Transanal ileal pouch-anal anastomosis for inflammatory bowel disease: a systematic review and meta-analysis of short-term outcomes

AIM

Restorative proctocolectomy with transabdominal ileal pouch-anal anastomosis (abd-IPAA) has become the standard surgical treatment for medically refractory ulcerative colitis (UC). However, it requires a technically difficult distal anorectal dissection and anastomosis due to the bony confines of the deep pelvis. To address these challenges, the transanal IPAA approach (ta-IPAA) was developed. This novel approach may offer increased visibility and range of motion compared with abd-IPAA, although its postoperative benefits remain unclear. The aim of this work was to perform a systematic review and meta-analysis to compare and inform the frequency of postoperative outcomes between ta-IPAA and abd-IPAA for patients with UC.

METHOD

Several databases were searched from inception until May 2022 for studies reporting postoperative outcomes of patients undergoing ta-IPAA. Reviewers, working independently and in duplicate, evaluated studies for inclusion and graded the risk of bias. Odds ratios (OR), mean differences (MD) and prevalence ratio (PR) and their corresponding 95% confidence intervals (CIs) were calculated using random-effects models. Sensitivity analysis was performed.

RESULTS

Ten retrospective studies comprising 284 patients with ta-IPAA were included. Total mesorectal excision was performed in 61.8% of cases and close rectal dissection in 27.9%. There was no difference in the odds of Clavien-Dindo (CD) I-II complications, CD III-IV and anastomotic leak (OR 0.96, 95% CI 0.27-3.40; OR 1.18, 95% CI 0.65-2.16; OR 1.37, 95% CI 0.58-3.23; respectively) between ta-IPAA and abd-IPAA. The ta-IPAA pooled CD I-II complication rate was 18% (95% CI 5%-35%) and for CD III-IV 10% (95% CI 5%-17%), and the anastomotic leak rate was 6% (95% CI 2%-10%). There were no deaths reported.

CONCLUSIONS

This meta-analysis compared the novel ta-IPAA procedure with abd-IPAA and found no difference in postoperative outcomes. While the need for randomized controlled trails and comparison of functional outcomes between both approaches remains, this evidence should assist colorectal surgeons to decide if ta-IPAA is a viable alternative.

Chinese family care partners of older adults in Canada have grit: A qualitative study

AIM

To explain the process taken by Chinese family care partners of older adults in the Greater Toronto Area, Canada, to access health and social services in their communities. The research question was: What mechanisms and structures impact the agency of Chinese family care partners of older adults, in the process of assisting them to access health and social services?

DESIGN

This qualitative study was informed by critical realism.

METHODS

Chinese family care partners of older adults in the Greater Toronto Area, Canada, were interviewed from August 2020 to June 2021. Transcripts underwent thematic analysis.

FINDINGS

Twenty-eight Chinese family care partners expressed a firm commitment to maintain caregiving conditions and to judiciously access health and social services. Their commitment was made up of three parts: (a) legislative and cultural norms of family, work, and society; (b) their perseverance to fill gaps with limited social and financial resources; (c) the quality of their relationship to, and illness trajectory of the older adults. The social structures created tension in how Chinese family care partners made decisions, negotiated resources, and ultimately monitored and coordinated timely access with older adults.

CONCLUSION

Participants' commitment and perseverance were conceptualized as "grit," central to their agency to conform to legislative and cultural norms. Moreover, findings support grit's power to motivate and sustain family caregiving, in order for older adults to age in place as long as possible with finite resources.

IMPLICATIONS FOR THE PROFESSION

This study highlights the importance of cultural awareness education for nurses, enabling continuity of care at a systems level and for a more resilient healthcare system.

IMPACT

Family care partners' grit may be crucial for nurses to harness when together, they face limited access to culturally appropriate health and social services in a system grounded in values of equity and inclusion, as in Canada.

REPORTING METHOD

When writing this manuscript, we adhered to relevant EQUATOR guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ).

PATIENT OR PUBLIC INVOLVEMENT AND ENGAGEMENT

No patient or public involvement.

How to do a laparoscopic-assisted endoscopic 'clean sweep' for small bowel polyp clearance in Peutz Jeghers syndrome

We demonstrate the technical details of laparoscopic-assisted endoscopic 'clean sweep' for small bowel polyp clearance in Peutz Jeghers Syndrome. A 'clean sweep' reduces the risk for future recurrences but was previously performed with an open technique. A minimally invasive approach is safe, reduces bowel trauma and has good postoperative outcomes.

