AB0737 MEASUREMENT PROPERTIES OF RADIOGRAPHIC OUTCOME MEASURES IN PSORIATIC ARTHRITIS: A SYSTEMATIC REVIEW FROM THE GRAPPA-OMERACT INITIATIVE

Background:

Structural damage was identified as an important outcome domain in the Psoriatic Arthritis (PsA) Core Domain Set and should be assessed at least once in the development of a new therapeutic.

Objectives:

To conduct a systematic literature review (SLR) to identify studies addressing the measurement properties (MPs) for ROIs and appraise the evidence through the OMERACT Filter 2.1 Framework Instrument Selection Algorithm (OFISA). [1]

Methods:

An SLR was conducted in EMBASE and MEDLINE to identify full-text English studies developing or assessing MPs of ROIs in PsA. Determination of eligibility, data extraction and methodology asssessment were performed by 2 reviewers. MPs were rated according to the ‘Provisional Standards’ and assigned a Red/Amber/White/Green (RAWG) rating (Figure 1). [1, 2]

Results:

3621 references were screened, 531 full-text articles reviewed, and 12 were included (Figure 2). Nine instruments assessing peripheral radiographs and six assessing axial radiographs were identified (Table 1). Three of the nine peripheral radiographic instruments had adequate evidence for reliability and some evidence for construct validity: the modified Steinbrocker, Ratingen, and modified Sharp van der Heijde scores. There was scant evidence for reliability, construct validity and responsiveness for the axial ROIs, compounded by the lack of a standardized definition of axial PsA.

Conclusion:

This SLR summarizes the MPs of ROIs and identifies relevant knowledge gaps that need to be addressed prior to endorsement of an instrument for the PsA Core Domain Set.

References:

[1]Richards P and De Wit M, editors. The OMERACT Handbook (March 2019)

[2]Mokkink LB and D’Agostino MA. Protocol for performing a systematic review on imaging techniques (unpublished)

Figure 1.

Criteria for the RAWG Rating

Figure 2.

PRISMA Diagram

Table 1.

Summary of Measurement Properties

ROIDomain MatchFeasibilityConstruct ValidityDiscriminationReliabilityResponsivenessInter-raterIntra-raterMeasurement ErrorLongitudinal Construct ValidityClinical Trial DiscriminationThresholds of MeaningOriginal Steinbrocker ScoreA[1]A[1]R[1]Modified Steinbrocker Score#G[2]G[2]A[1]A[2]Modified Larsen ScoreA[1]A[1]A[1]*Ratingen Score#A[1]G[3]G[3]A[3]A[1]mTSS-AA[1]A[1]A[1]mTSS-B#A[1]A[1]A[1]A[1]*mSvdHs#A[2]G[2]G[2]A[1]A[1]*ReXPsAR[0]SPARS#A[1]A[1]A[1]Axial PsA Definition 1MSASSS#A[2]R[0]BASRI - Total#A[2]R[0]PASRI#A[2]R[0]Axial PsA Definition 2MSASSS#A[1]R[1]A[1]A[1]BASRI - Spine#R[1]A[1]A[1]PASRI#A[1]A[1]A[1]Modified NYC#R[1]A[1]RASSS#R[1]A[1]A[1]

A = Amber, R = Red, G = Green

[Total available studies for synthesis following excluding studies with poor methodology]

* RCT data available but no published effect sizes

# Feasibility data available

Disclosure of Interests:

