Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel

Surgical treatments for ischemic priapism (IP) include shunts or penile implants. Non-ischemic priapism (NIP) is usually the result of penile/perineal trauma causing an arterial fistula and embolisation may be required. We conducted a systematic review on behalf of the EAU Sexual and Reproductive health Guidelines panel to analyse the available evidence on efficacy and safety of surgical modalities for IP and NIP. Outcomes were priapism resolution, sexual function and adverse events following surgery. Overall, 63 studies (n = 923) met inclusion criteria up to September 2021. For IP (n = 702), surgery comprised distal (n = 274), proximal shunts (n = 209) and penile prostheses (n = 194). Resolution occurred in 18.7-100% for distal, 5.7-100% for proximal shunts and 100% for penile prostheses. Potency rate was 20-100% for distal, 11.1-77.2% for proximal shunts, and 26.3-100% for penile prostheses, respectively. Patient satisfaction was 60-100% following penile prostheses implantation. Complications were 0-42.5% for shunts and 0-13.6% for IPP. For NIP (n = 221), embolisation success was 85.7-100% and potency 80-100%. The majority of studies were retrospective cohort studies. Risk of bias was high. Overall, surgical shunts have acceptable success rates in IP. Proximal/venous shunts should be abandoned due to morbidity/ED rates. In IP > 48 h, best outcomes are seen with penile prostheses implantation. Embolisation is the mainstay technique for NIP with high resolution rates and adequate erectile function.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Surgeon educator perspectives of implementing a national undergraduate curriculum in otolaryngology

OBJECTIVE

The General Medical Council will be implementing a national medical licensing assessment for all UK medical students by 2024-25. Surgeon educator perceptions on a national undergraduate curriculum in otolaryngology were reviewed accordingly.

METHOD

A mixed methods study was undertaken within a UK school of surgery assessing ENT surgeon educators. Perspectives on teaching content, quality and student experience were assessed with degree of agreement assessed (Likert scoring). Associated qualitative focus group sessions underwent detailed thematic analysis according to grounded theory.

RESULTS

A response rate of 50 per cent was achieved involving 21 participants working across 14 hospitals. These showed strong agreement that implementation of a national curriculum would improve the standard of teaching delivered at a personal, institutional and national level. Further themes were identified relating to the personal, institutional and specialty related factors influencing practical delivery.

CONCLUSION

A series of practical recommendations are made to potentially assist the implementation of a national ENT curriculum.

Point of care ultrasound: Current and future directions for Acute Medicine

Point of care ultrasound (POCUS) represents an exciting tool for current and future acute care practitioners. POCUS has come a long way in a short space of time and its widespread implementation may well be one of the biggest changes seen in acute medicine across the next decade. This narrative review explores the increasing evidence base for the accuracy of POCUS use in various acute scenarios, whilst also addressing current gaps in the evidence and areas for potential future POCUS development.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

The humanistic burden of vitiligo: a systematic literature review of quality-of-life outcomes

Despite historical mischaracterization as a cosmetic condition, patients with the autoimmune disorder vitiligo experience substantial quality-of-life (QoL) burden. This systematic literature review of peer-reviewed observational and interventional studies describes comprehensive evidence for humanistic burden in patients with vitiligo. PubMed, EMBASE, Scopus and the Cochrane databases were searched through February 10, 2021, to qualitatively assess QoL in vitiligo. Two independent reviewers assessed articles for inclusion and extracted data for qualitative synthesis. A total of 130 included studies were published between 1996 and 2021. Geographical regions with the most studies were Europe (32.3%) and the Middle East (26.9%). Dermatology-specific instruments, including the Dermatology Life Quality Index (DLQI; 80 studies) and its variants for children (CDLQI; 10 studies) and families (FDLQI; 4 studies), as well as Skindex instruments (Skindex-29, 15 studies; Skindex-16, 4 studies), were most commonly used to measure humanistic burden. Vitiligo-specific instruments, including the Vitiligo-specific QoL (VitiQoL; 11 studies) instrument and 22-item Vitiligo Impact Scale (VIS-22; 4 studies), were administered in fewer studies. Among studies that reported total scores for the overall population, a majority revealed moderate or worse effects of vitiligo on patient QoL (DLQI, 35/54 studies; Skindex, 8/8 studies; VitiQoL, 6/6 studies; VIS-22, 3/3 studies). Vitiligo also had a significant impact on the QoL of families and caregivers; 4/4 studies reporting FDLQI scores indicated moderate or worse effects on QoL. In general, treatment significantly (P < 0.05) improved QoL, but there were no trends for types or duration of treatment. Among studies that reported factors significantly (P ≤ 0.05) associated with reduced QoL, female sex and visible lesions and/or lesions in sensitive areas were most common. In summary, vitiligo has clinically meaningful effects on the QoL of patients, highlighting that greater attention should be dedicated to QoL decrement awareness and improvement in patients with vitiligo.

