Separating the components of an abdominal wall fellowship

Complex abdominal wall reconstruction is an emerging subspecialty yet, despite the abundance of abdominal wall hernias requiring treatment and the increasing complexity of this type of surgery, there are few opportunities for surgeons to gain subspecialist training in this field. In this paper we discuss the need for focused training in complex abdominal wall reconstruction, outline some of the problems that may be hindering the availability of such opportunities and propose potential solutions to these issues.

Erratum: Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande [Phys. Rev. Lett. 130, 031802 (2023)]

This corrects the article DOI: 10.1103/PhysRevLett.130.031802.

Quality of amoxicillin/clavulanic acid oral formulations for intended veterinary use in the UK, Malaysia, Serbia and Thailand

OBJECTIVES

Amoxicillin/clavulanate is the most commonly used oral antimicrobial drug in companion animals. The objective of the study was to detect types and frequency of deficits in the quality of veterinary oral formulations of amoxicillin/clavulanate in various countries.

MATERIALS AND METHODS

In a prospective study with purposive sampling, amoxicillin/clavulanate tablet formulations for canine use were collected in four countries (wholesalers or veterinary practice) and shipped to a central bioanalytical laboratory. Twenty-four samples were collected from the UK (nine), Malaysia (nine), Serbia (four) and Thailand (two), yielding 18 different formulations (10 veterinary). Packaging inspection, tablet disintegration and content assay were conducted (validated high-performance liquid chromatography with ultra-violet detection); content was acceptable when within the 90% to 120% pre-specified range (US Pharmacopeia).

RESULTS

Secondary packaging was present for 13 of 24 samples and primary packaging integrity was verified for all but one sample. Amoxicillin trihydrate/potassium clavulanate label ratio was 4:1, except for three formulations (2:1). Tablet dose strength ranged from 250 to 625 mg. All formulations contained both analytes. For amoxicillin, two of 24 samples were out of specification with 72.8% (Malaysia) and 82.3% (Thailand) of labelled content. For clavulanate, four of 24 samples were out of specification with 46.9% (Serbia), 79.0% (UK), 84.3% (Serbia) and 86.5% (Thailand) of labelled content. One formulation (Thailand) failed for both analytes.

CLINICAL SIGNIFICANCE

Antimicrobial formulations of substandard quality have negative consequences for efficacy in patients and potentially promote antimicrobial resistance. There was evidence of substandard formulations in all countries, not only for amoxicillin but especially for clavulanate; this could compromise equitable access to acceptable quality essential veterinary medicines worldwide.

Local anaesthetic for pain post rubber band ligation of haemorrhoids: a prospective, single-blinded randomised controlled trial

BACKGROUND

Rubber band ligation (RBL) is a widely accepted intervention for the treatment of haemorrhoids. However, post procedure pain is a common complaint. The aim of this study was to determine whether the addition of local anaesthetic (LA) to the haemorrhoid pedicle base, post RBL, aids in reducing early post-procedure pain. Additionally, to compare perceived perianal numbness, oral analgesia usage and total consumption, and adverse events.

METHODS

This study was a prospective, single-blinded randomised controlled trial. Patients were recruited from colorectal clinics in two Australian hospitals between 2018-2019. Patients randomised to the intervention (LA) group received 2mls bupivacaine 0.5% with adrenaline 1:200,000 to each haemorrhoid base. Patients in the control group were not administered LA. Pain scores were recorded over 48 h using visual analogue scales. Analgesia consumption was documented and other secondary objectives were recorded dichotomously (yes/no).

RESULTS

At 1 h post-procedure, patient reported pain scores were significantly lower in the LA group compared to the control group (p = 0.04). There were no significant differences in pain scores between the groups at 4, 24 or 48 h. Additionally, there were no significant differences between groups with respect to oral analgesia usage, perianal numbness or adverse events.

CONCLUSIONS

LA to the haemorrhoid pedicle post RBL may significantly reduce early post procedure pain without any increased risk of adverse effects.

