role in the overall cardiovascular risk management, aiming to reduce the HCRU associated with ASCVD. DISCLOSURES: Ms Fonseca, Dr Laguna, Dr Itani, Dr Rachel Studer, and Dr Ferber are employees of Novartis Pharma AG, Basel, Switzerland. Ms Byrne is an employee of Novartis AG, Dublin, Ireland. Dr Costa-Scharplatz is an employee of Novartis Sweden AB, Stockholm, Sweden. Dr Heo and Ms Dillon are employees of Genesis Research. Genesis Research was commissioned to conduct the study (data extraction and analysis) on behalf of Novartis Pharma AG.

EGS P21 A review of emergency laparoscopic cholecystectomies during the COVID-19 pandemic compared to pre-pandemic. Is there a difference in patient and financial outcomes?

Background

The COVID-19 pandemic was declared the greatest challenge the NHS would face since its creation. As a means of combatting the unprecedented strains COVID-19 was expected to force upon hospitals and their staff, NHS England sanctioned the postponement of all non-urgent elective surgery during the first wave of the COVID-19 pandemic.

Approximately 70 000 cholecystectomies are performed every year in the UK, with the vast majority of these being elective laparoscopic cholecystectomies (LC). However, in the early stages of the pandemic, both national and international surgical bodies warned of the potential risks of aerosol virus transmission with the use of laparoscopy. Therefore, conservative management for emergency general surgical pathologies was recommended where possible.

Delays in performing LC are associated with recurrent cholecystitis, pancreatitis and cholangitis; all of which present as emergencies with significant associated morbidity and mortality. This in turn has an economic impact on the NHS.

We aimed to evaluate if patients undergoing emergency LC during the COVID-19 pandemic at our site, had different outcomes compared to those treated prior to the pandemic. Has the COVID-19 pandemic negatively impacted their patient journey? Furthermore, has the pandemic led to increased costs for our site?

Methods

A retrospective data collection was performed to identify all patients who had an emergency LC from March 2019 – March 2021. Patients were subsequently categorised into ‘pre-COVID-19’ and ‘during COVID-19’ groups. Hospital computer systems were used to review operative admission length of stay (LoS), rate of conversion to open surgery/subtotal cholecystectomy, operative time, post-operative complications/return to theatre and readmission rate. Histopathology reports were analyzed to assess if the ‘during COVID-19’ cohort had a higher rate of complicated cholecystitis. Finally costs of the operative admission and associated admissions (pre and post-operatively), as well as the tariff for investigations performed for gallstone disease were calculated for each cohort of patients.

Results

158 patients were included in the study. A 42% reduction in emergency LC cases was observed during the COVID-19 pandemic compared to pre-pandemic. No statistically significant differences were seen between the two groups when reviewing the rate of conversion to open surgery or the incidence of post-operative complications/need to return to theatre. The rate of subtotal cholecystectomy was higher in the ‘during COVID-19’ group (12% vs. 3%) and this was found to be statistically significant (p-value 0.024). Operating times were longer during the pandemic (93 vs. 80 mins), as was the LoS for the operative admission (5 vs. 6 days), however these results were not statistically significant.

Interestingly, same day emergency care (SDEC) reviews were more frequent in the ‘during COVID-19’ group (13.1 vs. 29.3%) and this was statistically significant (p-value 0.015). There was no statistically significant difference between the groups in relation to histopathology results. The most prevalent histopathology of both cohorts was chronic cholecystitis (58 vs. 48.28%). Acute on chronic cholecystitis (23 vs. 25.86%) and necrotising/gangranous changes (11 vs. 12.07%) were more prevalent in the ‘during COVID-19’ group. When reviewing costs between the two groups, no statistically significant differences in LoS, nor investigation tariffs was observed.

Conclusions

Our study shows that the COVID-19 pandemic has had a negative impact on two clinical aspects of emergency LC – an increase in the rate of subtotal cholecystectomy, as well as SDEC reviews. This could be explained by delays in elective surgery encountered during the pandemic, leading to patients experiencing recurrent infections, or other associated complications of gallstone disease and consequently requiring more frequent clinician/SDEC reviews. These complications can also result in unclear anatomy, diffuse scarring, necrosis and abscess formation, all of which can lead to increasingly complex cases encountered intra-operatively. If surgeons are unable to safely achieve a critical view of safety, guidance recommends subtotal cholecystectomy as a bail out procedure, in order to avoid serious damage to the bile duct or blood vessels. This could justify the statistically significant higher rate of subtotal cholecystectomy in the ‘during COVID-19’ group. Currently, there are approximately 6 million patients on NHS surgical waiting lists and this issue must be addressed urgently in the COVID-19 recovery phase, so as to prevent adverse outcomes for both patients and the NHS.

