311 FROM ONE FRONT DOOR TO ANOTHER: OUTCOMES OF PATIENTS DIRECTLY DISCHARGED FROM THE FRAILTY AT THE FRONT DOOR SERVICE

Background

The Frailty at the Front Door service is a novel service that provides comprehensive geriatric assessment in the emergency department for older adults who have an unplanned emergency presentation to hospital. It is important to monitor outcomes of patients discharged by the service to ensure appropriate patient selection.

Methods

Patients over the age of 75 with a Manchester Triage Score of between three and five and a possible frailty syndrome are eligible for review by the service. After initial review patients are either discharged directly or recommended for admission. We reviewed the outcomes of patients who were discharged directly after Emergency Department (ED) assessment by the service.

Results

Discharge disposition was available for review in 413 (95%) of patients since initiation of the service in October 2021. 30% (n= 122) of patients were discharged directly after initial ED review. Elevated 4AT score (p = 0.002) but not frailty (p = 0.80) was associated with decreased chances of direct discharge. Of patients discharged directly from ED 13% were reviewed post discharge by the community integrated care team (GICOP), with 43% of these reviews taking place within 30 days. Overall, 16% of patients discharged directly represented to ED within 30 days. There was a trend towards lower rates of representation to ED among patients who were seen by GICOP after discharge from ED (p = 0.12).

Conclusion

There was a high rate of direct discharge after review by the service, with low rates of representation to hospital. While limited by low numbers there was a trend towards lower representation rates in patients reviewed post-discharge by the integrated care team. Future quality improvement initiatives will aim to improve the integration between the services and highlighting patients who would benefit from more timely reviews.

342 THE DISCRIMINATORY VALUE OF ANP-LED CGA ON PATIENT REPORTED SYMPTOMS AND IMPACT ON CARERS: A CROSS-SECTIONAL STUDY

Background

Comprehensive Geriatric Assessment (CGA) is a cornerstone in geriatric care. Objective findings from CGA may differ to patient and carer reported symptoms. This study compared patient reported symptoms with objective metrics collected during CGA and explored the relationship with carer burnout.

Methods

Cross-sectional study of patients attending an Advanced Nurse Practitioner (ANP)-led integrated care clinic. Patient-reported geriatric syndromes included low mood, memory concerns, incontinence, falls or dizziness. CGA metrics collected included Barthel Index, Lawton IADLs, MOCA scores, Geriatric depression scale scores, Rockwood Clinical Frailty Scale (CFS) scores and presence or absence of carer burnout. Descriptive statistics were used to compare the relationship between these variables and logistic regression explored the magnitude of association with carer burnout.

Results

We reviewed 99 CGAs over three months. Median age was 81 (IQR 75–86) with 62% female. Cognitive impairment was present in 96% of patients. Self-reported memory trouble was associated with lower MOCA scores (9 vs 23, p < 0.001) and the presence of dizziness was associated with an increased prevalence of falls (89% vs 24%, < 0.001). The presence of incontinence and functional dependency on IADL were both associated with carer strain and a larger magnitude of association with carer strain was seen with increasing frailty (OR 13.7, 95% CI 3.8-58.8 for moderate to severe frailty) than moderate to severe cognitive impairment (OR 8, 95% CI 3.0–24.1)

Conclusion

Older people reported a wide range of symptoms often subtle, some of which are unmasked during CGA. The resultant frailty syndromes often represent increasing degrees of functional impairment impacting on patient and carer quality of life. Striking the balance between patient reported symptoms and objective measurement is important to allow individualised care pathways to be developed as well as highlighting patients at risk of functional and cognitive decline.

355 PREDICTORS OF HOME SUPPORT SERVICES AND THE CONSEQUENCES OF MISMATCH BETWEEN ALLOCATED AND RECEIVED SERVICES IN COGNITIVELY-IMPAIRED OLDER ADULTS

Background

Home support services aim to support older people to remain at home. Despite substantial investment in home support hours (€600 million), this has not translated into increased carers on the ground for older people. We aimed to report patterns of home support service utilisation in older patients with memory problems, and identify any mis-matches between allocated and received hours, and the impact on patients and caregivers.

