Predictive performance of the Garvan Fracture Risk Calculator: a registry-based cohort study

The G arvan Fracture Risk Calculator predicts risk of osteoporotic fractures. We evaluated its predictive performance in 16,682 women and 2839 men from Manitoba, Canada, and found significant risk stratification, with a strong gradient across scores. The tool outperformed clinical risk factors and bone mineral density for fracture risk stratification.

INTRODUCTION

The optimal model for fracture risk estimation to guide treatment decision-making remains controversial. Our objective was to evaluate the predictive performance of the Garvan Fracture Risk Calculator (FRC) in a large clinical registry from Manitoba, Canada.

METHODS

Using the population-based Manitoba Bone Mineral Density (BMD) registry, we identified women and men aged 50-95 years undergoing baseline BMD assessment from September 1, 2012, onwards. Five-year Garvan FRC predictions were generated from clinical risk factors (CRFs) with and without femoral neck BMD. We identified incident non-traumatic osteoporotic fractures (OFs) and hip fractures (HFs) from population-based healthcare data sources to March 31, 2018. Fracture risk was assessed from area under the receiver operating characteristic curve (AUROC). Cox regression analysis and calibration ratios (5-year observed/predicted) were assessed for risk quintiles. All analyses were sex stratified.

RESULTS

We included 16,682 women (mean age 66.6 + / - SD 8.7 years) and 2839 men (mean age 68.7 + / - SD 10.2 years). During a mean observation time of 2.6 years, incident OFs were identified in 681 women and 140 men and HFs in 199 women and 22 men. AUROC showed significant fracture risk stratification with the Garvan FRC. Tool predictions without BMD were better than from age or decreasing weight, and the tool with BMD performed better than BMD alone. Garvan FRC with BMD performed better than without BMD, especially for HF prediction (AUROC 0.86 in women, 0.82 in men). There was a strong gradient of increasing risk across Garvan FRC quintiles (highest versus lowest, hazard ratios women 5.75 and men 3.43 for any OF; women 101.6 for HF). Calibration differences were noted, with both over- and underestimation in risk.

CONCLUSIONS

Garvan FRC outperformed CRFs and BMD alone for fracture risk stratification, particularly for HF, but may require recalibration for accurate predictions in this population.

Anatomage - the virtual dissection tool and its uses: A narrative review

Advancement in technology has given students and institutes an educational, interactive, and diagnostic aid with virtual reality functionality known as the Anatomage table. This review analyses the various spheres of the medical field where the 3D virtual tool is being used and assesses its acceptability, convenience, and practical application. A search for relevant studies in various databases namely Pubmed, Embase, Wiley Library, and Google Scholar was performed, and the data was compiled to understand the use of the Anatomage table. The search yielded a total of 24 studies that focused on the use of the Anatomage table. Eleven articles focused on using Anatomage as a learning tool and 13 described the perception of the Table. Anatomage table offers an excellent tool for learning anatomy by virtual dissection. The tool is not only used as a teaching aid, but also as a diagnostic and planning tool in residency programs. Adding the tool as an educational aid boosts the existing curriculum and helps to counter the challenges with cadaveric dissection. The equipment cost and its maintenance charges may be a deciding factor for the underutilization of the tool in developing countries.

Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment

BACKGROUND

There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined.

STUDY DESIGN

This retrospective case-control study including infants <  1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios.

RESULTS

The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated.

CONCLUSION

Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

785 Is Subspecialisation Important for The Emergency Laparotomy Outcomes?

Introduction

High mortality and morbidity is associated with Emergency Laparotomy. This study looks at outcomes of different subspecialties of surgeons performing Emergency Laparotomies identified from National Emergency Laparotomy Audit (NELA).

Method

Results

Conclusions

482 Is Subspecialisation Important for Emergency Laparotomy Outcomes?

Introduction

High mortality and morbidity is associated with Emergency Laparotomy. This study looks at outcomes of different subspecialties of surgeons performing Emergency Laparotomies identified from National Emergency Laparotomy Audit (NELA).

Method

Results

Conclusions

Role of postoperative intact serum PTH as an early predictor of severe post-thyroidectomy hypocalcemia: a prospective study

BACKGROUND

Post thyroidectomy hypocalcemia is a major sequel of thyroidectomy and continues to trouble the endocrinologists and the endocrine surgeons as there is no ideal predictive marker of hypocalcemia which has the potential to develop into a life-threatening complication. The role of early serum intact parathormone (iPTH) to predict post thyroidectomy hypocalcemia is becoming useful but the literature is still unclear regarding the optimal time of testing and the optimal cut-off value of serum iPTH.

