A retrospective, comparative analysis of A&E attendance paserns in Irish Traveller versus non-Traveller general practice patients.

BACKGROUND: Very little is known about Gypsy, Roma, and Traveller health, or access to and utilisation of health care. They are not coded in NHS data systems and there are multiple barriers including illiteracy, digital exclusion, and discrimination. AIM: To gain rare insight into Irish Traveller patients' emergency healthcare utilisation and outcomes. METHOD: A retrospective general practice review of A&E attendances was performed from January to December 2017, comparing Travellers with the rest of the practice patient population. A search was done for all A&E attendance letters and related admissions. Blind review of the diagnosis and management were assessed by two reviewers for appropriateness of attendance at A&E. The frequency and recurrence of A&E attendances, referral pathway toA&E, location of A&E, and age distribution were compared. RESULTS: Traveller patients attending A&E were younger. There were fewer repeat attendances in the travelling community but proportionally more in the Traveller under-20-year-old cohort. Only 38% of A&E attendances in Travellers (56% non-Travellers) were deemed appropriate (χ2 7.16, P = 0.007). Only 20% of Travellers (36% non-Travellers) attending A&E were admitted to hospital (χ2 6.33, P = 0.01). Further, 93% of A&E attendances in Irish Travellers (75% non-Travellers) did not follow initial contact with either a GP or NHS 111 (χ2 9.86, P<0.002). Finally, 51% of Irish Travellers (6% non-Travellers) attended A&E departments distant to their registered GP practice (χ2 89.5, P<0.001). CONCLUSION: This work throws light on health service utilisation patterns by Irish Travellers. A&E attendances may have been more suited to a non-emergency setting and there may have been missed opportunities for contact with primary care or NHS 111, which may have an impact on continuity, onward referral, and quality of care.

Illicit drugs in the emergency department: Can we determine on clinical grounds if patients are intoxicated? Results from the Western Australian Illicit Substance Evaluation (WISE) study.

INTRODUCTION: Presentations related to illicit drugs are a feature of emergency department practice. Clinicians may form a belief that a patient is intoxicated with illicit drugs based on patient self-report, clinical features on presentation and the local prevalence of illicit drug use. But evidence of the accuracy of this assessment is lacking. The Western Australian Illicit Substance Evaluation (WISE) study enrolled patients believed by their treating clinician to be intoxicated with illicit drugs, and this analysis aims to evaluate the validity of this belief. METHODS: A blood sample was taken on patient arrival and details of patient history, examination and interventions were collected by clinical and research staff. Toxicological examination of biological samples used liquid chromatography-mass spectrometry techniques including Quadrupole Time of Flight screening and Triple Quadrupole targeted analyses. RESULTS: Of 632 study presentations, 518 had illicit drugs detected representing a positive predictive value of 0.82 (95% confidence interval 78.7, 84.9). Those with illicit drugs detected were significantly less likely to arrive by police transport (p = 0.010) or to have used alcohol (p < 0.001). They were significantly more likely to report illicit drug use (p < 0.001) and a much smaller proportion were admitted to a psychiatric ward (3.5% vs. 19.3%, p < 0.0001). Heart rate and systolic blood pressure were significantly higher in the illicit drug group (p = 0.004 and p = 0.003). DISCUSSION AND CONCLUSIONS: In this study, the positive predictive value of clinicians determining if their patient had taken illicit drugs was 0.82. Contemporaneous biochemical analysis in the clinical setting would increase this accuracy and inform patient care.

Angioembolisation for arterial haemorrhage related to pelvic ring injury.

