A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery)

PURPOSE

Screening for frailty in people admitted with emergency surgical pathology can initiate timely referrals to enhanced perioperative services such as intensive care and geriatric medicine. However, there has been little research exploring surgical healthcare professionals' opinions to frailty assessment, or accuracy in identification. This study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions.

METHODS

We designed a cross-sectional multicentre study developed by a multiprofessional team of surgeons, geriatricians, and supported by patients. A semi-structured survey examined attitudes and behaviours. Knowledge was assessed by comparing respondents' accuracy in scoring twenty-two surgical case vignettes using the Clinical Frailty Scale.

RESULTS

Eleven hospitals across England, Wales, and Scotland participated. Two hundred and eleven clinicians responded-20.4% junior doctors, 43.6% middle grade doctors, 24.2% senior doctors, 11.4% nurses and physician associates. Respondents strongly supported perioperative frailty assessment. Most were already assessing for frailty, although frequently not using a standardised tool. There was a strong call for more frailty education. Participants scored 2175 vignettes with 55.4% accurately meeting the gold standard; accuracy improved to 87.3% when categorised into "not frail/mildly frail/severely frail" and 94% when dichotomised to "not frail/frail".

CONCLUSION

Frailty assessment is well supported by healthcare professionals working in surgery. However, standardised tools are not routinely being used, and only half of respondents could accurately identify frailty. Better education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

Complex epistatic interactions between ELF3, PRR9, and PRR7 regulate the circadian clock and plant physiology

Circadian clocks are endogenous timekeeping mechanisms that coordinate internal physiological responses with the external environment. EARLY FLOWERING3 (ELF3), PSEUDO RESPONSE REGULATOR (PRR9), and PRR7 are essential components of the plant circadian clock and facilitate entrainment of the clock to internal and external stimuli. Previous studies have highlighted a critical role for ELF3 in repressing the expression of PRR9 and PRR7. However, the functional significance of activity in regulating circadian clock dynamics and plant development is unknown. To explore this regulatory dynamic further, we first employed mathematical modeling to simulate the effect of the prr9/prr7 mutation on the elf3 circadian phenotype. These simulations suggested that simultaneous mutations in prr9/prr7 could rescue the elf3 circadian arrhythmia. Following these simulations, we generated all Arabidopsis elf3/prr9/prr7 mutant combinations and investigated their circadian and developmental phenotypes. Although these assays could not replicate the results from the mathematical modeling, our results have revealed a complex epistatic relationship between ELF3 and PRR9/7 in regulating different aspects of plant development. ELF3 was essential for hypocotyl development under ambient and warm temperatures, while PRR9 was critical for root thermomorphogenesis. Finally, mutations in prr9 and prr7 rescued the photoperiod-insensitive flowering phenotype of the elf3 mutant. Together, our results highlight the importance of investigating the genetic relationship among plant circadian genes.

AraLeTA: An Arabidopsis leaf expression atlas across diurnal and developmental scales

Mature plant leaves are a composite of distinct cell types, including epidermal, mesophyll and vascular cells. Notably the proportion of these cells, and the relative transcript concentrations within different cell types, may change over time. While gene expression data at a single-cell level can provide cell-type-specific expression values, it is often too expensive to obtain this data for high-resolution time series. Although bulk RNA-seq can be performed in a high-resolution time series, RNA-seq using whole leaves measures average gene expression values across all cell types in each sample. In this study, we combined single-cell RNA-seq data with time-series data from whole leaves to assemble an atlas of cell-type-specific changes in gene expression over time for Arabidopsis (Arabidopsis thaliana). We inferred how the relative transcript concentrations of different cell types vary across diurnal and developmental time scales. Importantly, this analysis revealed three sub-groups of mesophyll cells with distinct temporal profiles of expression. Finally, we developed tissue-specific gene networks that form a community resource: An Arabidopsis Leaf Time-Dependent Atlas (AraLeTa). This allows users to extract gene networks that are confirmed by transcription factor binding data and specific to certain cell types at certain times of day and at certain developmental stages. AraLeTa is available at: https://regulatorynet.shinyapps.io/araleta/.

