Seroprevalence of SARS-CoV-2 among potential convalescent plasma donors and analysis of their deferral pattern: Experience from tertiary care hospital in western India

Background and objectives

Seroprevalence estimation of COVID-19 is quite necessary for controlling the transmission of SARS-CoV-2 infection. Seroprevalence rate in recovered COVID-19 patients help us to identify individual with anti-SARS-CoV-2 antibodies and its protective nature. The objective of present study was to evaluate seroprevalence of SARS-CoV-2 among potential convalescent plasma donors and analysis of their deferral reasons.

Materials and methods

A total 400 potential convalescent plasma donors were enrolled over five-month period for this prospective study. Inclusion criteria were lab confirmed COVID-19 recovered patients and 14 days of symptoms free period. All prospective plasmapheresis donors were tested for IgG SARS-CoV-2 antibody through chemiluminescent microparticle immunoassay, CBC, serum protein, blood grouping along with other required test for normal blood donation as per Drugs & Cosmetics Act. After pre donation testing and medical examination if donor was found to be ineligible for plasmapheresis was deferred. Seroprevalence rate was calculated by positive IgG antibody test results among the potential plasma donors.

Results

Seroprevalence rate was 87% for IgG SARS-CoV-2 antibodies in prospective convalescent plasma donors (recovered COVID-19 patients). There was no significant difference in seroprevalence rate between different sub-groups with respect to gender, age, blood groups, Rh factor, mode of treatment, day of Ab testing and repeat plasma donation. Most common reason for their deferral was absent IgG SARS-CoV-2 antibodies (13%) followed by absenteeism of eligible screen donors (6.7%), low Hb (1.7%) and poor veins for plasmapheresis (1.7%). Till five-month study period none of the plasmapheresis develop symptoms of reinfection with COVID-19.

Conclusion

In all, 13% recovered patients did not develop IgG antibodies after SARS-CoV-2 infection. SARS-CoV-2 IgG antibodies persist for quite some time and are protective against reinfection. More long-term serology studies are needed to understand better antibody response kinetics and duration of persistence of IgG antibodies.

Patients 80 + have similar medication initiation rates to those aged 50-79 in Ontario FLS

Among individuals presenting to an Ontario FLS, we compared bone active medication initiation rates of patients 80 years and older with those 50-79 years old. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates between the two age groups INTRODUCTION: A Fracture Liaison Service (FLS) offers post-fracture services to individuals over the age of 50 years and could potentially address age inequities in pharmacotherapy often observed for older adults. Among individuals presenting to an Ontario FLS and classified as being at high risk for future fracture, our objective was to compare bone active medication initiation rates of patients 80 years and older with those 50-79 years old.

METHODS

In 39 FLS fracture clinics across Ontario, Canada, fracture prevention coordinators identified, assessed, and facilitated the referral of eligible patients for bone densitometry, fracture risk assessment, and implementation of pharmacotherapy in patients classified as high risk for future fracture. Variables assessed at baseline included age, sex, marital status, living location, fracture location, history of previous fracture, parent's history of hip fracture, history of falls, and fracture risk status. At 6 months, bone active medication initiation was assessed in patients classified as high risk for future fracture. The Chi-square test of independence was used to compare medication initiation rates between patients 80 + and those 50-79 years old.

RESULTS

Our sample size consisted of 808 patients aged 50-79 years and 346 aged 80 + years. After accounting for fracture risk status, there was no statistically significant difference in medication initiation rates of patients 50-79 and 80 + years old (76.9% versus 73.7%, p = 0.251).

CONCLUSION

A systematic approach to identifying patients at high risk for future fracture and tailoring treatment recommendations to these patients appeared to eliminate differences in treatment initiation rates based on older age.

Increased concentration of serum gamma-glutamyl transferase in ischemic stroke patients

BACKGROUND:

Stroke is responsible for the largest proportion of neurological disorders causing a significant morbidity. Gamma-glutamyl transferase (GGT) enzyme has an active involvement in atherosclerosis through its role in oxidative and inflammatory mechanisms. Recent evidence suggests that serum GGT is related to the risk and prognosis of cerebrovascular diseases.

METHODS:

A total of 200 patients (100 with acute ischemic stroke and 100 without stroke) were recruited from various medical wards and medical intensive care unit. Categorical variables were compared between two groups using Chi-squared test and odds ratio (OR). Independent sample t-test was used to see to compare mean GGT level of stroke patients with control.

RESULTS:

There was no statistical difference with respect to distribution of age groups (χ² = 1.25, P = 0.741) and gender (χ² = 2.678, P = 0.1018) between cases and controls. Mean age of stroke patients (mean [M] = 61.7, standard deviation [SD] = 13.8) did not differ from controls (M = 62.2, SD = 13.6), P = 0.80. The odds of suffering from diabetes were significantly higher in stroke patients than cases (OR = 2.25, P = 0.005). Independent sample t-test found a significant difference in serum GGT level between cases (M = 57.47, SD = 11.8) and control (M = 41.72, SD = 7.5), P ≤ 0.0001.

CONCLUSIONS:

Serum GGT was significantly higher in stroke patients than age-sex-matched nonstroke patients. Association remained significant in stroke patients irrespective of age, gender, and other risk factors. Stroke patients with diabetes, hypertension, dyslipidemia, obesity, and smoking had higher level serum GGT level than those without these risk factors. Prospective cohort studies can further explore the potential of GGT as a predictor of acute ischemic stroke.

Intriguing role of novel ionic liquids in stochastic degradation of chitosan

Green technique for hydrolysis of chitosan was developed using novel Brønsted Acidic Ionic Liquids (BAILs) as homogenous reusable catalysts. Efficiency of BAILs in controlling stochastic and irregular breakdown of chitosan was compared with that of mineral acids. Structural elucidation of the novel BAILs was performed using H¹-NMR evaluation and supplemented using mass spectroscopy. Additionally, thermal characterization was conducted using TGA-DTA analysis, while acidity was estimated by deriving the Hammet acidity function. BAILs investigated in this work enabled consistent production of LMWCS variants, with minimum formation of residual impurities. Around 80 % reduction in molecular weight was noted as compared to original under extreme conditions employed. Further, Box-Behnken Design (BBD) was implemented to optimize effect of processing parameters for conversion of chitosan to low molecular weight congeners.

Sleep problems in opioid dependent patients maintained on buprenorphine

Introduction

Opioid dependent individuals frequently complain of sleep problems in withdrawal and during abstinence.

Objectives

The objectives were to assess the subjective sleep parameters among buprenorphine-maintained opioid-dependent patients and to correlate it with socio-demographics, concomitant drug use and treatment related variables

Methods

Using a cross-sectional study design, 106 hundred six opioid-dependent patients maintained on buprenorphine for at least six months and on same dose in past month were interviewed. Sleep was assessed by Pittsburgh sleep quality index (PSQI) and Epworth sleepiness scale. Association between subjective sleep parameters, socio-demographics, concomitant drug use and treatment related variables was also studied.