TH3.8 Retrospective study on the use of colonic stents in malignancy; a bridge to surgery or the end of the line?

Aim

Colonic stenting is a management option for obstructed left sided colorectal malignancy in the emergency and elective setting. Stenting can provide a bridge to curative surgery or to adjuvant treatment. The aim of this study was to assess the role of colonic stenting in management of obstructed colorectal cancer.

Methods

This retrospective cohort study analyses prospectively collected data from two centres within one Health Board in Wales. Patients were recorded in a cancer database, who underwent colonic stenting for left sided colonic malignancy between January 2008 and December 2021. Patient demographics, treatment pathways, length of admission, stoma formation rates and morbidity were recorded.

Results

In total, 98 patients, with a mean age of 73.5 years (range 37–97) underwent a colonic stent. The majority were elective 55% (n=54). The sigmoid colon was the commonest site of tumour in 33 patients, with metastatic disease in 82% (n=80). The study found 86% (n=84) of patients were successfully stented. The mean length of admission was 13 days. The complication rate was 23% (n=23), most commonly stent obstruction (n=6). Stenting was a bridge to curative surgery for 3 patients, and 47% (n=46) received adjuvant treatment. Five-year survival was 19.3% (n=19). The overall stoma rate was 10.2% (10 patients).

Conclusion

This study shows colonic stenting is a viable alternative in surgical management for advanced obstructing colorectal malignancy but not as a bridge to surgery. The majority of this cohort returned home following stenting, had a low overall stoma rate and 19% survival at 5 years.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

AB0905 Routine Assessment of Patient Index Data 3 (RAPID3) in Patients With Active Psoriatic Arthritis (PsA) After Inadequate Response or Intolerance to DMARDs: Pooled Results From the Phase 3, Randomized, Double-Blind KEEPsAKE 1 and 2 Trials

Background

PsA is a chronic, systemic inflammatory disease with diverse clinical manifestations that can impact a patients’ quality of life. Risankizumab (RZB), a humanized immunoglobulin G1 monoclonal antibody that specifically inhibits interleukin 23 by binding to its p19 subunit, is approved for the treatment of active PsA in adults. In the phase 3 KEEPsAKE 1 and 2 studies, RZB treatment resulted in significantly greater improvements in signs and symptoms of active PsA compared with placebo (PBO).1,2 RAPID3 is frequently used in clinical practice to evaluate PsA disease activity and consists of 3 key patient-reported measures (physical function, pain, and patient’s global assessment of disease activity [PtGA]).3

Objectives

To evaluate short- (24 week) and long-term (52 week) improvements in RAPID3 scores and achievement of RAPID3 minimal clinically important difference (MCID) across the RZB KEEPsAKE 1 and 2 clinical program.

Methods

In KEEPsAKE 1 (NCT03675308) and KEEPsAKE 2 (NCT03671148), patients with active PsA who experienced inadequate response or intolerance to ≥ 1 csDMARD (KEEPsAKE 1) and/or ≤ 2 biological therapies (KEEPsAKE 2) were randomized to PBO or RZB 150 mg from baseline to week (W) 24; from W28–W52, all patients received open-label RZB 150 mg. At W16, nonresponders could add or modify rescue therapy. This post hoc analysis assessed the mean change from baseline to W24 and W52 in RAPID3 scores and the proportion of patients who achieved a RAPID3 MCID (defined as a decrease of ≥3.8 points4). Modified RAPID3 scores (range: 0–30) were calculated using pain scores, PtGA, and HAQ-DI, each rescaled to 0–10 and summed together.3

Results

A total of 961 and 443 patients were included from KEEPsAKE 1 and 2, respectively. At baseline, mean RAPID3 scores were 15.3 in both treatment arms of KEEPsAKE 1 (PBO n = 479, RZB n = 482) and 15.1 (PBO n = 219) and 14.8 (RZB n = 224) in KEEPsAKE 2. From W4 to W24, RAPID3 scores were significantly reduced with RZB treatment compared with PBO in both KEEPsAKE 1 (mean change from baseline at W24 of −5.3 vs −2.4, respectively, P <.001) and KEEPsAKE 2 (−3.8 vs −1.6, P <.001; Figure 1 A, B), and a significantly greater proportion of patients achieved MCID at W24 with RZB than with PBO in KEEPsAKE 1 (57.0% vs 36.4%, P <.001) and KEEPsAKE 2 (48.8% vs 32.8%, P <.001; Table 1). At W52 among patients who received RZB from W0–W52, mean change from baseline was −7.0 (KEEPsAKE 1) and −5.2 (KEEPsAKE 2; Figure 1 C, D), and MCID was achieved by 67.5% (KEEPsAKE 1) and 56.5% (KEEPsAKE 2) of patients. Patients who switched from PBO to RZB at W24 experienced similar and substantial improvements in RAPID3 scores by W52.

