Should Long-Term Survival in Elderly Patients Presenting with Diabetic Foot Complications Impact Treatment Decision Making?

Patients presenting with diabetic foot ulceration (DFU) and associated complications often require revascularisation. Although current evidence advocates for an open bypass first strategy if patients are expected to live more than two years, this may not be appropriate in octogenarians. We sought to investigate the survival of patients aged over 70 years presenting with complicated DFU and chronic limb threatening ischaemia (CLTI) to clarify its prognosis and guide subsequent management. A database of patients admitted into a large tertiary service over the age of 70 years with DFU and CLTI between 2014 and 2017 were included. Survival data was obtained from medical records and public obituaries through to 2020. Patients were divided into three age groups: seventies (70-79 years), eighties (80-89 years) and nineties (≥90 years). Survival was evaluated using a stratified log-rank test and Kaplan-Meier methods. A total of 323 patients were included for analysis. Survival information was available for 225 patients (69%). Mean duration of follow-up was 19 months. There were 113 deaths recorded (35%). Mean survival for patients in their seventies, eighties and nineties was 63 months (95% CI 48.8-65.5), 37 months (95% CI 27.4-44.9) and 6 months (95% CI 2.3-19.2), respectively. In patients over 70 years of age presenting with DFU and CLTI, long-term survival decreases rapidly with increasing age, especially in the octogenarians. With recent technological advances and reduced morbidity, an endovascular approach may sufficiently treat acute presentations in octogenarians while reserving an open first strategy for younger patients with better long-term survival and adequate autologous conduit.

Spontaneous rupture of a solitary oligometastatic hepatic melanoma

A mid-50s woman presented with acute right upper quadrant pain 1-day post second cycle of pembrolizumab. She has a significant history for two concurrent malignancies: a solitary oligometastatic hepatic melanoma (NRAS mutant) of unknown primary diagnosed 2 months prior, and a 10-year history of breast carcinoma with pulmonary metastases on palliative chemotherapy. Multiphase CT scan demonstrated active venous bleeding without active arterial bleeding. The patient received two units of packed red blood cells, followed by selective transcatheter arterial embolisation (TAE) of the right hepatic artery branches to segment 7 and 8. Spontaneous rupture of solitary liver metastases are exceedingly rare. TAE is a safe and effective treatment choice in patients with spontaneous rupture. Given progressive tumour burden, changes in management with a different immunotherapy agent can be considered.

A Meta-Analysis of Short-Term Outcomes After Laparoscopic Lavage Versus Colonic Resection in the Treatment of Perforated Diverticulitis

The management of perforated non-faeculent diverticulitis has traditionally involved performing a colonic resection (CR). Laparoscopic lavage (LL) has emerged as a less invasive alternative in recent years. The aim of this meta-analysis was to assess the role of LL in the surgical treatment of perforated non-faeculent diverticulitis. To that end, we conducted a search on Embase, Medline, and Cochrane databases for comparative studies in the English language published till June 2021 [PROSPERO (CRD42021269410)]. The risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2) and the methodological index for non-randomised studies (MINORS). Data were analysed using Cochrane RevMan. Pooled odds ratio (POR) and cumulative weighted ratios (CWR) were calculated. A total of 13 studies involving 1061 patients were found eligible, including seven studies based on three randomised control trials (RCTs). LL was associated with a reduced risk of wound infection, stoma formation, and need for further surgery by 77% [POR: 0.23, 95% confidence interval (CI): 0.07-0.74], 83% (POR: 0.17, 95% CI: 0.05-0.56), and 53% (POR: 0.47, 95% CI: 0.23-0.97) respectively. Duration of surgery and hospitalisation was reduced by 54% and 43% respectively. However, LL was associated with higher rates of unplanned reoperations (POR: 2.05, 95% CI: 1.22-3.42), recurrence (POR: 9.47, 95% CI: 3.24-27.67), and peritonitis (POR: 8.92, 95% CI: 2.71-29.33). No differences in mortality or readmission rates were observed. LL in Hinchey III diverticulitis lowers the incidence of stoma formation and overall reoperations without an increase in mortality but at the cost of higher recurrence rates and peritonitis. A limitation of this study was the inclusion of non-RCTs. An elective resection should be considered after LL. Guidelines for surgical techniques in LL need to be standardised.