P-069 A SINGLE CENTRE RETROSPECTIVE 14 YEAR REVIEW OF PATIENT OUTCOMES FOLLOWING IPOM LAPAROSCOPIC VENTRAL HERNIA REPAIR WITH PVDF MESH

Aim

Laparoscopic ventral hernia repair (LVHR) is a widely accepted minimally invasive technique. However, there remains debate regarding appropriate patient selection, the type of mesh used and for what size and type of defect. We aimed to review our experience of IPOM LVHR using PVDF mesh and compare our outcomes to the current literature.

Material and Methods

Operative records identified all patients who had undergone an IPOM LVHR with PVDF mesh from 2007–2021. The type, number and size of hernial defects, the sac contents, along with the size of mesh used and the type of fixation was collated. Length of stay (LoS), as well as early and late post-operative complications were also analyzed.

Results

A total of 287 patients are included in the study to date. 32.3% of patients were categorised within Obese Class II or III (BMI 35 – &gt;40). Major early and late complications were observed in 4.6% and 3.1% of cases respectively. An 8.7% recurrence rate was observed. 87% of recurrences had an original defect classed as large (&gt;4cm), with a median BMI of 30.5.

Conclusion

In conclusion, our post-operative outcomes are in keeping with those reported in the literature. In our experience, a high BMI does not preclude patients from undergoing a LVHR and having a good result. Debates are ongoing with regards to the timing and indication for LVHR in the obese and our results are encouraging, especially considering current national statistics estimate approximately 30% of the UK population are classed as obese.

The burden of coronary revascularization associated with lipoprotein(a) in patients with atherosclerotic cardiovascular disease: data from the UK Biobank

Background/Introduction

Elevated lipoprotein(a) [Lp(a)] is an inherited, independent, and causal risk factor for atherosclerotic cardiovascular disease (ASCVD). In a previous analysis of 30,510 ASCVD patients from UK Biobank, adjusted models showed a 100 nmol/L (≈50 mg/dL) difference in Lp(a) was associated with a 19% (95% CI 14–23%) higher risk of coronary revascularization (Welsh P, 2022).

Purpose

To determine the absolute risk for coronary revascularization in an ASCVD population with elevated versus normal Lp(a) levels.

Methods

This was an observational, retrospective study including 32,537 patients from UK Biobank with an ASCVD diagnosis (CHD, cerebrovascular or peripheral arterial disease). Absolute risk (AR) of coronary revascularization (number of coronary revascularizations per 100-person-years) was reported in patients with normal (&lt;65 nmol/L ≈ 30 mg/dL; n=22,257) and elevated (≥150 nmol/L ≈ 70 mg/dL; n=5,204) Lp(a) levels across two time periods: within the first year of ASCVD diagnosis, and using all available follow-up data (median 4.7 years). Lp(a) was measured in an accredited single laboratory using a method standardized to WHO/IFCC reference material. The AR was also calculated for various subgroups within the ASCVD population.

Results

Within the first year after ASCVD diagnosis, 628 (12.07%) of the population with elevated Lp(a) underwent coronary revascularization compared to 1,787 (8.03%) with normal Lp(a). Those with elevated Lp(a) had a higher AR (14.00 per 100-person-years, 95% CI 13.02–14.99; p&lt;0.001) than those with normal Lp(a) (9.34; 95% CI 8.92–9.76). This also held in a subgroup with myocardial infarction (MI; n=9,588), AR of 18.98 (95% CI 16.95–21.01) in those with elevated Lp(a) (n=1,571) vs. AR of 13.02 (95% CI 12.16–13.89) in those with normal Lp(a) (n=6,441) (p&lt;0.001). AR of coronary revascularization within the first year of ASCVD diagnosis was also greater in participants with family history of CV disease (p&lt;0.001) and premature CV disease (&lt;60 years of age) (p&lt;0.001). When using all available follow-up, AR of coronary revascularization was higher in participants with elevated versus normal Lp(a) in the ASCVD population (3.79 vs 2.55; p&lt;0.001) and across all subgroups.