Table 1.

Proportion of Patients Achieving a Minimal Clinically Important Difference From Baseline in RAPID3 (AO).

Patients, % (n/N) [95% CI]KEEPsAKE 1KEEPsAKE 2PBORZB 150 mgPBORZB 150 mgW2436.4 (166/456) [32.0, 40.8]57.0 (262/460) [52.4, 61.5]***32.8 (64/195) [26.2, 39.4]48.8 (104/213) [42.1, 55.5]***PBO to RZB 150 mgaRZB 150 mgPBO to RZB 150 mgaRZB 150 mgW5259.8 (260/435) [55.2, 64.4]67.5 (297/440) [63.1, 71.9]57.4 (105/183) [50.2, 64.5]56.5 (109/193) [49.5, 63.5]

aPatients randomized to PBO at W0 switched to open-label RZB 150 mg at W24.

***, P < .001 vs PBO.

AO, as observed; PBO, placebo; RAPID3, Routine Assessment of Patient Index Data 3; RZB, risankizumab; W, week.

Figure 1.

Mean Change From Baseline in RAPID3 Scores During KEEPsAKE 1 and 2.

**, P < .01; ***, P < .001 vs PBO.

AO, as observed; LS, least squares; MMRM, mixed-effect model repeated measurement; PBO, placebo; RAPID3, Routine Assessment of Patient Index Data 3; RZB, risankizumab.

Conclusion

RZB 150 mg was associated with improvement in RAPID3 total scores over 24–52 weeks of treatment in patients with active PsA in KEEPsAKE 1 and 2.

References

[1]Kristensen LE, et al. Ann Rheum Dis. 2022;81:225–231.

[2]Östör A, et al. Ann Rheum Dis. 2021;annrheumdis-2021-221048.

[3]Coates LC, et al. Arthritis Care Res (Hoboken). 2018;70:1198–1205.

[4]Ward MM, et al. J Rheumatol. 2019;46:27–30.

Acknowledgements

AbbVie Inc. participated in the study design; study research; collection, analysis, and interpretation of data; and writing, reviewing, and approving of this abstract for submission. All authors had access to the data; participated in the development, review, and approval of and in the decision to submit this abstract to EULAR 2022 for consideration as a poster or oral presentation. No honoraria or payments were made for authorship. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. AbbVie funded the research for this study and provided writing support for this abstract.

Medical writing assistance, funded by AbbVie, was provided by Callie A. S. Corsa, PhD, of JB Ashtin.

Disclosure of Interests

Alexis Ogdie Consultant of: AO has received consulting fees and/or honoraria from AbbVie, Amgen, Bristol Myers Squibb, Celgene, CorEvitas, Gilead, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AO has received grants from AbbVie, Novartis, and Pfizer to the trustees of University of Pennsylvania, and from Amgen to Forward., Laura Coates Speakers bureau: LCC has been paid as a speaker for AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Medac, Novartis, Pfizer and UCB., Consultant of: LCC has worked as a paid consultant for AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Moonlake, Novartis, Pfizer and UCB, Grant/research support from: LCC has received grants/research support from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, RICARDO ACAYABA DE TOLEDO Speakers bureau: RAT has received honoraria as a speaker/consultant for Abbvie, Celltrion, Janssen, Novartis, Pfizer, and UCB, Consultant of: RAT has received honoraria as a speaker/consultant for Abbvie, Celltrion, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: RAT has received grants as an investigator from Abbvie, GSK, Novartis, and Pfizer., Ana Biljan Shareholder of: AB may hold AbbVie stock or stock options., Employee of: AB is a full-time employee of AbbVie., Heather Jones Shareholder of: HJ may hold AbbVie stock or stock options., Employee of: HJ is a full-time employee of AbbVie., Kristin Tacelosky Shareholder of: KT may hold AbbVie stock or stock options., Employee of: KT is a full-time employee of AbbVie., Cuiyong Yue Shareholder of: CY may hold AbbVie stock or stock options., Employee of: CY is a full-time employee of AbbVie., Byron Padilla Shareholder of: BP may hold AbbVie stock or stock options., Employee of: BP is a full-time employee of AbbVie., Martin Bergman Shareholder of: MB is a stock holder of Johnson & Johnson and Merck., Speakers bureau: MB has received honoraria as a speaker/consultant for Abbvie, Amgen, GSK, Janssen, Novartis, Pfizer, Sanofi, and Scipher, Consultant of: MB has received honoraria as a speaker/consultant for Abbvie, Amgen, GSK, Janssen, Novartis, Pfizer, Sanofi, and Scipher

Vitiligo Prevalence and Quality of Life Among Adults in Europe, Japan, and the United States

Background

Vitiligo, an autoimmune disorder characterised by skin depigmentation, is associated with reduced quality of life (QoL). Vitiligo may be under‐reported, in part because of misconceptions that it is a cosmetic disease.