AB0781 Malaysia Spondylarthritis Accelerated Management (SAM) Model: Expediting AxSpA patient journey from early referral, diagnosis and access to optimal care

Background

Axial spondyloarthritis (axSpA) is an important cause of inflammatory back pain (IBP). It is under-recognized, leading to significant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, significant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert.

Objectives

The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia.

Methods

The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The first local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded ‘3-R’ referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021.

Figure 1.

Summary of optimal Key performance indicators (KPIs) for Malaysia SAM

Results

At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a first Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had x-rays (sacroiliac joints or pelvis). MRI requests in x-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic.

Conclusion

The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.

References

[1]Lau, Ing Soo et al., Malaysian family physician, vol. 16,2 2-6. 27 May. 2021

Acknowledgements

Authors would like to acknowledge that this abstract is part of the Malaysia SpA Consortium Working Group. The SAM expert panel discussion and the preparation of this abstract were funded by Novartis (Malaysia). The authors acknowledge writing support from Vidya Sagar AEC (Novartis, Hyderabad)

Disclosure of Interests

Fariz Yahya Speakers bureau: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Janssen, Gilead, Abbvie, Upjohn, Paid instructor for: Novartis, ZP Therapeutics, Abbvie, Consultant of: Novartis, Eli Lilly, ZP Therapeutics, Pfizer, Gilead, Abbvie, Janssen, Grant/research support from: Gilead, Galapagos, Abbvie, Janssen, Novartis, Habibah Mohd Yusoof: None declared, Asmah Mohd: None declared, Shereen Ch’ng Suyin Speakers bureau: Pfizer, Boehringer Ingelheim, Johnson & Johnson, Novartis, Abbvie, Suk Chyn Gun: None declared, Mollyza Mohd Zain: None declared, Sargunan Sockalingam Speakers bureau: Novartis, Roche, Johnson & Johnson, Pfizer, Paid instructor for: Johnson & Johnson, Grant/research support from: Novartis, Siew Li Lai Employee of: Novartis, Chen Bao Jing Employee of: Novartis, John Tiong Employee of: Novartis, Ing Soo Lau: None declared, Raj Sengupta Speakers bureau: Abbvie, Biogen, Celgene, Lilly, Novartis, Roche, UCB, Consultant of: Advisory boards for Abbvie, Biogen, Lilly, Novartis, UCB, Grant/research support from: Abbvie, Celgene, Novartis, UCB

A rare case of iliopsoas abscess caused by a retained shrapnel from a blast injury

Iliopsoas abscesses (IPA) are uncommon, with an associated mortality rate of up to 20%. We describe the case of a 55-year-old man war veteran who presented with an unusual cause of IPA secondary to retained foreign body (FB). His initial trauma 30 years before was a result of a blast injury with shrapnel penetration suffered after inadvertently driving over a landmine as an ambulance driver in a conflict region. A CT scan was performed, revealing a 13 mmx8 mm radio-opaque FB within the right psoas at the level of the fifth lumbar vertebra with a surrounding collection. Subsequent open surgical exploration removed two gravel fragments. Given the knowledge of a traumatic blast injury with retained FB and repeated episodes of sepsis, surgical exploration is warranted. To our knowledge, this is the first case of recurrent IPA secondary to a retained FB from a historical trauma.

Temporal migration of gonadotrophin-releasing hormone-1 neurones is modified in GAD67 knockout mice

Gonadotrophin-releasing hormone (GnRH-1) neurones reside in the forebrain and regulate gonadal function via the hypothalamic-pituitary-gonadal axis. Disruption of this axis results in reproductive dysfunction. During embryonic development, GnRH-1 neurones migrate from the nasal pit through the nasal/forebrain junction (NFJ) into the developing brain. Prenatally gamma-aminobutyric acid (GABA) is excitatory and has been shown to play a role in nervous system development. Both in vivo and in vitro experiments suggest that GABA inhibits migration of GnRH-1 neurones. The present study examines the migration of GnRH-1 neurones in GAD67 knockout (KO) mice to further elucidate the role of GABA on GnRH-1 neuronal development. Three stages were examined, embryonic day (E)12.5, E14.5 and E17.5. GnRH-1 cell number and location were analysed by immunocytochemistry and in situ hybridisation histochemistry. The total number of GnRH-1 immunopositive cells was similar between wild-type (WT) and KO mice. However, significant differences were found in the overall distribution of GnRH-1 immunopositive cells in GAD67 KO compared to WT mice at all stages. Subsequent analysis by area revealed differences occurred at the NFJ with an increase in GnRH-1 cells in GAD67 KO at E14.5 and a decrease in GnRH-1 cells in GAD67 KO at E17.5. Comparable counts for cells expressing GnRH-1 transcript and protein were obtained. These data indicate that attenuated levels of GABA accelerate GnRH-1 cell migration in nasal areas as well as movement of GnRH-1 cells into the central nervous system at the NFJ.

