Macro- and micro-genetic environmental sensitivity of yearling weight in Angus beef cattle

Australian beef cattle experience variable conditions, which may give rise to genotype-by-environment interactions depending on the genotypes' macro- and/or micro-genetic environmental sensitivity (GES). Macro-GES gives rise to genotype-by-environment interactions across definable and shared environments, while micro-GES causes heritable variation of phenotypes, e.g., the performance of progeny from one sire may be more variable than other sires. Yearling weight (YW) is a key trait in Australian Angus cattle that may be impacted by both macro- and micro-GES. Current models for genetic evaluation of YW attempt to account for macro-GES by fitting sire-by-herd interactions (S × H). Variation in micro-GES had not yet been estimated for YW in Australian Angus. The aim of this study was to estimate genetic variation due to macro- and micro-GES in YW of Australian Angus cattle. A reaction norm with contemporary group effects as the environmental covariate was fitted either as an alternative to or in combination with a random S × H effect to account for macro-GES. Double hierarchical generalised linear models (DHGLM), fitted as sire models, were used to estimate the genetic variance of the dispersion as a measure of micro-GES. Variation due to both macro- and micro-GES were found in YW. The variance of the slope of the reaction norm was 0.02-0.03 (SEs 0.00), while the S × H variance accounted for 7% of the phenotypic variance in all models. Results showed that both a random S × H effect and a reaction norm should be included to account for both macro-GES and the additional variation captured by an S × H effect. The heritability of the dispersion on the measurement scale ranged from 0.06 to 0.10 (SEs 0.00) depending on which model was used. It should therefore be possible to alter both macro- and micro-GES of YW in Australian Angus through selection. However, care should be taken to ensure an appropriate data structure when including sire-by-herd interactions in the mean part of a DHGLM; otherwise, it can cause biased estimates of micro-GES.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Egg-sensitised infants have elevated CD4+ effector memory T regulatory cells from birth

BACKGROUND

IgE-mediated sensitisation to egg is common in infants. In some cases, the processes leading to egg sensitisation are established in early life, even before introduction to solid foods. The underlying mechanisms remain poorly understood.

METHODS

We performed detailed immune cell phenotyping of peripheral blood mononuclear cells and determined in vitro cytokine responses following allergen specific and non-specific immune stimulation. To determine if unique immune profiles were linked to early-life egg sensitisation, we compared 92 infants at 4-6 months of age, with (EggCAP+, n = 41) and without (EggCAP-, n = 51) early egg sensitisation. Additionally, 47 cord blood samples were analysed. For a subset of participants (n = 39), matching cord blood mononuclear cells were assessed by flow cytometry to establish the impact of IgE sensitisation on immune developmental trajectories.

RESULTS

EggCAP+ infants were found to exhibit a unique immune phenotype characterised by increased levels of circulating CD4+ T regulatory cells (Treg), CD4+ effector memory (EM) Treg and increased expression of the IgE receptor, FcεR1, on basophils. The increased CD4+ EM Treg profiles were already present in cord blood samples from EggCAP+ infants. A general Th2-skewing of the immune system was observed based on increased IL-13 production following phytohemagglutinin stimulation and by comparing immune developmental trajectories, EggCAP+ infants displayed an expansion of basophils and reduced levels of CD4- T cells compared to EggCAP- infants.

CONCLUSIONS

Immunological profiles associated with egg sensitisation are detectable in infant circulation at 4-6 months of age and at birth. Understanding the immune mechanisms underlying early-life sensitisation could provide important insights for future food allergy prevention strategies.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Implementation of a Knowledge Management System in Mental Health and Addictions: Mixed Methods Case Study

BACKGROUND

Mental health and addictions (MHA) care is complex and individualized and requires coordination across providers and areas of care. Knowledge management is an essential facilitator and common challenge in MHA services.

OBJECTIVE

This paper aimed to describe the development of a knowledge management system (KMS) and the associated processes in 1 MHA program. We also aimed to examine the uptake and use, satisfaction, and feedback on implementation among a group of pilot testers.

METHODS

This project was conducted as a continuous quality-improvement initiative. Integrated stakeholder engagement was used to scope the content and design the information architecture to be implemented using a commercially available knowledge management platform. A group of 30 clinical and administrative staff were trained and tested with the KMS over a period of 10 weeks. Feedback was collected via surveys and focus groups. System analytics were used to characterize engagement. The content, design, and full-scale implementation planning of the KMS were refined based on the results.

RESULTS

Satisfaction with accessing the content increased from baseline to after the pilot. Most testers indicated that they would recommend the KMS to a colleague, and satisfaction with KMS functionalities was high. A median of 7 testers was active each week, and testers were active for a median of 4 days over the course of the pilot. Focus group themes included the following: the KMS was a solution to problems for staff members, functionality of the KMS was important, quality content matters, training was helpful and could be improved, and KMS access was required to be easy and barrier free.

CONCLUSIONS

Knowledge management is an ongoing need in MHA services, and KMSs hold promise in addressing this need. Testers in 1 MHA program found a KMS that is easy to use and would recommend it to colleagues. Opportunities to improve implementation and increase uptake were identified. Future research is needed to understand the impact of KMSs on quality of care and organizational efficiency.

Anorexia in Medicare Fee-for-Service Beneficiaries: A Claims-Based Analysis of Epidemiology and Mortality

OBJECTIVES

Loss of appetite in older adults can lead to malnutrition, weight loss, frailty, and death, but little is known about its epidemiology in the United States (US). The objective of this study was to estimate the annual prevalence and incidence of anorexia in older adults with Medicare fee-for-service (FFS) health insurance.

