341 Is CT Imaging Mandated for Confirming the Diagnosis of Acute Appendicitis in Patients Over the Age of 40?

Aim

Acute appendicitis remains a largely clinical diagnosis, with clinical scoring systems such as the Alvarado score calculated to give a quantitative assessment of the diagnostic probability. It remains common practice amongst surgeons to rely on CT scanning to confirm the diagnosis however, especially in older patients. Our aim was to assess the diagnostic performance of CT scanning compared with that of the Alvarado score in patients aged over 40 years old.

Method

We conducted a retrospective observational study of 149 patients greater than 40 years old who had a diagnosis of acute appendicitis and had undergone an appendicectomy with subsequent histological analysis. Data was extracted from patients’ electronic medical records. This was recorded in Microsoft Excel and analysed using NCSS.

Results

When using an Alvarado score cut-off point of ≥7, the sensitivity and specificity were 44.1% and 60.0% respectively. The sensitivity of the test improved to 80.3% when using a cut-off point of ≥ 5, however the specificity decreased to 50%. The accuracy improved to 78.1% from 45.3%, when using ≥ 5 as a cut-off point. On the other hand, the sensitivity of the CT scan was 84.9% and the specificity was 45.5%. The accuracy of CT scanning was 81.8%.

Conclusions

When comparing performance, pre-operative CT scanning did not show a statistically significant improvement in the diagnosis of acute appendicitis relative to Alvarado score. We recommend using an Alvarado score cut-off point of ≥ 5 to aid in diagnosing appendicitis in patients older than 40, as it accounts for a higher sensitivity.

A26 DECONSTRUCTING DISTRESS: STAKEHOLDER ENGAGEMENT FOR EVIDENCE-BASED, PATIENT-CENTERED INTERVENTIONS FOR THE MANAGEMENT OF IBD-ASSOCIATED PSYCHOLOGICAL DISTRESS

Background

The growing prevalence of Inflammatory Bowel Disease (IBD) along with increasing complexity of providing high-quality, patient-centered care within a resource-constrained healthcare environment presents a major challenge. IBD-related psychological distress (IBD-PD) is the emotional impact of IBD and is associated with mental health disorders, increased disease severity, and premature mortality. With estimates of nearly 90% of IBD patients experiencing PD, the inability to provide high-quality, person-centered care for IBD-PD that is proportionate to clinical need is a significant care gap in the Canadian healthcare system.

Aims

To generate stakeholder-derived data to inform the design and development of stepped-intensity, cognitive behavioral therapy-based interventions for IBD-PD using evidence-based, patient–centered interventions and implementation strategies.

Methods

Virtual semi-structured interviews were conducted from September to October 2021. The interview guide was developed iteratively by researchers, IBD care providers, and patient research partners and guided by the COM-B Model of Behaviour and the Theoretical Domains Framework. Questions assessed perceptions, experiences, barriers, and facilitators to accessing IBD-PD care. Adults diagnosed with IBD were recruited from academic centers across Canada. Interviews were co-facilitated by a researcher and patient research partner, audio recorded, and transcribed. Using thematic analysis, codes were generated to identify themes using an inductive approach.

Results

As of October 2021, six interviews have been completed, with data collection ongoing. The mean participant age was 34.3 years (range 21–55 years) with 100% of respondents being female. The majority of participants worked full time (4/6, 67%) and all had completed at least high school. Diagnoses of Crohn’s Disease (3/6, 50%) and ulcerative colitis (3/6, 50%) were evenly distributed. Thematic analyses identified five major themes: 1) Lack of holistic care and acknowledgement of IBD-PD; 2) System-level and financial barriers to psychological support; 3) Lack of psychological support from providers with an understanding of IBD; 4) Preference for individualized virtual-based support; 5) Heavy reliance on informal support structures (caregivers) due to lack of access to formal psychological support.

Conclusions

As part of human-centered design, stakeholder engagement is key to understanding behavioral, social, attitudinal, and environmental barriers and facilitators for accessing IBD-PD care. Interviews are ongoing and specific intervention functions will be defined and incorporated into patient-centered implementation strategies.