Skin lifting in aesthetic cervicofacial rhytidectomy: personal experience in more than 1500 patients

BACKGROUND

Skin lifting alone in face-lifting surgery is limited to minor lifts in younger patients. The extent of skin undermining depends on the operative plan.

AIMS

An optimal aim is to minimize the amount of undermining to achieve a pleasing, natural rejuvenated result.

RESULTS

By respecting the extensive network of the dermal vascular plexus and by good surgical technique, ischaemia of the elevated skin may be minimized.

CONCLUSION

Moderate to maximal lifting, however, has proven to be anatomically sound in over 1500 cases operated on over the last 20 years using classical face-lift techniques to correct the pathoanatomy of the ageing face.

Effect of nitrogen dioxide and other combustion products on asthmatic subjects in a home-like environment

Nitrogen dioxide (NO2) is one of a number of nitrogen compounds that are by-products of combustion and occur in domestic environments following the use of gas or other fuels for heating and cooking. In this study, we examined the effect of two levels of NO2 on symptoms, lung function and airway hyperresponsiveness (AHR) in asthmatic adults and children. In addition, in the same subjects, we examined the effects of the same levels of NO2 mixed with combustion by-products from a gas space heater. The subjects were nine adults, aged 19-65 yrs, and 11 children, aged 7-15 yrs, with diagnosed asthma which was severe enough to require daily medication. All subjects had demonstrable AHR to histamine. Exposures were for 1 h on five separate occasions, 1 week apart, to: 1) ambient air, drawn from outside the building; 2) 0.3 parts per million (ppm) NO2 in ambient air; 3) 0.6 ppm NO2 in ambient air; 4) ambient air+combustion by-products+NO2 to give a total of 0.3 ppm; and 5) ambient air+combustion by-products+NO2 to give a total of 0.6 ppm. Effects were measured as changes in lung function and symptoms during and 1 h after exposure, in AHR 1 h and 1 week after exposure, and in lung function and symptoms during the week following exposure. Exposure to NO2 either in ambient air or mixed with combustion by-products from a gas heater, had no significant effect on symptoms or lung function in adults or in children. There was a small, but statistically significant, increase in AHR after exposure to 0.6 ppm NO2 in ambient air. However, there was no effect of 0.6 ppm NO2 on AHR when the combustion by-products were included in the test atmosphere nor of 0.3 ppm NO2 under either exposure condition. We conclude that a 1 h exposure to 0.3 or 0.6 ppm NO2 has no clinically important effect on the airways of asthmatic adults or children, but that 0.6 ppm may cause a slight increase in airway hyperresponsiveness.

Production and characterization of monoclonal antibodies specific for the murine T cell receptor zeta chain

The T cell receptor (TCR) comprises an antigen-specific alpha beta heterodimer non-covalently associated with the CD3 gamma delta epsilon and TCR zeta subunits. Both the CD3 and TCR zeta subunits are proposed to be responsible for the intracellular signal-transduction events. We report here the production of eight monoclonal antibodies (mAbs) that bind in an ELISA assay to a 113 amino acid synthetic peptide corresponding to the cytoplasmic domain of TCR zeta. Western blot analysis of anti-CD8 precipitates of lysates of transfectants expressing chimeric CD8/zeta constructs encoding increasing COOH-terminal truncations of TCR zeta indicates that four of these mAbs recognized the region of TCR zeta chain comprising the last 29 COOH-terminal residues. Thus, this region of TCR theta may encode an immunodominant epitope. Furthermore, one of these mAbs, G3, is capable of precipitating both non-phosphorylated and tyrosine phosphorylated TCR zeta. The G3 mAb should be useful for elucidating the structural and signalling characteristics of the TCR zeta chain.