Results

All participants were males. Their mean age was 41.1 years (SD:14.3). The mean duration of illicit opioid use was 10 years (IQR: 5,22). About 63.2% (n=67) had PSQI scores more than 5 denoting sleep problem. The scores obtained in Epworth Sleeping Scale were in normal range. Mean subjective total sleep time of the sample was 403.5 (SD 94.8) minutes and median sleep latency was 35 (IQR 18.8, 62.5) minutes. Subjective total sleep time was significantly higher in participants who had use tobacco in the past three months (p value=0.03) and who were in moderate ASSIST risk category (p value=0.04). Subjective sleep latency was significantly higher (p value=0.04) in participants who had used opioids in last three months. It was observed that age was a significant predictor of subjective total sleep time and OST compliance was a significant predictor of sleep latency.

Conclusions

A sizeable proportion of opioid dependent patients on buprenorphine have sleep problems

A99 OPTIMIZING COLONOSCOPY PROCEDURES AND REDUCING PATIENT ANXIETY THROUGH RECENTLY DEVELOPED ONLINE INFORMATION RESOURCES

Background

Invasive medical procedures such as colonoscopies are known to cause psychological distress and anxiety. Patient anxiety leads to reduce patient compliance for colonoscopy and increased adverse effects. Patient education prior to colonoscopy has previously been shown to have positive effects on outcomes and experience. Based on patient and provider input, we have developed easy to read written materials and easy to follow video materials, which other patients have rated highly. These, along with other materials, are embedded on Mycolonoscopy.ca. Mycolonoscopy.ca is a website that provides online information access for patients regarding preparation and peri-procedural expectations. Information about accessing the website is provided with appointment materials (which includes information about split-dose versus one day bowel preparation, giving patients the option between the two) mailed to all patients undergoing outpatient colonoscopy in Winnipeg.

Aims

(1) To evaluate the current use of mycolonoscopy.ca among patients undergoing colonoscopy (2) To determine whether there is an association between visitation to the website and patient outcomes such as reduction in procedural anxiety, bowel preparation tolerance/compliance, and bowel preparation score.

Methods

A paper-based survey was given out to patients at their colonoscopy appointments. Univariate and multivariate logistic regression analyses was performed to determine the factors associated with website visitation and association with procedural anxiety, bowel preparation compliance and bowel preparation scores.

Results

A total of 593 participants were given the surveys, of which 506 were completed. 17.4% of participants had visited the website prior to their colonoscopy. Visitors to mycolonoscopy.ca and those that had heard of the website were more likely to consume a split-dose bowel preparation (63.9% and 68.2% respectively) compared with non-visitors (52.5%) (p=0.0062). Individuals who consumed split-dose bowel preparation had a median Boston bowel preparation score of 9, compared with a score of 7 for individuals who used other forms of preparation (p<0.0001). 31.3% of website visitors were very or extremely worried about their colonoscopy compared with 17.9% of non-visitors. 76.6% of individuals agreed or strongly agreed that visiting the website helped them prepare for their colonoscopy and 69.7% who visited the website agreed or strongly agreed that it helped to reduce their stress/anxiety for the procedure as well.

Conclusions

Our study suggests that use of an informative online platform such as mycolonoscopy.ca can help to improve patient education prior to colonoscopy, reduce anxiety and stress surrounding the procedure, and improve bowel preparation compliance and bowel cleansing score.

Funding Agencies

CAG

Gender-affirming hormone therapy in cystic fibrosis - A case of new Pseudomonas infection

Background

Little is known about the impact of hormone therapy on transgender youth with Cystic Fibrosis (CF). This case report describes an 18-year-old affirmed female with CF who was treated with hormone therapy associated in timing with new growth of Pseudomonas aeruginosa in her sputum culture.

Discussion

We highlight important considerations, including the impact of gender-affirming hormone therapy on overall CF disease course. Evidence supports that females with CF have worse outcomes than males, which are partly attributed to estrogen effects. Pseudomonas aeruginosa is one of the most prevalent pathogens in people with CF. Here, we highlight a transfemale who grows Pseudomonas aeruginosa for the first time since her youth, nearly 1 year after starting estrogen therapy. This is consistent with previous literature of an association between high estrogen levels and Pseudomonas aeruginosa prevalence, but has never been evaluated in a transgender population.

Conclusion

Through this case, we demonstrate the need for additional research to understand the relationship between gender-affirmative hormone transition and CF care and management.

Serial Imaging of Virus-Associated Necrotizing Disseminated Acute Leukoencephalopathy (VANDAL) in COVID-19

BACKGROUND AND PURPOSE

Various patterns of leukoencephalopathy have been described in coronavirus disease 2019 (COVID-19). In this article, we aimed to describe the clinical and imaging features of acute disseminated leukoencephalopathy in critically ill patients with COVID-19 and the imaging evolution during a short-term follow-up.

MATERIALS AND METHODS

We identified and reviewed the clinical data, laboratory results, imaging findings, and outcomes for 8 critically ill patients with COVID-19 with acute disseminated leukoencephalopathy.

RESULTS

All patients demonstrated multiple areas of white matter changes in both cerebral hemispheres; 87.5% (7/8) of patients had a posterior predilection. Four patients (50%) had short-term follow-up imaging within a median of 17 days after the first MR imaging; they developed brain atrophy, and their white matter lesions evolved into necrotizing cystic cavitations. All (8/8) patients had inflammatory cytokine release syndrome as demonstrated by elevated interleukin-6, D-dimer, lactate dehydrogenase, erythrocyte sedimentation rate, C-reactive protein, and ferritin levels. Most (7/8; 87.5%) patients were on prolonged ventilator support (median, 44.5 days; interquartile range, 20.5 days). These patients had poor functional outcomes (6/8 [75%] patients were discharged with mRS 5) and high mortality (2/8, 25%).

CONCLUSIONS

Critically ill patients with COVID-19 can develop acute disseminated leukoencephalopathy that evolves into cystic degeneration of white matter lesions with brain atrophy during a short period, which we dubbed virus-associated necrotizing disseminated acute leukoencephalopathy. This may be the result of COVID-19-related endothelial injury, cytokine storm, or thrombotic microangiopathy.

Practical consensus recommendations regarding role of mastectomy in metastatic breast cancer

Whether to recommend mastectomy in metastatic disease or not has been a matter of debate. Is local therapy, such as mastectomy, of any benefit in advanced breast cancer is the main question. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Probing synergistic interplay between bio-inspired peptidomimetic chitosan-copper complexes and doxorubicin

The current investigation reports a novel and facile method for modification of low molecular weight chitosan (Cs) with guanidine moieties, aimed at enhancing its cellular interaction and thus augmenting its cellular internalization. Guadinylated chitosan-copper (Cs-Gn-Cu) chelates, based on copper-nitrogen co-ordination, were established. Characterization of chelates was conducted using ¹H NMR, ¹³C NMR, XPS, XRD, TGA-DTA, and GPC techniques. Anticancer activity of formed chelates was confirmed against A549 cells using MTT assay. Experimental outcomes, for the first time, have provided an empirical evidence for synergistic interaction between the chelated polymer (Cs-Gn-Cu) and the established anti-cancer agent, Doxorubicin (Dox), based on analysis by the Chou Talalay method and estimation of their combination indices. ROS induction was demonstrated as the mechanism of action of the chelated polymer, which supplemented rapid destruction of cancerous cells by Dox. These findings strongly advocate the need for harnessing unexplored potential of these innovative metal polymer chelates in cases of Dox resistant lung cancer, wherein the polymeric system itself would serve as an anti-cancer agent.