Anna Antony: None declared, Richard Holland: None declared, Wieneke Mokkink: None declared, Maria-Antonietta d’Agostino: None declared, Walter P Maksymowych Grant/research support from: Received research and/or educational grants from Abbvie, Novartis, Pfizer, UCB, Consultant of: WPM is Chief Medical Officer of CARE Arthritis Limited, has received consultant/participated in advisory boards for Abbvie, Boehringer, Celgene, Eli-Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, UCB, Speakers bureau: Received speaker fees from Abbvie, Janssen, Novartis, Pfizer, UCB., Heidi Bertheussen: None declared, Lori Schick: None declared, Niti Goel Shareholder of: UCB and Galapagos, Consultant of: VielaBio, Mallinckrodt, and IMMVention, Alexis Ogdie Grant/research support from: Pfizer, Novartis, Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Janssen, Lilly, Pfizer, Novartis, Ana-Maria Orbai Grant/research support from: Abbvie, Eli Lilly and Company, Celgene, Novartis, Janssen, Horizon, Consultant of: Eli Lilly; Janssen; Novartis; Pfizer; UCB. Ana-Maria Orbai was a private consultant or advisor for Sun Pharmaceutical Industries, Inc, not in her capacity as a Johns Hopkins faculty member and was not compensated for this service., Pil Hoejgaard: None declared, Laura C Coates: None declared, Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Robin Christensen: None declared, Ying Ying Leung Speakers bureau: Novartis, Janssen, Eli Lilly, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, William Tillett Grant/research support from: AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer Inc, UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc, UCB, Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc, UCB

AB0794 CLINICAL TRIAL DISCRIMINATION OF PHYSICAL FUNCTION INSTRUMENTS FOR PSORIATIC ARTHRITIS: A SYSTEMATIC REVIEW

Background:

Physical function is a core domain to be measured in randomized controlled trials (RCTs) of psoriatic arthritis (PsA). The discriminative performance of patient reported outcome measures (PROMs) for physical function (PF) in RCTs has not been evaluated systematically.

Objectives:

In this systematic review, the GRAPPA-OMERACT working group aimed to evaluate the clinical trial discrimination of PF-PROMs in PsA RCTs.

Methods:

We searched PubMed and Scopus databases in English to identify all original RCTs conducted in PsA. We limited the review to RCTs of biologic and targeted synthetic DMARDs. Groups of two researchers extracted data independently for PF-PROMs. We assessed quality in each article using the OMERACT good method checklist. Effect sizes (ES) for the PF-PROMs were calculated and appraised usinga priorihypotheses. Evidence supporting clinical trial discrimination for each PF-PROM was summarized to derive recommendations.

Results:

32 articles were included (Figure 1). Four PF-PROMs had data for evaluation: HAQ-Disability Index (DI), HAQ-Spondyloarthritis (S), Short Form 36-item Health Survey Physical Component Summary (SF-36 PCS), and the Physical Functioning domain (SF-36 PF) (Table 1). The ES for intervention versus (vs.) control arms for HAQ-DI ranged from -0.55 to -1.81 vs. 0.24 to -0.52; and for SF-36 PCS ranged from 0.30 to 1.86 vs. -0.02 to 0.63.

Table 1.

Summary of Measurement Properties Table for clinical trial discrimination

ArticlesHAQ-DIHAQ-SSF-36 PCSSF-36 PFAntoni 2005 (IMPACT); Gottlieb 2009 (UST)+Antoni 2005 (IMPACT2)++Kavanaugh 2006 (IMPACT2)+Mease 2005 (ADEPT); Genovese 2007 (ADA); Mease 2010 (ETN); Kavanaugh 2009 (GO-REVEAL); Kavanaugh 2017 (GO-VIBRANT); Gladman 2014 (RAPID-PsA); Mease 2015 (FUTURE1); McInnes 2015 (FUTURE2); Kavanaugh, 2016 (FUTURE2)-subgroup; Nash 2018 (FUTURE3); Mease 2017 (SPIRIT-P1); Nash 2017 (SPIRIT-P2); Deodhar 2018 (GUS); Mease 2016 (CLZ)++Mease 2000 (ETN); McInne, 2013 (PSUMMIT 1); Ritchlin 2014 (PSUMMIT 2); Araugo 2019 (ECLIPSA)++Gniadecki 2012 (PRESTA)+Mease 2019 (SEAM-PsA)+/-+McInnes 2014 (SEC)++Mease 2014 (BRO)++Mease 2011 (ABT)+/-+Mease 2017 (ASTRAEA)++Mease 2006 (ALC)+/-Mease 2017 (OPAL Broaden); Gladman 2017 (OPAL Beyond)++Mease 2018 (EQUATOR)++Mease 2018 (ABT-122)+Total available articles311244Total articles for evidence synthesis291232Overall rating+++

