POS0902 RISK FACTORS FOR LUNG FUNCTION DECLINE IN SYSTEMIC SCLEROSIS INTERSTITIAL LUNG DISEASE IN A LARGE SINGLE-CENTER COHORT

Background

Systemic sclerosis associated interstitial lung disease (SSc-ILD) is the leading cause of scleroderma-related mortality.

Objectives

This work identifies factors associated with SSc-ILD decline on pulmonary function testing (PFT).

Methods

This single center cohort identified 312 patients with ILD as determined by high resolution chest. 184 patients (59% of 312) completed baseline and serial PFTs (with at least two follow-up PFTs) and were included in this analysis. Mixed linear models were fit to assess the decline in the percent predicted forced vital capacity (ppFVC) over time. Demographics, disease factors, autoantibodies, and ILD features were included in the univariate mixed linear model; those achieving a p-value <0.20 were included in the multivariable mixed linear model. Patients were followed longitudinally, with survival as an endpoint identified using the National Death Registry Index, reviewing death certificates, and hospital records.

Results

The 184 patients were an average of 53.2 [12.1] years old; the median [IQR] disease duration from the first non-Raynaud’s phenomenon symptom was 1.8 [0.7, 4.8] years. SSc subtype was diffuse in 55.4% (n=102), limited in 32.6% (n=60), overlap syndrome in 8.2% (n=15), and SSc sine scleroderma in 3.87% (n=7). Serologies were positive for anti-topoisomerase I (ATA), anti-centromere and anti-RNA polymerase III in 31.4% (n=53/169), 10.4% (16/154) and 22.9% (25/109) respectively. Mean ppFVC was 70.8 (18.9) and ppDLco 57.2 (20.8). Whole lung involvement (WLI%) of ≥20% on visual read was found in 49.3% of subjects (74/150 (49.3%)) where quantification was available. Over a median of 4.9 (2.4, 6.8) years, 21 patients (11.4%) died. The ppFVC declined a mean of 0.28/year in the overall group. There were differences in terms of ppFVC decline/year between patients who died in the first 2 years (n=10, -8.28%), 2-8 years (n=5, -3.89%), after 8 years (n=6, -1.00%), or who were still alive (n=163, -0.13%). The primary cause of death was ILD (6/21, 28.6%); those who died in the first 2 years most often died from progressive ILD (4/6, 67%). Factors significantly associated with decline in ppFVC on univariate analyses, included longer disease duration (ref. < median, P=0.0048), ATA positivity (ref. negative, P=0.0081), and WLI ≥20% (ref. 0-20%, P=0.0484). In multivariate analysis the only statistically significant variable associated with decline in ppFVC/ year was ATA positivity.

Conclusion

In a large single center cohort of SSc-ILD, ATA positivity is a risk factor for developing progressive SSc-ILD, consistent with other SSc-ILD cohorts. Stratifying patients by survival demonstrates that lung function declines dramatically in those who died within 2 years, whose main cause of death was progressive ILD. These data support the growing need to identify risk factors for disease severity and risk for progression, and to target intervention in patients most likely to develop progressive SSc-ILD1,2.

References

[1]Roofeh D, Lin CJF, Goldin JG, et al. Tocilizumab Prevents Progression of Early Systemic Sclerosis Associated Interstitial Lung Disease. Arthritis Rheum. 2021

[2]Roofeh D, Lescoat A, Khanna D. Treatment for systemic sclerosis-associated interstitial lung disease. Curr Opin Rheumatol. 2021

Disclosure of Interests

None declared

Employing L-Lactic Acid Powder in the Preparation of a Dry “Acid Concentrate” for use in a Bicarbonate-Based Dialysis Solution-Generating System: Experience in Hemodialysis Patients

By replacing the liquid acetic acid present in the “acid concentrate” of a bicarbonate-based dialysis solution-generating system with an equimolar amount of solid L-lactic acid and by using the dry forms of the remaining constituents, we were able to create a dry “acid concentrate” just prior to use, and successfully employed this “acid concentrate” to produce a bicarbonate-based solution to hemodialyze patients.