Reducing admission hypothermia in newborns at a tertiary care NICU of northern India: A quality improvement study

BACKGROUND

Hypothermia at admission to neonatal intensive care units (NICU) is associated with increased morbidity and mortality in newborns. A baseline study at a tertiary care hospital with all out-born babies showed admission hypothermia of 82%.

OBJECTIVE

To reduce admission hypothermia (moderate) in newborns at least by 50% in next 6 months.

METHODS

A quality improvement (QI) study was planned using WHO Point of Care Quality Improvement Model (POCQI), [17] using PDSA (Plan-Do-Study-Act) cycle approach from April 2018 to March 2019, and including 427 term and preterm babies. We educated the staff, reinforced the use of caps, cling wraps, warm linen, introduced Ziploc bags and ensured adequate use of transport incubator.

RESULTS

After 6 months, overall admission hypothermia decreased from 82% to 45%, moderate hypothermia reduced from 46% to <10% (P < 0.001) and severe hypothermia (3%) was completely eliminated. There was also significant reduction in incidence of Intraventricular hemorrhage (13% Vs 4.7%), Late onset neonatal sepsis (38% Vs 19%) and metabolic acidosis (43% Vs 28%). We were able to sustain this improvement for the next 6 months and is ongoing. The strongest predictor of hypothermia was newborns being in the phase before QI initiative was started (OR 2.36, 95% CI 1.47, 3.23).

CONCLUSION

This study is a cost effective approach in reducing admission hypothermia in NICU in a resource limited setting with all outborn babies, and further decreasing the morbidity associated with it. Hence, emphasizing the importance of maintaining euthermia, not only in delivery rooms, but also during transportation.

Few fragility fracture patients perceive that their bone health is affected by their comorbidities and medications

We examined fragility fracture patients' perceptions of associations between bone health and other chronic conditions and medications. Awareness of the associations between bone health and these conditions and medications was low. Providers should increase patients' awareness of these associations in order to minimize the risk of future fracture.

INTRODUCTION

Among patients with a fragility fracture presenting with at least one other chronic health condition, we examined (1) perceptions of the association between bone health and their other health conditions, and (2) perceptions of the association between bone health and prescribed medications taken for other health conditions.

METHODS

We identified fragility fracture patients presenting to a Canadian urban fracture clinic with at least one self-reported chronic health condition (in addition to bone fragility). In-depth interviews, 60-90 min in duration, were conducted. Our qualitative methodology was informed by saliency analysis.

RESULTS

We interviewed 26 patients (21 females, 5 males) aged 45 to 84 years old. Participants were taking 1-13 medications each and presented with a variety of comorbidities (range 1-7). All participants described at least one condition or medication they were currently taking for which there existed evidence of a negative effect on bone health (increased risk of fracture, bone loss, falling). Two participants perceived a correct association between their other health conditions and compromised bone health, and four participants perceived a correct association between their medications and compromised bone health.

CONCLUSION

All patients reported a chronic health condition and/or were taking at least one medication that potentially compromised their bone health. Patient awareness of the association between bone health and other health conditions and prescribed medications was low. Health care providers should increase patients' awareness of the bone health significance of their chronic conditions and medications in order to minimize the risk of future fracture.

Association of Preoperative Hemoglobin A1c with In-hospital Mortality Following Valvular Heart Surgery

Objective

To determine the association between the preoperative level of hemoglobin A1c (HbA1c) and in-hospital mortality in patients who underwent valvular heart surgery in our center in a retrospective cohort.

Methods

In this retrospective consecutive cohort study, patients with type 2 diabetes mellitus who were referred to our center for elective valvular surgery were enrolled and followed up. The endpoint of this study was in-hospital mortality. Based on the level of HbA1c, patients were dichotomized around a level of 7% into two groups: exposed patients with HbA1c ≥ 7% and unexposed patients with HbA1c < 7%. Then, the study variables were compared between the two groups.

Results

Two hundred twenty-four diabetic patients who were candidates for valvular surgery were enrolled; 106 patients (47.3%) had HbA1c < 7%, and 118 patients (52.6%) had HbA1c ≥ 7%. The duration of diabetes was higher in patients with HbA1c ≥ 7% (P=0.007). Thirteen (5.8%) patients died during hospital admission, of which nine patients were in the high HbA1c group. There was no significant difference between the groups regarding in-hospital mortality (P=0.899). Both the unadjusted and adjusted logistic regression models showed that HbA1c was not a predictor for in-hospital mortality (P=0.227 and P=0.388, respectively)

Conclusion

This study showed no association between preoperative HbA1c levels and in-hospital mortality in candidates for valvular heart surgery.

Maslinic acid differentially exploits the MAPK pathway in estrogen-positive and triple-negative breast cancer to induce mitochondrion-mediated, caspase-independent apoptosis

Breast cancer accounts for 1.4 million new cases every year. Triple-negative breast cancer (TNBC) is one the leading cause of mortality in developing countries and is associated with early age onset (under 40 years old). Chemotherapy has a poor success rate in patients with TNBC as compared to other types of breast cancers. It is due to the lack of expression of three validated molecular markers for breast cancer, the estrogen and progesterone receptors, and the amplification of HER-2/Neu. Therefore, a clear need exists for a greater understanding of TNBC at all levels and for the development of better therapies. We have studied the anti-tumor effects of a potential drug, maslinic acid, which can be extracted from olive oil industry waste. This natural product showed inhibitory effect at concentrations ranging from 30 to 50 µM within 24 h. It exhibited divergent effects in cell cycle progression for the MCF7 (estrogen positive) cell line when compared with TNBCs like MDA-MB-231 and MDA-MB-468. Also, maslinic acid treatment altered the mitochondrial membrane electrochemical potential and the reactive oxygen species (ROS) levels to cause a caspase-independent programmed cell death. In silico approaches and immunoblotting suggested the involvement of the MAPK pathway explaining the variability in cell cycle progression along with the apoptotic cell death caused by maslinic acid.

Educational booklet reinforces knowledge of osteoporosis and influences intentions to improve bone health in previously diagnosed and treated patients

We examined individuals' experiences using an educational booklet developed by the Ontario Osteoporosis Strategy. The booklet appeared to motivate individuals to make changes to their existing management of their bone health and served as a reference tool reaffirming current practices and beliefs for others.

INTRODUCTION

The purpose of this study was to examine individuals' experiences of the educational booklet and explore the influence of the booklet on individuals' beliefs and actions regarding their bone health.

METHODS

Eligible individuals were those who had been prescribed medication to treat low bone mass. One-on-one telephone interviews were conducted over an 18-month period. Participants were interviewed for approximately 1 hour and asked to provide their feedback on the booklet, and to discuss what they were doing with respect to the recommendations made in the booklet.

