A Model-Based Approach to Bridging Plasma and Dried Blood Spot Concentration Data for Phase 3 Verubecestat Trials

In-clinic venous dried blood spot (DBS) pharmacokinetic (PK) sampling was incorporated into two phase 3 studies of verubecestat for Alzheimer's disease (EPOCH [NCT01739348] and APECS [NCT01953601]), as a potential alternative to plasma PK sampling. Initially, plasma and DBS PK samples were collected concurrently to better understand the DBS-plasma verubecestat concentration relationship, with the intention of discontinuing DBS or plasma sampling following interim analysis. Following initial analyses and comparison of results with prespecified selection criteria, plasma PK sampling was discontinued; however, a stability issue resulting in generally lower DBS verubecestat concentrations with longer collection-to-assay times was subsequently discovered (associated with non-compliance in DBS sample handling), prompting reintroduction of plasma sampling. To enable inclusion of DBS data in population PK analyses, a conversion algorithm for calculating plasma-equivalent concentrations (accounting for DBS sample instability) was developed using paired (time-matched) plasma and DBS data from the EPOCH study. Verubecestat population PK models developed from pooled phase 1/1b and EPOCH data using either (1) plasma-only data or (2) plasma and plasma-equivalent concentrations (calculated from non-paired DBS samples) yielded similar results. The algorithm robustness was demonstrated using DBS data from paired samples from the APECS study and comparison between plasma and plasma-equivalent concentrations. The population PK model was updated with APECS data (both plasma and, if no plasma sample available, plasma equivalents). The results demonstrated similar PK in the two phase 3 populations and exposures consistent with expectations from phase 1 data. This case study illustrates challenges with employing new sampling techniques in large, global trials and describes lessons learned.

[Transarterial chemoembolization of hepatocellular carcinoma]

Transarterial chemoembolization (TACE) is used as palliative and neoadjuvant treatment for patients with hepatocellular carcinoma (HCC). TACE should be offered as palliative treatment to patients with intermediate stage large or multinodular HCC if no curative treatment option is available by resection or thermoablation and if extrahepatic metastases and tumor infiltration of main portal and systemic veins has been excluded. TACE is possible only in patients with preserved liver function (Child-Pugh A-B, best up to 7 points) and with good performance status (ECOG 0). TACE can be used for bridging and for downstaging prior to liver transplantation with the intention to maintain or reach limited intrahepatic tumor load defined by Milan criteria. TACE should be adapted to the vascularization pattern of the HCC nodules and performed as selective as possible and repetetively if necessary with the goal of complete devascularization of the tumor tissue. Conventional TACE (cytotoxic drugs, iodized oil and embolic particles) and drug-eluting TACE (anthracycline preloaded in microspheres) can be used in a comparable way. During drug-eluting TACE, peripheral concentration of cytotoxic drugs is lower. Using conventional TACE in a palliative setting, survival benefit for patients was 8-11 months compared to best supportive care; however, this requires that all known contraindications and other criteria in terms of tumor and liver disease, respectively, associated with negative prognosis be taken into consideration. Better local response is achieved by drug-eluting TACE; however, no related survival benefit was shown compared to conventional TACE so far. Response to neoadjuvant local treatment is associated with improved prognosis after liver transplantation.

Bridging and Clumping: Investigating Platelet Interactions with P. falciparum-Infected Red Blood Cells and Endothelial Cells in Cerebral Malaria

The methods presented in this chapter describe how to perform ex vivo clumping and in vitro bridging assays in the context of cerebral malaria. Both the protocols are detailed, and emphasis is made on how to prepare platelet suspensions suitable to each technique, including description of specific buffers and reagents to minimize the risk of aggregation while maintaining the platelet properties.

Bridging juvenile justice and behavioral health systems: development of a clinical pathways approach to connect youth at risk for suicidal behavior to care

BACKGROUND

Justice-involved youth have high rates of suicidal behavior and co-morbid psychiatric disorders, yet low rates of service use. Implementation efforts aimed at supporting cross-agency linkage protocols may be useful components of interventions promoting behavioral healthcare service access for youths on probation. The purpose of this study was to develop clear referral Pathways for three suicide risk classifications of youth, across 10 counties in a single state through a community-academic partnership in New York state, a strategic planning process between county Probation departments and community Behavioral Health.