Color code in each box indicate study quality by OMERACT good methods. GREEN: “likely low risk of bias”; AMBER: “some cautions but can be used as evidence”; RED: “don’t use as evidence”. WHITE (empty boxes): absence of information from that study. (+): findings had adequate performance of the instrument; (+/-): equivocal performance; (-): poor performance (less than adequate).

Conclusion:

Clinical trial discrimination was supported for HAQ-DI and SF-36 PCS in PsA with low risk of bias; and for SF-36 PF with some caution. More studies are required for HAQ-S.

Disclosure of Interests:

Ying Ying Leung Speakers bureau: Novartis, Janssen, Eli Lilly, Richard Holland: None declared, Ashish Mathew: None declared, Christine Lindsay Employee of: Previously employed (worked) for pharmaceutical company., Niti Goel Shareholder of: UCB and Galapagos, Consultant of: VielaBio, Mallinckrodt, and IMMVention, Alexis Ogdie Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, BMS, Eli Lilly, Novartis, Pfizer, Takeda – consultant, Ana-Maria Orbai Grant/research support from: Abbvie, Eli Lilly and Company, Celgene, Novartis, Janssen, Horizon, Consultant of: Eli Lilly; Janssen; Novartis; Pfizer; UCB. Ana-Maria Orbai was a private consultant or advisor for Sun Pharmaceutical Industries, Inc, not in her capacity as a Johns Hopkins faculty member and was not compensated for this service., Pil Hoejgaard: None declared, Jeffrey Chau: None declared, Laura C Coates: None declared, Vibeke Strand: None declared, Dafna D Gladman Grant/research support from: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – grant/research support, Consultant of: AbbVie, Amgen Inc., BMS, Celgene Corporation, Janssen, Novartis, Pfizer, UCB – consultant, Robin Christensen: None declared, William Tillett: None declared, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau

0042 Stroke Volume and Cardiac Index are Differentially Altered by Total Sleep Deprivation and Psychological Stress in Resilient vs. Vulnerable Individuals and Predict Cognitive Performance

Introduction

Individuals show robust resilience and vulnerability in neurobehavioral performance to sleep loss and stress. For the first time, we investigated the time course of two cardiovascular measurements, stroke volume (SV) and cardiac index (CI), both derived from echocardiography, across baseline, total sleep deprivation (TSD), the combination of TSD+psychological stress, and recovery. We also determined whether these variables differ in resilient vs. vulnerable individuals and whether they predict differential vulnerability in cognitive performance.

Methods

Thirty-one healthy adults (ages 27–53; mean±SD, 35.4±7.1y; 14 females) participated in a five-day experiment consisting of two 8h time-in-bed (TIB) baseline nights, 39h TSD, and two 8h-10h TIB recovery nights. A modified Trier Social Stress Test (TSST) was conducted on the TSD day to induce psychological stress. Echocardiographic measures of SV and CI were obtained at six time points (pre-study, baseline, during TSD, during TSD after the TSST, after recovery, and post-study). A median split of TSD performance [total lapses (>500 ms response time) and errors] on the 10-minute Psychomotor Vigilance Test (PVT), defined cognitively resilient (n=15) and vulnerable (n=16) groups. Repeated measures ANOVA and post-hoc comparisons corrected for multiple testing, examined SV and CI across time points between groups.

Results

There was a significant time*group interaction for SV: cognitively resilient individuals had greater SV during the five-day experiment. In addition, in both resilient and vulnerable individuals, SV increased with TSD and with TSD+psychological stress compared with baseline. Like SV, there was a significant time*group interaction for CI: resilient individuals had greater CI at all points of the experiment.

