Cut-off scores for mild and moderate dementia on the Addenbrooke's Cognitive Examination-III and the Mini-Addenbrooke's Cognitive Examination compared with the Mini-Mental State Examination

AIMS AND METHOD

We aimed to establish cut-off scores to stage dementia on the Addenbrooke's Cognitive Examination-III (ACE-III) and the Mini-Addenbrooke's Cognitive Examination (M-ACE) compared with scores traditionally used with the Mini-Mental State Examination (MMSE). Our cross-sectional study recruited 80 patients and carers from secondary care services in the UK.

RESULTS

A score ≤76 on the ACE-III and ≤19 on the M-ACE correlated well with MMSE cut-offs for mild dementia, with a good fit on the receiver operating characteristic analysis for both the ACE-III and M-ACE. The cut-off for moderate dementia had lower sensitivity and specificity. There were low to moderate correlations between the cognitive scales and scales for everyday functioning and behaviour.

CLINICAL IMPLICATIONS

Our findings allow an objective interpretation of scores on the ACE-III and the M-ACE relative to the MMSE, which may be helpful for clinical services and research trials.

X-ray Diffraction of Water in Polyvinylpyrrolidone

PVP is a hydrophilic polymer commonly used as an excipient in pharmaceutical formulations. Here we have performed time-resolved high-energy X-ray scattering experiments on pellets of PVP at different humidity conditions for 1-2 days. A two-phase exponential decay in water sorption is found with a peak in the differential pair distribution function at 2.85 Å, which is attributed to the average (hydrogen bonded) carbonyl oxygen-water oxygen distance. Additional scattering measurements on powders with fixed compositions ranging from 2 to 12.3 wt % H2O were modeled with Empirical Potential Structure Refinement (EPSR). The models reveal approximately linear relations between the carbonyl oxygen-water oxygen coordination number (nOC-OW) and the water oxygen-water oxygen coordination number (nOW-OW) versus water content in PVP. A stronger preference for water-water hydrogen bonding over carbonyl-water bonding is found. At all the concentrations studied the majority of water molecules were found to be randomly isolated, but a wide distribution of coordination environments of water molecules is found within the PVP polymer strands at the highest concentrations. Overall, the EPSR models indicate a continuous evolution in structure versus water content with nOW-OW=1 occurring at ∼12 wt % H2O, i.e., the composition where, on average, each water molecule is surrounded by one other water molecule.

RNA- and ATAC-sequencing Reveals a Unique CD83+ Microglial Population Focally Depleted in Parkinson's Disease

All brain areas affected in Parkinson's disease (PD) show an abundance of microglia with an activated morphology together with increased expression of pro-inflammatory cytokines, suggesting that neuroinflammation may contribute to the neurodegenerative process in this common and incurable disorder. We applied a single nucleus RNA- and ATAC-sequencing approach using the 10x Genomics Chromium platform to postmortem PD samples to investigate microglial heterogeneity in PD. We created a multiomic dataset using substantia nigra (SN) tissues from 19 PD donors and 14 non-PD controls (NPCs), as well as three other brain regions from the PD donors which are differentially affected in this disease: the ventral tegmental area (VTA), substantia inominata (SI), and hypothalamus (HypoTs). We identified thirteen microglial subpopulations within these tissues as well as a perivascular macrophage and a monocyte population, of which we characterized the transcriptional and chromatin repertoires. Using this data, we investigated whether these microglial subpopulations have any association with PD and whether they have regional specificity. We uncovered several changes in microglial subpopulations in PD, which appear to parallel the magnitude of neurodegeneration across these four selected brain regions. Specifically, we identified that inflammatory microglia in PD are more prevalent in the SN and differentially express PD-associated markers. Our analysis revealed the depletion of a CD83 and HIF1A- expressing microglial subpopulation, specifically in the SN in PD, that has a unique chromatin signature compared to other microglial subpopulations. Interestingly, this microglial subpopulation has regional specificity to the brainstem in non-disease tissues. Furthermore, it is highly enriched for transcripts of proteins involved in antigen presentation and heat-shock proteins, and its depletion in the PD SN may have implications for neuronal vulnerability in disease.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

871 The Efficacy and Safety of Bariatric Surgery in Patients with End-Stage Renal Disease Awaiting Listing for Kidney Transplantation: A Systematic Review and Meta-Analysis

Aim

Obesity is associated with adverse outcomes in end-stage renal disease (ESRD) and hinders changes for waiting list allocation of kidney transplantation (KT). Bariatric surgery (BS) is an effective solution to obesity. The authors aim to summarise the evidence for the efficacy and safety of BS in ESRD awaiting KT.

Method

We performed a systematic review and meta-analysis to determine the efficacy and safety of BS in patients with ESRD awaiting KT. A literature search of MEDLINE, EMBASE and Web of Science was conducted from inception to April 2021. The methodological quality of selected studies was assessed using the Newcastle-Ottowa tool. Our primary outcome was change in BMI, with secondary outcomes including adverse events, graft outcomes and KT listing rate.

Results

Nine observational studies met the inclusion criteria with a total of 1903 patients (43.9% male). Mean change in BMI following BS was -11.3 (-15.3 to -7.3, p &lt;0.001) within a median follow up time of 27.6 months (IQR 12 to 36.6 months). Sleeve gastrectomy (44.6%, n=849) and gastric bypass (43.6%, n=829) were the most common procedures. Mean age at BS was 47.3 years with a mean rate to KT listing of 59.9% (SD = 1.13).

Conclusion

This review highlights that BS is both safe and efficacious on patients with ESRD and can aid with optimisation for waiting list allocation.