RESULTS

We interviewed 50 participants who ranged in age from 58 to 89. The overall impression of the booklet was positive. Participants described the language in the booklet as clear and easy to understand. Participants stated that they would have appreciated receiving this tool at the onset of their diagnosis. Forty-two participants had already taken action, or expressed an intention to make changes, to their existing routines to improve their bone health. In contrast, eight participants used the booklet to reaffirm current practices and beliefs. For these individuals, the recommendations made in the booklet were consistent with what they had already been doing.

CONCLUSION

The booklet can engage patients in discussions about bone health. The booklet appeared to motivate individuals to make changes to their existing routines in an effort to achieve better health outcomes for their bone health. Providing a tool like this to people recently diagnosed with a bone health issue may prove to be beneficial.

Diagnosis and principles of management of gestational diabetes mellitus in the prevailing COVID-19 pandemic

BACKGROUND

Limited medical facilities are available due to Covid-19 pandemic. Nevertheless, all efforts should be made in planning judicial and possible methods of delivering health care, particularly to pregnant woman with GDM. GDM may play a crucial role in the increasing prevalence of diabetes and obesity and also may be the origin of cardiometabolic diseases.

METHODS

It is mandatary to diagnose and care pregnant woman with GDM. The test suggested to diagnose GDM has to be evidence based and in this regard "a single test procedure" evaluated meets this requirement. This doable test has been accepted by the Diabetes in Pregnancy Study Group India (DIPSI) and approved by MHFW-GOI, WHO, International Diabetes Federation, and International Federation of Obstetricians and Gynecologists. MHFW-GOI also recommends testing at first antenatal visit and then at 24-28 weeks of gestation. This opportunity can also be utilized for performing ultrasonography for assessing fetal development.

RESULT

The first-line management is MNT and life style modifications. Non-responders may require insulin or OHA. The target glycemic control is FPG ~ 5.0 mmol/dl (90 mg/dl) and 2 h PPPG ~ 6.7 mmol/dl (120 mg/dl). The goal is to obtain newborns birth weight appropriate for gestational age between 2.5 and 3.5 kg, a step to prevent offspring developing diabetes.

CONCLUSION

The essential precaution required during COVID pandemic is to wear face mask, avoid crowded places, and maintain social distancing. Finally, the economical and evidence based "single test procedure" of DIPSI is most appropriate for screening during the COVID pandemic.

Cerebral Venous Thrombosis Associated with COVID-19

Despite the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. We report a unique series of young patients with COVID-19 presenting with cerebral venous system thrombosis. Three patients younger than 41 years of age with confirmed Severe Acute Respiratory Syndrome coronavirus 2 (SARS-Cov-2) infection had neurologic findings related to cerebral venous thrombosis. They were admitted during the short period of 10 days between March and April 2020 and were managed in an academic institution in a large city. One patient had thrombosis in both the superficial and deep systems; another had involvement of the straight sinus, vein of Galen, and internal cerebral veins; and a third patient had thrombosis of the deep medullary veins. Two patients presented with hemorrhagic venous infarcts. The median time from COVID-19 symptoms to a thrombotic event was 7 days (range, 2-7 days). One patient was diagnosed with new-onset diabetic ketoacidosis, and another one used oral contraceptive pills. Two patients were managed with both hydroxychloroquine and azithromycin; one was treated with lopinavir-ritonavir. All patients had a fatal outcome. Severe and potentially fatal deep cerebral thrombosis may complicate the initial clinical presentation of COVID-19. We urge awareness of this atypical manifestation.

Surprise Diagnosis of COVID-19 following Neuroimaging Evaluation for Unrelated Reasons during the Pandemic in Hot Spots

During the height of the recent outbreak of coronavirus 19 (COVID-19) in New York City, almost all the hospital emergency departments were inundated with patients with COVID-19, who presented with typical fever, cough, and dyspnea. A small number of patients also presented with either unrelated conditions (such as trauma) or other emergencies, and some of which are now known to be associated with COVID-19 (such as stroke). We report such a scenario in 17 patients who were admitted and investigated with CT spine imaging and CT angiography for nonpulmonary reasons (trauma = 13, stroke = 4). Their initial work-up did not suggest COVID-19 as a diagnosis but showed unsuspected/incidental lung findings, which led to further investigations and a diagnosis of COVID-19.

THU0196 TOFACITINIB IN PATIENTS WITH RHEUMATOID ARTHRITIS AND INDICATIVE OF DEPRESSION AND/OR ANXIETY: A POST HOC ANALYSIS OF PHASE 3 AND PHASE 3B/4 CLINICAL TRIALS

Background:

Depression/anxiety are common in RA pts. SF-36 MCS ≤38 can identify probable major depressive disorder and/or probable generalised anxiety disorder (pMDD/pGAD) in RA pts. Tofacitinib is an oral JAK inhibitor for the treatment of RA.

Objectives:

To assess pMDD/pGAD prevalence in the tofacitinib RA program and efficacy by baseline (BL) pMDD/pGAD status.

Methods:

Data from pts receiving tofacitinib, ADA, or PBO were pooled from 5 Phase (P)3 and 1 P3b/4 trials. Demographics/BL characteristics were reported by BL pMDD/pGAD (SF-36 MCS ≤38, presence; >38, absence). Month (M)3/6/9/12 SF-36 MCS change from BL (Δ) was estimated, and % with pMDD/pGAD reported. M3/6/12 efficacy outcomes compared tofacitinib-treated pts by BL pMDD/pGAD.

Results:

BL pMDD/pGAD was seen in 44.5% (tofacitinib 5 mg BID), 39.8% (tofacitinib 10 mg BID), 45.4% (ADA 40 mg Q2W) and 39.1% (PBO) of pts. pMDD/pGAD pts had higher BL CRP and worse disability, fatigue, pain and sleep vs pts without. SF-36 MCS increases were greater for tofacitinib vs PBO/ADA (Fig 1a). The % of pts with BL pMDD/pGAD who continued to have pMDD/pGAD reduced over time, and was generally lower for tofacitinib vs PBO/ADA (Fig 1b). Regardless of BL pMDD/pGAD, efficacy was generally similar for tofacitinib 5 mg BID (Table) and 10 mg BID.

Conclusion:

~40% of RA pts had BL pMDD/pGAD. SF-36 MCS improvements were greater for tofacitinib vs PBO/ADA. With tofacitinib, % of pts with SF-36 MCS ≤38 reduced by ~60% at M12. Tofacitinib efficacy was similar in pts with/without BL pMDD/pGAD. Limitations include using SF-36 MCS to identify probable rather than confirmed MDD or GAD. Future research using gold standard psychiatric interviews to validate use of SF-36 MCS ≤38 is needed.

Table.