Measurements of neutrino oscillation parameters from the T2K experiment using 3.6×1021 protons on target

The T2K experiment presents new measurements of neutrino oscillation parameters using 19.7 ( 16.3 ) × 10 20 protons on target (POT) in (anti-)neutrino mode at the far detector (FD). Compared to the previous analysis, an additional 4.7 × 10 20 POT neutrino data was collected at the FD. Significant improvements were made to the analysis methodology, with the near-detector analysis introducing new selections and using more than double the data. Additionally, this is the first T2K oscillation analysis to use NA61/SHINE data on a replica of the T2K target to tune the neutrino flux model, and the neutrino interaction model was improved to include new nuclear effects and calculations. Frequentist and Bayesian analyses are presented, including results on sin 2 θ 13 and the impact of priors on the δ CP measurement. Both analyses prefer the normal mass ordering and upper octant of sin 2 θ 23 with a nearly maximally CP-violating phase. Assuming the normal ordering and using the constraint on sin 2 θ 13 from reactors, sin 2 θ 23 = 0 . 561 - 0.032 + 0.021 using Feldman-Cousins corrected intervals, and Δ m 32 2 = 2 . 494 - 0.058 + 0.041 × 10 - 3 eV 2 using constant Δ χ 2 intervals. The CP-violating phase is constrained to δ CP = - 1 . 97 - 0.70 + 0.97 using Feldman-Cousins corrected intervals, and δ CP = 0 , π is excluded at more than 90% confidence level. A Jarlskog invariant of zero is excluded at more than 2 σ credible level using a flat prior in δ CP , and just below 2 σ using a flat prior in sin δ CP . When the external constraint on sin 2 θ 13 is removed, sin 2 θ 13 = 28 . 0 - 6.5 + 2.8 × 10 - 3 , in agreement with measurements from reactor experiments. These results are consistent with previous T2K analyses.

Search for Cosmic-Ray Boosted Sub-GeV Dark Matter Using Recoil Protons at Super-Kamiokande

We report a search for cosmic-ray boosted dark matter with protons using the 0.37  megaton×years data collected at Super-Kamiokande experiment during the 1996-2018 period (SKI-IV phase). We searched for an excess of proton recoils above the atmospheric neutrino background from the vicinity of the Galactic Center. No such excess is observed, and limits are calculated for two reference models of dark matter with either a constant interaction cross section or through a scalar mediator. This is the first experimental search for boosted dark matter with hadrons using directional information. The results present the most stringent limits on cosmic-ray boosted dark matter and exclude the dark matter-nucleon elastic scattering cross section between 10^{-33}cm^{2} and 10^{-27}cm^{2} for dark matter mass from 1  MeV/c^{2} to 300  MeV/c^{2}.

7-Steps medication reviews: analysis of medicine changes in acute medical wards

Introduction

In Northern Ireland, medication errors cause 20 patient deaths, lead to around 800 non-elective hospital admissions and cost £1.9 million annually.1 The iSIMPATHY (implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years) project is an EU-funded partnership between Scotland, Ireland and Northern Ireland delivering medication reviews using the 7-Steps medication review tool and asking ‘what matters to you?’ 2 The iSIMPATHY 7-Steps review is a new research study in Northern Ireland.

Aim

To identify medicine changes made by an independent prescribing pharmacist during 7-Steps medication reviews.

Method

Medication reviews were delivered on acute medical wards in the Northern Health and Social Care Trust. No patients were excluded from reviews, however reviews were targeted at patients aged 50 years and older and resident in a care home, approaching the end of their lives, prescribed 10 or more medicines or on high-risk medication. Data on medication changes made during 192 medication reviews was collected and analysed to identify the numbers and types of medicines stopped, started and doses altered. Ethical approval was not required, an approved Data Protection Impact Assessment was in place.