RESULTS

We sought to clarify service destinations for youth in three classes of risk for suicidal behavior: Class I (Crisis, Imminent Risk); Class II (Crisis, Non-Imminent Risk); and Class III (Non-Crisis but in Need of Service). Prior to Pathway Meetings, there was a low degree of agreement between Probation and Behavioral Health leadership for the appropriate service destination for youths in crisis, whether at imminent risk (Class I: 57.8% overlap) or at lower than imminent risk (Class II: 45.6% overlap). Options for referral destinations for Classes I and II decreased significantly (indicating greater overlap) as a result of Pathway Meetings [(Class I: from 2.5 to 1.1 (t₍₉₎ = 3.28, p < 0.01); Class II: from 2.8 to 1.3 (t₍₉₎ = 4.025, p < 0.003)]. Pathway Meetings allowed Behavioral Health and Juvenile Justice systems to make joint decisions regarding referral pathways, resulting in innovative solutions, such as the use of mobile crisis.

CONCLUSIONS

The community-academic partnership served to bring internal (Juvenile Justice) and external (Behavioral Health) contexts together to successfully generate agreed upon Pathways to care for youths demonstrating risk for suicidal behavior. Bridging Behavioral Health and Juvenile Justice systems together to agree to referral Pathways for each risk class can increase appropriate service use.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03586895 . Registered 21 June 2018, https://register.clinicaltrials.gov/prs/app/template/EditRecord.vm?epmode=Edit&listmode=Edit&uid=U0003B7I&ts=4&sid=S00080NN&cx=-n4kinh.

Thrombolysis and embolectomy in treatment of acute stroke as a bridge to open-heart resection of giant cardiac myxoma: A case report

BACKGROUND

Cardiac embolism is a common cause of ischemic stroke in young adults. Neurological complications associated with atrial myxoma most frequently include cerebral infarct due to embolus. Early complete resection of giant cardiac myxoma is the key to its treatment and prevention of stroke recurrence.

CASE SUMMARY

A 42-year-old, previously healthy woman was admitted to the hospital with sudden-onset inability to speak and right-sided hemiplegia. While sweeping the floor 2 h prior to hospital admission, the patient developed sudden inability to express herself or understand what others were saying, accompanied by dyskinesia of the right limb, inability to walk or hold objects, and involuntary choreiform movements of the left upper limb. The patient was diagnosed with cerebral embolism and cardiac myxoma, complicated by left middle cerebral artery occlusion. The acute stroke was treated with intravenous thrombolytic therapy and arterial embolectomy as a bridging therapy to open resection of left atrial cardiac myxoma. The patient condition improved remarkably following initial thrombolysis and embolectomy and subsequently underwent emergency open resection of the atrial cardiac myxoma. She had no recurrence during 1-year follow-up.

CONCLUSION

Strong consideration should be given to urgent intravenous thrombolysis (rt-PA, alteplase) in young adult stroke patients at the time of hospital admission. The present case demonstrated a highly successful outcome that combined thrombolysis and arterial embolus retrieval as a bridge to early complete resection of a giant cardiac myxoma for both stroke treatment and recurrence prevention.

Assessment of the attitude, awareness and practice of periprocedural warfarin management among health care professional in Qatar. A cross sectional survey

It is estimated that 10-15% of oral anticoagulant (OAC) patients, would need to hold their OAC for scheduled surgery. Especially for warfarin, this process is complex and requires multi-layer risk assessment and decisions across different specialties. Clinical guidelines deliver broad recommendations in the area of warfarin management before surgery which can lead to different trends and practices among practitioners. To evaluate the current attitude, awareness, and practice among health care providers (HCPs) on warfarin periprocedural management. A multiple-choice questionnaire was developed, containing questions on demographics and professional information and was completed by187 HCPs involved in warfarin periprocedural management. The awareness median (IQR) score was moderate [64.28% (21.43)]. The level of awareness was associated with the practitioner's specialty and degree of education (P = 0.009, 0.011 respectively). Practice leans to overestimate the need for warfarin discontinuation as well as the need for bridging. Participants expressed interest in using genetic tests to guide periprocedural warfarin management [median (IQR) score (out of 10) = 7 (5)]. In conclusion, the survey presented a wide variation in the clinical practice of warfarin periprocedural management. This study highlights that HCPs in Qatar have moderate awareness. We suggest tailoring an educational campaign or courses towards the identified gaps.

Pharmacokinetics and safety of liposomal bupivacaine after local infiltration in healthy Chinese adults: a phase 1 study

Background

Liposomal bupivacaine (LB) is a long-acting formulation of bupivacaine. The safety and efficacy of LB has been demonstrated across surgical procedures. However, pharmacokinetic (PK) parameters and safety of LB in the Chinese population have not been assessed.

