The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

PURPOSE

Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking.

MATERIALS AND METHODS

We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes.

RESULTS

Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH.

CONCLUSION

This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

Enhancing Wheat Disease Diagnosis in a Greenhouse Using Image Deep Features and Parallel Feature Fusion

Since the assessment of wheat diseases (e.g., leaf rust and tan spot) via visual observation is subjective and inefficient, this study focused on developing an automatic, objective, and efficient diagnosis approach. For each plant, color, and color-infrared (CIR) images were collected in a paired mode. An automatic approach based on the image processing technique was developed to crop the paired images to have the same region, after which a developed semiautomatic webtool was used to expedite the dataset creation. The webtool generated the dataset from either image and automatically built the corresponding dataset from the other image. Each image was manually categorized into one of the three groups: control (disease-free), disease light, and disease severity. After the image segmentation, handcrafted features (HFs) were extracted from each format of images, and disease diagnosis results demonstrated that the parallel feature fusion had higher accuracy over features from either type of image. Performance of deep features (DFs) extracted through different deep learning (DL) models (e.g., AlexNet, VGG16, ResNet101, GoogLeNet, and Xception) on wheat disease detection was compared, and those extracted by ResNet101 resulted in the highest accuracy, perhaps because deep layers extracted finer features. In addition, parallel deep feature fusion generated a higher accuracy over DFs from a single-source image. DFs outperformed HFs in wheat disease detection, and the DFs coupled with parallel feature fusion resulted in diagnosis accuracies of 75, 84, and 71% for leaf rust, tan spot, and leaf rust + tan spot, respectively. The methodology developed directly for greenhouse applications, to be used by plant pathologists, breeders, and other users, can be extended to field applications with future tests on field data and model fine-tuning.

Characteristics of the leachate produced during nutrient recycling of food and poultry slaughter wastes by fly larvae

Biowaste management is a pertinent problem and nutrient recycling utilizing fly larvae is an emerging solution. The leachate produced during biowaste management has potential implications for the environment but studies on this issue are scanty. This study was conducted to assess the characteristics of leachate produced during the bioconversion of food (BW-I) and poultry slaughter waste (BW-II) by natural fly larval activity. The results showed that total volumes of 2.2 L and 1.1 L leachate were produced for BW-I and II respectively. The highest pH in BW-I leachate was 7.43 ± 0.01 and the lowest pH in BW-II was 3.30 ± 0.12. The highest levels of BOD in BW-I and II were 36733.33 ± 430.63 mg/l and 2800.000 ± 999.50 mg/l. The highest level of COD in BW-I was 52575.000 ± 1076.86mg/l while in BW-II it was 4316.67 ± 790.45 mg/l. The high BOD and COD values of the leachate indicated that they needed to be pretreated before being released into the environment.

AB0360 A DECADE OF SUSPECTED GIANT CELL ARTERITIS: CLINICAL FEATURES OF A HIGHLY HETEROGENEOUS DISEASE

Background:

Giant cell arteritis is the most common chronic systemic vasculitis in older adults. Permanent visual loss is the most concerning complication can occur in up to 20% of patients (1). Diagnosis is based on a combination of clinical findings, laboratory evidence of inflammatory markers, and temporal artery biopsy (TAB) confirming histologic evidence of inflammation. There are no definitive markers of the disease when TAB is negative.

Objectives:

The objective of this study was to illustrate the clinical features of subjects suspected with GCA evaluated at the Dallas Veterans Affairs Medical Center (VAMC) and identify those features that would differentiate between TAB positive GCA, TAB negative GCA and non-GCA patients.

Methods:

This retrospective study searched the Dallas VAMC database for subjects between January of 2010 until December 2019 with ICD-9 and ICD-10 entry code for GCA. Based on the 1990 ACR clinical classification criteria for GCA, suspected patients were classified as TAB positive GCA, TAB negative GCA and non-GCA. Subjects with incomplete data needed for classification were excluded. Group comparisons were performed with Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables.