INTRODUCTION: Haemorrhage related to pelvic fractures has been associated with mortality rates of up to 50%. Angioembolisation for the management of pelvic haemorrhage was performed as early as 1972; however, there remains uncertainty over its exact use, timing and priority as a component of modern pelvic management protocols. METHODS: We retrospectively analysed cases of angioembolisation for arterial haemorrhage related to pelvic ring fractures at a level 1 trauma centre. Patient demographics were assessed as well as the time taken to reach the interventional radiology (IR) suite from the time of trauma and also arriving at the emergency room (ER). Other factors analysed included the volume of blood products consumed and fracture pattern. RESULTS: Fifty-four patients received pelvic angiography for pelvic ring injuries between 2006 and 2021. The average age was 45.1 (20.5) years, with the male to female ratio 2.4:1. Forty (74.1%) of these patients had embolisation to actively bleeding pelvic arterial vessels. Median time to the IR was 4.4 [IQR 3.1-8.1] hours from time of trauma and 2.5 [IQR 2.1-4.2] hours from arrival to ER. The overall mortality rate was 18.5% and the median amount of blood transfused was 4584 mL [IQR 1643.5-8026.5]. In the subset of embolised patients (n = 40), mortality rate was 10% and there was an inverse association between time from ER to IR and volume of blood product consumption (P = 0.024). CONCLUSION: Angioembolisation is a life-saving intervention in very severely injured patients and is growing in popularity as a component of modern pelvic trauma management protocols.

Analytically confirmed illicit and novel psychoactive drug use in Western Australian emergency departments: initial results from the Emerging Drugs Network of Australia (EDNA).

INTRODUCTION: The burden of acute illicit drug use in Australia is largely unknown. Establishing a prospective drug surveillance system in emergency departments using analytical confirmation may facilitate the early identification of emerging drugs. We describe demographic data and acute toxicity patterns, stratified by analytical confirmation of illicit drugs and novel psychoactive substances, to emergency departments in Western Australia. METHODS: Patients presenting with severe and/or unusual clinical features consistent with recreational drug toxicity were identified across five Western Australian emergency departments participating in the Emerging Drugs Network of Australia between April 2020 and December 2021. Demographic and toxicology patterns in patients with and without analytically confirmed illicit drugs/novel psychoactive substances from blood samples were collected during the emergency department presentation. RESULTS: The cohort included 434 severe and/or unusual toxicology presentations; median age 33 years (first and third quartiles 25-40 years), 268 (61.8%) males. Any substance (illicit, novel psychoactive substance, pharmaceutical) was detected in 405 (93.3%) presentations. Illicit drugs/novel psychoactive substances were detected in 257 (59.2%) presentations, including 73 (28.3%) with more than one confirmed illicit drug/novel psychoactive substance. Frequent illicit drugs identified were metamfetamine (n = 201, 77.9%) and gamma-hydroxybutyrate (n = 30, 11.6%). Forty-eight novel psychoactive substances were detected within 43 (16.7%) presentations. Novel benzodiazepines were most frequently detected (n = 29, 60.4%). Frequent pharmaceuticals detected included diazepam (n = 100, 26.1%) and clonazepam (n = 40, 10.4%). One hundred and fifty-five (35.7%) presentations were discharged home and 56 (12.9%) were admitted to intensive care. Presentations with detected illicit drugs/novel psychoactive substances had a lower median intensive care length of stay compared to presentations without detected illicit drugs/novel psychoactive substances (32.6 h versus 50.8 h respectively, P < 0.001). CONCLUSIONS: Integration of clinical and analytic data in patients with severe and/or unusual toxicology presentations via the Emerging Drugs Network of Australia provides insight into illicit drug/novel psychoactive substance use responsible for acute harm across Western Australian emergency departments.

Interpreting contrast imaging to plan breast surgery.

BACKGROUND: Contrast enhanced mammography (CEM) and magnetic resonance imaging (MRI) are more accurate than conventional imaging (CI) for breast cancer staging. How adding CEM and MRI to CI might change the surgical plan is understudied. METHODS: Surgical plans (breast conserving surgery (BCS), wider BCS, BCS with diagnostic excision (>1BCS), mastectomy) were devised by mock-MDT (radiologist, surgeon and pathology reports) according to disease extent on CI, CI + CEM and CI + MRI. Differences in the mock-MDT's surgical plans following the addition of CEM or MRI were investigated. Using pre-defined criteria, the appropriateness of the modified plans was assessed by comparing estimated disease extent on imaging with final pathology. Surgery performed was recorded from patient records. RESULTS: Contrast imaging modified mock-MDT plans for 20 of 61(32.8%) breasts. The addition of CEM changed the plan in 16/20 (80%) and MRI in 17/20 breasts (85%). Identical changes were proposed by both CEM and MRI in 13/20 (65%) breasts. The modified surgical plan based on CI + CEM was possibly appropriate for 6/16 (37.5%), and CI + MRI in 9/17, (52.9%) breasts. The surgery performed was concordant with the mock-MDT plan for all 10 patients where the plans could be compared (BCS 1, >1 BCS 2 and mastectomy 7). CONCLUSION: Adding CEM or MRI to CI changed mock-MDT plans in up to one third of women, but not all were appropriate. Changing surgical plans following addition of contrast imaging to CI without biopsy confirmation could lead to over or under-treatment.