DESIGN

Retrospective and observational analysis of administrative health insurance claims data.

SETTING

This study included Medicare FFS claims from all settings (eg, hospital inpatient/outpatient, office, assisted living facility, skilled nursing facility, hospice, rehabilitation facility, home).

PARTICIPANTS

This study included all individuals aged 65 to 115 years old with continuous Medicare FFS medical coverage (Parts A and/or B) for at least one 12-month period from October 1, 2015, to September 30, 2021 (ie, approximately 30 million individuals each year).

INTERVENTION

Not applicable.

MEASUREMENTS

Anorexia was identified using medical claims with the ICD-10 diagnosis code "R63.0: Anorexia". This study compared individuals with anorexia to a control group without anorexia with respect to demographics, comorbidities using the Charlson Comorbidity Index (CCI), Claims-based Frailty Index (CFI), and annual mortality. The annual prevalence and incidence of anorexia were estimated for each 12-month period from October 1, 2015, to September 30, 2021.

RESULTS

The number of individuals with anorexia ranged from 317,964 to 328,977 per year, a mean annual prevalence rate of 1.1%. The number of individuals newly diagnosed with anorexia ranged from 243,391 to 281,071 per year, a mean annual incidence rate of 0.9%. Individuals with anorexia had a mean (±standard deviation) age of 80.5±8.7 years (vs 74.9±7.5 years without anorexia; p<.001), 64.4% were female (vs 53.8%; p<.001), and 78.4% were White (vs 83.2%; p<.001). The most common CCI comorbidities for those with anorexia were chronic pulmonary disease (39.4%), dementia (38.3%), and peripheral vascular disease (38.0%). Median (interquartile range [IQR]) CCI with anorexia was 4 [5] (vs 1 [3] without anorexia; p<.001). The annual mortality rate among those with anorexia was 22.3% (vs 4.1% without anorexia; relative risk 5.49 [95% confidence interval, 5.45-5.53]).

CONCLUSION

Approximately 1% of all adults aged 65-115 years old with Medicare FFS insurance are diagnosed with anorexia each year based on ICD-10 codes reported in claims. These individuals have a higher comorbidity burden and an increased risk of annual mortality compared to those without a diagnosis of anorexia. Further analyses are needed to better understand the relationship between anorexia, comorbidities, frailty, mortality, and other health outcomes.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Effects of odanacatib on bone-turnover markers in osteoporotic postmenopausal women: a post hoc analysis of the LOFT study

This post hoc analysis and modeling study examined the mechanism of action of odanacatib using a statistical model to explain sCTx response in ODN-treated patients as a function of other bone-turnover biomarkers that, with other observed biomarker changes, showed that odanacatib persistently inhibited osteoclastic bone removal activity without preventing osteoclastogenesis.

INTRODUCTION

Odanacatib (ODN) is an oral selective cathepsin K (CatK) inhibitor, previously in development for osteoporosis treatment. A post hoc analysis examined ODN's mechanism of action on bone-turnover biomarkers.

METHODS

A subset of patients who completed 60 months' treatment in the Long-Term Odanacatib Fracture Trial (LOFT; NCT00529373) (N = 112 [57 ODN, 55 placebo]) were evaluated. Serum (s) and urine (u) samples were assayed at baseline and months 6-60 for 10 known bone-remodeling biomarkers: sCTx, uαα- and uββCTx/Cr, uNTx/Cr, sNTx, uDPD/Cr, sICTP, sTRAP5b, sPINP, and sBSAP. Because the CrossLaps® CTx assay identifies the CTx peptide as well as larger molecular weight CTx-containing peptides, including ICTP, a best-fit model was developed to explain the transient sCTx reduction in ODN-treated patients.

RESULTS

ODN persistently reduced the bone-resorption markers sNTx, uNTx/Cr, uαα- and uββCTx/Cr, and uDPD/Cr, and gradually increased the target-engagement marker sICTP and osteoclast number (sTRAP5b), versus placebo from baseline to month 60. sCTx was transiently reduced with ODN within 12 months, returning to baseline by month 48. Modeling suggested that sCTx changes in the ODN group were primarily due to increased accumulation of larger CTx species, including sICTP. The bone-formation markers sPINP and sBSAP showed partial reductions, versus placebo, in the first 6 months but approached baseline by months 48-60.

CONCLUSION

Observed changes in bone-turnover biomarkers support the persistent efficacy of ODN in direct inhibition of osteoclastic bone-resorption activity, without inhibition of osteoclastogenesis. Long-term evaluation also underscores the unique mechanism of ODN on osteoclastic collagen processing and subsequently osteoblastic bone formation.

TRIAL REGISTRATION

NCT00529373.

Feasibility of Text Messages for Enhancing Therapeutic Engagement Among Youth and Caregivers Initiating Outpatient Mental Health Treatment: Mixed Methods Study

BACKGROUND

Pathways to mental health services for youth are generally complex and often involve numerous contact points and lengthy delays. When starting treatment, there are a host of barriers that contribute to low rates of therapeutic engagement. Automated text messages offer a convenient, low-cost option for information sharing and skill building, and they can potentially activate positive behaviors in youth and caregivers prior to beginning formal therapy. To date, there is little evidence for the feasibility of initiating transdiagnostic text messages during the early stages of youth and caregiver contact with community outpatient mental health services.

OBJECTIVE

To develop and test the feasibility of implementing 2 novel text messaging campaigns aimed at youth clients and their caregivers during the early stages of engaging with outpatient mental health services.