Methods

Retrospective analysis of consecutive patients referred to community geriatric clinic from January 2021 to May 2022. 95/104 patients who were identified were suitable for inclusion.

Results

Participants had a median age of 82 (IQR 78-86) of whom 57% were female (n=54). 80% (n=76) were frail (CFS ≥4), with 82% dependent for IADLs (Lawton-Brody IADL Scale ≤6). Median MOCA score was 18, with 44% having moderate to severe cognitive impairment (MOCA ≤17). 40% of patients lived with alone (n=38). 52% (n=49) received formal home supports while 80% (n=76) had an informal carer. 37% (n=18) had a mismatch between hours allocated and hours received. There was a significant difference between median hours of care allocated (7) and median hours of care received (5), p <0.001. Increasing age and frailty, worsening cognitive and functional impairment and living status (living alone) predicted allocation of home supports. Patients who lived with family members were 3 times more likely not to receive allocated hours (OR 3.84 (95% CI 1.2–13.7))

Conclusion

In this vulnerable population with cognitive and functional decline, just over half received formal home support hours. A large proportion experienced significant mismatch between allocated and received hours. Family and informal caregivers often have to fill gaps, adding to existing carer strain. Future models of home support should prioritise early intervention for people with IADL loss to remain independent at home and broaden of the scope of practice of carers to facilitate this.

90 IMPACT OF AN INTEGRATED CARE MODEL FOR OLDER PERSONS: EVALUATING A PILOT PROGRAMME

Background

In September 2019 Sláintecare helped establish an Integrated Care team for Older People. The aim of this service was to provide a Comprehensive Geriatric Assessment (CGA) to older people within a community network. Service user experience/feedback are critically important for development of a team and a service. To give service users a platform to evaluate the service a patient experience survey was conducted.

Methods

The survey was designed by the multidisciplinary team, consisting of 13 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. A question on impact of COVID-19 was also included.

150 of the 950 service users who received a CGA from June 2020 to June 2021 were selected randomly and invited to participate in the postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys.

Results

47% response rate (71/150). 77% were aged ≥75. 52% completed the survey themselves, 48% required assistance. 61% attended more than twice and most would prefer to attend a local spoke clinic. 96% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 93% agreed that they were involved in care decisions. 82% reported their carers had the opportunity to discuss concerns. Themes emerging included importance of care close to home, avoiding acute hospital, difficulty parking at tertiary centres. 42% highlighted isolation and loneliness due to COVID-19 as a major issue.

Conclusion

Service users had an overwhelmingly positive experience especially when care was delivered in clinics close to their homes. Development of the hub and spoke model is acceptable and feasible to older people and their carers’ in this region and will be the focus for expansion of this service.

112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age > 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

102 PROMOTING BRAIN HEALTH IN AN INTEGRATED CARE OUTREACH PROGRAMME

Background

Lifestyle modifications, in older at risk populations, may prevent or slow the rate of cognitive decline. Promotion of brain health has been recommended by the WHO and other governing bodies. Supporting patients in making these lifestyle changes, however, can be complex. Generic guidance may not apply to all in a heterogenous and frail patient cohort, when physical mobility may be limited and weight loss/nutrition a concern. We sought to review current practices and barriers to brain health guidance in a regional integrated care outreach programme (ICOP).

Methods

From March–June’21 the comprehensive geriatric assessment (CGA) of consecutive patients were reviewed. Those presenting with cognitive complaints, for their first assessment, were included. Demographic data and data on screening for hearing impairment and sleep disturbance were collected, in addition to information on physical activity and nutritional risk. Whether information and guidance on aspects of brain health was given was also assessed.

Results

30 patients met the inclusion criteria. The mean age was 80.3 and the mean clinical frailty scale (CFS) was 4.4. Hearing impairment was present in 20% (n = 6), with no information available in 10% (n = 3). All patients were screened for sleep disturbance, with 13% (n = 4) not fully satisfied with their sleep. Mobility aids, assistance or supervision were required in 40% (n = 12), and 23% (n = 7) were at medium or high malnutrition risk. Only 30% (n = 9) cooked their own meals. Generic brain health advice, or advice about sleep was documented in 30 (n = 9), without hearing impairment advice documented in any patient.