The Great Contrast Shortage of 2022-Lessons learnt in Australia.

INTRODUCTION: Computed tomography (CT) imaging is one of the most commonly used diagnostic tools. Iodine-based contrast media (IBCM) are frequently administered intravenously to improve soft tissue contrast in a wide range of CT scans. Supply chain disruptions triggered by the SARS-CoV-19 pandemic led to a global shortage of IBCM in mid-2022. The purpose of this study was to explore the impact of this shortage on the delivery of healthcare in Western Australia. METHODS: We performed a single-centre retrospective analysis of the provision of CT studies, comparing historical patterns to the shortage period. We focussed our attention on the total number of CT scans (noncontrast CT [NCCT] and contrast-enhanced CT [CECT]) and also specifically CT pulmonary angiogram (CTPA) and CT neck angiogram with or without inclusion of circle of Willis (CTNA) examinations. We also examined whether a decrease was compensated by increasing frequency of alternate examinations such as ventilation/perfusion (V/Q) scans, carotid Doppler ultrasound studies and Magnetic Resonance Angiograms (MRAs). RESULTS: Since 2012, there has been an approximate linear increase in the frequency of CT examinations. During the period of contrast shortage, there was an abrupt drop-off by approximately 50% in the CECT, CTPA and CTNA groups compared with the preceding 6 weeks (49%, 55% and 44%, respectively, with P < 0.001 in all cases). During the contrast shortage, the frequency of V/Q scans increased fivefold (from 13 to 65; P < 0.001). However, the provision of carotid Doppler ultrasound studies and MRAs remained approximately stable in frequency across recent time intervals. CONCLUSION: Our findings demonstrate that the IBCM shortage crisis had a very significant impact on the delivery of healthcare. While V/Q scans could (partially) substitute for CTPA studies in suspected pulmonary emboli, there appeared to be no valid alternative for CTNA studies in stroke calls. The unexpected and critical shortage of IBCM forced healthcare professionals to conserve resources, prioritise indications, triage patients based on risk, explore alternate imaging strategies and prepare for similar events recurring in the future.

Effect of intravenous fluid volume on biomarkers of endothelial glycocalyx shedding and inflammation during initial resuscitation of sepsis.

PURPOSE: To investigate the effect of IV fluid resuscitation on endothelial glycocalyx (EG) shedding and activation of the vascular endothelium and inflammation. MATERIALS AND METHODS: A planned biomarker sub-study of the REFRESH trial in which emergency department (ED) patients) with suspected sepsis and hypotension were randomised to a restricted fluid/early vasopressor regimen or IV fluid resuscitation with later vasopressors if required (usual care). Blood samples were collected at randomisation (T0) and at 3 h (T3), 6 h (T6)- and 24 h (T24) for measurement of a range of biomarkers if EG shedding, endothelial cell activation and inflammation. RESULTS: Blood samples were obtained in 95 of 99 enrolled patients (46 usual care, 49 restricted fluid). Differences in the change in biomarker over time between the groups were observed for Hyaluronan (2.2-fold from T3 to T24, p = 0.03), SYN-4 (1.5-fold from T3 to T24, P = 0.01) and IL-6 (2.5-fold from T0 to T3, p = 0.03). No difference over time was observed between groups for the other biomarkers. CONCLUSIONS: A consistent signal across a range of biomarkers of EG shedding or of endothelial activation or inflammation was not demonstrated. This could be explained by pre-existing EG shedding or overlap between the fluid volumes administered in the two groups in this clinical trial. Trial registration Australia New Zealand Clinical Trials Registry ACTRN126160000006448 Registered 12 January 2016.