Video plethysmography for contactless blood pressure and heart rate measurement in perioperative care

The purpose of this study was to evaluate the feasibility and accuracy of remote Video Plethysmography (VPPG) for contactless measurements of blood pressure (BP) and heart rate (HR) in adult surgical patients in a hospital setting. An iPad Pro was used to record a 1.5-minute facial video of the participant's face and VPPG was used to extract vital signs measurements. A standard medical device (Welch Allyn) was used for comparison to measure BP and HR. Trial registration: NCT05165381. Two-hundred-sixteen participants consented and completed the contactless BP and HR monitoring (mean age 54.1 ± 16.8 years, 58% male). The consent rate was 75% and VPPG was 99% successful in capturing BP and HR. VPPG predicted SBP, DBP, and HR with a measurement bias ± SD, -8.18 ± 16.44 mmHg, - 6.65 ± 9.59 mmHg, 0.09 ± 6.47 beats/min respectively. Pearson's correlation for all measurements between VPPG and standard medical device was significant. Correlation for SBP was moderate (0.48), DBP was weak (0.29), and HR was strong (0.85). Most patients were satisfied with the non-contact technology with an average rating of 8.7/10 and would recommend it for clinical use. VPPG was highly accurate in measuring HR, and is currently not accurate in measuring BP in surgical patients. The VPPG BP algorithm showed limitations in capturing individual variations in blood pressure, highlighting the need for further improvements to render it clinically effective across all ranges. Contactless vital signs monitoring was well-received and earned a high satisfaction score.

Quantum gate algorithm for reference-guided DNA sequence alignment

Reference-guided DNA sequencing and alignment is an important process in computational molecular biology. The amount of DNA data grows very fast, and many new genomes are waiting to be sequenced while millions of private genomes need to be re-sequenced. Each human genome has 3.2B base pairs, and each one could be stored with 2 bits of information, so one human genome would take 6.4B bits or ∼760MB of storage (National Institute of General Medical Sciences, n.d.). Today's most powerful tensor processing units cannot handle the volume of DNA data necessitating a major leap in computing power. It is, therefore, important to investigate the usefulness of quantum computers in genomic data analysis, especially in DNA sequence alignment. Quantum computers are expected to be involved in DNA sequencing, initially as parts of classical systems, acting as quantum accelerators. The number of available qubits is increasing annually, and future quantum computers could conduct DNA sequencing, taking the place of classical computing systems. We present a novel quantum algorithm for reference-guided DNA sequence alignment modeled with gate-based quantum computing. The algorithm is scalable, can be integrated into existing classical DNA sequencing systems and is intentionally structured to limit computational errors. The quantum algorithm has been tested using the quantum processing units and simulators provided by IBM Quantum, and its correctness has been confirmed.

Quantum algorithm for de novo DNA sequence assembly based on quantum walks on graphs

De novo DNA sequence assembly is based on finding paths in overlap graphs, which is a NP-hard problem. We developed a quantum algorithm for de novo assembly based on quantum walks in graphs. The overlap graph is partitioned repeatedly to smaller graphs that form a hierarchical structure. We use quantum walks to find paths in low rank graphs and a quantum algorithm that finds Hamiltonian paths in high hierarchical rank. We tested the partitioning quantum algorithm, as well as the quantum algorithm that finds Hamiltonian paths in high hierarchical rank and confirmed its correct operation using Qiskit. We developed a custom simulation for quantum walks to search for paths in low rank graphs. The approach described in this paper may serve as a basis for the development of efficient quantum algorithms that solve the de novo DNA assembly problem.

Anal cancer: a 20-year retrospective study from Australia

BACKGROUNDS

Anal cancer is an uncommon condition, occurring at higher rates in specific subpopulations. Clinical experience is limited and substantial changes have recently occurred in our understanding of this condition. We, therefore, set out to characterize patients presenting with anal cancer and investigate whether there have been any changes over the past 20 years.

METHODS

Retrospective audit of cases identified from pathology and clinical databases during the period 1 January 2000 to 31 December 2019.

RESULTS

Two hundred and sixteen patients had anal squamous cell carcinomas, comprising 160 (74%) males and 56 (26%) females. Mean age at initial diagnosis was 55.1 ± 11.20 for males and 60.6 ± 15.18 for females (P = 0.02). At initial diagnosis, HIV-positive cases were significantly younger than HIV negative cases (mean 52.2 ± 9.35 vs. 62.8 ± 11.61, P < 0.001); 46% of cases were classified as intra-anal, 29% perianal and 25% both; 52% were > 2 cm at diagnosis. At presentation, intra-anal cases were larger and more advanced than perianal cases (P = 0.049). Compared with the period 2000-2009, anal cancers presented more commonly in 2010-2019 (148 vs. 76), were more likely to occur in HIV-negative people and to be diagnosed at a similar stage.