Conclusion

SV and CI differed between resilient and vulnerable individuals across TSD, psychological stress and recovery sleep. Greater SV and greater CI at baseline predicted resilience to TSD and TSD+psychological stress. CI and SV are novel physiological biomarkers of sleep loss, stress, and individual differences in cognitive performance.

Support

NASA NNX14AN49G.

1100 Self-Monitoring Of PVT Performance In Healthy Adults And Individuals With MDD

Introduction

Negativity bias in depression has been repeatedly demonstrated in the judgment and decision-making literature. Research investigating the impact of sleep deprivation on self-evaluation of performance in healthy or depressed populations is limited. We examined 1) whether individuals with Major Depressive Disorder (MDD) exhibit a negativity bias in subjective ratings of performance on the Psychomotor Vigilance Task (PVT) as compared with healthy adults, and 2) the impact of total sleep deprivation (TSD) on these ratings.

Methods

N=33 individuals with MDD and n=9 healthy adults completed a 5-day study protocol including two baseline nights (B1-B2, 9h TIB), 36 hours of TSD, and one night of recovery sleep opportunity (Rec). The PVT was administered every 2-4 hours. A brief questionnaire was administered immediately prior to (PRE) and following (POST) the PVT, asking participants to estimate their average reaction time (RT) using a 9-point Likert-type scale. Mixed-effects models examined the impact of group (MDD, Control), protocol day (B1, B2, SD, Rec), and their interaction on objective PVT performance (mean RT) and subjective performance estimates (PRE and POST ratings).

Results

Mean RT was significantly slower during TSD (p<0.001) for all participants. Individuals with MDD and healthy adults did not differ in objective PVT performance (p=0.25) across days. There was no significant interaction between group and protocol day (p=0.96). Both groups predicted slower RTs during TSD as compared with baseline or recovery days (PRE-PVT, p=0.006). Individuals with MDD anticipated slower RTs as compared with healthy adults (p=0.001). On POST-PVT estimates, all participants reported subjective poorer performance during TSD (p<0.008). Individuals with MDD reported slower RTs as compared with healthy adults (p=0.002). Interaction effects between group and protocol day on PRE- and POST- performance ratings were not significant.

Conclusion

This project is the first to investigate subjective estimates of PVT performance in healthy and depressed individuals. Individuals with MDD subjectively reported slower response times as compared with control participants, despite similar objective performance. Depressive symptoms may be a potential confounder of subjective, but not objective, PVT performance.

Support

5R01MH107571

0041 Heart Rate Variability Differs in Resilient vs. Vulnerable Adults from Total Sleep Deprivation and Psychological Stress and Predicts Cognitive Performance

Introduction

There are substantial individual differences (resilience and vulnerability) in neurobehavioral performance from psychosocial stress and sleep loss. However, the time course of heart rate variability (HRV) across baseline, total sleep deprivation (TSD), the combination of TSD + psychological stress, and recovery has not been investigated; in addition, it remains unknown whether HRV and blood pressure (BP) differ in resilient vs. vulnerable individuals and predict individual differences in cognitive performance.

Methods

Thirty-one healthy adults (ages 27–53; mean±SD, 35.4±7.1y; 14 females) participated in a five-day experiment consisting of two 8h time-in-bed (TIB) baseline nights, 39h TSD, and two 8h-10h TIB recovery nights. A modified Trier Social Stress Test (TSST) induced psychological stress on the TSD day. Systolic and diastolic BP and HRV (derived from echocardiographic R-R interval) were obtained at six time points (pre-study, baseline, during TSD, during TSD after the TSST, after recovery, and post-study). Cognitively resilient (n=15) and vulnerable (n=16) groups were defined by a median split on 10-minute Psychomotor Vigilance Test (PVT) TSD performance [total lapses (>500ms response time) and errors]. Repeated measures ANOVA and post-hoc comparisons corrected for multiple testing, examined BP and HRV across time points between groups.