Results

Mean number of medicines per patient pre- and post-review were 12.2 and 12.3 respectively. Medicines were stopped in 49% of patients, dose decreased in 36%, changed to a more appropriate medicine in 15%, dose increased in 15% and new medicines started in 55%. Medicines stopped included opioids and gabapentenoids (18%), nutritional and electrolyte supplements (15%), items for comfort (9%), antidepressants (including amitriptyline for pain) (10%), antihypertensives and diuretics (8%), bladder anticholinergics and mirabegron (5%), laxatives (4%), betahistine (3%), quinine (2%). Dose decreases were made for analgesics including opioids (28%), PPI/H2RA (23%), anticoagulants (13%), statins and fibrates (6%), antihypertensives (6%), benzodiazepines and z-drugs (5%), antidiabetics (3%). Dose increases were made for anticoagulants and items for comfort (both 26%), laxatives (24%), pancreatin (15%), nutritional and electrolyte supplements (9%). Medicines started included nutritional and electrolyte supplements (45%), medicines for comfort (19%), laxatives (15%), nicotine replacement (7%), PPI/H2RA (2%), bisphosphonates (2%).

Discussion/Conclusion

The 7-STEPS medicine reviews led to important medicine changes while the number of medicines following review remained the same. The person-centred, holistic approach facilitated identification and actioning of the medicine changes that mattered to individual patients. Stopped and decreased dose medicines included high risk medicines, those likely to cause adverse effects or high anticholinergic burden and medicines no longer needed or effective for the individual. Medicine doses were increased for high risk medicines, to ensure sufficient nutritional, electrolyte and enzyme replacement and items for comfort for example constipation. Importantly, unmet therapeutic needs were identified and new medicines were prescribed to address these needs, for example, acid suppressants, bisphosphonates, anticoagulants, statins, antidiabetics, nicotine replacement therapy and for patient’s comfort including pain relief. Limitations include results may not be reflective of all hospital patients as set in an acute setting and through the iSIMPATHY project.

References

1. Transforming medication safety in Northern Ireland, Department of Health 2022. Available from: https://www.health-ni.gov.uk/sites/default/files/publications/health/Transforming-medication-safety-in-Northern-Ireland_1.pdf

2. iSimpathy. Making Medication Personal. 2022. Available from: https://www.isimpathy.eu/

Symptom burden and health-related quality of life in moderate to severe chronic rhinosinusitis with nasal polyposis

Background: Chronic rhinosinusitis with nasal polyposis (CRSwNP) affects up to 4% of individuals. Common symptoms include nasal congestion/obstruction, nasal discharge, facial pain, and reduced sense of smell. This study describes patient- and physician-reported CRSwNP symptom burden and health-related quality of life (HRQOL) in a real-world clinical setting. Methods: This multinational, geographically diverse, point-in-time survey invited physicians to evaluate 5 consecutive adults with confirmed bilateral moderate to severe CRSwNP (consecutive sampling) plus the next 2 patients with recurrent nasal polyps and ≥1 surgery for polyp removal (oversampling). Patients’ and physicians’ surveys were assessed in the entire consecutive sample and by categories of physician-determined CRSwNP severity, and by categories of asthma comorbidity (total sample). Patients’ and physicians’ responses were compared in a matched sample. Results: The total sample of 1,782 patients comprised 1,296 (72.7%) from consecutive sampling and 486 (27.3%) from oversampling. Among the consecutive sample (mean age, 46.9 years), 1,122 (86.6%) had moderate and 174 (13.4%) had severe CRSwNP. Of 1,697 patients from total sampling with known asthma status, 708 (41.7%) had asthma and 989 (58.3%) did not. Patients’ self-reported symptom frequency, severity, and burden on HRQOL worsened with increasing CRSwNP severity and comorbid asthma. Physicians underreported prevalence, severity, and impact of symptoms on daily activities compared with patients (matched sample). Conclusion: Patients and physicians from real-world settings both described a considerable burden of CRSwNP, but physicians consistently reported fewer and less severe symptoms than patients. This suggests a more patient-centric view is needed when assessing CRSwNP symptom burden and HRQOL.