870 The Efficacy and Safety of Bariatric Surgery in Kidney Transplantation Candidates: A Systematic Review and Meta-Analysis

Introduction

Kidney transplantation (KT) remains a high-risk procedure which requires extensive pre-operative assessment and optimisation. Obesity is known to increase the risk of adverse post-operative consequences. Bariatric surgery (BS) is an effective solution to obesity. The authors aim to summarise the evidence for the efficacy and safety of BS in KT candidates.

Method

We performed a systematic review and meta-analysis to determine the efficacy and safety of BS in patients KT candidates. A literature search of MEDLINE, EMBASE and Web of Science was conducted from inception to April 2021. The methodological quality of selected studies was assessed using the Newcastle-Ottowa tool. Our primary outcome was change in BMI, with secondary outcomes including adverse events, graft outcomes and KT rate.

Results

Nine observational studies met the inclusion criteria with a total of 179 patients (48% male). Mean change in BMI following BS was -11.2 (-12.9 to -9.5, p &lt; 0.001) within a median follow up time of 43 months (IQR 36 to 47 months). Sleeve gastrectomy (44.7%, n=80) and gastric bypass (46.9%, n=84) were the most common procedures. Median time from BS to KT was 17 months (IQR 6 to 18 months) with a mean KT rate of 80.1% (SD = 14.9).

Conclusion

This review highlights that BS is both safe and efficacious for KT candidates and can be an effective means of optimising BMI prior to transplantation.

268 The Efficacy and Safety of Bariatric Surgery in Patients with End-Stage Renal Disease and Kidney Transplantation: A Systematic Review and Meta-Analysis

Aim

Obesity is associated with adverse outcomes in end-stage renal disease (ESRD) and kidney transplant (KT) recipients. Bariatric surgery (BS) is an effective solution to obesity. The authors aim to summarise the evidence for the efficacy and safety of BS in ESRD or KT.

Method

A literature search was conducted using MEDLINE, EMBASE and Web of Science from inception to date (April 2021). Articles were categorised into patients awaiting waiting list acceptance, awaiting transplantation, undergoing simultaneous BS and kidney transplantation, and undergoing BS following transplantation in the past. Primary outcome was change in BMI with secondary outcomes as adverse events, graft outcomes and KT.

Results

Twenty-eight articles were selected: fourteen on patients awaiting listing (n = 1984), nine on patients listed for KT (n = 196), one on simultaneous BS and KT and ten on patients undergoing BS following KT (n = 198). Mean change in BMI for patients awaiting listing was -10.5 (-4.1 to -17.0, p = 0.001), change in BMI for patients listed for KT was -11.2 (-9.5 to -12.9, p&lt;0.001) and change for patients with prior KT was -11.0 (-7.09 to -14.9, p&lt;0.001). 60.4% of patients undergoing BS were successfully listed for KT. 74.1% of patients listed for KT undergoing BS underwent KT within 17 months (SD = 78.5). Time from KT to BS was 59.2 months (SD = 43.0).

Conclusion

BS is both safe and efficacious on patients with ESRD, those awaiting KT, and those with prior KT and should be considered when obesity is a hurdle to favourable outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

796 THE IMPORTANCE OF CHEST X RAYS AS AN INITIAL INVESTIGATION IN ROUTINE ACUTE ELDERLY CARE ADMISSIONS

Introduction

The Chest X-Ray (CXR) is a common and central initial investigation for any patient that has been admitted via Accident and Emergency (A&E). In the context of elderly care, it is a useful measure of a patient’s baseline functional status as well as a tool for cancer surveillance and other aspects of clinical care. Accurate documentation of CXR review is also imperative for closed loop communication of clinical information amongst a multi-disciplinary team.

Methods

Twenty-eight random inpatients in a local NHS Trust Healthcare of Older People (HCOP) department were selected to be part of this two-cycle study. Using hospital database records, the CARESTREAM imaging system and patient clinical documentation, data including the following was collected: whether a CXR was completed, was CXR review documented in patient notes and initial reason for admission. As per local practice, all acute HCOP admissions should undergo a CXR and have an image review clearly documented in patients’ clinical noting. The established target was 95% compliance for both. Following intervention by way of ward poaters and presentation at a local quality improvement meeting the cycle was repeated to ascertain improvement in compliance.

Results

22 (79%) HCOP patients had a CXR on admission. Of those completed CXRs, only 6 (27%) of these showed evidence of review (documentation in clinical noting). Following the above mentioned interventions, 25 (89%) of HCOP patients had a CXR on admission, showing an improvement. Of those completed CXRs, 20 (80%) showed evidence of documented clinical review– once again showing improvement.

Conclusions

CXRs and their accurate documentation is an important aspect of the holistic care of the HCOP patient. Ensuring that compliance for completing the scan and documenting results should be a priority in clinical quality and safety. Our interventions have shown an improvement in compliance and resulted in sustainable change.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Patient and physician perspectives guiding intra-articular treatment choice in knee osteoarthritis: stakeholders are aligned on treatment priorities but have different assessments of treatment effect

OBJECTIVES

Knee osteoarthritis (OA) is a leading cause of health-related disability. In the absence of curative non-operative therapies, treatment goals are limited to symptom relief. Data are limited on how patients and physicians prioritise available treatment options. We assessed patients' preferences for and physicians' attitudes towards intra-articular treatments including corticosteroids (IACS), an extended-release corticosteroid (TA-ER) and hyaluronic acids (IAHA).

METHODS

We conducted a prospective, IRB-exempt, double-blind survey of patients with and providers who treat knee OA. Respondents were required to have received or prescribed TA-ER in a non-trial setting. We evaluated patients' OA history, impact of knee OA and treatment preferences, and physicians' decision-making and prescribing experiences.

