Gender diversity in adolescents with polycystic ovary syndrome

OBJECTIVES

The objective of our study was to describe the prevalence of gender diverse (GD) youth  among adolescents with polycystic ovary syndrome (PCOS).

METHODS

We conducted a retrospective chart review on patients who met NIH criteria for PCOS in our Multidisciplinary Adolescent PCOS Program (MAPP). We compared those with PCOS to MAPP patients who did not meet PCOS criteria as well as to non-PCOS patients from the Adolescent Specialty Clinic (ASC). Variables analyzed included gender identity, androgen levels, hirsutism scores, and mood disorders. We used chi-square, Fisher's exact, t-tests, and Wilcoxon rank sum tests to compare groups.  Gender identities self-reported as male, fluid/both or nonbinary  were pooled into the GD category.

RESULTS

Within the MAPP, 7.6% (n=12) of PCOS youth self-identified as GD compared to 1.8% (n=3) of non PCOS youth (p=0.01, chi-square). When compared to non-PCOS GD adolescents from ASC (4.4%; n=3), the difference to PCOS youth was no longer significant (p=0.56). Among MAPP patients, gender diversity was associated with higher hirsutism scores (p<0.01), but not higher androgen levels. In PCOS, depression/anxiety was higher in GD vs cisgender youth (100% vs. 37.6%, p<0.01 and 77.8% vs. 35.8%, p=0.03 respectively).

CONCLUSIONS

Gender diversity was observed more commonly in those meeting PCOS criteria. PCOS GD youth were more hirsute and reported more depression/anxiety. Routine screening for differences in gender identity in comprehensive adolescent PCOS programs could benefit these patients, as alternate treatment approaches may be desired to support a transmasculine identity.

95 EXPLORING HIP FRACTURE OUTCOMES IN POST-ACUTE REHABILITATION: A MULTI-SITE AUDIT

Background

In 2020, 28% of all hip fractures in Ireland were discharged to off-site rehabilitation. The annual Irish Hip Fracture Database (IHFD) report captures patient outcomes at the point of acute discharge however patient outcomes at discharge from offsite rehabilitation are unknown.

Methods

A multi-site retrospective audit was completed examining hip fracture outcomes for patients admitted to four post-acute rehabilitation hospitals during 2021, using IHFD HIPE portals as well as local databases. Descriptive statistics including demographics, pre-fracture mobility as well as outcomes measured including acute length of stay, rehabilitation length of stay, discharge destination and independence with mobility on discharge from rehabilitation. A comparison analysis between sites was completed.

Results

A total of 445 patients were admitted post hip fracture to the four rehabilitation hospitals in 2021. Most were female (69%, n=307), mean age 82.5, 49% lived alone and most (55%) had low pre-fracture mobility as measured by New Mobility Score of 0-6. The mean acute length of stay was 11.8 days and rehabilitation stay 37.6 days. Most (90.2% of complete data, n=333) discharged home, 4.5% (n=17) were transferred to hospital, 3.2% (n=12) were newly admitted to nursing home and 1% (n=4) died. Most (82.2% of complete data, n=256) were independently mobile (CAS 6) at discharge from rehabilitation. There was no significant difference in patient profile between sites however there were significant difference in both acute length of stay (median range 8-13days) as well as rehabilitation length of stay (median range 16-39days).

Conclusion

The findings of this audit provide a new perspective on recovery post hip fracture and insight into longer term hip fracture outcomes. It shows that data collection is feasible in off-site rehabilitation units and should be considered for inclusion in the IHFD. Further work could explore the establishment of standards of care in the post-acute phase of hip fracture rehabilitation.

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21

Background

Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection.

Methods

A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID.

Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea.

Discussion

Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals.

Trial registration

ClinicialTrials.gov NCT04900961. Prospectively registered on 25 May 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06632-y.

O-187 An analysis of the outcome of 11,712 men applying to be sperm donors at Cryos International in Denmark and the USA

Study question

Is the outcome of donor recruitment influenced by the country in which recruitment took place or the initial ID-release choice of applicants?

Summary answer

More applicants are accepted as donors in Denmark than the USA and those who choose ID release are more frequently accepted than those who don’t.

