Correlation of frailty assessment metrics in one-year follow-up of aged care residents: a sub-study of a randomised controlled trial

INTRODUCTION

Frailty is increasingly recognised as a dynamic syndrome, with multiple causes, dimensions and consequences. There is little understanding of how those frailty assessment metrics interact over time. The aim of this study was to describe the longitudinal correlation between five frailty metrics, namely multimorbidity, muscular strength, mood alterations, cognitive capacity, and functional capacity in a cohort study of aged care (nursing home) residents.

METHODS

248 aged care residents with Frailty Index at baseline of < 0.4 and no dementia were followed for 12 months. A multimorbidity score and an activity of daily living limitation score were created using individual items of the Frailty Index. Muscular strength was measured by grip strength. Cognitive capacity was measured using the Montreal Cognitive Assessment (MoCA) test. Mood alterations were measured using the anxiety/depression screening question from EQ-5D. We analysed the inter-individual correlation at baseline, association between baseline and future change, and within-individual correlation at baseline, 6 and 12 months.

RESULTS

Population analysis shows that metrics were not associated at baseline. All of the studied metrics at baseline were associated with change in 12 months, with the exception of anxiety/depression scores. Pairwise within-individual correlation was strong between MoCA and grip strength (0.13, p = 0.02) and activity of daily living (- 0.48, p < 0.001), and between activities of daily living and multimorbidity index (0.28, p < 0.001). No within-individual correlation was found between anxiety depression score and other metrics.

CONCLUSION

The results suggest an interdependence between comorbidities, physical capacity, cognition and activities of daily living in aged care residents. Comprehensive measurement of frailty-related metrics may provide improved understanding of frailty progression at later life stages.

A service evaluation of patient care relating toClostridioides difficile infection (CDI) in Oxford University Hospital NHS Foundation

Introduction

The bacterium Clostridioides difficile (C. difficile) frequently colonises the human intestine. In an adult who is healthy, this organism is relatively harmless. However, disruption of the normal gut flora, which is frequently brought on by the use of antibiotics, can result in Clostridioides difficile (C. difficile) infection (CDI). As a result, C. difficile can grow and produce a toxin that causes diarrhoea. Due to the ease with which C. difficile can be spread in healthcare environments, it is essential to recognise and treat CDI patients as soon as possible and in accordance with best practises.

Aim

This service evaluation aimed to explore and understand how adult inpatients presenting with diarrhoea where (CDI is suspected are managed according to Trust Clostridioides difficile guidelines.

Methods

Purposive sampling of up to 100 adult inpatients presenting with diarrhoea where C. difficile is suspected and the patient has been an in-patient for least 48 hours post sample request. A data collection tool was developed, pilot tested and used to collect patient data from the Oxford University Hospital's Electronic Prescribing Record. Data was analysed using descriptive statistics and the Functional Resonance Analysis Method (FRAM) that involved 1) Identifying and describing key functions relating to the management of patients 2) Identifying variability in performing key functions and 3) Determine the possibility of function resonance. Ethical approval was obtained from University of Reading.

Results

Fifty patient records were accessed. The results showed that many patients had a stool sample sent for review as soon as possible, a clinical review of their condition and where there was the absence of a strong suspicion or strong evidence of C. Difficile a delay in the initiation of empirical therapy. Documentation was an area with poor compliance to guidelines. 50 % had a Bristol stool chart completed before sample sent and after CDI suspected, 60 % had isolation of the patient documented, 47 % had placement of contact precautions documented, and 20 % had documentation of discontinuation of empirical therapy. A FRAM model was developed and a total of 14 functions were identified with three functions “Record Bristol stool charts”, “clinical review of the patient”, and “placement of contact precautions” being most connected to the other functions, demonstrating the significance of these functions in the management of patients who are suspected of having CDI.