CONCLUSION

The number of anal cancer cases almost doubled over the study period and people living with HIV presented 10 years younger than others. Perianal cases presented earlier than those originating in intra-anal locations. Together with the large size at diagnosis, this suggests the potential value of screening, particularly for intra-anal cancers in those at high risk.

Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022.

PATIENTS

Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale.

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition.

MAIN RESULTS

Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I2: 0%; P = 0.0005).

CONCLUSIONS

There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.

Initial Experience with the Commercial Electron FLASH Research Extension

PURPOSE/OBJECTIVE(S)

The purpose of this study was to introduce a new commercial electron FLASH system that has the potential to become widely available for FLASH researchers globally. In this study, we first present the initial acceptance and commissioning tests for the FLASH system, and second, we highlight preliminary FLASH effect results from our cell studies.

MATERIALS/METHODS

A linear accelerator was converted into a commercial research platform with the FLASH Research Extension, enabling the generation of a powerful 16 MeV electron FLASH beam. The dosimetric and stability tests were conducted using various dosimeters (i.e., radiochromic film, optically stimulated luminescent dosimeters (OSLDs), and a plane-parallel ionization chamber). To evaluate the FLASH effect, normal and cancer cell lines were FLASH irradiated using different pulse repetition frequencies (PRF) of 18 pulses/s and 180 pulses/s.

RESULTS

The electron FLASH mode was able to generate over 1 Gy per pulse at the isocenter and a dose rate of up to 690 Gy/s near the accessory mount of the Linac gantry head. The charge collected by the plane-parallel ionization chamber at the highest PRF (i.e., 180 pulses/s) showed a linear relationship with the delivered number of pulses (i.e., 1 to 99 pulses) with a coefficient of determination (R2) of 0.9996. The absorbed dose measured using radiochromic film and OSLDs agreed within 3%, on average, and followed an inverse square law as the source-to-axis distance (SAD) varied for which the R2 values were 0.9972 and 0.9955 for radiochromic film and OSLDs, respectively. The profile of the FLASH beam was symmetrical but was not as flat as the conventional 16 MeV electron beam due to the use of a thinner custom scattering foil to reduce the degradation of the ultra-high dose rate. The depth-dose curve beyond the build-up region for the FLASH beam was similar to the conventional 16 MeV electron beam for which the range at 50% the maximum dose (R50) agreed within 0.5 mm. The FLASH beam output remained consistent over a 4-month period with a variation of 2.5%, on average. The FLASH sparing effect was observed in vitro for healthy human pancreatic cells. Furthermore, we observed that the highest PRF beam (180 pulses/s) was more effective at destroying pancreatic cancerous cells while minimizing damage to healthy cells compared to the lowest PRF beam (18 pulses/s).

CONCLUSION

The novel commercial FLASH Research Extension system was dosimetrically characterized for pre-clinical FLASH research, and preliminary in vitro results demonstrated the FLASH effect. Given the prevalence of linear accelerators, this new commercial system has the potential to greatly increase the access to FLASH research.

Chemokine receptor 5 signaling in PFC mediates stress susceptibility in female mice

Chronic stress induces changes in the periphery and the central nervous system (CNS) that contribute to neuropathology and behavioral abnormalities associated with psychiatric disorders. In this study, we examined the impact of peripheral and central inflammation during chronic social defeat stress (CSDS) in female mice. Compared to male mice, we found that female mice exhibited heightened peripheral inflammatory response and identified C-C motif chemokine ligand 5 (CCL5), as a stress-susceptibility marker in females. Blocking CCL5 signaling in the periphery promoted resilience to CSDS. In the brain, stress-susceptible mice displayed increased expression of C-C chemokine receptor 5 (CCR5), a receptor for CCL5, in microglia in the prefrontal cortex (PFC). This upregulation was associated with microglia morphological changes, their increased migration to the blood vessels, and enhanced phagocytosis of synaptic components and vascular material. These changes coincided with neurophysiological alterations and impaired blood-brain barrier (BBB) integrity. By blocking CCR5 signaling specifically in the PFC were able to prevent stress-induced physiological changes and rescue social avoidance behavior. Our findings are the first to demonstrate that stress-mediated dysregulation of the CCL5-CCR5 axis triggers excessive phagocytosis of synaptic materials and neurovascular components by microglia, resulting in disruptions in neurotransmission, reduced BBB integrity, and increased stress susceptibility. Our study provides new insights into the role of cortical microglia in female stress susceptibility and suggests that the CCL5-CCR5 axis may serve as a novel sex-specific therapeutic target for treating psychiatric disorders in females.