Conclusion

Elevated Lp(a) in patients with ASCVD was associated with increased risk of coronary revascularization in the first year (and subsequently), including those with a prior MI, premature CV disease, or family history of CV disease. Lp(a) testing in ASCVD patients can therefore aid estimations for the risk of revascularization, and thus the targeting of additional therapies to lower such risks.

Funding Acknowledgement

Type of funding sources: None.

TU5.4 ‘Learning lessons, inspiring change and driving improvements’ - A review of morbidity and mortality meetings in General and Vascular surgery

Aim

According to RCS/ASGBI guidance all surgeons should regularly attend Morbidity and Mortality meetings (M&Ms), as they are a key activity for reviewing the performance the team and ensuring quality of care. We aimed to review General and Vascular Surgery M&Ms at our site – are they in keeping with guidelines and can improvements be made?

Methods

A retrospective review of General and Vascular Surgery M&Ms was performed. Presentations were assessed against 12 key performance indicators (KPIs) as recommended by RCS/ASGBI. Following audit Cycle 1, a standardized M&M presentation proforma and an M&M outcome form were introduced, with subsequent second and third audit cycles completed.

Results

In comparison to Cycle 1, overall improvements were seen in 9/12 KPIs in both General and Vascular Surgery M&Ms. 100% compliance was demonstrated in both General and Vascular Surgery M&Ms in 7 KPIs. Improvements can still be made in the completion of Clavien-Dindo scoring, NCEPOD classification, as well as M&M outcome forms. Literature review discussions were not included in any General Surgery M&Ms in either cycle and in only 14% of Vascular Surgery cases.

Conclusion

Significant improvement in RCS/ASGBI compliance was demonstrated with the introduction of an M&M presentation proforma. Emphasis and encouragement should still be placed on the importance of literature reviews to promote learning, although we appreciate time limitations can have an impact on this. By improving the quality of M&Ms, surgical teams can learn lessons, inspire change and drive improvements.

TU8.13 How can we help things move along? – A review of the management of the acute bowel obstruction

Background

Acute bowel obstruction (ABO) is a common surgical emergency and is associated with significant morbidity and mortality. Currently there is no national guidance for the management of ABO and an NCEPOD study highlighted the resulting variance in care nationwide. This study recommended several standards of care for the management of ABO and we aimed to review our practice against this guidance.

Method

A retrospective review identified all adult patients admitted with a radiologically confirmed diagnosis of ABO, over an 8 month period. 8 key performance indicators (KPIs) were adapted from the NCEPOD recommendations and data was collected from patient notes, drug charts and computer records. A total of 22 patients are included in this study to date.

Results

The median length of time from referral to surgical review and from surgical review to CT scan was 112 mins and 134 mins respectively. 31.8% of patients underwent emergency surgery. Pain documentation was the only KPI that met 100% target compliance. A MUST score was completed in 72.7% of cases, a treatment escalation plan in 36.4% of cases, hydration status was documented in 4.5% of cases and no patients had a frailty score documented.

Conclusion

Our results demonstrate that significant improvements can be made in the management of ABO and the recognition of aspects known to impact patient morbidity and mortality. In keeping with NCEPOD recommendations we suggest the implementation of an ABO pathway. We hope this will assist clinicians in caring for patients with ABO, promote MDT collaboration and highlight clinical concerns early.

1544 The Doctor Will Call You Now – Patients’ Perspective of The Implementation of Telephone Clinics in the COVID-19 Era

Aim

During the first wave of the COVID-19 pandemic, clinical guidelines advised the implementation of remote consultations with the aim of preventing viral transmission. Guidance included the introduction of telephone clinics and in March 2020, these were initiated for General Surgery at our rural DGH. The aim of this study was to review patients’ perspectives of these remote consultations.

Method

Using telephone clinic schedules, the first 100 patients of the telephone clinics were retrospectively identified. A survey was created using Google forms and questions covered patient demographics, as well as patients’ opinions on the organisation and efficacy of the clinic. The survey was completed via a telephone conversation with each patient between June to August 2020.

