Inhibition of thrombin-activatable fibrinolysis inhibitor via DS-1040 to accelerate clot lysis in patients with acute pulmonary embolism: a randomized phase 1b study

BACKGROUND

The optimal treatment of intermediate-risk pulmonary embolism (PE) in hemodynamically stable patients remains unknown. Fibrinolytics reduce the risk of hemodynamic deterioration but increase bleeding risk. DS-1040, an inhibitor of thrombin-activatable fibrinolysis inhibitor, enhanced endogenous fibrinolytic activity without increasing bleeding risk in preclinical studies.

OBJECTIVES

To evaluate the tolerability and explore the efficacy of DS-1040 in patients with acute PE.

METHODS

In this multicenter, randomized, double-blind, placebo-controlled study, ascending doses of intravenous DS-1040 (20-80 mg) or placebo were added to enoxaparin (1 mg/kg twice daily) in patients with intermediate-risk PE. The primary endpoint was the number of patients with major or clinically relevant nonmajor bleeding. The percentage change in thrombus volume and right-to-left ventricular dimensions, assessed using quantitative computed tomography pulmonary angiography, at baseline and after 12 to 72 hours were used to explore the efficacy of DS-1040.

RESULTS

Of 125 patients with all available data, 38 were randomized to placebo and 87 to DS-1040. The primary endpoint occurred in 1 patient in the placebo group (2.6%) and 4 patients who received DS-1040 (4.6%). One subject experienced major bleeding (DS-1040 80 mg group); no fatal or intracranial bleeding occurred. Thrombus volume was 25% to 45% lower after infusion, with no differences between the DS-1040 and placebo groups. There was no difference in the change from baseline right-to-left ventricular dimensions between the DS-1040 and placebo groups.

CONCLUSION

In patients with acute PE, adding DS-1040 to standard anticoagulation was not associated with an increase in bleeding but did not improve thrombus resolution or right ventricular dilation.

OC-080 COMPLETE VERSUS PARTIAL EXCISION OF AN INFECTED MESH FOLLOWING ABDOMINAL WALL HERNIA REPAIR: A SYSTEMATIC REVIEW AND META-ANALYSIS

Aims

To evaluate comparative outcomes of complete and partial excision of infected mesh following abdominal wall hernia repair.

Methods

A systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits was conducted. Surgical site infection (SSI), chronic sinus formation, recurrent hernia and need for reoperation were the evaluated outcome measures.

Results

Six comparative observational studies were identified, reporting a total of 317 patients of whom 193 underwent complete mesh excision and the remaining 123 patients underwent partial mesh excision for an infected mesh following abdominal wall hernia repair. The complete mesh excision was associated with significantly lower rates of SSIs (OR: 0.36; 95% CI, 0.16–0.81, p=0.01), chronic sinus formation (OR: 0.11; 95% CI, 0.02–0.71, p=0.02), and reoperation (OR: 0.10; 95% CI, 0.03–0.33, p=0.0001) compared to the partial mesh excision. There was no significant difference in hernia recurrence rate (OR: 3.96.16, 95% CI 0.62–25.44, p=0.15) between two groups.

Conclusions

Our meta-analysis demonstrated that complete mesh excision may be associated with lower SSI, chronic sinus formation and need for reoperation when compared to the partial mesh excision in an infected mesh event. However, the available evidence has failed to report the outcomes with respect to the main confounding factors which, together with other important outcomes such as fistula formation, should be considered by future high quality research.

Ethnic inequalities in treatment with clozapine

Introduction

Ethnic disparities in treatment with clozapine, the antipsychotic recommended for treatment-resistant schizophrenia (TRS), have been reported. However, these investigations frequently suffer from potential residual confounding. For example, few studies have restricted the analyses to TRS samples and none has controlled for benign ethnic neutropenia.

Objectives

This study investigated if service-users’ ethnicity influenced clozapine prescription in a cohort of people with TRS.