Methods

In this single-arm, single center, phase 1, open-label study, PK and safety of local infiltration with LB 266 mg were assessed in healthy Chinese adults. Eligible participants were aged 18 to 55 years with biologic parents and grandparents of Chinese ethnicity, in generally good health (i.e., no clinically significant abnormalities), and with a body mass index (BMI) 19.0 to 24.0 kg/m² (inclusive) and body weight ≥ 50 kg.

Results

Participants (N = 20) were predominantly men (80 %); mean age was 32 years; and mean BMI was 21.8 kg/m². After LB administration, mean plasma levels of bupivacaine rapidly increased during the first hour and continued to increase through 24 h; plasma levels then gradually decreased through 108 h followed by a monoexponential decrease through 312 h. Geometric mean maximum plasma concentration was 170.9 ng/mL; the highest plasma bupivacaine concentration detected in any participant was 374.0 ng/mL. Twenty-two treatment-emergent adverse events were reported (mild, n = 21; moderate, n = 1).

Conclusions

After single-dose administration of LB, PK measures were similar to a previously reported profile in US adults. The highest observed peak plasma concentration of bupivacaine was several-fold below the plasma concentration threshold accepted as being associated with neurotoxicity or cardiotoxicity (2000–4000 ng/mL). These data support that LB is well tolerated and safe in individuals of Chinese descent.

Trial registration

NCT04158102 (ClinicalTrials.gov identifier), Date of registration: November 5, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01407-5.

The bridging and normal dimensions of sella turcica in Yemeni individuals

Objective

This study aimed to evaluate and compare sizes, shapes and bridging of the sella turcica (ST) in Yemeni individuals with different skeletal patterns, genders, and ages, and to assess the association between the linear dimension of ST and gender, age, or skeletal patterns. The standard anatomical structure of ST among Yemeni subjects is still unknown and this study can be considered as the first reference regarding ST of Yemeni individuals.

Materials and methods

Cephalogram images for 234 subjects (167 females and 67 males) were traced and classified for groups by gender, age, and dentofacial skeletal patterns. Size, shape, and bridging of ST were assessed. Multivariate ANOVA (MANOVA) analysis was used to detect the interaction between gender, age, and skeletal patterns on ST dimensions.

Results

The mean values for length, anteroposterior diameter, and depth of ST were 8.02 ± 1.67, 11.37 ± 1.60, and 8.56 ± 1.26 mm, respectively. A significant difference in length of ST between gender and age stages (p < 0.05) was detected while older subjects revealed a greater anteroposterior diameter than younger subjects (p < 0.05). The morphological variations of ST were observed in 55.6% of samples. No significant association between the shape of ST and skeletal patterns (p > 0.05) was found.

Conclusions

ST bridging was highly prevalent in Yemeni subjects (35.9%). Samples showed a higher rate of complete ST bridging in the three skeletal patterns, Class I (17.1%), Class II (18.9%), and Class III (20%). ST dimensions and shape findings in this study can be used as reference standards for further investigation, including the ST area in the Yemeni population.

Insights on Bridging Stent Grafts in Fenestrated and Branched Aortic Endografting

Major branches of the aortic arch and visceral aorta pose a particular challenge for endovascular repair of aneurysms involving these regions. To preserve perfusion through these essential branches, fenestrated and branched endografts have been used. Current fenestrated and branched aortic endografts have evolved into modular devices in which the aortic main body provides appropriate access to the target branch vessel either through reinforced fenestrations or directional cuffs as the hinge point for bridging stent grafts (BSGs). BSGs are used to connect the aortic main body and target branch vessel, and must provide both unhindered flow and a seal. Appropriate selection of BSG for target vessels in branched and fenestrated endovascular aortic repair is critical for technical success and durability. At present, there are no dedicated devices for use as BSGs, and a variety of stent grafts are currently used off-label. In this report, we review the available published series on the performance of presently available BSGs in relation to their design and selection.

The role of interfacial reactions in controlling the distribution of Cd within goethite-humic acid-bacteria composites

Mineral-organic interfacial reactions strongly influence the adsorption, distribution and bioavailability of metal cations in soil systems. The molecular binding mechanisms and distribution of Cd onto goethite, humic acid, Pseudomonas putida cells, and their composites at different mass ratios were studied through the combination of bulk adsorption coupled with EXAFS, ITC and SCM. In binary and ternary composites, the energetics of the overall adsorption of Cd was dominated by the entropy of Cd adsorption onto the organic fraction. The formation of a type-B HA bridging complex >FeOH-HACOOCdOH enhanced Cd adsorption by 10-30% at low Cd concentrations, and more than 93.5% of the adsorbed Cd was bound onto HA fraction. In ternary systems, the component additivity over-estimated Cd adsorption onto bacteria by ~21.8%, likely due to site blocking effects. Models involving the masking of phosphoryl sites and HA bridging reactions can simulate the distribution of Cd in the composites. Our modelling suggests that HA is the main scavenger of Cd under a range of environmental conditions, and that bacteria become important in affecting the distribution of Cd under lower pH settings. This study demonstrates the impact of iron oxide-HA-bacteria interactions on the fate and distribution of Cd in soils and associated environments.