RESULTS

Of the 97 patient participants, mean age was 56 years, 70.0% were women, 75.0% had bilateral knee OA and 46.4% were diagnosed over 5 years ago. Of the 50 physician participants, 42.0% were orthopaedic surgeons, 34.0% were rheumatologists and 60.0%, on average, treat 50+ patients with knee OA per month. Treatment selection factors considered 'very important' to patients and physicians included disease severity (88.7%, 82.0%), impact on quality of life (88.7%, 72.0%), disease extent (84.5%, 54.0%) and activity level (80.4%, 64.0%). A majority (93.8%) of patients indicated moderate to severe difficulty with their knees. Fewer patients (76.3%) reported shared decision making compared with physicians (92.0%). Half (50.5%) of the patients reported that they experienced months of pain relief with TA-ER, 27.7% with IACS and 18.8% with IAHA. Physician assessments were consistent but estimated a greater duration of treatment effects than that reported by patients across all therapies.

CONCLUSION

While knee OA has a tremendous impact on patients, there are significant unmet treatment needs. The increasing use of patient-reported outcomes will allow patients and physicians to track pain and functional status over time and across therapies, improving shared decision-making.

Identification of robust and interpretable brain signatures of autism and clinical symptom severity using a dynamic time-series deep neural network

Introduction

Autism spectrum disorder (ASD) is among the most common and pervasive neurodevelopmental disorders. Yet, despite decades of research, the neurobiology of ASD is still poorly understood, as inconsistent findings preclude the identification of robust and interpretable neurobiological markers and predictors of clinical symptoms.

Objectives

Identify robust and interpretable dynamic brain markers that distinguish children with ASD from typically-developing (TD) children and predict clinical symptom severity.

Methods

We leverage multiple functional brain imaging cohorts (ABIDE, Stanford; N = 1004) and exciting recent advances in explainable artificial intelligence (xAI), to develop a novel multivariate time series deep neural network model that extracts informative brain dynamics features that accurately distinguish between ASD and TD children, and predict clinical symptom severity.

Results

Our model achieved consistently high classification accuracies in cross-validation analysis of data from the ABIDE cohort. Crucially, despite the differences in symptom profiles, age, and data acquisition protocols, our model also accurately classified data from an independent Stanford cohort without additional training. xAI analyses revealed that brain features associated with the default mode network, and the human voice/face processing and communication systems, most clearly distinguished ASD from TD children in both cohorts. Furthermore, the posterior cingulate cortex emerged as robust predictor of the severity of social and communication deficits in ASD in both cohorts.

Conclusions

Our findings, replicated across two independent cohorts, reveal robust and neurobiologically interpretable brain features that detect ASD and predict core phenotypic features of ASD, and have the potential to transform our understanding of the etiology and treatment of the disorder.

Disclosure

No significant relationships.

Efficacy of vitamin D supplementation in major depression: A meta-analysis of randomized controlled trials

Background:

There is a need to develop and periodically evaluate new treatment strategies in major depression due to the high burden of nonresponse and inadequate response to antidepressants.

Aim:

We aimed to assess the effect of vitamin D supplementation on depression symptom scores among individuals with clinically diagnosed major depression.

Materials and Methods:

Electronic search of databases was carried out for published randomized controlled trials in English language, peer-reviewed journals from inception till August 2017. Outcome measure used for effect size calculation was depression symptom scores. Effect sizes for the trials were computed using standardized mean difference (Cohen's d), and I² test was used to assess sample heterogeneity. Pooled mean effect sizes were derived using both fixed and random-effects model. Critical appraisal of studies was done using the Cochrane risk of bias assessment tool.

Results:

A total of four trials involving 948 participants were included in the study. In three trials, the intervention group received oral vitamin D supplementation whereas in one parenteral vitamin D was given. Pooled mean effect size for vitamin D supplementation on depressive symptom ratings in major depression was 0.58 (95% confidence interval, 0.45–0.72). The I² value for heterogeneity was 0 suggesting low heterogeneity among studies. Egger plot intercept indicated minimal publication bias.

Conclusion:

Vitamin D supplementation favorably impacted depression ratings in major depression with a moderate effect size. These findings must be considered tentative owing to the limited number of trials available and inherent methodological bias noted in few of them.

Neural correlates of cognitive variability in childhood autism and relation to heterogeneity in decision-making dynamics

Heterogeneity in cognitive and academic abilities is a prominent feature of autism spectrum disorder (ASD), yet little is known about its underlying causes. Here we combine functional brain imaging during numerical problem-solving with hierarchical drift-diffusion models of behavior and standardized measures of numerical abilities to investigate neural mechanisms underlying cognitive variability in children with ASD, and their IQ-matched Typically Developing (TD) peers. Although the two groups showed similar levels of brain activation, the relation to individual abilities differed markedly in ventral temporal-occipital, parietal and prefrontal regions important for numerical cognition: children with ASD showed a positive correlation between functional brain activation and numerical abilities, whereas TD children showed the opposite pattern. Despite similar accuracy and response times, decision thresholds were significantly higher in the ASD group, suggesting greater evidence required for problem-solving. Critically, the relationship between individual abilities and engagement of prefrontal control systems anchored in the anterior insula was differentially moderated by decision threshold in subgroups of children with ASD. Our findings uncover novel cognitive and neural sources of variability in academically-relevant cognitive skills in ASD and suggest that multilevel measures and latent decision-making dynamics can aid in characterization of cognitive variability and heterogeneity in neurodevelopmental disorders.