Results:

One-hundred and sixty-nine subjects had ICD-9/10 entry code for GCA. Ophthalmology was the specialty who did the initial evaluation in 46% of the suspected cases. Seventy-one patients were excluded due to incomplete data. Of the remaining 98 patients, 42 (42.9%) were diagnosed with GCA out of which 10 patients had a positive TAB. Seventy-six percent of patients diagnosed with GCA had negative temporal artery biopsies. In 56 (57.1%) patients GCA was ruled out (Figure 1). New-onset headache was the predominant symptom suggestive of GCA affecting 88.9% TAB positive and 100% of TAB negative cases compared to 56.6% of non-GCA patients (p< 0.001), followed by scalp tenderness in 33.3%, 58.1% and 10.9%, respectively (p< 0.001), jaw claudication in 57.1%, 34.5% and 14.9% (p=0.021), and elevated sedimentation rate in 33%, 65.6% and 33% (p=0.013) (Table 1). Polymyalgia rheumatica was present in 28.6% and 21.7% of patients diagnosed with GCA compared to zero percent in non-GCA cases (p=0.017). More than 30% of patients with GCA had normal acute phase reactants in this cohort.

Table 1.

Comparison of demographics and clinical features of patients with suspected GCA

GCA TAB Positive (n=10)GCA - TAB Negative (n=32)non-GCA (n=56)n%n%n%pAge (mean/sd)71.3 (7.8)67.3 (8.1)67.3 (8.9)0.367Male99030/3293.851/5691.10.885Clinical findingsNew onset headache8/988.932/3210030/5356.6<0.001Visual symptoms9/109022/3268.842/5477.80.351Jaw claudication4/757.110/2934.57/4714.90.021PMR2/728.65/2321.70/3000.017Scalp tenderness2/633.318/3158.15/4610.9<0.001Fever0/505/2321.72/355.70.117ESR > 501/333.321/3265.618/5433.30.013CRP > 101/333.35/3016.76/5411.10.473Anemia (hemoglobin < 12 g/ dl)2/728.615/3246.921/5240.40.642Thrombocytosis (platelets >400)2/728.63/329.44/517.80.228

Conclusion:

There is clinical heterogeneity within the patients diagnosed with GCA regardless of TAB. A high index of clinical suspicion needs to be the cornerstone of diagnosis. There is need for new classification criteria to include patients with negative TAB.

References:

[1]Soriano A, et al. Nat Rev Rheumatol. 2017 Aug;13(8):476-484.

Disclosure of Interests:

Adela Castro: None declared, Jiby Mathew: None declared, Ola Azzouqah: None declared, Jesus Diaz: None declared, Andreas Reimold Consultant of: Lilly, Grant/research support from: Abbvie

Pfizer

Gilead, Kyawt Shwin: None declared

Evaluation of Anti-quorum Sensing Potential of Saraca asoca (Family Caesalpiniaceae) against Chromobacterium violaceum and Pseudomonas aeruginosa PA01

Aim: The present study was performed to evaluate the anti-quorum sensing (QS) potential of traditional medicinal herb Saracaasoca (family Caesalpiniaceae) stem bark extract against Chromobacterium violaceum and Pseudomonas aeruginosa PA01. Study Design: First, the test sample (bark extract) was screened for anti-QS activity. Then systematic in-vitro and biochemical tests were performed to evaluate the effect of the test sample on the QS mediated virulence factors. Place and Duration of Study: All the experimental works were performed in Lab 311, pharmacology division, CSIR-NBRI Lucknow from June 2019 to October 2019. Methodology: The samples of Saraca asoca stem bark were washed, dried and extracted using 70% methanol. The minimum inhibitory concentration (MIC) of the prepared Sarca asoca bark extract was determined using the Alamar blue assay, and the anti-QS activity was screened using standard agar overlay method against CV 12472 at subinhibitory concentrations 100, 200 and 300 µg (< MIC value). SAE effect on biofilms formation was assessed by growing biofilms on glass slides in a static culture of PA01. Anti-virulence effect of SAE on the production of QS-regulated virulence factors such as Pyocyanin, proteases, elastases, rhamnolipid and alginate in Pseudomonas aeruginosa was determined using the supernatant of a 24 hours old broth culture of PA01 supplemented with SAE. Using the agar plate technique, the swimming and swarming motility assays were conducted on 0.3% and 0.5% agar plates respectively. One-way ANOVA was used to analyze the data, presented as mean ± SD (standard deviation) of three independent experiments. Results: Preliminary screening results showed significant QS inhibition against CV 12472 in an agar overlay disk diffusion assay in a concentration-dependent manner. Data from the biofilm assay showed loose, distorted, irregular PA01 biofilm formation at 200 µg (48%) and 300 µg (65%). SAE caused a significant drop in virulence factor production, with maximum reduction in pyocyanin (58%), proteases (67%), elastases (52%), rhamnolipid (53%), and alginate (44%) observed at 300 µg concentration. At SAE sub-lethal concentrations (200 and 300 µg), both the swimming and swarming motility of PA01 were significantly inhibited. Conclusions: The present study demonstrates the broad-spectrum anti-QS potential of SAE, reported for the first time, suggesting that SAE could be considered as an alternative herbal source to develop antimicrobial agents which can be either solitary or synergistically with conventional antimicrobial drugs.