Genome-wide association studies and Mendelian randomization analyses provide insights into the causes of early-onset colorectal cancer

BACKGROUND

The incidence of early-onset colorectal cancer (EOCRC; diagnosed <50 years of age) is rising globally; however, the causes underlying this trend are largely unknown. CRC has strong genetic and environmental determinants, yet common genetic variants and causal modifiable risk factors underlying EOCRC are unknown. We conducted the first EOCRC-specific genome-wide association study (GWAS) and Mendelian randomization (MR) analyses to explore germline genetic and causal modifiable risk factors associated with EOCRC.

PATIENTS AND METHODS

We conducted a GWAS meta-analysis of 6176 EOCRC cases and 65 829 controls from the Genetics and Epidemiology of Colorectal Cancer Consortium (GECCO), the Colorectal Transdisciplinary Study (CORECT), the Colon Cancer Family Registry (CCFR), and the UK Biobank. We then used the EOCRC GWAS to investigate 28 modifiable risk factors using two-sample MR.

RESULTS

We found two novel risk loci for EOCRC at 1p34.1 and 4p15.33, which were not previously associated with CRC risk. We identified a deleterious coding variant (rs36053993, G396D) at polyposis-associated DNA repair gene MUTYH (odds ratio 1.80, 95% confidence interval 1.47-2.22) but show that most of the common genetic susceptibility was from noncoding signals enriched in epigenetic markers present in gastrointestinal tract cells. We identified new EOCRC-susceptibility genes, and in addition to pathways such as transforming growth factor (TGF) β, suppressor of Mothers Against Decapentaplegic (SMAD), bone morphogenetic protein (BMP) and phosphatidylinositol kinase (PI3K) signaling, our study highlights a role for insulin signaling and immune/infection-related pathways in EOCRC. In our MR analyses, we found novel evidence of probable causal associations for higher levels of body size and metabolic factors-such as body fat percentage, waist circumference, waist-to-hip ratio, basal metabolic rate, and fasting insulin-higher alcohol drinking, and lower education attainment with increased EOCRC risk.

CONCLUSIONS

Our novel findings indicate inherited susceptibility to EOCRC and suggest modifiable lifestyle and metabolic targets that could also be used to risk-stratify individuals for personalized screening strategies or other interventions.

Feasibility of individualised patient modelling for continuous vancomycin infusions in outpatient antimicrobial therapy, a retrospective study

BACKGROUND

The area under the curve (AUC) to minimum inhibitory concentration (MIC) ratio is proposed as a therapeutic drug-monitoring parameter for dosing vancomycin continuous infusion in methicillin-resistant Staphylococcus aureus (MRSA) infection. Individualised pharmacokinetic-pharmacodynamic (PK/PD) calculation of AUC24 may better represent therapeutic dosing than current Therapeutic Drug Monitoring (TDM) practices, targeting a Steady State Concentration of 15-25 mg/L.

AIM

To compare real world TDM practice to theoretical, individualised, PK/PD target parameters utilising Bayesian predictions to steady state concentrations (Css) for outpatients on continuous vancomycin infusions.

METHOD

A retrospective single centre study was conducted at a tertiary hospital on adult patients, enrolled in an outpatient parenteral antimicrobial therapy (OPAT) program, receiving vancomycin infusions for MRSA infection. Retrospective Bayesian dosing was modelled to target PK/PD parameters and compared to real world data.

RESULTS

Fifteen patients were evaluated with 53% (8/15) achieved target CSS during hospitalisation, and 83% (13/15) as outpatient. Median Bayesian AUC/MIC was 613 mg.h/L with CSS 25 mg/L. Patients suffering an Acute Kidney Injury (33%) had higher AUC0-24/MIC values. Retrospective Bayesian modelling demonstrated on median 250 mg/24 h lower doses than that administered was required (R2 = 0.81) which achieved AUC24/MIC median 444.8 (range 405-460) mg.h/L and CSS 18.8 (range 16.8-20.4) mg/L.