Objectives

This survey sought to characterise vitiligo prevalence and explore the relationship between sociodemographic and clinical characteristics with QoL in a population‐based, multinational study.

Methods

Participants aged ≥18 years were recruited via an online panel in Europe, Japan and the USA to answer questions regarding skin disorders they may have experienced. Those reporting vitiligo (diagnosed or undiagnosed) or vitiligo signs (experiencing loss of skin colour but unaware of vitiligo and not diagnosed) were included in the analyses of vitiligo prevalence. Participants who self‐reported physician‐diagnosed vitiligo were given a broader survey to characterise disease progression, management and QoL (as measured with the Vitiligo‐specific QoL [VitiQoL] instrument).

Results

The total estimated vitiligo prevalence among 35 694 survey participants (Europe, n = 18 785; USA, n = 8517; Japan, n = 8392) was 1.3% (diagnosed, 0.6%; undiagnosed, 0.4%; vitiligo signs, 0.3%). Among 219 patients formally diagnosed with vitiligo (Europe, n = 150; USA, n = 48; Japan, n = 21), total VitiQoL scores were associated with age (P = 0.00017), disease extent (P < 0.0001), disease progression (P < 0.0001), disease management (P < 0.0001) and time since diagnosis (P = 0.0015). Behaviour scores varied based on skin phototype (P = 0.024) and ethnicity (P = 0.048). Higher total VitiQoL scores were reported in patients with head lesions (P = 0.027) and those with head and hand and/or wrist lesions (P = 0.018). Substantial high concern (rated 8–10 on an 11‐point Likert scale) for lesions was found across all body areas and varied with geographical region.

Conclusions

The vitiligo prevalence rate may be higher than previously reported, with a substantial proportion attributed to people who have not received a formal diagnosis. Among formally diagnosed patients with vitiligo, QoL was most severely impacted by more progressive and higher extent of disease.

IMPARTER, Phase 1 of an intervention to improve patients' understanding of gene expression profiling tests in breast cancer

PURPOSE

To compare participants' knowledge about gene expression profiling (GEP) tests and recurrence risks after reading an information leaflet with that following viewing of an information film.

METHODS

Using a randomised cross-over design, at time-point one (T1), women aged 45-75 years without breast cancer either read leaflets or watched information films about Oncotype DX or Prosigna tests. Participants answered nine questions assessing knowledge (maximum score 18). Next-day information in the opposite modality was provided and knowledge re-assessed. Additional questions probed which format was easiest to understand, participants' preferences for film or leaflet and their reasons for these.

RESULTS

120 women participated (60 received OncotypeDX films and leaflets; 60 received the Prosigna versions). T1 mean knowledge scores were higher following film viewing (13.37) compared with that after reading leaflets (9.25) (mean difference 4.1; p < 0.0001; 95% CI 3.2, 5.0). When participants read leaflets first and subsequently viewed films, all increased their scores (mean + 6.08, from T1 of 9.25, p < 0.0001; 95% CI 5.44, 6.72). When films were viewed first, followed by leaflets, (36/60, 60%), participants' scores declined (mean-1.55 from T1 of 13.37, p < 0.001; 95% CI -2.32, -0.78). A majority of participants expressed preferences for the films (88/120, 73.3%) irrespective as to whether they described OncotypeDX or Prosigna. Reasons included the clarity, ease of understanding, visual material and reassuring voice-over.

CONCLUSION

Discussions between oncologists and patients about recurrence risk results can be challenging. Information leaflets may aid understanding but often employ complex language. Information films significantly improved knowledge and were preferred by participants.

The effects of exercise training in the cold on cerebral blood flow and cerebrovascular function in young healthy individuals