What is known already

The successful recruitment of sperm donors is essential to provide a range of Assisted Reproductive Technologies (ART) which rely upon donor sperm. However, while much has been written about the medical screening and assessment of sperm donors from a safety perspective, relatively little has been written about the process of recruiting donors and how it works in practice. There are differences in attitudes between donors who choose to allow their identity to be released to any donor conceived people (ID-release) compared to those who don’t (non ID-release). Therefore, we reasoned this may also influence the likelihood of them being recruited.

Study design, size, duration

A total of 11,712 men applied to be sperm donors at Cryos International in Denmark and the USA during 2018 and 2019.

Participants/materials, setting, methods

Anonymised records of all donor applicants were examined to assess the number passing through (or lost) at each stage of the recruitment process. Statistical analysis was carried out by Chi Squared test, using Graphpad Prism (San Diego, USA) to examine differences between location (Denmark or USA) and/or donor type (ID-release vs non-ID release).

Main results and the role of chance

Few applicants (3.79%) were accepted as donors and had samples released for use. This was higher in Denmark (6.53%) than the USA (1.03%) (χ2 = 243.2; 1df; z = 15.60; p &lt; 0.0001) and was higher in donors who opted at the outset to be ID-release (4.70%) compared to those who didn’t (3.15%) (χ2 = 18.51; 1df; z = 4.303; p &lt; 0.0001). Most potential donors were lost during recruitment because they: (i) withdrew, failed to respond, did not attend an appointment, or return a questionnaire (54.91%); (ii) reported a disqualifying health issue or failed a screening test (17.41%); (iii) did not meet the eligibility criteria at the outset (11.71%); or (iv) had semen quality which was not adequate (11.20%). In each case, there were statistically significant differences between countries and the donor’s initial ID choice. During recruitment, some donors decided to change ID-type. There were no country differences in the frequency in which this occurred (χ2 = 0.2852; 1df; z = 0.5340; p = 0.5933), but it was more common for donors to change from non-ID release to ID release (27.19%) than the other way around (11.45%) (χ2 = 17.75; 1df; z = 4.213; p &lt; 0.0001) although movements in both directions did occur in both countries.

Limitations, reasons for caution

No information was available about the demographic characteristics of the applicants which may also have influenced their chances of being accepted as a donor (e.g., ethnicity, age etc). Donor recruitment procedures may differ in other locations according to local laws or guidelines.

Wider implications of the findings

A better understanding of when and why potential donors are lost in the recruitment process may help develop leaner and efficient pathways for interested donors and sperm banks. This could ultimately increase the number of donors recruited through enhanced information, support and reassurance during the recruitment process.

Trial registration number

not applicable

222 OLDER ADULT INPATIENTS’ PERCEPTIONS OF PROGRESSIVE RESISTANCE TRAINING IN A SPECIALIST GERIATRIC REHABILITATION SETTING

Background

Progressive resistance training (PRT) has the potential to reduce age-related disability and has been proven to benefit the older adult in a variety of ways. PRT is prescribed routinely by physiotherapists for frail older adults in an inpatient setting. To date little is known of their experiences engaging in PRT. This study aimed to explore older adult inpatients’ perceptions and experience of PRT as part of their overall physiotherapy program in a Specialised Geriatric Rehabilitation Unit.

Methods

The study had a qualitative design. Semi-structured interviews explored experiences and perceptions of PRT along with motivators and barriers to participation. Interviews were face to face and conducted in the unit. Data was analysed using thematic analysis. 11 frail older inpatients with orthogeriatric (n = 5), neurological (n = 2), general surgical (n = 2) and general medical (n = 2) diagnoses were interviewed.

Results

The study identified three overarching themes: Acceptability, Facilitators and Barriers. In the category of Acceptability participants identified the subthemes: (1) PRT is challenging, (2) PRT is Rewarding and (3) PRT is Enjoyable. In the category of Facilitators, the following subthemes emerged: (4) Positive outcomes as motivators and (5) Supervision is necessary for engagement. In the category of Barriers, (6) Low self-efficacy beliefs and (7) the Negative effects of PRT, such as pain and fatigue affected participation.