PATIENTS AND METHODS

This is a prospective cohort study of 111 patients who underwent total thyroidectomy in a tertiary care endocrine surgery referral unit. Serum iPTH was measured after 20 min and 4 h of surgery. Receiver-Operator characteristic Curve (ROC) was used to find out of the best cut-off value of S. iPTH 20 min and 4 h after surgery in predicting hypocalcemia.

RESULTS

Hypocalcemia was noted in 60 (54%) out of 111 subjects who underwent total thyroidectomy. The best cut-off values of Serum iPTH to predict hypocalcemia was found to be 4.28 pmol/l at 20 min post total thyroidectomy with a sensitivity and specificity of 81.7% and 51%, respectively. In addition, patients with malignancy or central lymph nodal dissection were significantly over-represented in the hypocalcemia group with serum iPTH above the threshold level of 4.28 pmol/l. Below the cut off level, parenteral calcium supplementation was required in 23% (17/74) subjects while the rate was only 5.4% (2/37) patients when serum iPTH was above the cut-off level.

CONCLUSIONS

The decline of serum iPTH below a specific level after surgery has predictive value together with other factors strictly related to patient, the thyroid disease itself and surgery. The risk of development of hypocalcemia and consequent need for calcium supplementation should be evaluated by clinical assessment along with serum PTH measurement.

P–638 Status of insulin resistance in infertile women and its effect on ovulation induction

Study question

Is insulin resistance ( IR) a confounding variable in infertile women, other than those those having polycystic ovarian syndrome (PCOS)

Summary answer

IR was identified in 20.5% of infertile women. The presence of IR did not affect response to ovulation induction but reduced chances of conception

What is known already

Obesity is strongly correlated with insulin resistance. Obesity also has an adverse effect on fertility. In 2008 Steeg et al reported 5% reduction in chances of spontaneous conception with each unit increase in body mass index (BMI). Tetsurou Sakumoto et al (2010) reported hyperinsulinemia to affect granulose cells in small follicles inducing early response to luteinising hormone and anovulation. Adverse effect on endometrial function and implantation was also postulated. Insulin resistance has been studied in cases of PCOS but has not been studied in infertile women not fulfilling criteria for diagnosis of PCOS . So the present study was planned

Study design, size, duration

A prospective cohort study was conducted in infertility unit, King George Medical University, Lucknow, India over a period of one year from August 2018 to July 2019. Total 102 women with unexplained infertility were enrolled. Ethical clearance was obtained from institutional ethical committee

Participants/materials, setting, methods

Women with PCOS; diminished ovarian reserve documented by antral follicle count &lt;7 and anti Mullerian hormone &lt; 1.1ng/ml; bilateral tubal block; abnormal semen analysis; untreated hypothyroidism, hyperprolactinaemia; known diabetes were excluded. All women underwent ovulation induction with clomiphene citrate followed by single intrauterine insemination. Homeostasis model assessment insulin resistance index (HOMA IR) was calculated

HOMA-IR = Fasting S. Glucose (mg/dl) x Fasting insulin (µlU) / 405.

Value ≥ 2 denoted insulin resistance

Main results and the role of chance

: IR was identified in 21/102 (20.5%) cases. Fasting insulin levels were in the range of 5 – 9.9 mIU/ml in 53/102 women; &lt;5mIU/ml in 29 and &gt;10mIU/ml in 20. Fasting insulin &gt; 9.45mIU/ml was found to have 90.5% sensitivity and 96.3% specificity in predicting insulin resistance. None of the cases had abnormal fasting and post prandial plasma glucose levels. IR was seen to be significantly correlated with BMI &gt; 25kg/m2 (p = 0.0018) and waist hip ratio of &gt; 0.85 (p = 0.0024).All women had follicular development and follicle rupture irrespective of presence of IR. Women with IR were more likely to have monofollicular development (17/21 IR cases). Correlation of endometrial thickness with IR was not seen. Mean endometrial thickness was 8.9mm. There were 6 pregnancies among the 102 women studied. None of the women with IR conceived.

So IR was found to be affecting one fifth of women with unexplained infertility. Failure of any woman with IR to conceive was significant but the finding needs to be further studied.

Limitations, reasons for caution

: It was a small study with only 102 cases and the women were followed for only one cycle of ovulation induction and intrauterine insemination so results need to be validated in a larger study with a longer follow up.