Results

72 patients consented to participate (age range: 24-80 years; 65% female). 44% of consultations were follow up, with 23% of patients having their initial appointment remotely. Although 82% of patients were able to discuss all concerns, nearly half of patients (43%) felt not having a face-to-face appointment affected their consultation. 78% of patients preferred remote consultations during the pandemic, but beyond this specific situation, 53% felt that in the future they would still prefer a face-to-face consultation. 57.6% of patients rated the newly implemented telephone consultations as 10/10.

Conclusions

The majority of patient feedback was positive. However, outside of the COVID-19 pandemic, our patients would prefer the traditional face-to-face consultation format. This outcome has been demonstrated in other similar studies worldwide, as it enables patients to be examined by and meet their surgeon prior to potential surgery.

1464 Breaking Tradition – A Rural DGH’s Experience of The Management of Acute Appendicitis During the First Wave of the COVID-19 Pandemic

Aim

Acute appendicitis (AA) is the most common abdominal surgical emergency in the UK and traditionally, operative management is the mainstay of treatment. However, during the first wave of the COVID-19 pandemic, ACPGBI discouraged laparoscopy, due to potential risks of aerosol viral transmission. We aimed to review clinical outcomes of patients treated for AA at our DGH prior to and after the change in ACPGBI guidance.

Method

The first 30 patients treated for AA prior to (Group A) and following the update in ACPGBI guidance (Group B), were identified.

Results

Group A: 7% managed conservatively vs 93% operative management. Group B: 74% managed conservatively vs 26% operative management. No statistically significant difference was seen in the rate of post-operative complications, or readmission. In Group B, of those managed conservatively and then readmitted, 75% underwent an operation (RR &lt; 1.00). The average length of stay (LOS) of those managed conservatively in Group A was 3.5 days vs 2.4 days in Group B (p &lt; 0.05). Statistically significant differences in LOS were also observed in patients who underwent surgery - Group A 5.5 day vs 8.25 days in Group B (p &lt; 0.001).

Conclusions

In conclusion, the change in ACPGBI guidance in the early stages of the COVID-19 pandemic, saw statistically significant differences in LOS at our DGH. A shorter LOS in those conservatively managed in Group B could be explained by hospital bed pressures. An increase in LOS for Group B patients with operative management is understandable, as only cases of complicated AA, or those readmitted underwent emergency surgery.

Variations in colorectal cancer surgery practice across the United Kingdom during the COVID-19 pandemic - 'Every land has its own law'

BACKGROUND

In March 2020 NHS England issued guidelines recognizing the elective component of cancer surgeries may be 'curtailed', due to staffing and supply shortages during the COVID-19 pandemic. However, it suggested, 'local solutions' should be sought in order to protect the delivery of cancer services. We aimed to compare surgeons' practice for the provision of colorectal (CR) cancer surgery across the United Kingdom (UK), against updated Joint Royal Colleges & ACPGBI guidelines and highlight differences in practice, if any.

METHOD

An online survey was conducted. It examined surgical practice across the UK against current protocols for CR cancer surgeries, during the COVID-19 pandemic.

RESULTS

29 individual responses were received from 23 NHS Trusts across the UK. 23/29 (79%) surgeons ceased or experienced delays in their CR cancer surgeries during the pandemic, with 3/29 (10%) yet to reintroduce these services. 19/26 (73%) surgeons instructed their patients to self-isolate prior to surgery, of which 5/19 (26%) correctly enforced a duration of 14 days. 10/19 (53%) participants adhered to guidelines of performing a CT chest within 24 h of surgery. 10/26 (38%) participants believe their patients are experiencing longer hospital admissions in the COVID-19 setting.

CONCLUSION

This snap shot survey highlights the dramatic variations in CR cancer surgery practice within the UK and inconsistent adherence to protocols. Guidelines will no doubt change as our knowledge of COVID-19 increases both nationally and internationally. It is essential CR surgeons keep up to date with changes in guidance, so uniformity in practice can be maintained.

Burden of disease from exposure to secondhand smoke in children in Europe

BACKGROUND

Secondhand smoke (SHS) exposure at home and fetal SHS exposure during pregnancy are a major cause of disease among children. The aim of this study is quantifying the burden of disease due to SHS exposure in children and in pregnancy in 2006-2017 for the 28 European Union (EU) countries.