Funding Agencies

None

244 Does Direct Admission to ICU In Emergency Laparotomy Patients with A NELA Score ≥ 10% Affect Outcome at Fiona Stanley Hospital?

Introduction

The Australian and New Zealand Emergency Laparotomy Audit (ANZELA) is a quality improvement project based on UK NELA. Direct admission to ICU post-operatively for patients with a NELA ≥ 10% is recommended. In the current pandemic, the use of critical care beds must be rationalised. We investigated if patients with NELA ≥ 10% experienced worse outcomes if admitted to the ward post-operatively (instead of ICU).

Method

We performed a retrospective audit of emergency laparotomies at Fiona Stanley Hospital over 6 months December 2019 – May 2020. NELA scores were obtained from the ANZELA database and patient notes reviewed to identify post-operative unplanned ICU admissions and mortalities.

Results

Twenty-four (30%) emergency laparotomy patients had a NELA ≥ 10%. Ten (42%) patients were admitted to the ward post-operatively. There were no unplanned ICU admissions in this group. Two (20%) patients had a documented ‘code blue’ but were managed conservatively on the ward. No patients in this group died within 30 days.

Conclusions

Post-operative ward admission in selected patients with NELA ≥ 10% does not result in unplanned ICU admissions or increased mortality at a tertiary Acute Surgical Unit. This data is reassuring as we expect future ICU bed shortages for non-COVID surgical patients during the pandemic.

A175 BEHAVIORAL INTERVENTIONS TO ADDRESS INFLAMMATORY BOWEL DISEASE-RELATED DISTRESS AND QUALITY OF LIFE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Inflammatory bowel disease-associated psychological distress (IBD-PD) (inclusive of anxiety, depression, and high levels of stress) is prevalent amongst persons living with IBD. IBD-PD impairs quality of life (QoL) and worsens disease outcomes. Research relating to the efficacy of behavioral interventions for IBD-PD has been limited.

Aims

This systematic review and meta-analysis was conducted to evaluate the efficacy of cognitive behavioral therapy (CBT)-based interventions for the management of IBD-PD and QoL in persons living with IBD.

Methods

Pre-defined criteria were used to identify randomized controlled studies reporting on the efficacy of CBT-based interventions for IBD-PD and QoL in adults living with IBD. Electronic databases including CINAHL, Cochrane Library, Embase, MEDLINE, PsycArticles, PsycInfo, Pubmed, and Web of Science were searched from inception to May 30, 2020. Studies published in English or French were included. Risk of bias was assessed using the Cochrane risk-of-bias tool by two independent reviewers (CH and MRF). Data was extracted and summarized qualitatively. A random-effects model was used to generate pooled estimates.

Results

Eight studies (922 participants) met criteria for inclusion in this review. The studies evaluated outcomes of quality of life and IBD-PD using the IBD Questionnaire (IBDQ), United Kingdom IBDQ, Short IBSQ, 36-Item Short Form Survey (SF-36), Short Health Scale, Perceived Stress Questionnaire (PSQ), Perceived Stress Scale (PSS-10), Hospital anxiety depression scale (HADS) and the Depression, Anxiety and Stress Scale-21 Items (DASS-21). Of the 8 studies, 2 were low, 2 high, and 4 at intermediate risk of bias. Interventions, duration, and outcome assessments differed across studies and observed attrition rates were high. The pooled odds ratio for the short-term impact of CBT on IBDQ (n=3) was 0.30 (95% CI 0.17- 0.44) favoring CBT. Perceived stress (PSQ and PSS-10) were only reported in 3 studies as secondary outcomes. Overall, CBT had no observed benefit for perceived stress. Measurement of anxiety and depression was inconsistent across studies. The impact of CBT on anxiety and depression varied with studies revealing both neutral and positive results.

Conclusions

In patients IBD-PD, CBT-based interventions were observed to lead to short-term improvements in disease-related QoL. The impact of CBT on IBD-PD remains unclear due to limitations in study quality and heterogeneity in study design. Further studies are needed to evaluate the efficacy of CBT-based interventions for IBD-PD and to define the role of behavioral interventions delivered within the context of collaborative, biopsychosocial models of care. Expert consensus on best practice for CBT-based interventions and IBD-PD evaluation are needed.

Funding Agencies

None

Husk to caryopsis adhesion in barley is influenced by pre- and post-anthesis temperatures through changes in a cuticular cementing layer on the caryopsis

BACKGROUND

At ripeness, the outer husk of "covered" barley grains firmly adheres to the underlying caryopsis. A cuticular cementing layer on the caryopsis is required for husk adhesion, however the quality of adhesion varies significantly among cultivars which produce the cementing layer, resulting in the economically important malting defect, grain skinning. The composition of the cementing layer, and grain organ development have been hypothesised to influence the quality of husk adhesion. Plants of Hordeum vulgare 'Concerto' were grown at different temperatures pre- and post-anthesis to effect changes in the development of the husk, caryopsis and cuticular cementing layer, to determine how these variables influence the quality of husk-to-caryopsis adhesion.

RESULTS

Warm conditions pre-anthesis decreased the quality of husk adhesion, and consequently increased the incidence of grain skinning. Cool post-anthesis conditions further decreased the quality of husk adhesion. The composition of the cementing layer, rather than its structure, differed with respect to husk adhesion quality. This cementing layer was produced at the late milk stage, occurring between nine and 29 days post-anthesis, conditional on the temperature-dependent growth rate. The compounds octadecanol, tritriacontane, campesterol and β-sitosterol were most abundant in caryopses with high-quality husk adhesion. The differences in adhesion quality were not due to incompatible husk and caryopsis dimensions affecting organ contact.

CONCLUSIONS

This study shows that husk-to-caryopsis adhesion is dependent on cementing layer composition, and implies that this composition is regulated by temperature before, and during grain development. Understanding this regulation will be key to improving husk-to-caryopsis adhesion.

Optimized, Minimal Specific Absorption Rate MRI for High-Resolution Imaging in Patients with Implanted Deep Brain Stimulation Electrodes

BACKGROUND AND PURPOSE

Obtaining high-resolution brain MR imaging in patients with a previously implanted deep brain stimulator has been challenging and avoided by many centers due to safety concerns relating to implantable devices. We present our experience with a practical clinical protocol at 1.5T by using 2 magnet systems capable of achieving presurgical quality imaging in patients undergoing bilateral, staged deep brain stimulator insertion.

MATERIALS AND METHODS

Protocol optimization was performed to minimize the specific absorption rate while providing image quality necessary for adequate surgical planning of the second electrode placement. We reviewed MR imaging studies performed with a minimal specific absorption rate protocol in patients with a deep brain stimulator in place at our institution between February 1, 2012, and August 1, 2015. Images were reviewed by a neuroradiologist and a functional neurosurgeon. Image quality was qualitatively graded, and the presence of artifacts was noted.

RESULTS

Twenty-nine patients (22 with Parkinson disease, 6 with dystonia, 1 with essential tremor) were imaged with at least 1 neuromodulation implant in situ. All patients were imaged under general anesthesia. There were 25 subthalamic and 4 globus pallidus implants. Nineteen patients were preoperative for the second stage of bilateral deep brain stimulator placement; 10 patients had bilateral electrodes in situ and were being imaged for other neurologic indications, including lead positioning. No adverse events occurred during or after imaging. Mild device-related local susceptibility artifacts were present in all studies, but they were not judged to affect overall image quality. Minimal aliasing artifacts were seen in 7, and moderate motion, in 4 cases on T1WI only. All preoperative studies were adequate for guidance of a second deep brain stimulator placement.

CONCLUSIONS

An optimized MR imaging protocol that minimizes the specific absorption rate can be used to safely obtain high-quality images in patients with previously implanted deep brain stimulators, and these images are adequate for surgical guidance.

Improved limits on spin-dependent WIMP-proton interactions from a two liter CF3I bubble chamber

Data from the operation of a bubble chamber filled with 3.5 kg of CF3I in a shallow underground site are reported. An analysis of ultrasound signals accompanying bubble nucleations confirms that alpha decays generate a significantly louder acoustic emission than single nuclear recoils, leading to an efficient background discrimination. Three dark matter candidate events were observed during an effective exposure of 28.1  kg  day, consistent with a neutron background. This observation provides strong direct detection constraints on weakly interacting massive particle (WIMP)-proton spin-dependent scattering for WIMP masses >20  GeV/c2.

Role of Ets transcription factors in mammary gland development and oncogenesis

PEA3 is the founding member of a subfamily of closely related ets genes that includes ER81 and ERM. PEA3 is expressed in the epithelial cells of mammary buds at the time that these first appear during mouse embryogenesis, and it is differentially expressed during postnatal mammary gland development. PEA3 expression is highest at the onset of puberty and during early pregnancy, times of extensive epithelial outgrowth and branching. PEA3 is expressed in undifferentiated epithelial cap cells of terminal end buds, and in differentiated myoepithelial cells of ducts and alveoli. Loss-of-function mutations in the PEA3 gene compromise mammary ductal branching at the onset of puberty and early during pregnancy. PEA3 is overexpressed in the vast majority of human breast tumors and in nearly all of the HER2-positive subclass of such tumors. PEA3 is similarly overexpressed in transgenic mouse models of this malignancy. Expression of dominant-negative PEA3 in the mouse mammary gland of MMTV-HER2 transgenic mice dramatically delays the onset and reduces the incidence of mammary tumors. Hence PEA3 and/or its close relatives play key regulatory roles in both mammary gland development and oncogenesis.

A comparison of the composition of epicuticular wax from red raspberry (Rubus idaeus L.) and hawthorn (Crataegus monogyna Jacq.) flowers

Epicuticular waxes have been characterised from the flowers of raspberry and hawthorn, on both of which adult raspberry beetles (Byturus tomentosus) can feed. The flower wax from both species had similar alkane profiles and also contained long-chain alcohols, aldehydes and fatty acids. The range of the carbon numbers detected for these classes of compounds was broadly similar in both but the relative amounts of each differed between species. Raspberry flower wax also contained fatty acid methyl esters, a group of compounds that has rarely been detected in plant epicuticular waxes, however, these were not observed in hawthorn flower wax. Long-chain alcohol-fatty acid esters with carbon numbers ranging from C36 to C48 were also detected in both plant species. However, an examination of their constituent acids indicated that in hawthorn the esters based on the C16 fatty acid predominated, whilst in raspberry flower wax, esters based on the C20 fatty acid were most abundant. Both species also contained pentacyclic triterpenoids, which accounted for, on average, over 16 and 48% of the total wax extracted from raspberry and hawthorn flowers respectively. In the former, ursolic and oleanolic acids accounted for over 90% of the pentacyclic triterpenes, whilst hawthorn flower wax, in addition to containing these acids, also contained high relative concentrations of both free and esterified alpha- and beta-amyrins.

Alterations in exon 4 of the p53 gene in gastric carcinoma

BACKGROUND & AIMS

Our long-term goal was to evaluate the role of p53 in the prognosis of gastric cancer. We previously showed a discrepancy between p53 expression and the presence of mutations when only exons 5-9 were examined. We then evaluated exon 4.

METHODS

DNA was sequenced from 217 gastric cancers to detect exon 4 alterations. Codon 72 was examined by restriction enzyme digestion.

RESULTS

Mutations were present in 3.2% of tumors. In addition, 2 polymorphic sites were found at codons 36 and 72. Polymorphisms at codon 36 were only found in 2 patients. In contrast, the codon 72 polymorphism was very frequent. The genotype frequency was arg/arg (54%), arg/pro (33%), and pro/pro (14%). The genotype of the polymorphic site varied with race (P = 0.001): 64% of whites had the arg/arg genotype, compared with 24% of blacks. The difference in genotype by site, sex, or histological tumor type was not statistically significant (P = 0.067).

CONCLUSIONS

There are several exon 4 alterations in gastric cancers. These include the rare mutations and the very rare codon 36 polymorphism. The most common change is the codon 72 polymorphism, the genotype of which differs significantly with race. The more common arg/arg genotype in whites may explain why whites are more prone to develop cardiac cancer, whereas the more common proline allele in blacks may explain why they are more prone to develop antral cancers. Further studies are required to determine whether the codon 72 polymorphism affects patient predisposition to gastric cancer.