Exercise elicits acute increases in cerebral blood flow velocity (CBFv) and provokes long-term beneficial effects on CBFv, thereby reducing cerebrovascular risk. Acute exposure to a cold stimulus also increases CBFv. We compared the impact of exercise training in cold and thermoneutral environments on CFBv, cerebrovascular function and peripheral endothelial function. Twenty-one (16 males, 22 ± 5 years) individuals were randomly allocated to either a cold (5 °C) or thermoneutral (15 °C) exercise intervention. Exercise consisted of 50-min cycling at 70% heart rate max, three times per week for eight weeks. Transcranial Doppler was used to determine pre and post intervention CBFv, dynamic cerebral autoregulation (dCA) and cerebrovascular reactivity (CVRCO2). Conduit endothelial function, microvascular function and cardiorespiratory fitness were also assessed. Cardiorespiratory fitness improved (2.91 ml.min.kg-1, 95%CI 0.49, 5.3; P = 0.02), regardless of exercise setting. Neither intervention had an impact on CBFv, CVRCO2, FMD or microvascular function (P > 0.05). There was a significant interaction between time and condition for dCA normalised gain with evidence of a decrease by 0.192%cm.s-1.%mmHg-1 (95%CI -0.318, -0.065) following training in the cold and increase (0.129%cm.s-1.%mmHg-1, 95%CI 0.011, 0.248) following training in the thermoneutral environment (P = 0.001). This was also evident for dCA phase with evidence of an increase by 0.072 rad (95%CI -0.007, 0.152) following training in the cold and decrease by 0.065 (95%CI -0.144, 0.014) radians following training in the thermoneutral environment (P = 0.02). Both training interventions improved fitness but CBFv, CVRCO2 and peripheral endothelial function were unaltered. Exercise training in the cold improved dCA whereas thermoneutral negated dCA.

409 Audit of a Patient Satisfaction Survey for a Nasal Fracture Pathway?

Introduction

We present an audit of a patient satisfaction survey assessing the contentment of patients using the nasal fracture pathway created by the ENT department in University Hospital Southampton. This is a patient triggered follow-up pathway where patients presenting to the emergency department for a possible nasal fracture were given an information leaflet to self-refer if needed.

Method

The data collection took place over the phone and ranged from July to August 2021 and consisted of thirty patients. Five of which were not given the leaflet, seven were uncontactable, two did not use it and the remaining fifteen patients took part in the survey.

Results

Of the fifteen patients included 100 % were satisfied with the patient triggered pathway. The following questions were asked. Did you think the leaflet clearly explained when you should seek medical advice? 27 % said excellent, 32% very good, 32% good and 7% fair and none as poor. Did you understand when to contact ENT? 20% reported excellent, 27% very good, 32% good, 14% fair and 7% poor. Next, how easy to read was it? 27% said excellent, 32% very good, 27% good, 7% fair and 7% poor. Lastly, how well designed and formatted was it? 7% reported excellent, 60% very good, 20% good, 7% fair and none as poor.

Conclusions

This pathway was introduced due to Covid restrictions. This audit has demonstrated high user acceptability. There are resource and cost saving implications. Thus, this pathway has potential to be incorporated into routine clinical practise going forward.

1452 How Did We Nose? COVID Adaptation of Our Nasal Fracture Service

Introduction

Nasal fractures are a common ENT emergency that present to ED typically with a history of trauma. They can leave behind functional problems with breathing and can be cosmetically very deforming. For this reason, they need to be managed appropriately by the specialist team. In UHS, Southampton Hospital these patients were initially followed up by Care UK but during COVID, in order to minimise patient contact we came up with a modified patient initiated follow up pathway. (PIFU)

Method

Based on commonly agreed departmental guidelines:

We looked at the statistics from 2019 and compared it with data from August – October 2020 and reviewed all patients who presented via ED and GP to us with nasal fractures visa image and telephone review and face to face meetings over a 3-month period.

Results

Despite lower attendances in ED during months of lockdown we still had 48 patients in 3 months i.e., nearly 4 patients every week. 50% did not initiate follow up. Of the patients who initiated follow up a third required MUA of which one was under general anaesthesia. All patients were treated within 21 days.

Conclusions

Our modified management pathway is compliant with the guidelines despite some consultations via telephone calls and image reviews.

Mitral valve dysfunction among sudden death victims

Funding Acknowledgements

Type of funding sources: None.

Introduction

Mitral dysfunction is a commonly found valvular abnormality in the US. The association between mitral dysfunction with sudden death is both complex and controversial.

Purpose

To assess mitral dysfunction as a potential risk factor for sudden death using medical and autopsy records in a population-based registry of sudden deaths.

Methods

From 2013-2015, out-of-hospital deaths aged 18-64 reported by Emergency Medical Services in Wake County, North Carolina were screened to adjudicate 399 sudden death victims. Medical records were available in 270 victims, echocardiograms in 53, and autopsies in 64. Echocardiogram reports of none/trace/trivial mitral insufficiency were compared to patients with mild, moderate, or severe insufficiency. Autopsy reports for thickened mitral leaflets, calcification, and redundancy were reviewed. Additionally, available echocardiograms from a control group of 1101 patients were reviewed for mitral insufficiency. Demographics and clinical comorbidities were assessed from medical and death records. Mean, t-tests, and a bivariate logistic regression were estimated, as appropriate.