40 Improving Urinary Catheter Documentation and Care in Geriatric Wards

Introduction

NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps.

Local problem

These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes.

Methods

We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed.

Interventions

We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2).

Results

A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards.

Conclusion

By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.

Penile fracture associated with complete urethra and bilateral corpora cavernosa transection

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis. It occurs due to the forcible bending of the turgid erect penis against resistance leading to tunica albuginea tear. The rupture of tunica albuginea surrounding the corpora cavernosa leads to hematoma formation and classical 'aubergine' deformity. Timely intervention is essential to improve sexual function. Urethral injury may occur concomitantly in case of severe trauma. Blood at the meatus, inability to void and haematuria are distinctive features. We describe a case of 36-year-old man who presented to the emergency department with penile fracture during sexual intercourse associated with blood at the meatus and voiding difficulty. On surgical exploration, complete bilateral corpora cavernosa tear and penile urethral transection was noted. The patient was successfully managed with timely repair. This case highlights the need for suspicion of an associated urethral injury in patients of penile fracture with blood at the meatus.

Glycolipid-peptide vaccination induces liver-resident memory CD8+ T cells that protect against rodent malaria

Liver resident-memory CD8⁺ T cells (T_RM cells) can kill liver-stage Plasmodium-infected cells and prevent malaria, but simple vaccines for generating this important immune population are lacking. Here, we report the development of a fully synthetic self-adjuvanting glycolipid-peptide conjugate vaccine designed to efficiently induce liver T_RM cells. Upon cleavage in vivo, the glycolipid-peptide conjugate vaccine releases an MHC I-restricted peptide epitope (to stimulate Plasmodium-specific CD8⁺ T cells) and an adjuvant component, the NKT cell agonist α-galactosylceramide (α-GalCer). A single dose of this vaccine in mice induced substantial numbers of intrahepatic malaria-specific CD8⁺ T cells expressing canonical markers of liver T_RM cells (CD69, CXCR6, and CD101), and these cells could be further increased in number upon vaccine boosting. We show that modifications to the peptide, such as addition of proteasomal-cleavage sequences or epitope-flanking sequences, or the use of alternative conjugation methods to link the peptide to the glycolipid improved liver T_RM cell generation and led to the development of a vaccine able to induce sterile protection in C57BL/6 mice against Plasmodium berghei sporozoite challenge after a single dose. Furthermore, this vaccine induced endogenous liver T_RM cells that were long-lived (half-life of ~425 days) and were able to maintain >90% sterile protection to day 200. Our findings describe an ideal synthetic vaccine platform for generating large numbers of liver T_RM cells for effective control of liver-stage malaria and, potentially, a variety of other hepatotropic infections.

AB0596 PREDICTORS, LONG TERM CLINICAL AND TREATMENT OUTCOMES IN SOUTH ASIAN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS: A SINGLE CENTER STUDY

Background:

Idiopathic inflammatory myositis (IIM) are a heterogeneous group of immune-mediated disorders with varied presentations and multiple organ involvement. Data on long term outcome among South Asian patients with IIM is sparse.

Objectives:

To study the long term clinical outcome, treatment responses and factors predicting outcome among adult patients with IIM

Methods:

Patients diagnosed as ‘Idiopathic Inflammatory Myositis’ under the department of Clinical Immunology and Rheumatology at CMC, Vellore, India were screened retrospectively. Patients aged 18 years and above, satisfying Bohan and Peter criteria, having follow up of one year or more with atleast two outpatient or inpatient visits between January 2010 and April 2019 were included in this study. Those patients with connective tissue disease associated myositis were not included. Details on muscle weakness, extramuscular involvement, muscle enzymes and treatment administered were recorded at baseline, 3, 6, 12, 18, 24 months and yearly thereafter. After assessing their cumulative response, categorization of patients into complete and partial responders was done. Complete responders were defined as patients with persistent muscle power of more than 4/5 and/or MMT 8 more than 76/80, complete resolution of skin, articular and lung involvement (if any) as well as muscle enzymes less than twice the upper limit of normal without any documented flares during the entire follow up period. Patients not satisfying the said criterias were grouped as Partial responders. Disease free survival duration was also analyzed.