OC-022 MAINTAINING AN ELECTIVE ABDOMINAL WALL RECONSTRUCTION SERVICE DURING THE COVID 19 PANDEMIC

Aim

Elective surgery services suffered significantly due to the COVID-19 pandemic. The aim of this study was to analyse the impact and outcomes of abdominal wall reconstruction (AWR) performed during the COVID-19 pandemic, assessing safety and sustainability.

Material and Methods

A retrospective review of all patients undergoing AWR in a single NHS trust, multiple surgeons, between 23rd March 2020 and 22rd March 2022, the 2 years following U.K. Government imposed lockdown, was undertaken and compared with the pre-pandemic AWR activity. Procedures were initially undertaken at a cold site and when demonstrated to be safe, main site operating restarted. The primary outcome was 90 day mortality, secondary outcomes of COVID-19 infection within 7 days, length of stay, critical care requirement, and complication rate.

Results

In the study period, 173 patients underwent AWR, compared with 99 cases in a single year preceding lockdown. 90 day mortality rate was zero. No patients returned positive COVID tests to the trust within 7 days of AWR, and no patients were readmitted for COVID related symptoms. Critical care admission was required in 7 patients, 3 of these were planned admissions pre-operatively. The surgical site occurrence rate was 9.8% (17), infection 5.8% (10), seroma 2.3% (4) and haematoma 1.7% (3). There were no recurrences reported, with follow up ranging between 1 and 18 months.

Conclusion

Continuing AWR services during the COVID pandemic is feasible and safe. Peri-operative COVID infection rates are low, critical care requirements minimal, and there is no impact on patient morbidity or mortality.

P-135 FIRST EXPERIENCE WITH A NEW CLOSED INCISION NEGATIVE PRESSURE WOUND THERAPY, PREVENA™, IN ABDOMINAL WALL RECONSTRUCTION PATIENTS

Aim

Surgical site infection (SSI) contributes a significant proportion of post operative morbidity in patients undergoing abdominal wall reconstruction (AWR). Prevena™ closed incision negative pressure wound therapy (ciNPT) has been demonstrated to reduce SSI rates in the elective and emergency laparotomy setting. However, there is no evidence for Prevena™ use in AWR patients. The aim of this study was to assess the safety and feasibility of Prevena™ in AWR patients.

Materials and Method

Patients undergoing AWR at a single trust were selected at random to receive Prevena™. This was applied to the incision under sterile conditions, a continuous pressure of -125mmHg was applied for 7 days. The primary outcome measure was SSI, with secondary outcomes of 90 day mortality, complications and length of stay.

Results

10 patients received ciNPT in the study period, 8 female 2 male, mean BMI was 34.5. All patients had a Rives-Stoppa repair, with 2 patients also requiring bilateral transversus abdominal release (TAR). A vertical panniculectomy with umboplasty was used in 7 cases, fleur-de-lys panniculectomy with umboplasty in 2 cases, and a single case approached via transverse panniculectomy. There were no deaths within 90 days, median length of stay was 4 days. There was a single SSI managed with oral antibiotics, not requiring admission.

Conclusion

Prevena™ has been shown to reduce SSI rates in other patient cohorts and this small series demonstrates it is feasible and safe to use in the AWR setting. Larger studies are required to demonstrate SSI rate reduction in AWR patients.

Reading a preoperative CT scan to guide complex abdominal wall reconstructive surgery

Computed tomography (CT) scanning is the imaging modality of choice when planning the overall management and operative approach to complex abdominal wall hernias. Despite its availability and well-recognised benefits there are no guidelines or recommendations regarding how best to read or report such scans for this application. In this paper we aim to outline an approach to interpreting preoperative CT scans in abdominal wall reconstruction (AWR). This approach breaks up the interpretive process into 4 steps-concentrating on the hernia or hernias, any complicating features of the hernia(s), the surrounding soft tissues and the abdominopelvic cavity as a whole-and was developed as a distillation of the authors' collective experience. We describe the key features that should be looked for at each of the four steps and the rationale for their inclusion.

