Medical management and surgery versus medical management alone for symptomatic cerebral cavernous malformation (CARE): a feasibility study and randomised, open, pragmatic, pilot phase trial

BACKGROUND

The highest priority uncertainty for people with symptomatic cerebral cavernous malformation is whether to have medical management and surgery or medical management alone. We conducted a pilot phase randomised controlled trial to assess the feasibility of addressing this uncertainty in a definitive trial.

METHODS

The CARE pilot trial was a prospective, randomised, open-label, assessor-blinded, parallel-group trial at neuroscience centres in the UK and Ireland. We aimed to recruit 60 people of any age, sex, and ethnicity who had mental capacity, were resident in the UK or Ireland, and had a symptomatic cerebral cavernous malformation. Computerised, web-based randomisation assigned participants (1:1) to medical management and surgery (neurosurgical resection or stereotactic radiosurgery) or medical management alone, stratified by the neurosurgeon's and participant's consensus about the intended type of surgery before randomisation. Assignment was open to investigators, participants, and carers, but not clinical outcome event adjudicators. Feasibility outcomes included site engagement, recruitment, choice of surgical management, retention, adherence, data quality, clinical outcome event rate, and protocol implementation. The primary clinical outcome was symptomatic intracranial haemorrhage or new persistent or progressive non-haemorrhagic focal neurological deficit due to cerebral cavernous malformation or surgery during at least 6 months of follow-up. We analysed data from all randomly assigned participants according to assigned management. This trial is registered with ISRCTN (ISRCTN41647111) and has been completed.

FINDINGS

Between Sept 27, 2021, and April 28, 2023, 28 (70%) of 40 sites took part, at which investigators screened 511 patients, of whom 322 (63%) were eligible, 202 were approached for recruitment, and 96 had collective uncertainty with their neurosurgeon about whether to have surgery for a symptomatic cerebral cavernous malformation. 72 (22%) of 322 eligible patients were randomly assigned (mean recruitment rate 0·2 [SD 0·25] participants per site per month) at a median of 287 (IQR 67-591) days since the most recent symptomatic presentation. Participants' median age was 50·6 (IQR 38·6-59·2) years, 68 (94%) of 72 participants were adults, 41 (57%) were female, 66 (92%) were White, 56 (78%) had a previous intracranial haemorrhage, and 28 (39%) had a previous epileptic seizure. The intended type of surgery before randomisation was neurosurgical resection for 19 (26%) of 72, stereotactic radiosurgery for 44 (61%), and no preference for nine (13%). Baseline clinical and imaging data were complete for all participants. 36 participants were randomly assigned to medical management and surgery (12 to neurosurgical resection and 24 to stereotactic radiosurgery) and 36 to medical management alone. Three (4%) of 72 participants withdrew, one was lost to follow-up, and one declined face-to-face follow-up, leaving 67 (93%) retained at 6-months' clinical follow-up. 61 (91%) of 67 participants with follow-up adhered to the assigned management strategy. The primary clinical outcome occurred in two (6%) of 33 participants randomly assigned to medical management and surgery (8·0%, 95% CI 2·0-32·1 per year) and in two (6%) of 34 participants randomly assigned to medical management alone (7·5%, 1·9-30·1 per year). Investigators reported no deaths, no serious adverse events, one protocol violation, and 61 protocol deviations.

INTERPRETATION

This pilot phase trial exceeded its recruitment target, but a definitive trial will require extensive international engagement.

FUNDING

National Institute for Health and Care Research.

Triplet Rydberg States of Aluminum Monofluoride

Aluminum monofluoride (AlF) is a suitable molecule for laser cooling and trapping. Such experiments require extensive spectroscopic characterization of the electronic structure. Two of the theoretically predicted higher-lying triplet states of AlF, the counterparts of the well-characterized D1Δ and E1Π states, had not been experimentally identified yet. We here report on the characterization of the d3Π (v = 0-6) and e3Δ (v = 0-2) states, confirming the predicted energetic ordering of these states (J. Chem. Phys. 1988, 88, 5715-5725), as well as of the f3Σ+ (v = 0-2) state. The transition intensity of the d3Π, v = 3 - a3Π, v = 3 band is negligibly small. This band gets its weak, unexpected rotational structure via intensity borrowing from the nearby e3Δ, v = 2 - a3Π, v = 3 band, made possible via spin-orbit and spin-rotation interaction between the d3Π and e3Δ states. This interaction affects the equilibrium rotational constants in both states; their deperturbed values yield equilibrium internuclear distances that are consistent with the observations. We determined the ionization potential of AlF to be 78,492(1) cm-1 by ionization from the d3Π state.

A Ventral Hernia Management Pathway; A "Getting It Right First Time" approach to Complex Abdominal Wall Reconstruction

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.

METHODS

We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.

RESULTS

We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.

CONCLUSION

In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Estimating meaningful change thresholds for Skin Pain-Numeric Rating Scale, Sleep-Numeric Rating Scale and Dermatology Life Quality Index in patients with prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is characterized by intensely itchy nodules/lesions and skin pain, which can have a substantial impact on health-related quality of life (HRQoL). Treatment benefits on such symptoms and impacts are best assessed in trials using patient-reported outcome (PROs) instruments such as Skin Pain Numerical Rating Scale (NRS), Sleep-NRS and Dermatology Life Quality Index (DLQI). However, no guidance exists for interpreting meaningful changes in scores using these PROs in patients with PN.

OBJECTIVES

The main objective was to derive within-patient (responder definition) and between-group improvement thresholds for interpreting Skin Pain-NRS, Sleep-NRS and DLQI total scores in patients with PN. The measurement properties of the three PROs were also evaluated.

METHODS

Intention-to-treat (ITT), blinded and pooled data were used from the Phase 3 PRIME (NCT04183335) and PRIME2 (NCT04202679) studies evaluating the efficacy of dupilumab in adult patients with PN. Anchor- and distribution-based methods were applied to derive responder definition and between-group thresholds for Skin Pain-NRS, Sleep-NRS and DLQI. Data were additionally used to examine the instrument measurement properties, including reliability, validity and responsiveness.

RESULTS

A total of 311 patients (mean age 49.5 years, 65.3% female) were included in the pooled ITT population. The within-patient improvement threshold for Skin Pain-NRS was estimated as 4.0 points, 2.0 points for Sleep-NRS and 9.0 points for DLQI total score. A 1.5-point improvement in Skin Pain-NRS scores, 1.0-point in Sleep-NRS and 4.0-point in DLQI indicated a between-group meaningful change. Adequate to good psychometric properties were demonstrated for all three instruments.

