"People are now working together for a common good": The effect on social capital of participatory design for community-level sanitation infrastructure in urban informal settlements

Communities with higher levels of social capital perform better than communities with lower social capital in community-level water and sanitation interventions and have better health outcomes. Although research recommends bolstering social capital to improve intervention outcomes, few studies provide empirical evidence on the effect of intervention activities on social capital. This study aimed to evaluate the effect of participatory design and community engagement activities on social capital among urban informal settlements in Suva, Fiji and Makassar, Indonesia enrolled in the Revitalizing Informal Settlements and their Environments trial using the Short Adapted Social Capital Assessment Tool. We performed confirmatory factor analyses (CFA) to test tool performance and built structural equation models to assess intervention effect on CFA-informed, sub-scale scores for cognitive and structural social capital. Qualitative in-depth interviews in Fiji and Indonesia and focus group discussions in Fiji provided nuanced understanding of intervention effects on social capital from residents' perspectives. Results confirmed the hypothesized two-factor solution but revealed differences by country and by gender in Indonesia. The intervention appeared positively related to cognitive social capital among men and women in Indonesia and negatively related to cognitive and structural social capital among men and women in Fiji. While effect sizes were small and cluster-adjustment for a small number of settlements yielded non-significant effects, trends were consistent across models and bivariate analyses and were corroborated by qualitative findings. Several contextual factors may explain these results, including timing and duration of intervention activities and influence of COVID-19. Qualitative data suggested that the relationship between participatory design and social capital may be bidirectional, helping to explain why certain settlements appeared to be better equipped to benefit from intervention activities. Practitioners and program designers should carefully consider the social pre-conditions of communities in which they intend to work to optimize program outcomes and avoid unintended consequences.

AB1465 BLACK PATIENTS ARE LESS SATISFIED WITH THE PROCESS OF CARE FOLLOWING PRIMARY HIP AND KNEE ARTHROPLASTY: A RETROSPECTIVE STUDY

Background

Patients’ post-operative satisfaction with their hospital experience is important to patient care, hospital reimbursement, and comparison between hospitals. The Press Ganey (PG) inpatient survey is commonly administered to assess patient satisfaction with the process of care. However, whether patient PG survey scores following primary unilateral hip and knee arthroplasty are associated with a patient’s race and socioeconomic status (SES) is unknown.

Objectives

We aimed to determine whether patient PG survey overall assessment scores differ by race and SES.

Methods

We linked data for patients in large institutional hip and knee arthroplasty registries consisting of surgeries from July 2010–February 2012 to their PG survey responses. Patients undergoing primary unilateral surgery of Black or White race who resided in New York, New Jersey, or Connecticut at the time of surgery were included in the analysis. The primary outcome variable was the PG overall assessment score, calculated as the mean of a patient’s ratings for the three questions in the “Overall Assessment” section of the PG survey and dichotomized as either completely satisfied (score of 100) or not completely satisfied (score <100). Primary payor was used as a proxy for patient SES. Multivariable logistic regression was performed for the hip and knee cohorts separately to determine if patient race and primary payor were associated with not being completely satisfied, adjusting for age, sex, and American Society of Anesthesiology (ASA) score.

Results

There were 2,516 hip patients and 2,113 knee patients with PG overall assessment scores included in the analyses (Table 1). Black patients were more likely to be not completely satisfied compared to White patients in both cohorts [hip (odds ratio (OR)=1.64; 95% confidence interval (CI): 1.03, 2.61; p=0.04)]; [knee (OR=1.83; 95% CI: 1.16, 2.88; p=0.01). In the hip cohort, patients between 70-79 years old (OR=1.71; 95% CI: 1.09, 2.67; p=0.02) and older than 80 years (OR=2.00; 95% CI: 1.20, 3.32; p<0.01) were more likely to be not completely satisfied. In the knee cohort, patients 50-59 years old (OR=0.56; 95% CI: 0.33, 0.97; p=0.04) and 60-69 years old (OR=0.57; 95% CI: 0.33, 0.96; p=0.03) were less likely to be not completely satisfied compared to patients <50 years old.

Table 1.

Likelihood of not being completely satisfied with the process of care (PG score <100)

VariableReferenceCategoryHip Cohort (n = 2,516)Knee Cohort (n = 2,113)Odds Ratio95% CIp-valueOdds Ratio95% CIp-valueAge Group<5050-591.02(0.69, 1.50)0.9390.56(0.32, 0.97)0.039<5060-691.04(0.70, 1.54)0.8580.57(0.33, 0.96)0.034<5070-791.71(1.09, 2.67)0.0190.63(0.36, 1.11)0.113<5080+2.00(1.20, 3.32)0.0080.97(0.53, 1.77)0.912SexFemaleMale0.84(0.69, 1.02)0.0821.03(0.83, 1.26)0.816RaceWhiteBlack1.64(1.03, 2.61)0.0381.83(1.16, 2.88)0.010ASA status121.04(0.70, 1.55)0.8321.23(0.60, 2.51)0.580131.45(0.91, 2.29)0.1161.36(0.64, 2.87)0.41914<0.01(0.00, ***)0.968<0.01(0.00, ***)0.977Primary PayorMedicareMedicaid1.35(0.26, 7.01)0.718<0.01(0.00, ***)0.983MedicareOther/Unknown1.24(0.94, 1.64)0.1260.87(0.65, 1.17)0.362MedicarePrivate1.13(0.61, 2.10)0.6881.01(0.57, 1.78)0.983

ASA = American Society of Anesthesiologist (ASA) physical status classification. PG = Press Ganey. CI = Confidence Interval. *** indicates >999.99. Bold indicates p < 0.05

Conclusion

Black patients were less likely to be completely satisfied compared to White patients following total hip and knee arthroplasty. More research is needed to investigate other factors such as perceived staff courtesy and baseline pain and function to understand why these disparities exist.

Acknowledgements

This work was supported by the Stavros Niarchos Complex Joint Reconstruction Center at Hospital for Special Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the center.