Role of decompressive hemicraniectomy in extensive middle cerebral artery strokes: a meta-analysis of randomised trials

BACKGROUND

Prognosis for patients with 'malignant' or space-occupying oedema post middle cerebral artery infarct remains poor despite maximal medical therapy delivered in the intensive care setting.

AIM

We performed a meta-analysis to evaluate the value of surgical decompression versus medical management alone in patients suffering from malignant middle cerebral artery infarct.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

The overall OR for mRS 6 (death) at 6 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.19 (95% CI: 0.10-0.37). The frequency of patients with mRS 2, 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 3.29 (95% CI: 1.76-6.13). The overall OR for mRS 6 (death) at 12 months for decompressive surgery as compared with standard medical management revealed a statistically significant reduction with OR of 0.17 (95% CI: 0.10-0.29). The frequency of patients with mRS 3 and 5 outcomes was higher in the decompressive surgery cohort; however, these outcomes did not reach statistical significance. On the other hand, the number of patients with a mRS score of 4 was significantly higher in the decompressive surgery cohort with an OR of 4.43 (95% CI: 2.27-8.66). In the long run it was also observed that the number of patients with a mRS score of 2 was significantly higher in the decompressive surgery cohort an OR of 4.51 (95% CI: 1.06-19.24).

CONCLUSIONS

Our results imply that surgical intervention decreased mortality of patients with fatal middle cerebral artery infarct at the expense of increasing the proportion suffering from substantial disability at the conclusion of follow up.

HER2 expression in oesophageal carcinoma and Barrett's oesophagus associated adenocarcinoma: An Australian study

BACKGROUND

Several studies have evaluated the prognostic value of HER2 in oesophageal cancer, but the prognostic influence of HER2 overexpression in oesophageal cancer remains uncertain. The aim of this study was to assess the incidence of HER2 positivity and relationship with clinicopathological features in patients with oesophageal cancer.

DESIGN

The study cohort consisted of 269 patients diagnosed with oesophageal carcinoma in a single institution. HER2 expression was analysed by immunohistochemistry (IHC) and silver in situ hybridization (SISH) in 152 archival oesophageal cancer specimens. Survival analysis was assessed using Hazard models.

RESULTS

HER2 expression was IHC3+ in 14 (9.2%), IHC2+ in 14 (9.2%), IHC1+ in 57 (37.5%), and IHC0 in 67 (44.1%) cases. SISH results confirmed that 15 specimens (9.9%) were HER2 gene amplified. Among 27 squamous cell carcinomas (SCCs) only 3.7% were HER2 positive whereas 11.2% of 125 adenocarcinomas were HER2 positive. The HER2 positive tumours were more likely to occur in men (OR: 5.00, 95% CI: 1.69-14.29), smokers (OR: 10.00, 95% CI: 4.17-25) and in patients with Barrett's oesophagus (OR: 8.33, 95% CI: 3.71-20.00). There was no significant difference in survival between the (HER2 +ve, 14.3 months vs HER2 -ve, 24.6 months, p = 0.42) CONCLUSION: A HER2 prevalence rate of 9.9% was found among patients with oesophageal cancer and no correlation with survival was detected overall.

Systematic review with meta-analysis: the relationship between chronic Salmonella typhi carrier status and gall-bladder cancer

BACKGROUND

Carcinoma of the gall-bladder is the fifth commonest gastrointestinal tract cancer and is endemic in several countries. An association of chronic typhoid carriage and carcinoma of the gall-bladder has been reported.

AIM

To clarify whether chronic Salmonella typhi carrier state is associated with carcinoma of the gall-bladder.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents, Cochrane library, Google Scholar, Science Direct and Web of Science. Original data were abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI).