CONCLUSIONS

The results of this study can aid interpretation of Skin Pain-NRS, Sleep-NRS and DLQI scores in patients with PN in both clinical trials and clinical practice to better understand and treat PN-related skin pain and the impact of PN on sleep quality and HRQoL.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

IL-32 Drives the Differentiation of Cardiotropic CD4+ T-Cells Carrying HIV DNA in People Living with HIV

IL-32 is a potent multi-isoform proinflammatory cytokine, which is upregulated in people living with HIV (PLWH) and is associated with cardiovascular disease (CVD) risk. However, the impact of IL-32 isoforms on CD4 T-cell cardiotropism, a mechanism potentially contributing to heart inflammation, remains unknown. Here we show that IL-32 isoforms β and γ induce the generation of CCR4 + CXCR3 + double positive (DP) memory CD4 T-cell subpopulation expressing the tyrosine kinase receptor c-Met, a phenotype associated with heart-homing of T-cells. Our ex vivo studies on PLWH show that the frequency of DP CD4 T-cells is significantly higher in individuals with, compared to individuals without, subclinical atherosclerosis and that DP cells from antiretroviral-naïve and treated individuals are highly enriched with HIV DNA. Together, these data demonstrate that IL-32 isoforms have the potential to induce heart-homing of HIV-infected CD4 T-cells, which may further aggravate heart inflammation and CVD in PLWH.

Maximizing use of existing carcinogenicity data to support acceptable intake levels for mutagenic impurities in pharmaceuticals: Learnings from N-nitrosamine case studies

The unexpected finding of N-nitrosamine (NA) impurities in many pharmaceutical products raised significant challenges for industry and regulators. In addition to well-studied small molecular weight NAs, many of which are potent rodent carcinogens, novel NAs associated with active pharmaceutical ingredients have been found, many of which have limited or no safety data. A tiered approach to establishing Acceptable Intake (AI) limits for NA impurities has been established using chemical-specific data, read-across, or a class-specific TTC limit. There are ∼140 NAs with some rodent carcinogenicity data, but much of it is older and does not meet current guidelines for what constitutes a 'robust' bioassay. Nevertheless, these data are an important source of information to ensure the best science is used for assessing NA impurities and assuring consumer safety while minimizing impact that can lead to drug shortages. We present several strategies to maximize the use of imperfect data including using a lower confidence limit on a rodent TD50, and leveraging data from multiple NAs. Information on the chemical structure known to impact potency can also support development of an AI or potentially conclude that a particular NA does not fall in the cohort of concern for potent carcinogenicity.

Experimental determination of concentration factors of Ni, Ru and Sb in the model diatom Phaeodactylum tricornutum

This paper describes the experimental determination of concentration factors (CF) for nickel, ruthenium and antimony in the model diatom Phaeodactylum tricornutum Bohlin (Bacillariophyceae), which was chosen as a representative of marine phytoplankton. Better determinations of these CF are needed to improve the modelling of marine ecosystems at release points, where radioactive pollutants enter the ecosystem, for more accurate predictions of radiation dose to humans caused by these pollutants. A literature study revealed that the currently implemented values of these CF are based on very scarce data, and a computational sensitivity study showed that the radiation dose caused by radioisotopes of these elements depend strongly on the phytoplankton CF. Nutrient-enriched water samples from Swedish coastal waters were used as a medium for growing of the diatom species P. tricornutum and radioactive isotopes of the studied elements were added to the cultures during the exponential growth phase. The radioactivity in the P. tricornutum and in the culture medium were measured separately and used for determination of CF. Conservative estimates of the CF based on this phytoplankton proxy on the present data are 6400 L/kg for nickel, 20,000 L/kg for ruthenium and 890 L/kg for antimony, with P. tricornutum biomass masses referring to dry weight. The estimates for nickel and ruthenium are similar to previously published values, which underpins the credibility of radiation dose calculations based on these values. The estimate for antimony is uncertain, but also, to our knowledge, represents the first published experimentally based data on this CF.

A portable primary-standard level graphite calorimeter for absolute dosimetry in clinical pencil beam scanning proton beams

Objective. To report the use of a portable primary standard level graphite calorimeter for direct dose determination in clinical pencil beam scanning proton beams, which forms part of the recommendations of the proposed Institute of Physics and Engineering in Medicine (IPEM) Code of Practice (CoP) for proton therapy dosimetry.Approach. The primary standard proton calorimeter (PSPC) was developed at the National Physical Laboratory (NPL) and measurements were performed at four clinical proton therapy facilities that use pencil beam scanning for beam delivery. Correction factors for the presence of impurities and vacuum gaps were calculated and applied, as well as dose conversion factors to obtain dose to water. Measurements were performed in the middle of 10 × 10 × 10 cm3homogeneous dose volumes, centred at 10.0, 15.0 and 25.0 g·cm-2depth in water. The absorbed dose to water determined with the calorimeter was compared to the dose obtained using PTW Roos-type ionisation chambers calibrated in terms of absorbed dose to water in60Co applying the recommendations in the IAEA TRS-398 CoP.Main results.The relative dose difference between the two protocols varied between 0.4% and 2.1% depending on the facility. The reported overall uncertainty in the determination of absorbed dose to water using the calorimeter is 0.9% (k= 1), which corresponds to a significant reduction of uncertainty in comparison with the TRS-398 CoP (currently with an uncertainty equal or larger than 2.0% (k= 1) for proton beams).Significance. The establishment of a purpose-built primary standard and associated CoP will considerably reduce the uncertainty of the absorbed dose to water determination and ensure improved accuracy and consistency in the dose delivered to patients treated with proton therapy and bring proton reference dosimetry uncertainty in line with megavoltage photon radiotherapy.