Results:

Out of 310 patients of IIM identified, 187 (60.3%) patients satisfied the inclusion criteria. Women were 2.2 times more than men and mean age at symptom onset was 35.7±12.6 years. Dermatomyositis was the predominant myositis subtype seen. All patients were put on steroids with the mean dose being 45.9 ± 18.6 mg/day. At baseline, the key immunosuppressants used were methotrexate in 44.9% and mycophenolate in 37.6% patients. The median follow up duration was 48 (25-80) months. An associated malignancy was diagnosed in 3.2% after a median duration of 24.5 months. Five patients expired after a median duration of 80 months from diagnosis. Normal muscle power was attained in 76.1% patients and 88.6% were vocational by the last follow up visit. Steroids were discontinued in 56.7% patients after a median duration of 24 months (p=0.0002). Discontinuation of the immunosuppressant was feasible in 10.2% patients after a median duration of 44 months. Assessment of the cumulative responses revealed a relapsing and remitting course in 45.9%. Outcome predictors in univariate analysis were Jo-1 status, presence of arthritis, interstitial lung disease and pericardial effusion at baseline. On multivariate analysis, absence of pericardial effusion (p=0.011) and interstitial lung disease (p=0.067) at baseline were found to be predictors of complete response. Disease free survival probability estimated at 5 years and 10 years was 91.6% and 72.4% respectively. Estimating the probability gender wise, males achieved disease free status earlier than females.

Conclusion:

A favorable clinical and functional outcome was seen in a significant proportion of these patients with IIM on long term follow up. Pericardial effusion and ILD were identified as predictors of poor clinical outcome.

References:

[1]Taborda AL, Azevedo P, Isenberg DA. Retrospective analysis of the outcome of patients with idiopathic inflammatory myopathy: a long-term follow-up study. Clin Exp Rheumatol. 2014 Apr; 32(2):188–93.

Acknowledgments:

Nil

Disclosure of Interests:

None declared

THU0523 CLINICAL UTILITY OF TESTING CONVENTIONAL AND NON-CONVENTIONAL ANTI-PHOSPHOLIPID ANTIBODIES IN SUSPECTED OBSTETRIC ANTI-PHOSPHOLIPID SYNDROME

Background:

Anti-phospholipid syndrome (APS) is an important cause for recurrent pregnancy losses (RPL). Conventional APS antibodies (aPLs) like lupus anti-coagulant (LA), anti-cardiolipin(ACL) and anti-beta 2 glycoprotein I (anti-β2 GP I) are not present in significant number of obstetric APS(OAPS) patients, leading to a state described as “ sero-negative” OAPS (SNOAPS). Recent literature shows non-conventional aPLs like Anti phosphatidylserine-prothrombin complex (Anti-PSPT) and Anti-Annexin V (Anti-Ann V) can be positive in up to 50% of SNOAPS patients

Objectives:

Testing the performance of conventional and non-conventional aPLs in suspected OAPS patients (obstetric events as defined in the Sydney classification criteria for APS)

Methods:

We performed a retrospective chart review of 101 patients who underwent combined testing for non-conventional aPLs for suspected OAPS from May 2016 to November 2019 at our department. Patients were categorized into OAPS cases (n=50, median age 31 years) and controls (n=51, median age 30 years) based on their fulfillment of clinical definition of OAPS events defined by Sydney criteria. Conventional aPLs were tested by methods adapted in Sydney criteria and Anti PSPT /Anti Ann V were tested by commercial ELISA. The sample size(n=101) has 95% confidence interval with a margin of error of 10% for the objective of the study.

Results:

36 cases (72%) were ‘sero-positive’ & 14 cases (28%) were truly ‘sero-negative’ for conventional aPLs. 5 (35.7%) of the SNOAPS patients were positive for Ant-PSPT and/or Anti AnnV antibodies. Performance of the various aPLs in suspected OAPS is displayed in Table 1 & Figure 1.

Table 1

showing the performance of the various conventional and non-conventional APLs in suspected obstetric APS cases

AntibodySensitivitySpecificityLikelihood Ratio(+)Likelihood Ratio (-)Positive Predictive ValueNegative Predictive ValueAccuracyYouden’s IndexLA50%94.1 %8.50.589.3%65.7%72.3%44.1%ACL32%98%16.30.794.1%59.5 %65.3%30 %anti β2 GP I IgM38.4%91.4 %4.50.783.3%57.1 %63.5%29.8%anti β2 GP I IgG24%96.1 %6.10.885.7%56.3%60.4%20.1%Anti PSPT28%96.1 %7.10.787.5%57.6 %62.4%24.1%Anti AnnV28%98 %14.30.793.3%58.1%63.4%26%Conventional APLs72%88.2%6.10.385.7%76.3 %79.8%60.2%Non-conventional APLS38%94.1%6.40.786.4%60.7 %66.3%32.1%All APLs82%86.3%6.000.2085.4%83 %84.2%68.3%Figure 1

showing the comparative diagnostic performance of Conventional aPL testing vs Combined testing along with non-conventional aPLs in suspected obstetric APS scenario

Conclusion:

In a delicate situation like RPL, performance of non-conventional aPLs on their own, though not as sensitive as conventional aPLs, still demonstrate better specificity. Non-conventional APLs can newly identify 1/3rd of SNOAPS as APS. The real value of testing Anti PSPT & Anti Ann V in RPL, is combined testing with conventional aPLs wherein they improve the sensitivity and accuracy of diagnosis of OAPS by 10% & 4.4 % respectively, with only 1.9% drop in specificity. Non-conventional aPLs should be tested in SNOAPS.

Disclosure of Interests:

None declared

Glycolipid-peptide vaccination induces liver-resident memory CD8+ T cells that protect against malaria

Liver resident-memory CD8+ T cells (TRM cells) can kill liver-stage Plasmodium-infected cells and prevent malaria, but simple vaccines for generating this important immune population are lacking. Here, we report the development of a fully synthetic self-adjuvanting glycolipid-peptide conjugate vaccine designed to efficiently induce liver TRM cells. Upon cleavage in vivo, the glycolipid-peptide conjugate vaccine releases an MHC I-restricted peptide epitope (to stimulate Plasmodium-specific CD8+ T cells) and an adjuvant component, the NKT cell agonist a-galactosylceramide (a-GalCer). Following transfer of a transgenic CD8+ T cell population, a single dose of this vaccine induced substantial numbers of intrahepatic CD8+ T cells expressing canonical markers of liver TRM cells (CD69, CXCR6 and CD101), and these cells could be further increased in number upon vaccine boosting. We show that modifications to the peptide, such as addition of proteosomal-cleavage sequences or epitope-flanking sequences, or the use of alternative conjugation methods to link the peptide to the glycolipid, improved liver TRM cell generation and led to the development of a vaccine able to induce sterile protection in C57BL/6 mice against P. berghei sporozoite challenge after a single dose. Incorporation of a cognate malaria antigen into the vaccine resulted in the generation of large numbers of long-lived liver TRM cells derived from the endogenous T cell population that were capable of providing sterile immunity. Our findings describe an ideal synthetic vaccine platform for generating large numbers of liver TRM cells for effective control of liver-stage malaria and, potentially, a variety of other hepatotropic infections

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia

INTRODUCTION

Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured.

CONCLUSION

The guideline highlights select pre-hospital criteria's and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Video-tube thoracostomy in trauma resuscitation: A pilot study

BACKGROUND

Complications related to incorrect positioning of tube thoracostomy (TT) have been reported to be as high as 30%. The aim of this study was to assess the feasibility of flexible videoscope guided placement of a pre-loaded chest tube, permitting direct intrapleural visualization and placement (Video-Tube Thoracostomy [V-TT]).

METHODS

A prospective, single centre, phase 1 pilot study with a parallel control group was undertaken. The population studied were adult thoracic trauma patients requiring emergency TT who were haemodynamically stable. The intervention performed was VTT. Patients in the control group underwent conventional TT. The primary outcome was tube position as defined by a consultant radiologist's interpretation of chest x-ray (CXR) or CT. The trial was registered with ANZCTR.org.au (ACTRN: 12,615,000,870,550).

RESULTS

There were 37 patients enrolled in the study - 12 patients allocated to the VTT intervention group and 25 patients allocated to conventional TT. Mean age of participants was 48 years (SD 15) in intervention group and 46 years (SD 15) years in the control group. In the VTT group all patients were male; the indications were pneumothorax (83%), haemothorax (8%) and haemopneumothorax (8%). The median injury severity score was 23 (16-28). There were 1 positional and 1 insertional complications. In the control group 72% of patients were male, the indications were pneumothorax (56%), haemothorax (4%) and haemopneumothorax (40%). The median injury severity score was 24 (14-36). There were 8 (32%) positional complications and no insertional complications.

CONCLUSION

V-TT was demonstrated to be a feasible alternative to conventional thoracostomy and merits further investigation.

Single-tube tetradecaplex panel of highly polymorphic microsatellite markers < 1 Mb from F8 for simplified preimplantation genetic diagnosis of hemophilia A

Essentials Preimplantation genetic diagnosis (PGD) of severe hemophilia A relies on linkage analysis. Simultaneous multi-marker screening can simplify selection of informative markers in a couple. We developed a single-tube tetradecaplex panel of polymorphic markers for hemophilia A PGD use. Informative markers can be used for linkage analysis alone or combined with mutation detection.

SUMMARY

Background It is currently not possible to perform single-cell preimplantation genetic diagnosis (PGD) to directly detect the common inversion mutations of the factor VIII (F8) gene responsible for severe hemophilia A (HEMA). As such, PGD for such inversion carriers relies on indirect analysis of linked polymorphic markers. Objectives To simplify linkage-based PGD of HEMA, we aimed to develop a panel of highly polymorphic microsatellite markers located near the F8 gene that could be simultaneously genotyped in a multiplex-PCR reaction. Methods We assessed the polymorphism of various microsatellite markers located ≤ 1 Mb from F8 in 177 female subjects. Highly polymorphic markers were selected for co-amplification with the AMELX/Y indel dimorphism in a single-tube reaction. Results Thirteen microsatellite markers located within 0.6 Mb of F8 were successfully co-amplified with AMELX/Y in a single-tube reaction. Observed heterozygosities of component markers ranged from 0.43 to 0.84, and ∼70-80% of individuals were heterozygous for ≥ 5 markers. The tetradecaplex panel successfully identified fully informative markers in a couple interested in PGD for HEMA because of an intragenic F8 point mutation, with haplotype phasing established through a carrier daughter. In-vitro fertilization (IVF)-PGD involved single-tube co-amplification of fully informative markers with AMELX/Y and the mutation-containing F8 amplicon, followed by microsatellite analysis and amplicon mutation-site minisequencing analysis. Conclusions The single-tube multiplex-PCR format of this highly polymorphic microsatellite marker panel simplifies identification and selection of informative markers for linkage-based PGD of HEMA. Informative markers can also be easily co-amplified with mutation-containing F8 amplicons for combined mutation detection and linkage analysis.

Strain-specific variation in plant growth promoting volatile organic compounds production by five different Pseudomonas spp. as confirmed by response of Vigna radiata seedlings

AIM

Analysis of a blend of volatile organic compounds (VOCs) released by Pseudomonas spp. with growth-promoting effect in Vigna radiata seedlings.

METHODS AND RESULTS

Plant growth-promoting activity of VOCs produced by five different Pseudomonas spp. was investigated by I-plate technique. VOCs produced by different organisms were extracted by various solvents (methanol, ethyl acetate, hexane and butanol) and were identified by gas chromatography-mass spectrometric analysis. The major VOCs identified were undecane, nonadecane, hexacosane, tetradecane, heptacosane, pentadecane, dodecane and tetratetracontane. The cultural conditions for the production of VOCs with plant growth enhancement effect were optimized and further confirmed using pure pentadecane as a candidate VOC.

CONCLUSIONS

The study provides insight into plant beneficial effect of VOCs produced by Pseudomonas spp. Remarkable modulation in the production of VOCs with plant growth-promoting effect by rhizobacteria was found to be dependent on the bacterial strain and its concentration.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study describes the requirement to consider bacterial VOC production also for preparing plant probiotic formulations. As VOCs are least considered for preparation of commercial plant growth-promoting rhizobacterial strain formulation, the results of the study is highly significant.

Age- and sex-specific prevalence of diabetes associated with diseases of the exocrine pancreas: A population-based study

BACKGROUND AND AIMS

Diabetes associated with diseases of the exocrine pancreas (DP) is a recognized clinical condition but data on its prevalence are limited to a few single centre studies. Relative contribution of the three major diseases of the exocrine pancreas (acute pancreatitis, chronic pancreatitis, pancreatic cancer) to prevalence of DP as well as the effect of age and sex is largely unknown. The study aimed to determine age- and sex-specific prevalence of DP overall and after acute pancreatitis, chronic pancreatitis, and pancreatic cancer alone at the population level.

METHODS

Nationwide population database covering nearly 3 million residents in New Zealand over a 10-year study period was used. DP was identified based on International Classification of Diseases-10 codes. Data were reported as prevalence per 1000 population and corresponding 95% confidence intervals.

RESULTS

The crude prevalence of DP was 1.13 [1.12, 1.14] per 1000, with 70-79 years age group having the highest prevalence at 3.94 [3.92, 3.97] per 1000. Men had an overall prevalence of 1.32 [1.31, 1.33] per 1000 and women-0.93 [0.92, 0.94] (p<0.05). Acute pancreatitis contributed 61% to overall prevalence of DP.

CONCLUSIONS

Prevalence of DP in the general population is close to that of type 1 diabetes. Three out of five DP cases develop after acute pancreatitis. There is a variation in age of onset of DP, with the working and ageing population most affected. Men have a 40% higher risk of developing DP than women.

Ethnic and geographic variations in the incidence of pancreatitis and post-pancreatitis diabetes mellitus in New Zealand: a nationwide population-based study

AIM

To determine the incidence of acute pancreatitis (AP), chronic pancreatitis (CP), and post-pancreatitis diabetes mellitus (DP) in New Zealand, and the effect of ethnic and geographic variations.

METHODS

Data were collected from all district health boards in New Zealand by the Ministry of Health (Manatū Hauora). Diagnosis of AP, CP and DP was determined by the International Classification of Diseases-10 codes. Incidence rates per 100,000 population per year were calculated using incident AP, CP and DP cases as the numerator, and the adult resident population of New Zealand as the denominator. Poisson distribution was used to estimate 95% confidence intervals. The district health board domicile codes and corresponding incidence rates were used to map geographical variations for AP, CP and DP.

RESULTS

On average, 2,072 new cases of AP, CP and DP were diagnosed in New Zealand every year. The crude incidence of AP was 58.42 [57.55, 59.30], CP - 3.97 [3.74, 4.20], and DP - 7.95 [7.62, 8.27] per 100,000 population per year. Māori had the highest incidence of AP (95.21 [91.74, 98.68] per 100,000 population per year), CP (6.27 [5.37, 7.16] per 100,000 population per year), and DP (18.23 [16.71, 19.76] per 100,000 population per year). Incidence of AP and DP was at least 1.8 and 2.6 times higher in Māori than New Zealand Europeans in every age group, and incidence of DP was at least 1.9 times higher in Pacific people than New Zealand Europeans in every age group. Auckland/Northland had the highest incidence of AP (135.25 [134.82, 135.68] per 100,000 population), and CP (9.03 [8.60, 9.46] per 100,000 population), while Lakes/Waikato had the highest incidence of DP (20.64 [20.21, 21.07] per 100,000 population) in New Zealand.

CONCLUSIONS

New Zealanders have a very high incidence rate of AP, with Māori having the highest reported incidence of AP worldwide. There is a significant geographic variation in incidence of pancreatic diseases, with the Upper North Island having the highest incidence rates of AP, CP and DP in the country. Future high-quality studies are required to understand the mechanisms of pancreatitis and DP in order to develop preventive and therapeutic strategies that would benefit New Zealanders in general and Māori in particular.

Evidence of enhanced photocurrent response in corannulene films

Experimental optical absorption and photoconductivity spectra of thin films with GW–BSE theoretical predictions provide evidence for diffuse super atomic molecular orbitals (SAMOs) in corannulene, C₂₀H₁₀.

Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

BACKGROUND

The aim of our study was to assess various predictors for local recurrence (LR) in patients undergoing breast conservation surgery (BCS) for ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

An audit was performed of 582 consecutive patients with DCIS between Jan 1975 to June 2008. In patients undergoing BCS, local guidelines reported a margin of ≥10 mm during the above period. Guideline with regard to margin of excision changes soon after this period. We retrospectively analysed clinical and pathological risk factors for local recurrence in patients undergoing BCS. Statistical analysis was carried out using SPSS version 19, and a cox regression model for multivariate analysis of local recurrence was used.