Results

Of the 53 victims with echocardiograms, mean age was 53 years, 36 (65.5%) were male, and 21 (39.6%) were African-American. Victims with available echocardiograms were more likely to have congestive heart failure (41.8%), coronary artery disease (50.9%), and diabetes (47.3%) compared to victims without echocardiograms. None/trivial/trace insufficiency was present in 27 victims (50.9%), mild insufficiency in 18 (34.0%), and moderate-severe insufficiency in 8 (15.1%). There was no association between severity of mitral insufficiency with demographic covariates or comorbid conditions. The presence of structural mitral valve abnormalities, including thickened leaflets, calcification, and redundancy of the mitral valve, were present in only 8 (12.5%) of 64 victims with autopsies. In a control group of 1101 date-matched patients from the same county, 57 (4.8%) patients had an echocardiogram available. 14 (24.6%) of these patients had mild-moderate mitral insufficiency.

Conclusion

Mitral insufficiency and structural abnormalities of the mitral valve are often identified in echocardiograms or autopsies of sudden death victims. Living controls had approximately half the prevalence of mitral insufficiency, suggesting that mitral dysfunction and its associated comorbidities are associated with sudden death.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

Introduction

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

Objectives

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

Methods

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

Results

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

Conclusion

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

Key Words

Community, priorities, FASD, rapid review, Australia.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Effects of breeding history and crop management on the root architecture of wheat

AIMS

Selection for optimal root system architecture (RSA) is important to ensure genetic gains in the sustainable production of wheat (Triticum aestivum L.). Here we examine the hypothesis that past wheat breeding has led to changes in RSA and that future breeding efforts can focus directly on RSA to improve adaptation to target environments.

METHODS

We conducted field trials using diverse wheat varieties, including modern and historic UK varieties and non-UK landraces, tested under contrasting tillage regimes (non-inversion tillage versus conventional ploughing) for two trial years or different seeding rates (standard versus high rate) for one trial year. We used field excavation, washing and measurement of root crowns ('shovelomics') to characterise RSA traits, including: numbers of seminal, crown and nodal roots per plant, and crown root growth angle.

RESULTS

We found differences among genotypes for all root traits. Modern varieties generally had fewer roots per plant than historic varieties. On average, there were fewer crown roots and root angles were wider under shallow non-inversion tillage compared with conventional ploughing. Crown root numbers per plant also tended to be smaller at a high seeding rate compared with the standard. There were significant genotype-by-year, genotype-by-tillage and genotype-by-seeding-rate interactions for many root traits.

CONCLUSIONS

Smaller root systems are likely to be a result of past selection that facilitated historical yield increases by reducing below-ground competition within the crop. The effects of crop management practices on RSA depend on genotype, suggesting that future breeding could select for improved RSA traits in resource-efficient farming systems.

HPV may not play a role in all lacrimal transitional cell papilloma

BACKGROUND

Tumours of the lacrimal duct apparatus (LDA) are rare and heterogenous but knowledge of their aetiology is important for the rhinologist. A link between transitional cell papilloma/carcinoma (TCP/TCC) and human papilloma virus (HPV) has been suggested in previous studies. We aimed to add to this body of evidence by submitting 16 LDA tumour samples from our tertiary referral centre for HPV analysis.

METHODOLOGY

All LDA tumour samples stored in the University College London tissue bank were submitted for HPV analysis by centralised nucleic acid extraction and HPV genotyping via a sensitive polymerase chain reaction (PCR).

RESULTS

Only one of six transitional cell papillomas tested positive for HPV. Two of three transitional cell carcinomas returned HPV 16 positive results. Two inverted papillomas submitted were also HPV positive.

CONCLUSIONS

Previously published literature has suggested a strong link between HPV and neoplasia of the lacrimal system. HPV has previously been demonstrated in all TCP and TCC. This is in contrast to our data, particularly for transitional cell papilloma where, in the largest sample of transitional cell papilloma in the literature thus far, we did not find a strong association with HPV. This casts doubt on the role of HPV in the papillomatous process in the lacrimal apparatus.

Temporary faecal diversion in ileocolic resection for Crohn's disease: is there an impact on long-term surgical recurrence?

AIM

Temporary faecal diversion after ileocolic resection (ICR) for Crohn's disease reduces postoperative anastomotic complications in high-risk patients. The aim of this study was to assess if this approach also reduces long-term surgical recurrence.

METHOD

This was a multicentre retrospective review of prospectively maintained databases. Patient demographics, medical and surgical details were collected by three specialist centres. All patients had undergone an ICR between 2000 and 2012. The primary end-point was surgical recurrence.

RESULTS

Three hundred and twelve patients (80%) underwent an ICR without covering ileostomy (one stage). Seventy-seven (20%) had undergone an ICR with end ileostomy/double-barrel ileostomy/enterocolostomy followed by closure (two stage). The median follow-up was 105 months [interquartile range (IQR) 76-136 months]. The median time to ileostomy closure was 9 months (IQR 5-12 months). There was no significant difference in surgical recurrence between the one- and two-stage groups (18% vs 16%, P = 0.94). We noted that smokers (20% vs 34%, P = 0.01) and patients with penetrating disease (28% vs 52%, P < 0.01) were more likely to be defunctioned. A reduced recurrence rate was observed in the small high-risk group of patients who were smokers with penetrating disease behaviour treated with a two-stage strategy (0/10 vs 4/7, P = 0.12).