Anatomical endoscopic retrograde cholangiopancreatography simulator using moulded meshed silicone: A novel simulator pilot study

INTRODUCTION

Endoscopic retrograde cholangio-pancreatography (ERCP) has higher rates of morbidity and mortality compared to upper or lower gastrointestinal tract endoscopy. The availability of magnetic resonance cholangiopancreatography means ERCP is usually performed for therapeutic purposes. Simulation could provide an adjunct to patient-based training in ERCP however models to date have been unconvincing.

METHODS

This ERCP simulation model was constructed from moulded meshed silicone by co-designers: Jean Wong and Kai Cheng. The anatomical orientation was based on a combination of anatomical specimens, sectional atlases, and the clinical experience of expert endoscopists.

RESULTS

From March to October 2022, we recruited 5 surgeons/gastroenterologists to the expert group and 14 medical students, junior doctors, or surgical/gastroenterological trainees to the novice group. Most experts either agreed or strongly agreed that the simulation anatomy appearance (100%), anatomical orientation (83%), tactile feedback (66%), traversal actions (67%), cannula positioning (66%) and papilla cannulation (67%) resembled the procedure in humans. Experts statistically significantly outperformed novices in obtaining a cannulating position (80% vs. 14%, P = 0.006) and successful papilla cannulation (80% vs. 7%, P = 0.0015) on their first attempt. The novice group had statistically significant improvements in time to obtaining a cannulating position (3.53 vs. 11.5 min, P = 0.006) and passing the duodenoscope to the papilla (2.55 vs. 4 passes, P = 0.009).

CONCLUSIONS

The simulator showed statistically significant results in face, content, and construct validity. A follow-up validation study should recruit participants across multiple institutions. External validity could be assessed by comparing expert proceduralist simulator performance against clinical ERCP performance.

Opioid sparing effects of intravenous and oral acetaminophen in hip fracture patients: A population-based study

STUDY OBJECTIVE

Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects.

DESIGN

Retrospective study of population-based database.

PATIENTS

The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery.

INTERVENTIONS

None.

MEASUREMENTS

The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes.

MAIN RESULTS

In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP.

CONCLUSIONS

In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients.

Peripheral parenteral nutrition in surgery - a systematic review and meta-analysis

BACKGROUND

Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery.

METHODS

A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN.

RESULTS

The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites.

CONCLUSION

PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.

Interdisciplinary management of an adult patient with significant tooth wear

Adult patients may present with compromised dentitions which require extensive oral rehabilitation. This case report shows the fulfilment of both functional and aesthetic treatment objectives for a patient with significant tooth wear through carefully planned interdisciplinary management. © 2022 Australian Dental Association.

The Impact of Peri-operative Enteral Immunonutrition on Post-operative Complications in Gastrointestinal Cancer Surgery: A Meta-Analysis

BACKGROUND

Immunonutrition (IMN) in gastrointestinal (GI) cancer surgery remains under-utilised and contentious. Despite previous meta-analysis reporting benefit, most recent randomised control trials (RCTs) have failed to demonstrate this and have recommended against its routine use. A contemporary meta-analysis may contribute to the recommendations for immunonutrition use and help select which patients may benefit. The objective of this study was to review IMN and its impact on post-operative outcomes in GI cancer surgery, exploring its role in both malnourished and non-malnourished populations, the optimal dose to use, cancer type of patients using IMN and the timing of IMN relative to the peri-operative period.

PATIENTS AND METHODS

The EMBASE and Medline databases were searched from 2000 to 2022 for RCTs evaluating IMN in adults undergoing GI cancer surgery.

RESULTS

Thirty-seven studies were included (22 pre-operative IMN studies, 11 peri-operative IMN trials and 9 post-operative IMN trials; 4 trials had multiple IMN protocols) that reported on 3793 patients. The main outcome of post-operative infectious complications was reduced with IMN [odds ratio (OR) 0.58, 95% confidence interval (CI) 0.47-0.72]. This association was significant in subgroup analysis only with pre-operative and peri-operative administration and in trials including upper GI cancers, colorectal cancer and 'mixed GI' cancer populations, and significance was independent of nutritional status. IMN in pooled analysis reduced surgical site infection (SSI) (OR 0.65, 95% CI 0.52-0.81), anastomotic leak (OR 0.67, 95% CI 0.47-0.93) and length of stay (LOS) by 1.94 days (95% CI - 3 to - 0.87).

CONCLUSION

Immunonutrition was associated with reduced post-operative complications. Peri-operative administration may be the preferred strategy in reducing infectious complications, anastomotic leak, SSI and LOS.

Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool

Currently, the quality of guidelines for the perioperative management of patients with obstructive sleep apnea (OSA) is unknown, leaving anesthesiologists to make perioperative management decisions with some degree of uncertainty. This study evaluated the quality of clinical practice guidelines regarding the perioperative management of patients with OSA. This study was reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of the MedlineALL (Ovid) database was conducted from inception to February 26, 2021, for clinical practice guidelines in the English language. Quality appraisal of guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Descriptive statistical analysis of each of the 6 domains was expressed as a percentage using the formula: (obtained score - minimum possible score)/(maximum possible score - minimum possible score). Of 192 articles identified in the search, 41 full texts were assessed for eligibility, and 10 articles were included in this review. Intraclass correlation coefficients of the AGREE II scores across the 7 evaluators for each guideline were each >0.9, suggesting that the consistency of the scores among evaluators was high. Sixty percent of recommendations were based on evidence using validated methods to grade medical literature, while the remainder were consensus based. The median and range scores of each domain were: (1) scope and purpose, 88% (60%-95%); (2) stakeholder involvement, 52% (30%-82%); (3) rigor of development, 67% (40%-90%); (4) clarity of presentation, 74% (57%-88%); (5) applicability, 46% (20%-73%); and (6) editorial independence, 67% (19%-83%). Only 4 guidelines achieved an overall score of >70%. This critical appraisal showed that many clinical practice guidelines for perioperative management of patients with OSA used validated methods to grade medical literature, such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Oxford classification, with lower scores for stakeholder involvement due to lack of engagement of patient partners and applicability domain due to lack of focus on the complete perioperative period such as postdischarge counseling. Future efforts should be directed toward establishing higher focus on the quality of evidence, stakeholder involvement, and applicability to the wider perioperative patient experience.

Association Between the FRAIL Scale and Postoperative Complications in Older Surgical Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Several frailty screening tools have been shown to predict mortality and complications after surgery. However, these tools were developed for in-person evaluation and cannot be used during virtual assessments before surgery. The FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale is a brief assessment that can potentially be conducted virtually or self-administered, but its association with postoperative outcomes in older surgical patients is unknown. The objective of this systematic review and meta-analysis (SRMA) was to determine whether the FRAIL scale is associated with mortality and postoperative outcomes in older surgical patients.

METHODS

Systematic searches were conducted of multiple literature databases from January 1, 2008, to December 17, 2022, to identify English language studies using the FRAIL scale in surgical patients and reporting mortality and postoperative outcomes, including postoperative complications, postoperative delirium, length of stay, and functional recovery. These databases included Medline, Medline ePubs/In-process citations, Embase, APA (American Psychological Association) PsycInfo, Ovid Emcare Nursing, (all via the Ovid platform), Cumulative Index to Nursing and Allied Health Literature (CINAHL) EbscoHost, the Web of Science (Clarivate Analytics), and Scopus (Elsevier). The risk of bias was assessed using the quality in prognosis studies tool.

RESULTS

A total of 18 studies with 4479 patients were included. Eleven studies reported mortality at varying time points. Eight studies were included in the meta-analysis of mortality. The pooled odds ratio (OR) of 30-day, 6-month, and 1-year mortality for frail patients was 6.62 (95% confidence interval [CI], 2.80-15.61; P < .01), 2.97 (95% CI, 1.54-5.72; P < .01), and 1.54 (95% CI, 0.91-2.58; P = .11), respectively. Frailty was associated with postoperative complications and postoperative delirium, with an OR of 3.11 (95% CI, 2.06-4.68; P < .01) and 2.65 (95% CI, 1.85-3.80; P < .01), respectively. The risk of bias was low in 16 of 18 studies.

CONCLUSIONS

As measured by the FRAIL scale, frailty was associated with 30-day mortality, 6-month mortality, postoperative complications, and postoperative delirium.

1301 OUTCOMES FROM A PILOT PROJECT OFFERING FRAIL OLDER ADULTS LIVING WITH HIV A VIRTUAL MDT COMPREHENSIVE GERIATRIC ASSESSMENT

Introduction

Advancements in HIV treatment has resulted in an ageing population in people living with HIV (PLWH). Increasing prevalence of frailty in older PLWH has been demonstrated, giving rise to multi-morbidities, polypharmacy and consequently, complex medical and social needs. Approximately 5650 people are living with HIV across Greater Manchester. With increasing patient complexity, a pathway was developed to help provide holistic care and improve quality of life for older adults living with HIV.

Methods

A pilot involving multi-disciplinary professionals from the hospital frailty, HIV and community teams was established. Patients were screened using the Clinical Frailty Scale and patients with a CFS ≥ 4 were referred for completion of a comprehensive geriatric assessment (CGA). Patients would then be discussed at the Frailty MDT meeting, where action plans were devised.