Wider implications of the findings: If further larger studies corroborate the role of IR in women with unexplained infertility it could elucidate the possibility of using insulin sensitisers in management of such cases. IR may emerge as an important gamechanger in management of unexplained infertility.

Trial registration number

Not applicable

Selvam MK. P–011 Automated sperm morphology assessment using artificial intelligence technology

Study question

Can LensHooke X1 PRO semen analyzer be used to evaluate sperm morphology in men with infertility?

Summary answer

Morphology results generated by X1 PRO are highly reliable when normal sperm forms are ≥4% and therefore they can be reported in such cases .

What is known already

Most laboratories rely on manual evaluation of sperm morphology smears, which is a time-consuming procedure and its results are subjected to a relatively high variability. However, in recent years the computer-assisted semen analyzers are being increasingly used to evaluate sperm morphology. The X1 PRO semen quality analyzer was designed for in vitro diagnostic use to analyze sperm concentration, total, progressive and non-progressive motility as well as sperm morphology based on WHO 5th edition criteria. Evaluation of sperm morphology using X1 PRO based on AIOM (Artificial Intelligence Optical Microscopic)-based technology requires no fixation steps or staining unlike the manual method.

Study design, size, duration

This cross-sectional study used 31 semen samples from 8 normozoospermic healthy volunteers and 5 infertile men with a minimum abstinence period between 2 - 3 days. While the 8 healthy semen donors produced a total of 26 ejaculates, which were split into 88 aliquots, the 5 infertile patients produced 5 ejaculates that were split into 13 aliquots.

Participants/materials, setting, methods

A total of 101 aliquots were prepared from the native semen samples either by dilution or concentration using seminal plasma of the respective donors. Automated semen analysis was performed by the X1 PRO semen analyzer and the results of sperm morphology were compared with manual morphology results using Diff-Quik staining. Statistical analysis was carried out to calculate the positive predictive value (PPV) and negative predictive value (NPV) of X1 PRO semen analyzer.

Main results and the role of chance

The X1 PRO sperm morphology results show a weak non-significant (P = 0.2441) correlation (r = 0.119) with the manual results. However, X1 PRO demonstrated a high PPV (97.7%) and a low NPV (9.1%) for correct assessment of sperm morphology (≥4%) when compared to manual results. Due to its high PPV, laboratories can report the morphology results generated by X1 PRO in all such cases when normal sperm forms are ≥4%. However, a manual evaluation is necessary in patients with abnormal morphology (&lt;4%).

Limitations, reasons for caution

One of the limitation of this study is that X1 PRO morphology values did not correlate with manual results. The low NPV seen in our study is due to the inclusion of very few samples with abnormal sperm forms (&lt;4%) in the analysis.

Wider implications of the findings: The X1 PRO’s combination of speed, ease of use, accuracy and portability makes it a good choice of device for small medical offices to large IVF centers. High PPV of X1 PRO allows it to correctly identify normal sperm forms for diagnostic use.

Trial registration number

18–771

An experimental investigation to model wheezing in lungs

A quarter of the world's population experience wheezing. These sounds have been used for diagnosis since the time of the Ebers Papyrus (ca 1500 BC). We know that wheezing is a result of the oscillations of the airways that make up the lung. However, the physical mechanisms for the onset of wheezing remain poorly understood, and we do not have a quantitative model to predict when wheezing occurs. We address these issues in this paper. We model the airways of the lungs by a modified Starling resistor in which airflow is driven through thin, stretched elastic tubes. By completing systematic experiments, we find a generalized 'tube law' that describes how the cross-sectional area of the tubes change in response to the transmural pressure difference across them. We find the necessary conditions for the onset of oscillations that represent wheezing and propose a flutter-like instability model for it about a heavily deformed state of the tube. Our findings allow for a predictive tool for wheezing in lungs, which could lead to better diagnosis and treatment of lung diseases.

Organoid microphysiological system preserves pancreatic islet function within 3D matrix

Three-dimensional (3D) multicellular organoids recapitulate the native complexities of human tissue better than traditional cellular monolayers. As organoids are insufficiently supported using standard static culture, microphysiological systems (MPSs) provide a key enabling technology to maintain organoid physiology in vitro. Here, a polydimethylsiloxane-free MPS that enables continuous dynamic culture and serial in situ multiparametric assessments was leveraged to culture organoids, specifically human and rodent pancreatic islets, within a 3D alginate hydrogel. Computational modeling predicted reduced hypoxic stress and improved insulin secretion compared to static culture. Experimental validation via serial, high-content, and noninvasive assessments quantitatively confirmed that the MPS platform retained organoid viability and functionality for at least 10 days, in stark contrast to the acute decline observed overnight under static conditions. Our findings demonstrate the importance of a dynamic in vitro microenvironment for the preservation of primary organoid function and the utility of this MPS for in situ multiparametric assessment.

Fetal ventricular strain in uncomplicated and selective growth-restricted monochorionic diamniotic twin pregnancies and cardiovascular response in pre-twin-twin transfusion syndrome

OBJECTIVES

Our primary aim was to confirm whether intertwin discordance in ventricular strain and ductus venosus (DV) time intervals predicts twin-twin transfusion syndrome (TTTS). Secondary aims were to create gestational-age ranges for ventricular strain in uncomplicated monochorionic diamniotic (MCDA) twin pregnancies without selective intrauterine growth restriction (sIUGR) and to characterize the relationship of ventricular strain with gestational age in MCDA twin pregnancies with sIUGR that did not develop TTTS.

METHODS

In the period 2015-2018, we enrolled 150 MCDA twin pregnancies consecutively into this prospective, blinded study of global longitudinal left and right ventricular strain. With the observer blinded to twin pairing and pregnancy outcome, videoclips of the four-chamber view, which had been recorded during ultrasound surveillance in the usual window for development of TTTS (16-26 completed gestational weeks), underwent offline measurement of strain. Uncomplicated MCDA twin pregnancies, without sIUGR, were used to test the association between strain, gestational age and estimated fetal weight using mixed-effects multilevel regression. Inter-rater reliability was tested in 208 strain measurements in 31 fetuses from pregnancies which did not develop TTTS and within-fetus variation was assessed in 16 such fetuses, in which multiple four-chamber views were taken on the same day. The effect of sIUGR on strain in otherwise uncomplicated MCDA twin pregnancy was analyzed. MCDA twin pregnancies were defined as 'pre-TTTS' when, having been referred for TTTS evaluation, they did not satisfy Quintero staging criteria, but subsequently developed TTTS requiring laser treatment. MCDA pregnancies which did not develop TTTS comprised the 'non-TTTS' group. Cardiovascular parameters measured in these cases included tissue Doppler parameters and DV early filling time as a percentage of the cardiac cycle (DVeT%). Intertwin strain and DVeT% discordance was compared between non-TTTS and pre-TTTS cases, matched for gestational age.

RESULTS

Paired strain data were available for intertwin comparison in 127/150 MCDA twin pregnancies, comprising 14 pre-TTTS and 113 non-TTTS pregnancies, after exclusions. Scans were collected at a median frame rate of 97 (range, 28-220) Hz. Laser therapy was performed at a median gestational age of 20.6 (range, 17.2-26.6) weeks. There were no group differences in right (RV) or left (LV) ventricular strain discordance between 68/113 non-TTTS and 13/14 pre-TTTS MCDA twin pregnancies < 20 completed gestational weeks (RV, P = 0.338; LV, P = 0.932). DVeT% discordance > 3.6% was found in eight of 13 pre-TTTS pregnancies. In non-TTTS pregnancies, the estimated variability in ventricular strain within each twin during the day was high (RV, 19.7; LV, 12.9). However, within each pair (intertwin variation), variability was low (RV, 5.5; LV, 2.9). Interclass correlation reflecting the proportion of total variability represented by the variability between twin pairs was low (RV, 0.22; LV, 0.18). Both RV (P < 0.001) and LV (P = 0.025) strain showed a negative association with gestational age. Among non-TTTS MCDA twin pregnancies, LV strain was, on average, higher by 1.83 in sIUGR compared with normally grown fetuses (P = 0.023), with no statistically significant difference in RV strain (P = 0.271).

CONCLUSIONS

Although ventricular strain has been reported previously as a possible predictor of developing TTTS, in this blinded, prospective study, we found no significant intergroup differences in ventricular strain in pre-TTTS compared with age-matched non-TTTS MCDA twin pregnancies. We recommend using DVeT% discordance as a more practical screening tool in MCDA twin pregnancies. This study also provides new information on the changes with gestational age, and the biological and technical variation, of global longitudinal ventricular strain in uncomplicated MCDA twin pregnancies and those with isolated sIUGR. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.