CONCLUSION

Despite having higher baseline risk factors, the results in terms of rate of surgical recurrence over 9 years are similar for patients having a two-stage compared with a one-stage procedure.

Mortality for emergency laparotomy is not affected by the weekend effect: a multicentre study

INTRODUCTION

The 'weekend effect' describes variation in outcomes of patients treated over the weekend compared with those treated during weekdays. This study examines whether a weekend effect exists for patients who undergo emergency laparotomy.

MATERIALS AND METHODS

Data entered into the National Emergency Laparotomy Audit between 2014 and 2017 at four NHS trusts in England and Wales were analysed. Patients were grouped into those admitted on weekdays and those on weekends (Friday 5pm to Monday 8am). Patient factors, markers of quality of care and patient outcomes were compared. Secondary analysis was performed according to the day of surgery.

RESULTS

After exclusion of patients who underwent laparotomy more than one week after admission to hospital, a total of 1717 patients (1138 patients admitted on weekdays and 579 admitted on weekends) were analysed. Age, preoperative lactate and P-POSSUM scores were not significantly different between the two groups. Time from admission to consultant review, decision to operate, commencement of antibiotics and theatre were not significantly different. Grades of operating surgeon were also similar in both groups. Inpatient 60-day mortality was 12.5% on weekdays and 12.8% on weekends (P = 0.878). Median length of postoperative stay was 12 days in both groups. When analysed according to day of surgery, only number of hours from admission to antibiotics (12.8 weekday vs 9.4 weekend, P = 0.046) and number of hours to theatre (26.5 weekday vs 24.1 hours weekend, P = 0.020) were significantly different.

DISCUSSION

Quality of care and clinical outcomes for patients undergoing emergency laparotomy during the weekend are not significantly different to those carried out during weekdays.

Mortality assessment of moose (Alces alces) calves during successive years of winter tick (Dermacentor albipictus) epizootics in New Hampshire and Maine (USA)

Populations within ecological communities constantly fluctuate due to a multitude of interactions that can be influenced by climate change. Moose (Alces alces (Linnaeus, 1758)) populations in northern New Hampshire and western Maine, subunits of the largest regional moose population in the continental United States, are suspected to be declining due to increasing frequency of winter tick (Dermacentor albipictus Packard, 1869) epizootics that cause >50% late-winter mortality of 9- to 12-month-old calves. To investigate this hypothesis, we collected general health measurements of calves captured at two study sites in January 2014–2016 and subsequently performed field necropsies and histologic examination of tissues of those radio-marked calves that died during winter and spring. At capture, calves (n = 179) were in normal (66%) and thin (32%) physical condition with high infestations of winter ticks. Most (88%) mortalities (n = 125) were associated with moderate to severe infestations of winter ticks. Gross necropsies and histologic examination found high tick infestations, emaciation, anemia, and endoparasitism; lungworm (species of the genus Dictyocaulus Railliet and Henry, 1907) was also found in most (87%) calves. Three consecutive years (2014–2016) of winter tick epizootics is unprecedented in the region, rare in North America, and arguably reflects a host–parasite relationship strongly influenced by climate change at the southern fringe of moose habitat.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Meta-analysis of the prognostic value of CpG island methylator phenotype in rectal cancer

PURPOSE

The pathological and prognostic importance of CpG island methylator phenotype (CIMP) in rectal cancer, as a sub-population of colorectal cancer, is unknown. A meta-analysis was preformed to estimate the prognostic significance of CIMP in rectal cancer.

METHODS

A systematic search was performed of PubMed, Embase, MEDLINE, PubMed Central, and Cochrane electronic databases for articles pertaining to CIMP and rectal cancer. Articles were analysed and data extracted according to PRISMA standards.

RESULTS

Six studies including 1529 patients were included in the analysis. Following dichotomisation, the prevalence of CIMP-positive tumours was 10 to 57%, with a median of 12.5%. Meta-analysis demonstrated the pooled odds ratio for all-cause death for CIMP-positive tumours vs CIMP-negative tumours was 1.24 (95% CI 0.88-1.74). Z test for overall effect was 1.21 (p = 0.23). Heterogeneity between the studies was low (X2 5.96, df 5, p = 0.31, I2 = 16%). A total of 15 different loci were used for assessing CIMP across the studies, with a median of 6.5 loci (range 5-8).

CONCLUSIONS

No significant association between CIMP and poor outcomes in rectal cancer was demonstrated. There was a high degree of heterogeneity in CIMP assessment methodologies and in study populations. Rectal cancer datasets were frequently not extractable from larger colorectal cohorts, limiting analysis.