RESULTS

Of the articles selected, only 17 studies met full criteria for analysis. The overall OR for chronic S. typhi carrier state was 4.28(95% CI: 1.84-9.96). Most of the studies were from South Asia especially India and China. When a subgroup analysis was performed according to region, a significant association was observed in South-East Asia (OR: 4.13, 95% CI: 2.87-5.94, P value <0.01). Chronic S. typhi carrier state was associated with carcinoma of the gall-bladder based on detection methods of S. typhi antibody levels (OR: 3.52, 95% CI: 2.48-5.00, P value <0.01) and even more so on culture (OR: 4.14, 95% CI: 2.41-7.12, P value <0.01). The association was prominent in controls without gallstones (OR: 5.86, 95% CI: 3.84-8.95, P value <0.01) when compared with controls with gallstones (OR: 2.71, 95% CI: 1.92-3.83, P value <0.01).

CONCLUSIONS

Chronic S. typhi carrier state is an important risk factor among patients with carcinoma of the gall-bladder. Given the high risk associated with this carrier state, management options should include either elective cholecystectomy or careful monitoring using ultrasound.

Is complete lymph node dissection after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary? A meta-analysis

BACKGROUND

The current recommendation for patients with cutaneous melanoma and a positive sentinel lymph node (SLN) biopsy is a complete lymph node dissection (CLND). However, metastatic melanoma is not present in approximately 80% of CLND specimens. A meta-analysis was performed to identify the clinicopathological variables most predictive of non-sentinel node (NSN) metastases when the sentinel node is positive in patients with melanoma.

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google scholar, Science Direct, and Web of Science. The search identified 54 relevant articles reporting the frequency of NSN metastases in melanoma. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI).

FINDINGS

The pooled estimates that were found to be significantly associated with the high likelihood of NSN metastases were: ulceration (OR: 1.88, 95% CI: 1.53-2.31), satellitosis (OR: 3.25, 95% CI: 1.86-5.66), neurotropism (OR: 2.51, 95% CI: 1.39-4.53), >1 positive SLN (OR: 1.77, 95% CI: 1.2-2.62), Starz 3 (old) (OR: 1.83, 95% CI: 0.89-3.76), Angiolymphatic invasion (OR: 2.46, 95% CI: 1.34-4.54), extensive location (OR: 2.22, 95% CI: 1.74-2.81), macrometastases >2 mm (OR: 1.95, 95% CI: 1.61-2.35), extranodal extension (OR: 3.38, 95% CI: 1.79-6.40) and capsular involvement (OR: 3.16, 95% CI: 1.37-7.27). There were 3 characteristics not associated with NSN metastases: subcapsular location (OR: 0.51, 95% CI: 0.38-0.67), Rotterdam Criteria <0.1 mm (OR: 0.29, 95% CI: 0.17-0.50) and Starz I (new) (OR: 0.44, 95% CI: 0.22-0.91). Other variables including gender, Breslow thickness 2-4 mm and extremity as primary site were found to be equivocal.

INTERPRETATION

This meta-analysis provides evidence that patients with low SLN tumor burden could probably be spared the morbidity associated with CLND. We identified 9 factors predictive of non-SLN metastases that should be recorded and evaluated routinely in SLN databases. However, further studies are needed to confirm the standard criteria for not performing CLND.

Nasoenteric Tube Complications

The use of nasoenteric tubes (NETs) is ubiquitous, and clinicians often take their placement, function, and maintenance for granted. NETs are used for gastrointestinal decompression, enteral feeding, medication administration, naso-biliary drainage, and specialized indications such as upper gastrointestinal bleeding. Morbidity associated with NETETs is common, but frequently subtle, mandating high index of suspicion, clinical vigilance, and patient safety protocols. Common complications include sinusitis, sore throat and epistaxis. More serious complications include luminal perforation, pulmonary injury, aspiration, and intracranial placement. Frequent monitoring and continual re-review of the indications for continued use of any NETET is prudent, including consideration of changing goals of care. This manuscript reviews NET-related complications and associated topics.