CONCLUSION

Bayesian modelling could assist in obtaining more timely target parameters at lower doses for patients receiving continuous vancomycin infusion as part of an OPAT program, which may beget fewer adverse effects. Utilisation of personalised predictive modelling may optimise vancomycin prescribing, achieving earlier target concentrations as compared to empiric dosing regimens.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

11 A QUALITY IMPROVEMENT INITIATIVE TO MAXIMISE UTILISATION OF EARLY SUPPORTED DISCHARGE SERVICE IN A LEVEL 3 HOSPITAL SETTING

Background

Early Supported Discharge (ESD) originated in stroke care however also applies to general medical patients. This ESD service was funded by the local Integrated Care Programme for Older Persons (ICPOP) and saw over 100 patients in its first year. A review of current ESD criteria and limitations was undertaken

Methods

Data was collected, by chart review, over a 2-week period on medical wards. A general townland was used as the patient's address. All patients aged over 70 were included. ESD criteria include all of: living within 30km of the hospital, not living alone, assistance of 1 with mobility or Activities of Daily Living, medically discharged.

Results

91 patients aged over 70 years included 54 patients were medically discharged 27% of medically suitable patients lived outside the ESD radius 2 of 12 patients that met all ESD criteria but had been referred

Conclusion

From our data 54 patients met some ESD criteria but awaited assessment by the multidisciplinary team (MDT). Only 2 of 12 patients who met all criteria were referred to ESD. Education campaigns are ongoing within the hospital to increase awareness of the service. This includes a daily discharge huddle to identify potential candidates. Distance from the hospital was identified as a limiting factor. A business case is under development to support increasing this radius to allow an increased number of patients to avail of the service. ESD has been utilised successfully in urban settings. The continued success of this new service in a rural setting requires ongoing education to increase awareness of the service and development of existing criteria. Limited access to therapists in hospital reduces the effectiveness of ESD.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

218 INCREASING PREVALENCE OF METABOLIC SYNDROME IN OLDER ADULTS IN IRELAND

Background

Metabolic syndrome (MetS) is a cluster of inter-related risk factors of metabolic origin, occurring together more often than by chance alone. MetS is a recognised risk factor for cardiovascular disease, several other chronic medical conditions and mortality. This study aimed to describe the prevalence of MetS in older adults in Ireland and to examine if this changed over a 4-year follow-up period.

Methods

This study used data collected as part of wave 1 and 3 of The Irish Longitudinal Study of Ageing (TILDA). Using objective measurements of triglycerides, high-density lipoprotein cholesterol, blood pressure, height, weight, waist circumference and glycated haemoglobin (HbA1c), in addition to medication usage, the prevalence of MetS using both the National Cholesterol Education Program Third Adult Treatment Panel criteria (ATPIII) and the International Diabetes Foundation criteria (IDF) were determined. Weights were used to allow the sample to be representative of the population. Weights for wave 3 included an adjustment for attrition between wave 1 and wave 3. Weighted logistic regression models were undertaken to examine the odds ratios for age, sex and educational attainment.

Results

32.5% of the community-dwelling population aged ≥50 years at wave 1 had MetS according to the ATPIII criteria, with 39.3% according to the IDF criteria. Males were 36% (ATPIII) or 53% (IDF) more likely than females to have MetS at wave 1. MetS was increasingly prevalent with age, and lower educational attainment at both waves. Prevalence had increased by wave 3 with 35.1% and 41.3% meeting the ATPIII and IDF criteria respectively.

Conclusion

The prevalence of MetS, a modifiable disorder, is very high and increasing in older adults in Ireland, with nearly 400,000 of the community-dwelling population ≥ 54 years at wave 3 meeting either the ATPIII or IDF criteria. More public health interventions are warranted.

224 METABOLIC SYNDROME ASSOCIATED WITH INCREASED LIKELIHOOD OF INCIDENT FRAILTY

Background

Frailty and metabolic syndrome (MetS) are both associated with increased mortality. This study aimed to examine the association between MetS and incident frailty in older adults in Ireland over a 4-year follow-up period.

Methods

This study used data from wave 1 and 3 of The Irish Longitudinal Study of Ageing (TILDA). Frailty status was operationalised using Fried’s frailty phenotype (FP). FP was determined at both waves. MetS was determined at wave 1, according to the National Cholesterol Education Program Third Adult Treatment Panel (ATPIII) and the International Diabetes Foundation (IDF) criteria. Those who were frail/pre-frail at wave 3 having been classified as non-frail at wave 1 were deemed to have ‘worsening frailty’, while those non-frail at both waves were deemed ‘stable non-frail’. Logistic regression models examined the association between MetS and worsening frailty compared to stable non-frail.