Conclusion

There are several barriers to brain health advice in the ICOP setting, with only 30% of patients having brain health advice documented. We are currently developing patient information leaflets on brain health, that will take potential barriers into account. Dedicated and specific information on local hearing services is also in development, as part of an ongoing quality improvement project.

Towards Routine Implementation of Liquid Biopsies in Cancer Management: It Is Always Too Early, until Suddenly It Is Too Late

Blood-based liquid biopsies are considered a new and promising diagnostic and monitoring tool for cancer. As liquid biopsies only require a blood draw, they are non-invasive, potentially more rapid and assumed to be a less costly alternative to genomic analysis of tissue biopsies. A multi-disciplinary workshop (n = 98 registrations) was organized to discuss routine implementation of liquid biopsies in cancer management. Real-time polls were used to engage with experts' about the current evidence of clinical utility and the barriers to implementation of liquid biopsies. Clinical, laboratory and health economics presentations were given to illustrate the opportunities and current levels of evidence, followed by three moderated break-out sessions to discuss applications. The workshop concluded that tumor-informed assays using next-generation sequencing (NGS) or PCR-based genotyping assays will most likely provide better clinical utility than tumor-agnostic assays, yet at a higher cost. For routine application, it will be essential to determine clinical utility, to define the minimum quality standards and performance of testing platforms and to ensure their use is integrated into current clinical workflows including how they complement tissue biopsies and imaging. Early health economic models may help identifying the most viable application of liquid biopsies. Alternative funding models for the translation of complex molecular diagnostics, such as liquid biopsies, may also be explored if clinical utility has been demonstrated and when their use is recommended in multi-disciplinary consensus guidelines.

The global transcriptomic signature in sinonasal tissues reveals roles for tissue type and chronic rhinosinusitis disease phenotype

BACKGROUND

RNA sequencing (RNA-Seq) allows the characterization of a global transcriptomic signature in a least-biased fashion, but few studies have applied this method to investigate the pathophysiology of CRS.

METHODS

We collected mucosal tissue samples from 6 CRS without nasal polyps (CRSsNP), 6 CRS with nasal polyps (CRSwNP), and 6 control patients. Additional matched polyp samples were collected from the 6 CRSwNP patients. RNA was extracted and sequenced on the Illumina HiSeq-2500. Differential gene expression and pathway analyses were performed.

RESULTS

CRSsNP showed evidence of upregulated interferon-mediated immunity, MHC-class-I mediated antigen presentation, CXCR3 binding, neutrophil chemotaxis and degranulation, and potential downregulation of genes related to cilia movement and production. CRSwNP polyp tissue showed upregulation of B-cell mediated immune responses, but reduced expression of genes related to epithelial morphogenesis and haemostasis. Polyps also showed a generalized reduction of positive gene regulation. The sinonasal transcriptomic signature was largely determined by tissue type (polyp versus mucosa) and disease phenotype, with minimal signal originating from the individual patient.

CONCLUSION

RNA-Seq is a useful tool to explore the complex pathophysiology of CRS. Our findings stress the importance of tissue selection in molecular research utilizing sinonasal tissue, and demonstrate the limitation of the sNP/wNP paradigm (and the importance of endotyping). On the other hand, classical CRSsNP/wNP disease phenotypes played some role in determining the global transcriptomic signature, and should not be hastily discarded. The value of RNA-Seq-described transcriptomic signatures in exploring endotypes is yet to be explored in future studies.

Aberrant Splicing of SDHC in Families With Unexplained Succinate Dehydrogenase-Deficient Paragangliomas

Context

Germline mutations in the succinate dehydrogenase genes (SDHA/B/C/D, SDHAF2-collectively, "SDHx") have been implicated in paraganglioma (PGL), renal cell carcinoma (RCC), gastrointestinal stromal tumor (GIST), and pituitary adenoma (PA). Negative SDHB tumor staining is indicative of SDH-deficient tumors, usually reflecting an underlying germline SDHx mutation. However, approximately 20% of individuals with SDH-deficient tumors lack an identifiable germline SDHx mutation.