Infectious diseases and antimicrobial prescribing: Online spaced education for junior doctors

BACKGROUND

Inappropriate antimicrobial prescribing may harm patients and drive antimicrobial resistance. Junior doctors' knowledge of infectious diseases and antimicrobial prescribing is inadequate. Online spaced case-based learning can improve knowledge.

OBJECTIVE

To develop infectious diseases and antimicrobial prescribing course content for online spaced education and assess its effectiveness and feasibility for junior doctors.

METHODS

Infectious diseases and antimicrobial course content was developed for an online spaced education platform (Qstream Inc., Burlington, MA). Junior doctors (postgraduate years 1-3) at two tertiary teaching hospitals in Sydney participated in the study. Course content was provided with Qstream at one hospital and at the other hospital via two face-to-face (FTF) tutorials from August to October 2017. Knowledge and self-confidence were compared before and after training within and between both cohorts.

RESULTS

Participation in the course was higher in the Qstream cohort with 48/127 (37.8%) completing the course compared with 44/110 (40%) attending one or both FTF sessions, of whom 22/110 (20%) attended both. Improvement in mean knowledge score from 69.7% to 81.5% in the Qstream cohort was significantly greater than the FTF cohort's minimal improvement from 67.6% to 67.9% (95% CI 2.79-20.33; P=0.01). In the Qstream cohort mean confidence rating (0-10) improvement from 5.14 to 6.55 was greater than the FTF group improvement from 5.37 to 5.85 (95% CI 0.132-1.171; P=0.02). Qstream feedback was very positive.

CONCLUSIONS

Online spaced education in infectious diseases and antimicrobial prescribing was feasible, acceptable and effective for junior doctors. It has potential to reduce inappropriate antimicrobial prescribing and warrants further investigation.

P1951Serial left ventricular global longitudinal strain and mortality in patients with Takotsubo cardiomyopathy

Background

Recent studies on Takotsubo cardiomyopathy (TC) have challenged the common conception that it is a relatively benign condition with functional recovery observed in the majority of cases. However, it is important to recognize that overt functional recovery might not reflect the true regional recovery, which might have an adverse impact on survival.

Objective

We sought to assess baseline and follow-up left ventricular function characteristics and their impact on longer-term mortality in patients presenting with documented Takotsubo cardiomyopathy (TC) at a tertiary centre.

Methods

339 patients (66±14 years, 88% women) presented to our centre between 2006 and 2018 with acute anginal symptoms and were subsequently diagnosed with TC following clinical and angiographic evaluation. All patients returned for a follow-up evaluation including transthoracic echocardiography (TTE). Baseline and follow-up (3–6 months after TC diagnosis) LV ejection fraction (LVEF) and LV global longitudinal strain (LV-GLS using velocity vector imaging) were recorded on TTE. The primary endpoint was longer-term mortality.

Results

Hypertension, dyslipidaemia, and diabetes were present in 71%, 56%, and 26% of patients. Baseline mean troponin I peak, LVEF and LV-GLS were 0.9±7 ng/ml, 36±9%, and 11±3%; respectively. 94% had baseline LVEF<50%, 272 (80%) had apical ballooning, and 94% had LV-GLS worse than −18%. No patient had angiographically obstructive coronary artery disease. At 3–6 months follow-up, mean LVEF, and LV-GLS improved to 57±9% and 16±3%, respectively. 87% of patients had LVEF >50%, but in 70% LV-GLS remained worse than −18%. After 3.3±3 years, 72 patients (21%) died. On multivariable Cox survival analysis (adjusted for age, gender, baseline troponin peak and follow up LVEF), follow up LV-GLS was independently associated with longer-term mortality (hazard ratio 1.12 [95% confidence interval 1.05, 1.20], p<0.001). Significantly more patients with follow up LV-GLS worse than −18% died vs. those with LV-GLS better than −18% (57/237 [24%] vs. 15/102 [15%], log-rank statistic p-value 0.01, Kaplan-Meier figure 1).

Kaplan-Meier curve of freedom from death

Conclusions

In this large single-centre study of patients with documented TC (majority women), 87% recovered LVEF at 3–6 months, but in 70% LV-GLS remained worse than −18%, which was independently associated with higher longer-term mortality.

Psychiatric disorders and obesity: A review of association studies

Background:

Inconsistent evidence exists regarding the strength, direction, and moderators in the relationship between obesity and psychiatric disorders.

Aim:

This study aims to summarize the evidence on the association between psychiatric illness and obesity with particular attention to the strength and direction of association and also the possible moderators in each postulated link.

Materials and Methods:

Systematic electronic searches of MEDLINE through PubMed, ScienceDirect, PsycINFO, and Google Scholar were carried out from inception till October 2016. Generated abstracts were screened for eligibility to be included in the review. Study designs that evaluated the strength of relationship between obesity and psychiatric disorders were included in the study. Quality assessment of included studies was done using the Newcastle–Ottawa checklist tool.

Results:

From a total of 2424 search results, 21 eligible articles were identified and reviewed. These included studies on obesity and depression (n = 15), obesity and anxiety (four) and one each on obesity and personality disorders, eating disorder (ED), attention deficit hyperactivity disorder, and alcohol use. Maximal evidence existed for the association between depression and obesity with longitudinal studies demonstrating a bidirectional link between the two conditions. The odds ratios (ORs) were similar for developing depression in obesity (OR: 1.21–5.8) and vice versa (OR: 1.18–3.76) with a stronger association observed in women. For anxiety disorders, evidence was mostly cross-sectional, and associations were of modest magnitude (OR: 1.27–1.40). Among other disorders, obesity, and EDs appear to have a close link (OR: 4.5). Alcohol use appears to be a risk factor for obesity and not vice versa but only among women (OR: 3.84).

Conclusion:

Obesity and depression have a significant and bidirectional association. Evidence is modest for anxiety disorders and inadequate for other psychiatric conditions. Gender appears to be an important mediator in these relationships.

Comparison of Resource Utilization and Clinical Outcomes Following Screening with Digital Breast Tomosynthesis Versus Digital Mammography: Findings From a Learning Health System

RATIONALE AND OBJECTIVES

To compare outcomes associated with breast cancer screening with digital mammography (DM) alone versus in combination with digital breast tomosynthesis (DBT) in a large representative cohort.

MATERIALS AND METHODS

A total of 325,729 screening mammograms from 247,431 women were analyzed, across two healthcare systems, from June 2015 to September 2017. Patient level demographic, calculated risk levels, and clinical outcomes were extracted from radiology information system and electronic medical records. Multivariable regression modeling adjusting for institution, age, breast density, and first exam was conducted to compare patient characteristics, recall rates, time to biopsy and final diagnosis, clinical outcomes, and diagnostic performance. Participating institutions and the Coordinating Center received Institutional Review Board approval for a waiver of consent to collect and link data and perform analysis.

RESULTS

A total of 194,437 (59.7%) screens were DBT versus 131,292 (40.3%) with DM. Women with dense breasts and higher calculated risk were more likely to be screened with DBT. Recall rates were lower for DBT overall (8.83% DBT vs 10.98% DM, adjusted odds ratio, 95% confidence interval = 0.85, 0.83-0.87) and across all age groups, races, and breast densities, and at facilities that used predominantly DBT (8.05%) versus predominantly DM (11.22%), or a combination (10.73%). The most common diagnostic pathway after recall was mammography and ultrasound. Women recalled from DBT were more likely to proceed directly to ultrasound. The median time to biopsy (18 vs 22 days) and final diagnosis (10 vs 13 days) was shorter for DBT. The adjusted cancer rate, cancer detection rate, and specificity were higher for DBT.

CONCLUSION

DBT demonstrated a more efficient screening pathway and improved quality measures with lower recall rates in all patient types, reduced diagnostic mammography and shorter time to biopsy and final diagnosis.

HSR19-079: Disparities in Accessing Screening Mammography: Opportunities for Improving Diagnostic Outcomes

Introduction: Screening mammography is a key component of secondary prevention programs targeting reductions in breast cancer mortality. The early detection of cancers facilitates treatment at a more curable, locoregionally limited stage. We describe characteristics and outcomes of women who had only one screening mammogram versus those who had annual or biennial screens. Methods: A cloud-based big data platform is being used to integrate and transform data from electronic medical records, radiology management systems, and tumor registries to create a learning health system. This analysis includes data from 227,834 women, aged 40–79 years, who underwent screening mammograms between January 2015 and June 2018 at 64 imaging facilities within 3 large, geographically diverse healthcare organizations. Patients with breast cancer history or implants were excluded. Women were defined as having one screen if they had >24 months of follow-up with evidence of only one screen and were defined as having more than one screen if they had 2 screens at least 9 months apart. Interval cancer was defined as a breast cancer in the 12 months following a negative baseline mammogram. The chi-square test was used to test for differences between cohorts. Results: Of 227,834 women, 18.8% (n=42,911) met criteria for one screen [1-screen] and 81.2% (n=184,923) for 2 screens [2-screens]. There were significant differences between the groups in age (40.4% 60-79 years in the 1-screen cohort vs 49.1% in 2-screens; P<.001), race (24.7% African American and 5.3% Asian in the 1-screen cohort and 18.5% and 3.6% in 2-screens; P<.001), and lifetime risk of breast cancer (6.9% were in the elevated risk category in the 1-screen cohort and 9.3% in 2-screens; P<.001). Recall rate for the 1-screen cohort was 16.6% compared to 7.7% for the second screen for the 2-screens (P<.001). The interval cancer rate was significantly higher (P<.001) for the 1-screen cohort (2.9 per 1000 screens) as compared to the second screen for the 2-screens (0.8 per 1000 screens). Conclusion: Women with evidence of only one screen during the 3.5-year study period tended to be younger and non-white. Although they had lower scores for lifetime risk of breast cancer, recall rates were twofold higher and interval cancer rates were threefold higher in the 1-screen cohort. Targeted initiatives are needed to improve adherence to screening in women at risk of noncompliance.

Directional emission of rhodamine 6G on top of a silver grating

We have observed directional spontaneous emission of rhodamine 6G dye deposited on top of a silver grating and found that its angular distribution patterns were very different in TE and TM polarizations. The latter was related to the dispersion curves determined based on the polarized reflection spectra measured at multiple incidence angles. The most intriguing finding of this Letter was a resonance, which was coupled with TE-polarized light and determined the characteristic double-crescent patterns in the TE-polarized spontaneous emission. This observation, as well as nearly similar resonance observed in TM polarization, was tentatively explained in terms of leaky waveguide modes supported by a film of dye-doped polymer.

A report on an acute, in-hours, outpatient review clinic with ultrasonography facilities for the early evaluation of general surgical patients

Introduction In 2013 our hospital introduced an in-hours, consultant-led, outpatient acute surgical clinic (ASC) for emergency general surgical patients. In 2014 this clinic was equipped with a dedicated ultrasonography service. This prospective cohort study evaluated this service before and after the introduction of ultrasonography facilities. Methods Data were recorded prospectively for all patients attending the clinic during 2013 and 2014. The primary outcome was patient destination (whether there was follow-up/admission) after clinic attendance. Results The ASC reviewed patients with a wide age range and array of general surgical complaints. In 2013, 186 patients attended the ASC. After the introduction of the ultrasonography service in 2014, 304 patients attended. In 2014, there was a reduction in the proportion of patients admitted to hospital from the clinic (18.3% vs 8.9%, p=0.002). However, the proportion of patients discharged after ASC review remained comparable with 2013 (30.1% in 2013 vs 38.8% in 2014, p=0.051). The proportion of patients undergoing computed tomography (CT) scans also fell (14.0% vs 4.9%, p<0.001). Conclusions The ASC assessed a wide array of general surgical complaints. Only a small proportion required hospital admission. The introduction of an ultrasonography service was associated with a further reduction in admission rates and computed tomography.