Results

FP was determined for 3,317 participants at both wave 1 and wave 3 of TILDA, of which 970 (29%) and 1,201 (36%) had MetS at wave 1 according to ATPIII and IDF criteria respectively. 664 (20%) had worsening frailty, while 1,624 (49%) were stable non-frail. Adjusted for age, sex and education, MetS was associated with an increased likelihood of worsening frailty, for both ATPIII and IDF criteria, OR 1.70 (p &lt; 0.001) and OR 1.63 (p &lt; 0.001) respectively. This association persisted when further adjusted for smoking history, chronic conditions (excluding diabetes and hypertension), renal function and micronutrients [OR 1.50, p = 0.001 (ATPIII) and OR 1.46, p = 0.001 (IDF)].

Conclusion

MetS increases the likelihood of incident frailty/pre-frailty by approximately 50% over a 4-year period. MetS should be considered a risk factor for frailty and should be considered in any comprehensive geriatric assessment given the dynamic nature of frailty and the potentially modifiable nature of MetS.

837 High Prevalence of Anaemia and Mortality in Older Patients Undergoing Emergency Laparotomy

Aim

Anaemia affects 1in10 elderly (&gt;65) patients with a myriad of causes. Elderly patients undergoing emergency laparotomy often present with anaemia. Little is known however about the prevalence of anaemia in older people who require emergency laparotomy and the influence it may have on their outcomes.

Method

Elderly patients (&gt;65-years old) undergoing an emergency laparotomy between May2016-November2018 in a tertiary trauma centre were prospectively identified. Data included patient demographics, haemoglobin, MCV and ferritin, blood transfusions and iron products administered, readmissions and mortality.

Results

231 patients underwent emergency laparotomy. Prevalence of pre-operative anaemia in this group was 43%. 5% were very-anaemic and 38% mildly-anaemic. Ferritin was checked within 89 patients; insufficient levels were present in 20%. 31% of all patients were given blood in the peri-operative period. 100% of patients discharged, were anaemic. For pre-operative anaemic vs non-anaemic patients, ASA grade was higher (4 vs 3), readmission rate was 19% vs 18%, 30-day mortality was 18% vs 14% and 1-year mortality rate high(34% vs 22%, p &lt; 0.05). Very-anaemic patients (92%) received peri-operative blood compared to (41%) of mildly-anaemic patients. 30-day mortality was 0 vs 21% in very-anaemic vs mildly-anaemic patients. Mortality was 45.8% in patients who received transfusions compared to those who did not 19.9% (P &lt; 0.0001).

Conclusions

The prevalence of anaemia in older patients undergoing emergency laparotomy is high and related to significantly increased mortality(12 months after surgery). We have identified a high-risk group of older patients with mild anaemia on presentation who may be at increased risk of mortality 3months after surgery.

Asymptomatic COVID-19 in South Africa - implications for the control of transmission

Asymptomatic COVID-19 may contribute significantly to the pandemic trajectory based on global biological, epidemiological and modelling evidence. A retrospective analysis was done to determine the proportion of asymptomatic COVID-19 in the workplace during the lockdown period from 27 March to 31 May 2020. We found that nearly 45% of cases were asymptomatic at the time of the first test. This high proportion of asymptomatic COVID-19 cases has implications for interventions, such as enforcing quarantine of all close contacts of COVID-19 cases regardless of symptoms.

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study

BACKGROUND

The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19.

METHODS

Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease.

RESULTS

Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56).

CONCLUSIONS

Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople)

Background

Hospital admissions for non-coronavirus disease 2019 (COVID-19) pathology have decreased significantly. It is believed that this may be due to public anxiety about acquiring COVID-19 infection in hospital and the subsequent risk of mortality.

Aim

To identify patients who acquire COVID-19 in hospital (nosocomial COVID-19 infection (NC)) and their risk of mortality compared to those with community-acquired COVID-19 (CAC) infection.