Results

HRV showed a significant time*group interaction: while resilient individuals had significantly lower HRV at pre-study compared to vulnerable individuals, their HRV increased above that of vulnerable individuals with TSD and with TSD + psychological stress. By contrast, systolic and diastolic BP did not show significant time*group interactions and did not predict cognitive vulnerability during TSD.

Conclusion

HRV differed between resilient and vulnerable individuals across TSD, psychological stress and recovery sleep and predicted individual differences in cognitive performance, whereby lower HRV during full-rested conditions predicted resilience to TSD and TSD + psychological stress. HRV, but not BP, is a reliable biomarker of sleep deprivation, psychological stress, and neurobehavioral vulnerability.

Support

NASA NNX14AN49G.

0364 Sex and Race Influence Objective and Self-Report Sleep and Circadian Measures in Emerging Adults at Risk for Bipolar Spectrum Disorder

Introduction

There is a critical need to understand key factors that impact sleep and circadian rhythm function for emerging adults at risk for bipolar spectrum disorder (BSD). Sex and race are common demographic factors contributing to differences in health outcomes; however, the influence of these variables on sleep and circadian rhythm patterns for emerging adults at risk for BSD has not been characterized.

Methods

Multiple objective and self-report facets of sleep and circadian function, including dim light melatonin onset (DLMO), and measures derived from actigraphy and sleep diaries, were assessed in a 20-day ecological momentary assessment (EMA) study of 150 emerging adults (mean ± SD, 21.8 ± 2.1y; 58.7% female; 57.9% White, 23.4% Black, 10.3% Asian or Pacific Islander, 8.0% Other ethnicity) at-risk for BSD. Bivariate Pearson correlations (two-tailed, p <.05) were conducted between the sleep and circadian measures. ANCOVAs, controlling for BSD status, were conducted to evaluate differences on sleep and circadian characteristics by sex and race.

Results

Males exhibited better actigraphic sleep efficiency and later DLMO phase than females, whereas females exhibited more actigraphic discrete sleep periods. White participants exhibited more actigraphy-measured total sleep time, better sleep efficiency, and fewer sleep periods, and self-reported more total sleep time and better sleep efficiency than Black participants.

Conclusion

We show for the first time that sex and race are significant predictors of objective and self-reported sleep and circadian rhythm measures in a large sample of emerging adults at risk for BSD participating in an EMA study. Our findings extend the existing literature to a novel clinical population and to a naturalistic setting and inform ongoing research on sex and racial health disparities in sleep and circadian rhythms.

Support

This work was supported by NIH R01 MH77908 and R01 MH102310; a Banting Postdoctoral Fellowship from the Social Sciences and Humanities Research Council; and a National Science Foundation Graduate Student Research Fellowship.

0265 Cortisol and C-Reactive Protein Fail to Predict Individual Differences in Neurobehavioral Performance Responses to Total Sleep Deprivation and Psychological Stress

Introduction

Individuals show marked differential vulnerability in neurobehavioral deficits from psychosocial stress and sleep deprivation. Although changes in salivary cortisol and C-reactive protein (CRP) typically occur across total sleep deprivation (TSD) and recovery sleep, whether these biological markers during fully rested conditions predict individual differences in cognitive performance during TSD and stress remains unknown.

Methods

Thirty-one healthy adults (ages 27–53; mean ± SD, 35.4 ± 7.1y; 14 females) participated in a five-day experiment consisting of two 8h time-in-bed (TIB) baseline nights, followed by 39h TSD, and two 8h-10h TIB recovery nights. A modified Trier Social Stress Test (TSST) was conducted on the day of TSD to induce psychological stress. Salivary cortisol and CRP from blood were obtained at six time points during the study (pre-study, baseline, during TSD, during TSD after the TSST, after recovery, and post-study). A median split of TSD performance [total lapses (>500 ms response time) and errors] on the 10-minute Psychomotor Vigilance Test (PVT) defined cognitively resilient (n=15) and cognitively vulnerable (n=16) groups. Repeated measures ANOVA and post-hoc comparisons corrected for multiple testing, examined cortisol and CRP across time points between groups.