Contrast-enhanced mammography (CEM) versus MRI for breast cancer staging: detection of additional malignant lesions not seen on conventional imaging.

BACKGROUND: Contrast-enhanced mammography (CEM) is more available than MRI for breast cancer staging but may not be as sensitive in assessing disease extent. We compared CEM and MRI in this setting. METHODS: Fifty-nine women with invasive breast cancer underwent preoperative CEM and MRI. Independent pairs of radiologists read CEM studies (after reviewing a 9-case set prior to study commencement) and MRI studies (with between 5 and 25 years of experience in breast imaging). Additional lesions were assigned National Breast Cancer Centre (NBCC) scores. Positive lesions (graded NBCC ≥ 3) likely to influence surgical management underwent ultrasound and/or needle biopsy. True-positive lesions were positive on imaging and pathology (invasive or in situ). False-positive lesions were positive on imaging but negative on pathology (high-risk or benign) or follow-up. False-negative lesions were negative on imaging (NBCC < 3 or not identified) but positive on pathology. RESULTS: The 59 women had 68 biopsy-proven malignant lesions detected on mammography/ultrasound, of which MRI demonstrated 66 (97%) and CEM 67 (99%) (p = 1.000). Forty-one additional lesions were detected in 29 patients: six of 41 (15%) on CEM only, 23/41 (56%) on MRI only, 12/41 (29%) on both; CEM detected 1/6 and MRI 6/6 malignant additional lesions (p = 0.063), with a positive predictive value (PPV) of 1/13 (8%) and 6/26 (23%) (p = 0.276). CONCLUSIONS: While MRI and CEM were both highly sensitive for lesions detected at mammography/ultrasound, CEM may not be as sensitive as MRI in detecting additional otherwise occult foci of malignancy. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry: ACTRN 12613000684729.

Accuracy and precision of contrast enhanced mammography versus MRI for predicting breast cancer size: how "good" are they really?

OBJECTIVE: To evaluate and compare the accuracy and precision of contrast-enhanced mammography (CEM) vs MRI to predict the size of biopsy-proven invasive breast cancer. METHODS: Prospective study, 59 women with invasive breast cancer on needle biopsy underwent CEM and breast MRI. Two breast radiologists read each patient's study, with access limited to one modality. CEM lesion size was measured using low-energy and recombined images and on MRI, the first post-contrast series. Extent of abnormality per quadrant was measured for multifocal lesions. Reference standards were size of largest invasive malignant lesion, invasive (PathInvasive) and whole (PathTotal). Pre-defined clinical concordance ±10 mm. RESULTS: Mean patient age 56 years, 42 (71%) asymptomatic. Lesions were invasive ductal carcinoma 40 (68%) with ductal carcinoma in situ (31/40) in 78%, multifocal in 12 (20%). Median lesion size was 17 mm (invasive) and 27 mm (total), range (5-125 mm). Lin's concordance correlation coefficients for PathTotal 0.75 (95% CI 0.6, 0.84) and 0.71 (95% CI 0.56, 0.82) for MRI and contrast-enhanced spectral mammography (CESM) respectively. Mean difference for total size, 3% underestimated and 4% overestimated, and for invasive 41% and 50% overestimate on MRI and CESM respectively. LOAs for PathTotal varied from 60% under to a 2.4 or almost threefold over estimation. MRI was concordant with PathTotal in 36 (64%) cases compared with 32 (57%) for CESM. Both modalities concordant in 26 (46%) cases respectively. CONCLUSION: Neither CEM nor MRI have sufficient accuracy to direct changes in planned treatment without needle biopsy confirmation. ADVANCES IN KNOWLEDGE: Despite small mean differences in lesion size estimates using CEM or MRI, the 95% limits of agreement do not meet clinically acceptable levels.

No association between intravenous fluid volume and endothelial glycocalyx shedding in patients undergoing resuscitation for sepsis in the emergency department.