No man is an island: Psychological underpinnings of prosociality in the midst of the COVID-19 outbreak

In response to the COVID-19 outbreak, sustainable forms of collective resilience help societies coping cohesively with unprecedented challenges. In our empirical contribution, we framed collective resilience and cohesion in terms of prosociality. A study carried out in the midst of the COVID-19 outbreak in the UK (N = 399) articulated basic individual values, ideological orientations (i.e., authoritarianism and social dominance orientation), and core political values in a comprehensive framework to predict bonding and bridging forms of prosocial intentions, and prosocial behaviors directed towards vulnerable groups. According to our findings, people whose worldview incorporates collective and collaborative principles cared more about others' welfare. Jointly, self-transcendence, equality, and accepting immigrants predicted more prosociality, whereas social dominance orientation predicted less prosociality. Over and beyond all other predictors, self-transcendence uniquely predicted prosocial intentions and behaviors alike. To conclude, we suggest interventions to promote and sustain prosociality among people motivated by a larger array of life goals and worldviews.

Efficacy and Safety of Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation Undergoing Elective Surgical Procedures: A Meta-analysis

Objective: The study objective was to determine if peri-operative bridging anticoagulation in patients with atrial fibrillation is beneficial or harmful.Design: Systematic review and meta-analysis.Setting: Inpatient or in-hospital setting.Participants: Adults with atrial fibrillation having a CHADS2 score >1 undergoing elective surgical procedure on anticoagulation.Methods: A systemic search of multiple databases (Cochrane, Medline, PubMed) was performed regarding studies conducted on efficacy and safety of perioperative bridging anticoagulation in patients with atrial fibrillation. Studies identified were reviewed by two authors individually before inclusion. The results were then pooled using Review Manager to determine the combined effect. Stroke/systemic embolism was considered as the primary efficacy outcome. Major bleeding was the primary safety outcome.Results: The systematic search revealed 108 potential articles. The full texts of 28 articles were retrieved for assessment of eligibility. After full text review, 25 articles were excluded. Three articles met inclusion criteria. No significant difference in stroke/systemic embolism with bridging anticoagulation was noted (risk ratio, 1.25-95% confidence interval [CI], 0.55-2.85). Bridging was associated with significantly higher risk of major bleeding (risk ratio, 3.29-95% CI, 2.25-4.81).Conclusion: An individualized approach is required when initiating peri-operative bridging anticoagulation. There is certainly a higher risk of bleeding with bridging anticoagulation and no difference in stroke/systemic embolism. However, the results cannot be extrapolated to patients who have valvular atrial fibrillation or CHADS2 score of 5 or greater.

Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

BACKGROUND

Increasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation.

METHODS

We performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding.

RESULTS

A total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk.

CONCLUSION

Perioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

The effect of health on social capital; a longitudinal observation study of the UK

Background

UK health policy increasingly focusses on health as an asset. This represents a shift of focus away from specific risk factors towards the more holistic capacity by which integrated care assets in the community support improvements in both health and the wider flourishing of individuals. Though the social determinants of health are well known, relatively little research has focussed on the impact of an individual’s health on their social outcomes. This research investigates how improved health can deliver a social return through the development of social capital.

Methods

An observational study is undertaken on 25 years of longitudinal data, from 1991, drawn from the harmonised British Household Panel Survey (BHPS) and Understanding Society Survey (USS). Fixed effects instrumental variable panel data regression analysis is undertaken on individuals. The number of memberships of social organisations, as a measure of structural social capital, is regressed on subjectively measured general health and GHQ12 (Likert) scores. Distinction is drawn between males and females.

Results

Improved general health increases social capital though differences exist between males and females. Interaction effects, that identify the impacts of health for different age groups, reveal that the effect of increased health on social capital is enhanced for males as they age. However, in the case of females increases in general health increase social capital only in connection with their age group. In contrast mental illness generally reduces social capital for males and females, and these effects are reduced through aging.