Disclosure of Interests

J. Alex Gibbons: None declared, Orett Burke Jr: None declared, Huong Do: None declared, Emily Ying Lai: None declared, Bella Mehta Paid instructor for: Novartis, Letitia Bradford: None declared, Michael Parks Consultant of: ZimmerBiomet, Linda Russell: None declared, Anne Bass: None declared, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis

POS0417 LESS ACPA EPITOPE EXPANSION IS FOUND IN ACPA-POSITIVE IMMUNE CHECKPOINT INHIBITOR ARTHRITIS PATIENTS COMPARED TO ACPA-POSITIVE RHEUMATOID ARTHRITIS PATIENTS

Background

Immune checkpoint inhibitors (ICI) have markedly improved the treatment of many advanced cancers; however, they can result in immune-related adverse events (irAE) including ICI arthritis (ICI-A). ICI-A often resembles rheumatoid arthritis (RA) and ~9% of ICI-A patients are anti-citrullinated peptide antibody (ACPA) positive. In RA, ACPA epitope expansion occurs over the years prior to onset of clinical disease. In this study we examined the degree of ACPA epitope expansion in seropositive ICI-A patients in order to determine whether it is similar to early RA, or more suggestive of the pre-clinical phase of disease1.

Objectives

To compare the number of ACPA epitopes targeted in seropositive ICI-A versus RA.

Methods

We used clinical data and serum from 12 ACPA+ ICI-A patients enrolled in a prospective registry and 39 ACPA+ RA patients enrolled in the CATCH-US early RA cohort. ACPA screening was done using a commercial ELISA (positive >20 units/mL). A custom, bead-based antigen array was used to identify antibody reactivities to 16 putative RA associated citrullinated proteins. Synovial fluid (SF) samples from 3 of the ICI-A patients were also tested using the bead-based microarray. Hierarchical clustering software was used to create heatmaps to identify ACPA levels. Z-scores for fluorescence intensity were also calculated separately for each peptide, and a fluorescence level above the mean (Z-score>0) was defined as a positive ACPA. The number of positive epitopes for each patient was determined and compared categorically between the ICI-A and RA patients using Fischer’s exact test.

Results

Characteristics of ICI-A and early RA patients are listed in Table 1. Compared to RA patients, ICI-A patients were older (mean 71 years vs. 48 years), more likely to have ever smoked (67% vs. 36%) and less likely to have positive rheumatoid factor (RF) (8% vs. 69%). Median symptom duration for ICI-A patients was 3.7 months compared to 6.7 months in RA patients. The median ACPA titer was lower in ICI-A patients than RA patients (42 units/mL vs. 250 units/mL). As demonstrated in Figure 1, lower signal intensities (level of ACPA) and a lower number of distinct ACPA epitopes were seen in the serum of ICI-A patients compared to RA patients. Of ICI-A patients, 67% were positive for 0-4 ACPA epitopes, 8% for 5-10 epitopes and 25% for >10 epitopes, as opposed to 23% of RA patients positive for 0-4 epitopes, 36% for 5-10 epitopes, and 41% for >10 epitopes (p=0.02). The one ICI-A patient who was also RF positive had 12 positive ACPA epitopes. There was no significant difference in the number of ACPA epitopes in ICI-A patients who were smokers vs. nonsmokers, RA-like vs. PMR-like, or who received ICI combination vs. ICI monotherapy. In the 3 ICI-A patients with synovial fluid samples, SF ACPA was not demonstrated.

Table 1.

Baseline Characteristics of ACPA+ ICI-A and RA Patients

ICI-A (N=12)Early RA (N=39)Age in years, mean (SD)71.0 (8.3)48.2 (14.6)Female Sex7 (58%)33 (85%)White/Caucasian9 (75%)27 (69%)Symptom Duration in months, median [IQR]3.7 [1.0,11.3]6.7 [4.0,9.7]RF Positive1 (8%)27 (69%)ACPA level (units/mL), median [IQR]42.2 [29.4,70.5]250 [107.5,251.0]Obese (BMI≥30)3 (25%)9 (23%)Current/Past Smoker8 (67%)14 (36%)Cancer Typeǂ Melanoma4 (33%) Renal Cell Carcinoma3 (25%)ICI Regimen PD-1/PD-L17 (58%) CTLA-4+PD-15 (42%)ICI-A Phenotype RA-like9 (75%) PMR-like3 (25%)

ǂOther cancer types in ICI-A patients included urothelial carcinoma (n=2), non-small cell lung cancer (n=2), and head and neck cancer (n=1).

Figure 1.

Heat Map of ACPA repertoire in RA Patients and ICI-A Patients.

Conclusion

ICI-A patients had lower ACPA titers and targeted fewer ACPA epitopes than early RA patients. It remains to be determined if ICI-A represents an accelerated model of RA pathogenesis with ICI triggering an early transition from pre-clinical to clinical disease. This would require sequential sampling and analysis.

References

[1]Sokolove J. et al. PLoS One. 2012;7(5)e35296

Disclosure of Interests

Diviya Rajesh: None declared, Nilasha Ghosh: None declared, Jessica Kirschmann: None declared, Karmela Kim Chan: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Walgreens, and Cytodyn, Susan Goodman Consultant of: UCB Data Monitoring and Safety Board, Grant/research support from: Novartis, Vivian Bykerk Consultant of: Amgen, Bristol Myers Squibb, Genzyme, Gilead, Janssen, Pfizer, Sanofi-Aventis, and UCB, Grant/research support from: Bristol Myers Squibb, Amgen, and The Cedar Hill Foundation, William Robinson: None declared, Anne Bass: None declared.

AB1388 CHARACTERISTICS ASSOCIATED WITH MYCHART ACTIVATION AND REASONS FOR NON-USE AMONG RHEUMATOLOGY CLINIC PATIENTS

Background

Electronic patient portals, such as MyChart by Epic, allow patients to view their medical records, request medication refills, and communicate with their health care providers. Factors associated with portal use include being younger, female, White, having private insurance, and having chronic illness.1

The Hospital for Special Surgery (HSS) rheumatology clinic serves primarily patients with public insurance (Medicaid, which insures low-income adults, and Medicare, which insures adults >65 years old and those with eligible chronic illness/disability). These patients may be at increased risk for poor health outcomes due to clinical and socioeconomic factors and they are less likely to use MyChart than patients seen in HSS private practices. Increased MyChart use may benefit this high-risk group and improve health equity.

Objectives

This study aims to identify characteristics associated with MyChart activation and reasons for its underutilization among patients seen in the HSS rheumatology clinic.

Methods

We identified all patients aged ≥ 18 years seen in the HSS rheumatology clinic at least twice between January 15, 2019 and January 14, 2021, with at least one visit occurring between July 15, 2020 and January 14, 2021. MyChart status (active vs. inactive) and sociodemographic and clinical variables were extracted from the electronic health record (EHR). We used chi-square tests and t-tests to compare characteristics between patients with and without active MyChart; p-value <0.05 was considered significant (Table 1). In addition, 10 rheumatology fellows were prompted on 3 occasions over 6 weeks to informally survey their own clinic patients with inactive MyChart accounts by asking: “What is your primary reason for not using MyChart?”.