Discussion/Conclusion

The three key tasks outlined by FRAM are important to ensure that provide patients with the best care. Understanding variability in how the functions identified in FRAM are performed is important to understand how work is performed in order to then design ways of working that benefits both patients and HCPs. Further work is required to explore this area.

Fijian farmers’ attitude and knowledge towards antimicrobial use and antimicrobial resistance in livestock production systems: a qualitative study

Introduction

Antimicrobial resistance (AMR) is a global health issue to humans and livestock (1). To mitigate AMR risks, responsible use of antimicrobials in livestock production systems have been advocated (1). Studies have demonstrated the patterns of antimicrobial use (AMU) in livestock production systems; however, there is limited information on the drivers of AMU. For successful antimicrobial stewardship (AMS), identifying the psychological (knowledge and attitude) and contextual drivers (environmental factors, economic status, and resource accessibility) for intervention is a crucial first step in the agri-food value chain. The theory of planned behaviour (TPB) has been used to understand behaviour influenced by a person’s intention, attitude, and knowledge; therefore, evaluating behaviour allows understanding of drivers that affect and shape the farmers’ intention and decisions (2).

Aim

To explore and understand the attitude and knowledge of Fijian livestock farmers on AMU and AMR.

Methods

Face to face one-to-one semi-structured qualitative interviews were conducted between September and November 2019 with Fijian livestock farmers and managers located in the Central and Western divisions of Viti Levu, Fiji. A sample of at least 20 participants from the cattle and poultry production systems was targeted and recruited using purposive and snowball sampling methods. TPB informed the development of the semi-structured interview guide. The interviews were audio-recorded and analysed inductively using Braun and Clarke’s reflexive thematic analysis and deductively using the TPB framework (results reported elsewhere). An interpretative approach underpinned the design and conduct of this study.

Results

Nineteen livestock farmers and managers took part in interviews. Our analysis generated four themes: 1) Uninformed use of antimicrobials and unaware of AMR, 2) Safeguarding livestock and generating income source as primary motivators for using medicine, 3) Medicine shortage resulting in hoarding and self-prescribing, and 4) Foreign farmers and veterinarians trusted over Fijian veterinarian and para-veterinarian knowledge. Livestock farmers did not differentiate amongst different types of medicine, including antimicrobials. Therefore, antimicrobials were unwittingly used and without an awareness of the risks of AMR. Medicines, including antimicrobials, were used to protect livestock and promote production for food and financial security. Farmers hoarded medicines and self-prescribed them on the farms. Farmers lacked confidence in the advice on livestock management, and medicine use, provided by Fijian veterinarians and para-veterinarians. They sought help online and from foreign farmers and veterinarians. No participant sought advice from pharmacists who are experts in medicine.

Conclusion

This study uncovered the first documented accounts of Fijian livestock farmers’ attitude and knowledge on AMU and AMR. AMS programmes promoting awareness and rational use of antimicrobials and resistance in Fijian livestock production is recommended. These programmes need to consider the social, economic, and environmental factors driving irrational medicine use by farmers. We acknowledge the views shared by participants may not be representative of all farmers in Fiji; however, we believe all participants provided in-depth insight into the current drivers of AMU. Future studies exploring the attitude and knowledge of Fijian veterinarians, para-veterinarians and pharmacists on AMU and AMR in livestock production can inform the design of AMS programmes that currently do not exist.

References

(1) WHO. Antimicrobial Resistance Geneva Switzerland: World Health Organization; 2021 [cited 2021 1 September]. Available from: http://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance.

(2) Ajzen I. The theory of planned behaviour. Organizational Behaviour and Human Decision Processes. 1991;50(2):179-211.