Biodistribution of naturally occurring radionuclides and radiocesium in wild European perch (Perca fluviatilis)

Wild European perch (Perca fluviatilis) is one of the most important freshwater fish species, in Sweden, due to its widespread and his value for recreational fishing. Little it is known regarding the biodistribution of naturally occurring radionuclides such as ²³⁸U, ²³⁴U, ²²⁶Ra, ²¹⁰Po in perch. Therefore, in this study, perches from five lakes located in different counties in Sweden were collected to investigate the biodistribution of ²³⁸U, ²³⁴U, ²²⁶Ra, ²¹⁰Po and ¹³⁷Cs in organs and tissues of perch as well as their radiological impact. The results showed that uranium radionuclides ranged between 0.1 and 6 Bq/kg with an average value of 1.1 ± 1.5 Bq/kg. ²²⁶Ra varied from 0.4 to 8 Bq/kg with a mean concentration of 1.7 ± 1.9 Bq/kg. The ranged of ²¹⁰Po was 0.5 - 250 Bq/kg, with an average value of 24 ± 52 Bq/kg. On the other hand, the highest activity concentration of ¹³⁷Cs, 151 ± 1 Bq/kg, was detected in muscle samples of perch from Redsjösjön lake. For uranium radionuclides and ²²⁶Ra uptake from water is the main source whereas for ²¹⁰Po and ¹³⁷Cs the uptake is controlled by the perch diet. Regarding naturally occurring radionuclides, the perch tended to accumulated uranium radionuclides in fins, gills, and skin; ²²⁶Ra in bones, fins and skin and ²¹⁰Po in the organs linked to digestive system. Finally, in case of consumption, it is advised the consumption of skinned fillets of perch due to the higher bioaccumulation of the radionuclides investigated in the skin and scales.

Experimental determination of concentration factors of Mn, Zn and I in the phytoplankton species Phaeodactylum Tricornutum

Anthropogenic radionuclides released into the environment cause a radiation dose to wildlife and humans which must be quantified, both to assess the effect of normal releases, and to predict the consequences of a larger, unplanned release. To estimate the spread of the radioactive elements, the ecosystem around release points is modelled, and element uptake is usually quantified by concentration factors (CF), which relates the concentration of an element in an organism to the concentration of the same element in a medium under equilibrium conditions. In this work, we experimentally determine some phytoplankton CF that are needed for improved modelling of the marine ecosystems around nuclear facilities and release points. CFs that require better determination have been identified through literature search. Sensitivity studies, using the currently used ecosystem modelling software PREDO, show that for most studied groups, the dose committed by the respective radionuclides is almost proportional to the corresponding phytoplankton CFs. In the present work, CFs are determined through laboratory experiments with cultured phytoplankton and radionuclides of the concerned elements, assessing the element uptake by the phytoplankton through detection of the emitted radiation. The three CF assessed in this work were those for manganese, zinc and iodine in phytoplankton. Conservative estimates of these CF based on the present data are 40 000 L/kg for manganese, 50 000 L/kg for zinc and 180 L/kg for iodine with the phytoplankton masses referring to their dry weight.

First Constraints from DAMIC-M on Sub-GeV Dark-Matter Particles Interacting with Electrons

We report constraints on sub-GeV dark matter particles interacting with electrons from the first underground operation of DAMIC-M detectors. The search is performed with an integrated exposure of 85.23 g days, and exploits the subelectron charge resolution and low level of dark current of DAMIC-M charge-coupled devices (CCDs). Dark-matter-induced ionization signals above the detector dark current are searched for in CCD pixels with charge up to 7e^{-}. With this dataset we place limits on dark matter particles of mass between 0.53 and 1000  MeV/c^{2}, excluding unexplored regions of parameter space in the mass ranges [1.6,1000]  MeV/c^{2} and [1.5,15.1]  MeV/c^{2} for ultralight and heavy mediator interactions, respectively.

Altered synaptic connectivity in an in vitro human model of STXBP1 encephalopathy

Early infantile developmental and epileptic encephalopathies are devastating conditions, generally of genetic origin, but the pathological mechanisms often remain obscure. A major obstacle in this field of research is the difficulty of studying cortical brain development in humans, at the relevant time period in utero. To address this, we established an in vitro assay to study the impact of gene variants on the developing human brain by using living organotypic cultures of the human subplate and neighbouring cortical regions, prepared from ethically sourced, 14-17 post-conception week brain tissue (www.hdbr.org). We were able to maintain cultures for several months, during which time the gross anatomical structures of the cortical plate, subplate and marginal zone persisted, while neurons continued to develop morphologically and form new synaptic networks. This preparation thus permits the study of genetic manipulations and their downstream effects on an intact developing human cortical network. We focused on STXBP1 haploinsufficiency, which is among the most common genetic causes of developmental and epileptic encephalopathy. This was induced using shRNA interference, leading to impaired synaptic function and a reduced density of glutamatergic synapses. We thereby provide a critical proof-of-principle for how to study the impact of any gene of interest on the development of the human cortex.

Use of the Arctic Sun™ 5000 targeted temperature management system to achieve rewarming during a prolonged hypothermic cardiorespiratory arrest

Cardiorespiratory arrest due to severe hypothermia may require prolonged cardiopulmonary resuscitation whilst the patient is rewarmed. There are reported cases of successful resuscitation with good neurological outcomes after prolonged arrests and resuscitation up to 9 h. However, in the majority of these cases, extracorporeal life support was used to maintain perfusion and rewarm the patient. Here, we report a case of successful cardiopulmonary resuscitation lasting 6.5 h, following cardiac arrest secondary to severe hypothermia, with rewarming using an Arctic Sun™ 5000. The Arctic Sun 5000 is a targeted temperature management device which is conventionally used to prevent hyperthermia post-cardiac arrest. In this report, we discuss the reasons why the device was used in this case and the effects of severe hypothermia on cardiac arrest management. We believe that this is the longest reported successful cardiopulmonary resuscitation in a severely hypothermic patient without the use of extracorporeal life support.

BS O01 Closure of mesenteric defects during laparoscopic roux-en-y gastric bypass surgery and its effect on internal hernia rates and small bowel obstruction: A Meta- Analysis

Background

Roux-en-Y gastric bypass surgery is an important treatment for obesity and it's related diseases, however internal herniation and small bowel obstruction from mesenteric defects can lead to reoperation in 10–16% of patients. This can be early (<30 days) or late. Routine closure of meso-jejunal defecfs and/or Petersens defect is still not adopted worldwide.

Our objective was to systematically review and analyse pooled data from all studies, evaluating the impact of routine closure of mesenteric defects on the incidence of internal hernia in laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) surgery for obesity. Secondary endpoints for analysis included the incidence of early and late small bowel obstruction (SBO), need for reoperation, bleeding, anastomotic leak, marginal ulceration and weight loss.

Methods

Ovid, MEDLINE, EMBASE and Cochrane databases were searched on 13 September 2021 using a combination of MeSH and non-MeSH terms, including ‘gastric bypass’, ‘mesenteric defect’, ‘hernia’, and ‘small bowel obstruction’. Studies comparing closure with non-closure of mesenteric defects were included. Two researchers independently examined titles, then abstracts, and finally, full text articles. Disagreements were arbitrated with the senior author.