METHODS

Exposure to SHS was estimated using a multiple imputation procedure based on the Eurobarometer surveys, and SHS exposure burden was estimated with the comparative risk assessment method using meta-analytical relative risks. Data on deaths and disability-adjusted life years (DALYs) were collected from National statistics and from the Global Burden of Disease Study.

RESULTS

Exposure to SHS and its attributable burden stalled in 2006-2017; in pregnant women, SHS exposure was 19.8% in 2006, 19.1% in 2010, and 21.0% in 2017; in children it was 10.1% in 2006, 9.6% in 2010, and 12.1% in 2017. In 2017, 35,633 DALYs among children were attributable to SHS exposure in the EU, mainly due to low birth weight.

CONCLUSIONS

Comprehensive smoking bans up to 2010 contributed to reduce SHS exposure and its burden in children immediately after their implementation; however, SHS exposure still occurs, and in 2017, its burden in children was still relevant.

IMPACT

Exposure to secondhand smoke at home and in pregnancy is a major cause of disease among children. Smoking legislation produced the adoption of voluntary smoking bans in homes; however, secondhand smoke exposure at home still occurs and its burden is substantial. In 2017, the number of deaths and disability-adjusted life years in children attributable to exposure to secondhand smoke in the European Union countries were, respectively, 335 and 35,633. Low birth weight caused by secondhand smoke exposure in pregnancy showed the largest burden. Eastern European Union countries showed the highest burden.

Global Trends in Marine Plankton Diversity across Kingdoms of Life

The ocean is home to myriad small planktonic organisms that underpin the functioning of marine ecosystems. However, their spatial patterns of diversity and the underlying drivers remain poorly known, precluding projections of their responses to global changes. Here we investigate the latitudinal gradients and global predictors of plankton diversity across archaea, bacteria, eukaryotes, and major virus clades using both molecular and imaging data from Tara Oceans. We show a decline of diversity for most planktonic groups toward the poles, mainly driven by decreasing ocean temperatures. Projections into the future suggest that severe warming of the surface ocean by the end of the 21^st century could lead to tropicalization of the diversity of most planktonic groups in temperate and polar regions. These changes may have multiple consequences for marine ecosystem functioning and services and are expected to be particularly significant in key areas for carbon sequestration, fisheries, and marine conservation.

Video Abstract

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Most epipelagic planktonic groups exhibit a poleward decline of diversity

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No latitudinal diversity gradient was observed below the photic zone

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Temperature emerges as the best predictor of epipelagic plankton diversity

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Global warming may increase plankton diversity, particularly at high latitudes

Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome

INTRODUCTION

Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region.

METHODS

We describe a 60-year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine.

RESULTS

Pain disappeared and the result was maintained 3 months later.

DISCUSSION

This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region.

SIGNIFICANCE

The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.

An assessment of professionalism on students' Facebook profiles

INTRODUCTION

With the advent of social media, healthcare professionals not only need to be conscious of professionalism in their face-to-face interactions but also in the electronic environment. The aim of this study was to assess the level of online professionalism on Facebook profiles available for public viewing of students from a dental school.

MATERIALS AND METHODS

A search was performed via a new Facebook account of all students in the University Dental School (dental hygiene, dental nursing, dental science and dental technology). Profiles were categorised as 'private' or 'public'. Demographic details and photographs/comments of unprofessional behaviour were recorded for each individual Facebook profile. Each profile was subsequently scored with regard to professionalism based on a previously published score.

RESULTS

There are a total of 287 students in the dental school. Of these, 62% (n = 177) had a Facebook account. Three per cent (n = 6) had a public account (fully accessible) whilst 97% (n = 171) had a private account (limited access); 36% (n = 63) of students mentioned the dental school/hospital on their profile; 34% (n = 60) had questionable content on their profile whilst 3% (n = 6) had definite violations of professionalism on their profile; and 25% (n = 44) had unprofessional photographs on their profile. Of those with unprofessional content, 52% (n = 23) of these had a documented affiliation with the dental school also visible on their profile.

CONCLUSION

There was a concerning level of unprofessional content visible on students' Facebook profiles. Students need to be fully aware of their professional responsibility in the setting of social media.