Endothelial glycocalyx (EG) shedding is associated with septic shock and described following intravenous (IV) fluid administration. To investigate the possible impact of IV fluids on the pathobiology of septic shock we investigated associations between biomarkers of EG shedding and endothelial cell activation, and relationships with IV fluid volume. Serum samples were obtained on admission (T0) and at 24 h (T24) in patients undergoing haemodynamic resuscitation for suspected septic shock in the emergency department. Biomarkers of EG shedding-Syndecan-1 (Syn-1), Syndecan-4 (Syn-4), Hyaluronan, endothelial activation-Endothelin-1 (ET-1), Angiopoeitin-2 (Ang-2), Vascular Endothelial Growth Factor Receptor-1(VEGF-1) and leucocyte activation/inflammation-Resistin, Neutrophil Gelatinase Associated Lipocalin (NGAL) and a marker of cardiac stretch-Pro-Atrial Natriuretic Peptide (Pro-ANP) were compared to the total IV fluid volume administered using Tobit regression. Data on 86 patients (52 male) with a mean age of 60 (SD 18) years were included. The mean fluid volume administered to T24 was 4038 ml (SD 2507 ml). No significant association between fluid volume and Pro-ANP or any of the biomarkers were observed. Syn-1 and Syn-4 were significantly correlated with each other (Spearman Rho 0.43, p < 0.001) but not with Hyaluronan. Syn-1 and Syn-4 both correlated with VEGFR-1 (Rho 0.56 and 0.57 respectively, p < 0.001) whereas Hyaluronan correlated with ET-1 (Rho 0.43, p < 0.001) and Ang-2 (Rho 0.43, p < 0.001). There was no correlation between Pro-ANP and any of the EG biomarkers. Distinct patterns of association between biomarkers of EG shedding and endothelial cell activation were observed among patients undergoing resuscitation for sepsis. No relationship between IV fluid volume and Pro-ANP or any of the other biomarkers was observed.

Demographic and clinical characteristics of patients who recommence clozapine following therapy interruptions.

OBJECTIVE: The proportion of patients who recommence clozapine after cessation, the time taken to resume clozapine post-cessation, and distinguishing demographic and clinical characteristics of this group have been poorly researched. We evaluated these in the current study. METHOD: We retrospectively extracted selected demographic and clinical variables and clozapine treatment interruption and recommencement data up to December 2018 of a cohort of 458 patients who first commenced clozapine between 2006 and 2016. The study was conducted at three Australian health services. RESULTS: Of the 310 (69%) patients who had at least one interruption of clozapine treatment, 170 (54.8%) did not resume clozapine, and 140 (45.2%) recommenced it after the first interruption. More than half of those who recommenced did so within a month and 80% by 12 months. Cox regression analysis revealed that age was significantly associated with recommencement, with a 2% decrease in the likelihood of restarting after an interruption for each year later that clozapine was initially commenced (HR = 0.98 95%CI: 0.97, 0.997, p = 0.02). Those who ceased clozapine due to adverse effects were less likely to restart than those who ceased due to noncompliance (HR = 0.63 95%CI: 0.41, 0.97, p = 0.03). More time on clozapine prior to interruption increased the likelihood of restarting it, with each additional month on clozapine increasing this likelihood by 1% (HR = 1.01 95%CI: 1.01, 1.02, p < 0.001). CONCLUSION: If the distinguishing demographic and clinical characteristics of the group identified in this study are corroborated through further research, this could further validate the need to identify treatment resistance and commence clozapine early in people with schizophrenia and provide appropriate interventions to those more at risk of permanent discontinuation of clozapine.

Prenatal Testosterone Associates With Blood Pressure in Young Adults: A Prospective Cohort Study.

[Figure: see text].

Markers of Elevated Left Ventricular Filling Pressure Are Associated with Increased Mortality in Nonsevere Aortic Stenosis.