Fixed- or random-effect models were used, as appropriate. Results have been reported with 95% confidence intervals and I-squared indices to assess uniformity among results for each outcome measured.

Results

Seventeen studies met the criteria and were included, including two randomised trials. A total of 61,220 patients were included with follow-up ranging from 24–120 months. In the closure group the incidence of all types of internal hernia was lower (OR 0.22, 95% CI 0.19, 0.26), SBO beyond 30 days was less frequent (OR 0.47, 95% CI 0.44,0.52), and the reoperation rate was lower (OR 0.22, 95% CI 0.19,0.26). The incidence of SBO within 30 days was higher in the closure group (OR 1.34, CI 1.07,1.68).

Conclusions

This new pooled analysis updates previous meta-analyses, adding data from eight additional studies and almost 45,000 additional patients. This provides firm evidence that routine closure of mesenteric defects during laparoscopic gastric bypass reduces rates of internal herniation and SBO beyond the post-operative period. Closure of the mesenteric defects should be standard practice in RYGB. A higher incidence of early SBO was notable in the closure group, postulated by some studies as attributable to technical factors, including kinking of the jejunal anastomosis and bleeding. This must be considered when closing defects.

Total Ankle Replacement Versus Arthrodesis for End-Stage Ankle Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

End-stage ankle osteoarthritis causes severe pain and disability. There are no randomized trials comparing the 2 main surgical treatments: total ankle replacement (TAR) and ankle fusion (AF).

OBJECTIVE

To determine which treatment is superior in terms of clinical scores and adverse events.

DESIGN

A multicenter, parallel-group, open-label randomized trial. (ISRCTN registry number: 60672307).

SETTING

17 National Health Service trusts across the United Kingdom.

PATIENTS

Patients with end-stage ankle osteoarthritis, aged 50 to 85 years, and suitable for either procedure.

INTERVENTION

Patients were randomly assigned to TAR or AF surgical treatment.

MEASUREMENTS

The primary outcome was change in Manchester-Oxford Foot Questionnaire walking/standing (MOXFQ-W/S) domain scores between baseline and 52 weeks after surgery. No blinding was possible.

RESULTS

Between 6 March 2015 and 10 January 2019, a total of 303 patients were randomly assigned; mean age was 68 years, and 71% were men. Twenty-one patients withdrew before surgery, and 281 clinical scores were analyzed. At 52 weeks, the mean MOXFQ-W/S scores improved for both groups. The adjusted difference in the change in MOXFQ-W/S scores from baseline was -5.6 (95% CI, -12.5 to 1.4), showing that TAR improved more than AF, but the difference was not considered clinically or statistically significant. The number of adverse events was similar between groups (109 vs. 104), but there were more wound healing issues in the TAR group and more thromboembolic events and nonunion in the AF group. The symptomatic nonunion rate for AF was 7%. A post hoc analysis suggested superiority of fixed-bearing TAR over AF (-11.1 [CI, -19.3 to -2.9]).

LIMITATION

Only 52-week data; pragmatic design creates heterogeneity of implants and surgical techniques.

CONCLUSION

Both TAR and AF improve MOXFQ-W/S and had similar clinical scores and number of harms. Total ankle replacement had greater wound healing complications and nerve injuries, whereas AF had greater thromboembolism and nonunion, with a symptomatic nonunion rate of 7%.

PRIMARY FUNDING SOURCE

National Institute for Health and Care Research Heath Technology Assessment Programme.

Optimal technique for intraoperative cholangiography (IOC) and are the technique and the findings optimally recorded at our institution?

BACKGROUND

Limited evidence exists describing the optimum protocol for intraoperative cholangiography (IOC) during laparoscopic cholecystectomy (LC). Images saved during surgery often fail to highlight the necessary anatomical landmarks and documentation is variable. Our aim was to identify the key characteristics of an optimal IOC and evaluate current practice at our institution.

METHODS

A literature search identified quality indicators for performing IOC and documenting key findings. A standardised proforma for scoring IOC was developed. Retrospective analysis was conducted of consecutive IOCs performed during elective LC. Visual documentation of seven anatomical landmarks on the captured IOC images and textual reporting in the operation note were assessed.

RESULTS

One hundred IOCs were evaluated. Only 32 (34%) of captured images had all 7 landmarks present. All cases failed to document all seven landmarks. There was a significant difference between landmarks that could be identified on the captured images and their documentation.

CONCLUSIONS

This study suggests that IOC image capture of the key seven landmarks and their textual reporting in this cohort is sub-optimal. We believe IOC technique, minimal data set for reporting and image capture should be standardised to allow better communication of findings and facilitate meaningful comparative research relating to the subject.

Vaccination policy strategies before and during the COVID-19 pandemic: an overview

Background

The debate on vaccination strategies has been periodically involving researchers, policymakers, and also the population. Interest waves have occurred both after a revival of childhood infectious diseases in 2016-2017, due to low vaccine coverages, and during the recent Coronavirus outbreak. This study aimed at overviewing vaccination strategies (and corresponding vaccine coverages) for childhood vaccinations and SARS-CoV-2.

Methods

Measles was chosen as a childhood vaccination indicator. Policy data were retrieved from health institutions (either European or national/regional) and, for COVID-19, also from press agencies and newspaper websites. Vaccine coverage data were retrieved from the World Bank, World Health Organisation, and UNICEF databases (for childhood vaccines), and from the “Our World in Data” platform for SARS-CoV-2. A qualitative comparison was performed between the two contexts.

Results

Unlike childhood vaccinations, few countries (and only Austria in Europe) imposed generalised COVID-19 mandates, most countries preferring targeted mandates for higher-risk groups. Many countries confirmed their traditional voluntary vaccination approach also for COVID-19, while countries historically relying on compulsory vaccination strategies, such as Slovenia and Hungary, surprisingly opted for voluntary SARS-CoV-2 vaccination, with unsatisfactory results. However, no tangible crude association was generally found between vaccination policies and achieved coverages, although factors such as cultural background, education, and religion appeared to influence the impact of vaccination policies.

Conclusions

The COVID-19 experience has enriched pre-existent vaccination strategy debates by adding interesting elements concerning attitudes toward vaccines in a novel context. Reading the available results in the frame of vaccine hesitancy determinants can help to understand the relationship between policies and actual coverages.

Key messages

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

O102 We know about left gastric artery embolisation and will embio provide the next solution to treat obesity?