Conclusion

Frail older inpatients find PRT to be an acceptable form of exercise. It is perceived to be challenging, but rewarding and enjoyable for most. Participants were motivated to participate in PRT by the positive outcomes (improved strength, general health, function, independence, confidence) they experienced. They felt supervision from professionals with medical expertise was essential to participation; and had low self-efficacy beliefs surrounding independent practice; fearing falling and causing harm. Pain and fatigue also impacted participation.

Perinatal mental health services for mothers from ethnic minority and migrant backgrounds

Perinatal mental health disorders are among the most common morbidities of the perinatal period with considerable adverse effects on mothers and their offspring. Members of ethnic minority groups, particularly those from migrant backgrounds, are at higher risk of developing mental illness with evidence of ongoing inequality in access to support. We will present an exploratory mixed-methods study scoping ethnic minority and migrant women's experiences accessing perinatal mental health services in the UK. Results showed how women perceived access to services as very challenging and how they experienced ‘suffering in silence', a ‘need for a safe space to talk and to be listened to', and a ‘need of finding other women like them'. We will complement these findings with the lessons learned from a related project, a three-site European study (ORAMMA) evaluating the feasibility of implementing an integrated perinatal care model for migrant mothers comprising maternity peer supporters (MPSs)-women from migrant backgrounds who had lived in the country for a longer time and were trained to support other migrant women during the childbearing continuum-. Results showed that MPSs supported migrant women accessing maternity care, overcoming language barriers, and advocating for them in their encounters with healthcare professionals. Besides, they provided emotional support and increased women's confidence, helping them overcome loneliness, encouraging them to build relationships with others and promoting bonding with the new baby. Bringing these two projects together, we will discuss how MPSs have the potential to help overcome barriers that immigrant women experience in seeking perinatal mental health and how the benefits of maternity peer supporters have the potential to reduce perinatal mental health risks amongst migrant mothers. Findings will point to the need for future research to evaluate the direct impacts of MPSs on immigrant's mother perinatal mental health.

P–537 What is the attitude of gamete donors towards expanded genetic testing

Study question

What is the opinion of gamete donors on extended carrier screening in Denmark and in US?

Summary answer

This study showed that the overwhelming majority of the donors were very positive towards genetic testing in general and the expanded carrier screening.

What is known already

There is a lack of empirical studies on the experiences of and attitudes of donors towards expanded carrier screening (ECS) (Amor et al. 2018). Oocyte donors in a Spanish clinic were surprised by the information on testing and the possibility of being carriers (Abuli et al., 2016). After adequate genetic counselling before and after the test, the results of testing did not seem to have a meaningful emotional or psychological impact on the donors.

Study design, size, duration

A questionnaire was emailed to all active sperm donors in a sperm bank in Denmark and in a sperm bank in US.

Participants/materials, setting, methods

A total of 393 donors received the email of which 233 donors completed the questionnaire, 196 in Denmark (response rate of 60.7%) and 37 in the United States (response rate of 52.9%).

Main results and the role of chance

We systematically compared the US and DK donors and ID-release versus non-ID-release donors for all characteristics and items. ID-release donors with a partner significantly more informed their partner about their donor status than non-ID-release donors (90.5% vs. 72.4%, p 0.027). ID-release donors significantly more intended to tell their own children (57.5% vs. 21.2%, p 0.001). ID-release donors significantly more thought about their potential donor children (56.2% vs. 35.0%; p 0.002) and significantly more likely to want information on whether a pregnancy occurred from their donation (70.6% vs. 55.0%, p 0.017). In addition, they also significantly more wished to obtain information about the children conceived with their sperm: the number of children (64.0% vs. 50.0%, p 0.048), their gender (40% vs. 26.2%, p 0.042), and their health (59.3% vs. 42.5%, p 0.018). The ID-release donors were much less likely than the other type not to want any information (19.3% vs. 32.5%, p 0.034). This general attitude is extended to the wish to be informed if a child with a hereditary disease is born after using their sperm. The ID-release donors were more likely to desire contact if their genetic child was diagnosed with a genetic disease (73.9% vs. 55.0%, p 0.003).

Limitations, reasons for caution

The main element that makes the study unique (i.e., the choice between ID-release and non-ID-release) also renders the generalization of the findings more difficult. Wider implications of the findings: A better understanding of the attitude among gamete doners will possibly guide future legislation and ensure the safety and welfare of the donors too.