M3/6/12 efficacy with tofacitinib 5 mg BID, by BL pMDD/pGADa

SF-36 MCS ≤38SF-36 MCS >38OR (95% CI)P valueACR20 (%)b,cM355.157.90.89 (0.74, 1.08)0.2330M661.762.80.96 (0.79, 1.16)0.6511M1258.458.60.99 (0.80, 1.22)0.9279ACR50 (%)b,cM325.929.20.85 (0.70, 1.03)0.1022M636.038.00.92 (0.76, 1.11)0.3724M1233.834.30.98 (0.80, 1.20)0.8366ACR70 (%)b,cM310.111.00.91 (0.69, 1.18)0.4704M616.516.51.00 (0.79, 1.26)0.9901M1218.317.51.06 (0.83, 1.34)0.6560DAS28-4(ESR)<2.6 (%)b,cM35.47.40.72 (0.49, 1.05)0.0872M65.98.50.68 (0.49, 0.94)0.0199*M128.011.90.64 (0.47, 0.89)0.0073**ΔHAQ-DI, LS meanc,dSF-36 MCS ≤38SF-36 MCS >38Difference (95% CI)P valueM3-0.41-0.430.01 (-0.04, 0.06)0.6008M6-0.49-0.48-0.01 (-0.06, 0.04)0.6617M12-0.52-0.52-0.01 (-0.06, 0.05)0.8475

*p<0.05; **p<0.01 Data pooled from 5 P3 and 1 P3b/4 tofacitinib trialsaBL pMDD/pGAD = SF-36 MCS ≤38;bLogistic regression fit;cFor PBO pts advancing to tofacitinib post-M3, only PBO data were included;dMixed-effects linear model fit

Δ, change from baseline; ACR, American College of Rheumatology; BID, twice daily; BL, baseline; CI, confidence interval; DAS28-4(ESR), Disease Activity Score in 28 joints, erythrocyte sedimentation rate; HAQ-DI, Health Assessment Questionnaire-Disability Index; LS, least squares; M, month; MCS, Mental Component Summary score; OR, odds ratio; P, Phase; pGAD, probable generalised anxiety disorder; PBO, placebo; pMDD, probable major depressive disorder; pt, patient; RA, rheumatoid arthritis; SF-36, Short Form-36 health survey

Acknowledgments:

Study sponsored by Pfizer Inc. Medical writing support was provided by Sarah Piggott of CMC Connect and funded by Pfizer Inc.

Disclosure of Interests:

Gustavo Citera Grant/research support from: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Consultant of: AbbVie, Amgen, Eli Lilly, Gema, Genzyme, Novartis and Pfizer Inc, Rakesh Jain Grant/research support from: Allergan, Eli Lilly, Lundbeck, Otsuka, Pfizer Inc, Shire and Takeda, Consultant of: Acadia, Alfasigma, Allergan, Eisai, Eli Lilly, Evidera, Impel, Janssen, Lundbeck, Merck, Neos Therapeutics, Neurocrine Biosciences, Osmotica, Otsuka, Pamlab, Pfizer Inc, Shire, Sunovion, Supernus, Takeda and Teva, Speakers bureau: Alkermes, Allergan, Eli Lilly, Janssen, Lundbeck, Merck, Neos Therapeutics, Neurocrine, Otsuka, Pamlab, Pfizer Inc, Shire, Sunovion, Takeda, Teva and Tris Pharmaceuticals, Fedra Irazoque-Palazuelos Consultant of: Bristol-Myers Squibb, Janssen, Pfizer Inc, Roche and UCB, Renato Guzman: None declared, Hugo Madariaga: None declared, David C Gruben Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lisy Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Lori Stockert Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Ming-Ann Hsu Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Karina Santana Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Abbas Ebrahim Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Dario Ponce de Leon Shareholder of: Pfizer Inc, Employee of: Pfizer Inc

SUN-380 Opportunistic Screening with Abdominal CT in Patients with Diabetes Can Identify Those at High Risk of Osteoporosis and Osteopenia

Background: Diabetes mellitus (DM) increases the risk of fracture at any given bone mineral density (BMD). However, the optimal strategy for osteoporosis screening with DXA is unknown in those with DM. A previously described strategy in the general population known as “Opportunistic Osteoporosis Screening” uses computer tomography (CT) images done for other reasons to assess the attenuation (density) of L1 in Hounsfield units (HU)—this was found to correlate with DXA-derived T-score. However, neither the methodology nor the cut-points have been specifically validated in those with DM. Thus, the goal of this study was to examine the performance of this methodology and define thresholds corresponding with low BMD in those with DM.

Methods: This was retrospective study using electronic medical record data. Patients with DM were identified by ICD code. Those with both abdominal CT and DXA within a 6-month period were included, excluding patients with CKD stage 5, solid organ transplantation, bariatric surgery, or L1 hardware. L1 attenuation, measured by 2 readers on sagittal view, were averaged. A different reader assessed for vertebral fractures. Fractures of the hip, forearm, humerus, and pelvis were identified by ICD code. The lowest T-score of lumbar spine, femoral neck, total hip, or forearm (available in 11 subjects) was used to compare to L1 attenuation. ROC curves were derived from univariate logistic regression.

Results: 320 subjects met study criteria; 10 (3.2%) had vertebral fractures, 8 (2.6%) had prior major non-vertebral fracture, and 33 (10.3%) had osteoporosis by BMD.

The 18 subjects with major fractures had lower T-scores (-2.3 ± 1.4 vs. -0.8 ± 1.4, p<0.001) and lower L1 attenuation (104 ± 46 vs. 149 ± 47 HU, p<0.001). T-score and L1 attenuation had similar discrimination for prior fracture by area under the ROC curve (0.77 vs. 0.76, p=NS). Moderate osteopenia (T-score -1.5 or less) and L1 attenuation of 130 HU or less had identical sensitivities (72.2% for both) and similar specificities (69.2% vs. 62.5%, respectively) for prior fracture.

In regards to L1 attenuation corresponding to DXA diagnosis of osteoporosis, 160 HU was 94% sensitive, while 110 HU was 80% specific. This is similar to the 90% sensitivity for 160 HU and 90% specificity for 110 HU previously reported in the general population. Given higher fracture risk in DM, moderate osteopenia (n=106) was also examined as an outcome: 130 HU was 61% sensitive and 71% specific. This threshold had similar or improved sensitivity and specificity among subgroups of insulin users, men, and women under age 65.

Conclusion: Our results validate the use of opportunistic osteoporosis screening in patients with DM, which could help clinicians decide on the need for screening DXA. Patients with diabetes and L1 attenuation below 130 HU on CT scan should be considered for DXA screening to formally assess the risk of fracture.

Prognostic Value of Preoperative MRI Metrics for Diffuse Lower-Grade Glioma Molecular Subtypes

BACKGROUND AND PURPOSE

Despite the improved prognostic relevance of the 2016 WHO molecular-based classification of lower-grade gliomas, variability in clinical outcome persists within existing molecular subtypes. Our aim was to determine prognostically significant metrics on preoperative MR imaging for lower-grade gliomas within currently defined molecular categories.

MATERIALS AND METHODS

We undertook a retrospective analysis of 306 patients with lower-grade gliomas accrued from an institutional data base and The Cancer Genome Atlas. Two neuroradiologists in consensus analyzed preoperative MRIs of each lower-grade glioma to determine the following: tumor size, tumor location, number of involved lobes, corpus callosum involvement, hydrocephalus, midline shift, eloquent cortex involvement, ependymal extension, margins, contrast enhancement, and necrosis. Adjusted hazard ratios determined the association between MR imaging metrics and overall survival per molecular subtype, after adjustment for patient age, patient sex, World Health Organization grade, and surgical resection status.