Introduction

Left gastric artery embolisation (LGAE) is a minimally invasive procedure which has shown promising results for weight loss in recent studies and could play a key role as a treatment option in-between our current tier-3 and tier-4 services. Imperial College NHS Trust will sponsor the EMBIO trial, the first multi-centre double blinded randomised controlled trial comparing LGAE vs Placebo procedure to evaluate its efficacy on weight loss and obesity related comorbidities over a 12 month follow up period. Here, we perform a systematic review of the existing literature.

Methods

9 studies were reviewed. Studies which investigated weight loss as a % +- Ghrelin % change at 3,6 and 12 months were included as these pre-defined time points correlate with the EMBIO protocol. 6 studies met our inclusion criteria, 5 single arm studies and 1 single blinded RCT.

Results

N=62 patients were included in our analysis. Mean weight loss reported was 8.5%, 8.8% and 10% at 3, 6 and 12 months respectively post LGAE. Ghrelin levels reduced by 36%, 16.2% and 16.5% at 3, 6 and 12 months respectively post LGAE. To date, the only reported adverse events recorded include superficial gastric erosions healed on endoscopy by day 90 and one case of subclinical pancreatitis.

Conclusion

LGAE potentially offers a day case procedure under local anaesthesia and sedation to treat obesity and its metabolic complications. The EMBIO trial will provide level 1 evidence to confirm if LGAE is a viable intervention for obesity and evaluate its safety profile.

Take-home message

Left gastric artery embolisation could be the perfect solution to treat obesity in between existing tier-3 and tier-4 treatments.

Heterogeneity of resting-state EEG features in juvenile myoclonic epilepsy and controls

Abnormal EEG features are a hallmark of epilepsy, and abnormal frequency and network features are apparent in EEGs from people with idiopathic generalized epilepsy in both ictal and interictal states. Here, we characterize differences in the resting-state EEG of individuals with juvenile myoclonic epilepsy and assess factors influencing the heterogeneity of EEG features. We collected EEG data from 147 participants with juvenile myoclonic epilepsy through the Biology of Juvenile Myoclonic Epilepsy study. Ninety-five control EEGs were acquired from two independent studies [Chowdhury et al. (2014) and EU-AIMS Longitudinal European Autism Project]. We extracted frequency and functional network-based features from 10 to 20 s epochs of resting-state EEG, including relative power spectral density, peak alpha frequency, network topology measures and brain network ictogenicity: a computational measure of the propensity of networks to generate seizure dynamics. We tested for differences between epilepsy and control EEGs using univariate, multivariable and receiver operating curve analysis. In addition, we explored the heterogeneity of EEG features within and between cohorts by testing for associations with potentially influential factors such as age, sex, epoch length and time, as well as testing for associations with clinical phenotypes including anti-seizure medication, and seizure characteristics in the epilepsy cohort. P-values were corrected for multiple comparisons. Univariate analysis showed significant differences in power spectral density in delta (2-5 Hz) (P = 0.0007, hedges' g = 0.55) and low-alpha (6-9 Hz) (P = 2.9 × 10-8, g = 0.80) frequency bands, peak alpha frequency (P = 0.000007, g = 0.66), functional network mean degree (P = 0.0006, g = 0.48) and brain network ictogenicity (P = 0.00006, g = 0.56) between epilepsy and controls. Since age (P = 0.009) and epoch length (P = 1.7 × 10-8) differed between the two groups and were potential confounders, we controlled for these covariates in multivariable analysis where disparities in EEG features between epilepsy and controls remained. Receiver operating curve analysis showed low-alpha power spectral density was optimal at distinguishing epilepsy from controls, with an area under the curve of 0.72. Lower average normalized clustering coefficient and shorter average normalized path length were associated with poorer seizure control in epilepsy patients. To conclude, individuals with juvenile myoclonic epilepsy have increased power of neural oscillatory activity at low-alpha frequencies, and increased brain network ictogenicity compared with controls, supporting evidence from studies in other epilepsies with considerable external validity. In addition, the impact of confounders on different frequency-based and network-based EEG features observed in this study highlights the need for careful consideration and control of these factors in future EEG research in idiopathic generalized epilepsy particularly for their use as biomarkers.

POS1329 SECONDARY HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A SINGLE-CENTRE EXPERIENCE

Background

Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterised by fever, organomegaly, cytopaenias, activated macrophages in haematopoietic organs and elevated ferritin. Primary HLH is caused by inherited defects in cytolytic pathway proteins and manifests in infancy[1]. Secondary HLH (sHLH) develops in individuals with a genetic susceptibility to hyperinflammation triggered by strongly immunogenic stimulus such as autoimmune conditions, haematological malignancy, organ transplantation or infection[2].

We present a cohort of patients with sHLH and detail their characteristics.

Objectives

To evaluate the characteristics and aetiology of sHLH patients at our Centre.

Methods

A single-centre retrospective observational study of all cases of sHLH between January 2018 and July 2021. Patients were identified from referrals and included if there was a diagnosis of HLH made by a rheumatologist with an H-score of 169 or greater. P-values were calculated using the Mann-Whitney test, unpaired t-test or Fisher exact as appropriate.

Results

30 patients (10 female) with sHLH were identified with a median age of 46, a mean H-score of 238 (range 186-317). 15 (50%) had pre-existing immunosuppression, which did not influence mortality (p=0.26). The following primary drivers were identified: lymphoma (n=8), non-HIV viral infections (n=9), first presentation of HIV/AIDS with opportunistic infections (n=4), Adult-onset Still’s disease (n=4), miliary tuberculosis (n=1), M. falciparum infection (n=1), meningococcal meningitis (n=1), checkpoint inhibitor therapy-related (n=1), and no diagnosis (n=1) - Table 1.

Table 1.

§ = Mann Whitney U test, τ = unpaired t-test, φ = Fisher exact

Total (n=30)Survived (n=18)Died (n=12)p-valueDemographicsMale2010100.78§Female1082Mean age4341470.348§Median H-score2402302540.059 τFerritin (ng/ml)4027734690484040.0949Trilineage cytopenia, n (%)9 (33%)5 (31%)4 (36%)0.28§Subgroup (not mutually exclusive)1 yr survivalLymphoma81712.5% (p=0.0025 φ)HIV/AIDS440100%AOSD440100%Transplant recipient41325%Other viral infection95444%  HSV330100%  CMV110100%  EBV1010%  Yellow fever2020%  Influenza A110100%Tuberculosis32166% with HIV220100%

Non-HIV viral infections were the most common cause overall. 6 of 9 were caused by Herpes virus family and all were primary infections. Two followed yellow fever viraemia following live vaccination and both patients died.