METHODS

A multidisciplinary panel of experts developed two 12-message interventions with youth and caregivers prior to deployment. Each message included a link to an external interactive or multimedia resource to extend skill development. Enrollment of youth aged 13 to 18 years, their caregivers, or both occurred at 2 early treatment timepoints. At both time points, text messages were delivered automatically 2 times a week for 6 weeks. Analytics and survey data were collected in 2 phases, between January and March 2020 and between January and May 2021. Enrollment, willingness to persist in using the intervention, engagement, satisfaction, perceived value, and impact were measured. Descriptive statistics were used to summarize youth and caregiver outcomes.

RESULTS

A total of 41 caregivers and 36 youth consented to participate. Follow-up survey response rates were 54% (22/41) and 44%, (16/36) respectively. Over 1500 text messages were sent throughout the study. More than three-quarters (14/16, 88%) of youth reported that they learned something new and noticed a change in themselves due to receiving the texts; the same proportion (14/16, 88%) of youth said they would recommend the text messages to others. Youth ranked the first text message, related to coping with difficult emotions, as the most helpful of the series. Caregivers reported acting differently due to receiving the texts. Over two-thirds of caregivers were satisfied with the texts (16/22, 73%) and would recommend them to others (16/22, 73%). Caregivers perceived diverse levels of value in the text topics, with 9 of the 12 caregiver texts rated by at least one caregiver as the most helpful.

CONCLUSIONS

Results are preliminary but show that brief, core skill-focused text messages for youth clients and caregivers in community outpatient mental health services are feasible. Both youth and caregivers reported promising knowledge and behavior change with exposure to only 12 messages over 6 weeks. A larger study with statistical power to detect changes in both perceived helpfulness and engagement is required to confirm the effectiveness of this type of transdiagnostic intervention.

Sleep Disordered Breathing and Recurrent Tonsillitis Are Associated With Polymicrobial Bacterial Biofilm Infections Suggesting a Role for Anti-Biofilm Therapies

Background

The underlying pathogenesis of pediatric obstructive sleep disordered breathing (SDB) and recurrent tonsillitis (RT) are poorly understood but need to be elucidated to develop less invasive treatment and prevention strategies.

Methods

Children aged between 1- and 16-years undergoing adenoidectomy, tonsillectomy or adenotonsillectomy for SDB (n=40), RT alone (n=18), or both SDB and RT (SDB+RT) (n=17) were recruited with age-matched healthy controls (n=33). Total bacterial load and species-specific densities of nontypeable Haemophilus influenzae (NTHi), Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae and Moraxella catarrhalis were measured by qPCR in nasopharyngeal swabs, oropharyngeal swabs, adenoid and tonsillar tissue from children with SDB, SDB+RT and RT, and in naso- and oro- pharyngeal swabs from healthy children. A subset of tonsil biopsies were examined for biofilms using 16S rRNA FISH (n=3/group).

Results

The 5 bacterial species were detected in naso- and oro- pharyngeal samples from all children. These species were frequently detected in adenotonsillar tissue (except S. aureus, which was absent in adenoids) from children with SDB, SDB+RT and RT. NTHi and S. aureus were observed in tonsils from 66.7-88.2% and 33.3-58.8% of children respectively. Similar total and species-specific bacterial densities were observed in adenotonsillar tissue from children with SDB, SDB+RT or RT. Nasopharyngeal and oropharyngeal swabs were more likely to have multiple bacterial species co-detected than adenotonsillar tissue where one or two targeted species predominated. Polymicrobial biofilms and intracellular bacteria were observed in tonsils from children with adenotonsillar disease.

Conclusions

Antimicrobials, particularly anti-biofilm therapies, may be a strategy for managing children with SDB.

141 Evaluation of Use of NABCOP Frailty Score and Interprofessional Variety of WHO Performance Score in Breast Cancer Patients Over 70 Years of Age

Aim

There is requirement to assess frailty of older patients with breast cancer as it can influence practice of treatment. In our department the fitness assessment was inconsistent. Therefore, we have decided to conduct qualitative study to evaluate ease of use of NABCOP frailty score (in comparison with other scales) as well as interprofessional variety of WHO performance score.

Method

We have conducted prospective data over 2 weeks period in our busy fast track breast clinic. All new patients over 70 years of age have been identified and asked to perform self-rating assessment. The patient has been later evaluated by NABCOP frailty score and WHO performance score by consultant, nurse, and HCA. This was compared to GP assessment which is part of 2WW referral.

Results

There have been matching results between patient’s self-assessment, clinician, and HCA in majority of patients. HCA perform assessment well with no discrepancy to other physician.

Conclusions

Self-rating and HCA assessment of performance status is accurate and can speed up clinic time. WHO performance scale is found easier and less time consuming by users (and felt provides similar information). We have now provided new assessment system which is undergoing trial in practice at present.