RESULTS

For isocitrate dehydrogenase (IDH) wild-type lower-grade gliomas, tumor size (hazard ratio, 3.82; 95% CI, 1.94-7.75; P < .001), number of involved lobes (hazard ratio, 1.70; 95% CI, 1.28-2.27; P < .001), hydrocephalus (hazard ratio, 4.43; 95% CI, 1.12-17.54; P = .034), midline shift (hazard ratio, 1.16; 95% CI, 1.03-1.30; P = .013), margins (P = .031), and contrast enhancement (hazard ratio, 0.34; 95% CI, 0.13-0.90; P = .030) were associated with overall survival. For IDH-mutant 1p/19q-codeleted lower-grade gliomas, tumor size (hazard ratio, 2.85; 95% CI, 1.06-7.70; P = .039) and ependymal extension (hazard ratio, 6.34; 95% CI, 1.07-37.59; P = .042) were associated with overall survival.

CONCLUSIONS

MR imaging metrics offers prognostic information for patients with lower-grade gliomas within molecularly defined classes, with the greatest prognostic value for IDH wild-type lower-grade gliomas.

Is a 'healthy diet' and a 'calcium-rich diet' the same thing? Qualitative study examining perceptions of a calcium-rich diet in individuals who have received bone health education

BACKGROUND

In the present study, we aimed to (i) examine perceptions of achieving calcium and vitamin D recommended dietary allowance (RDA) and (ii) determine how participants talked about food in relation to RDA recommendations.

METHODS

Participants aged ≥50 years who were prescribed osteoporosis medication and received two modes of bone health education were eligible. Relying on a qualitative description design, we interviewed participants 1 month after they had attended an education session and received a self-management booklet. Calcium and vitamin D intakes were estimated by in-depth questions about diet and supplements and compared with perceptions of achieved RDA levels. Interview transcripts were analysed based on an analytic hierarchical process.

RESULTS

Forty-five participants (29 reporting previous fragility fractures) were included. Calcium and vitamin D RDA appeared to be potentially achieved by 64% and 93% of participants, respectively, primarily because of reliance on supplements. Few participants talked about vitamin D in relation to food intake and 49% of participants were unclear about the calcium content of food. Most considered that a healthy diet was equivalent to a calcium-rich diet. We noted no differences in our findings in the subset of individuals with fragility fractures.

CONCLUSIONS

Despite reporting a prescription for osteoporosis medication and receiving bone health education, a substantial number of individuals appeared to have sub-optimal calcium levels. This may be attributed to the challenge of achieving RDA with diet alone and the misconception of a healthy diet as a calcium-rich diet.

Mechanistic insights into controlled depolymerization of Chitosan using H-Mordenite

Kinetics of chitosan depolymerization were studied in dilute acetic acid solution, in presence of H-Mordenite (H-MOR). Rate constants for chitosan depolymerization were determined by measurement of molecular weight, using Gel permeation Chromatography (GPC). Depolymerization rate of chitosan was altered in presence of an acidic, porous material like H-MOR. Maximum concentration of H-MOR studied during process led to minimal increase in energy of activation, from 20.54 kJ/moL to 23.25 kJ/moL. Infra-red spectroscopy, adsorption studies and rheological assessment indicated adsorption /grafting of chitosan onto porous H-MOR surface as the possible mechanism for facilitation of the depolymerization process. Under extreme conditions investigated during process optimization, H-MOR resulted in a three-fold reduction in 5-Hydroxy Methyl Furfural (5-HMF) formation and over ten times decrease in glucosamine content, as compared to reactions conducted without H-MOR. Therefore, presence of H-MOR is imperative to cleave chitosan in controlled manner and obtain products of desired molecular weight, with fewer impurities.

Multiple simultaneous fractures are associated with higher all-cause mortality: results from a province-wide fracture liaison service

Mortality rates in our fracture liaison service ranged from 2.7% at year 1 to 14.8% at year 5 post-screening. Presentation with multiple simultaneous fractures at screening was associated with higher risk of death. This finding indicates the need for increased focus on this high-risk group.

PURPOSE

To examine all-cause mortality rates in a provincial fracture liaison service (FLS) and the association between the index fracture type, particularly multiple simultaneous fractures, and the risk of death at follow-up.

METHODS

This cohort study includes fragility fracture patients aged 50+, enrolled in a provincial FLS in Ontario, Canada, between 2007 and 2010. All-cause mortality was assessed using administrative data. Multivariable Cox proportional hazards model was used to examine the risk of death 5 years after screening.

RESULTS

Crude mortality rates for 6543 fragility fracture patients were 2.7% at year 1, 5.6% at year 2, and 14.8% at year 5 after screening. After adjusting for age and sex, and relative to distal radius fracture, patients with multiple (simultaneous) fractures at screening had a higher risk of dying (HR = 1.8, 95%CI 1.3-2.4), followed by those with a hip fracture (HR = 1.5, 95%CI 1.3-1.8), a proximal humerus fracture (HR = 1.4, 95%CI 1.2-1.7), and other single fractures (HR = 1.4, 95%CI 1.1-1.7). Having an index ankle fracture was not associated with the risk of death over a distal radius fracture. As compared to the 50-65 age group, patients 66 years and older had a higher risk of death (for 66-70 age group: HR = 2.5, 95%CI 1.9-3.3; for 71-80: HR = 4.3, 95%CI 3.5-5.4; and for 81+: HR = 10.6, 95%CI 8.7-13.0). Females had a lower risk of death (HR = 0.5, 95%CI 0.5-0.6) than males.

CONCLUSIONS

Presenting with multiple fractures was an indicator of higher risk of death relative to a distal radius fracture. This finding indicates the need for increased focus on this high-risk group.

When are we Going to Settle the Diagnostic Criteria of Gestational Diabetes Mellitus?

Guidelines to diagnose Gestational Diabetes Mellitus (GDM) have changed a number of times from O'Sullivan and Mahan, Carpenter and Coustan, World Health Organization, American Diabetes Association to that of International Association of Diabetes in Pregnancy Study Group (IADPSG). The IADPSG guideline was based on Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) study which was performed in caucasian population only and thus literally cannot be considered as international. Recently a study commented that this guideline needs revision for standardization of this strategy for diagnosing GDM. Based on a prospective study, Diabetes in Pregnancy Study Group India (DIPSI) recommended A single step procedure of diagnosing GDM with 2hr PG > 140 mg/dl after 75g of oral glucose administered irrespective of the last meal timing. This guideline has been approved by the Ministry of Health Government of India, WHO, IDF and Federation of Gynaecologists and Obstetricians Society (FIGO). National Institute of Clinical Excellence (NICE) also recognises cut off value, 2hr PG > 140 mg/dl based on a study in multi ethnic population of UK. Hence, we can safely conclude, A Single Step procedure has settled the criteria for diagnosing GDM.

P3346Validation of obesity coding among newly-treated nonvalvular atrial fibrillation patients using an integrated electronic medical record and claims database

Background

Obesity is prevalent among patients with non-valvular atrial fibrillation (NVAF). Administrative claims databases offer the opportunity to evaluate obesity and morbid obesity in this patient population. However, there is limited information about the use and accuracy of diagnosis codes in claims data to identify obesity and morbid obesity among patients with NVAF.