Third-generation modular mandible endoprosthesis in Macaca fascicularis

The aim of this study was to develop a third-generation modular mandible endoprosthesis that would experience less stress concentration at its stems compared to earlier generations, thereby minimizing micromotion and achieving long-term stability. In this three-piece modular design, different degrees of movement were incorporated between the endoprosthesis module interfaces. It was hypothesized that this unique feature would minimize stress concentration at the stems and hence promote osseointegration during the early phase of implantation. The endoprosthesis system was made of commercially pure grade 4 titanium, machined and surface-treated, then sterilized and implanted in segmental mandible defects of nine Macaca fascicularis. Clinical, radiological, histological, and histomorphometric evaluations were performed 4 months post-implantation. The endoprosthesis systems with a degree of movement incorporated, exhibited superior performance compared to the rigid system: 30.9-34.8 times higher percentage bone-implant contact (P< 0.0001) and 3.4-4.1 times higher percentage bone area (P<0.0001), with osseointegration noted at the posterior stems. However, fibrous tissue encapsulation was noted around the majority of the anterior stems in all groups. Although the degree of movement was favourable for improving bone healing and stability of the endoprosthesis system, more work needs to be done to investigate other strategies to further reduce loading on the endoprosthesis to achieve predictable osseointegration at the stems.

USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair

PURPOSE

Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons.

METHODS

An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR).

RESULTS

110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively.

CONCLUSION

The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Association of blood mercury levels with nonmelanoma skin cancer in the U.S.A. using National Health and Nutrition Examination Survey data (2003-2016)

BACKGROUND

Some studies have reported increased incidence or mortality of lung and brain cancers associated with occupations involving potential mercury exposure. Epidemiological evidence related to skin cancer is also limited.

OBJECTIVES

To investigate the association between blood mercury (Hg) levels and nonmelanoma skin cancer (NMSC).

METHODS

We used National Health and Nutrition Examination Survey data from 2003 to 2016. The exposures were blood total (tHg), inorganic (iHg) and methylmercury (MeHg). The outcome was a self-reported diagnosis of NMSC. We included participants aged ≥ 20 years who had information on blood mercury and sociodemographic factors. We conducted a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of NMSC associated with quartiles of blood Hg, after adjusting for the sociodemographic factors and survey year.

RESULTS

The number of participants was 29 413; mean age was 49 years and 52% were female. Compared with those with a tHg ≤ 0·47 μg L^-1 (Q1), those with a tHg > 1·74 μg L^-1 (Q4) had nearly double the odds of NMSC (OR 1·79, 95% CI 1·19-2·71; P_trend = 0·004). Similarly, those in the highest quartile of MeHg (> 1·44 μg L^-1 ) had 1·7 times greater odds of NMSC (OR 1·74, 95% CI 1·13-2·70; P_trend = 0·01) than those in the lowest quartile (≤ 0·21 μg L^-1 ). iHg levels were nonsignificantly positively associated with NMSC (P_trend = 0·08).

CONCLUSIONS

We found that higher blood tHg and MeHg levels were associated with a higher prevalence of NMSC. Linked Comment: Taylor. Br J Dermatol 2020; 183:413-414.

A review of efferent cholinergic synaptic transmission in the vestibular periphery and its functional implications

It has been over 60 years since peripheral efferent vestibular terminals were first identified in mammals, and yet the function of the efferent vestibular system remains obscure. One reason for the lack of progress may be due to our deficient understanding of the peripheral efferent synapse. Although vestibular efferent terminals were identified as cholinergic less than a decade after their anatomical characterization, the cellular mechanisms that underlie the properties of these synapses have had to be inferred. In this review we examine how recent mammalian studies have begun to reveal both nicotinic and muscarinic effects at these terminals and therefore provide a context for fast and slow responses observed in classic electrophysiological studies of the mammalian efferent vestibular system, nearly 40 years ago. Although incomplete, these new results together with those of recent behavioral studies are helping to unravel the mysterious and perplexing action of the efferent vestibular system. Armed with this information, we may finally appreciate the behavioral framework in which the efferent vestibular system operates.