Methods

The COPE-Nosocomial Study was an observational cohort study. The primary outcome was the time to all-cause mortality (estimated with an adjusted hazard ratio (aHR)), and secondary outcomes were day 7 mortality and the time-to-discharge. A mixed-effects multivariable Cox's proportional hazards model was used, adjusted for demographics and comorbidities.

Findings

The study included 1564 patients from 10 hospital sites throughout the UK, and one in Italy, and collected outcomes on patients admitted up to April 28^th, 2020. In all, 12.5% of COVID-19 infections were acquired in hospital; 425 (27.2%) patients with COVID died. The median survival time in NC patients was 14 days compared with 10 days in CAC patients. In the primary analysis, NC infection was associated with lower mortality rate (aHR: 0.71; 95% confidence interval (CI): 0.51–0.98). Secondary outcomes found no difference in day 7 mortality (adjusted odds ratio: 0.79; 95% CI: 0.47–1.31), but NC patients required longer time in hospital during convalescence (aHR: 0.49, 95% CI: 0.37–0.66).

Conclusion

The minority of COVID-19 cases were the result of NC transmission. No COVID-19 infection comes without risk, but patients with NC had a lower risk of mortality compared to CAC infection; however, caution should be taken when interpreting this finding.

PRL3 enhances T-cell acute lymphoblastic leukemia growth through suppressing T-cell signaling pathways and apoptosis

T cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignancy of thymocytes and is largely driven by the NOTCH/MYC pathway. Yet, additional oncogenic drivers are required for transformation. Here, we identify protein tyrosine phosphatase type 4 A3 (PRL3) as a collaborating oncogenic driver in T-ALL. PRL3 is expressed in a large fraction of primary human T-ALLs and is commonly co-amplified with MYC. PRL3 also synergized with MYC to initiate early-onset ALL in transgenic zebrafish and was required for human T-ALL growth and maintenance. Mass spectrometry phosphoproteomic analysis and mechanistic studies uncovered that PRL3 suppresses downstream T cell phosphorylation signaling pathways, including those modulated by VAV1, and subsequently suppresses apoptosis in leukemia cells. Taken together, our studies have identified new roles for PRL3 as a collaborating oncogenic driver in human T-ALL and suggest that therapeutic targeting of the PRL3 phosphatase will likely be a useful treatment strategy for T-ALL.

C-45 A Descriptive Analysis of Change in Concussion Knowledge in Collegiate Student-Athletes Participating in a Novel Peer Concussion Education Program

Objective

This pilot study investigated the effect of a novel peer concussion education program on concussion knowledge in a sample of collegiate student-athletes.

Method

A pre-posttest design was employed to determine the effect of the program on concussion knowledge in a sample of 50 student-athletes (34 Men’s Lacrosse and 16 Women’s Soccer) participating at the NCAA Division II level of competition. Male participants made up 68% of the sample (n = 34). The majority of participants were white (88%). Concussion knowledge was assessed with a checklist adapted from Gioia and Collins’ (2006) Acute Concussion Evaluation and McLeod et al.’s (2007) questionnaire. This checklist included 19 actual symptoms and 8 false symptoms.

Results

A repeated-measures T Test was conducted to analyze pre-test and post-test scores of total concussion symptom knowledge. The results revealed a significant increase in concussion symptom knowledge after participation in the program, t(48) = 4.2, p < 0.001, d = 0.59. A domain analysis indicated that at baseline, cognitive symptoms were accurately identified at a rate ranging from 68 to 90%, sensory/physical at a rate ranging from 74 to 98% and affective ranging from 42 to 68%. At posttest, these ranges increased to 92-98% for cognitive, 88 to 100% for sensory/physical and 84 to 88% for affective symptoms. Non-symptoms were incorrectly endorsed at a rate ranging from 54 to 92% at baseline and 56 to 76% at posttest.

Conclusions

The program appears to have potential for increasing knowledge of actual concussion symptoms; however, incorrect endorsement of non-symptoms persisted at a relatively high rate despite participation in the program.

Frailty predicts mortality in all emergency surgical admissions regardless of age. An observational study

BACKGROUND

frail patients in any age group are more likely to die than those that are not frail. We aimed to evaluate the impact of frailty on clinical mortality, readmission rate and length of stay for emergency surgical patients of all ages.

METHODS

a multi-centre prospective cohort study was conducted on adult admissions to acute surgical units. Every patient presenting as a surgical emergency to secondary care, regardless of whether they ultimately underwent a surgical procedure was included. The study was carried out during 2015 and 2016.Frailty was defined using the 7-point Clinical Frailty Scale. The primary outcome was mortality at Day 90. Secondary outcomes included: mortality at Day 30, length of stay and readmission within a Day 30 period.

RESULTS

the cohort included 2,279 patients (median age 54 years [IQR 36-72]; 56% female). Frailty was documented in patients of all ages: 1% in the under 40's to 45% of those aged 80+. We found that each incremental step of worsening frailty was associated with an 80% increase in mortality at Day 90 (OR 1.80, 95% CI: 1.61-2.01) supporting a linear dose-response relationship. In addition, the most frail patients were increasingly likely to stay in hospital longer, be readmitted within 30 days, and die within 30 days.

CONCLUSIONS

worsening frailty at any age is associated with significantly poorer patient outcomes, including mortality in unselected acute surgical admissions. Assessment of frailty should be integrated into emergency surgical practice to allow prognostication and implementation of strategies to improve outcomes.

What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations?

OBJECTIVE:

To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa.

METHODS:

A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation.

RESULTS:

Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm³. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each).

CONCLUSION:

PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.

A practical risk scale for predicting morbidity and mortality in the emergency general surgical setting: A prospective multi-center study

BACKGROUND

Low albumin is a prognostic factor associated with poor surgical outcomes. We aimed to examine the predicative ability of easily obtainable point-of-care variables in combination, to derive a practical risk scale for predicting older adults at risk of poor outcomes on admission to the emergency general surgical setting.

METHODS

This is an international multi-center prospective cohort study conducted as part of the Older Persons Surgical Outcomes Collaboration (www.OPSOC.eu). The effect of having hypoalbuminemia (defined as albumin ≤3.5 g/dL) on selected outcomes was examined using fully adjusted multivariable models. In a subgroup of patients with hypoalbuminemia, we observed four risk characteristics (Male, Anemia, Low albumin, Eighty-five and over [MALE]). Subsequently, the impact of incremental increase in MALE score (each characteristic scoring 1 point (maximum score 4) on measured outcomes was assessed.

RESULTS

The cohort consisted of 1406 older patients with median (IQR) age of 76 (70-83) years. In fully adjusted models, hypoalbuminemia was significantly associated with undergoing emergency surgery (1.32 (95%CI 1.03-1.70); p = 0.03), 30-day mortality (4.23 (2.22-8.08); p < 0.001), 90-day mortality (3.36 (2.14-5.28); p < 0.001) (primary outcome), and increased hospital length of stay, irrespective of whether a patient received emergency surgical intervention. Every point increase in MALE score was associated with higher odds of mortality, with a MALE score of 4 being associated with 30-day mortality (adjusted OR(95% CI) = 33.38 (3.86-288.7); p = 0.001) and 90-day mortality (11.37 (3.85-33.59); p < 0.001) compared to the reference category of those with MALE score 0.

CONCLUSIONS

The easy to use and practical MALE risk score calculated at point of care identifies older adults at a greater risk of poor outcomes, thereby allowing clinicians to prioritize patients who may benefit from early comprehensive geriatric assessment in the emergency general surgical setting.

A systematic review of McKittrick-Wheelock syndrome

INTRODUCTION

McKittrick-Wheelock syndrome describes the condition of extreme electrolyte and fluid depletion caused by large distal colorectal tumours, usually the benign villous adenoma. Patients generally present critically unwell with severe hyponatraemia, hypokalaemia and/or acute kidney injury.

METHODS

A structured literature review was undertaken to discover what is known about this condition, which is almost universally described as rare. Important features of the syndrome were identified, including common presenting symptoms, blood results, tumour location and size.

FINDINGS

Our literature search identified 257 cases reported across all languages. The most remarkable features were the long duration of symptoms (median 24 months) and the significant electrolyte derangements (median sodium of 122mmol/l and median potassium of 2.7mmol/l at initial presentation). Five key recommendations are made to improve diagnosis, including aggressive fluid resuscitation to match rectal losses and surgical intervention on the index admission. The advantages and disadvantages of different treatment options are discussed, including minimally invasive alternatives to traditional resectional surgery.

CONCLUSIONS

McKittrick-Wheelock syndrome describes a normally benign condition that can cause patients to become critically unwell and so it behoves all clinicians to be aware of it. By publishing recommendations based on a comprehensive literature review, we aim to improve diagnosis and management of this life threatening condition.

Detection of Apparent Cell-free M. tuberculosis DNA from Plasma

New diagnostics are needed to improve clinicians’ ability to detect tuberculosis (TB) disease in key populations such as children and persons living with HIV and to rapidly detect drug resistance. Circulating cell-free DNA (ccfDNA) in plasma is a diagnostic target in new obstetric and oncologic applications, but its utility for diagnosing TB is not known. Here we show that Mycobacterium tuberculosis complex DNA can be detected in plasma of persons with sputum smear-positive TB, even in the absence of mycobacteremia. Among 40 participants with bacteriologically-confirmed smear-positive TB disease who had plasma tested by quantitative PCR (qPCR), 18/40 (45%) had a positive result on at least one triplicate reaction. Our results suggest that plasma DNA may be a useful target for improving clinicians’ ability to diagnose TB. We anticipate these findings to be the starting point for optimized methods of TB ccfDNA testing and sequence-based diagnostic applications such as molecular detection of drug resistance.

Pharmacokinetics of Recombinant Factor IX after Intravenous and Subcutaneous Administration in Dogs and Cynomolgus Monkeys

Hemophilia B therapy requires intravenous (IV) infusions of large volumes of factor IX due to the low concentration of factor IX in concentrates (∼100 IU/mL). High concentration recombinant factor IX (rFIX) could be a significant advance since it would reduce the large volumes necessary for IV dosing and allow for low-volume subcutaneous (SC) administration. To evaluate high concentration factor IX, we produced formulations with either 2,000 or 4,000 IU/mL and studied the SC bioavailability in beagle dogs, cynomolgus monkeys and hemophilia B dogs along with efficacy in hemophilia B dogs. Beagle dog SC bioavailability was 86.4% using a 2000 IU/mL formulation and 77.0% using a 4000 IU/mL formulation. Monkey bioavailability of a 4000 IU/mL formulation of rFIX was 34.8%. A single SC administration of 200 IU/kg (4000 IU/mL) of rFIX to hemophilia B dogs, produced factor IX clotting activity above 5% for 5 days with a bioavailability of 48.6%. High concentration SC rFIX has an acceptable pharmacokinetic profile in monkeys and dogs, and produces a sustained FIX activity in hemophilic dogs.

Quality of life measures predict cardiovascular health and physical performance in chronic renal failure patients

BACKGROUND

Patients with advanced chronic kidney disease (CKD) experience complex functional and structural changes of the cardiopulmonary and musculoskeletal system. This results in reduced exercise tolerance, quality of life and ultimately premature death. We investigated the relationship between subjective measures of health related quality of life and objective, standardised functional measures for cardiovascular and pulmonary health.

METHODS

Between April 2010 and January 2013, 143 CKD stage-5 or CKD5d patients (age 46.0±1.1y, 62.2% male), were recruited prospectively. A control group of 83 healthy individuals treated for essential hypertension (HTN; age 53.2±0.9y, 48.22% male) were recruited at random. All patients completed the SF-36 health survey questionnaire, echocardiography, vascular tonometry and cardiopulmonary exercise testing.

RESULTS

Patients with CKD had significantly lower SF-36 scores than the HTN group; for physical component score (PCS; 45.0 vs 53.9, p<0.001) and mental component score (MCS; 46.9 vs. 54.9, p<0.001). CKD subjects had significantly poorer exercise tolerance and cardiorespiratory performance compared with HTN (maximal oxygen uptake; VO2peak 19.9 vs 25.0ml/kg/min, p<0.001). VO2peak was a significant independent predictor of PCS in both groups (CKD: b = 0.35, p = 0.02 vs HTN: b = 0.27, p = 0.001). No associations were noted between PCS scores and echocardiographic characteristics, vascular elasticity and cardiac biomarkers in either group. No associations were noted between MCS and any variable. The interaction effect of study group with VO2peak on PCS was not significant (ΔB = 0.08; 95%CI -0.28-0.45, p = 0.7). However, overall for a given VO2peak, the measured PCS was much lower for patients with CKD than for HTN cohort, a likely consequence of systemic uremia effects.

CONCLUSION

In CKD and HTN, objective physical performance has a significant effect on quality of life; particularly self-reported physical health and functioning. Therefore, these quality of life measures are indeed a good reflection of physical health correlating highly with objective physical performance measures.

Outcomes for Patients with apparent Chronic Idiopathic Pelvic Pain and associated Pelvic Floor Disorders undergoing Laparoscopic Ventral Mesh Rectopexy

This article has been temporarily withdrawn, with the agreement of all authors and the journal editor, whilst an investigated is being carried out by the North Bristol NHS Trust and the General Medical Council following some concerns raised.

Comparison of Mycobacterium tuberculosis complex Yield and Contamination Rates using Lowenstein-Jensen with and without Antibiotics in Western Kenya

BACKGROUND

While molecular methods have been recently endorsed for diagnosis of tuberculosis (TB), mycobacterial culture remains the gold standard. Lowenstein-Jensen (LJ) is often used for the cultivation of Mycobacterium tuberculosis complex (MTBC); however contamination often renders a subset of cultures useless. We compared the MTBC yield and contamination rate of processed sputum inoculated on LJ with antibiotics (LJ PACT) to LJ without antibiotics (LJ).

METHODOLOGY

Sputum samples were obtained from people living with HIV enrolled in a TB screening study in western Kenya, processed using NALC/NaOH-Na citrate, then inoculated on LJ PACT and LJ media. Cultures were evaluated weekly with growth identified as acid-fast bacilli by Ziehl-Neelsen bright-field microscopy. MTBC and nontuberculous mycobacteria (NTM) were identified by immunochromatographic and line probe assays.

RESULTS

A total of 700 sputum samples were cultured on both LJ PACT and LJ between March and June 2012. Of those cultured on LJ PACT, 29 (4.1%) grew MTBC, 613 (87.6%) were negative, 12 (1.7%) grew NTM, and 46 (6.6%) were contaminated; on LJ, 28 (4%) grew MTBC, 553 (79%) were negative, 9 (1.3%) grew NTM, and 110 (15.7%) were contaminated. The difference in contamination on LJ PACT and LJ was statistically significant (p<0.0001), while the difference in MTBC growth was not (p=0.566).

Frailty and cognitive impairment: Unique challenges in the older emergency surgical patient

INTRODUCTION

Older patients (>65 years of age) admitted as general surgical emergencies increasingly require improved recognition of their specific needs relative to younger patients. Two such needs are frailty and cognitive impairment. These are evolving research areas that the emergency surgeon increasingly requires knowledge of to improve short- and long-term patient outcomes.

METHODS

This paper reviews the evidence for frailty and cognitive impairment in the acute surgical setting by defining frailty and cognitive impairment, introducing methods of diagnosis, discussing the influence on prognosis and proposing strategies to improve older patient outcomes.

RESULTS

Frailty is present in 25% of the older surgical population. Using frailty-scoring tools, frailty was associated with a significantly longer hospital stay and higher mortality at 30 and 90 days after admission to an acute surgical unit. Cognitive impairment is present in a high number of older acute surgical patients (approximately 70%), whilst acute onset cognitive impairment, termed delirium, is documented in 18%. However, patients with delirium had significantly longer hospital stays and higher in-hospital mortality than those with cognitive impairment.

CONCLUSIONS

Improved knowledge of frailty and delirium by the emergency surgeon allows the specialised needs of older surgical patients to be taken into account. Early recognition, and consideration of minimally invasive surgery or radiological intervention alongside potentially transferable successful elective interventions such as comprehensive geriatric assessment, may help to improve short- and long-term patient outcomes in this vulnerable population.