Estimation of macro- and micro-genetic environmental sensitivity in unbalanced datasets

Genotype-by-environment interaction is caused by variation in genetic environmental sensitivity (GES), which can be subdivided into macro- and micro-GES. Macro-GES is genetic sensitivity to macro-environments (definable environments often shared by groups of animals), while micro-GES is genetic sensitivity to micro-environments (individual environments). A combined reaction norm and double hierarchical generalised linear model (RN-DHGLM) allows for simultaneous estimation of base genetic, macro- and micro-GES effects. The accuracy of variance components estimated using a RN-DHGLM has been explicitly studied for balanced data and recommendation of a data size with a minimum of 100 sires with at least 100 offspring each have been made. In the current study, the data size (numbers of sires and progeny) and structure requirements of the RN-DHGLM were investigated for two types of unbalanced datasets. Both datasets had a variable number of offspring per sire, but one dataset also had a variable number of offspring within macro-environments. The accuracy and bias of the estimated macro- and micro-GES effects and the estimated breeding values (EBVs) obtained using the RN-DHGLM depended on the data size. Reasonably accurate and unbiased estimates were obtained with data containing 500 sires with 20 offspring or 100 sires with 50 offspring, regardless of the data structure. Variable progeny group sizes, alone or in combination with an unequal number of offspring within macro-environments, had little impact on the dispersion of the EBVs or the bias and accuracy of variance component estimation, but resulted in lower accuracies of the EBVs. Compared to genetic correlations of zero, a genetic correlation of 0.5 between base genetic, macro- and micro-GES components resulted in a slight decrease in the percentage of replicates that converged out of 100 replicates, but had no effect on the dispersion and accuracy of variance component estimation or the dispersion of the EBVs. The results show that it is possible to apply the RN-DHGLM to unbalanced datasets to obtain estimates of variance due to macro- and micro-GES. Furthermore, the levels of accuracy and bias of variance estimates when analysing macro- and micro-GES simultaneously are determined by average family size, with limited impact from variability in family size and/or cohort size. This creates opportunities for the use of field data from populations with unbalanced data structures when estimating macro- and micro-GES.

Copper transformation, speciation, and detoxification in anoxic and suboxic freshwater sediments

The complex chemistry of copper (Cu) in freshwater sediments at low concentrations is not well understood. We evaluated the transformation processes of Cu added to freshwater sediments under suboxic and anoxic conditions. Freshwater sediments from three sources in Michigan with different characteristics (Spring Creek, River Raisin, and Maple Lake) were spiked with 30 or 60 mg kg^-1 Cu and incubated under a nitrogen atmosphere. After 28-d, each treatment subset was amended with organic matter (OM) to promote anoxic conditions and evaluate its effects on Cu speciation. OM addition triggered a shift from suboxic to anoxic conditions, and sequential extractions showed that Cu accordingly shifted from acid-soluble to oxidizable fractions. Extended X-ray absorption fine-structure (EXAFS) spectroscopy revealed that Cu sulfides dominated all anoxic samples except for Spring Creek 30 mg kg^-1, where Cu(I) was predominantly complexed to thiol groups of OM. Covellite and chalcopyrite (CuFeS₂) were the predominant Cu species in nearly all anoxic samples, as determined by Raman spectroscopy, scanning electron microscopy, and X-ray absorption near-edge structure (XANES) spectroscopy. Copper reduction also occurred under suboxic conditions: for two of three sediments, around 80% had been reduced to Cu(I), while the remaining 20% persisted as Cu(II) complexed to OM. However, in the third coarsest (i.e., Spring Creek), around 50% of the Cu had been reduced, forming Cu(I)-OM complexes, while the remainder was Cu(II)-OM complexes. Toxicity tests showed that survival of H. azteca and D. magna were significantly lower in suboxic treatments. Anoxic sediments triggered a near-complete transformation of Cu to sulfide minerals, reducing its toxicity.

Non-coding RNA in raw and commercially processed milk and putative targets related to growth and immune-response

BACKGROUND

Bovine milk contains extracellular vesicles (EVs) that play a role in cellular communication, acting in either an autocrine, paracrine, or an exocrine manner. The unique properties of the EVs protect the cargo against degradation. We profiled the ncRNAs (non-coding RNA) present in the EVs from seven dairy products - raw whole milk, heat-treated skim milk, homogenized heat-treated skim milk, pasteurized homogenized skim milk, pasteurized heavy whipping cream, sweet cream buttermilk and cultured buttermilk with four replicates each, obtained at different processing steps from a commercial dairy plant. EVs and their cargo were extracted by using a validated commercial kit that has been shown to be efficient and specific for EVs. Further, to find the annotation of ncRNAs, we probed bovine and other organism repositories(such as miRBase, miRTarBase, Ensemble) to find homolog ncRNA annotation in case the annotations of ncRNA are not available in Bos Taurus database.

RESULTS

Specifically, 30 microRNAs (miRNAs), were isolated throughout all the seven milk samples, which later when annotated with their corresponding 1546 putative gene targets have functions associated with immune response and growth and development. This indicates the potential for these ncRNAs to beneficially support mammary health and growth for the cow as well as neonatal gut maturation. The most abundant miRNAs were bta-miR-125a and human homolog miR-718 based on the abundance values of read count obtained from the milk samples.bta-miR-125a is involved in host bacterial and viral immune response, and human homolog miR-718 is involved in the regulation of p53, VEGF, and IGF signaling pathways, respectively. Sixty-two miRNAs were up-regulated and 121 miRNAs were down-regulated throughout all the milk samples when compared to raw whole milk. In addition, our study explored the putative roles of other ncRNAs which included 88 piRNAs (piwi-interacting RNA), 64 antisense RNAs, and 105 lincRNAs (long-intergenic ncRNAs) contained in the bovine exosomes.

CONCLUSION

Together, the results indicate that bovine milk contains significant numbers of ncRNAs with putative regulatory targets associated with immune- and developmental-functions important for neonatal bovine health, and that processing significantly affects the ncRNA expression values; but statistical testing of overall abundance(read counts) of all miRNA samples suggests abundance values aren't much affected. This can be attributed to the breakage of exosomal vesicles during the processing stages. It is worth noting, however, that these gene regulatory targets are putative, and further evidence could be generated through experimental validation.