RESULTS

Overall 239 women had BCS for DCIS during the above period. The actuarial 5-year recurrence rate was 9.6%. The overall LR rate was 17% (40/239. LR was more common in patients ≤50 years: (10/31 patients, 32%) compared to patients > 50 years (30/208, 14%, P = 0.02). Forty three per cent of patients (6/14) with <5 mm margin developed LR which was significantly higher compared to patients with 5-9 mm margin (12%, 3/25) and with ≥10 mm margin (14%, 27/188, P = 0.01). On multivariate analysis age ≤50 years, <5 mm pathological margin were independent prognostic factors for local recurrence.

CONCLUSION

Our study shows that younger age (≤50 years) and a margin < 5 mm are poor prognostic factors for LR in patients undergoing breast conservation surgery for DCIS.

Favorable Waitlist and Posttransplant Outcomes in Children and Adolescent Patients Supported With Durable Continuous-Flow Ventricular Assist Devices

Pediatric centers are implanting durable adult continuous-flow ventricular assist devices (CFVADs) in children who are smaller than the industry-recommended size. Waitlist and posttransplant outcomes data in pediatric patients supported with CFVADs as a bridge to transplant are limited. We analyzed the United Network of Organ Sharing and Organ Procurement and Transplantation Network registry to identify patients aged ≤18 years with a CFVAD at the time of listing or transplantation. Patients were stratified by body surface area (BSA; >1.5 vs. ≤1.5 m(2) ) at time of listing. We identified 138 patients with a durable CFVAD during the listing period (100 with BSA >1.5 m(2) , 38 with BSA ≤1.5 m(2) ). Patients with BSA ≤1.5 m(2) were more likely to have a noncardiomyopathy diagnosis (18% vs. 4%, p = 0.007) and to be implanted with a centrifugal-flow rather than an axial-flow device (74% vs. 30%, p = 0.001). There was no difference in failure-free waitlist survival between BSA groups (p = 0.99) among patients with a CFVAD at listing. Posttransplantation survival was 100% and 88% at 1 and 5 years, respectively, for the entire cohort and did not differ by BSA group (p = 0.99). Consequently, waitlist and posttransplant outcomes are favorable for pediatric CFVAD recipients. Small patients (≤1.5 m(2) ) had pre- and posttransplant outcomes similar to those of larger patients that met the industry-recommended size for implantation.

Interleukin-6 is associated with chronic hyperglycemia and insulin resistance in patients after acute pancreatitis

BACKGROUND

Diabetes is a pervasive disease, with a mounting prevalence and burden on health care systems. Under this collective term of diabetes falls diabetes after diseases of the exocrine pancreas, a condition which was previously under-recognised and often mislabeled as type 2 diabetes mellitus and is now increasingly acknowledged as a stand-alone entity. However, there is a paucity of clinical studies investigating the underlying pathophysiology of diabetes after acute pancreatitis, the most frequent disease of the pancreas. This study aimed to investigate the role of adipocytokines in glucose metabolism after acute pancreatitis.

METHODS

This was a cross-sectional follow-up study of a patient cohort diagnosed with acute pancreatitis. Fasting venous blood samples were collected to analyse markers of glucose metabolism (fasting blood glucose, haemoglobin A1c, homeostasis model assessment (HOMA-IR) as a measure of insulin resistance) and adypocytokines (adiponectin, interleukin-6, leptin, monocyte chemoattractant protein-1, retinol binding protein-4, resistin, and tumor necrosis factor-α). Participants were categorized into two groups: normoglycemia after acute pancreatitis and chronic hyperglycemia after acute pancreatitis (CHAP). Binary logistic regression and linear regression analyses were used to investigate the association between each of the adipocytokines and markers of glucose metabolism. Potential confounders were adjusted for in multivariate analyses.

RESULTS

A total of 83 patients with acute pancreatitis were included, of whom 19 developed CHAP. Interleukin-6 was significantly associated with CHAP in both unadjusted and adjusted models (p = 0.030 and p = 0.018, respectively). Further, it was also significantly associated with HOMA-IR in both unadjusted and adjusted models (p = 0.029 and p = 0.037, respectively). Other adipocytokines were not significantly associated with markers of glucose metabolism.

CONCLUSION

Interleukin-6 appears to be implicated in the development of chronic hyperglycemia and insulin resistance in patients after acute pancreatitis. It may become a potential target in the prevention and early treatment of diabetes after diseases of the exocrine pancreas.