Table 1.

Baseline Characteristics of Hospital for Special Surgery Rheumatology Clinic Patients Stratified by MyChart Activation Status

MyChart Active (N=726)MyChart Inactive (N=501)p-valueAge, yrs - Mean (SD)50.3 (15.6)60.0 (15.3)<0.01Female - N (%)601 (82.8)412 (82.2)0.80Race - N (%)0.37•White/Caucasian275 (37.9)184 (36.7)•Black/African American185 (25.5)135 (27.0)•Asian58 (8.0)25 (5.0)•Other189 (26.0)145 (28.9)•Unknown18 (2.5)11 (2.2)Ethnicity - N (%)0.27•Hispanic/Latino294 (40.5)226 (45.1)•Not Hispanic/Latino422 (58.1)268 (53.5)•Unknown10 (1.4)7 (1.4)Preferred language - N (%)<0.01•English611 (84.2)332 (66.3)•Spanish72 (9.9)134 (26.8)•Other43 (5.9)35 (7.0)Needs interpreter - N (%)106 (14.6)156 (31.1)<0.01

Results

There were 1,227 patients included (93.2% with Medicaid and/or Medicare insurance). Compared to patients with inactive MyChart (42.9%), those with active MyChart (57.1%) were younger (50.3 ± 15.6 vs. 60.0 ± 15.3 years, p<0.01). The majority of patients in both groups was female. There was no significant difference in race or ethnicity between groups. Patients without active MyChart were less likely to identify English as their preferred language and more likely to require an interpreter for clinic visits (Table 1).

The rheumatology fellows collectively asked 16 clinic patients with inactive MyChart their primary reason for non-use. The most commonly cited reason was difficulty using the technology (n=8; 50.0%); others included visual impairment (n=2; 12.5%), preference for using the telephone (n=2; 12.5%), concerns about security/spam (n=2; 12.5%), not having a smart phone/computer (n=1; 6.3%), and having a language barrier (n=1; 6.3%).

Conclusion

In the HSS rheumatology clinic, patients who did not have active MyChart were older and less likely to be English-speaking than those who did. The most common barrier to MyChart use reported by patients was difficulty with the technology. This pilot data suggests a need for interventions to facilitate patient-provider communication, specifically targeting older and non-English-speaking rheumatology clinic patients, with the goal of advancing patient engagement and health equity.

References

[1]Ancker JS, et al. J Gen Intern Med. 2011 June 7. doi: 10.1007/s11606-011-1749-y.

Disclosure of Interests

Caroline Siegel: None declared, Anne Bass: None declared, Deanna Jannat-Khah Shareholder of: AstraZeneca, Walgreens, Cytodyn, Omar Bruce: None declared, Justin Olmscheid: None declared, Nilasha Ghosh: None declared, Sebastian E. Sattui Grant/research support from: AstraZeneca, Monica Schwartzman: None declared, Diane Zisa: None declared, Amit Lakhanpal: None declared, Kevin Yip: None declared, Linda Yue: None declared, Juliet Aizer Grant/research support from: Pfizer and Lilly, Jessica Berman: None declared

POS0402 CLONALLY EXPANDED CD38hi CYTOTOXIC CD8 T CELLS DEFINE THE T CELL INFILTRATE IN CHECKPOINT INHIBITOR-ASSOCIATED ARTHRITIS

Background

Immune checkpoint inhibitor (ICI) therapies that promote T cell activation have improved outcomes for advanced malignancies yet can also elicit harmful autoimmune reactions. The T cell mechanisms mediating these iatrogenic autoimmune events remain unclear.

Objectives

To investigate the immunophenotype, transcriptomic feature and clonotypes of T cells from joints of patients affected by ICI-induced inflammatory arthritis (ICI-arthritis).

Methods

Detailed immunophenotyping was performed on mononuclear cells from synovial fluid (SF) using mass cytometry and flow cytometry to identify significantly altered populations in ICI-A compared to seropositive rhrumatoid arthritis (RA) and psoriatic arthritis (PsA) (p<0.05). Bulk RNA-seq was performed on altered SF CD8 T cell subsets from ICI-A, RA and PsA to investigate their transcriptomic features. Cytokine profile and pathways enriched in ICI-A CD8 T cells were examined using differentially expressed genes, intracellular staining, and in vitro culture. TCR clonotypes were examined using single cell RNA-seq of T cells from synovial fluid, tissue and blood of ICI-A.

Results

Compared to the autoimmune arthritides RA and PsA, ICI-arthritis joints contained an expanded CD38hi CD127- CD8+ T cell subset that displays cytotoxic, effector, and interferon (IFN) response signatures. Exposure of synovial T cells to Type I IFN, more so than IFN-γ, induced the CD38hi cytotoxic phenotype. Single cell transcriptomic and T cell repertoire (TCR) analyses indicated that the abundance of CD38hi CD8 T cells in ICI-arthritis resulted from proliferation of a limited number of clones. The CD38hi population appeared distinct from dysfunctional T cells and clonally most related to TCF7+ memory populations. Comparison of synovial tissue from bilateral knees of the same patient demonstrated considerable sharing of TCR clonotypes among CD38hi CD8 T cells between the two joints. Further, TCR clonotypes expanded in synovial fluid of ICI-arthritis patients were detected in circulating T cells, and circulating CD38hi CD8 T cells are also expanded in ICI-arthritis patients.

Conclusion

These results define a distinct CD8 T cell subset in the synovial fluid and in the circulation of patients with ICI-A that may be directly activated by ICI therapy to mediate a tissue-specific autoimmune response.

Disclosure of Interests

None declared.

POS0285 ARE RACIAL DISPARITIES IN REVISION TKA OUTCOMES ASSOCIATED WITH HOSPITAL OR SURGEON VOLUME?

Background:

Total knee arthroplasty (TKA) outcomes are linked to surgical volume,1 despite the increase in TKA utilization, racial disparities in TKA outcomes persist. Blacks in the US are at a higher risk of aseptic revision of TKA (R-TKA) when compared to Whites, yet the reasons for this are not understood.

Objectives:

The objective of this study is to examine the relationship between hospital and surgeon annual TKA volume and R-TKA outcomes by race.