Methods

Information from the clinical records of South London and Maudsley NHS Trust was used to identify a cohort of service-users with TRS between 2007 and 2017. In this cohort, we used logistic regression to investigate any association between ethnicity and clozapine prescription while adjusting for potential confounding variables, including sociodemographic factors, psychiatric multimorbidity, substance use, benign ethnic neutropenia, and inpatient and outpatient care received.

Results

We identified 2239 cases that met the criteria for TRS. Results show that after adjusting for confounding variables, people with Black African ethnicity had half the odds of being treated with clozapine and people with Black Caribbean or Other Black background had about two-thirds the odds of being treated with clozapine compared White British service-users. No disparities were observed regarding other ethnic groups, namely Other White background, South Asian, Other Asian, or any other ethnicity.

Conclusions

There was evidence of inequities in care among Black ethnic groups with TRS. Interventions targeting barriers in access to healthcare are recommended.

Disclosure

During the conduction of the study, DFdF, GKS, and RH received funds from the NIHR Maudsley Biomedical Research Centre. For other activities outside the submitted work, DFdF received research funding from the UK Department of Health and Social Care, Janss

Evaluation of Results of Open Reduction and Internal Fixation (ORIF) of Fracture of Distal End of Femur with Intra-Articular Extension

INTRODUCTION

Fractures of the distal femur account for 0.4% of all fractures. They involve about 7% of all femur fractures, with bimodal age distribution, commonly occur during high-velocity trauma of motor vehicle accidents in the younger group of patients and are frequently associated with other skeletal injuries. The treatment of distal femoral fractures has evolved from conservative treatment to more aggressive operative treatment. The aim is to achieve and maintain a good reduction of the joint to allow early active mobilisation, thus minimising the joint stiffness and severe muscular atrophy encountered in the conservative treatment.

MATERIALS AND METHODS

This is a retrospective study of 25 patients with distal femur fracture with intra-articular extension treated with open reduction and internal fixation with DFLP, admitted at our institute between 2016 to 2019, with a minimum follow-up of six months.

RESULTS

In our study, 19 (76%) patients had excellent to good results. Three (12%) patients had fair outcomes, and three (12%) patients had poor outcomes according to Neer's score. The average time for bone union in closed fractures was earlier (4.25 months) than open fractures, averaging 5.86 months. The outcome was almost similar between closed and open fractures. There were 2 (8%) cases of infection in the early post-operative period, 7 (12%) patients suffered from knee stiffness, and there were 3 (12%) cases with a pre-operative bone loss that required bone grafting.

CONCLUSION

Management of complex intra-articular distal femur fracture has always been a challenge. Anatomical reduction of articular fragments and rigid fixation of these fractures are a must. DFLP provides angular stability with multiple options to secure fixation of both metaphyseal and articular fragments with the restoration of the joint congruity, limb length, alignment and rotation, allowing early mobilisation and aggressive physiotherapy without loss of fixation, resulting in gratifying functional outcome and low complication rate.

Comparing Proton to Photon Radiotherapy Plans: UK Consensus Guidance for Reporting Under Uncertainty for Clinical Trials

In the UK, the recent introduction of high-energy proton beam therapy into national clinical practice provides an opportunity for new clinical trials, particularly those comparing proton and photon treatments. However, comparing these different modalities can present many challenges. Although protons may confer an advantage in terms of reduced normal tissue dose, they can also be more sensitive to uncertainty. Uncertainty analysis is fundamental in ensuring that proton plans are both safe and effective in the event of unavoidable discrepancies, such as variations in patient setup and proton beam range. Methods of evaluating and mitigating the effect of these uncertainties can differ from those approaches established for photon therapy treatments, such as the use of expansion margins to assure safety. These differences should be considered when comparing protons and photons. An overview of the effect of uncertainties on proton plans is presented together with an introduction to some of the concepts and terms that should become familiar to those involved in proton therapy trials. This report aims to provide guidance for those engaged in UK clinical trials comparing protons and photons. This guidance is intended to take a pragmatic approach considering the tools that are available to practising centres and represents a consensus across multidisciplinary groups involved in proton therapy in the UK.

Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality

OBJECTIVES

The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes.

METHODS

We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality.

RESULTS

We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023).

CONCLUSIONS

Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Increased secretion of exopolysaccharide and virulence potential of a mucoid variant of Salmonella enterica serovar Montevideo under environmental stress

During an investigation to increase the recovery of Salmonella enterica from Oregano, an increased expression of exopolysaccharide was induced in Salmonella serovar Montevideo. The atypical mucoid (SAL242S) and the non-mucoid (SAL242) strains of Montevideo were compared and characterized using various methods. Serotyping analysis demonstrated that both strains are the same serovar Montevideo. Electron microscopy (EM) of cultured SAL242S cells revealed the production of a prominent EPS-like structure enveloping aggregates of cells that are composed of cellulose. Mucoid cells possessed a higher binding affinity for Calcofluor than that of the non-mucoid strain. Genotypic analysis revealed no major genomic differences between these morphotypes, while expression analyses using a DNA microarray shows that the mucoid variant exhibited heightened expression of genes encoding proteins produced by the SPI-1 type III secretion system. This increased expression of SPI1 genes may play a role in protecting Salmonella from environmental stressors. Based on these observations, Salmonella serovar Montevideo mucoid variant under stressful or low-nutrient environments presented atypical growth patterns and phenotypic changes, as well as an upregulated expression of virulence factors. These findings are significant in the understanding of survival abilities of Salmonella in a various food matrices.

A Comparison of Rapid Bovine Spongiform Encephalopathy Testing Methods on Autolyzed Bovine Brain Tissue

In 1999, the European Union (EU) approved 3 rapid methods for the testing of bovine brain samples for the presence of bovine spongiform encephalopathy (BSE). The evaluation that led to the approval did not include an analysis of autolyzed material. Member states of the EU have active surveillance programs for BSE, which target fallen stock as well as other categories of cattle. Autolysis is a common feature of fallen stock samples because there can be a considerable delay between death and collection of samples. Therefore, it is important to know whether these tests perform optimally on autolyzed samples. The Veterinary Laboratories Agency (VLA) selected 250 positive fallen stock samples. These had been detected during routine testing using the Prionics®-Check Western blot and confirmed as BSE cases by immunohistochemistry or electron microscopy. Samples were graded according to the degree of autolysis and then tested by the 3 methods: Prionics®-Check Western blot, Platelia test, and Enfer test. All 3 methods correctly classified the samples as positive BSE cases, therefore alleviating doubt about their ability to do so. Subsequent EU validation exercises, such as those conducted in 2002–2003, have included the testing of autolyzed material. It is important that all new methods be evaluated on autolyzed tissue before approval for official use.

Evaluation of self medication practices in rural area of town sahaswan at northern India

BACKGROUND

Many of the studies have investigated the prevalence and nature of self-medication. It is a common type of self-care behavior among the populace of various countries. World Health Organization promotes the practice of self-medication for effective and quick relief of symptoms without medical consultations to reduce the burden on health-care services, which are often understaffed and inaccessible in rural and remote areas.

AIM

The aim of the study was to determine the extent and pattern of self-medication among the population (patients) attending pharmacies at study sites and to note the association of self-medication variables with demographic factors.

SUBJECTS AND METHODS

The present study was a community based cross sectional study aimed to gather information about the prevalence of self-medication in the rural town of Sahaswan, Uttar Pradesh from June 2012 to July 2012. The sample size comprised of 600 respondents. Data were collected through a prepared questionnaire. All descriptive data were coded, entered and analyzed using the statistical package for Social sciences program version 17.0 (Chicago, IL, USA). Descriptive data analysis was conducted and reported as frequencies and percentage.