Methods

We performed whole-exome sequencing (WES) of germline and tumor DNA followed by Sanger sequencing validation, transcriptome analysis, metabolomic studies, and haplotype analysis in 2 Italian-Australian families with SDH-deficient PGLs and various neoplasms, including RCC, GIST, and PA.

Results

Germline WES revealed a novel SDHC intronic variant, which had been missed during previous routine testing, in 4 affected siblings of the index family. Transcriptome analysis demonstrated aberrant SDHC splicing, with the retained intronic segment introducing a premature stop codon. WES of available tumors in this family showed chromosome 1 deletion with loss of wild-type SDHC in a PGL and a somatic gain-of-function KIT mutation in a GIST. The SDHC intronic variant identified was subsequently detected in the second family, with haplotype analysis indicating a founder effect.

Conclusions

This is the deepest intronic variant to be reported among the SDHx genes. Intronic variants beyond the limits of standard gene sequencing analysis should be considered in patients with SDH-deficient tumors but negative genetic test results.

OR34-6 A Novel Mechanism of SDH-Deficient Tumorigenesis and Implications for Genetic Testing in Patients with Pheochromocytoma-Paraganglioma

Introduction: Germline mutations in the succinate dehydrogenase genes (SDHA/B/C/D, SDHAF2 - collectively, SDHx) have been implicated in paraganglioma (PGL), renal cell carcinoma (RCC), gastrointestinal stromal tumor (GIST) and pituitary adenoma (PA). Negative SDHB tumor staining is indicative of SDH-deficient tumors, and thereby germline SDHx mutations (Evenepoel et al Genet Med 2015; De Sousa et al Eur J Endocrinol 2017). As for most Sanger and next generation sequencing (NGS) tests, SDHx genetic testing targets exons and ≤20bp of flanking intronic regions. Deep intronic mutations thus represent a potentially missed cause of various heritable disorders. Methods: We investigated a family with novel co-occurrence of all four SDH-related tumors: PGL in two siblings; GIST in a third sibling; PA in the fourth sibling; and RCC in their deceased mother. Despite negative SDHB staining of the PGLs, no germline mutations were found in SDHx or other PGL genes after 12 yr of extensive testing. We proceeded to whole exome sequencing (WES; Illumina NextSeq 500) using germline DNA from the four siblings and tumor DNA from their available formalin-fixed operative specimens. Transcriptome analysis (RNAseq; Illumina TruSeq LT) was performed using whole blood from the proband. Local genomic pathology and clinical genetic databases were searched for similar cases. Results: Amongst 130 germline WES variants of interest, we found a novel, highly conserved, deep intronic variant in a known PGL gene, SDHC, in all four affected siblings. RNAseq revealed aberrant SDHC splicing with 71% of mRNA reads extending 75bp into intron 1 and terminating at the site of the familial variant. The retained intronic segment introduced a premature stop codon immediately after exon 1. Tumor WES of the available PGL specimen demonstrated Chr1 deletion with loss of the wild-type SDHC allele, consistent with the two-hit model of tumor suppressor genes. Amongst other local patients with SDH-deficient tumors, 9/27 (33%) also lacked SDHx mutations by standard testing. Re-analysis of five patients with available raw data from prior NGS tests revealed another patient with the same SDHC variant as the index family. NGS haplotype analysis showed that 7% of Chr1 was identical between this patient and the index family, suggesting cryptic relatedness. WGS is underway in another 12 unsolved cases of SDH-deficient tumors to identify other SDHx deep intronic mutations. Conclusions: This is the first report of a deep intronic SDHx mutation, highlighting a unique mechanism of SDH-related tumorigenesis and explaining at least some previously unsolved cases of SDH-deficient tumors. More broadly, this study demonstrates how deep intronic mutations may be a cause of false negative genetic test results and illustrates the expanding utility of NGS methodologies across heritable disorders.

Iatrogenic common bile duct injuries: Increasing complexity in the laparoscopic era: A prospective cohort study

PURPOSE

Iatrogenic bile duct injury (BDI) is the most significant associated complication to laparoscopic cholecystectomy (LC). Little is known about the evolution of the pattern of BDI in the era of laparoscopy. The aim of the study is to assess the pattern of post-LC BDIs managed in a tertiary referral centre.