Treatment threshold for intra-operative hypotension in clinical practice-a prospective cohort study in older patients in the UK

Intra-operative hypotension frequently complicates anaesthesia in older patients and is implicated in peri-operative organ hypoperfusion and injury. The prevalence and corresponding treatment thresholds of hypotension are incompletely described in the UK. This study aimed to identify prevalence of intra-operative hypotension and its treatment thresholds in UK practice. Patients aged ≥ 65 years were studied prospectively from 196 UK hospitals within a 48-hour timeframe. The primary outcome was the incidence of hypotension (mean arterial pressure <65 mmHg; systolic blood pressure reduction >20%; systolic blood pressure <100 mmHg). Secondary outcomes included the treatment blood pressure threshold for vasopressors; incidence of acute kidney injury; myocardial injury; stroke; and in-hospital mortality. Additionally, anaesthetists providing care for included patients were asked to complete a survey assessing their intended treatment thresholds for hypotension. Data were collected from 4750 patients. Hypotension affected 61.0% of patients when defined as mean arterial pressure <65 mmHg, 91.3% of patients had >20% reduction in systolic blood pressure from baseline and 77.5% systolic blood pressure <100 mmHg. The mean (SD) blood pressure triggering vasopressor therapy was mean arterial pressure 64.2 (11.6) mmHg and the mean (SD) stated intended treatment threshold from the survey was mean arterial pressure 60.6 (9.7) mmHg. A composite adverse outcome of myocardial injury, kidney injury, stroke or death affected 345 patients (7.3%). In this representative sample of UK peri-operative practice, the majority of older patients experienced intra-operative hypotension and treatment was delivered below suggested thresholds. This highlights both potential for intra-operative organ injury and substantial opportunity for improving treatment of intra-operative hypotension.

Bacterial communities in the rumen and feces of lactating Holstein dairy cows are not affected when fed reduced-fat dried distillers' grains with solubles

Reduced-fat dried distillers' grains with solubles (RF-DDGSs) are co-products of ethanol production and contain less fat than traditional distillers' grains. The fat in corn is ~91% unsaturated, and it is toxic to rumen microorganisms so it could influence the composition of the rumen microbiome. It has been demonstrated that RF-DDGS is a suitable ration ingredient to support the high-producing dairy cow, and this feedstuff is a promising alternative protein source for lactating dairy cows. The current study aims to better understand the effect of RF-DDGS on the rumen and fecal bacterial composition in lactating dairy cows. Thirty-six multiparous (two or three), mid-lactation Holstein cows (BW = 680 ± 11 kg; 106 ± 27 DIM) were randomly assigned to two groups which were fed a control diet made up of corn, corn silage, and alfalfa hay supplemented with expeller soybean meal or with added RF-DDGS (20% of the DM) containing approximately 6.0% fat. Whole rumen contents (rumen fluid and digesta; esophageal tubing method) and feces (free-catch method) were collected on day 35 of the experimental period, after the 14-d acclimation period. Rumen contents and feces from each cow were used for DNA extraction. The bacterial community composition in rumen and fecal samples was assessed via the 16S rRNA gene by using the Illumina MiSeq sequencing platform. Bacteroidetes, Actinobacteria, and Firmicutes were the most abundant phyla in rumen contents. The fecal microbiota was dominated by the phyla Firmicutes and Bacteroidetes, as well as Actinobacteria and Chloroflexi. RF-DGGS increased bacterial richness, evenness, and Shannon diversity in both rumen and fecal samples and was associated with several taxa that had different abundance in treatment versus control comparisons. The RF-DGGS, however, did not significantly alter the bacterial community in the rumen or feces. In general, these findings demonstrated that dietary inclusion of RF-DDGS did not impose any serious short-term (within 30 days) health or production consequences, as would be expected. With this study, we present further evidence that inclusion of 20% (DM basis) RF-DDGS in the diet of lactating dairy cows can be done without consequence on the microbiome of the rumen.

Trialling a novel socially-distanced teaching approach for OMFS dental core trainees: case-based discussions through WhatsApp©

In our tertiary level centre, the oral and maxillofacial (OMFS) rotas often change at short- notice due to service requirements and the development of guidance relating to the COVID-19 pandemic. Consequently, we have developed a novel teaching method for our dental core trainees (DCTs) to accommodate hectic schedules and conflicting availability between junior and senior staff. Here, we describe the innovative teaching approach we have established using case-based discussions via WhatsApp©. Feedback has been excellent. Respondents have stated that the most useful aspect is flexibility to participate in between tasks and across multiple sites, and 87% stated that they use the searchable summaries when managing patients. This teaching method is highly beneficial for OMFS DCTs. It allows flexibility for fluctuating schedules, is interactive, and provides an easily accessible resource whilst on call. We believe that other teams may benefit from the method if scheduling the time for regular didactic teaching is difficult, or they wish to supplement existing practices.

Autoantibody profiles are associated with specific clinical features in psychotic disorders

Introduction

Immune system abnormalities exist across a range of psychiatric disorders. Autoimmunity, characterized by the production of antibodies against the body’s own antigens, is a feature of immune system dysfunction and could play a role in mental disorder pathophysiology. Better understanding of the associations of auto-immunoglobulin G (IgG) repertoires with clinical features of mental illness could yield novel models of psychosis pathophysiology and markers for biological patient stratification.

Objectives

To undertake global screening for auto-IgG expression in a large cohort of people with psychotic disorders; to determine whether associations exist between autoantibody expression and clinical features.