Results

In both cognitively resilient and vulnerable individuals, cortisol increased with TSD compared to baseline in the morning and decreased with TSD + psychological stress in the afternoon compared to TSD alone. By contrast, there were no significant changes in CRP levels throughout the experiment. In addition, there were no significant time*group interactions in cortisol or CRP levels.

Conclusion

Salivary cortisol increased with TSD compared to baseline and showed a time-of-day effect with stress during TSD. Notably, cortisol and CRP did not differ between cognitively resilient and vulnerable individuals across TSD, psychological stress or recovery sleep and thus are not reliable biomarkers for predicting performance under these conditions.

Support

NASA NNX14AN49G.

1020 Sleep and Glycemic Control in Adults With Long-Standing Type 1 Diabetes and Hypoglycemia Unawareness

Introduction

Nocturnal hypoglycemia is life threatening for individuals with type 1 diabetes (T1D) due to loss of hypoglycemia symptom recognition (hypoglycemia unawareness) and impaired glucose counterregulation. These individuals also show disturbed sleep, which may result from glycemic dysregulation. Whether use of a hybrid closed loop (HCL) insulin delivery system with integrated continuous glucose monitoring (CGM) designed for improving glycemic control, relates to better sleep across time in this population remains unknown.

Methods

Six adults (median age=58y,T1D duration=41y) participated in an 18-month ongoing clinical trial assessing the effectiveness of an HCL system. Sleep and glycemic control were measured concurrently using wrist actigraphs and CGM at baseline (1 week) and months 3 and 6 (3 weeks) following HCL initiation. BMI and hemoglobin A1c (HbA1c) were collected at all timepoints. Spearman’s correlations modeled associations between sleep, BMI, and glycemic control at each time point. Repeated ANOVAs modeled sleep and glycemic control changes from baseline to 3 months and to 6 months.

Results

Sleep and glycemic control indices showed significant associations at baseline and 3 months. More time-in-bed and later sleep offset related to higher HbA1c levels at baseline. Later sleep onset, midpoint and offset, and greater sleep efficiency associated with greater %time with hyperglycemia (glucose >180 mg/dL) or hypoglycemia (glucose <70 mg/dL) at baseline and 3 months. Longer sleep duration and greater sleep efficiency related to greater %time with hyperglycemia at 3 months. At 3 months, more wake after sleep onset associated with lower HbA1c levels and longer nocturnal awakenings and more sleep fragmentation associated with less glycemic variability. While both sleep and glycemic control improved from baseline to 3 and 6 months, these were not statistically significant.

Conclusion

Various dimensions of actigraphic sleep related to concurrently estimated glycemic indices indicative of poorer glycemic control and HbA1c across time in adults with long-standing T1D and hypoglycemia unawareness.

Support

This work was supported by NIH R01DK117488 (NG), R01DK091331 (MRR), and K99NR017416 (SKM).

Fungal fibrosing mediastinitis in pregnancy - Case report with review of literature

Fibrosing mediastinitis (FM) is characterized by extensive and invasive fibro-inflammatory proliferation, triggered by a delayed hypersensitivity reaction to variety of infective or noninfective stimuli. The infective agents often have a geographic distribution such as Histoplasma capsulatum in North America and Mycobacterium tuberculosis in Asian regions. In few reports, the mediastinitis is caused by fungi, particularly Aspergillus species. We report the first case of possible aspergillous FM in a young pregnant woman.

A Comparison of the Reliability of the Patellar Tendon-Trochlear Groove (PTTG) Distance and the Tibial Tuberosity-Trochlear Groove (TTTG) Distance Measured on MRI

Introduction:

An increased tibial tuberosity-trochlear groove (TTTG) distance is used for deciding a treatment plan in patello-femoral instability (PFI). The centre of the patellar tendon and the chondral trochlear groove can be directly visualised on MRI, and measured, giving the patellar tendon-trochlear groove (PTTG) distance. A study was designed to compare the inter-rater and the test-retest reliabilities of PTTG and TTTG measurements in MRI of patients without PFI and in a group with PFI.

