Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Mortality and Complications of COVID-19 Among Adult Congenital Heart Disease Patients: A Retrospective Cohort Study Using the National Inpatient Sample Database

This study examines in-hospital mortality and complicated COVID-19 infection among adult congenital heart disease (ACHD) patients admitted with COVID-19, using the National Inpatient Sample (NIS). A total of 4219 COVID-19 patients with ACHD were included. We demonstrated that COVID-19 patients with ACHD were more likely to experience in-hospital mortality (OR 1.04, 95% CI 1.04-1.04, P < 0.01) and complicated COVID-19 infection (OR: 1.30, 95% CI: 1.11-1.53, P < 0.01). In our sub-group analysis, COVID-19 patients with tetralogy of Fallot (TOF) had higher mortality and COVID-19 patients with atrial septal defects (ASD) had a higher incidence of complicated infection when compared to COVID-19 patients with all other ACHDs. Risk factors for mortality among COVID-19 patients with ACHD include advanced age, lower income, unrepaired ACHD, malnutrition, and chronic liver disease. Accordingly, we recommend aggressive preventive care with vaccination and non-pharmacologic measures in order to improve survival for ACHD patients.

Population Risk Factors for Severe Disease and Mortality in COVID-19 in the United States during the Pre-Vaccine Era: A Retrospective Cohort Study of National Inpatient Sample

Background-Previous studies on coronavirus disease 2019 (COVID-19) were limited to specific geographical locations and small sample sizes. Therefore, we used the National Inpatient Sample (NIS) 2020 database to determine the risk factors for severe outcomes and mortality in COVID-19. Methods-We included adult patients with COVID-19. Univariate and multivariate logistic regression was performed to determine the predictors of severe outcomes and mortality in COVID-19. Results-1,608,980 (95% CI 1,570,803-1,647,156) hospitalizations with COVID-19 were included. Severe complications occurred in 78.3% of COVID-19 acute respiratory distress syndrome (ARDS) and 25% of COVID-19 pneumonia patients. The mortality rate for COVID-19 ARDS was 54% and for COVID-19 pneumonia was 16.6%. On multivariate analysis, age > 65 years, male sex, government insurance or no insurance, residence in low-income areas, non-white races, stroke, chronic kidney disease, heart failure, malnutrition, primary immunodeficiency, long-term steroid/immunomodulatory use, complicated diabetes mellitus, and liver disease were associated with COVID-19 related complications and mortality. Cardiac arrest, septic shock, and intubation had the highest odds of mortality. Conclusions-Socioeconomic disparities and medical comorbidities were significant determinants of mortality in the US in the pre-vaccine era. Therefore, aggressive vaccination of high-risk patients and healthcare policies to address socioeconomic disparities are necessary to reduce death rates in future pandemics.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Independent Predictors of Mortality in COVID-19 Myocardial Injury: The Role of Troponin Levels, GRACE Score, SOFA Score, and TIMI Score