Methods

Cross-sectional quantification of auto-IgGs in blood plasma of 461 people with established psychotic disorder diagnoses. For global screening, pooled samples of phenotypically representative patient groups were exposed to planar protein microarrays containing 42,000 human antigens. For targeted profiling, expression levels of 380 autoantibodies were quantified by suspension bead array (SBA) in each patient’s plasma.

Results

We identified highly individual autoantibody profiles with no evidence for co-expression patterns. We found 6 autoantibodies robustly associated with specific psychopathology: anti-AP3B2, detected in 5% of the cohort of whom 100% had persecutory delusions; anti-TDO2 (5% of the cohort, 100% hallucinations); anti-CRYGN (4%, 86% initial insomnia); anti-APMAP (3%, 86% poor appetite); anti-OLFM1 (2.5%, 100% above median cognitive function); and anti-WHAMMP3 (2%, 90% anhedonia and dysphoria). Examination of the auto-IgG binding site on the TDO2 protein revealed a putative pathophysiological mechanism involving the kynurenine pathway.

Conclusions

We identified 6 frequently occurring autoantibodies that were associated with specific clinical features in people with psychotic disorders.

Disclosure

No significant relationships.

Simulations of argon plasma decay in a thermionic converter

The dynamics of an argon plasma in the gap of a thermionic diode is investigated using particle-in-cell (PIC) simulations. The time-averaged diode current, as a function of the relative electrical potential between the electrodes, is studied while the plasma density depletes due to recombination on the electrode surfaces. Simulations were performed in both one and two dimensions, and significant differences were observed in the plasma decay between the two cases. Specifically, in two dimensions it was found that the electrostatic potential gradually changes as the plasma decays, while in one dimension fluctuations in the plasma led to large potential fluctuations which changed the plasma decay characteristics relative to the two-dimensional case. This creates significant differences in the time-averaged diode current. Furthermore, it was found that the maximum time-averaged current is collected when the diode voltage is set to the flat-band condition, where the cathode and anode vacuum biases are equal. This suggests a novel technique of measuring the difference in work functions between the cathode and anode in a thermionic converter.

Text Message Interventions in Adolescent Mental Health and Addiction Services: Scoping Review

BACKGROUND

The vast majority of adolescent mental health and substance use disorders go undiagnosed and undertreated. SMS text messaging is increasingly used as a method to deliver adolescent health services that promote psychological well-being and aim to protect adolescents from adverse experiences and risk factors critical for their current and future mental health. To date, there has been no comprehensive synthesis of the existing literature on the extent, range, and implementation contexts of these SMS text message interventions.

OBJECTIVE

The objective of this scoping review was to map and categorize gaps in the current body of peer-reviewed research around the use of SMS text messaging-based interventions for mental health and addiction services among adolescents.

METHODS

A scoping review was conducted according to Levac's adaptation of Arksey and O'Malley's methodological framework for scoping reviews in six iterative stages. A search strategy was cocreated and adapted for five unique databases. Studies were screened using Covidence software. The PICO (patient, intervention, comparator, outcome) framework and input from multiple stakeholder groups were used to structure and pilot a data extraction codebook. Data were extracted on study methodology and measures, intervention design, and implementation characteristics, as well as policy, practice, and research implications.

RESULTS

We screened 1142 abstracts. Of these, 31 articles published between 2013 and 2020 were eligible for inclusion. Intervention engagement was the most common type of outcome measured (18/31), followed by changes in cognitions (16/31; eg, disease knowledge, self-awareness) and acceptability (16/31). Interventions were typically delivered in less than 12 weeks, and adolescents received 1-3 messages per week. Bidirectional messaging was involved in 65% (20/31) of the studies. Limited descriptions of implementation features (eg, cost, policy implications, technology performance) were reported.

CONCLUSIONS

The use of SMS text messaging interventions is a rapidly expanding area of research. However, lack of large-scale controlled trials and theoretically driven intervention designs limits generalizability. Significant gaps in the literature were observed in relation to implementation considerations, cost, clinical workflow, bidirectionality of texting, and level of personalization and tailoring of the interventions. Given the growth of mobile phone-based interventions for this population, a rigorous program of large-scale, well-designed trials is urgently required.

Feeding lambs proportional mixtures of lucerne (Medicago sativa) and forage brassica (Brassica napus) grown under warm and dry conditions

Context Metabolisable energy (ME) and crude protein (CP) concentrations of forages are key determinants of lamb performance during pasture-based finishing. However, forage species often have unbalanced proportions of ME and CP, which can lead to below-optimum performance of lambs. This may be a problem with maturing lucerne (Medicago sativa L.) swards during dry summer conditions, and is a major challenge faced by grazing industries in Mediterranean environments. Aim We investigated whether two summer forages, lucerne and forage brassica (Brassica napus L. cv. Winfred), with differing ME and CP concentration could improve the growth of maternal-composite lambs when offered in mixtures compared with either forage fed alone. Methods A randomised complete block experiment with five treatments and 10 replicate animals per treatment was conducted in an animal house at Hamilton, Victoria, from February to March 2014. The treatments were 100% lucerne, 75% lucerne : 25% brassica, 50% lucerne : 50% brassica, 25% lucerne : 75% brassica, and 100% brassica on a dry-matter basis and fed to lambs. The lucerne and brassica were harvested daily and chopped to ~3 cm length before mixing and feeding. The lambs were adapted for 4 weeks before the start of the experimental phase. Key results Fasted liveweight gain of lambs increased linearly with an increasing proportion of brassica and a decreasing proportion of lucerne in the diet; no mixture performed better than brassica alone. Conclusions Under the warm and dry conditions of this experiment, the ME of lucerne was more limiting to lamb growth than its CP concentration. Implications The results suggest that a small increase in ME supply could improve the performance of lambs grazing a maturing lucerne sward during dry summer conditions. Further research is warranted into improving lamb growth and feed efficiency from lush lucerne and brassica forages.

Genetic Consequences of the Transatlantic Slave Trade in the Americas

According to historical records of transatlantic slavery, traders forcibly deported an estimated 12.5 million people from ports along the Atlantic coastline of Africa between the 16th and 19th centuries, with global impacts reaching to the present day, more than a century and a half after slavery's abolition. Such records have fueled a broad understanding of the forced migration from Africa to the Americas yet remain underexplored in concert with genetic data. Here, we analyzed genotype array data from 50,281 research participants, which-combined with historical shipping documents-illustrate that the current genetic landscape of the Americas is largely concordant with expectations derived from documentation of slave voyages. For instance, genetic connections between people in slave trading regions of Africa and disembarkation regions of the Americas generally mirror the proportion of individuals forcibly moved between those regions. While some discordances can be explained by additional records of deportations within the Americas, other discordances yield insights into variable survival rates and timing of arrival of enslaved people from specific regions of Africa. Furthermore, the greater contribution of African women to the gene pool compared to African men varies across the Americas, consistent with literature documenting regional differences in slavery practices. This investigation of the transatlantic slave trade, which is broad in scope in terms of both datasets and analyses, establishes genetic links between individuals in the Americas and populations across Atlantic Africa, yielding a more comprehensive understanding of the African roots of peoples of the Americas.

AB1173 RHEUMATOLOGIST CARE IS ASSOCIATED WITH FEWER EMERGENCY ROOM VISITS BY PERSONS WITH GOUT

Background:

Gout is one of the most common inflammatory arthropathies. By searching a large administrative data base (Symphony Integrated Dataverse), we found that persons with acute gout see a rheumatologist infrequently, whereas less than 50% of advanced gout patients are seen by a rheumatologist. Notably, however, gout patients seen by rheumatologists have more frequent urate measurements and are prescribed urate lowering therapy more frequently. This study sought to determine whether involvement of a rheumatologist in gout care had a positive impact on health outcomes

Objectives:

To determine whether involvement of a rheumatologist had a positive impact on health outcomes of patients with gout.

Methods:

We carried out a retrospective analysis to identify persons with gout over an approximately 3-year period from October 2015 to December 2018. This study used data from the Truven Marketscan®database, an administrative database covering over 190 million patients across the United States and based on fully adjudicated and paid insurance claims. Patients were identified as having gout if they were >18 years of age and had at least two medical claims for the diagnosis of gout on different days, separated by at least 3 months. Patients with acute gout were identified by ICD-10 code M10.*, chronic nontophaceous gout (M1A.***0), tophaceous gout (M1A.***1) and uncontrolled gout (M10.*, M1A.*), the latter manifested by three gout codes (any) in the primary diagnosis position and three urate measurements within the same calendar year. Particular attention was placed on Emergency Room (ER) visits by individuals in each category and by individuals who had been evaluated by a rheumatologist.

Results:

We identified 284,877 gout patients. The median age was 59.2 years and 79.0% were male. Of the 230,998 persons coded as acute gout, 10.7% were seen by a rheumatologist, whereas 26.9% of the 32,942 coded as chronic nontophaceous gout, 47.2% of the 7,723 coded as tophaceous gout and 43.6% of the13,514 coded as uncontrolled gout were seen by a rheumatologist. In each gout category, the frequency of ER visits was significantly reduced in persons who had been seen by a rheumatologist (Table 1). In acute gout, the frequencies of ER visits in those with and without rheumatologist care were 5.6% vs 6.6% (p<0.001), respectively. In chronic nontophaceous gout it was 5.5% vs 6.7% (p=0.001); in tophaceous gout it was 10.3% vs 14.7% (p<0.001); and in uncontrolled gout it was 12.8% vs 19.0%, respectively. If the frequencies of rheumatologist-associated gout patient ER visits were applied to all gout subjects, there would have been 3,088 less ER visits in this cohort of gout patients.

Table 1.Rheumatology BreakdownEmergency Room VisitsPopulationOverall NW/ RheumatologyPatients%With Gout ER Visit (%)p-value (comparing %)ER Visits* Per PatientAcute Gout230,698Yes24,63810.68%1373 (5.57%)<0.0011.47No206,06089.32%13632 (6.62%)1.53Non-Tophaceous Chronic32,942Yes8,86326.90%486 (5.48%)<0.0011.95No24,07973.10%1601 (6.65%)2.39Tophaceous Chronic7,723Yes3,64847.24%376 (10.31%)<0.0012.78No4,07552.76%597 (14.65%)2.89Uncontrolled13,514Yes5,88643.55%753 (12.79%)<0.0012.06No7,62856.45%1452 (19.04%)2.56

* ER Visits are only included in this analysis if the primary diagnosis code on the claim is a gout code (M10.X, M1A.X)

Conclusion:

There appears to be a positive impact of rheumatologist involvement in the care of gout patients, manifested by a significant decrease in the frequency of ER visits. Considering the inconvenience and cost of ER visits, rheumatologist care may have a significant impact on the well-being of gout patients and on the overall cost of their care.