Materials and Methods:

This cross-sectional reliability study was done on archival MRI films of 50 patients without patellar instability and 20 patients with patellar instability. TTTG and PTTG distances were independently measured by two orthopaedic surgeons and two radiologists. A hybrid PTTG measurement with bony landmarks on the femoral side and the patellar tendon landmark on the tibial side, was used to estimate the influence of the differences in the femoral and tibial landmarks on the difference in reliabilities. The intra-class correlation coefficient (ICC) was calculated for all four raters, as well as separately for each rater.

Results:

The PTTG distance had a higher inter-rater reliability (ICC=0.86, 95% CI=0.79-0.92) compared to the TTTG distance (ICC=0.70, 95% CI=0.59-0.80) in patients without PFI. Similar trends were seen in patients with PFI (0.83 vs 0.66). The inter-rater reliability for the hybrid PTTG distance was found to lie in between the TTTG and PTTG.

Conclusions:

The MRI-based PTTG distance had better inter-rater reliability compared with the MRI-based TTTG distance.

Screening for early onset neonatal sepsis: NICE guidance-based practice versus projected application of the Kaiser Permanente sepsis risk calculator in the UK population

OBJECTIVE

To compare management recommendations of the National Institute for Health and Care Excellence (NICE) guidelines with the Kaiser Permanente sepsis risk calculator (SRC) for risk of early onset neonatal sepsis (EONS).

DESIGN

Multicentre prospective observational projection study.

SETTING

Eight maternity hospitals in Wales, UK.

PATIENTS

All live births ≥34 weeks gestation over a 3-month period (February-April 2018).

METHODS

Demographics, maternal and infant risk factors, infant's clinical status, antibiotic usage and blood culture results from first 72 hours of birth were collected. Infants were managed using NICE recommendations and decisions compared with that projected by SRC.

MAIN OUTCOME MEASURE

Proportion of infants recommended for antibiotics on either tool.

RESULTS

Of 4992 eligible infants, complete data were available for 3593 (71.9%). Of these, 576 (16%) were started on antibiotics as per NICE recommendations compared with 156 (4.3%) projected by the SRC, a relative reduction of 74%. Of the 426 infants avoiding antibiotics, SRC assigned 314 (54.6%) to normal care only. There were seven positive blood cultures-three infants were recommended antibiotics by both, three were not identified in the asymptomatic stage by either; one was a contaminant. No EONS-related readmission was reported.

CONCLUSION

The judicious adoption of SRC in UK clinical practice for screening and management of EONS could potentially reduce interventions and antibiotic usage in three out of four term or near-term infants and promote earlier discharge from hospital in >50%. We did not identify any EONS case missed by SRC when compared with NICE. These results have significant implications for healthcare resources.

Iron deficiency in non-anemic chronic obstructive pulmonary disease in a predominantly male population: an ignored entity

Non-anemic iron deficiency has been studied in heart failure, but studies are lacking in chronic obstructive pulmonary disease (COPD). The potential clinical implications of association of iron deficiency with the severity of COPD warrant research in this direction. This was an observational, cross-sectional study on patients with COPD to compare disease severity, functional status and quality of life in non-anemic patients with COPD between two groups - iron deficient and non-iron deficient. Stable non-anemic COPD with no cause of bleeding were evaluated for serum iron levels, ferritin levels, TIBC, 6MWD, SGRQ, spirometry, and CAT questionnaire. The study patients were divided into iron replete (IR) and iron deficient (ID) groups. A total of 79 patients were studied, out of which 72 were men and seven were women. The mean age was 61.5±8.42 years. Of these, 36 (45.5%; 95% CI, 34.3-56.8%) had iron deficiency. Mean 6-minute-walk distance was significantly shorter in ID (354.28±82.4 meters vs 432.5±47.21 meters; p=0.001). A number of exacerbations in a year were more in ID group (p=0.003), and more patients in ID had at least two exacerbations of COPD within a year (p=0.001). However, the resting pO2, SaO2, and SpO2 levels did not differ significantly between the two groups (p=0.15 and p=0.52, respectively). Also, there was no significant difference in the distribution of patients of a different class of airflow limitations between the two groups. Non-anemic iron deficiency (NAID) is an ignored, yet easily correctable comorbidity in COPD. Patients with iron deficiency have a more severe grade of COPD, had lesser exercise capacity and more exacerbations in a year as compared to non-iron deficient patients. So, foraying into the avenue of iron supplementation, which has shown promising results in improving functional capacity in heart failure and pulmonary hypertension, may well lead to revolutionary changes in the treatment of COPD.