Post-Transcriptional Regulation of Hepatic DDAH1 with TNF Blockade Leads to Improved eNOS Function and Reduced Portal Pressure In Cirrhotic Rats

Portal hypertension (PH) is a major cause of morbidity and mortality in chronic liver disease. Infection and inflammation play a role in potentiating PH and pro-inflammatory cytokines, including TNF, are associated with severity of PH. In this study, cirrhotic bile duct ligated (BDL) rats with PH were treated with Infliximab (IFX, a monoclonal antibody against TNF) and its impact on modulation of vascular tone was assessed. BDL rats had increased TNF and NFkB compared to sham operated rats, and their reduction by IFX was associated with a reduction in portal pressure. IFX treatment also reduced hepatic oxidative stress, and biochemical markers of hepatic inflammation and injury. IFX treatment was associated with an improvement in eNOS activity and increased l-arginine/ADMA ratio and DDAH1 expression. In vitro analysis of HepG2 hepatocytes showed that DDAH1 protein expression is reduced by oxidative stress, and this is in part mediated by post-transcriptional regulation by the 3′UTR. This study supports a role for the DDAH1/ADMA axis on the effect of inflammation and oxidative stress in PH and provides insight for new therapies.

Meningococcal carriage in Dutch adolescents and young adults; a cross-sectional and longitudinal cohort study

OBJECTIVES

Current information on rates and dynamics of meningococcal carriage is essential for public health policy. This study aimed to determine meningococcal carriage prevalence, its risk factors and duration in the Netherlands, where meningococcal C vaccine coverage is >90%. Several methods to identify serogroups of meningococcal carriage isolates among adolescent and young adults were compared.

METHODS

Oropharyngeal swabs were collected from 1715 participants 13-23 years of age in 2013-2014; 300 were prospectively followed over 8 months. Cultured isolates were characterized by Ouchterlony, real-time (rt-) PCR or whole-genome sequencing (WGS). Direct swabs were assessed by rt-PCR. Questionnaires on environmental factors and behaviour were also obtained.

RESULTS

A meningococcal isolate was identified in 270/1715 (16%) participants by culture. Of MenB isolates identified by whole genome sequencing, 37/72 (51%) were correctly serogrouped by Ouchterlony, 46/51 (90%) by rt-PCR of cultured isolates, and 39/51 (76%) by rt-PCR directly on swabs. A sharp increase in carriage was observed before the age of 15 years. The age-related association disappeared after correction for smoking, level of education, frequent attendance to crowded social venues, kissing in the previous week and alcohol consumption. Three participants carried the same strain identified at three consecutive visits in an 8-month period. In these isolates, progressively acquired mutations were observed.

CONCLUSIONS

Whole genome sequencing of culture isolates was the most sensitive method for serogroup identification. Based upon results of this study and risk of meningococcal disease, an adolescent meningococcal vaccination might include children before the age of 15 years to confer individual protection and potentially to establish herd protection.

The LOREC APE registry: operative technique, oncological outcome and perineal wound healing after abdominoperineal excision

AIM

The Low Rectal Cancer Development programme (LOREC) perineal wound healing registry was developed to record data on abdominoperineal excision (APE) for rectal cancer in colorectal units in England between 2012 and 2014, to understand current practice in operative technique and results.

METHOD

Surgeons wishing to participate received secure Web-based access to the registry. Data were collected on preoperative staging, neoadjuvant treatment, operative details, histopathology, early outcome and follow up at 12 months.

RESULTS

Forty-two units entered 266 patients. Of these, 172 (65%) patients underwent extralevator APE (ELAPE) and 94 had non-ELAPE procedures. On preoperative staging, 64% were mrT3/4, and 67% received neoadjuvant treatment. For the ELAPE group the perineal wound was closed primarily with mesh in 55% of patients, without mesh in 15% and with a flap in 21%. For non-ELAPE procedures, 54% of wounds were closed primarily without mesh, 29% primarily with mesh and 5% by a flap. Wound breakdown occurred in 30% and 31% of patients in the ELAPE and non-ELAPE groups, respectively, and was more common after neoadjuvant radiotherapy. Donor-site complications occurred in 17% of patients treated with a flap. Perineal morbidity was recorded in 11% of patients at 12 months. On histopathology, the resection margin was positive in 13% of patients in the ELAPE group and in 4% of patients in the non-ELAPE group.

CONCLUSION

The LOREC registry provides a picture of current APE practice in England. ELAPE was used in two-thirds of patients but does not appear to confer any additional morbidity. Primary closure with mesh appeared as effective as flap reconstruction. The prevalence of an involved resection margin was lower than reported in many historical series but still remains high in the ELAPE group.