Mortality varied with aetiology. All four patients with AOSD survived, while 7 of 8 with lymphoma died, as per previous reports3. There was a strong association between lymphoma and mortality vs non-lymphoma sHLH (p=0.0025). Four patients post-solid organ transplantation were identified (three liver, one kidney), three with post-transplant lymphoproliferative disorder and one with CMV viraemia (50% mortality).

There was no significant difference between age, ferritin or H-score between surviving and deceased patients (Figure 1), but H-score trended higher in the deceased (p=0.059). Number of treatments given for HLH was higher in the deceased group vs survival (mean 3.41 deceased, mean 2.44 in survived). Anakinra was used in all 30 patients as treatment, including as monotherapy in one patient with HSV viraemia who survived.

Figure 1.

Conclusion

Ferritin, H-score at diagnosis or age do not appear to correlate with mortality in sHLH. Lymphoma is associated with a significantly worse outcome. Poor response to treatment and increasing numbers of treatment options is associated with increased mortality. Causes are varied and often co-exist.

References

[1]Jordan MB et al. An animal model of hemophagocytic lymphohistiocytosis (HLH): CD8+ T cells and interferon gamma are essential for the disorder. Blood. 2004.

[2]Carter SJ et al. Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatments. Rheumatology. 2019.

[3]Parikh SA et al. Prognostic Factors and Outcomes of Adults with Hemophagocytic Lymphohistiocytosis. Mayo Clin Proc. 2014.

Disclosure of Interests

None declared

Diffuse cutaneous systemic sclerosis following SARS-Co V-2 vaccination

The largest world-wide vaccination rollout ever is currently underway to tackle the covid-19 pandemic. We report a case of diffuse cutaneous systemic sclerosis (SSc) in a 70-year-old male with rapidly progressive skin thickening which developed two weeks after receiving the first dose of the ChAdOx1 nCOV-19 vaccine. As the onset of SSc skin was in close temporal proximity to the administration of the first dose vaccine with no other triggers, we suspected a possible adverse reaction to the ChAdOx1 nCOV-19 vaccine. We hypothesise that the recombinant adenoviral vector encoding the spike protein antigen of SARS-CoV-2 triggered an unexpected immune activation resulting in an atypical presentation of late-onset SSc, within the well-recognised ANA positive, ENA negative subgroup of patients.We review the possible mechanisms underlying autoimmunity when provoked by vaccination and other published rheumatological phenomenon occurring shortly after COVID vaccination.

213 Utility of Botox Injection in Early Laparostomy Closure for Abdominal Compartment Syndrome in Acute Severe Pancreatitis – a Case Report

Acute pancreatitis can cause significant visceral oedema due to fluid resuscitation, paralytic ileus and ascites with raised intra-abdominal pressure(IAP) and abdominal compartment syndrome (ACS >20mmHg). Failure of conservative management is an indication for decompressive laparostomy. Early fascial closure is the priority following laparostomy to reduce morbidity, mortality, and the risk of enteric fistulation. Chemical component separation with Botulinum toxin injection is proven to be of benefit prior to elective complex ventral hernia repairs and has been reported in laparostomy closure. We report our use of Botox to assist with vacuum and mesh-assisted early closure of laparostomy in a patient with acute severe pancreatitis.

A 29-year-old male was admitted with severe alcohol induced pancreatitis. He developed acute respiratory distress and was intubated and ventilated. On day 14 of admission, he developed raised IAP of >40mmHg with multiorgan dysfunction and underwent laparostomy and application of Abthera© vacuum assisted negative pressure dressing. 3 days later, the dressing was replaced and a prolene mesh was sutured to the fascial margins to allow approximation of the wound to prevent retraction of the rectus sheath. He underwent further dressing change with trimming of mesh on day 6 and received 300U of Botulinum toxin injection into the abdominal musculature bilaterally. On day 7 following botox injection, the mesh was excised, and the midline wound was closed without tension. He remained stable with normal IAP and no wound related complications. Chemical component separation with Botulinum toxin may be a valuable adjunct in early closure of laparostomy.

Faster than light (microscopy): superiority of digital pathology over microscopy for assessment of immunohistochemistry

AIMS

Digital pathology offers the potential for significant benefits in diagnostic pathology, but currently the efficiency of slide viewing is a barrier to adoption. We hypothesised that presenting digital slides for simultaneous viewing of multiple sections of tissue for comparison, as in those with immunohistochemical panels, would allow pathologists to review cases more quickly.

METHODS

Novel software was developed to view synchronised parallel tissue sections on a digital pathology workstation. Sixteen histopathologists reviewed three liver biopsy cases including an immunohistochemical panel using the digital microscope, and three different liver biopsy cases including an immunohistochemical panel using the light microscope. The order of cases and interface was fully counterbalanced. Time to diagnosis was recorded and mean times are presented as data approximated to a normalised distribution.

RESULTS

Mean time to diagnosis was 4 min 3 s using the digital microscope and 5 min 24 s using the light microscope, saving 1 min 21 s (95% CI 16 s to 2 min 26 s; p=0.02), using the digital microscope. Overall normalised mean time to diagnosis was 85% on the digital pathology workstation compared with 115% on the microscope, a relative reduction of 26%.

CONCLUSIONS

With appropriate interface design, it is quicker to review immunohistochemical slides using a digital microscope than the conventional light microscope, without incurring any major diagnostic errors. As digital pathology becomes more integrated with routine clinical workflow and pathologists increase their experience of the technology, it is anticipated that other tasks will also become more time-efficient.

Vagus nerve stimulation therapy in people with drug-resistant epilepsy (CORE-VNS): rationale and design of a real-world post-market comprehensive outcomes registry

Introduction

The Vagus Nerve Stimulation Therapy System (VNS Therapy) is an adjunctive neuromodulatory therapy that can be efficacious in reducing the frequency and severity of seizures in people with drug-resistant epilepsy (DRE). CORE-VNS aims to examine the long-term safety and clinical outcomes of VNS in people with DRE.

Methods and analysis

The CORE-VNS study is an international, multicentre, prospective, observational, all-comers, post-market registry. People with DRE receiving VNS Therapy for the first time as well as people being reimplanted with VNS Therapy are eligible. Participants have a baseline visit (prior to device implant). They will be followed for a minimum of 36 months and a maximum of 60 months after implant. Analysis endpoints include seizure frequency (average number of events per month), seizure severity (individual-rated categorical outcome including very mild, mild, moderate, severe or very severe) as well as non-seizure outcomes such as adverse events, use of antiseizure medications, use of other non-pharmacological therapies, quality of life, validated measures of quality of sleep (Pittsburgh Sleep Quality Index or Children’s Sleep Habit Questionnaire) and healthcare resource utilisation. While the CORE-VNS registry was not expressly designed to test hypotheses, subgroup analyses and exploratory analysis that require hypothesis testing will be conducted across propensity score matched treatment groups, where possible based on sampling.

Ethics and dissemination

The CORE-VNS registry has already enrolled 823 participants from 61 centres across 15 countries. Once complete, CORE-VNS will represent one of the largest real-world clinical data sets to allow a more comprehensive understanding of the management of DRE with adjunctive VNS. Manuscripts derived from this database will shed important new light on the characteristics of people receiving VNS Therapy; the practical use of VNS across different countries, and factors influencing long-term response.

Trail registration number

NCT03529045.

Development of a heterogeneous phantom to measure range in clinical proton therapy beams

PURPOSE

In particle therapy, determination of range by measurement or calculation can be a significant source of uncertainty. This work investigates the development of a bespoke Range Length Phantom (RaLPh) to allow independent determination of proton range in tissue. This phantom is intended to be used as an audit device.

METHOD

RaLPh was designed to be compact and allows different configurations of tissue substitute slabs, to facilitate measurement of range using radiochromic film. Fourteen RaLPh configurations were tested, using two types of proton fluence optimised water substitutes, two types of bone substitute, and one lung substitute slabs. These were designed to mimic different complex tissue interfaces. Experiments were performed using a 115 MeV mono-energetic scanning proton beam to investigate the proton range for each configuration. Validation of the measured film ranges was performed via Monte Carlo simulations and ionisation chamber measurements. The phantom was then assessed as an audit device, by comparing film measurements with Treatment Planning System (TPS) predicted ranges.

RESULTS

Varying the phantom slab configurations allowed for measurable range differences, and the best combinations of heterogeneous material gave agreement between film and Monte Carlo on average within 0.2% and on average within 0.3% of ionisation chamber measurements. Results against the TPS suggest a material density override is currently required to enable the phantom to be an audit device.

CONCLUSION

This study found that a heterogeneous phantom with radiochromic film can provide range verification as part of a dedicated audit for clinical proton therapy beams.

An updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Introduction

The most common cancers in the UK are keratinocyte cancers (KCs): the combined term for basal cell carcinomas (BCCs) and cutaneous squamous cell carcinomas (cSCCs). Registration of KC is challenging due to high numbers and multiplicity of tumours per person.

Methods

We provide an updated report on the descriptive epidemiology of trends in KC incidence for the resident populations of UK countries (England, Northern Ireland, Scotland and Wales) using population-based cancer registry and pathology report data, 2013-18.

Results

Substantial increases in cSCC incidence in England, Scotland and Northern Ireland can be detected for the period of 2013-18, and the incidence of cSCC also increased in Wales from 2016 to 2018. In contrast, however, the pattern of annual change in the incidence of BCC across the nations differs. In England, the incidence of BCC declined slightly from 2016 to 2018, however, the overall trend across 2013-18 is not statistically significant. In Scotland, the incidence of BCC shows some variability, declining in 2017 before increasing in 2018, and the overall trend across 2013-18 was also not statistically significant. In Northern Ireland, the incidence of BCC increased significantly over the study period, and in Wales, the incidence of BCC increased from 2016 to 2018. One in five people will develop non-melanoma skin cancers (NMSC) in their lifetime in England. This estimate is much higher than the lifetime risk of melanoma (1 in 36 males and 1 in 47 females born after 1960 in the UK), which further highlights the burden of the disease and importance of early prevention strategies.

Conclusions

We highlight how common these tumours are by publishing the first ever lifetime incidence of NMSC. Additionally, the first time reporting of the age standardised incidence of KC in Wales further confirms the scale of the disease burden posed by these cancers in the UK. With approximately one in five people developing NMSC in their lifetime, optimisation of skin cancer prevention, management and research are essential.

EP.TH.955Surgical site Infection prevention Bundle- One Centres Experience

Aim

Surgical Site Infections (SSIs) affects the patient’s recovery following surgery. Within Wales the colorectal SSI rate for both emergency and elective patients is 13%, as per a prospective all Wales observational study. The study further demonstrated that elective colorectal SSI rate was 21.1%. In light of this, a single centre within Wales developed and implemented an SSI bundle to help prevent SSIs.

Methods

A bundle was designed based on the WHO and CDCs guidelines and was agreed on by all colorectal consultants within the centre. There were 3 elements to the bundle – pre-operative, intra-operative and post-operative. The bundle was implemented for 50 elective colorectal patients to assess its feasibility and effectiveness.

Results

50 patients had the SSI bundle from 1 st November to 20 th December 2019. Compliance with the bundle was assessed and the resultant SSI rate improved by 40% with an SSI rate of 20% in this centre reducing to 12%. Further analysis of the SSIs that developed demonstrated that 2 were secondary to intra-abdominal complications and the other 4 failed to have all elements of the bundle implemented.

Conclusion

An SSI bundle can by effectively implemented and become standard care for colorectal patients to effectively reduce the SSI rate.

EP.FRI.537 Post-operative antibiotics for cutaneous abscess after incision and drainage: Variations in Clinical Practice or lack of guidelines

Aims

Acute cutaneous abscess is a common surgical condition which mostly require incision and drainage. Despite this, there is no standardised national or international guidance on the post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice of the post-operative antibiotics prescription for cutaneous abscesses in a University teaching hospital in London.

Methods

A retrospective data collection of emergency general surgical admissions for a period of six months from July to December 2020 was carried out. All patients with superficial skin abscess were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, Co-morbidities, local and systemic complications were studied.

Results

A total of 149 patients presented during this period. Mean age was 40 (54% were male). Most common site of abscess was perianal (24%), followed by pilonidal, axilla, back, gluteal, neck, abdominal wall and groin. At total of 108 (72.5%) were managed surgically with incision and drainage, 70 (65%) got antibiotics and only 23 (33%) had indications for it (i.e. diabetic, immunocompromised, sepsis, cellulitis, MRSA carriage) = (χ2[1] =22.03, p<.0001).

Co-amoxiclav was the most common post-operative empirical antibiotic prescribed in 61% of the patients. 