Neurocritical care of high-risk infants during inter-hospital transport

The centralisation of neonatal intensive care in recent years has improved mortality, particularly of extremely preterm infants, but similar improvements in morbidity, such as neurodevelopmental impairment, have not been seen. Integral to the success of centralisation are specialised neonatal transport teams who provide intensive care prior to and during retrieval of high-risk neonates when in-utero transfer has not been possible. Neonatal retrieval aims to stabilise the clinical condition and then transfer the neonate during a high-risk period for patient. Transport introduces the hazards of noise and vibration; acceleration and deceleration forces; additional handling and temperature fluctuations. The transport team must stabilise the infant fully prior to transport as when on the move they are limited by space and movement to effectively attend to clinical deterioration. Inborn infants have better neurodevelopmental outcome compared with the outborn and aetiology of this seems to be multifactorial with the impact of transport itself during critical illness, remaining unclear. To improve the neurological outcomes for transported infants, it seems imperative to integrate the advancing intensive care neuromonitoring tools into the transport milieu. This review examines current inter-hospital transport neuromonitoring and how new modalities might be applied to the neurocritical care delivered by specialist transport teams.

Trisomy 13 and 18-Prevalence and mortality-A multi-registry population based analysis

The aim of the study is to determine the prevalence, outcomes, and survival (among live births [LB]), in pregnancies diagnosed with trisomy 13 (T13) and 18 (T18), by congenital anomaly register and region. Twenty-four population- and hospital-based birth defects surveillance registers from 18 countries, contributed data on T13 and T18 between 1974 and 2014 using a common data-reporting protocol. The mean total birth prevalence (i.e., LB, stillbirths, and elective termination of pregnancy for fetal anomalies [ETOPFA]) in the registers with ETOPFA (n = 15) for T13 was 1.68 (95% CI 1.3-2.06), and for T18 was 4.08 (95% CI 3.01-5.15), per 10,000 births. The prevalence varied among the various registers. The mean prevalence among LB in all registers for T13 was 0.55 (95%CI 0.38-0.72), and for T18 was 1.07 (95% CI 0.77-1.38), per 10,000 births. The median mortality in the first week of life was 48% for T13 and 42% for T18, across all registers, half of which occurred on the first day of life. Across 16 registers with complete 1-year follow-up, mortality in first year of life was 87% for T13 and 88% for T18. This study provides an international perspective on prevalence and mortality of T13 and T18. Overall outcomes and survival among LB were poor with about half of live born infants not surviving first week of life; nevertheless about 10% survived the first year of life. Prevalence and outcomes varied by country and termination policies. The study highlights the variation in screening, data collection, and reporting practices for these conditions.

Improved Value for the Gamow-Teller Strength of the ^{100}Sn Beta Decay

A record number of ^{100}Sn nuclei was detected and new isotopic species toward the proton dripline were discovered at the RIKEN Nishina Center. Decay spectroscopy was performed with the high-efficiency detector arrays WAS3ABi and EURICA. Both the half-life and the β-decay end point energy of ^{100}Sn were measured more precisely than the literature values. The value and the uncertainty of the resulting strength for the pure 0^{+}→1^{+} Gamow-Teller decay was improved to B_{GT}=4.4_{-0.7}^{+0.9}. A discrimination between different model calculations was possible for the first time, and the level scheme of ^{100}In is investigated further.