METHODS

Post-LC BDI referred over two decades were studied. Demographic data, type of BDI (classified using the Strasberg System), clinical symptoms, diagnostic investigations, timing of referral, post-referral management and morbidity were analysed. The pattern of injury, associated vascular injuries rate and their management were compared over two time periods (1992-2004,2005-2014).

RESULTS

78 BDIs were referred. During the second time period Strasberg A injuries decreased from 14% to 0 and Strasberg E1increased from 4% to 23%, the rate of associated vascular injury was six time higher (3.6% versus 22.7%), more patients had an attempted repair at the index hospital (16% versus 35%) sand fewer patients could be managed without surgical intervention at the referral hospital (28% versus 4%).

CONCLUSION

Complexity of referred BDIs and rate of associated vascular injuries have increased over time. These findings led to more patients managed requiring surgical intervention at the referral hospital.

Mutations in the mammalian target of rapamycin pathway regulators NPRL2 and NPRL3 cause focal epilepsy

OBJECTIVE

Focal epilepsies are the most common form observed and have not generally been considered to be genetic in origin. Recently, we identified mutations in DEPDC5 as a cause of familial focal epilepsy. In this study, we investigated whether mutations in the mammalian target of rapamycin (mTOR) regulators, NPRL2 and NPRL3, also contribute to cases of focal epilepsy.

METHODS

We used targeted capture and next-generation sequencing to analyze 404 unrelated probands with focal epilepsy. We performed exome sequencing on two families with multiple members affected with focal epilepsy and linkage analysis on one of these.

RESULTS

In our cohort of 404 unrelated focal epilepsy patients, we identified five mutations in NPRL2 and five in NPRL3. Exome sequencing analysis of two families with focal epilepsy identified NPRL2 and NPRL3 as the top candidate-causative genes. Some patients had focal epilepsy associated with brain malformations. We also identified 18 new mutations in DEPDC5.

INTERPRETATION

We have identified NPRL2 and NPRL3 as two new focal epilepsy genes that also play a role in the mTOR-signaling pathway. Our findings show that mutations in GATOR1 complex genes are the most significant cause of familial focal epilepsy identified to date, including cases with brain malformations. It is possible that deregulation of cellular growth control plays a more important role in epilepsy than is currently recognized.

HENMT1 and piRNA Stability Are Required for Adult Male Germ Cell Transposon Repression and to Define the Spermatogenic Program in the Mouse

piRNAs are critical for transposable element (TE) repression and germ cell survival during the early phases of spermatogenesis, however, their role in adult germ cells and the relative importance of piRNA methylation is poorly defined in mammals. Using a mouse model of HEN methyltransferase 1 (HENMT1) loss-of-function, RNA-Seq and a range of RNA assays we show that HENMT1 is required for the 2’ O-methylation of mammalian piRNAs. HENMT1 loss leads to piRNA instability, reduced piRNA bulk and length, and ultimately male sterility characterized by a germ cell arrest at the elongating germ cell phase of spermatogenesis. HENMT1 loss-of-function, and the concomitant loss of piRNAs, resulted in TE de-repression in adult meiotic and haploid germ cells, and the precocious, and selective, expression of many haploid-transcripts in meiotic cells. Precocious expression was associated with a more active chromatin state in meiotic cells, elevated levels of DNA damage and a catastrophic deregulation of the haploid germ cell gene expression. Collectively these results define a critical role for HENMT1 and piRNAs in the maintenance of TE repression in adult germ cells and setting the spermatogenic program.

Piwi-interacting RNAs (piRNAs) are small non-coding RNAs found in great abundance within both embryonic and adult male germ cells. Within embryonic germ cells, piRNAs have a well-recognized role in transposable element (TE) silencing, however, their role in adult cells remains poorly defined. Here we demonstrate that HENMT1 dysfunction and the resultant piRNA instability dramatically impacts multiple aspects of adult germ cell biology. Specifically, pachytene piRNAs are required to maintain TE silencing in adult germ cells and to set the spermatogenic gene expression program. piRNA loss leads to a more active chromatin state in the regulatory regions of numerous normally haploid germ cell genes and their precocious expression during meiosis, followed by a catastrophic deregulation of gene expression in haploid cells and male sterility.