Results

47 patients were assessed between October 2020 to December 2021, with 30 eligible for review in the frailty clinic. Commonly reported issues were mobility n=26 (86.6%), pain n=23 (76.6%), low mood n= 14 (46.6%), memory issues n=3 (43.3%) and falls n=12 (40%). Following MDT recommendations, 8 (26.6%) referrals were completed for social care, 1 (3%) referral for safeguarding and 9 (30%) referrals for active case management community teams for co-ordination of care in the community. Deprescribing recommendations were suggested for 16 (53.3%) patients and new medicine recommendations made for 24 (80%) patients.

Conclusion

A collaborative MDT approach to managing older PLWH can facilitate formulation of action plans to address patients physical, psychological and social needs.

Benefits of dietary polyphenols in Alzheimer's disease

Alzheimer's disease (AD) is an irreversible progressive neurodegenerative disease affecting approximately 50 million people worldwide. It is estimated to reach 152 million by the year 2050. AD is the fifth leading cause of death among Americans age 65 and older. In spite of the significant burden the disease imposes upon patients, their families, our society, and our healthcare system, there is currently no cure for AD. The existing approved therapies only temporarily alleviate some of the disease's symptoms, but are unable to modulate the onset and/or progression of the disease. Our failure in developing a cure for AD is attributable, in part, to the multifactorial complexity underlying AD pathophysiology. Nonetheless, the lack of successful pharmacological approaches has led to the consideration of alternative strategies that may help delay the onset and progression of AD. There is increasing recognition that certain dietary and nutrition factors may play important roles in protecting against select key AD pathologies. Consistent with this, select nutraceuticals and phytochemical compounds have demonstrated anti-amyloidogenic, antioxidative, anti-inflammatory, and neurotrophic properties and as such, could serve as lead candidates for further novel AD therapeutic developments. Here we summarize some of the more promising dietary phytochemicals, particularly polyphenols that have been shown to positively modulate some of the important AD pathogenesis aspects, such as reducing β-amyloid plaques and neurofibrillary tangles formation, AD-induced oxidative stress, neuroinflammation, and synapse loss. We also discuss the recent development of potential contribution of gut microbiome in dietary polyphenol function.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

The Impact of Virtual Interviews on the Resident Candidate: A Before-and-After Comparison

BACKGROUND AND OBJECTIVES

A significant impact of the COVID-19 pandemic on family medicine residency recruitment has been a requested transition to virtual interviewing by the Association of American Medical Colleges and the academic family medicine community. This has led to creative and adaptive approaches to virtual interviewing with little previous knowledge, experience, or processes. This work describes the impact of transitioning to virtual recruitment on applicants' reported experiences and factors influencing decision-making with family medicine at a large research university.

METHODS

We made a comparison of 2 years of in-person interview day surveys with 2 years of virtual interview surveys following transition to virtual recruitment. We tested differences between in-person and virtual interviews for significance using χ2 tests.

RESULTS

There were significant differences in factors influencing a candidate's decision to apply. Candidates who participated in virtual interviews were more interested in urban training settings, a community setting, and obstetrical training compared with the in-person interview cohort. Nearly 50% of virtual candidates reported preferring virtual interviews in the future. There were no significant differences in how candidates rated their experience of the interview process and they indicated adequate contact with resident personnel despite a transition to virtual interviews.

CONCLUSIONS

The transition to virtual recruitment has been well received by candidates, as indicated by the high positive ratings of the cohorts. The transition has not resulted in a negative impact on the recruitment experience or the ability to meet with resident leadership.

The prevention of delirium in elderly surgical patients with obstructive sleep apnea (PODESA): a randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) is associated with neurocognitive impairment - a known risk factor for postoperative delirium. However, it is unclear whether OSA increases the risk of postoperative delirium and whether treatment is protective. The objectives of this study were to identify OSA with a home sleep apnea test (HSAT) and to determine whether auto-titrating positive airway pressure (APAP) reduces postoperative delirium in older adults with newly diagnosed OSA undergoing elective hip or knee arthroplasty.

METHODS

We conducted a multi-centre, randomized controlled trial at three academic hospitals in Canada. Research ethics board approval was obtained from the participating sites and informed consent was obtained from participants. Inclusion criteria were patients who were [Formula: see text]0 years and scheduled for elective hip or knee replacement. Patients with a STOP-Bang score of ≥ 3 had a HSAT. Patients were defined as having OSA if the apnea-hypopnea index was ≥ 10/h. These patients were randomized 1:1 to either: 1) APAP for 72 h postoperatively or until discharge, or 2) routine care after surgery. The primary outcome was postoperative delirium, assessed twice daily with the Confusion Assessment Method for 72 h or until discharge or by chart review. The secondary outcome measures included length of stay, and perioperative complications occurring within 30 days after surgery.