Diversity and dynamics of the DNA- and cDNA-derived compost fungal communities throughout the commercial cultivation process for Agaricus bisporus

Commercial cultivation of the button mushroom Agaricus bisporus is performed through the inoculation of a semipasteurized composted material. Pasteurization of the compost material prior to inoculation results in a substrate with a fungal community that becomes dominated by A. bisporus. However, little is known about the composition and activity in the wider fungal community beyond the presence of A. bisporus in compost throughout the mushroom cropping process. In this study, the fungal cropping compost community was characterized by sequencing nuc rDNA ITS1-5.8S-ITS2 amplified from extractable DNA and RNA. The fungal community generated from DNA extracts identified a diverse community containing 211 unique species, although only 51 were identified from cDNA. Agaricus bisporus was found to dominate in the DNA-derived fungal community for the duration of the cropping process. However, analysis of cDNA extracts found A. bisporus to dominate only up to the first crop flush, after which activity decreased sharply and a much broader fungal community became active. This study has highlighted the diverse fungal community that is present in mushroom compost during cropping.

A multi-scale model of the interplay between cell signalling and hormone transport in specifying the root meristem of Arabidopsis thaliana

The growth of the root of Arabidopsis thaliana is sustained by the meristem, a region of cell proliferation and differentiation which is located in the root apex and generates cells which move shootwards, expanding rapidly to cause root growth. The balance between cell division and differentiation is maintained via a signalling network, primarily coordinated by the hormones auxin, cytokinin and gibberellin. Since these hormones interact at different levels of spatial organisation, we develop a multi-scale computational model which enables us to study the interplay between these signalling networks and cell-cell communication during the specification of the root meristem. We investigate the responses of our model to hormonal perturbations, validating the results of our simulations against experimental data. Our simulations suggest that one or more additional components are needed to explain the observed expression patterns of a regulator of cytokinin signalling, ARR1, in roots not producing gibberellin. By searching for novel network components, we identify two mutant lines that affect significantly both root length and meristem size, one of which also differentially expresses a central component of the interaction network (SHY2). More generally, our study demonstrates how a multi-scale investigation can provide valuable insight into the spatio-temporal dynamics of signalling networks in biological tissues.

Post-transcriptional regulation in the nucleus and cytoplasm: study of mean time to threshold (MTT) and narrow escape problem

Messenger RNAs (mRNAs) can be repressed and degraded by small non-coding RNA molecules. In this paper, we formulate a coarsegrained Markov-chain description of the post-transcriptional regulation of mRNAs by either small interfering RNAs (siRNAs) or microRNAs (miRNAs). We calculate the probability of an mRNA escaping from its domain before it is repressed by siRNAs/miRNAs via calculation of the mean time to threshold: when the number of bound siRNAs/miRNAs exceeds a certain threshold value, the mRNA is irreversibly repressed. In some cases, the analysis can be reduced to counting certain paths in a reduced Markov model. We obtain explicit expressions when the small RNA bind irreversibly to the mRNA and we also discuss the reversible binding case. We apply our models to the study of RNA interference in the nucleus, examining the probability of mRNAs escaping via small nuclear pores before being degraded by siRNAs. Using the same modelling framework, we further investigate the effect of small, decoy RNAs (decoys) on the process of post-transcriptional regulation, by studying regulation of the tumor suppressor gene, PTEN: decoys are able to block binding sites on PTEN mRNAs, thereby reducing the number of sites available to siRNAs/miRNAs and helping to protect it from repression. We calculate the probability of a cytoplasmic PTEN mRNA translocating to the endoplasmic reticulum before being repressed by miRNAs. We support our results with stochastic simulations.