Segmental duodenal resection: indications, surgical techniques and postoperative outcomes

INTRODUCTION

Segmental duodenal resections (DR) have been increasingly performed for the treatment of primary duodenal tumours. The aim of the study is to review the indications for, clinical and operative details, and outcomes of patients undergoing elective DR.

MATERIAL AND METHODS

We retrospectively reviewed all patients who underwent elective segmental DR for the treatment of primary duodenal tumours, at a single institution between January 2007 and December 2013. Demographic data, clinical presentation, preoperative investigations, operative details, postoperative complications/mortality and histopathological results were recorded.

RESULTS

In the study period, 11 duodenal resections were performed (7 male, median age 61 years). Thirty-six percent of the patients presented with anaemia. Surgical resection included two or more segments in seven patients. The most frequently resected part of the duodenum was segment 3 (n = 7). Median operative time was 191 min and blood loss was 675 ml. End-to-end and end-to-side anastomoses were performed in equal numbers. The pathology of resected specimens included adenocarcinoma (n = 4), gastrointestinal stromal tumour (GIST) (n = 1), adenoma (n = 5) and lymphoma (n = 1). Median hospital stay was 14 days. Overall, 30-day morbidity rate was 82% (78% Clavien 2 or less).

CONCLUSIONS

Segmental duodenal resection is a safe and effective surgical technique for the resection of primary duodenal tumours.

Caecal diverticulitis: a rare cause of right iliac fossa pain

We present a case of a young boy with an unusual cause of right iliac fossa pain. His history, examination and laboratory investigations suggested a diagnosis of acute appendicitis. However preoperative abdominal CT revealed an inflamed solitary caecal diverticulum and a normal appendix. He was subsequently treated conservatively and recovered well, saving him from undergoing a general anaesthetic and abdominal surgery.

A randomized controlled trial comparing polyethylene glycol + ascorbic acid with sodium picosulphate + magnesium citrate solution for bowel cleansing prior to colonoscopy

INTRODUCTION

Adequate bowel cleansing which is acceptable to the patient is a prerequisite for safe and effective colonoscopy. A 2-L polyethylene glycol solution containing ascorbic acid and electrolytes (PEG-Asc) is an alternative to sodium picosulphate + magnesium citrate (SPS-Mg) for bowel preparation. The aim of the current study is to compare PEG-Asc to SPS-Mg in terms of tolerability and efficacy.

METHODS

This was a single blind, randomized controlled trial. A blinded assessment of bowel cleansing was made by the attending endoscopist. Patients completed a questionnaire on the acceptability of the preparation.

RESULTS

One hundred and thirty (130) consecutive patients attending for day case colonoscopy were randomly allocated to bowel preparation with PEG-Asc (n = 66) or SPS-Mg (n = 64). More patients found PEG-Asc to taste unpleasant (37.9 vs. 10.9%, P < 0.001) and more patients found PEG-Asc to be a more distressing preparation than SPS-Mg (15.1 vs. 4.7%, P = 0.043). However, there was no difference in the proportion of patients being able to complete bowel preparation (PEG-Asc vs. SPS-Mg, 92.4 vs. 93.8%, P = 0.520). There was no detectable difference between PEG-Asc and SPS-Mg in the quality of cleansing with a good or very good preparation being reported by the endoscopist in 46.9 and 54.5% of cases, respectively (P = 0.242).

CONCLUSIONS

More patients find PEG-Asc to taste unpleasant and to be a more distressing preparation than SPS-Mg. However, there was no detectable difference between PEG-Asc and SPS-Mg in bowel cleansing prior to colonoscopy.