Purpose

To evaluate the use and accuracy of diagnosis codes in claims data for identifying obesity and morbid obesity among newly-treated NVAF patients using a large geographically-diverse US database.

Methods

This retrospective study used Optum's de-identified integrated electronic medical record (EMR) and claims database (1/1/2013–3/31/2018). Adult (≥18 years) patients with ≥1 claim for an oral anticoagulant (OAC) from 1/1/2014–9/30/2017 were identified (treatment date as index date). Patients were required to have ≥1 atrial fibrillation diagnosis prior to the index date and were excluded if they had evidence of OAC use or valvular disease during the 12 months prior to the index date. Patients were required to have ≥12 months of continuous enrollment prior to and ≥6 months after the index date as well as ≥1 BMI measurement in the EMR data during the 6 months before or after the index date. Based on the World Health Organization's definition, patients were classified as obese if their BMI was ≥30 kg/m2 and morbidly obese if their BMI was ≥40 kg/m2. Sensitivity, specificity, and positive predictive value (PPV) were calculated to assess the accuracy of diagnosis codes for obesity (ICD-9 diagnosis codes: 278.00, 278.01, 278.03, V85.30-V85.39, V85.41-V85.45; ICD-10 diagnosis codes: E66.01, E66.09, E66.2, E66.8, E66.9, Z68.30-Z68.39, Z68.41-Z68.45) and morbid obesity (ICD-9 diagnosis codes: 278.01, V85.41-V85.45; ICD-10 diagnosis codes: E66.01, E66.2, Z68.41-Z68.45) commonly used in claims database research.

Results

There were 7,501 patients included in the newly-treated NVAF cohort (mean [±SD] age=72.4 [±10.7] years, 55% male, 90% white, and mean [±SD] Quan-Charlson Comorbidity Index =2.10 [±2.08]). Forty-six percent of these patients had BMI≥30 kg/m2, of whom about one-quarter (11% of the overall sample) had a BMI≥40 kg/m2. In contrast, 25% and 10% of patients had a diagnosis code for obesity or morbid obesity, respectively. For obesity diagnosis codes, sensitivity, specificity, and PPV were 49% (95% CI: 47%-50%), 95% (95%-96%), and 90% (88%-91%), respectively. For morbid obesity diagnosis codes, sensitivity, specificity, and PPV were 63% (59%-63%), 96% (96%-97%) and 68% (64%-71%), respectively.

Conclusion

Among newly-treated NVAF patients, obesity diagnosis codes in the claims database had high PPV, high specificity, and modest sensitivity. Morbid obesity diagnosis codes also had high specificity but modest PPV and sensitivity. These findings have implications for both case selection and control for obesity as a confounder in observational studies using a claims database.

Acknowledgement/Funding

The funding for the research project was provided by Pfizer Inc.

OS12.4 In vivo dynamics and targeting of vessel co-option in glioma

BACKGROUND

Gliomas comprise heterogeneous malignant glial and stromal cells. While blood vessel co-option is a potential mechanism to escape anti-angiogenic therapy, the relevance of glial phenotype in this process is unclear.

MATERIAL AND METHODS

Here, we intravitally study preclinical syngenetic models of glioma as well as patient-derived cells transplanted orthotopically. Moreover, we profoundly confirm our preclinical results with histological studies on patient specimens.

RESULTS

We show that Olig2+ oligodendrocyte precursor-like glioma cells invade by single-cell vessel co-option and preserve the blood-brain barrier (BBB). Conversely, Olig2-negative glioma cells form dense perivascular collections and promote angiogenesis and BBB breakdown, leading to innate immune cell activation. Experimentally, Olig2 promotes Wnt7b expression, a finding that correlates in human glioma profiling. Targeted Wnt7a/7b deletion or pharmacologic Wnt inhibition blocks Olig2+ glioma single-cell vessel co-option and enhances responses to temozolomide. Finally, Olig2 and Wnt7 become upregulated after anti-VEGF treatment in preclinical models and patients.

CONCLUSION

Here, we show that glioma is able to employ vessel co-option, i.e. the movement of tumor cells towards and along the pre-existing vasculature.

Glioma oligodendrocyte-like (OPCL) cells express Wnt7 that is necessary for vessel co-option and Wnt inhibitors significantly improve survival with temozolomide. Moreover, we demonstrated that anti-VEGF-treatment of glioma selects for Olig2/Wnt7+ cells

Simvastatin downregulates adipogenesis in 3T3-L1 preadipocytes and orbital fibroblasts from Graves' ophthalmopathy patients

BACKGROUND

Smoking is a strong risk factor for the development of Graves' ophthalmopathy (GO). Immediate early genes (IEGs) are overexpressed in patients with active GO compared to healthy controls. The aim of this study was to study the effects of tobacco smoking and simvastatin on preadipocytes and orbital fibroblasts (OFs) in the adipogenic process.

METHODS

Cigarette smoke extract (CSE) was generated by a validated pump system. Mouse 3T3-L1 preadipocytes or OFs were exposed to 10% CSE with or without simvastatin. Gene expression was studied in preadipocytes and OFs exposed to CSE with or without simvastatin and compared to unexposed cells or cells treated with a differentiation cocktail.

RESULTS

In 3T3-L1 preadipocytes, Cyr61, Ptgs2, Egr1 and Zfp36 expression levels were two-fold higher in cells exposed to CSE than in unexposed cells. Simvastatin downregulated the expression of these genes (1.6-fold, 5.5-fold, 3.3-fold, 1.4-fold, respectively). CSE alone could not stimulate preadipocytes to differentiate. Scd1, Ppar-γ and adipogenesis were downregulated in simvastatin-treated preadipocytes compared to nontreated preadipocytes 18-, 35- and 1.7-fold, respectively. In OFs, similar effects of CSE were seen on the expression of CYR61 (1.4-fold) and PTGS2 (3-fold). Simvastatin downregulated adipogenesis, PPAR-γ (2-fold) and SCD (27-fold) expression in OFs.

CONCLUSION

CSE upregulated early adipogenic genes in both mouse 3T3-L1 preadipocytes and human OFs but did not by itself induce adipogenesis. Simvastatin inhibited the expression of both early and late adipogenic genes and adipogenesis in preadipocytes and human OFs. The effect of simvastatin should be investigated in a clinical trial of patients with GO.

Five-year refracture rates of a province-wide fracture liaison service

We examined the 5-year refracture rate of 6543 patients and found an overall rate of 9.7%. Adjusted analysis showed that presenting with multiple fractures was an indicator of a higher refracture risk; while presenting with an ankle fracture was associated with a lower refracture risk.

INTRODUCTION

To examine refractures among patients screened in a province-wide fracture liaison service (FLS).

METHODS

We assessed the 5-year refracture rate of fragility fracture patients aged 50+ who were screened at 37 FLS fracture clinics in Ontario, Canada. Refracture was defined as a new hip, pelvis, spine, distal radius, or proximal humerus fracture. Kaplan-Meier curves and Cox proportional hazards model adjusting for age, sex, and index fracture type were used to examine refracture rates.