RESULTS

Of 549 recruited patients, 474 completed a HSAT. A total of 234 patients with newly diagnosed OSA were randomized. The mean age was 68.2 (6.2) years and 58.6% were male. Analysis was performed on 220 patients. In total, 2.7% (6/220) patients developed delirium after surgery: 4.4% (5/114) patients in the routine care group, and 0.9% (1/106) patients in the treatment group (P = 0.21). The mean length of stay for the APAP vs. the routine care group was 2.9 (2.9) days vs. 3.5 (4.5) days (P = 0.24). On postoperative night 1, 53.5% of patients used APAP for 4 h/night or more, this decreased to 43.5% on night 2, and 24.6% on night 3. There was no difference in intraoperative and postoperative complications between the two groups.

CONCLUSIONS

We had an unexpectedly low rate of postoperative delirium thus we were unable to determine if postoperative delirium was reduced in older adults with newly diagnosed OSA receiving APAP vs. those who did not receive APAP after elective knee or hip arthroplasty.

TRIAL REGISTRATION

This trial was retrospectively registered in clinicaltrials.gov NCT02954224 on 03/11/2016.

Effect of intravenous acetaminophen on postoperative outcomes in hip fracture patients: a systematic review and narrative synthesis

PURPOSE

Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients.

SOURCE

We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers.

PRINCIPAL FINDINGS

Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium.

CONCLUSION

There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population.

STUDY REGISTRATION

PROSPERO (CRD42021198174); registered 15 August 2021.

AB0979 Recommendations for weight management in osteoarthritis: a systematic review of clinical practice guidelines

Background

Weight loss interventions are often recommended to target overweight and obesity in the clinical practice guidelines (CPGs) for the management of osteoarthritis. This is despite evidence from meta-analyses of clinical trials that significant weight loss results in modest improvements in symptoms and minimal effects on disease progression1,2. There is evidence that weight gain is associated with increase in knee pain3,4. In countries such as USA, adults gain on average 0.5 to 1 kilogram per year from early to middle adulthood Preventing weight gain is easier to achieve and sustain than losing weight.

Objectives

Given that weight loss is accepted as fundamental to osteoarthritis management, we systematically reviewed the recommendations and approaches for weight management in all current osteoarthritis CPGs.

Methods

Nine databases were searched (1st January 2010 to 30th September 2021) to identify guidelines informing the non-pharmacological management of osteoarthritis. Three reviewers appraised guidelines according to the AGREE II instrument, and independently extracted data on their characteristics. One author extracted and summarised guideline recommendations on weight management. This systematic review is registered on PROSPERO (CRD42021274195).

Results

Fifteen CPGs from developed and developing countries were included. Weight loss was recommended for knee (12 of 13 guidelines) and hip (10 of 11 guidelines) but not hand osteoarthritis (0 of 4 guidelines). Combination approaches of diet and/or exercise were recommended for overweight or obese individuals (knee: 8 of 12; hip: 4 of 10), with 2 guidelines specifying ≥5% weight loss for knee and hip osteoarthritis. One of 15 guidelines specified strategies for weight loss and maintenance of lost weight. Two of 15 guidelines recommended controlling body weight for osteoarthritis, regardless of obesity status.

Conclusion

Most CPGs for knee and hip osteoarthritis include recommendations for weight loss in those with overweight or obesity as key to managing osteoarthritis, despite evidence of modest at best effect of weight loss on symptoms and no effect on joint structure1,2. Given obesity is a major risk factors for osteoarthritis, the prevention of weight gain may be more effective and practical in improving clinical outcomes for osteoarthritis, and hence should be considered as part of the key management in osteoarthritis.

References

[1]Chu IJH, Lim AYT, Ng CLW. Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: a systematic review and meta-analysis. Obes Rev. 2018;19(11):1597-1607.

[2]Daugaard CL, Hangaard S, Bartels EM, Gudbergsen H, Christensen R, Bliddal H, et al. The effects of weight loss on imaging outcomes in osteoarthritis of the hip or knee in people who are overweight or obese: a systematic review. Osteoarthritis Cartilage. 2020;28(1):10-21.

[3]Tanamas SK, Wluka AE, Davies-Tuck M, Wang Y, Strauss BJ, Proietto J, et al. Association of weight gain with incident knee pain, stiffness, and functional difficulties: a longitudinal study. Arthritis Care Res (Hoboken). 2013;65(1):34-43.

[4]Teichtahl AJ, Wluka AE, Tanamas SK, Wang Y, Strauss BJ, Proietto J, et al. Weight change and change in tibial cartilage volume and symptoms in obese adults. Annals of the rheumatic diseases. 2015;74(6):1024-1029.

[5]Zheng Y, Manson JE, Yuan C, Liang MH, Grodstein F, Stampfer MJ, et al. Associations of Weight Gain From Early to Middle Adulthood With Major Health Outcomes Later in Life. JAMA. 2017;318(3):255-269.

Disclosure of Interests

None declared

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

STUDY OBJECTIVE

To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.

DESIGN

A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.

SETTING

Preoperative assessment.

PATIENTS

Older patients (≥ 60 years) undergoing non-cardiac surgery.

MEASUREMENTS

Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.

RESULTS

Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).

CONCLUSIONS

Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.

Long term non-invasive endothelial function assessment in patients with paediatric inflammatory multisystem syndrome temporarily associated with Covid 19 (PIMS TS)

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with PIMS-TS present with features of vasculitis (bright coronary arteries and diffuse coronary ectasia on transthoracic echocardiography) and prothrombotic features (e.g. elevated D Dimers) indicating involvement of the endothelial layer in the inflammatory process. Impairment in endothelial function may contribute to the acute but also to possible long-term consequences in patients with PIMS-TS. The aim of this pilot study is to assess non-invasively the endothelial (dys)function using reactive hyperemic peripheral arterial tonometry (RH-PAT) 6 months after the acute inflammatory phase. 

Methods

Ten patients with previous diagnosis of PIMS-TS were compared to  age-matched controls. The endothelial function was assessed using the EndoPAT device which provides the reactive hyperemic index (RHI) of endothelial function in a 15-min test. Cardiac function indices by means of LV fractional shortening (FS) was also assessed.

Results

There were no significant differences regarding age (11.2 ± 3.0 vs 13.6 ± 2.4, p = 0.063), height, weight and body surface area, (BSA: 1.49 ± 0.36 vs 1.52 ± 0.25, p = 0.856) in patients with previous diagnosis of PIMS-TS and controls respectively. The two groups also had similar LV systolic function assessed by FS (36.3 ± 9.1% vs 36.7 ± 7.1%, p = 0.922). The RHI in the PIMS TS group was similar to the control group (1.65 ± 0.43 vs 1.81 ± 0.60, p = 0.533 respectively).

Conclusions.  Patients with PIMS-TS who may present with features of vasculitis during the acute phase, do not show evidence of endothelial dysfunction during the long term follow-up, suggesting resolution. Further studies are required to accurately determine the endothelial (dys)function during the acute phase of the inflammatory syndrome and course.

Impact of a continuous enhanced cardio-respiratory monitoring pathway on cardio-respiratory complications after bariatric surgery: A retrospective cohort study

STUDY OBJECTIVE

To determine the impact of an enhanced monitoring pathway consisting of continuous postoperative cardio-respiratory monitoring on adverse outcomes after bariatric.

DESIGN

Single-center, retrospective cohort study.

PATIENTS

Adult patients who underwent bariatric surgeries between 2009 and 2016.

INTERVENTIONS

We evaluated the use of an enhanced monitoring pathway consisting of a distant, continuous, non-invasive respiratory monitoring system on postoperative cardio-respiratory complications in patients undergoing bariatric surgery. Treating physicians had the option to assign patients to enhanced monitoring (intervention group) in the postoperative period for suspected or diagnosed OSA or other clinical concerns. The control group had intermittent vital sign checks as per institutional standards.

MEASUREMENTS

The primary outcome was a composite of cardio-respiratory complications (rapid response team activation, intensive care admission, respiratory complications), major adverse cardiac events, and all-cause mortality. The secondary outcome was length of stay (LOS).

MAIN RESULTS

Of 1450 patients, 752 patients received enhanced monitoring (intervention) and 698 patients received standard monitoring (control). Univariate analysis showed that, compared to control, enhanced monitoring was associated with lower odds of composite cardio-respiratory complications (OR: 0.41, 95%CI: 0.32-0.53, p < 0.001) and lower odds of prolonged LOS > 2 days (OR: 0.37, 95% CI: 0.28-0.49, p < 0.001. After adjusting for potential confounders, enhanced monitoring remained associated with a reduction in composite cardio-respiratory complications (OR: 0.64, 95% CI: 0.46-0.88, p = 0.005).

CONCLUSIONS

Our study demonstrates that postoperative enhanced monitoring pathway was associated with a lower incidence of cardio-respiratory composite events, compared to a standard of care, in patients undergoing bariatric surgery. As our results show association rather than causation, future prospective randomized trials are needed to confirm the benefit of enhanced monitoring. Findings of our study add to the existing literature involved in clinical management pathways to reduce the incidence of adverse postoperative outcomes in high-risk patients undergoing inpatient surgeries.