Methods:

This is an observational cohort study. New York Statewide Planning and Research Cooperative System data for 2004 – 2013 was used to identify patients who underwent primary TKA. Data through 2015 was used to identify R-TKA within 2 years of the index TKA. Hospital characteristics were obtained from the AHA Annual Survey. Surgeon data was collected from New York State Education Department and New York State Physician Profile. Surgeon annual TKA volume was categorized based on cutoffs established by Wilson et al1 as </=12, 13-59, 60-145 or >/= 146, and hospital TKA volume as </=89, 90-235, 236-644 and >/=645. We calculated the odds of R-TKA in Whites and Blacks separately and generated crude odds ratios (OR) comparing Blacks to Whites to examine trends across volume categories. A multivariable logistic regression model adjusted for known R-TKA risk factors was also performed.

Results:

A total of 163,576 patients were included. Mean (SD) age was 66.4 (10.4) years, 107,233 (65.6%) were female, 124,277 (76.6%) were White and 15,990 (9.8%) were Black. 2925 patients underwent aseptic R-TKA. In logistic regression analysis, Blacks had a higher risk of R-TKA (OR 1.42, 95%CI 1.26-1.6) (Table 1). Risk of R-TKA was also higher when surgeon annual volume was </=12 (OR 1.5, 95%CI 1.25-1.8) or 13-59 (OR 1.16, 95%CI 1.04-1.29) TKA compared to the highest volume surgeons (>/=146). Patients who had surgery at a hospital with annual volume of 236-634 TKA were less likely to undergo R-TKA compared to the highest volume hospitals (>/=645) (OR 0.88, 95%CI 0.79-0.98). Other risk factors for R-TKA were younger age and worker’s compensation, while patients with inflammatory arthritis had a lower risk. Figures 1A and 1B show the odds of R-TKA in Whites and Blacks, respectively, by hospital and surgeon volume. Figure 1C shows the crude OR for Blacks to Whites for each category pair. The OR ranged from 0.9 to 2.5, with the largest disparity found in patients who have TKA performed by surgeons with 60-145 annual TKA volume at the highest volume hospitals (>/=645).

Conclusion:

Patients having TKA by a surgeon performing <60 TKA per year have higher risk of R-TKA. Racial disparities in R-TKA risk are highest for TKA by surgeons performing 60-145 TKA per year at hospitals performing >/=645 TKA per year. Future studies should examine factors, such as whether trainees are involved the surgery, that may vary based on social determines of health, such as patient race and payor.

References:

[1]Wilson S. et al Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. Journal of bone and joint surgery. 2016;98:1683

Table 1.

Logistic regression of risk for R-TKA

Variable (reference)LevelOdds ratio95% CIp-valueAge--0.950.94-0.95<.001Sex (female)Male1.070.99-1.150.108Race (whiteAsian0.650.42-0.960.031Black1.421.26-1.6<.001Unknown0.810.64-1.020.07Other1.050.92-1.210.446Insurance (Medicare)Medicaid0.890.75-1.060.193Other0.890.7-1.130.331Private0.820.74-0.91<.001Work compensation1.561.35-1.8<.001Surgeon volume (>/=146)</=121.51.25-1.8<.00113-591.161.04-1.290.00660-1451.00.91-1.110.957Hospital volume (>/=645)</= 890.980.84-1.150.84890-2350.990.88-1.120.869236-6440.880.79-0.980.018Hospital bed size (>400 beds)6-1991.131.02-1.250.024200-3991.060.96-1.170.262

Other variables in model: diabetes, obesity, renal disease, COPD, osteoarthritis, osteonecrosis, dislocation, inflammatory arthritis, surgical complication, infection, no college, poverty >20%, years since residency, US/Canada medical school, orthopedic board certified, AHA control, teaching, rural hospital

Disclosure of Interests:

Serene Mirza: None declared, Susan Goodman: None declared, Yi Zhang: None declared, Huong Do: None declared, Bella Mehta: None declared, Stephen Lyman: None declared, Lisa A. Mandl: None declared, Mark Figgie: None declared, Michael Parks Consultant of: Zimmer biomet, Grant/research support from: Zimmer biomet, Linda Russell: None declared, Anne Bass: None declared

OP0328 A UNIQUE PD1+CD38+ CD8+ T CELL POPULATION CHARACTERIZES CHECKPOINT INHIBITOR-ASSOCIATED INFLAMMATORY ARTHRITIS

Background:

Immune checkpoint inhibitors (CI) are monoclonal antibodies that block CTLA-4, PD-1 or PD-L1, resulting in cytotoxic T cell activation in the tumor microenvironment. They have revolutionized the management of metastatic cancer but unleash “immune related adverse events” in > 80% of treated patients, including inflammatory arthritis in ~4%1. CI-associated arthritis (CI-A) often presents as a symmetrical polyarthritis, phenotypically indistinguishable from rheumatoid arthritis (RA), but whether it shares cellular and molecular features of RA has not been determined.

Objectives:

To compare synovial fluid (SF) T cell populations from CI-A patients to those in patients with RA, phenotypically and functionally.

Methods:

We immunophenotyped SF mononuclear cells from patients with CI-A caused by anti-PD-(L)1 therapy (n=9), seropositive RA (n=5), and psoriatic arthritis (PsA) (n=5) using a 39-marker mass cytometry (CyTOF) panel. FlowSOM was used to cluster CD4 and CD8 T cells into 15 ‘metaclusters’ based on multidimensional phenotypes. We used Kruskal-Wallis or Mann-Whitney tests to identify significantly altered populations (p<0.05), which we confirmed by biaxial gating. Flow cytometry was used to confirm SF findings in an independent cohort, and to identify cells of interest in peripheral blood. Cytokine staining was performed on sorted T cells populations after CDCD3/CD28 stimulation for 72 hours, followed by 4 hour PMA/ION+BRA/MON restimulation.

Results:

In CI-A patients, T cells represented 50% of SF mononuclear cells (53% CD4, 40% CD8), followed by monocytes (24%) and NK cells (8%), comparable to RA and PsA. However, FlowSOM analysis revealed expansion of a distinct population of PD-1+CD38hiCD127-CD8 T cells (CD8 metacluster2) (Fig. 1). These cells comprised 30% of CD8+ SF T cells in CI-A, a 3.4-fold increase over RA/PsA, p=0.0002 (Fig. 2). Over 40% of these cells expressed Ki67 in CI-A, suggesting active proliferation. Flow cytometry on SF cells from an independent cohort of CI-A patients (n= 5) and RA/PsA comparators (n= 9) confirmed our findings. PD-1+CD38hiCD127-CD8 T cells were also expanded in the blood of CI-A patients, where they represented 4.6% of CD8 Tcells, a 2.8-fold increase over RA, p = 0.0057. In addition to expressing high levels of PD-1, CD38hiCD127-, these CD8 T cells express other immune checkpoint receptors including ICOS and TIGIT. After in vitro stimulation, CD38hiCD127-CD8 T cells produced granzyme B along with TNF and IFN-γ at comparable levels to other CD8 populations, suggesting that they are not functionally exhausted.