Laparoscopic colorectal resections during the COVID-19 pandemic - business as usual?

INTRODUCTION

To analyse the outcomes of major colorectal resections performed during the COVID-19 pandemic, to assess safety and explore all precautionary measures.

METHOD

All patients who underwent major elective colorectal resections at St Helens and Knowsley Teaching Hospital NHS Trust between 24th March 2020 (the date that the Royal Colleges of Surgery produced their guidelines re operating during the pandemic) and 17th April 2020 were analysed from a prospectively maintained database. The primary outcome was 7-day mortality and secondary outcomes were the development of a positive COVID-19 test consequent to hospital stay and the overall complication rate.

RESULTS

In this 24 day time frame 27 patients (17 males) underwent elective colorectal resections at St Helens and Knowsley NHS Trust. The median age was 69 (41-84) years and median ASA was 2 (1-3). The median Body Mass Index was 30 (21-40.7). Twenty-five patients underwent surgery for cancer and two patients had urgent resections for low-grade sepsis secondary to diverticular colovesical fistulae. 24 patients underwent laparoscopic colorectal resections and 3 patients underwent planned open surgery. 7-day mortality was 0%, and no patients/staff contracted COVID-19 during the post-operative period. The overall complication rate was 14.8%. At a median follow-up of 29 (17-44) days via telephone, there have been no reported COVID-19 related symptoms in any of these patients.

CONCLUSION

Our experience demonstrated that it was possible to undertake laparoscopic colorectal resections despite the COVID-19 pandemic posing a major threat to humanity, providing that adequate and stringent precautions are undertaken.

A mathematical framework for modelling 3D cell motility: applications to glioblastoma cell migration

The collection of 3D cell tracking data from live images of micro-tissues is a recent innovation made possible due to advances in imaging techniques. As such there is increased interest in studying cell motility in 3D in vitro model systems but a lack of rigorous methodology for analysing the resulting data sets. One such instance of the use of these in vitro models is in the study of cancerous tumours. Growing multicellular tumour spheroids in vitro allows for modelling of the tumour microenvironment and the study of tumour cell behaviours, such as migration, which improves understanding of these cells and in turn could potentially improve cancer treatments. In this paper, we present a workflow for the rigorous analysis of 3D cell tracking data, based on the persistent random walk model, but adaptable to other biologically informed mathematical models. We use statistical measures to assess the fit of the model to the motility data and to estimate model parameters and provide confidence intervals for those parameters, to allow for parametrization of the model taking correlation in the data into account. We use in silico simulations to validate the workflow in 3D before testing our method on cell tracking data taken from in vitro experiments on glioblastoma tumour cells, a brain cancer with a very poor prognosis. The presented approach is intended to be accessible to both modellers and experimentalists alike in that it provides tools for uncovering features of the data set that may suggest amendments to future experiments or modelling attempts.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

C-65 Transdiagnostic Factors of Social Impairment in Comorbid Autism Spectrum Disorder and Attention Deficit Hyperactivity Disorder

Objective

Comorbid Autism Spectrum Disorder (ASD) and ADHD are associated with greater symptom severity, including social impairment. Furthering work by Lerner, Pothoff, and Hunter (2015), we sought to identify unique and shared factors that contribute to parent-reported social deficits in children with ADHD, ASD, and ADHD+ASD. We hypothesized attention, hyperactivity, and motor skills would predict social deficits in ADHD, while functional communication and motor skills would predict social deficits in ASD; and additively, all factors would predict social deficits in ADHD+ASD.