Trial registration number

none

Proceedings From the Ice Hockey Summit III: Action on Concussion

OBJECTIVES

The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these 5 objectives: (1) describe sport related concussion (SRC) epidemiology; (2) classify prevention strategies; (3) define objective, diagnostic tests; (4) identify treatment; and (5) integrate science and clinical care into prioritized action plans and policy.

METHODS

Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches, and officials) voted to prioritize these action items in the final Summit session.

RESULTS

To (1) establish a national and international hockey database for SRCs at all levels; (2) eliminate body checking in Bantam youth hockey games; (3) expand a behavior modification program (Fair Play) to all youth hockey levels; (4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues; (5) establish objective tests to diagnose concussion at point of care; and (6) mandate baseline testing to improve concussion diagnosis for all age groups.

CONCLUSIONS

Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity, and consequences of concussion in the sport of ice hockey.

PET Tau Imaging and Motor Impairments Differ Between Corticobasal Syndrome and Progressive Supranuclear Palsy With and Without Alzheimer's Disease Biomarkers

Introduction: Frontotemporal lobar degeneration (FTLD)-related syndrome includes progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS). PSP is usually caused by a tauopathy but can have associated Alzheimer's disease (AD) while CBS can be caused by tauopathy, transactive response DNA binding protein 43 kDa, or AD pathology. Our aim was to compare the parkinsonian syndromes presenting without AD biomarkers (CBS/PSP-non-AD) to parkinsonian syndromes with AD biomarkers (CBS/PSP-AD).

Materials and Methods: Twenty-four patients [11 males, 13 females; age (68.46 ± 7.23)] were recruited for this study. The whole cohort was divided into parkinsonian syndromes without AD biomarkers [N = 17; diagnoses (6 CBS, 11 PSP)] and parkinsonian syndromes with AD biomarkers [N = 7; diagnoses (6 CBS-AD, 1 PSP-AD)]. Anatomical MRI and PET imaging with tau ligand [18F]-AV1451 tracer was completed. Cerebrospinal fluid analysis or [18F]-AV1451 PET imaging was used to assess for the presence of AD biomarkers. Progressive supranuclear palsy rating scale (PSPRS) and unified Parkinson's disease rating scale (UPDRS) motor exam were implemented to assess for motor disturbances. Language and cognitive testing were completed.

Results: The CBS/PSP-non-AD group [age (70.18 ± 6.65)] was significantly older (p = 0.028) than the CBS/PSP-AD group [age (64.29 ± 7.32)]. There were no differences between the groups in terms of gender, education, years of disease duration, and disease severity as measured with the Clinical Dementia Rating scale. The CBS/PSP-non-AD group had significantly lower PET Tau Standard Volume Uptake Ratio (SUVR) values compared to the CBS/PSP-AD group in multiple frontal and temporal areas, and inferior parietal (all p < 0.03). The CBS/PSP-non-AD group had significantly higher scores compared to the CBS/PSP-AD group on PSPRS (p = 0.004) and UPDRS motor exam (p = 0.045). The CBS/PSP-non-AD group had higher volumes of inferior parietal, precuneus, and hippocampus (all p < 0.02), but lower volume of midbrain (p = 0.02), compared to the CBS/PSP-AD group.

Discussion: The CBS/PSP-non-AD group had higher motor disturbances compared to the CBS/PSP-AD group; however, both groups performed similarly on neuropsychological measures. The AD biomarker group had increased global uptake of PET Tau SUVR and lower volumes in AD-specific areas. These results show that the presenting phenotype of CBS and PSP syndromes and the distribution of injury are strongly affected by the presence of AD biomarkers.

Interaction of APOE4 alleles and PET tau imaging in former contact sport athletes

BACKGROUND

Genetic polymorphisms like apolipoprotein E (APOE) and microtubule-associated protein tau (MAPT) genes increase the risk of neurodegeneration.

METHODS

38 former players (age 52.63±14.02) of contact sports underwent neuroimaging, biofluid collection, and comprehensive neuropsychological assessment. The [F-18]AV-1451 tracer signal was compared in the cortical grey matter between APOE4 allele carriers and non-carriers as well as carriers of MAPT H1H1 vs non-H1H1. Participants were then divided into the high (N = 13) and low (N = 13) groups based on cortical PET tau standard uptake value ratios (SUVRs) for comparison.