Memory and cognitive control circuits in mathematical cognition and learning

Numerical cognition relies on interactions within and between multiple functional brain systems, including those subserving quantity processing, working memory, declarative memory, and cognitive control. This chapter describes recent advances in our understanding of memory and control circuits in mathematical cognition and learning. The working memory system involves multiple parietal-frontal circuits which create short-term representations that allow manipulation of discrete quantities over several seconds. In contrast, hippocampal-frontal circuits underlying the declarative memory system play an important role in formation of associative memories and binding of new and old information, leading to the formation of long-term memories that allow generalization beyond individual problem attributes. The flow of information across these systems is regulated by flexible cognitive control systems which facilitate the integration and manipulation of quantity and mnemonic information. The implications of recent research for formulating a more comprehensive systems neuroscience view of the neural basis of mathematical learning and knowledge acquisition in both children and adults are discussed.

Anhedonia and general distress show dissociable ventromedial prefrontal cortex connectivity in major depressive disorder

Anhedonia, the reduced ability to experience pleasure in response to otherwise rewarding stimuli, is a core symptom of major depressive disorder (MDD). Although the posterior ventromedial prefrontal cortex (pVMPFC) and its functional connections have been consistently implicated in MDD, their roles in anhedonia remain poorly understood. Furthermore, it is unknown whether anhedonia is primarily associated with intrinsic 'resting-state' pVMPFC functional connectivity or an inability to modulate connectivity in a context-specific manner. To address these gaps, a pVMPFC region of interest was first identified using activation likelihood estimation meta-analysis. pVMPFC connectivity was then examined in relation to anhedonia and general distress symptoms of depression, using both resting-state and task-based functional magnetic resonance imaging involving pleasant music, in current MDD and healthy control groups. In MDD, pVMPFC connectivity was negatively correlated with anhedonia but not general distress during music listening in key reward- and emotion-processing regions, including nucleus accumbens, ventral tegmental area/substantia nigra, orbitofrontal cortex and insula, as well as fronto-temporal regions involved in tracking complex sound sequences, including middle temporal gyrus and inferior frontal gyrus. No such dissociations were observed in the healthy controls, and resting-state pVMPFC connectivity did not dissociate anhedonia from general distress in either group. Our findings demonstrate that anhedonia in MDD is associated with context-specific deficits in pVMPFC connectivity with the mesolimbic reward system when encountering pleasurable stimuli, rather than a static deficit in intrinsic resting-state connectivity. Critically, identification of functional circuits associated with anhedonia better characterizes MDD heterogeneity and may help track of one of its core symptoms.

A prospective evaluation of retroequatorial recession of horizontal rectus muscles and Hertle-Dell'Osso tenotomy procedure in patients with infantile nystagmus with no definite null position

PURPOSE

To compare results of retroequatorial recession of horizontal rectus muscles and Hertle-Dell'Osso tenotomy procedure in patients with infantile nystagmus with null in primary position.

METHODS

In this prospective study, 10 subjects ≥5 years of age with infantile nystagmus with null in primary position were randomly assigned to two groups: group 1 underwent a large retroequatorial recession of the four horizontal rectus muscles; group 2, simple tenotomy and resuturing (Hertle-Dell'Osso procedure) of the four muscles. Patients were evaluated using Snellen and logMAR visual acuity charts, contrast sensitivity testing, color vision testing, stereopsis testing (TNO), and electronystagmography (ENG) for nystagmus waveforms, frequency, amplitude, and intensity.

RESULTS

Group 1 patients showed a trend toward 1-line improvement in their visual acuity for distance on the logMAR and ETDRS charts (P = 0.32); there was no improvement in group 2 patients. Contrast sensitivity improved significantly in both groups (P = 0.03), as did stereopsis (P = 0.02 [group 1], P = 0.04 [group 2]). The amplitude and intensity of nystagmus showed a tendancy to decrease in both the groups in all gazes, although the frequency showed no change in either group. Intergroup variability on all the parameters was not statistically significant.

CONCLUSIONS

Both retroequatorial recession of horizontal recti and the Hertle-Dell'Osso procedure showed a trend toward reducing ENG amplitude and improved contrast sensitivity and stereopsis in infantile nystagmus with null in primary position.

Antimicrobial resistance in urosepsis: outcomes from the multinational, multicenter global prevalence of infections in urology (GPIU) study 2003-2013

Objective

Primary objective was to identify the (1) relationship of clinical severity of urosepsis with the pathogen spectrum and resistance and (2) appropriateness of using the pathogen spectrum and resistance rates of health-care-associated urinary tract infections (HAUTI) as representative of urosepsis. The secondary objective was to provide an overview of the pathogens and their resistance profile in patients with urosepsis.

Population and Methods

A point prevalence study carried out in 70 countries (2003–2013). Population studied included; 408 individuals with microbiologically proven urosepsis, 1606 individuals with microbiological proof of HAUTI and 27,542 individuals hospitalised in urology wards. Main outcomes are pathogens and resistance identified in HAUTIs and urosepsis including its clinical severity. A statistical model that included demographic factors (study year, geographical location, hospital setting) was used for analysis.

Results

Amongst urology practices, the prevalence of microbiologically proven HAUTI and urosepsis was 5.8 and 1.5 %, respectively. Frequent pathogens in urosepsis were E. coli (43 %), Enterococcus spp. (11 %), P. aeruginosa (10 %) and Klebsiella spp. (10 %). Resistance to commonly prescribed antibiotics was high and rates ranged from 8 % (imipenem) to 62 % (aminopenicillin/β lactamase inhibitors); 45 % of Enterobacteriaceae and 21 % of P. aeruginosa were multidrug-resistant. Resistance rates in urosepsis were higher than in other clinical diagnosis of HAUTI (Likelihood ratio <0.05).

Conclusions

It is not appropriate to use the pathogen spectrum and resistance rates of other HAUTIs as representative of urosepsis to decide on empirical treatment of urosepsis. Resistance rates in urosepsis are high, and precautions should be made to avoid further increase.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-015-1722-1) contains supplementary material, which is available to authorized users.

Appropriate initial antibiotic therapy in hospitalized patients with gram-negative infections: systematic review and meta-analysis

Background

The rapid global spread of multi-resistant bacteria and loss of antibiotic effectiveness increases the risk of initial inappropriate antibiotic therapy (IAT) and poses a serious threat to patient safety. We conducted a systematic review and meta-analysis of published studies to summarize the effect of appropriate antibiotic therapy (AAT) or IAT against gram-negative bacterial infections in the hospital setting.

Methods

MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched until May 2014 to identify English-language studies examining use of AAT or IAT in hospitalized patients with Gram-negative pathogens. Outcomes of interest included mortality, clinical cure, cost, and length of stay. Citations and eligible full-text articles were screened in duplicate. Random effect models meta-analysis was used.

Results

Fifty-seven studies in 60 publications were eligible. AAT was associated with lower risk of mortality (unadjusted summary odds ratio [OR] 0.38, 95 % confidence interval [CI] 0.30-0.47, 39 studies, 5809 patients) and treatment failure (OR 0.22, 95 % CI 0.14–0.35; 3 studies, 283 patients). Conversely, IAT increased risk of mortality (unadjusted summary OR 2.66, 95 % CI 2.12–3.35; 39 studies, 5809 patients). In meta-analyses of adjusted data, AAT was associated with lower risk of mortality (adjusted summary OR 0.43, 95 % CI 0.23–0.83; 6 studies, 1409 patients). Conversely, IAT increased risk of mortality (adjusted summary OR 3.30, 95 % CI 2.42–4.49; 16 studies, 2493 patients). A limited number of studies suggested higher cost and longer hospital stay with IAT. There was considerable heterogeneity in the definition of AAT or IAT, pathogens studied, and outcomes assessed.

Discussion

Using a large set of studies we found that IAT is associated with a number of serious consequences,including an increased risk of hospital mortality. Infections caused by drug-resistant, Gram-negative organisms represent a considerable financial burden to healthcare systems due to the increased costs associated with the resources required to manage the infection, particularly longer hospital stays. However, there were insufficient data that evaluated AAT for the outcome of costs among patients with nosocomialGram-negative infections.

Conclusions

IAT in hospitalized patients with Gram-negative infections is associated with adverse outcomes. Technological advances for rapid diagnostics to facilitate AAT along with antimicrobial stewardship, surveillance, infection control, and prevention is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1123-5) contains supplementary material, which is available to authorized users.

Predictors of weight loss at 1 year after laparoscopic adjustable gastric banding and the role of presurgical quality of life

BACKGROUND

There is uncertainty regarding preoperative predictors of a successful outcome for bariatric surgery (BarSurg), on which to determine appropriateness for such a procedure. Our aims were to identify preoperative clinical and psychosocial predictors of success following BarSurg and to explore the influence of body mass index (BMI) on these parameters.

METHODS

Preoperative data, including Impact of Weight on Quality of Life-Lite (IWQOL-Lite) scores transformed to Health-Related Quality of Life (HRQOL) scores, were accrued from 76 morbidly obese adults awaiting BarSurg. Pre- and postoperative data were also accrued for 26 patients who had completed 1-year follow-up post-bariatric surgery (laparoscopic adjustable gastric banding-LAGB). Statistical analysis was performed to assess the relationships between preoperative HRQOL scores, preoperative BMI and excess weight loss 1 year following BarSurg (EWL-1 year).

RESULTS

Preoperative BMI showed a significant independent, negative linear correlation with the public distress domain of preoperative quality of life (QOL) (r = -0.368, p = 0.001; β = -0.245, p = 0.009). Preoperative BMI had a significant, positive and independent association with EWL-1 year (r = 0.499, p = 0.009; β = 0.679, p = 0.015). Preoperative QOL scores had no association with EWL-1 year.

CONCLUSIONS

Preoperative BMI appears to predict EWL-1 year following restrictive bariatric surgery (LAGB). Preoperatively, patients with higher BMI appear to manifest greater public distress. Preoperative QOL scores, however, do not appear to have any predictive value for EWL-1 year post-LAGB. Preoperative BMI should therefore be employed as a predictor of EWL-1 year post-LAGB. Other measures of successful outcomes of bariatric surgeries (such as effects on QOL scores at 1 year) should be explored in future, larger and longer term studies.