Hydrodynamic dispersion within porous biofilms

Many microorganisms live within surface-associated consortia, termed biofilms, that can form intricate porous structures interspersed with a network of fluid channels. In such systems, transport phenomena, including flow and advection, regulate various aspects of cell behavior by controlling nutrient supply, evacuation of waste products, and permeation of antimicrobial agents. This study presents multiscale analysis of solute transport in these porous biofilms. We start our analysis with a channel-scale description of mass transport and use the method of volume averaging to derive a set of homogenized equations at the biofilm-scale in the case where the width of the channels is significantly smaller than the thickness of the biofilm. We show that solute transport may be described via two coupled partial differential equations or telegrapher's equations for the averaged concentrations. These models are particularly relevant for chemicals, such as some antimicrobial agents, that penetrate cell clusters very slowly. In most cases, especially for nutrients, solute penetration is faster, and transport can be described via an advection-dispersion equation. In this simpler case, the effective diffusion is characterized by a second-order tensor whose components depend on (1) the topology of the channels' network; (2) the solute's diffusion coefficients in the fluid and the cell clusters; (3) hydrodynamic dispersion effects; and (4) an additional dispersion term intrinsic to the two-phase configuration. Although solute transport in biofilms is commonly thought to be diffusion dominated, this analysis shows that hydrodynamic dispersion effects may significantly contribute to transport.

A multi-method evaluation of a training course on dual diagnosis

A training course on dual diagnosis was developed within the Irish forensic mental health service, to bridge the gap in the lack of training on dual diagnosis in Ireland. The course was designed for service providers within mental health and addiction services. Twenty participants involving nursing, social work, police and social welfare disciplines attended the first training course. A mixed methodology research design was adapted to describe participants' evaluation of the training course. Data were collected using multiple methods: pre- and post-test, daily evaluation and focus group interviews. Quantitative data were analysed using the spss Version 16.0 and qualitative data were analysed thematically. Findings from the pre- and post-test suggest an increase in participants' knowledge of dual diagnosis and an increase in confidence in conducting groups. Daily evaluation indicates that the course content largely met participants' needs. Finally, three themes emerged from the focus group interview: increased confidence, the training course/teaching methods and personal/organizational challenges. This study implies that service providers within mental health and addiction services benefit from inter-professional, needs and skills based courses incorporating a variety of teaching methods. The way forward for future dual diagnosis training course developments would be working in partnership with service users and carers.

Healthcare-associated infection in Irish long-term care facilities: results from the First National Prevalence Study

BACKGROUND

Prevalence of healthcare-associated infection (HCAI) and antimicrobial use in Irish long-term care facilities (LTCFs) has never been studied.

AIM

To collect baseline data on HCAI prevalence and antibiotic use in Irish LTCFs to inform national LTCF policy and plan future HCAI prevention programmes.

METHODS

A prevalence study of HCAI and antibiotic use was undertaken in Irish LTCFs. Participation was voluntary. Data on HCAI risk factors, signs and symptoms of infection and antimicrobial use were collected prospectively on a single day in each institution.

FINDINGS

Sixty-nine Irish LTCFs participated and 4170 eligible residents were surveyed; 472 (11.3%) had signs/symptoms of infection (266, 6.4%) and/or were on antibiotics (426, 10.2%). A third of residents (1430, 34.3%) were aged ≥85 years and more than half disorientated (2110, 50.6%) with impaired mobility (2101, 50.4%). HCAI prevalence was 3.7% (range: 0-22.2%). The most common HCAI was urinary tract infection (UTI) (62 residents, 40% of HCAI). Presence of a urinary catheter was associated with UTI (P < 0.0000001). Antibiotics were prescribed for treatment (262 residents, 57.8%) and prophylaxis (182 residents, 40.2%) of infection. The most common indication for prophylaxis was UTI prevention (35.8% of total prescriptions). Fourteen (10.2%) residents on UTI prophylaxis had a urinary catheter. The most common indications for therapy included respiratory tract infections (35.1%), UTI (32.1%) and skin infection (21.8%).

CONCLUSION

This study highlights the frequency of prophylactic antimicrobial prescribing and provides an important baseline to inform future preventive strategies.