Detection of clinically relevant copy number variants with whole-exome sequencing

Copy number variation (CNV) is a common source of genetic variation that has been implicated in many genomic disorders. This has resulted in the widespread application of genomic microarrays as a first-tier diagnostic tool for CNV detection. More recently, whole-exome sequencing (WES) has been proven successful for the detection of clinically relevant point mutations and small insertion-deletions exome wide. We evaluate the utility of short-read WES (SOLiD 5500xl) to detect clinically relevant CNVs in DNA from 10 patients with intellectual disability and compare these results to data from two independent high-resolution microarrays. Eleven of the 12 clinically relevant CNVs were detected via read-depth analysis of WES data; a heterozygous single-exon deletion remained undetected by all algorithms evaluated. Although the detection power of WES for small CNVs currently does not match that of high-resolution microarray platforms, we show that the majority (88%) of rare coding CNVs containing three or more exons are successfully identified by WES. These results show that the CNV detection resolution of WES is comparable to that of medium-resolution genomic microarrays commonly used as clinical assays. The combined detection of point mutations, indels, and CNVs makes WES a very attractive first-tier diagnostic test for genetically heterogeneous disorders.

Hypotensive resuscitation

Hypotensive resuscitation in the trauma setting can be defined as deliberately allowing blood pressure to remain below normal until any active bleeding has been controlled. The dangers of aggressive fluid resuscitation in trauma were recognised as long ago as the First World War, in the intervening time, aggressive fluid resuscitation has become a mainstay of trauma management. More recently this trend of aggressive fluid resuscitation for trauma management seems to be reversing. Aggressive fluid resuscitation in trauma is based on animal studies from the 1950s and 1960s. These studies used models of controlled haemorrhage rather than uncontrolled haemorrhage. More recent studies using models of uncontrolled haemorrhage suggest an improved outcome with hypotensive resuscitation. Should there be a potential for uncontrolled haemorrhage a permissive hypotensive resuscitation strategy should be pursued until the haemorrhage has been controlled, but in certain types of trauma including blunt trauma and brain trauma the data is unclear as to the best fluid resuscitation strategy.

Significant influence of the primary liver disease on the outcomes of hepatic retransplantation

BACKGROUND

There are many indications for hepatic retransplantation.

AIM

To identify factors influencing retransplantation needs and outcomes.

PATIENTS AND METHODS

Retransplantation records from January 1993 to March 2005 were analysed. Patient and disease characteristics and survival outcomes for retransplantation were compared between various groups.

RESULTS

Totally, 286 primary and 42 hepatic retransplantations were performed. Retransplantation indications included primary sclerosing cholangitis (PSC), primary biliary cirrhosis, chronic hepatitis C (HCV), chronic active hepatitis (CAH), and alcohol-related disease. Mean follow-up post-retransplantation was 31 +/- 9 months. Actuarial patient survival at 3 months, 1 year, 3 years, 5 years, and at the end of study was 71.4, 69, 59.5, 54.7, and 50%, respectively. Early and late retransplantation had 1-year survival of 73 and 68.5%, respectively. Retransplantation need was significantly higher for PSC, HCV, and CAH.

CONCLUSIONS

Hepatic retransplantation remains a successful salvage option for transplant complications; however, its need is significantly influenced by the primary liver disease.

Discovery of a previously unrecognized microdeletion syndrome of 16p11.2–p12.2

We have identified a recurrent de novo pericentromeric deletion in 16p11.2-p12.2 in four individuals with developmental disabilities by microarray-based comparative genomic hybridization analysis. The identification of common clinical features in these four individuals along with the characterization of complex segmental duplications flanking the deletion regions suggests that nonallelic homologous recombination mediated these rearrangements and that deletions in 16p11.2-p12.2 constitute a previously undescribed syndrome.

Internal jugular vein compression to assess the correct placement of an epidural catheter in postpartum women

We investigated whether the increase in epidural pressure produced by jugular compression could be used as a test for correct placement of epidural catheters in 20 postpartum women who had good epidural analgesia during labour. We measured the epidural pressure by using the epidural catheter as a manometer, and measured the rise in the meniscus in response to jugular vein compression whilst the epidural catheter was still in the epidural space. The catheter was then withdrawn until the tip lay just outside the epidural space and the response to jugular vein compression reassessed. In all subjects, jugular vein compression produced a rise in the meniscus only whilst the catheter tip lay in the epidural space. Jugular compression is a useful test for confirming the correct placement of the epidural catheter.