Metal nanocluster light-emitting devices with suppressed parasitic emission and improved efficiency: exploring the impact of photophysical properties

Here we investigate the photophysical properties of Au(0)@Au(i)-thiolate nanoclusters by controlling the degree of aggregation, and measure electrochemical energy levels to design a metal nanocluster-based thin film LED (MNC-LED) structure. These efforts allow us to implement MNC-LEDs with luminance exceeding 40 cd m(-2) and external quantum efficiency exceeding 0.1% with clearly visible orange emission. It is also demonstrated that by varying the sizes of nanoclusters, the electroluminescence spectrum of the device can be tuned to the infrared emission, indicating the possibility of exploiting metal nanocluster emitters for use over a wide spectral range.

Clinical and economic consequences of hospital-acquired resistant and multidrug-resistant Pseudomonas aeruginosa infections: a systematic review and meta-analysis

Background

Increasing rates of resistant and multidrug-resistant (MDR) P. aeruginosa in hospitalized patients constitute a major public health threat. We present a systematic review of the clinical and economic impact of this resistant pathogen.

Methods

Studies indexed in MEDLINE and Cochrane databases between January 2000-February 2013, and reported all-cause mortality, length of stay, hospital costs, readmission, or recurrence in at least 20 hospitalized patients with laboratory confirmed resistant P. aeruginosa infection were included. We accepted individual study definitions of MDR, and assessed study methodological quality.

Results

The most common definition of MDR was resistance to more than one agent in three or more categories of antibiotics. Twenty-three studies (7,881 patients with susceptible P. aeruginosa, 1,653 with resistant P. aeruginosa, 559 with MDR P. aeruginosa, 387 non-infected patients without P. aeruginosa) were analyzed. A random effects model meta-analysis was feasible for the endpoint of all-cause in-hospital mortality. All-cause mortality was 34% (95% confidence interval (CI) 27% – 41%) in patients with any resistant P. aeruginosa compared to 22% (95% CI 14% – 29%) with susceptible P. aeruginosa. The meta-analysis demonstrated a > 2-fold increased risk of mortality with MDR P. aeruginosa (relative risk (RR) 2.34, 95% CI 1.53 – 3.57) and a 24% increased risk with resistant P. aeruginosa (RR 1.24, 95% CI 1.11 – 1.38), compared to susceptible P. aeruginosa. An adjusted meta-analysis of data from seven studies demonstrated a statistically non-significant increased risk of mortality in patients with any resistant P. aeruginosa (adjusted RR 1.24, 95% CI 0.98 – 1.57). All three studies that reported infection-related mortality found a statistically significantly increased risk in patients with MDR P. aeruginosa compared to those with susceptible P. aeruginosa. Across studies, hospital length of stay (LOS) was higher in patients with resistant and MDR P. aeruginosa infections, compared to susceptible P. aeruginosa and control patients. Limitations included heterogeneity in MDR definition, restriction to nosocomial infections, and potential confounding in analyses.

Conclusions

Hospitalized patients with resistant and MDR P. aeruginosa infections appear to have increased all-cause mortality and LOS. The negative clinical and economic impact of these pathogens warrants in-depth evaluation of optimal infection prevention and stewardship strategies.

Electronic supplementary material

The online version of this article (doi:10.1186/2047-2994-3-32) contains supplementary material, which is available to authorized users.

Painful fat necrosis resulting from insulin injections

The case is a 34-year-old woman with long-standing type 1 diabetes mellitus with existing follow-up in the outpatient clinic at the Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism, UHCW. She had maintained good glycaemic control and glycaemic stability with basal bolus regimen for many years. She had not developed any diabetes-related complications and had no other co-morbidities. Six months ago, she presented to A&E with sudden-onset, well-localised and severe pain in the right iliac fossa, just lateral to the para-umbilical area. Her biochemistry was normal. Ultrasound scan, however, revealed a right-sided ovarian cyst, which was thought to have caused pain to her. She was discharged from A&E with simple analgesia. On subsequent gynaecological follow-up 4 weeks later, her pain remained severe and examination revealed an exquisitely tender subcutaneous nodule at the same location measuring 2 cm in diameter. Magnetic resonance imaging (MRI) scan at the time revealed a 1 cm mass in the subcutaneous adipose tissue, which co-localised to her pain. The mass demonstrated a central fat signal surrounded by a peripheral ring: observations consistent with fat necrosis. There were other smaller subcutaneous nodules also observed in the left para-umbilical area. Subsequent surgical resection of the main area of fat necrosis was performed. The patient made an excellent recovery and her pain resolved post-operatively. Histology confirmed the presence of fat necrosis. Fat necrosis is a rare complication of s.c. insulin injection. This case illustrates the importance of considering this diagnosis in patients who inject insulin and develop localised injection-site pain.

Submucous fibroids and infertility: Effect of hysteroscopic myomectomy and factors influencing outcome

BACKGROUND

Submucosal myomas are associated with infertility and may be treated by hysteroscopic resection.

OBJECTIVE

The aim of this retrospective study was to analyze 37 subfertile patients who unnderwent hysteroscopic myomectomy in a tertiary care center with particular regard to their postprocedure reproductive outcome.

MATERIALS AND METHODS

The entire patient group (n = 37) underwent the procedure between March 2004 and March 2010. The submucosal myomas were type 0 (n = 27), type 1 (n = 8), and type 2 (n = 2). The mean myoma size was 2.1 cm; mean duration of the procedure was 54 mins and mean follow-up was 26 ± 10 months. 22 patients had one or more associated infertility factors.

RESULTS

The complication rate was 5.4%. 11 patients (29.7%) conceived after the procedure. The pregnancy rate was better when myoma was the exclusive etiology of infertility (40%), when the myoma was completely intracavitary (33.3%), when the lesion was ≥ 30 mm in size (50%), and there were no associated intramural fibroids.

CONCLUSION

Hysteroscopic myomectomy is a safe procedure to enhance fertility especially in cases with unexplained infertility.