BACKGROUND: Echocardiographic measures of elevated left ventricular filling pressures are associated with an adverse prognosis. The aim of this study was to determine the relationship between acute (ratio of early transmitral flow to mitral annular velocity [E/e']) and chronic (indexed left atrial volume) markers of left ventricular filling pressure and mortality in patients with nonsevere aortic stenosis (AS), within the National Echo Database Australia cohort, testing the hypothesis that they would reflect the early hemodynamic consequences of AS and be associated with increased mortality in this setting. METHODS: The first record for patients ≥18 years of age showing hemodynamically significant but nonsevere (mild or moderate) AS (mean pressure gradient ≥ 10 to <40 mm Hg and aortic valve area > 1 cm2) was analyzed. Baseline demographics and echocardiographic variables were compared with those among patients without AS (mean pressure gradient < 10 mm Hg). Mortality linkage data were available for all patients. RESULTS: Of 78,886 patients with aortic valve mean pressure gradients < 40 mm Hg and aortic valve areas > 1 cm2, 13,768 (17%) were identified with nonsevere AS (aortic valve mean pressure gradient 10-40 mm Hg), of whom 57% were men (mean age, 73 ± 13.4 years) with a median follow-up of 3.4 years (interquartile range, 1.7-6.1 years). In unadjusted time-varying coefficient models, nonsevere AS and indexed left atrial volume > 34 mL/m2 (hazard ratio [HR], 2.29; 95% CI, 2.03-2.58), E/e' ratio > 14 (HR, 2.27; 95% CI, 2.08-2.49), left ventricular ejection fraction < 50% (HR, 2.82; 95% CI, 2.50-3.19), and tricuspid regurgitation peak velocity > 280 cm/sec (HR, 2.54; 95% CI, 2.30-2.80) were associated with increased mortality hazard at the time of echocardiography. All markers were significant when combined in a multivariate model. CONCLUSIONS: Indices of elevated left ventricular filling pressure are independently associated with death in patients with nonsevere AS. Risk stratification models incorporating these variables may identify patients at risk for complications, warranting closer surveillance and possibly earlier intervention.

ApoB48-Lipoproteins Are Associated with Cardiometabolic Risk in Adolescents with and without Polycystic Ovary Syndrome.

CONTEXT: Adolescents with polycystic ovary syndrome (PCOS) have increased incidence of cardiometabolic risk factors including dyslipidemia. Atherogenic apolipoprotein (apo) B-lipoprotein remnants are associated with increased cardiovascular disease (CVD) risk. OBJECTIVE: The aim of this study was to determine the concentrations of fasting plasma apoB-lipoprotein remnants, apoB48 and apoB100, and their association with cardiometabolic risk factors and androgen indices in adolescent girls with and without PCOS. DESIGN SETTING AND PARTICIPANTS: Participants (n = 184) aged 17 years were recruited in the Menstruation in Teenagers Study from the Western Australian Pregnancy Cohort (Raine) Study. THE MAIN OUTCOME MEASURES: Fasting plasma apo-B48 and -B100 lipoprotein remnant concentrations in adolescent girls with and without PCOS. RESULTS: Fasting plasma apoB48-lipoprotein remnants but not apoB100-lipoprotein remnants were elevated in adolescent girls with increased cardiometabolic risk compared with those with lower cardiometabolic risk (13.91 ± 5.06 vs 12.09 ± 4.47 µg/mL, P < .01). ApoB48-lipoprotein remnants were positively correlated with fasting plasma triglycerides (b = .43, P < .0001). The prevalence of increased cardiometabolic risk factors was 2-fold higher in those diagnosed with PCOS (35.3%) than in those without PCOS (16.3%).Conclusion: Adolescents with PCOS have a 2-fold higher incidence of cardiometabolic risk factors than those without PCOS. Fasting apoB48-lipoprotein remnants are elevated in adolescent girls with a high prevalence of cardiometabolic risk factors.

Modified Chester Step Test in a Healthy Adult Population: Measurement Properties and Development of a Regression Equation to Estimate Test Duration.