Improved survival outcomes for liver transplantation

Liver transplantation is the treatment of choice for end stage liver disease and fulminant hepatic failure. Outcome of the procedure may be dependent on multiple factors including patient selection, donor selection, and centre experience.

AIM

To determine whether the outcome for liver transplantation has improved over the time for the Irish National Liver Transplant Unit since its initial set up in 1993.

METHODS

All patients who underwent liver transplantation between Jan 1993 to Oct 2004 were included. Patients were sub-divided into three sequential cohorts of 90 patients each. Survival outcomes were compared between the groups.

RESULTS

270 patients (male = 137) underwent 323 liver transplants (median age 49 yrs, range 16-68 yrs). Indications included primary biliary cirrhosis (14.1%), alcohol related liver disease (6.2%), fulminant hepatic failure (14.2%), primary sclerosing cholangitis (10.1%), chronic active hepatitis (9.5%), viral hepatitis (9.5%) and cryptogenic cirrhosis (7.1%). Most procedures (85.8%) were elective. Re-transplantation rates within the first 3 months of primary procedure were 9%, 5%, and 5% for the three chronological groups. Overall calculated 3-month, 1-year and 3 year survival rates for group 1 were 87%, 82% and 77%. For the groups 2 and 3 the figures were 86%, 81%, 77% and 89%, 89%, and 81% respectively. One- and 3-year survival rates were significantly better for group 3 compared to group 1 (p < 0.05).

CONCLUSIONS

Survival outcome has improved significantly over the past 12 years and is likely attributed to increasing experience of the transplant centre.

Maternal hepatotoxicity with nevirapine as part of combination antiretroviral therapy in pregnancy

OBJECTIVES

To describe the maternal tolerability of nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland and to determine risk factors for development of significant hepatotoxicity.

METHODS

A retrospective study was carried out of all women prescribed nevirapine as part of combination antiretroviral therapy in pregnancy at three HIV centres in Dublin, Ireland (October 2000 to February 2003). Toxicities experienced were graded according to the Division of AIDS toxicity guidelines for adults. Statistical analysis was performed to determine whether there were differences between those that did and those that did not experience significant hepatotoxicity.

RESULTS

A total of 123 women initiated nevirapine as part of combination antiretroviral therapy in the study period. Eight women developed significant hepatotoxicity, including two women who died from fulminant hepatitis. Women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts (P=0.01).

CONCLUSIONS

In this cohort, women who experienced more severe hepatotoxicity had higher pretreatment CD4 counts, lending additional weight to the need for caution in using nevirapine as part of combination antiretroviral therapy in women not requiring antiretroviral therapy for their own health.

Three microarray platforms: an analysis of their concordance in profiling gene expression

Background

Microarrays for the analysis of gene expression are of three different types: short oligonucleotide (25–30 base), long oligonucleotide (50–80 base), and cDNA (highly variable in length). The short oligonucleotide and cDNA arrays have been the mainstay of expression analysis to date, but long oligonucleotide platforms are gaining in popularity and will probably replace cDNA arrays. As part of a validation study for the long oligonucleotide arrays, we compared and contrasted expression profiles from the three formats, testing RNA from six different cell lines against a universal reference standard.

Results

The three platforms had 6430 genes in common. In general, correlation of gene expression levels across the platforms was good when defined by concordance in the direction of expression difference (upregulation or downregulation), scatter plot analysis, principal component analysis, cell line correlation or quantitative RT-PCR. The overall correlations (r values) between platforms were in the range 0.7 to 0.8, as determined by analysis of scatter plots. When concordance was measured for expression ratios significant at p-values of <0.05 and at expression threshold levels of 1.5 and 2-fold, the agreement among the platforms was very high, ranging from 93% to 100%.

Conclusion

Our results indicate that the long oligonucleotide platform is highly suitable for expression analysis and compares favorably with the cDNA and short oligonucleotide varieties. All three platforms can give similar and reproducible results if the criterion is the direction of change in gene expression and minimal emphasis is placed on the magnitude of change.