RESULTS

The percentage of patients who were seeking self-medication was approximately 50% (300/600). Most of the patients were seeking self-medication for headache and other pain (23.3% [140/600]), fever (14.5% [87/600]), urinary tract infections (9.7% [58/600]) and respiratory tract infections (11.7% [70/600]). The drugs most commonly purchased for practicing self-medication were non-steroidal anti-inflammatory drugs (25.3% [152/600]), medications used for gastro intestinal problems (20.8% [125/600]) and antibiotics (16.7% [100/600]).

CONCLUSION

Prevalence of self-medication was high primarily among illiterate males aged above 15 years with a low income. Patient health awareness programs, assistance by community pharmacists and pharmacist continuing education are necessary for controlling self-medication. There is a need for planning interventions to promote rational self-medication through mass medias such as newspaper, magazine and TV.

Audit of the job satisfaction levels of the UK radiography and physics workforce in UK radiotherapy centres 2012

OBJECTIVE

Workforce planning reports identify a staff shortfall that jeopardizes the ability of UK radiotherapy centres to meet future demands. Obtaining an understanding of the work experiences of radiotherapy professionals will support the development of strategies to increase job satisfaction, productivity and effectiveness.

METHODS

A quantitative survey assessed job satisfaction, attitudes to incident reporting, stress and burnout, opportunities for professional development, workload, retention and turnover. Clinical oncologists were not included, as the Royal College of Radiologists, London, UK, had recently assessed their members' satisfaction. All questions were taken from validated instruments or adapted from the "UK National Health Service Staff Survey".

RESULTS

The survey yielded 658 completed responses (approximately 16% response rate), from public and private sectors. Over a third (36%) of respondents were classified as satisfied for job satisfaction with 11% dissatisfied and the remaining 53% ambivalent. A significant proportion of clinical staff (37.5%) report high emotional exhaustion. Presenteeism was an issue with 42.4% attending work despite feeling unable to fulfil their role.

CONCLUSION

Radiotherapy professionals are prone to the effects of compassion fatigue and burnout. Attention must be paid to workload and its impact on practitioners' job satisfaction. Professional development that is supported and informed by a performance development review is a simple and effective means of enhancing satisfaction. Individuals have a responsibility to themselves and their colleagues as their behaviours and attitudes influence job satisfaction.

ADVANCES IN KNOWLEDGE

This work identifies areas for future research to enhance the professional resilience of practitioners, in order to provide high-quality treatments.

Patterns of adherence to NICE glaucoma guidance in two different service delivery models

PURPOSE

To assess adherence patterns to the UK National Institute of Health and Clinical Excellence (NICE) guidelines on glaucoma management (2009) in a tertiary referral centre shared care setting and in a district general hospital (DGH) setting.

METHOD

We performed a retrospective case note analysis of 200 patients from two centres between January and June 2010. The two centres involved were a consultant-guided teaching hospital optometry-led shared care setting (setting 1) and a consultant-led DGH clinic setting (setting 2). The main outcome measures were compliance with eight of the main NICE guidelines on glaucoma diagnosis and management (2009).

RESULTS

Both centres showed good adherence to the guidelines regarding the choice of initial treatment (96% vs 100%, settings 1 and 2, respectively) and arranging appropriate monitoring intervals (92% vs 86%). However, significant differences were seen when assessing whether an optic disc image was obtained at the initial visit (74% vs 10%), whether an appropriate initial assessment was performed (96% vs 58%), whether patients' review interval complied with the NICE guidance regardless of hospital cancellations (92% vs 66%), and whether concordance with medication was checked (88% vs 24%) (settings 1 and 2, respectively, P<0.01-Fisher's exact test).

CONCLUSION

Our study provides evidence to suggest that a hospital-based shared care service with trained optometrists using assessment sheets compares favourably to non-specialist glaucoma care delivered by ophthalmologists.

Ocular adnexal diffuse large B-cell lymphoma: local disease correlates with better outcomes

PURPOSE

To describe the clinical, immunohistochemical and prognostic features, as well as outcomes of a large series of patients with orbital and periorbital diffuse large B-cell lymphoma (DLBCL).

DESIGN

This study is a multicentre, retrospective non-comparative consecutive case series.

METHODS

The setting for this study was institutional. A total of 37 consecutive patients identified from the institutions' databases with periorbital and orbital DLBCL were enrolled in the study. A retrospective chart review was used for observation. The main outcome measures were patient demographics, clinical features, imaging, immunohistochemical and histopathological data, treatments administered, and survival.

RESULTS

A total of 20 out of 37 cases (54.1%) represented localised periorbital disease (group L), 11 of 37 (29.7%) had systemic disease at presentation with periorbital disease (group S1), and 6 of 37 (16.2%) had previous history of systemic lymphoma (group S2). In all, 28 out of 30 (93.3%) patients were CD20+, 5 of 25 (20%) were CD3+, and 11 of 11 (100%) were CD79a+ (varying denominators reflect the different numbers of patients tested). A total of 25 out of 32 patients (78.1%) received chemotherapy, 14 (43.8%) received rituxmab plus chemotherapy, and 19 (59.3%) received radiotherapy. Nine deaths occurred, one in group L (not lymphoma related), six in group S1, and two in group S2. Five-year Kaplan-Meier survival estimates were 55.9% for all cases, 90.9% for group L, 36.0% for group S1, and 0% for group S2. One-year progression-free survival estimates in groups S1 and S2 combined were 58.3% for patients treated with rituximab and 28.6% for those who were not.

CONCLUSIONS

To our knowledge, this report represents the largest series of patients with periorbital and orbital DLBCL in the literature. The difference in survival between groups L, S1 and S2 was striking, reflecting the grave prognosis of systemic DLBCL, but conversely the relatively optimistic outlook for patients with localised disease. Rituximab plus chemotherapy may be associated with increased survival.

Design and implementation of an electronic data recording and processing system for physics quality control checks in external beam radiotherapy

Quality control (QC) of external beam radiotherapy equipment ensures that commissioning performance is maintained. Paper based data recording is still used for QC, but this is resource intensive in terms of data calculation and processing. Electronic systems of data recording have many advantages; for example, they facilitate the analysis of data on a regular basis, allowing the user to examine the "health" of each machine; they help review and audit local frequencies of each check and can possibly predict component failure. They also allow for secure calculation of results and automatic charting for routine trend analysis. Initially, data recording at our centre was paper-based for daily, weekly and monthly checks. This paper system has been successfully replaced with an electronic system for QC data recording and processing for linear accelerators and superficial units. The system makes use of personal digital assistants and networked laptops for online recording of data, and networked desktop PCs for offline work. The systems of data recording have been designed using the power of macros within Microsoft Excel, which automatically calculate each QC parameter and charts the data recorded for long-term analysis of trends. As of the beginning of 2006, these systems have been fully implemented. The benefits of implementing such a system are numerous, for example, central storage, backup and archiving of data, for greater security and reducing operator errors in calculations. Other benefits are discussed within the paper. In the future, we hope to develop similar systems of data recording for QC checks on other radiotherapy equipment.

Dosimetric characteristics of the Elekta Beam Modulator™

The dosimetric characteristics of a production pilot multi-leaf collimator (Elekta Beam Modulator, Elekta Oncology Systems, Crawley, UK) having a 4 mm leaf width (at isocentre) have been investigated. Characteristics explored included leaf bank set-up, penumbra width (80-20%) as a function of leaf position, leaf positioning reproducibility, interleaf leakage and leaf transmission. The penumbra values for leaf ends were measured to be between 4.2 and 4.8 mm for various large rectangular fields studied using Kodak X-omat V film at isocentre (1.5 cm deep). Similar films were taken with a standard 1 cm width multi-leaf collimator (MLC) and the penumbra for leaf ends was found to range from 4.3 to 5.2 mm. Other results showed that the rounded leaf tip provided tight control of the penumbra across the leaves' full range of travel. The positioning of the leaves was within a 0.5 mm range when approaching from the same direction. The maximum interleaf leakage was found to be 1.7% and the average leaf transmission less than 1.0%. No major differences were observed in leakage and transmission with changing gantry angle.