OBJECTIVE: Healthy working-aged adults performed the modified Chester Step Test (mCST) to (1) determine the effect of repetition on test duration, (2) report cardiorespiratory and symptom responses, (3) establish a regression equation to estimate duration, and (4) calculate the minimal detectable change of the test. METHODS: In this observational study conducted in a hospital physical therapy, adult participants aged 25 to 65 years who were healthy performed the mCST twice. This submaximal test required participants to step on and off a 20-cm step at a standardized cadence that increased every 2 minutes. The criteria for test completion were either a heart rate equal to 80% of age-predicted maximum or the onset of intolerable symptoms. The primary measure was time to test completion during the mCST (seconds). Cardiorespiratory and symptom responses were also collected during the mCST. RESULTS: A total of 83 participants (40 men, mean [SD] age = 44 [12] years) completed data collection. There was no systematic effect of test repetition with median test duration of the first test (522 seconds, range = 400-631 seconds) and second test (501 seconds, range = 403-631 seconds). The test elicited moderate symptoms of breathlessness and leg fatigue. In the multivariable model, age, sex, weight, and height were retained as significant predictors of test duration (R2 = 0.48). The minimal detectable change was 119 seconds. CONCLUSIONS: The mCST is a reliable and valid clinically applicable test of aerobic capacity in working-aged adults. Independent pretest predictors can be used to estimate the clinical time required to complete the test. IMPACT: The mCST was stable between test repetitions, suggesting no learning effect. For any given individual, a test duration change of 2 minutes represents change was beyond the natural variability. The mCST has good applicability to clinical settings.

ApoB48-remnant lipoproteins are associated with increased cardiometabolic risk in adolescents.

BACKGROUND AND AIMS: Cardiovascular disease (CVD) begins in youth, and is exacerbated by obesity and metabolic syndrome. Apolipoprotein (Apo)B-remnant cholesterol is considered a primary contributor to CVD risk. Fasting plasma apoB48 can be used as a biomarker of intestinal remnant cholesterol as well as postprandial dyslipidemia. In adults, elevated fasting plasma apoB48 strongly associates with cardiometabolic risk factors and obesity, whereas in adolescents there is limited data. The aim of this study was to measure fasting plasma apoB48 and determine the relationship with cardiometabolic risk factors in adolescents. METHODS: This is a cross-sectional study of fasting plasma apoB48 from the Western Australian Pregnancy Cohort (Raine) Study. Subjects were adolescent males and females aged 17 years with complete fasting plasma apoB48, biochemical, and anthropometry data (n = 1045). The relationship between fasting plasma apoB48 and other cardiometabolic risk factors was determined. The high-risk metabolic cluster variable was defined using elevated BMI, HOMA-IR, fasting plasma triglycerides, and systolic blood pressure. RESULTS: Fasting plasma apoB48 was significantly higher in male (15.28 ± 2.95 µg/mL) compared to female (12.45 ± 2.43 µg/mL) adolescents (p = 0.0003), and was increased by 21% (3.60 µg/mL; p = 0.0000) in the high-risk metabolic cluster group and more pronounced in males (31%, 6.15 µg/mL; p = 0.0000). Fasting plasma apoB48 was positively associated with fasting plasma triglycerides, total-cholesterol (but not LDL-C), insulin, leptin, HOMA-IR, and the anthropometric parameters, waist-circumference and skinfold-thickness. Fasting plasma apoB48 was inversely associated with fasting plasma HDL-C, and adiponectin. CONCLUSIONS: Plasma apoB48 remnant lipoproteins associate with cardiometabolic risk factors in adolescents and provide support for the screening of remnant cholesterol in youth.

Multicentre Covariate Adjustment Analysis of Short-Term and 5-Year Outcomes after Endovascular Repair according to Sex.

BACKGROUND: Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. METHODS: A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. RESULTS: A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%. CONCLUSION: This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.

Modified frailty index and hypoalbuminemia as predictors of adverse outcomes in older adults presenting to acute general surgical unit / Índice de fragilidad modificado e hipoalbuminemia como pronosticadores de resultados adversos en adultos mayores que se presentan a la unidad de cirugía general aguda

INTRODUCTION: Health professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit. MATERIALS AND METHODS: This prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65 years and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days. RESULTS: We found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission. CONCLUSION: Frailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting

INTRODUCCIÓN: Los profesionales de la salud se basan progresivamente en el concepto de fragilidad como determinante de los resultados quirúrgicos adversos de los adultos mayores. Se intentó determinar la prevalencia de la fragilidad y la correlación entre la fragilidad y la mortalidad entre los adultos mayores ingresados en la unidad de cirugía aguda. MATERIALES Y MÉTODOS: Este estudio de cohorte prospectivo se llevó a cabo en la unidad de cirugía general aguda durante un período de 2 meses. Se reclutaron 150 pacientes consecutivos de 65 años y más. El índice de fragilidad modificada se empleó para medir la fragilidad y los niveles de albúmina en el momento del ingreso se obtuvieron a partir de historias clínicas electrónicas. Los pacientes fueron seguidos durante un período de 30 días. RESULTADOS: Se encontró que más del 40% de los adultos mayores ingresados en la unidad de cirugía general aguda eran frágiles, y la fragilidad se asoció con mayores tasas de mortalidad a los 30 días. La hipoalbuminemia se asoció con una mayor duración de la estancia, una tasa más alta de complicaciones y una mayor probabilidad de alta a un centro de rehabilitación. También hubo una correlación univariada significativa entre la fragilidad y la presencia de hipoalbuminemia en el ingreso. CONCLUSIÓN: La fragilidad y la hipoalbuminemia son frecuentes en los pacientes de cirugía general de edad avanzada, y predicen la probabilidad de algunos de los resultados adversos relevantes para los adultos mayores y la economía de la salud como la mortalidad, el aumento de la duración de la estancia, la tasa de complicaciones y la probabilidad de alta en un centro de rehabilitación. Los estudios adicionales deben investigar una posible asociación causal entre la fragilidad y los niveles bajos de albúmina en un contexto quirúrgico agudo

Towards the Development of an Integrative, Evidence-Based Suite of Indicators for the Prediction of Outcome Following Mild Traumatic Brain Injury: Results from a Pilot Study.

BACKGROUND: Persisting post-concussion symptoms (PPCS) is a complex, multifaceted condition in which individuals continue to experience the symptoms of mild traumatic brain injury (mTBI; concussion) beyond the timeframe that it typically takes to recover. Currently, there is no way of knowing which individuals may develop this condition. METHOD: Patients presenting to a hospital emergency department (ED) within 48 h of sustaining a mTBI underwent neuropsychological assessment and demographic, injury-related information and blood samples were collected. Concentrations of blood-based biomarkers neuron specific enolase, neurofilament protein-light, and glial fibrillary acidic protein were assessed, and a subset of patients also underwent diffusion tensor-magnetic resonance imaging; both relative to healthy controls. Individuals were classified as having PPCS if they reported a score of 25 or higher on the Rivermead Postconcussion Symptoms Questionnaire at ~28 days post-injury. Univariate exact logistic regression was performed to identify measures that may be predictive of PPCS. Neuroimaging data were examined for differences in fractional anisotropy (FA) and mean diffusivity in regions of interest. RESULTS: Of n = 36 individuals, three (8.33%) were classified as having PPCS. Increased performance on the Repeatable Battery for the Assessment of Neuropsychological Status Update Total Score (OR = 0.81, 95% CI: 0.61-0.95, p = 0.004), Immediate Memory (OR = 0.79, 95% CI: 0.56-0.94, p = 0.001), and Attention (OR = 0.86, 95% CI: 0.71-0.97, p = 0.007) indices, as well as faster completion of the Trails Making Test B (OR = 1.06, 95% CI: 1.00-1.12, p = 0.032) at ED presentation were associated with a statistically significant decreased odds of an individual being classified as having PPCS. There was no significant association between blood-based biomarkers and PPCS in this small sample, although glial fibrillary acidic protein (GFAP) was significantly increased in individuals with mTBI relative to healthy controls. Furthermore, relative to healthy age and sex-matched controls (n = 8), individuals with mTBI (n = 14) had higher levels of FA within the left inferior frontal occipital fasciculus (t (18.06) = -3.01, p = 0.008). CONCLUSION: Performance on neuropsychological measures may be useful for predicting PPCS, but further investigation is required to elucidate the utility of this and other potential predictors.

Modified frailty index and hypoalbuminemia as predictors of adverse outcomes in older adults presenting to acute general surgical unit.

INTRODUCTION: Health professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit. MATERIALS AND METHODS: This prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65yrs and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days. RESULTS: We found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission. CONCLUSION: Frailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting.