The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

FRI0649-HPR HYDROXYCHLOROQUINE PRESCRIBING AND OPHTHALMOLOGY SCREENING WITHIN RHEUMATOLOGY DEPARTMENTS IN THE NORTH-WEST OF THE UNITED KINGDOM: A PROSPECTIVE REGIONAL AUDIT

Background:

Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of <1% up to five years and <2% up to ten years, but increases sharply to almost 20% after 20 years. Risk factors for retinopathy include doses >5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).

Objectives:

To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.

Methods:

Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.

Results:

473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.

20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR <60ml/min/m2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking <5mg/kg. In total, 36% of new starters were referred for a formal baseline Ophthalmology review.

In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for <5 years, and 33% of patients on HCQ for >5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.

Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.

Conclusion:

This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.

Acknowledgments:

Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.

Disclosure of Interests:

None declared

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

BACKGROUND

Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects.

METHODS

FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762.

FINDINGS

Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839-1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26-6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38-2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months.

INTERPRETATION

Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function.

FUNDING

UK Stroke Association and NIHR Health Technology Assessment Programme.

Improving the rates of organ donation for transplantation

Organ donation is a complex and sensitive area. It is complicated by ethical, legal and social factors, as well as differing views about consent. Although organ donation rates have risen, there continues to be a significant gap between organ supply and demand. Despite previous calls for a change to the opt-in consent system used in England, and the move towards presumed or opt-out consent in Wales, the Organ Donation Taskforce rejected any such policy change in England, in favour of improving the infrastructure and systems surrounding organ donation. This article examines the various systems of consent for organ donation and strategies for improving organ donation rates.

A unique emotional processing profile of euthymic bipolar disorder? A critical review

OBJECTIVES

To undertake a critical review of the literature on emotional processing (EP) in bipolar patients in remission. This literature review focuses on a number of dimensions of EP including facial emotion recognition, emotional memory, affective theory of mind (ToM), affective attention and affective auditory information processing.

METHODS

A systematic search was conducted through PsychINFO and Medline databases to obtain relevant literature. Studies that include behavioural measures of EP were included.

RESULTS

The findings from this review demonstrate that bipolar disorder (BD) patients continue to exhibit some EP deficits during euthymic phases. A number of factors believed to contribute to such findings have been highlighted.

CONCLUSIONS

This review has shed light on some of the conflicting findings reported in the literature and thus offers a more comprehensive profile of euthymic bipolar patients' EP abilities. This information could enrich clinicians' therapeutic efforts to minimise relapse by attending to euthymic bipolar patients' specific emotional processing difficulties.

Outcome of partner notification in patients diagnosed with genital warts attending a provincial clinic in East Anglia, England

We retrospectively reviewed partner notification of patients diagnosed with first episode genital warts seen in the genitourinary (GU) medicine clinic, Great Yarmouth, UK, from January 2005 to December 2008. Of 947 patients diagnosed with genital warts, 486 (51.3%) were men, median age 25 years; 461 (48.7%) were women, median age 21 years and the partner notification index was 32.9%. In our cohort, 310 patients 33.2% reported having had a casual partner that could not be traced. The median relationship duration of partners whose contact attended was nine months and those whose contact did not attend was two months, (χ(2) = 49.72, P < 0.0001). The odds ratio (OR) of a contact attending after seeing a health adviser was 2.94 (95% confidence interval [CI] = 1.79-4.86). In our cohort 35.6% of contacts whose partners saw a health adviser attended compared with 15.7% of contacts whose partner did not see a health adviser (χ(2) = 19.7, P < 0.0001). Among the contacts 26% had genital warts, 28% had another sexually transmitted infection (STI) and 12% had both genital warts and another STI. The low partner notification index was associated with the reported casual partnerships seen in the cohort. Partner notification was enhanced when patients saw a health adviser.

Parental perspectives on the causes of an autism spectrum disorder in their children

Autism Spectrum Disorders (ASDs) are complex neurodevelopmental disorders with many biological causes, including genetic, syndromic and environmental. Such etiologic heterogeneity impacts considerably upon parents' needs for understanding their child's diagnosis. A descriptive survey was designed to investigate parental views on the cause(s) of ASD in their child. Among the 41 parents who replied to the questionnaire, genetic influences (90.2%), perinatal factors (68.3%), diet (51.2%), prenatal factors (43.9%) and vaccines (40.0%) were considered to be the most significant contributory factors. Parents reported inaccurately high recurrence risks, misperceptions of the contribution of various putative factors, feelings of guilt and blame regarding their child's diagnosis, as well as a lack of advocacy for genetic counseling by non-geneticist professionals. This study offers clinicians and researchers further insight into what parents believe contributed to their child's diagnosis of ASD and will help facilitate genetic counseling for these families.

Prevention of vaginal trichomoniasis by compliant use of the female condom

BACKGROUND

Several case-control studies suggest that the male condom protects women against some sexually transmitted diseases. The female condom is the first barrier device under the woman's control that may be effective in the prevention of sexually transmitted diseases.

GOAL OF THIS STUDY

To determine if appropriate use of the female condom decreased the rate of recurrent vaginal trichomoniasis in previously diagnosed and treated women.

STUDY DESIGN

One hundred and four sexually active women with vaginal trichomoniasis were treated with metronidazole and assigned to a group using the female condom or a control group during a 45-day period of continued sexual activity. Fifty women served as controls, and 54 women were assigned to use the female condom.

RESULTS

Only 20 women used the female condom each time they had sexual intercourse. Reinfection with trichomonas occurred in 7/50 (14%) controls, in 5/34 (14.7%) noncompliant users, and in 0/20 compliant users of the female condom.

CONCLUSION

The compliant use of the female condom is effective in preventing recurrent vaginal trichomoniasis.

TestPack Chlamydia for chlamydial detection in physicians' offices

Chlamydia trachomatis is widely recognized as the most prevalent sexually transmitted disease. It is often asymptomatic and can lead to serious sequelae, including infertility and ectopic pregnancy. For this reason, testing of patients at risk is a necessary health care measure. This study compared TestPack Chlamydia to Chlamydiazyme for the direct detection of chlamydial antigen in endocervical specimens. One thousand three hundred seventy-six patients seen in 47 private practice offices of obstetrician-gynecologists and family practitioners were screened. TestPack Chlamydia, a 25-minute enzyme immunoassay, had a specificity of 98.6% and sensitivity of 90% when compared with Chlamydiazyme, a four-hour laboratory test. The overall prevalence of chlamydial infection in this population was 3.6%. The prevalence among patients less than or equal to 24 years of age was 7.6% higher among subgroups with symptoms and other identified risk factors. The positive predictive value of TestPack Chlamydia (83.7%) makes it an accurate assay for testing women at risk for chlamydial infections.

Echinococcal disease of the extrahepatic biliary tract

Cystic hydatid disease of the liver is uncommon in the United States. It is caused by the larval cestode Echinococcus granulosus. One complication of this disorder is rupture of the hepatic hydatid cyst into the biliary ducts. There have been few reported cases of this complication of hydatid disease in the US literature. We describe a case of this disorder and briefly review the literature.

Granular cell tumor of the breast mimicking carcinoma in pregnancy

A granular cell tumor of the breast in a 20-year-old black pregnant woman is reported. Malignancy had been suspected clinically, radiologically, and on gross pathologic examination. Frozen section provided the correct diagnosis and the lesion was excised, obviating more radical surgery.

Lymphokine-mediated induction of antigen-presenting ability in thymic stromal cells

We have established and characterized long term thymic stromal cultures from BALB/c (H-2d) and CBA/J (H-2k) mice. All cultures contained multiple adherent cell types, whereas some also contained thymic macrophages (TM). Culture supernatants from all cultures tested contained macrophage colony-stimulating factor activity, whereas only cultures with TM had soluble or membrane-associated interleukin (IL)-1. However, a thymic epithelial cell line (3D . 1), cloned from one of these cultures, produced IL-1 bioactivity. Further analysis confirmed the production of IL-1 alpha mRNA by the epithelial cell. No IL-2 or IL-4 (formerly called B cell stimulatory factor 1) activity was detected in any of the cultures. Antigen-presenting (AP) ability was determined using the chicken ovalbumin (OVA)-specific, I-Ad-restricted T cell hybridoma 3DO-18.3. Harvested TM exhibited antigen-specific, Ia-restricted AP ability which was enhanced by IL-4 as well as interferon-gamma (IFN-gamma). In contrast, AP ability was detected in non-macrophage stromal cell cultures (NMSC) only after preincubation with IFN-gamma. AP by preinduced NMSC was also Ia-restricted and could be blocked by anti-I-Ad antibodies. Since the T cell receptor of 3DO-18.3 is known to recognize a peptide produced by CNBr degradation of OVA, these observations suggest that both TM and NMSC can process OVA to produce this peptide. Glutaraldehyde-fixation experiments confirmed that NMSC must process native OVA into antigenic peptides for successful AP. Assays using several cloned stromal cell lines of different lineages suggested that only epithelial cells could be induced with IFN-gamma to exhibit competent AP. Given the possible role for IFN-gamma in the maintenance of Ia in the thymus, we investigated whether IFN-gamma production could be ascribed to a subpopulation of thymocytes. Culture supernatants from calcium ionophore and phorbol ester-stimulated peanut agglutinin-negative, but not peanut agglutinin-positive, thymocytes induced AP ability in NMSC. Thus, some thymocytes can produce an Ia-inducing lymphokine (most likely IFN-gamma) which may play an important role in T cell ontogeny through its effects on both thymic macrophages and thymic epithelial cells.

Lymphokine-mediated induction of antigen-presenting ability in thymic stromal cells

We have established and characterized long term thymic stromal cultures from BALB/c (H-2d) and CBA/J (H-2k) mice. All cultures contained multiple adherent cell types, whereas some also contained thymic macrophages (TM). Culture supernatants from all cultures tested contained macrophage colony-stimulating factor activity, whereas only cultures with TM had soluble or membrane-associated interleukin (IL)-1. However, a thymic epithelial cell line (3D . 1), cloned from one of these cultures, produced IL-1 bioactivity. Further analysis confirmed the production of IL-1 alpha mRNA by the epithelial cell. No IL-2 or IL-4 (formerly called B cell stimulatory factor 1) activity was detected in any of the cultures. Antigen-presenting (AP) ability was determined using the chicken ovalbumin (OVA)-specific, I-Ad-restricted T cell hybridoma 3DO-18.3. Harvested TM exhibited antigen-specific, Ia-restricted AP ability which was enhanced by IL-4 as well as interferon-gamma (IFN-gamma). In contrast, AP ability was detected in non-macrophage stromal cell cultures (NMSC) only after preincubation with IFN-gamma. AP by preinduced NMSC was also Ia-restricted and could be blocked by anti-I-Ad antibodies. Since the T cell receptor of 3DO-18.3 is known to recognize a peptide produced by CNBr degradation of OVA, these observations suggest that both TM and NMSC can process OVA to produce this peptide. Glutaraldehyde-fixation experiments confirmed that NMSC must process native OVA into antigenic peptides for successful AP. Assays using several cloned stromal cell lines of different lineages suggested that only epithelial cells could be induced with IFN-gamma to exhibit competent AP. Given the possible role for IFN-gamma in the maintenance of Ia in the thymus, we investigated whether IFN-gamma production could be ascribed to a subpopulation of thymocytes. Culture supernatants from calcium ionophore and phorbol ester-stimulated peanut agglutinin-negative, but not peanut agglutinin-positive, thymocytes induced AP ability in NMSC. Thus, some thymocytes can produce an Ia-inducing lymphokine (most likely IFN-gamma) which may play an important role in T cell ontogeny through its effects on both thymic macrophages and thymic epithelial cells.

Splenic abscess caused by Shigella flexneri and Bacteroides fragilis

We report a case of splenic abscess from which only Shigella flexneri (serotype 1a) and Bacteroides fragilis were isolated. The patient was a 59-year-old diabetic female who displayed minimal gastrointestinal symptoms. The S. flexneri isolate was resistant to chloramphenicol and tetracycline. The possible synergistic relationship between the two organisms is discussed.

Residual sensorimotor deficits in the adult head-injured patient. A treatment approach

Deficits in sensorimotor integration, cognition, and psychosocial behavior may lead to a characteristic set of problems in the head-injured adult. An inpatient Sensorimotor Integration Class for ambulatory head-injured patients was developed to introduce challenging sensorimotor activities before these patients established avoidance patterns. The class includes perceptual motor, sensory integration, and sports activities. Clinical observations suggest that the class leads to improved quality of movement for participants. Objective research is needed to document clinical observations.

A herpesvirus antigen in human premalignant and malignant cervical biopsies and explants

Cervical biopsies and explant cultures from patients with squamous metaplasia, various grades of dysplasia, carcinoma in situ (CIS), and invasive squamous cell carcinoma were screened for VP143, an early nonstructural polypeptide of herpes simplex virus type 2 (HSV-2), VP143 was identified in 31% of biopsies exhibiting severe dysplasia, 29% with CIS, and 41% with invasive squamous cell carcinoma. Similar results were obtained when explants derived from these biopsies were examined for VP143. The expression of the protein persisted in passaged subcultures in four of five invasive carcinomas which originally contained VP143. Staining for VP157, the major capsid protein of HSV-2, was absent. Furthermore, virus structures were not seen by electron microscopy and infectious virus was not isolated from cell cultures inoculated with biopsy extracts. These results suggest that VP143 was expressed in the premalignant and malignant cervical cells in the absence of productive viral infection. Thus, a fragment of the HSV-2 genome was retained within the cells, the expression of which resulted in the production of VP143.

Expression of herpes simplex virus type 2 antigens in premalignant and malignant human vulvar cells

Vulvar biopsies and explants from patients with vulvitis, hyperkeratosis, condyloma acuminatum, severe dysplasia, and squamous cell carcinoma were screened for herpes simplex virus type 2 (HSV-2) antigens. Immunoperoxidase staining for VP143, an early nonstructural polypeptide of HSV-2, was identified within three biopsies exhibiting severe dysplasia, three of seven with carcinoma in situ, and one of three with invasive squamous cell carcinoma. Similar staining for VP143 was observed in derived explants. Staining for VP119, the major envelope glycoproteins of HSV-2, was identified within tissues which were positive for VP143. Both proteins were expressed in the absence of staining for virus capsid proteins, detection of virus structures by electron microscopy, and isolation of infectious virus by co-cultivation, indicating that only a fragment of the virus genome was expressed. Neither VP143 nor VP119 was identified in biopsies exhibiting vulvitis, hyperkeratosis, or condyloma acuminatum. These data indicate a close relationship between HSV-2 and vulvar neoplasia.

The smooth endoplasmic reticulum as a possible storage site for dendritic dopamine in substantia nigra neurones

In dendrites of the substantia nigra neurones the monoamine marker 5-hydroxydopamine injected intracerebrally was localized inside of smooth endoplasmic reticulum cisterns. This observation opens the possibility of the existence of an alternative site for dopamine storage in dendrites as opposed to the well-known vesicular storage.