Disclosure of Interests:

Naomi Schlesinger Grant/research support from: Pfizer, Amgen, Consultant of: Novartis, Horizon Therapeutics, Selecta Biosciences, Olatec, IFM Therapeutics, Mallinckrodt Pharmaceuticals, N. Lawrence Edwards Consultant of: Horizon Therapeutics, Takeda Pharmaceuticals US, Aclaris Therapeutics, Atom Biosciences, Sanders Clark: None declared, Peter Lipsky Consultant of: Horizon Therapeutics

Giant solitary fibrous tumour: an uncommon approach for an uncommon tumour

Complete surgical resection of a giant solitary fibrous tumour of the pleura can be challenging. We describe our technique for dealing with one such tumour. A clamshell incision proved inadequate for visualising the extent of the tumour. An additional lower sternotomy incision was then made, which significantly improved exposure. With the aid of cardiopulmonary bypass, it was then possible to mobilise and completely excise the tumour. Complete resection remains the mainstay of treatment for such pleural-based tumours. Every attempt must be made to achieve this, including any modification of the traditional approach if required.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Frailty and hospital outcomes within a low socioeconomic population

BACKGROUND

Clinical frailty scales (CFS) predict hospital-related outcomes. Frailty is more common in areas of higher socioeconomic disadvantage, but no studies exclusively report on the impact of CFS on hospital-related outcomes in areas of known socioeconomic disadvantage.

AIMS

To evaluate the association of the CFS with hospital-related outcomes.

DESIGN

Retrospective observational study in a community hospital within a disadvantaged area in Australia (Social Economic Index for Areas = 0.1%).

METHODS

The CFS was used in the emergency department (ED) for people aged ≥ 75 years. Frailty was defined as a score of ≥4. Associations between the CFS and mortality, admission rates, ED presentations and length of stay (LOS) were analysed using regression analyses.

RESULTS

Between 11 July 2017 and 31 March 2018, there were 5151 ED presentations involving 3258 patients aged ≥ 75 years. Frail persons were significantly more likely to be older, represent to the ED and have delirium compared with non-frail persons. CFS was independently associated with 28-day mortality, with odds of mortality increasing by 1.5 times per unit increase in CFS (95% CI: 1.3-1.7). Frail persons with CFS 4-6 were more likely to be admitted (OR: 1.2; 95% CI: 1.0-1.5), have higher geometric mean LOS (1.43; 95% CI 1.15-1.77 days) and higher rates of ED presentations (IRR: 1.12; 95% CI 1.04-1.21) compared with non-frail persons.

CONCLUSIONS

The CFS predicts community hospital-related outcomes in frail persons within a socioeconomic disadvantage area. Future intervention and allocation of resources could consider focusing on CFS 4-6 as a priority for frail persons within a community hospital setting.

Oral propranolol in the treatment of proliferating infantile haemangiomas: British Society for Paediatric Dermatology consensus guidelines

BACKGROUND

Infantile haemangiomas (IH) are the most common vascular tumours of infancy. Despite their frequency and potential complications, there are currently no unified U.K. guidelines for the treatment of IH with propranolol. There are still uncertainties and diverse opinions regarding indications, pretreatment investigations, its use in PHACES (posterior fossa malformations-haemangiomas-arterial anomalies-cardiac defects-eye abnormalities-sternal cleft and supraumbilical raphe) syndrome and cessation of treatment.

OBJECTIVES

To provide unified guidelines for the treatment of IH with propranolol.

METHODS

This study used a modified Delphi technique, which involved an international treatment survey, a systematic evidence review of the literature, a face-to-face multidisciplinary panel meeting and anonymous voting.

RESULTS

The expert panel achieved consensus on 47 statements in eight categories, including indications and contraindications for starting propranolol, pretreatment investigations, starting and target dose, monitoring of adverse effects, the use of propranolol in PHACES syndrome and how to stop treatment.

CONCLUSIONS

These consensus guidelines will help to standardize and simplify the treatment of IH with oral propranolol across the U.K. and assist in clinical decision-making.

The LAPLAP study: a randomized placebo-controlled clinical trial assessing postoperative functional recovery using intraperitoneal local anaesthetic in laparoscopic colorectal surgery

AIM

Postoperative pain remains a major factor in recovery from colorectal resection. There is increasing interest in opioid-sparing analgesia, and intraperitoneal local anaesthetic (IPLA) has recently been shown to be useful in minor laparoscopic and open colorectal procedures. The aim of this study was to evaluate the impact of IPLA on functional recovery following major laparoscopic surgery. In this controlled trial, mobility, as measured by the De Morton Mobility Index (DEMMI), was used as a surrogate for postoperative functional recovery.

METHOD

Patients undergoing laparoscopic colorectal resection were randomized either to continuous ropivacaine (0.2% at 4-6 ml/h) or to saline (0.9%) which were administered via intraperitoneal catheter for 3 days postoperatively. Results were analysed in a double-blind manner. DEMMIs were assessed on postoperative days 1, 2, 3, 7 and 30, and data on pain, opioid consumption, gut and respiratory function, length of stay (LOS) and complications were recorded.

RESULTS

Ninety-six patients were recruited. There was no difference in primary outcome (i.e., functional recovery) between IPLA and placebo groups. Opioid consumption and LOS were similar between groups, and no differences were found for any secondary outcome measure. There were no adverse events related to ropivacaine.

CONCLUSION

Infusional intraperitoneal local anaesthetic appears to be safe but does not improve functional recovery or analgesic consumption following elective laparoscopic colorectal surgery, in the setting of an established enhanced recovery programme.