Figure 1.

Mass cytometry CD8+T cells (tSNE plots) with FlowSOM metaclusters.

Figure 2.

Synovial fluid PD-1+CD38hiCD127-CD8+T cells

FlowSOM analysis of SF CD4 T cells in CI-A patients revealed the expansion of a subpopulation of CD4 cells with a similar surface phenotype of PD-1+CD38hiCD127-(metacluster2, 10% of CD4s in CI-A, a 2.4-fold increase over RA/PsA, p=0.0047). In contrast, RA patients had a significantly expanded population of PD-1hiICOS+ CD4 T peripheral helper (Tph) cells (metacluster5, 30% of CD4s in RA, p=0.006), but these cells were not expanded in CI-A (Fig 3).

Figure 3.

Synovial fluid CD4+T peripheral helper cells

Conclusion:

CyTOF analysis of SF revealed a uniquely expanded PD-1+CD38hiCD127-CD8 T cell population in CI-A not present in RA or PsA, and a similar PD-1+CD38hiCD127-CD4 T cell population. These cells may contribute to the amplified immune response seen in CI-A patients. Further functional and transcriptional analysis of these cells will help to elucidate their function may reveal key mechanisms driving CI-associated immune related adverse events.

References:

[1]Kostine M. Ann Rheum Dis 2018;77(3):393-398

Disclosure of Interests:

Runci Wang: None declared, Karmela Kim Chan: None declared, Amy Cunningham-Bussel: None declared, Laura Donlin Consultant of: Consultant – Genentech/Roche, Gregory Vitone: None declared, Aidan Tirpack: None declared, Caroline Benson: None declared, Gregory Keras: None declared, A. Helena Jonsson: None declared, Michael Brenner: None declared, Anne Bass: None declared, Deepak Rao Grant/research support from: Has received research grant support from Celgene and Merck., Consultant of: Has received consulting fees or honoraria from Merck, Pfizer, GlaxoSmithKine, Bristol-Myers Squibb, Janssen, and Scipher Medicine

Incidental bilateral calcaneal fractures following overground walking with a wearable robotic exoskeleton in a wheelchair user with a chronic spinal cord injury: is zero risk possible?

Many individuals with spinal cord injury (SCI) rely on wheelchairs as their primary mode of locomotion leading to reduced weight-bearing on the lower extremities, which contributes to severe bone loss and increased risk of fragility fractures. Engaging in a walking program may reverse this vicious cycle, as this promotes lower extremity weight-bearing and mobility, which may reduce bone loss and fragility fracture risk. However, fragility fracture risk associated with the use of wearable robotic exoskeletons (WREs) in individuals with SCI needs consideration. A 35-year-old man with chronic complete sensorimotor SCI (neurological level = T₆) and low initial bone mineral density enrolled in a 6- to 8-week WRE-assisted walking program after successfully completing an initial clinical screening process and two familiarization sessions with the WRE. However, after the first training session with the WRE, he developed bilateral localized ankle edema. Training was suspended, and a CT-scan revealed bilateral calcaneal fractures, which healed with conservative treatment over a 12-week period. Opportunities for improving clinical screening and WRE design are explored. The relevance of developing clinical practice guidelines for safe initiation and progression of intensity during WRE-assisted walking programs is highlighted. This case of bilateral calcaneal fractures illustrates that aiming for "zero risk" during WRE-assisted walking programs may not be realistic. Although WREs are a relatively new technology, current evidence confirms their potential to greatly improve health and quality of life in individuals with chronic SCI. Hence, ensuring their safe use remains a key priority.

The treatment of an unstable slipped capital femoral epiphysis by either intracapsular cuneiform osteotomy or pinning in situ

We undertook a retrospective comparative study of all patients with an unstable slipped capital femoral epiphysis presenting to a single centre between 1998 and 2011. There were 45 patients (46 hips; mean age 12.6 years; 9 to 14); 16 hips underwent intracapsular cuneiform osteotomy and 30 underwent pinning in situ, with varying degrees of serendipitous reduction. No patient in the osteotomy group was lost to follow-up, which was undertaken at a mean of 28 months (11 to 48); four patients in the pinning in situ group were lost to follow-up, which occurred at a mean of 30 months (10 to 50). Avascular necrosis (AVN) occurred in four hips (25%) following osteotomy and in 11 (42%) following pinning in situ. AVN was not seen in five hips for which osteotomy was undertaken > 13 days after presentation. AVN occurred in four of ten (40%) hips undergoing emergency pinning in situ, compared with four of 15 (47%) undergoing non-emergency pinning. The rate of AVN was 67% (four of six) in those undergoing pinning on the second or third day after presentation.

Pinning in situ following complete reduction led to AVN in four out of five cases (80%). In comparison, pinning in situ following incomplete reduction led to AVN in 7 of 21 cases (33%). The rate of development of AVN was significantly higher following pinning in situ with complete reduction than following intracapsular osteotomy (p = 0.048). Complete reduction was more frequent in those treated by emergency pinning and was strongly associated with AVN (p = 0.005).

Non-emergency intracapsular osteotomy may have a protective effect on the epiphyseal vasculature and should be undertaken with a delay of at least two weeks. The place of emergency pinning in situ in these patients needs to be re-evaluated, possibly in favour of an emergency open procedure or delayed intracapsular osteotomy. Non-emergency pinning in situ should be undertaken after a delay of at least five days, with the greatest risk at two and three days after presentation. Intracapsular osteotomy should be undertaken after a delay of at least 14 days. In our experience, closed epiphyseal reduction is harmful.

Cite this article: Bone Joint J 2015;97-B:412–19.

Alemtuzumab more effective than interferon β-1a at 5-year follow-up of CAMMS223 clinical trial

OBJECTIVE

To report the long-term safety and efficacy results from CAMMS223 comparing alemtuzumab with interferon β-1a in early, active relapsing-remitting multiple sclerosis (RRMS). What are the long-term effects of alemtuzumab treatment, received 36 to 48 months previously, on relapse and disability in early, active RRMS? This study provides evidence of the effectiveness of alemtuzumab in reducing the relapse rate and accumulation of disability compared with interferon β-1a (IFNβ-1a) through extended follow-up (up to 60 months from baseline).

METHODS

Of 334 patients originally randomized, 198 participated in the extension phase (151 [68%] alemtuzumab and 47 [42%] IFNβ-1a). Disability, relapses, and safety were assessed as in the original study period. Efficacy outcomes were analyzed from baseline of the original trial period to 60 months. Safety data extended beyond 60 months.

RESULTS

Over 5 years, alemtuzumab lowered the risk of sustained accumulation of disability by 72% and the rate of relapse by 69% compared with IFNβ-1a (both p < 0.0001). The annualized relapse rate from baseline to month 60 was 0.11 for alemtuzumab and 0.35 for IFNβ-1a. Complete safety follow-up reflected 988 and 376 person-years for alemtuzumab and IFNβ-1a patients, respectively. Serious infections were seen in 7% of alemtuzumab patients and 3% of IFNβ-1a patients, and thyroid disorders were seen in 30% of alemtuzumab patients vs 4% of IFNβ-1a patients. Immune thrombocytopenia occurred in 3% of alemtuzumab patients and 0.9% of IFNβ-1a patients during the initial study period; no additional events were reported during the extension phase. One alemtuzumab patient developed Goodpasture disease 39 months after the second annual cycle of alemtuzumab.

CONCLUSIONS

Through extended follow-up, alemtuzumab remained significantly more efficacious than IFNβ-1a, with a safety profile consistent with previous reports.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that alemtuzumab is more effective than interferon β-1a in reducing relapses and disability in patients with RRMS in a long-term follow-up of a rater-blinded, randomized clinical trial with 59.5% of patients participating in the extended follow-up period.

Long-term follow-up of patients with asymptomatic occlusion of the internal carotid artery with good and impaired cerebral vasomotor reactivity

BACKGROUND

Cerebral hemodynamic status might be prognostic for either the symptomatic or asymptomatic course of carotid occlusive disease. It is determined by evaluating cerebral vasomotor reactivity (VMR). We assessed VMR in asymptomatic patients with total occlusion of the internal carotid artery (ICA) and followed them to evaluate the role of impaired VMR in predicting ischaemic stroke (IS).

METHODS

Thirty-five patients (21 men, mean age ± SD 68 ± 7.5 years) with unilateral asymptomatic ICA occlusion were studied by transcranial Doppler and the Diamox test (intravenous 1.0 g acetazolamide) and followed for 48 months or until reaching the end-points of IS, transient ischaemic attack, or vascular death. VMR% was evaluated by recording the percent differences in peak systolic blood flow velocities in each middle cerebral artery at baseline and after Diamox administration.

RESULTS

Based on VMR% calculations, 14 (40%) patients had good VMRs and 21 (60%) had impaired VMRs. The global annual risk of ipsilateral ischaemic events was 5.7%. The annual ipsilateral ischaemic event risk was 1.8% in patients with good VMRs, whilst it was 7.1% in patients with impaired VMRs. An impaired VMR was significantly correlated with ipsilateral IS (Kaplan-Meier log rank statistic, P = 0.04).

CONCLUSIONS

Our results support the value of VMR assessment for identifying asymptomatic patients with carotid occlusion who belong to a high-risk subgroup for IS. New trials using extracranial-to-intracranial bypass surgery in patients with asymptomatic ICA occlusion and impaired VMRs are warranted.

Hyperbaric oxygen, oxidative stress, NO bioavailability and ulcer oxygenation in diabetic patients

BACKGROUND

Hyperbaric oxygen therapy (HBO2) increases tissue oxygenation, thus serving as an adjunct therapy for diabetic wounds. However, in some patients there is insufficient increase in tissue O2.

AIMS

To investigate the pathophysiology of insufficient HBO2 and the possible role of N-acetylcysteine (NAC).

METHODS

Prospective, randomized, cross-over trial included 50 diabetic patients with non-healing ulcers. Each patient received two treatments with 100% oxygen/2ATA. NAC was administered i.v. at one of the two treatments. Basal and post-treatment peri-wound transcutaneous O2 (TcPO2) pressure, malondialdehyde (MDA), total anti-oxidant status (TAOS) and nitric oxide (NO) were assessed. An ulcer oxygenation increase above 200 mmHg was accepted as sufficient.

RESULTS

During HBO2, 17 patients (34%) demonstrated insufficient increase in TcPO2. Concomitantly, their TAOS and NO decreased, while MDA increased. NAC administration attenuated these parameters, thus improving the HBO2 outcome. In those affected by NAC, the cure rate was 75%. By contrast, in 66% of patients with sufficient increase in TcPO2 TAOS was increased and MDA decreased irrespective of NAC administration. The cure rate in this subgroup was 82%.

CONCLUSIONS

Insufficient increase of ulcer oxygenation during HBO2 results from exaggerated oxidative stress and decreased NO bioavailability. NAC administration-induced modulation of both parameters and may improve ulcer oxygenation during HBO2.

Traumatic transepiphyseal separation of the upper femoral epiphysis following seizures in two children with cerebral palsy

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

Treatment of idiopathic club foot using the Ponseti method. Initial experience

We report our initial experience of using the Ponseti method for the treatment of congenital idiopathic club foot. Between November 2002 and November 2004 we treated 100 feet in 66 children by this method. The standard protocol described by Ponseti was used except that, when necessary, percutaneous tenotomy of tendo Achillis were performed under general anaesthesia in the operating theatre and not under local anaesthesia in the out-patient department. The Pirani score was used for assessment and the mean follow-up time was 18 months (6 to 30). The results were also assessed in terms of the number of casts applied, the need for tenotomy of tendo Achillis and recurrence of the deformity. Tenotomy was required in 85 of the 100 feet. There was a failure to respond to the initial regimen in four feet which then required extensive soft-tissue release. Of the 96 feet which responded to initial casting, 31 (32%) had a recurrence, 16 of which were successfully treated by repeat casting and/or tenotomy and/or transfer of the tendon of tibialis anterior. The remaining 15 required extensive soft-tissue release. Poor compliance with the foot-abduction orthoses (Denis Browne splint) was thought to be the main cause of failure in these patients.

Practice management software for the equine practitioner

Practice management software benefits the equine practitioner in many ways. Ready access to patient records, rapid entry and lookup of clinical findings, easy invoicing and monitoring of revenues, inventory management, rapid search and sorting of data, reminder and recall maintenance, and integrated word processing are just some of the software functions that assist the successful practitioner. Computer use in veterinary practice may have seemed to many to be a gimmick at one time. Now that computers have become a part of our everyday life, it is clear that they can be an essential component of the modem, successful, and profitable equine practice.

Do CT scans aid assessment of distal tibial physeal fractures?

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers' assessments were compared using the paired Student's t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs. We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.

Congenital anomalies of the inferior vena cava revealed on CT in patients with deep vein thrombosis

OBJECTIVE

We describe a possible relationship between inferior vena cava anomalies and extensive thrombosis of the inferior vena cava and the iliac and femoral veins.

CONCLUSION

An anomaly of the inferior vena cava should be considered in young patients who present with deep vein thrombosis of the femoral and iliac veins. Coagulation abnormalities, frequently found in these patients, may be a contributory factor.

Delayed rupture of abdominal aortic false aneurysm following blunt trauma

Blunt injury of the abdominal aorta resulting in pseudoaneurysm formation is very rare. Such a pseudoaneurysm may rupture at any time, usually with fatal outcome. We report the case of a 32-year-old man with a clinically unsuspected ruptured abdominal aorta pseudoaneurysm, which had probably formed 3 years earlier, and emphasize the CT features.

Thromboembolic complications of central venous catheterization of the arm and neck veins

For more than 30 years central venous catheterization has provided an important means of long-term vascular access and circulatory monitoring. Thrombosis of central veins is one of the serious complications of this procedure, The reported incidence of thrombosis varies and it is often underestimated clinicaIly due to the pau city of signs and symptoms. Symptomatic subelavian vein thrombosis is estimated to occur in up to 15% of patients with indwelling venous access devices.

Ontogenetic development of energy-supplying enzymes in rat and guinea-pig heart

The purpose of the present study was to compare the ontogenetic development of the activity of myocardial energy-supplying enzymes in two mammalian species, differing significantly in their level of maturation at birth. The animals were investigated during the late prenatal period and 2, 7, 14, 21, 25, 30, 63, 120 and 730 days after birth in the rat and 2, 21, 84 and 175 days in the guinea-pig. The following enzymes were assayed in the right and left ventricular myocardium: lactate dehydrogenase (LDH, lactate uptake and/or formation), triose phosphate dehydrogenase (TPDH, carbohydrate metabolism), glycerol phosphate dehydrogenase (GPDH, glycerol-P shuttle)), hexokinase (HK, glucose phosphorylation), malate dehydrogenase (MDH, tricarboxylic cycle), citrate synthase (CS, tricarboxylic cycle) and hydroxyacyl-CoA dehydrogenase (HOADH, fatty acid breakdown). The rat heart, highly immature at birth, exhibits three different developmental patterns of energy-supplying enzymes, identical in both ventricles: (i) two mitochondrial enzymes of aerobic metabolism (CS, HOADH) and GPDH have a relatively low activity at the end of prenatal life; thereafter their activity steadily increases, approaching the adult levels between the 3rd and 4th postnatal weeks. A significant decrease was observed between the 4th and 24th months. (ii) MDH and LDH: prenatal values were significantly higher as compared with the 2nd postnatal day; after this period the activities increased up to adulthood (4 months) and decreased during senescence. (iii) The activities of HK and TPDH are characterized by only moderate changes during development. HK differs from all other enzymes by the highest prenatal values, which exceed even adult values. In contradiction to the rat heart, the developmental differences in more mature guinea-pig heart were significantly less pronounced. The only ontogenetic differences observed were the lower activities of enzymes connected with aerobic metabolism at the end of the prenatal period. Our results point to possible differences in the development of adaptive metabolic pathways in animals with different levels of maturation at birth.

Treatment of postcatheterisation false aneurysms: ultrasound-guided compression vs ultrasound-guided thrombin injection

OBJECTIVES

to compare the efficacy and cost-effectiveness of ultrasound-guided compression (UGC) with ultrasound-guided thrombin injection (UGTI) for treatment of postcatheterisation arterial false aneurysms (cFA).

DESIGN

prospective clinical study using historical controls.

MATERIALS AND METHODS

we prospectively collected data on 33 consecutive patients diagnosed with cFA larger than 1.5 cm in diameter. These were treated with UGTI. We performed a retrospective review of data on a former group of 33 consecutive historical control patients that were treated by UGC.

RESULTS

the groups were similar in respect of demographic and clinical variables. Thirty patients were suitable for UGC and 33 patients were suitable for UGTI. The success rate for UGC was 26/30 (87%) compared to 33/33 (100%) for UGTI (p<0.05). Thrombosis was achieved during the first treatment session in 7/26 patients treated by UGC, compared to 26/33 in the UGTI group (p<0.0001). Four patients that failed UGC and two patients that were unsuitable for UGC required surgical repair. UGTI as compared to UGC was shorter in duration (25 vs 75 min) and required no sedation. No thromboembolic or systemic complications occurred in either group. Cost analysis revealed savings of $US 517 for each patient treated by UGTI as compared with UGC.

CONCLUSIONS

in our study, UGTI is superior to UGC, and we suggest that UGTI should become the procedure of choice for the treatment of cFA.

Epidemiology and control of diphtheria in the Republic of Moldova, 1946-1996

In 1994-1996, the Republic of Moldova was stricken with an epidemic of diphtheria after >30 years of routine diphtheria immunization and the near absence of the disease for nearly 20 years. The intensity of the epidemic gradually grew, reaching a peak in 1994-1995. The epidemiology of diphtheria in Moldova during this period is described along with laboratory findings and control measures. Pharyngeal diphtheria was the predominant clinical form of the disease (97% of cases), and it most often developed in a localized form (70%), with 20% in the toxic form. The clinical diagnosis of diphtheria was bacteriologically confirmed in 91% of cases: Of the cases tested for biotype, 91.3% were gravis, 8.5% were mitis, and 0. 2% were intermedius. Of 494 toxigenic isolates from cases and carriers at the beginning of the epidemic, 47% were nonphagotypeable strains, and 25.7% were phagotype VI strains. Aggressive population-based diphtheria control measures, a mass immunization campaign, rapid case identification, antibiotic prophylaxis and supplemental immunization of close contacts in clusters of infection, and high coverage with routine immunization rapidly controlled the epidemic within Moldova.

Strategies for safe injections

In 1998, faced with growing international concern, WHO set out an approach for achieving injection safety that encompassed all elements from patients' expectations and doctors' prescribing habits to waste disposal. This article follows that lead and describes the implications of the approach for two injection technologies: sterilizable and disposable. It argues that focusing on any single technology diverts attention from the more fundamental need for health services to develop their own comprehensive strategies for safe injections. National health authorities will only be able to ensure that injections are administered safely if they take an approach that encompasses the whole system, and choose injection technologies that fit their circumstances.

The problem of "concreteness"

"Concrete" patients manifest resistance to interpretation per se. Their apparently primitive thinking is the result of complex psychodynamics, explicable in terms of the mechanisms of wish fulfillment and a revised theory of fetishism. The general thesis is that an unconscious equation of differentiation with overwhelming tension leads to a global process of defense against the differentiating function of the analytic frame. The wider implications of this theory can be integrated with Freud's mostly unknown late attempt to generalize the theory of fetishism.

Transiently increased basilar artery flow velocity following severe head injury: a time course transcranial Doppler study

BACKGROUND AND PURPOSE

Transcranial Doppler ultrasonography has been used to study changes in cerebral hemodynamics following head injury. However, most studies evaluated the anterior circulation and little information exists on transcranial Doppler of the vertebrobasilar arteries after head injury.

METHODS

Thirty-two patients with a Glasgow Coma Scale (GCS) score between 4-8 and 11 patients with a GCS score between 9-14 were studied using transcranial Doppler ultrasonography for the first 10 days after injury. Daily variations in the mean blood flow velocities of all major cerebral arteries were recorded.

RESULTS

In patients with GCS score between 4-8, the mean blood flow velocities in the middle cerebral and basilar arteries gradually increased beginning on day 2 postinjury and peaked on the 4th-5th day after injury. Those changes were more prominent, and appeared earlier, in the basilar artery. The ratio between the mean flow velocities of the middle cerebral artery and the basilar artery during the first 4 days was significantly lower than in normal controls, indicating a particular increase of flow velocity in the basilar artery. Nineteen out of 32 patients (60%) with severe head injury showed mean blood flow velocity increased over 75 cm/sec in the basilar artery. Mean blood flow velocity >90 cm/sec in the basilar artery, compatible with vasospasm, was observed in 12 of 32 patients (37%). Spasm in the middle cerebral artery was observed in 12 (37%) of patients; 10 of them also had evidence of basilar artery spasm. On the whole, 14 of 32 (43%) patients had evidence of spasm either in the middle cerebral or basilar arteries or in both. In 5 of 11 patients (50%) with moderate head injury (GCS score 9-14), blood flow velocity in the basilar artery greater than 75 cm/sec was observed, but in only two of them it reached the values over 90 cm/sec. Vasospasm in the middle cerebral artery was noted in one patient.

CONCLUSIONS

A significant number of patients develop increased flow velocities compatible with vasospasm in the basilar artery after severe head injury. This phenomenon may represent an additional factor that contributes to the poor outcome of severely head-injured patients.

Lateral venous ulcer and short saphenous vein insufficiency

PURPOSE

The objective of this report is to emphasize the importance of saphenopopliteal junction (SPJ) reflux in the genesis of lateral leg ulcers and to suggest a proper diagnostic and therapeutic approach.

METHODS

Twenty legs with isolated lateral perimalleolar ulcers from the basis for this report. None had medial ankle ulcers, and most showed no hyperpigmentation or lipodermatosclerosis. Fifteen had been treated with a nonvenous diagnosis. Reflux at the SPJ was detected by handheld continuous wave Doppler and was confirmed with duplex scans. No other abnormalities were found. Brief conservative treatment and duplex localization of the SPJ preceded its ligation and division.

RESULTS

All ulcers healed within 12 weeks, but one in a radiated leg recurred at 9 months. Other complications included two hematomas and one each of ankle edema, superficial wound infection, and sural neuropathy.

CONCLUSIONS

Even isolated lateral leg and ankle ulcers with minimal accessory venous stigmata can be of venous reflux origin. Detection with the continuous wave Doppler and confirmation of reflux and localization of the SPJ allow surgical correction to proceed swiftly with an expectation of satisfactory results.

Closure of the abdomen by mesh for planned re-laparotomy. A technical modification

Temporary closure of the abdomen with a synthetic mesh and multiple planned relaparotomies are the essentials of the modern strategy for treating severe intra-abdominal sepsis or pancreatic necrosis. One of the complications associated with mesh closure of the abdomen is facial necrosis at the wound edges leading to evisceration. Tension of the strictures between mesh and facia called local ischemia, which combined with infection leads to the facial disintegration and separation of the mesh from the abdominal wall. A modified technique of suturing the mesh was developed in our department and its technical details are presented. Twenty-four patients treated with the "open abdominal technique and planned relaparotomies" are presented. The new technique was used in 9 patients for closure of evisceration after mesh separation.

Vascular complications of total abdominal perfusion and aortic stop-flow infusion

During a 2 year period (1992-1993), 149 patients with advanced abdominal cancer underwent total abdominal ischemic perfusion (TAP) and stop-flow infusion (SFI) 159 times in an attempt to achieve palliation. These procedures and aortic stop-flow infusion require insertion of balloon catheters into the abdominal aorta and inferior vena cava by a transfemoral approach. Flow is arrested for 15 minutes, during which time chemotherapeutic agents are infused into the aorta, distal to the balloon occlusion. Femoral access is by a surgical incision. The passage of the catheters is guided by fluoroscopy. Some tumor response was observed in 35% of the patients. Ten patients had major vascular complications; two iliac artery aneurysms were lacerated and required emergency repair. There were two femoral artery false aneurysms that required surgical correction, one early and one late. Aortic dissection was detected in four patients, but these did not require surgical intervention. Two patients had thrombosis distal to the occluded vessel, both required surgical intervention. To reduce the incidence of these vascular complications we recommend: (1) a clinical and vascular laboratory evaluation before the procedure, and (2) angiography of normal flow in patients with underlying vascular disease.

Two cases of acetabular fractures sustained during competitive cycling

This paper reports two cases of posterior acetabular fracture obtained in an almost identical way in competitive cycling and presents potential diagnostic difficulties.

A software toolkit for hierarchical task analysis

This paper describes a prototype software tool that offers support to the human factors specialist using hierarchical task analysis (HTA). The tool provides a direct manipulation diagram editor for HTA and provides high-quality output of analyses, in both graphic and automatically generated tabular form. The tool is implemented in Smalltalk-80 and currently runs on Macintosh computers.