FINDINGS

Cortical grey matter PET tau SUVR values were significantly higher in APOE4 carriers compared to non-carriers (p = 0.020). In contrast, there was no significant difference in SUVR between MAPT H1H1 vs non-H1H1 carrier genes (p = 1.00). There was a significantly higher APOE4 allele frequency in the high cortical grey matter PET tau group, comparing to low cortical grey matter PET tau group (p = 0.048). No significant difference in neuropsychological function was found between APOE4 allele carriers and non-carriers.

INTERPRETATION

There is an association between higher cortical grey matter tau burden as seen with [F-18]AV-1451 PET tracer SUVR, and the APOE4 allele in former professional and semi-professional players at high risk of concussions. APOE4 allele may be a risk factor for tau accumulation in former contact sports athletes at high risk of neurodegeneration.

FUNDING

Toronto General and Western Hospital Foundations; Weston Brain Institute; Canadian Consortium on Neurodegeneration in ageing; Krembil Research Institute. There was no role of the funders in this study.

Proceedings from the Ice Hockey Summit III: Action on Concussion

The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these five objectives: 1) describe sport-related concussion (SRC) epidemiology, 2) classify prevention strategies, 3) define objective, diagnostic tests, 4) identify treatment, and 5) integrate science and clinical care into prioritized action plans and policy. Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches, and officials) voted to prioritize these action items in the final Summit session. 1) Establish a national and international hockey data base for SRC at all levels, 2) eliminate body checking in Bantam youth hockey games, 3) expand a behavior modification program (Fair Play) to all youth hockey levels, 4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues, 5) establish objective tests to diagnose concussion at point of care (POC), and 6) mandate baseline testing to improve concussion diagnosis for all age groups. Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity, and consequences of concussion in the sport of ice hockey.

Metastatic gestational choriocarcinoma: a masquerader in obstetrics

We describe a case of a 36-year-old woman presenting with vaginal bleeding and suboptimally rising serum human chorionic gonadotropin levels, who was investigated for a pregnancy of unknown location. Ultrasonography, laparoscopy and dilatation and curettage failed to reveal signs of an intra-uterine or intra-abdominal pregnancy. Following computed tomography imaging, a mediastinal mass was histologically determined to be a gestational choriocarcinoma. Following surgical resection and chemotherapy, the patient recovered and proceeded to have a successful intra-uterine pregnancy. We describe this exceptionally rare case and emphasise the importance of follow-up of hCG levels in pregnancy of unknown location.

Perception of Home Environment and School Abilities as Predictors of Reading Power and School Achievements

A sample of 565 sixth grade, middle-school students in two urban settings in the Southwestern United States completed the My Education (ME) scale and the Degrees of Reading Power. Responses to the 55 items in the ME Scale were factor analyzed by the principal components solution. Five rotated factors contributed 47% to the cumulative proportion of common variance. The first factor, labeled “Values Learned From Parents,” contained item responses which were the best predictors of reading power with a correlation of .41. Reading power and ability among 565 sixth graders was motivated highest by perceived values learned at home.

AxGxE: Using Flies to Interrogate the Complex Etiology of Neurodegenerative Disease

Progressive and late-onset neurological disorders such as Parkinson's disease and Alzheimer's disease affect up to 50 million people globally-a number postulated to double every 20 years in a continually aging population. While predisposing allelic variants in several genes clearly confer risk, individual age and specific environmental influences are equally important discriminators of disease onset age and progression. However, none of these factors can independently predict disease with significant precision. Therefore, we must actively develop models that accommodate contributions from all factors, potentially resulting in an A × G × E (age-gene-environment) metric that reflects individual cumulative risk and reliably forecasts disease outcomes. This effort can only be enabled by a deep quantitative understanding of the contribution of these factors to neurodegenerative disease, both individually and in combination. This is also an important consideration because neuronal loss typically precedes clinical presentation and disease-modifying therapies are contingent on early diagnosis that is likely to be informed by an accurate estimation of individual risk. Although epidemiological studies continue to make strong advances in these areas with the advent of powerful "omics"-based approaches, systematic phenotypic modeling of AxGxE interactions is currently more feasible in model organisms such as Drosophila melanogaster where all three parameters can be manipulated with manageable experimental burden. Here, we outline the advantages of using fruit flies for investigating these complex interactions and highlight potential approaches that might help synthesize existing information from diverse fields into a cogent description of age-dependent, environmental, and genetic risk factors in the pathophysiology of neurological disorders.