SV40 Tag transformation of the normal invasive trophoblast results in a premalignant phenotype. I. Mechanisms responsible for hyperinvasiveness and resistance to anti-invasive action of TGFbeta

Invasion of the uterus by first trimester human placental extravillous trophoblast (EVT) cells depends on mechanisms shared by malignant cells. However, unlike tumor invasion, trophoblast invasion of the uterus is stringently controlled in situ by local molecules such as transforming growth factor (TGF)beta. Since EVT cells possess active invasion-associated genes but are nontumorigenic, our objective was to induce premalignant and then malignant phenotype into a normal EVT cell line in order to identify the molecular basis of tumor progression. Simian virus 40 large T antigen (SV40 Tag) was introduced into a normal human first trimester invasive EVT cell line, HTR8, established in our laboratory. Since the HTR8 line has a limited in vitro lifespan of 12-15 passages, SV40 Tag-transformed cells were selected on the basis of extended lifespan. A long-lived line, RSVT-2, was produced and an immortalized subclone, RSVT2/C, was further derived under a forced crisis regimen. We examined transformation-induced alterations in proliferative and invasive abilities, responses to the invasion and proliferation-regulating growth factor TGFbeta and changes in gene expression for invasion-associated enzymes or enzyme inhibitors. RSVT-2 and RSVT2/C cell lines were hyperproliferative and hyperinvasive when compared with the parental HTR8 cell line. They were also variably resistant to the anti-proliferative and anti-invasive signals from TGFbeta. Since both cell lines remained non-tumorigenic in nude mice, these properties indicate that they attained a premalignant phenotype. Both cell lines showed reduced expression of tissue inhibitor of metalloproteases (TIMP)-1, while TIMP-2 and plasminogen activator inhibitor (PAI)-I expression was was also reduced in RSVT2/C cells, thus contributing to their hyperinvasiveness. Their resistance to the anti-invasive action of TGFbeta was explained by the failure of TGFbeta to upregulate TIMPs and PAI-I, in contrast to the TGFbeta-induced upregulation noted in parental HTR8 cells.

Acute purulent pericarditis in children caused by haemophilus influenzae

Acute purulent pericarditis caused by Haemophilus influenzae is an unusual condition, especially in childhood. In most cases, respiratory symptoms are the presenting features, and children aged less than 4 years are most often affected. A high index of suspicion and aggressive microbiological and cardiological evaluation are often warranted to make an early diagnosis. We herein report two cases of pericarditis caused by H. influenzae in children aged less than two years. Pericardiocentesis was performed in each case. Early recognition, rapid diagnosis and aggressive medical and surgical therapy are paramount in the successful treatment of this condition.

Thiuram Disulfides in Compounding

Perhaps the chief drawback to the greater employment of thiuram disulfides has been the fear, often groundless, of scorching during processing, and for this reason the work detailed in this paper is devoted entirely to this aspect of their use. The scorching tendency, taken as the commencement of cure, and the rate of vulcanization were studied by means of a modified Goodrich type of plastometer, and the results are expressed as the percentage recovery against time in minutes at 120° C. This temperature (equivalent to 15 lbs. per sq. in. steam pressure) was chosen as being the highest likely to be reached in normal mixing, calendering and extrusion. The rubber compounds tested were prepared from one large batch of base stock comprising: smoked sheet rubber, 100 parts; zinc oxide, 5 parts; and stearic acid, 2 parts. After mixing, the stock was divided into the required number of portions and to these were added the various ingredients detailed later; in all cases the same milling time and temperatures were adhered to so that results would be comparable, especially plasticity. An interval of 24 hours at room temperature was allowed in each case before cutting plastometer test-pieces to dissipate strains imposed in the stock during mixing and sheeting. The test-pieces were then placed in an oven at 120° C, and percentage recovery determinations were made at 5-minute intervals over a range of 5 to 60 minutes.