Nursing teamwork in the care of older people: A mixed methods study

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

Making global river ecosystem health assessments objective, quantitative and comparable

Assessing and comparing global river ecosystem health in an objective and quantitative way remains a major challenge. In this study the widely-used semi-quantitative methods Rapid Biological assessment Protocols (RBPs) was used to determine the health of rivers. The findings were then compared to the results derived from our new UAV (Unmanned aerial vehicles) orthophotographic imagery method. This method quantitatively and objectively assesses river ecosystem health. As a comparison, our method was used to quantitatively measure distance and areas of a range of hydrological and biological attributes thus improving the accuracy of distance- and area-related indices, consequently avoiding subjective errors in these estimations that is fraught in methods like the RBPs. To strengthen the objectivity of the assessment the weights of these indices were objectively determined using the entropy weighting method. This new method was then tested using 9551 UAV orthophotographs taken over six field campaigns. It performed satisfactorily, showing that in our study area the health status of mountain rivers was the best with the highest score of 0.94 out of 1.0. Temporally, the health of the river was better in summer (0.65) compared with that in autumn (0.40). Changes in river ecosystem health were driven by variations in biology and water quality. In contrast the outputs of RBPs, especially in relation to distance and area indices, had ~ 20% uncertainty due to visual errors and subjectivity in estimations by observers. The UAV orthophotographic imaging method proposed in this study can improve the ability to compare the health of rivers across different periods and regions throughout the globe.

Deubiquitinase USP10 regulates Notch signaling in the endothelium

Notch signaling is a core patterning module for vascular morphogenesis that codetermines the sprouting behavior of endothelial cells (ECs). Tight quantitative and temporal control of Notch activity is essential for vascular development, yet the details of Notch regulation in ECs are incompletely understood. We found that ubiquitin-specific peptidase 10 (USP10) interacted with the NOTCH1 intracellular domain (NICD1) to slow the ubiquitin-dependent turnover of this short-lived form of the activated NOTCH1 receptor. Accordingly, inactivation of USP10 reduced NICD1 abundance and stability and diminished Notch-induced target gene expression in ECs. In mice, the loss of endothelial Usp10 increased vessel sprouting and partially restored the patterning defects caused by ectopic expression of NICD1. Thus, USP10 functions as an NICD1 deubiquitinase that fine-tunes endothelial Notch responses during angiogenic sprouting.

Expression and function of macrophage-inducible C-type lectin (Mincle) in inflammation driven parturition in fetal membranes and myometrium

The pivotal role of inflammatory processes in human parturition is well known, but not completely understood. We have performed a study to examine the role of macrophage-inducible C-type lectin (Mincle) in inflammation-associated parturition. Using human samples, we show that spontaneous labour is associated with up-regulated Mincle expression in the myometrium and fetal membranes. Mincle expression was also increased in fetal membranes and myometrium in the presence of pro-labour mediators, the proinflammatory cytokines interleukin (IL)-1B and tumour necrosis factor (TNF), and Toll-like receptor (TLR) ligands fsl-1, poly(I:C), lipopolysaccharide (LPS) and flagellin. These clinical studies are supported by mouse studies, where an inflammatory challenge in a mouse model of preterm birth increased Mincle expression in the uterus. Importantly, elimination of Mincle decreased the effectiveness of proinflammatory cytokines and TLR ligands to induce the expression of pro-labour mediators; namely, proinflammatory cytokines and chemokines, contraction-associated proteins and prostaglandins, and extracellular matrix remodelling enzymes, matrix metalloproteinases. The data presented in this study suggest that Mincle is required when inflammatory activation precipitates parturition.

Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Abstract OT1-06-05: Atomic force microscopy (AFM) - a novel nanotool for cancer diagnostics: A prospective, blinded study of nanomechanical profiling of human breast tissue as a potential biomarker for stratifying low- and high-risk breast cancer subtypes

Background

The crucial point in making treatment decisions for breast cancer patients is the assessment of tumour aggressiveness. The established prognostic markers may be insufficient to stratify cancer patients into treatment relevant risk groups. Emerging evidence indicates that mechanical properties of cancer cells and their microenvironment that occur on a nanometre scale play a critical role in cancer invasion and metastases. Therefore, detecting these nanomechanical changes could serve as biomarker of cancer aggressiveness.

Trial design

We conduct a prospective, blinded study in a routine clinical setting. Using minimal invasive breast biopsies we measure the nanomechanical (stiffness) properties of human breast tissue with our atomic force microscope (AFM) based method known as ARTIDIS (Automated and Reliable Tissue Diagnostics). These properties can only be measured using fresh (non-fixed) tissue under physiological conditions (Custodiol transplant buffer). This novel method is based on the use of a micro-fabricated 20nm-sharp tip that indents several thousand individual locations across tissue specimens within 60-180 minutes. Each indentation effectively measures the stiffness of local structures (e.g. cancer cells, extracellular matrix) located under the tip. Thus we obtain a quantitative, biopsy-wide, nanomechanical profile. Post-AFM the same biopsy is used for routine histopathological diagnosis, the current diagnostic gold standard to which the nanomechanical profile is then correlated.

Eligibility criteria

All women undergoing a minimal invasive breast biopsy (core needle or vacuum assisted biopsy) at the breast centre of the University of Basel.

Exclusion criteria: age younger than 18years, necrotic/disintegrated biopsy, and technical limitations

Specific aims

Our primary endpoint is to differentiate benign from cancerous breast lesions based on their nanomechanical properties. Our secondary endpoint is to subclassify biopsies with cancerous lesions into the current four main breast cancer subgroups (Luminal A, Luminal B, HER2+ and basal-like).

Statistical analysis

The full dataset will include all patients with valid AFM measurements. Primary analysis: the proportion of true positive results divided by the total number of patients with malignant tumour (sensitivity) will be estimated and presented together with its 95% confidence interval. The histological diagnosis of the same biopsy as analysed by AFM will serve as gold standard.

Present accrual and target accrual

Present accrual as of June 12, 2017: 200 breast tissue biopsies.

Target accrual is 508 biopsies. This will allow for a power of 0.8 and a sensitivity of 90%.

Contact information: Rosemarie.Burian@usb.ch

Citation Format: Burian R, Appenzeller T, Oertle P, Raez C, Lim R, Forte S, Dellas S, Münst S, Obermann E, Plodinec M. Atomic force microscopy (AFM) - a novel nanotool for cancer diagnostics: A prospective, blinded study of nanomechanical profiling of human breast tissue as a potential biomarker for stratifying low- and high-risk breast cancer subtypes [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-06-05.

The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose

BACKGROUND

Adverse events due to energy device use in surgical operating rooms are a daily occurrence. These occur at a rate of approximately 1-2 per 1000 operations. Hundreds of operating room fires occur each year in the United States, some causing severe injury and even mortality. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) therefore created the first comprehensive educational curriculum on the safe use of surgical energy devices, called Fundamental Use of Surgical Energy (FUSE). This paper describes the history, development, and purpose of this important training program for all members of the operating room team.

METHODS

The databases of SAGES and the FUSE committee as well as personal photographs and documents of members of the FUSE task force were used to establish a brief history of the FUSE program from its inception to its current status.

RESULTS

The authors were able to detail all aspects of the history, development, and national as well as global implementation of the third SAGES Fundamentals Program FUSE.

CONCLUSIONS

The written documentation of the making of FUSE is an important contribution to the history and mission of SAGES and allows the reader to understand the idea, concept, realization, and implementation of the only free online educational tool for physicians on energy devices available today. FUSE is the culmination of the SAGES efforts to recognize gaps in patient safety and develop state-of-the-art educational programs to address those gaps. It is the goal of the FUSE task force to ensure that general FUSE implementation becomes multinational, involving as many countries as possible.

The risk of internal hernia or volvulus after laparoscopic colorectal surgery: a systematic review

AIM

To determine the incidence of internal hernias after laparoscopic colorectal surgery and evaluate the risk factors and strategies in the management of this serious complication.

METHOD

Two databases (MEDLINE from 1946 and Embase from 1949) were searched to mid-September 2015. The search terms included volvulus or internal hernia and laparoscopic colorectal surgery or colorectal surgery or anterior resection or laparoscopic colectomy. We found 49 and 124 articles on MEDLINE and Embase, respectively, an additional 15 articles were found on reviewing the references. After removal of duplicates, 176 abstracts were reviewed, with 33 full texts reviewed and 15 eligible for qualitative synthesis.

RESULTS

The incidence of internal hernia after laparoscopic colorectal surgery is low (0.65%). Thirty-one patients were identified. Five cases were from two prospective studies (5/648, 0.8%), 20 cases were from seven retrospective studies (20/3165, 0.6%) and six patients were from case reports. Of the 31 identified cases, 21 were associated with left-sided resection, four with right sided resection, two with transverse colectomy, one with a subtotal colectomy and in three cases the operation was not specified. The majority of cases (64.3%) were associated with a restorative left sided resection. Nearly all cases occurred within 4 months of surgery. All patients required re-operation and reduction of the internal hernia and 35.7% of cases required a bowel resection. In 52.2% of cases, the mesenteric defect was closed at the second operation and 52.6% of cases were successfully managed laparoscopically. There were three deaths (0.08%).

CONCLUSION

Mesenteric hernias are a rare but important complication of laparoscopic colorectal surgery. The evidence does not support routine closure for all cases, but selective closure of the mesenteric defect during left-sided restorative procedures in high-risk patients at the initial surgery may be considered.

"Threshold-crossing": A Useful Way to Establish the Counterfactual in Clinical Trials?

A central question in the assessment of benefit/harm of new treatments is: how does the average outcome on the new treatment (the factual) compare to the average outcome had patients received no treatment or a different treatment known to be effective (the counterfactual)? Randomized controlled trials (RCTs) are the standard for comparing the factual with the counterfactual. Recent developments necessitate and enable a new way of determining the counterfactual for some new medicines. For select situations, we propose a new framework for evidence generation, which we call "threshold-crossing." This framework leverages the wealth of information that is becoming available from completed RCTs and from real world data sources. Relying on formalized procedures, information gleaned from these data is used to estimate the counterfactual, enabling efficacy assessment of new drugs. We propose future (research) activities to enable "threshold-crossing" for carefully selected products and indications in which RCTs are not feasible.

Adaptive Biomedical Innovation: Evolving Our Global System to Sustainably and Safely Bring New Medicines to Patients in Need

The current system of biomedical innovation is unable to keep pace with scientific advancements. We propose to address this gap by reengineering innovation processes to accelerate reliable delivery of products that address unmet medical needs. Adaptive biomedical innovation (ABI) provides an integrative, strategic approach for process innovation. Although the term "ABI" is new, it encompasses fragmented "tools" that have been developed across the global pharmaceutical industry, and could accelerate the evolution of the system through more coordinated application. ABI involves bringing stakeholders together to set shared objectives, foster trust, structure decision-making, and manage expectations through rapid-cycle feedback loops that maximize product knowledge and reduce uncertainty in a continuous, adaptive, and sustainable learning healthcare system. Adaptive decision-making, a core element of ABI, provides a framework for structuring decision-making designed to manage two types of uncertainty - the maturity of scientific and clinical knowledge, and the behaviors of other critical stakeholders.

IFPA meeting 2015 workshop report IV: placenta and obesity; stem cells of the feto-maternal interface; placental immunobiology and infection

Workshops are an important part of the IFPA annual meeting as they allow for discussion of specialised topics. At the 2015 IFPA annual meeting there were 12 themed workshops, three of which are summarized in this report. These workshops related to various aspects of placental biology and collectively covered areas of obesity and the placenta, stem cells of the feto-maternal interface, and placental immunobiology and infection.