Patient Satisfaction and Acceptability: A Journey through an Ambulatory Gynaecology Clinic in the West of Ireland

Ambulatory Gynaecology allows a 'see-and-treat' approach to managing gynaecological conditions, providing a more streamlined, integrated care pathway than the traditional gynaecology clinic and inpatient care model. This study was designed to assess patient satisfaction and acceptability of Ambulatory Gynaecology services in Mayo University Hospital, Castlebar, Ireland. It also provided for feedback from patients as to how the service might be improved. Eighty questionnaires were appropriately completed. Outcomes revealed positive responses in 84% with respect to their experience before attending the clinic, 93% relating to the Ambulatory Gynaecology clinic environment, 96% for communication within the service, 91% for their experience during the procedure and 88% for aftercare information. This study concludes that an ambulatory approach to managing a range of gynaecology referrals is a highly acceptable approach in an Irish gynaecological population. Valuable feedback was gained from the study, which will allow us to further enhance the service for our patients.

Image-guided Percutaneous Drainage for Treatment of Post-Surgical Anastomotic Leak in Patients with Crohn's Disease

BACKGROUND AND AIMS

Anastomotic leaks with abscess formation are a common complication after bowel surgery in Crohn's disease patients. Image-guided percutaneous drainage is an attractive alternative to reoperation because of decreased morbidity and length of hospital stay. Because data for this specific population are scarce, the purpose of this study is to determine the safety and efficacy of image-guided percutaneous drainage in the management of post-surgical anastomotic leak in patients with Crohn's disease.

METHODS

A total of 41 patients who underwent percutaneous drain placement for the treatment of fluid collections due to anastomotic leak from September 2004 to November 2013 were retrospectively identified from the electronic medical record and picture archiving and communication system. Data recorded included number, size, and location of anastomotic leaks, number of drains placed, number of follow-up visits, post-drainage complications, abscess resolution, and subsequent surgeries.

RESULTS

In all, 41 patients with 76 fluid collections were identified as having received percutaneous drains. The mean number of targeted fluid collections per patient was 1.5, and the mean duration between surgery and percutaneous drain placement was 18.5 days. The mean number of drains placed was 1.6, and the median drain size was 10 French [range 8-16 French]. One of 41 [2.4%] patients experienced a minor complication from drain placement [injury to a superficial abdominal artery] and no major complications occurred. Two of 41 [4.9%] patients required repeat surgeries.

CONCLUSIONS

Image-guided percutaneous drainage for the treatment of post-surgical anastomotic leaks in Crohn's patients is effective and safe, with low rates of complications and reoperations.

Neuroimaging findings in sickle cell disease

At least 25% of individuals with sickle cell disease will have a neurological complication over their lifetime, often as early as in childhood. Neuroradiological findings in patients with sickle cell disease are common and include acute territorial infarction, silent ischaemia and intracranial haemorrhage. Imaging abnormalities are typically, but not always, manifestations of the underlying vasculopathy. Coexisting acute and chronic pathology may pose challenges to interpretation.

SPECT-CT: applications in musculoskeletal radiology

This article reviews the technique, basic science principles and applications of integrated single photon emission CT (SPECT)-CT in musculoskeletal radiology. A review of the current evidence on the topic was undertaken, and selected clinical cases from the authors' institution have been used for illustration. SPECT-CT is a technology with emerging applications that offers technical advantages to image fusion of separately acquired SPECT and CT studies. The prevailing evidence indicates that there may be benefit in adding SPECT-CT to conventional imaging algorithms during the evaluation of some malignant and benign musculoskeletal conditions. SPECT-CT can improve both sensitivity and specificity by reducing equivocal interpretation in comparison to planar scintigraphy or SPECT alone. The evidence base for SPECT-CT in musculoskeletal radiology is still evolving. There is a lack of evidence comparing SPECT-CT with MRI in many key indications, and further research is required in these areas.