Background Coronavirus disease 2019 (COVID-19) infection is associated with troponin elevation, which is associated with increased mortality. However, it is not clear if troponin elevation is independently linked to increased mortality in COVID-19 patients. Although there is considerable literature on risk factors for mortality in COVID-19-associated myocardial injury, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction (TIMI), and Sequential Organ Failure Assessment (SOFA) scores have not been studied in COVID-19-related myocardial injury. This data is important in risk-stratifying COVID-19 myocardial injury patients. Methodology Of the 1,500 COVID-19 patients admitted to our hospitals, 217 patients who had troponin levels measured were included. Key variables were collected manually, and univariate and multivariate cox regression analysis was done to determine the predictors of mortality in COVID-19-associated myocardial injury. The differences in clinical profiles and outcomes of COVID-19 patients with and without troponin elevation were compared. Results Mortality was 26.5% in the normal troponin group and 54.6% in the elevated troponin group. Patients with elevated troponins had increased frequency of hypotension (p = 0.01), oxygen support (p < 0.01), low absolute lymphocyte (p < 0.01), elevated blood urea nitrogen (p < 0.01), higher C-reactive protein (p < 0.01), higher D-dimer (p < 0.01), higher lactic acid (p < 0.01), and higher Quick SOFA (qSOFA), SOFA, TIMI, and GRACE (all scores p < 0.01). On univariate cox regression, troponin elevation (hazard ratio (HR) = 1.85, 95% confidence interval (CI) = 1.18-2.88, p < 0.01), TIMI score >3 (HRv = 1.79, 95% CI = 1.11-2.75, p = 0.01), and GRACE score >140 (HR = 2.27, 95% CI = 1.45-3.55, p < 0.01) were highly associated with mortality, whereas cardiovascular disease (HR = 1.40, 95% CI = 0.89-2.21, p = 0.129) and cardiovascular risk factors (HR = 1.15, 95% CI = 0.73-1.81, p = 0.52) were not. After adjusting for age, use of a non-rebreather or high-flow nasal cannula, hemoglobin <8.5 g/dL, suspected or confirmed source of infection, and qSOFA and SOFA scores (HR = 1.18, 95% CI = 1.07-1.29, p < 0.01) were independently associated with mortality, whereas troponin (HR = 1.08, 95% CI = 0.63-1.85, p = 0.76), TIMI score (HR = 1.02, 95% CI = 0.99-1.06, p = 0.12) and GRACE scores (HR = 1.01, 95% CI = 0.99-1.02, p = 0.10) were not associated with mortality. Conclusions Our study shows that troponin, GRACE score, and TIMI score are not independent predictors of mortality in COVID-19 myocardial injury. This may be because troponin elevation in COVID-19 patients may be related to demand ischemia rather than acute coronary syndrome-related. This was shown by the association of troponin with a higher degree of systemic inflammation and end-organ dysfunction. Therefore, we recommend SOFA scores in risk-stratifying COVID-19 patients with myocardial injury.

Inequalities in accessing quality healthcare, does insurance play a role? retrospective analysis of aortic emergencies from national inpatient sample 2019

Background

Aortic emergencies, dissection and rupture, are rare but catastrophic entities, with the cornerstone to survival being prompt diagnosis and treatment. Insurance status often limits access to healthcare, and our study aims to determine if it plays a role in the outcomes of aortic emergencies.

Method

A retrospective analysis of the 2019 Nationwide Inpatient Sample was conducted to identify hospitalization (Age ≥18 & non-elective) with aortic dissection and ruptured aortic aneurysms using ICD-10 codes. Discharge-level weight analysis was used to produce a national estimate. Variables were screened with univariate regression, and intermediate and co-linear variables were screened-out before a multivariable regression analysis model was built and performed to calculate the odds ratio.

Results

A total of 19,685 (0.06%) hospitalizations are identified for aortic emergencies (14965 dissections & 4720 ruptured aneurysms). The mean age was 58.56, 62.7% were males, and ethnic distribution was 65.1% white, 19.5% blacks, 7.6% Hispanics, and others.

11.4% of the hospitalizations underwent diagnostic imaging with either CTA/MRA/TEE/Aortography within 24 hours. Hypotension/shock was present in 32% of these hospitalizations and was a risk factor for mortality OR 3.21 (p&lt;0.00), increasing LOS by an average of 5.1 days and resource utilization by 156,000$. Another risk factor for mortality was stroke/TIA (OR-1.76, p&lt;0.00), increasing LOS and resource utilization by 3.1 days and 80,662$, respectively.

3220 hospitalizations (16.4%) did not survive the course, and the mortality rate in uninsured, Medicare, and Medicaid was 17%, 20%,9% compared with 12% in privately insured. On crude analysis, uninsured and medicare patients appeared to have higher odds of mortality [OR 1.50, p&lt;0.04, and OR 1.83 p-value &lt;0.002 respectively], however upon adjusting for confounders, only uninsured patients showed statistically significant difference (OR 2.13, p&lt;0.002). Similar results were corroborated on analyzing hospitalizations for aortic dissection; however, insurance status did not influence mortality in a ruptured aneurysm.

When comparing hospitalization of median household income of ≥79,000$ with household of median income of 59,000–78,999 $, 46,000–58,999 $ and &lt;46,000$ had higher odds of mortality (OR-1.38, p&lt;0.04), (OR-1.44, p&lt;0.02) and (OR-1.44, p&lt;0.03) respectively. Of all the insurance types, a statistically significant difference compared with private insurance, Medicaid on average, had 2.8 more days and incurred an additional 62,912$ in resource utilization (p&lt;0.00).

Conclusion

Inequalities in accessing healthcare, median household income, and insurance status are risk factors for mortality in aortic emergencies. Efforts are needed to bridge the gap in this particular facet of social determinants of health to find a sustainable and equitable solution for quality healthcare for aall regardless of their insurance status.

Funding Acknowledgement

Type of funding sources: None.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

130 Paediatric Hand Fractures Requiring Surgery – the Results of a Bespoke Hand Surgery Service

Aim

To evaluate the management of The Royal Devon and Exeter Hospital (RD&E) bespoke hand surgery service on paediatric closed hand fractures. In particular, an assessment against The British Society for Surgery of the Hand (BSSH) closed fracture standards on treatment timelines and national guidance compliance.

Method

A retrospective review of all paediatric patients requiring plastic surgery seen at the RD&E plastics trauma clinic from 1st Nov 2020 to 28th Feb 2021 was performed. This was compared to two previous audit cycles completed during winter 2019 and summer 2020. Health informatics was collated via our IT department and thoroughly reviewed using departmental notes. Exclusion criteria included: all non-fracture injuries, patients &gt; 18 years old and open fractures.

Results

In winter 2020–21 all patients were referred the same day of injury and 92% were seen by a Plastic Surgeon within 24 hours of injury. This was an improvement from the mean time from referral to clinic of 5 days in winter 2019 and 1.33 days in summer 2020 respectively. 85% of cases are now operated within 48 hours of review and 92% of cases were operated within 72 hours of the decision to operate where conservative management had failed.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures. We should continue to focus on improving and increasing capacity of this service as it has likely improved both the patient journey and outcomes.

Combined Use of Wells Scores and D-dimer Levels for the Diagnosis of Deep Vein Thrombosis and Pulmonary Embolism in COVID-19: A Retrospective Cohort Study

Introduction

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are key complications of coronavirus disease 2019 (COVID-19). The study's primary outcome was assessing the utility of Wells DVT, Wells PE scores, and D-dimers in diagnosing DVT and PE. Secondary outcomes were the risk factors for the development of PE and DVT in COVID-19 patients.

Materials and methods

We compared COVID-19 patients with a positive and negative lower extremity (LE) duplex. A similar approach was made for patients who underwent imaging for PE.

Results

The prevalence of PE was 23.8% (26 out of 109 patients), and the prevalence of DVT was 33% (35 out of 106). A D-dimer of 500 ng/mL had a sensitivity of 95.6% and 93.7% for the diagnosis of PE and DVT, respectively. A Wells DVT score of 3 points had a specificity of 92.9% and sensitivity of 8.8% for DVT diagnosis in COVID-19. A Wells PE score of 4 had a specificity of 100% and a sensitivity of 20% for the diagnosis of PE. The combined approach of using a Wells DVT score of 3 in suspected DVT and a Wells PE score of 4 in suspected PE and D-dimers of 500 ng/ml has a sensitivity of 94.2% and 96.1%, respectively.

In the suspected DVT group, male gender (OR 3.88, 95% CI 1.55-9.7, P=0.004), lower body mass index (BMI) (OR 0.92, 95% CI 0.86-0.99, P=0.037), antiplatelet use (OR 0.19, 95% CI 0.04-0.88, P=0.035), systolic blood pressure ≤100 mmhg (OR 4.96, 95% CI 1.37-17.86, P=0.014), absolute lymphocytes ≤1 (OR 2.57, 95% CI 1.07-6.12, P=0.033), D-dimer ≥500 ng/ml (OR 6.42, 95% CI 1.40-29.38, P=0.016), blood urea nitrogen (BUN) ≥20 mg/dl (OR 2.33, 95% CI 1.00-5.41, P=0.048), and intubation (OR 3.32, 95% CI 1.26-8.78, P=0.015) were found to be statistically significant for DVT.

In the suspected PE group, history of cancer (OR 10.69, 95% CI 1.06-107.74, P=0.044), total WBC count (OR 1.07, 95% CI 0.95-1.21, P=0.032), platelets ≥ 400,000 (OR 5.13, 95% CI 1.79-14.68, P=0.002), D-dimer levels ≥ 500 ng/ml (OR 25.47, 95% CI 3.27-197.97, P=0.002), Wells PE score (OR 2.46, 95% CI 1.50-4.06, P<0.001), pulmonary embolism rule-out criteria (PERC) score (OR 1.79, 95% CI 1.05-3.05, P=0.054), and Sequential Organ Failure Assessment (SOFA) score (OR 1.91, 95% CI 1.16-3.12, P=0.002) were statistically significant.

Conclusions

The combined approach of using a Wells DVT score of 3 in suspected DVT and Wells PE score of 4 in suspected PE and D-dimers of 500 ng/ml may be used to diagnose PE and DVT in COVID-19. Venous thromboembolism (VTE) occurrence in COVID-19 is associated with non-traditional risk factors such as intubation and higher severity of systemic inflammation, and these patients may benefit from more aggressive testing for VTE.

1018 Did COVID Compromise the Care of Closed Paediatric Hand Fractures?

Aim

To assess the effect of a ‘rapid-access’ musculoskeletal unit, established in March 2020, as part of the Royal Devon & Exeter hospital COVID response, with direct assessment of hand trauma by the Plastic Surgery department staff, on treatment timelines and national guidance compliance for closed paediatric hand fractures.

Method

This was a retrospective review from 1st January to 31st December 2019 and a prospective study from the 1st April to 15th June 2020. The retrospective cases were collated by health informatics. The prospective data was recorded on the department’s database. Exclusion criteria: nail bed injuries with tuft fractures, ligament injuries only, open fractures and patients aged 18 at time of surgery.

Results

In 2019 the majority (73%) of patients (n = 26) were referred within 48hrs but waited a median of 5 days to be seen in clinic by a hand surgeon resulting in significant delays in treatment. After service reconfiguration in 2020, all patients (n = 6) were operated on within 72 hours of the decision to operate - mean time to surgery 1.5 days (range 0-3 days). The mean time from referral to clinic was 1.33 days (range 0-6 days). 4 patients were operated on within 7 days of injury. Of the 2 patients operated on &gt; 7 days, 1 was referred 32 days post injury and 1 failed conservative management.

Conclusions

The introduction of a ‘rapid-access’ musculoskeletal unit with early senior review and a dedicated theatre has created ‘gold-standard’ compliance with national standards for the operative management of closed paediatric fractures.

89 Do Corticosteroid and Local Anaesthetic Hip Injections Administered Proximal or Distal to The Zona Orbicularis Have an Effect on Patient Satisfaction?

Aim

Pubofemoral and ischiofemoral ligaments blend to make zona orbicularis. Zonaorbicularis has been suggested to force fluid from peripheral compartment to central compartment in unidirectional flow. This study aims to assess whether injection of corticosteroid with local anaesthetic injected either proximal or distal to the zona orbicularis has effect on patient satisfaction.

Method

This retrospective study investigated consecutive patients undergoing ultrasound guided hip injections at a single centre in the UK between November 2018 and March 2019. Patients were identified using IMPAX© picture archiving and communications system. Radiographs were assessed to see if radiopaque dye and therefore corticosteroid and local anaesthetic had been injected proximal or distal to the zona orbicularis. Clinic letters were accessed on the electronic patient record and we recorded whether patients had pain relief at 24 hours and 2 weeks following hip injection.

Results

133 Patients were identified during the study period, of which 40 were included. At 24 hours post-injection 72% of patients were satisfied and 28% were unsatisfied, for which there was 76% and 70% satisfaction for proximal and distal injections respectively (p = 0.63). At 2 weeks post-injection 45% of patients were satisfied and 55% of patients unsatisfied, for which there was 47% and 44% satisfaction for proximal and distal injections respectively (p = 0.9).

Conclusions

Overall patient satisfaction is high following hip corticosteroid and local anaesthetic injection. No difference was found between injections proximal and distal to the zona orbicularis. Further research is needed to quantify the association between proximal and distal injections.

Multifocal Pneumonia Amidst the Global COVID-19 Pandemic: A Case of Daptomycin-Induced Eosinophilic Pneumonia

Multifocal pneumonia amidst this global pandemic is often attributed to COVID-19, resulting in missed diagnosis of other potentially fatal illnesses such as eosinophilic pneumonia. Eosinophilic pneumonia is often associated with antibiotics and non-steroidal anti-inflammatory drugs. A 65-year-old male presented to the emergency department for a four-day history of fatigue, cough, and worsening dyspnea; CT thorax showed extensive multifocal pneumonia, and COVID-19 was suspected. COVID-19 testing using reverse transcription polymerase chain reaction was negative, and complete blood count revealed peripheral eosinophilia, which is not expected in COVID-19. The patient was being treated concomitantly with daptomycin and ceftaroline for septic arthritis and methicillin-resistant Staphylococcus aureus bacteremia. We reconsidered our initial diagnosis and held daptomycin, after which the patient started to improve. Due to hypoxia, steroids were added, which resulted in a dramatic improvement of the patient's symptoms. Daptomycin can have toxic effects, resulting in the accumulation of eosinophils in the lung parenchyma. Symptoms usually arise by the third week and include dyspnea, peripheral eosinophilia, and infiltrates involving the outer one-third of the lung fields. FDA drug safety guidance helped to establish this diagnosis. The treatment options include the removal of offending agents and steroids in severe cases.

Secondary Immune Thrombocytopenic Purpura Triggered by COVID-19

Multiple infectious causes have been implicated with the development of secondary immune thrombocytopenic purpura (ITP). Nevertheless, new pathogens, including coronavirus disease 2019 (COVID-19), are recently being described in its development. A 41-year-old Hispanic male presented to the Emergency Department with a two-day history of bleeding gums and blood-tinged sputum. A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) test was positive on admission. Initial laboratory studies showed severe thrombocytopenia of 3x10⁹/L (150-400x10⁹/L) with no abnormal platelets or schistocytes seen on peripheral blood smear, with normal prothrombin time/international normalized ratio (PT/INR), partial thromboplastin time (PTT) and fibrinogen levels. Secondary causes of thrombocytopenia were ruled out. One unit of single donor platelets was transfused and the patient was treated with intravenous dexamethasone for a total of five days and intravenous immunoglobulin (IVIG) for two days. One week after discharge the patient had a recurrence of epistaxis and hematuria requiring a second course of steroids and IVIG and the decision was made to start the patient on eltrombopag 50mg daily, which maintained his platelet counts within normal limits. COVID-19-associated ITP can be severe and life-threatening and hence warrants rapid and prompt management with steroids and IVIG. In refractory cases, thrombopoietin receptor agonists should be used.

Wildland Fire Emission Sampling at Fishlake National Forest, Utah Using an Unmanned Aircraft System

Emissions from a stand replacement prescribed burn were sampled using an unmanned aircraft system (UAS, or "drone") in Fishlake National Forest, Utah, U.S.A. Sixteen flights over three days in June 2019 provided emission factors for a broad range of compounds including carbon monoxide (CO), carbon dioxide (CO₂), nitric oxide (NO), nitrogen oxide (NO₂), particulate matter < 2.5 microns in diameter (PM_2.5), volatile organic compounds (VOCs) including carbonyls, black carbon, and elemental/organic carbon. To our knowledge, this is the first UAS-based emission sampling for a fire of this magnitude, including both slash pile and crown fires resulting in wildfire-like conditions. The burns consisted of drip torch ignitions as well as ground-mobile and aerial helicopter ignitions of large stands comprising over 1,000 ha, allowing for comparison of same-species emission factors burned under different conditions. The use of a UAS for emission sampling minimizes risk to personnel and equipment, allowing flexibility in sampling location and ensuring capture of representative, fresh smoke constituents. PM_2.5 emission factors varied 5-fold and, like most pollutants, varied inversely with combustion efficiency resulting in lower emission factors from the slash piles than the crown fires.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.

Effect of sodium molybdate supplementation on high concentrations of Cu in liver of yearling bulls

AIM

To determine the impact of sodium molybdate treatment, given weekly, on concentrations of Cu in liver, activity of liver enzymes, and weight gain over 4 weeks, in yearling bulls with elevated concentrations of Cu in liver.

METHODS

The study was carried on two commercial grazing farms in the Otago region of New Zealand in yearling Friesian bulls (n=150 on Farm A and n=49 on Farm B) with mean concentration of Cu in liver >3,000 µmol/kg fresh weight. On Day 0, all animals were weighed and half were systematically allocated to treatment with sodium molybdate (3 mg/kg liveweight on Farm A and 7 mg/kg liveweight on Farm B); the remainder received no treatment (Control). Sodium molybdate was given as a drench weekly for 4 weeks and all animals were weighed again on Day 28. Ten animals on each farm (five from each treatment group) were systematically selected for blood sampling and liver biopsies on Days 0 and 28. Samples were analysed for concentrations of Cu in plasma, vitamin B₁₂ in serum, activities of γ-glutamyl transferase, aspartate aminotransferase and glutamate dehydrogenase in serum, and concentrations of Cu and vitamin B₁₂ in liver. Separate multivariable linear models were used to compare the change in outcome variables between Days 0 and 28 between bulls that had been drenched with sodium molybdate or not.

RESULTS

On Farm A, mean concentrations of Cu in liver on Day 28, as a percentage of concentrations on Day 0, for the control group was 55 (95% CI=40-73)% and for the treatment group was 73 (95% CI=43-111)%. On Farm B, the equivalent mean for the control group was 75 (95% CI=42-131)% and for the treatment group was 85 (95% CI=38-134)%. The multivariable linear models indicated that the changes in concentrations of Cu in liver, activities of liver enzymes and weight gain between Days 0 and 28 did not differ between the bulls treated or not with sodium molybdate (p>0.18).

CONCLUSIONS AND CLINICAL RELEVANCE

Treatment with sodium molybdate in one bolus at weekly intervals for 4 weeks did not affect concentrations of Cu in liver, activity of liver enzymes or weight gain in animals with high concentrations of Cu liver on two farms.

Evidence-based management of adult trigger digits

The aim of this systematic review was to develop an evidence-based guideline to assist clinicians in the treatment of adult trigger digits. There is moderate evidence to suggest that local corticosteroid injection is a safe and effective short-term treatment and it may, therefore, be recommended as an initial treatment for this condition. However, when compared with surgery, there is strong evidence that corticosteroid injection is associated with increased rates of ongoing or recurrent symptoms at 6 months after intervention. There is strong evidence suggesting that trigger digit can be managed safely by surgical release. There is weak evidence to support the use of splinting or other non-operative modalities. Hence a single corticosteroid injection may be offered as the first line in treatment of adult trigger digits, but percutaneous release is a safe alternative. Surgery should be the next line if the injection fails, symptoms recur or the patient chooses.

LEVEL OF EVIDENCE

I.

Cemented or cementless humeral fixation in reverse total shoulder arthroplasty?

Aims

To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA).

Methods

A systemic review comprising 41 clinical studies was performed to compare the functional outcome and rate of complications of cemented and uncemented stems in RSA. These included 1455 cemented and 329 uncemented shoulders. The clinical characteristics of the two groups were similar. Variables were compared using pooled frequency-weighted means and relative risk ratios (RR).

Results

Uncemented stems had a significantly higher incidence of early humeral stem migration (p < 0.001, RR 18.1, 95% confidence interval (CI) 5.0 to 65.2) and non-progressive radiolucent lines (p < 0.001, RR 2.4, 95% CI 1.7 to 3.4), but a significantly lower incidence of post-operative fractures of the acromion compared with cemented stems (p = 0.004, RR 14.3, 95% CI 0.9 to 232.8). There was no difference in the risk of stem loosening or revision between the groups. The cemented stems had a greater relative risk of infection (RR 3.3, 95% CI 0.8 to 13.7), nerve injury (RR 5.7, 95% CI 0.7 to 41.5) and thromboembolism (RR 3.9, 95% CI 0.2 to 66.6). The functional outcome and range of movement were equivalent in the two groups.

Discussion

RSA performed with an uncemented stem gives them equivalent functional outcome and a better complication profile than with a cemented stem. The natural history and clinical relevance of early stem migration and radiolucent lines found with uncemented stems requires further long-term study. Take home message: This study demonstrates that uncemented stems have at least equivalent clinical and radiographic outcomes compared with cemented stems when used for reverse total shoulder arthroplasty. Cite this article: Bone Joint J 2016;98-B:65–74

Direct observation of the coherent nuclear response after the absorption of a photon

How molecules convert light energy to perform a specific transformation is a fundamental question in photophysics. Ultrafast spectroscopy reveals the kinetics associated with electronic energy flow, but little is known about how absorbed photon energy drives nuclear motion. Here we used ultrabroadband transient absorption spectroscopy to monitor coherent vibrational energy flow after photoexcitation of the retinal chromophore. In the proton pump bacteriorhodopsin, we observed coherent activation of hydrogen-out-of-plane wagging and backbone torsional modes that were replaced by unreactive coordinates in the solution environment, concomitant with a deactivation of the reactive relaxation pathway.

Are soft tissue measurements on lateral cervical spine X-rays reliable in the assessment of traumatic injuries?

INTRODUCTION

Traumatic neck pain is a common presentation to the emergency department. Lateral plain radiographs remain the primary investigation in the assessment of these injuries. Soft tissue assessment forms an integral component of these radiographs. They can provide information on subtle injuries that may not be obvious. Many methods are used to assess the prevertebral soft tissue shadows. The two more commonly used techniques include the 'seven at two and two at seven' rule (method 1) and the ratio of the soft tissues with respect to the vertebral width (method 2).

AIM

To assess which of the above two methods in assessing cervical spine soft tissue shadows on lateral radiographs is more sensitive in the presence of cervical spine injuries.

METHODS

A retrospective analysis of consecutive traumatic cervical spine films performed within a busy trauma tertiary centre over a period of 7 months. Patients were divided into two groups: group 1-fractures; group 2-no fractures. The prevertebral soft tissue shadows were measured at referenced points on the lateral cervical spine films with respect to the above two methods and comparisons between the groups were made.

RESULTS

Thirty-nine patients in group 1 were compared to a control group of 60 patients in group 2. Both methods failed to identify any significant differences between the two groups. The sensitivity and specificity for method 1 was 7.6 and 93 %, and for method 2, they were 7.6 and 98 %, respectively.

CONCLUSION

There is no significant difference between the soft tissue shadows when comparing patients with and without cervical spine fractures on lateral radiographs. Both commonly used measures of soft tissue shadows in clinical practice are insensitive in identifying patients with significant osseous injuries. They, therefore, do not offer any further value in interpreting traumatic cervical spine radiographs. The management of patients with cervical spine trauma in the absence of obvious osseous injury on standard radiographs should warrant a computed tomography (CT) scan if clinically indicated.

Inhibition of CXCR3-mediated chemotaxis by the human chemokine receptor-like protein CCX-CKR

BACKGROUND AND PURPOSE

Induction of cellular migration is the primary effect of chemokine receptor activation. However, several chemokine receptor-like proteins bind chemokines without subsequent induction of intracellular signalling and chemotaxis. It has been suggested that they act as chemokine scavengers, which may control local chemokine levels and contribute to the function of chemokines during inflammation. This has been verified for the chemokine-like receptor proteins D6 and DARC as well as CCX-CKR. Here, we provide evidence for an additional biological function of human (h)CCX-CKR.

EXPERIMENTAL APPROACH

We used transfection strategies in HEK293 and human T cells.

KEY RESULTS

Co-expression of hCCX-CKR completely inhibits hCXCR3-induced chemotaxis. We found that hCCX-CKR forms complexes with hCXCR3, suggesting a relationship between CCX-CKR heteromerization and inhibition of chemotaxis. Moreover, negative binding cooperativity induced by ligands both for hCXCR3 and hCCX-CKR was observed in cells expressing both receptors. This negative cooperativity may also explain the hCCX-CKR-induced inhibition of chemotaxis.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that hCCX-CKR prevents hCXCR3-induced chemotaxis by heteromerization thus representing a novel mechanism of regulation of immune cell migration.