Conclusions

This study has identified significant variation in clinical practice regarding post-operative antibiotic usage in superficial abscesses. Further research is required in cooperation with microbiologists to develop standardised evidence-based treatment protocol for management of such common surgical condition.  

EP.FRI.535 A clinical audit of post-operative antibiotics prescription in uncomplicated perianal abscesses

Aims

Management of perianal abscesses continues to revolve around prompt surgical drainage. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines state that all patients should have incision and drainage within 24 hours and antibiotics are not indicated in routine uncomplicated perianal abscesses. We aimed to study the antibiotics prescription after surgical drainage in a London university teaching hospital against the national standard. 

Methods

A single-centred retrospective analysis of all emergency surgical admissions for incision and drainage of perianal abscess was carried out for a 6 month period. Patients’ demographics, Co-morbidities, local and systemic complications and readmissions were studied. 

Results

A total of 36 patients, (mean age 43, 64% males) were included in this study, 21 received incision and drainage without antibiotics prescription, while 15 received empirical post-operative antibiotics. Indications for antibiotic therapy in this group included diabetes, immunocompromise, local complications (necrosis, cellulitis) and recurrence. There was no clear indication for antibiotics in 60% of patients who received them. 86% of patients had surgical drainage within 24 hours of presentation. One patient was readmitted for a second drainage 3 months later. Most common empirical agent used was co-amoxiclav (53%), followed by (33%) combination of co-amoxiclav and metronidazole. 

Conclusion

Although surgical drainage was generally carried out in timely manner according to guidance, there was excessive post-operative antibiotic prescriptions. Increase awareness of guidelines is required to improve antibiotic stewardship in these surgical patients in order to avoid unnecessary drugs’ prescription.

1630 Laparoscopic Repair of Linea Arcuata Hernia Presenting as Generalised Abdominal Pain - a Case Report

Background

Arcuate line hernia (LAH) is an abnormal ascending herniation of intraperitoneal structures over the linea arcuate, between the rectus abdominus muscle and the posterior layer of its sheath. It is a rare clinical entity often associated with non-specific abdominal pain, posing a significant diagnostic challenge. The true prevalence is unknown, and diagnosis is almost always radiological.

Case Report

We report the case of a 57-year-old lady investigated extensively for frequent episodes of generalised abdominal pain. No palpable hernial defect or other pathology was identified on clinical examination. Subsequent computed tomography(CT) of the abdomen and pelvis revealed a 95 x 74 mm arcuate line hernia(LAH) anterior to the transversalis fascia, containing small bowel loops. She underwent an elective laparoscopic repair involving closure of the hernial defect with 2-0 knotless barbed sutures and reinforcement with a 20 x 15 cm underlay mesh. Postoperative recovery was uneventful, with complete resolution of her symptoms. One year after the repair there were no signs of recurrence.

Discussion

To our knowledge, only eleven prior cases of symptomatic LAH have been reported in the literature. There is no conclusive evidence regarding most appropriate diagnostic imaging, treatment approach and follow up regimen. Clinical diagnosis is difficult. Existing literature suggests use of CT scan as the primary imaging modality for diagnosis. The laparoscopic approach is safe, feasible and has certain advantages. This includes confirmation of diagnosis, excludes the presence of concomitant hernias and enables inspection of herniated viscera. Prosthetic mesh reinforcement is considered to minimise recurrence. Long term follow-up of these patients is required

A summary of the updated report on the incidence and epidemiological trends of keratinocyte cancers in the United Kingdom 2013-2018

Skin cancer is the commonest cancer in the UK. Skin cancer referrals via the two-week wait (urgent suspected cancer) pathway outnumber any other suspected malignancy.^{1, 2} The commonest skin cancers are keratinocyte cancers (KCs) which represents Basal Cell Carcinomas (BCC) and Cutaneous Squamous Cell Carcinomas (cSCC). Accurate KC incidence reporting is crucial for healthcare planning.

Neutron calorimeter design for pulsed neutron experiment diagnostics

Neutron calorimeter for diagnostic support of both fission- and fusion-based pulsed neutron experiments is described. The calorimeter generates a voltage signal output via a pair of thermocouples contacting a sample material, which experiences a temperature increase due to interactions with an incident neutron fluence. Advantages of the calorimeter include the versatility derived from its small size, modularity, and the variety of employable neutron absorber materials and sizes. These characteristics permit use with neutron energies between the thermal and fast (up to 14 MeV) spectra. Design overview and requirements, Monte Carlo particle transport simulation results, test data, and possibilities for calorimeter development are provided and discussed.

6 Plantar plate repair – a single centre, single procedure case series

Aim

The plantar plate (PP) is an important structure that maintains stability of the metatarsophalangeal joints1 and is commonly injured in athletes such as sprinters and ballet dancers. However, clinical outcomes following plantar plate repair are limited due to the lack of studies and the heterogeneity of surgical procedures.2 This retrospective case series reviews the pre- and post-operative outcomes of a single-procedure PP repair series.

Methods

Patients who underwent PP repair using the Arthrex Complete Plantar Plate Repair System (CPR™) were identified in a single academic hospital centre. Pre- and post-operative outcomes were compared using clinical notes, radiological evaluation and the national podiatry surgery clinical outcomes database (PASCOM-10). Parameters measured included PP rupture grading, congruence, alignment, joint stability and Manchester-Oxford Foot Questionnaire (MOXFQ) scores.

Results

A total of 20 patients with confirmed PP rupture underwent CPR™ procedure with a team comprising 4 surgeons. Post-operative congruence correction was achieved in 95% of patients, whereas average alignment score (range 0–4) improved from 2.7 to 0.5 and joint stability score (range 0–4) from 2.6 to 0.25. MOXFQ functional outcome scores were available for 65% of patients, showing a 42%, 53% and 42% improvement for weightbearing (W/S), pain and social interaction (SI) domains respectively.

Conclusions

This is the first single-centre, single procedure PP repair case series. Objective radiological and clinical measures showed good improvement in the majority of patients. Functional outcome scores were more heterogeneous and limited by incomplete data collection. Our results appear replicable with no difference between surgeons performing the same procedure.

References

Nery C, Coughlin M, Baumfeld D, Raduan F, Mann TS, Catena F. How to classify plantar plate injuries: parameters from history and physical examination. Rev Bras Ortop 2015; 50(6):720–728.

Elmajee M, Shen Z, A’Court J, Pillai A. A Systematic Review of Plantar Plate Repair in the Management of Lesser Metatarsophalangeal Joint Instability. The Journal of Foot & Ankle Surgery 2017; 56(6):1244–1248.