Endovascular management of chronic upper extremity deep vein thrombosis and superior vena cava syndrome

Chronic upper extremity deep vein thrombosis (UEDVT) and superior vena cava syndrome (SVCS) are important and underdiagnosed entities that are associated with significant morbidity, and both are becoming increasingly common due to the use of indwelling catheters and implantable central venous access devices. Currently, as many as 25% of patients with an indwelling catheter are diagnosed with chronic UEDVT or venous stenosis. SVCS is most commonly seen in the setting of malignancy, especially lung cancer and lymphoma. Endovascular management of chronic UEDVT and SVCS is accepted as an important first-line treatment given its high overall success rate and low morbidity as compared with medical and surgical treatments. In this article, the indications for treatment, complications, and success rates of the endovascular management of UEDVT and SVCS are reviewed. Relevant findings on presentation and physical exam as well as various imaging modalities and imaging findings are evaluated. Details of preprocedure evaluation, relevant anatomy, and avoidance of potential complications are discussed.

Ultrasound-guided core biopsy in the diagnosis of lymphoma of the head and neck. A 9 year experience

OBJECTIVES

This retrospective study aimed to evaluate the diagnostic utility of ultrasound-guided core biopsy (USCB) in lymphoma of the head and neck, in particular whether core biopsy can provide sufficient diagnostic information for definitive treatment.

METHODS

All lymphomas diagnosed in the head and neck at Eastbourne General Hospital between January 2000 and June 2009 were identified. Radiology and pathology reports were reviewed and the diagnostic techniques recorded. The type of biopsy (fine needle aspiration, needle core, surgical excision biopsy) used to establish a diagnosis sufficient to allow treatment, i.e. the "index" diagnostic technique, was identified. Previous inconclusive or inadequate biopsies were noted. Pathology reports based on USCB were graded 0-3 according to diagnostic completeness and ability to provide treatment information.

RESULTS

Of 691 overall cases of lymphoma diagnosed over the 9 year period, 171 different patients presented with lymphoma in the head and neck. Of these 171, 83 had USCB biopsy during diagnostic work up. 60 were regarded as grade 3 where a confident diagnosis of lymphoma was made. In seven patients, clinical management proceeded on the basis of a suggestive (grade 2) pathology report without surgical excision, and these were therefore also included as "index" biopsies. Overall therefore, 67/83 core biopsies (81%) provided adequate information to allow treatment. Surgical excision biopsy was the index modality in 104 cases.

CONCLUSION

In the majority of cases USCB is adequate for confident histopathological diagnosis avoiding the need for surgical excision biopsy in cases of suspected head and neck lymphoma.

Impact of a direct access occupational physiotherapy treatment service

BACKGROUND

Musculoskeletal disorders (MSDs) cause significant morbidity and absence from work for both manual and sedentary occupations.

AIMS

To examine the impact of a direct access physiotherapy treatment service in an occupational setting.

METHODS

This was a pilot study carried out as a service audit. Physiotherapy patients were assessed pre- and post-treatment using the work function score (WFS), a visual analogue scale for pain (VASP) and adjusted clinical score (ACS). Self-report questionnaires were completed on sickness absence, attendance at work and the World Health Organization (five) Well-being Index.

RESULTS

There were 231 participants. Patient improvement was reported in WFS (63%), ACS (84%) and VASP (94%). Compared with those who had one or two sessions, improvement was most likely after three to four sessions for WFS [odds ratio (OR): 4.5; 95% confidence interval: 1.4-14.3, P < 0.05], VASP (OR: 32.2; 95% confidence interval: 3.5-294.2, P < 0.01) and five to six sessions for ACS (OR: 6.9; 95% confidence interval: 1.9-25.9, P < 0.01). While the self-reported questionnaire response rate was low at 29%, respondents indicated that there was potential to reduce and prevent sickness absence and improve mental well-being.

CONCLUSIONS

Brief physiotherapy treatment for MSDs may have the potential to improve not only clinical status and pain as expected but also work function, psychological well-being and sickness absence. Further research is warranted to confirm these positive impacts and to endorse physiotherapy as an effective intervention in occupational settings and a useful component in rehabilitation and 'Fit for Work' programmes.

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial

BACKGROUND

HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.

METHODS

In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.

FINDINGS

Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases).

INTERPRETATION

ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment.

FUNDING

UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.