RESULTS

The 5-year refracture rate of 6543 patients was 9.7%. Those presenting with multiple fractures at baseline (i.e., two or more fractures occurring simultaneously) had the highest refracture rate of 19.6%. As compared to the 50-65 age group, refracture risk increased monotonically with age group (66-70 years: HR = 1.3, CI 95%, 1.0-1.7; 71-80 years: HR = 1.7, CI 1.4-2.1; 81+ years: HR = 3.0, CI 2.4-3.7). Relative to distal radius, presenting with multiple fractures at screening was associated with a higher risk of refracture (HR = 2.3 CI 1.6-3.1), while presenting with an ankle fracture was associated with a lower risk of refracture (HR = 0.7 CI 0.6-0.9). Sex was not a statistically significant predictor of refracture risk in this cohort (HR = 1.2, CI 1.0-1.5).

CONCLUSIONS

One in ten patients in our cohort refractured within 5 years after baseline. Presenting with multiple fractures was an indicator of a higher refracture risk, while presenting with an ankle fracture was associated with a lower refracture risk. A more targeted FLS approach may be appropriate for patients at a higher refracture risk.

The clinical implications of computerised fluid dynamic modelling in rhinology

BACKGROUND

The nose is a dynamic organ and is the first point of contact between inhaled air and mucosal surfaces. Within the nasal cavity, there are changes of air flow and pressure occurring during the respiratory cycle, as well as exchanges of heat and humidity, and important immune responses to inhaled antigens and allergens.

METHODOLOGY

This review is a summary for rhinologists covering what is known about airflow within the nose and sinuses and the impact of pathology and treatments on the physical environment of the nasal cavity. The review will concentrate largely on the significant contribution that computational fluid dynamics has had on this field.

RESULTS

The complex anatomical structure of the nasal cavity provides an aerodynamic environment that guides the airflow throughout the nasal cavities. However, anatomical or inflammatory changes can modify the air flow, heat and humidity exchanges, with negative consequences on nasal physiology. Restoration of normal airflow is a key goal to achieve success in the treatment of nasal diseases.

CONCLUSIONS

Computational fluid dynamics is a method of analysis originating from engineering which has been adapted for rhinology. Although still an expensive and laborious technique, it may become a viable diagnostic tool in the future for studying nasal physiology.

Extent of Surgical Resection in Lower-Grade Gliomas: Differential Impact Based on Molecular Subtype

BACKGROUND AND PURPOSE

Diffuse lower-grade gliomas are classified into prognostically meaningful molecular subtypes. We aimed to determine the impact of surgical resection on overall survival in lower-grade glioma molecular subtypes.

MATERIALS AND METHODS

For 172 patients with lower-grade gliomas (World Health Organization grade II or III), pre- and postsurgical glioma volumes were determined using a semiautomated segmentation software based on FLAIR or T2-weighted MR imaging sequences. The association of pre- and postsurgical glioma volume and the percentage of glioma resection with overall survival was determined for the entire cohort and separately for lower-grade glioma molecular subtypes based on isocitrate dehydrogenase (IDH) and 1p/19q status, after adjustment for age, sex, World Health Organization grade, chemotherapy administration, and radiation therapy administration.

RESULTS

For the entire cohort, postsurgical glioma volume (hazard ratio, 1.80; 95% CI, 1.18-2.75; P = .006) and the percentage of resection (hazard ratio, 3.22; 95% CI, 1.79-5.82; P < .001) were associated with overall survival. For IDH-mutant 1p/19q-codeleted oligodendrogliomas, the percentage of resection (hazard ratio, 6.69; 95% CI, 1.57-28.46; P = .01) was associated with overall survival. For IDH-mutant 1p/19q-noncodeleted astrocytomas, presurgical glioma volume (hazard ratio, 3.20; 95% CI, 1.22-8.39; P = .018), postsurgical glioma volume (hazard ratio, 2.33; 95% CI, 1.32-4.12; P = .004), and percentage of resection (hazard ratio, 4.34; 95% CI, 1.74-10.81; P = .002) were associated with overall survival. For IDH-wild-type lower-grade gliomas, pre-/postsurgical glioma volume and percentage of resection were not associated with overall survival.

CONCLUSIONS

The extent of surgical resection has a differential survival impact in patients with lower-grade gliomas based on their molecular subtype. IDH-mutant lower-grade gliomas benefit from a greater extent of surgical resection, with the strongest impact observed for IDH-mutant 1p/19q-noncodeleted astrocytomas.

SAT-515 Racial-Ethnic Differences in Diabetes-Related Fracture Risk

Background: Diabetes mellitus (DM), a novel risk factor for fracture, has not been well studied among African American (AA) and Hispanic (HIS) patients, who have the highest rates of DM in the United States and have higher rates of other major DM complications. Thus, the purpose of this study was to examine DM-related fracture risk among the multi-ethnic population of a large, urban academic center. Methods: We conducted a retrospective study using the electronic medical record. 19,171 subjects with DM (7,622 Caucasians [CA], 7,468 AA and 4,081 HIS) were identified through ICD codes and compared with 26,235 reference subjects with hypertension (HTN) but without DM (15,146 CA, 8,311 AA, and 2,778 HIS). Included subjects were at least 40 years of age, had at least 180 days of follow up, and had at least 1 outpatient visit per year. Subjects with end stage renal disease, bariatric surgery, Paget’s disease, and organ transplantation were excluded. Fractures and co-morbid conditions were identified through ICD codes. Fractures of the humerus, wrist, and hip were analyzed as major osteoporotic fractures (MOF). A Cox proportional hazards model was used to assess the impact of DM on the risk of incident MOF. A random sample of 235 subjects with incident MOF codes was chosen to assess the accuracy of fracture ICD codes and demonstrated an 85% validity rate regardless of race-ethnicity or DM/HTN status. Results: The two cohorts had a total of 717 MOFs over mean 3.2 years of follow-up. Among DM patients, there were significantly more incident MOF in CA and HIS than in AA (unadjusted rates of 1.9% and 1.7% versus 1.1%, respectively, p<0.01 for both). The unadjusted rates of MOF in DM did not differ significantly from rates in the reference cohort with HTN among the same racial-ethnic group (1.8% in CA, 1.3% in HIS, 1.3% in AA). In a comprehensive model that included age, BMI, gender, race, and prior MOF, DM was not significantly associated with the incidence of MOF when the three racial-ethnic groups were analyzed together (HR 1.16, 95% CI 0.99-1.36, p=0.07). However, the effect of DM differed in AA as compared to CA and HIS (AA race by DM interaction p=0.036). DM was significantly associated with the incidence of MOF only in CA and HIS (HR 1.24, 95% CI 1.03-1.49, p=0.02) but not in AA (HR 0.92, 95% CI 0.68-1.23, p=0.56). Interestingly, the association between MOF and prior fracture was far stronger in AA (HR 10.09, 95% CI 5.14-19.81, p<0.001) than in CA and HIS (HR 2.03, 95% CI 1.01-4.09, p=0.048). Conclusion: In a comprehensive model, the presence of diabetes was associated with elevated fracture risk in Hispanics and Caucasians, but not in African Americans. Instead, prior fracture demonstrated a remarkably strong association with incident fracture in African Americans. Our findings may have significant ramifications for case detection and management of diabetes-related fracture risk in multi-ethnic populations in the United States.