Method

Utilizing a clinical database, we identified 236 participants (4-21 years; Mage = 10.6; 71% male; 28% African American; FSIQ M = 94.31) with diagnoses of ADHD, ASD, and ADHD+ASD. We examined FSIQ from the WISC-4/5, WPPSI-3, or DAS-2, motor skills and social impairment from the SIB-R and attention, hyperactivity, and functional communication from the BASC-2/3.

Results

Using hierarchical linear regression and controlling for FSIQ, hypotheses were partially supported. FSIQ was controlled for in each group. For ADHD, hyperactivity, functional communication, and motor skills contributed significantly to the model (p < .001), while for ASD, motor skills contributed significantly to the model (p < .001). For ASD + ADHD, functional communication and motor skills contributed significantly to the model (p < .001)

Conclusion

Results support previous findings that motor deficits and functional communication are associated with social impairment in children with ADHD and ASD, independently and comorbidly. This suggests that targeting motor dysfunction and functional communication concurrently may be effective for improving social interaction skills in children with ADHD +ASD.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Skin cancer knowledge, attitudes, beliefs, and prevention practices among medical students: A systematic search and literature review

BACKGROUND

As future physicians, medical students will play an important role in the prevention of skin cancers by becoming directly involved in skin cancer prevention education and counseling patients about the hazards of ultraviolet light.

OBJECTIVE

We assessed the skin cancer-related knowledge, attitudes, beliefs, and prevention practices reported in previous studies of medical students.

METHODS

The search for relevant articles was performed in four electronic databases: PubMed (Medline), Cumulative Index to Nursing and Allied Health, ERIC, and PsycINFO. Studies were included if they met the following criteria: 1) targeted medical students; 2) assessed sun avoidance, sun protection, skin self-examination, and/or indoor tanning behaviors; 3) were published in peer-reviewed journals; and 4) complete data were available for extraction.

RESULTS

A total of 21 studies are included in this review. Important findings include moderate-to-high levels of skin cancer knowledge and low levels of both sunscreen and ultraviolet light knowledge. The attitudes and knowledge of medical students reflect a low level of concern with regard to the perceived importance of skin cancer compared with other forms of cancer despite a high level of concern for the importance of skin cancer prevention. Furthermore, this review demonstrated that medical students fail to protect themselves routinely from the sun and have a high interest in tanning bed use.

CONCLUSION

This review demonstrates the need to educate medical students about skin cancer and skin cancer preventive behaviors. New strategies and educational campaigns should be developed to communicate better information on skin cancer morbidity, mortality, and prevention to medical students. This will pay dividends by improving the practice of these future physicians in all specialties.

An observational study of perioperative risk associated with aortic stenosis in non-cardiac surgery

This prospective multicentre observational study investigated the risk of non-cardiac surgery in patients with moderate or severe aortic stenosis (AS). Patients with AS undergoing non-cardiac surgery in five New Zealand hospitals between August 2011 and September 2015 were studied. Preoperative variables were analysed for a significant association with postoperative major adverse cardiac events (MACE) and 30-day mortality. Of the 147 patients recruited, 13 (9%) died within 30 days and 33 (22%) had a MACE. Using univariate analysis, patients with severe AS had four times higher 30-day mortality than patients with moderate AS (16% versus 4%, <i>P</i>=0.007). Other factors associated with increased 30-day mortality included having a smaller aortic valve area, smaller dimensionless severity index, concomitant mitral regurgitation, and higher overall surgical risk. Patients with symptoms attributable to AS had a higher incidence of MACE compared to patients without symptoms (36% versus 16%, <i>P</i>=0.011). Variables significantly associated with both 30-day mortality and MACE were age, American Society of Anesthesiologists physical status, emergency surgery, New York Heart Association classification, preoperative albumin level, frailty, and history of congestive heart failure. Using multivariate analysis, emergency surgery, symptoms attributable to AS, preoperative albumin level, and AVA remained significantly associated with adverse outcome. While these findings should be interpreted with caution due to the observational nature of the study, limited power and multiple simultaneous comparisons, they suggest that patients with severe AS have a higher risk of adverse outcome after non-cardiac surgery than patients with moderate AS.

Multiple-therapy-resistant major depressive disorder: a clinically important concept

Many novel therapeutic options for depression exist that are either not mentioned in clinical guidelines or recommended only for use in highly specialist services. The challenge faced by clinicians is when it might be appropriate to consider such 'non-standard' interventions. This analysis proposes a framework to aid this decision.Declaration of interestIn the past 3 years R.H.M.W. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending advisory boards) from various pharmaceutical companies including Astra Zeneca, Cyberonics, Eli Lilly, Janssen, LivaNova, Lundbeck, MyTomorrows, Otsuka, Pfizer, Roche, Servier, SPIMACO and Sunovion. D.M.B.C. has received fees from LivaNova for attending an advisory board. In the past 3 years A.J.C. has received fees for lecturing from Astra Zeneca and Lundbeck; fees for consulting from LivaNova, Janssen and Allergan; and research grant support from Lundbeck.In the past 3 years A.C. has received fees for lecturing from pharmaceutical companies namely Lundbeck and Sunovion. In the past 3 years A.L.M. has received support for attending seminars and fees for consultancy work (including advisory board) from Medtronic Inc and LivaNova. R.M. holds joint research grants with a number of digital companies that investigate devices for depression including Alpha-stim, Big White Wall, P1vital, Intel, Johnson and Johnson and Lundbeck through his mindTech and CLAHRC EM roles. M.S. is an associate at Blueriver Consulting providing intelligence to NHS organisations, pharmaceutical and devices companies. He has received honoraria for presentations and advisory boards with Lundbeck, Eli Lilly, URGO, AstraZeneca, Phillips and Sanofi and holds shares in Johnson and Johnson. In the past 3 years P.R.A.S. has received support for research, expenses to attend conferences and fees for lecturing and consultancy work (including attending an advisory board) from life sciences companies including Corcept Therapeutics, Indivior and LivaNova. In the past 3 years P.S.T. has received consultancy fees as an advisory board member from the following companies: Galen Limited, Sunovion Pharmaceuticals Europe Ltd, myTomorrows and LivaNova. A.H.Y. has undertaken paid lectures and advisory boards for all major pharmaceutical companies with drugs used in affective and related disorders and LivaNova. He has received funding for investigator initiated studies from AstraZeneca, Eli Lilly, Lundbeck and Wyeth.

Engaging stakeholders in research to address water-energy-food (WEF) nexus challenges

The water-energy-food (WEF) nexus has become a popular, and potentially powerful, frame through which to analyse interactions and interdependencies between these three systems. Though the case for transdisciplinary research in this space has been made, the extent of stakeholder engagement in research remains limited with stakeholders most commonly incorporated in research as end-users. Yet, stakeholders interact with nexus issues in a variety of ways, consequently there is much that collaboration might offer to develop nexus research and enhance its application. This paper outlines four aspects of nexus research and considers the value and potential challenges for transdisciplinary research in each. We focus on assessing and visualising nexus systems; understanding governance and capacity building; the importance of scale; and the implications of future change. The paper then proceeds to describe a novel mixed-method study that deeply integrates stakeholder knowledge with insights from multiple disciplines. We argue that mixed-method research designs-in this case orientated around a number of cases studies-are best suited to understanding and addressing real-world nexus challenges, with their inevitable complex, non-linear system characteristics. Moreover, integrating multiple forms of knowledge in the manner described in this paper enables research to assess the potential for, and processes of, scaling-up innovations in the nexus space, to contribute insights to policy and decision making.

The Lewis superacid Al[N(C6F5)2]3 and its higher homolog Ga[N(C6F5)2]3 - structural features, theoretical investigation and reactions of a metal amide with higher fluoride ion affinity than SbF5

Herein we present the synthesis of the two Lewis acids Al[N(C6F5)2]3 (ALTA) and Ga[N(C6F5)2]3 (GATA) via salt elimination reactions. The metal complexes were characterized by NMR-spectroscopic methods and X-ray diffraction analysis revealing the stabilization of the highly Lewis acidic metal centers by secondary metal-fluorine contacts. The Lewis acidic properties of Al[N(C6F5)2]3 and Ga[N(C6F5)2]3 are demonstrated by reactions with Lewis bases resulting in the formation of metallates accompanied by crucial structural changes. The two metallates [Cs(Tol)3]+[FAl(N(C6F5)2)3]- and [AsPh4]+[ClGa(N(C6F5)2)3]- contain interesting weakly coordinating anions. The reaction of Al[N(C6F5)2]3 with trityl fluoride yielded [CPh3]+[FAl(N(C6F5)2)3]- which could find application in the activation of metallocene polymerization catalysts. The qualitative Lewis acidity of Al[N(C6F5)2]3 and Ga[N(C6F5)2]3 was investigated by means of competition experiments for chloride ions in solution. DFT calculations yielded fluoride ion affinities in the gas phase (FIA) of 555 kJ mol-1 for Al[N(C6F5)2]3 and 472 kJ mol-1 for Ga[N(C6F5)2]3. Thus, Al[N(C6F5)2]3 can be considered a Lewis superacid with a fluoride affinity higher than SbF5 (493 kJ mol-1) whereas the FIA of the corresponding gallium complex is slightly below the threshold to Lewis superacidity.

Correction to: Abstracts : 29th European Congress of Pathology

Due to an error with the registration system, the following abstract was regrettably omitted from the Poster Sessions. The abstract should have been included as PS-10-021 and displayed on page S166.

Shortening of an existing generic online health-related quality of life instrument for dogs

OBJECTIVE

Development, initial validation and reliability testing of a shortened version of a web-based questionnaire instrument to measure generic health-related quality of life in companion dogs, to facilitate smartphone and online use.

MATERIALS AND METHODS

The original 46 items were reduced using expert judgment and factor analysis. Items were removed on the basis of item loadings and communalities on factors identified through factor analysis of responses from owners of healthy and unwell dogs, intrafactor item correlations, readability of items in the UK, USA and Australia and ability of individual items to discriminate between healthy and unwell dogs. Validity was assessed through factor analysis and a field trial using a "known groups" approach. Test-retest reliability was assessed using intraclass correlation coefficients.

RESULTS

The new instrument comprises 22 items, each of which was rated by dog owners using a 7-point Likert scale. Factor analysis revealed a structure with four health-related quality of life domains (energetic/enthusiastic, happy/content, active/comfortable, and calm/relaxed) accounting for 72% of the variability in the data compared with 64% for the original instrument. The field test involving 153 healthy and unwell dogs demonstrated good discriminative properties and high intraclass correlation coefficients.

CLINICAL SIGNIFICANCE

The 22-item shortened form is superior to the original instrument and can be accessed via a mobile phone app. This is likely to increase the acceptability to dog owners as a routine wellness measure in health care packages and as a therapeutic monitoring tool.

Primary, congenital neuroaxonal dystrophy with peripheral nerve demyelination in Merino-Border Leicester × Polled Dorset lambs

CASE REPORT

Clinicopathological features of neuroaxonal dystrophy (NAD) in newborn, Merino-Border Leicester × Polled Dorset lambs are described. The affected lambs were unable to walk at birth and microscopic examination of brainstem and spinal cord sections revealed bilaterally symmetrical accumulations of axonal swellings (spheroids), the histological hallmark of primary NAD. The neurological deficit was also exacerbated by myelin loss and secondary axonal degeneration, particularly in the spinal cord and sciatic nerves, but also, to a more limited extent, in brainstem and spinal nerves.

CONCLUSIONS

Although lambs previously diagnosed with NAD have ranged in age from 2 days to 7 months, this is believed to be the first report of congenital NAD in this species. Moreover, the present cases are the only ones in which peripheral nerve demyelination has been found.