Studies on the effect of temperature and pH on the inactivation of fish viral and bacterial pathogens

Disposal of fish by-products in the European Community must comply with Regulation (EC) No 1069/2009 which categorizes animal by-products according to risk, and specifies methods of disposal of by-products according to that risk. There is provision under the regulation for composting or ensiling to be used for by-products from aquatic animals. Biosecurity considerations require knowledge of the parameters of time and temperature, or time and pH, required to inactivate any fish pathogens that may be present. To provide those data, we undertook laboratory studies on the inactivation of a number of fish pathogenic viruses and bacteria at 60 °C, pH 4.0 and pH 12.0 as a preliminary to conducting subsequent trials with the most resistant viruses and bacteria in fish tissues. The most resistant bacterium to 60 °C, pH 4.0 as well as pH 12.0 was Lactococcus garvieae. Its concentration was reduced to the level of sensitivity of the test after 24-48 h exposure to 60 °C, but it survived for at least 7 days at pH 4.0 and 14 days at pH 12.0. The most resistant virus to 60 °C was infectious pancreatic necrosis virus, and to pH 12.0 was infectious salmon anaemia virus. The majority of the viruses tested survived exposure to pH 4.0 for up to 28 days. The results suggest that the process of acid ensiling alone is not an effective method for the inactivation of many viral and bacterial pathogens, and fish by-products would need further treatment by a method approved under the regulation following ensiling, whereas alkaline or heat treatment are likely to provide an increased degree of biosecurity for on-farm processing of mortalities.

A model of cell migration within the extracellular matrix based on a phenotypic switching mechanism

Cell migration involves different mechanisms in different cell types and tissue environments. Changes in migratory behaviour have been observed experimentally and associated with phenotypic switching in various situations, such as the migration-proliferation dichotomy of glioma cells, the epithelial-mesenchymal transition or the mesenchymal-amoeboid transition of fibrosarcoma cells in the extracellular matrix (ECM). In the present study, we develop a modelling framework to account for changes in migratory behaviour associated with phenotypic switching. We take into account the influence of the ECM on cell motion and more particularly the alignment process along the fibers. We use a mesoscopic description to model two cell populations with different migratory properties. We derive the corresponding continuum (macroscopic) model by appropriate rescaling, which leads to a generic reaction-diffusion system for the two cell phenotypes. We investigate phenotypic adaptation to dense and sparse environments and propose two complementary transition mechanisms. We study these mechanisms by using a combination of linear stability analysis and numerical simulations. Our investigations reveal that when the cell migratory ability is reduced by a crowded environment, a diffusive instability may appear and lead to the formation of aggregates of cells of the same phenotype. Finally, we discuss the importance of the results from a biological perspective.

Calciphylaxis: calcific uraemic arteriolopathy--a case study

Having worked in nephrology for more than 20 years, and never encountering this condition before, we came across three patients who had been diagnosed with calciphylaxis in the space of 12 months. This condition is also known as calcific uraemic arteriolopathy and is a syndrome of medical calcification of the small arteries, which leads to painful ischaemia of the surrounding subcubitis and skin (1). Prevalence of 1-4% has been estimated in various haemodialysis populations. Also 1% per year in dialysis patients has also been suggested (3). The mortality rate for distal lesions is 23%, whilst the mortality for proximal lesions is 63% (4). The pathogenesis of this condition remains uncertain. However, vascular calcium deposition is thought to be important, and raised serum phosphate levels were associated with a substantially increased risk of calciphylaxis. Although PTH levels were high, plasma PTH was not consistently higher in patients with calciphylaxis than controls (5). The important aspect of the condition for the patients is the sheer pain and distress suffered, as well as the high mortality rate. Therefore, the implications for nurses are early detection, to allow speedy treatment to take place and involvement of the multidisciplinary team to enhance care and provide as much support as possible, thus facilitating optimal outcome and comfort.

Neonatal transportation: the effects of a national neonatal transportation programme

BACKGROUND

The transport of critically ill newborns by specialised transport teams has been shown to be associated with a significant improvement in their clinical condition on arrival at the receiving hospital.

AIM

To determine if the National Neonatal Transport Programme introduced in 2001 improved clinical condition of newborns at the end of transfer.

METHODS

A retrospective study of all 176 patients transported by the National Neonatal Transport Programme between March 2001 and March 2002.

RESULTS

Before transfer, 17% of patients were hypothermic, 2% hypoglycaemic and 11% acidotic as were 7%, 3% and 5% respectively at the end of transfer. A review of 172 neonatal transports between 1987 and 1989 revealed that 21% of patients were hypothermic, 13% hypoglycaemic and 20% acidotic at the end of transfer.

CONCLUSIONS

The National Neonatal Transport Programme has resulted in improved clinical condition of newborns at the end of transfer when compared to their condition before transfer and compared to outcomes prior to the introduction of the programme.