Conclusions

Investing in health as an asset can improve the social outcomes of individuals. Increasing the outcomes requires tailoring integrated care systems to ensure that opportunities for social engagement are available to individuals and reflect age groups. Targeting improvements in mental health is required, particularly for younger age groups, to promote social capital. The results suggest the importance of ensuring that opportunity for engagement in social and civic organisation be linked to general and mental health care support.

A scoping review to characterize bridging tasks in the literature on aging with disability

Background

Bridging involves improving knowledge sharing and collaboration across different fields, such as aging and disability. The objectives of this review were to describe: 1) the contexts where bridging has occurred in relation to delivery of health services for adults aging with neurological or developmental conditions; and 2) characterize and map bridging tasks, stakeholders involved, and outcomes discussed in peer-reviewed literature.

Methods

Seven databases were searched around the core concepts of “bridging,” “aging,” and “disability.” In total, 10,819 articles were screened with 49 meeting the inclusion criteria of discussing aging with developmental or neurological disability, explicitly describing bridging tasks, published in English and a peer-reviewed publication. Bibliographic information, sample characteristics, and data on bridging was extracted and included in the qualitative synthesis.

Results

Intellectual and/or Developmental disabilities were the most studied population (76% of articles), and most articles were published in the United States (57%). Twenty-two bridging tasks were identified, and categorized into three domains: health and social service delivery (e.g., care coordination tasks), policy (e.g., policy change), and research and training (e.g., mentoring). Stakeholders involved ranged from health care professionals to policy makers and organizations in aging and disability services.

Conclusions

The resulting matrix will assist in the specification of bridging in research and practice. Future work should evaluate specific models of bridging and their effects on health service delivery.

An Updated Review on Myocardial Bridging

Myocardial bridging is a congenital coronary anomaly with normal epicardial coronary artery taking an intra-myocardial course also described as tunneled artery. The majority of patients with this coronary anomaly are asymptomatic and generally it is a benign condition. However, it is an important cause of myocardial ischemia, which may lead to anginal symptoms, acute coronary syndrome, cardiac arrhythmias and rarely sudden cardiac death. There are numerous studies published in the recent past on understanding the pathophysiology, diagnostic and management strategies of myocardial bridging. This review highlights some of the recent updates in the diagnosis and management of patients with myocardial bridging. We discuss the role of various non-invasive and invasive diagnostic methods to evaluate functional significance of bridging. In addition, role of medical therapy such as beta-blockers, percutaneous coronary intervention with stents/bioresorbable scaffolds and surgical unroofing in patients unresponsive to medical therapy is highlighted as well.

Polymer-mediated colloidal stability: on the transition between adsorption and depletion

Addition of polymers to a colloidal dispersion modulates the interactions between the colloids. We briefly review the effects of positive and negative adsorption (also termed depletion). The effective colloid-polymer interactions sensitively affect the colloidal phase behavior. We present a theoretical framework to predict the phase behavior of colloid-polymer mixtures for varying affinities between colloid and polymer, leading to either positive or negative adsorption of polymer segments. For certain conditions, polymers are neither depleted nor adsorbed: the polymer concentration is essentially constant up to the colloidal surface, a condition which we term neutral adsorption. Near this condition, the calculated phase diagrams reveal a stable-unstable-restabilisation transition with increasing polymer concentration. Similar effects have been reported experimentally, for instance as a function of temperature [Feng et al., Nat. Mat., 2015, 14, 61-65], which may modulate the effective polymer-colloid affinity. Understanding how to achieve neutral adsorption opens up the possibility of preparing highly dense, yet stable, colloid-polymer mixtures.

'I don't think there are great sex differences there': Processes of discursive bridging and othering in a discussion of gendered norms related to alcohol, sexual behaviour, and aggression

BACKGROUND

Existing research indicates that sexual behaviour and aggression are particularly important to the reproduction of gendered drinking norms, both in the media and in face-to-face interaction. However, research has yet to understand in more detail the discursive processes whereby actors negotiate gendered norms related to alcohol, sexual behaviour, and aggression. This article examines how actors make symbolic distinctions between themselves and others in discussing alcohol, aggression, and sexual desire, and analyses the similarities and differences within and across gender that they identify in this process.

METHODS

The study relies on individual qualitative interviews with 25 Swedish women and men. To elicit participants' normative positions, we used a newspaper article as a probe during the interviews.

RESULTS

Findings show that participants highlight similarities between women and men, and variation and individual differences among men and among women in discussing alcohol's effects on sexual desire and 'sexually active behaviour'. Differences, by contrast, are most salient when they discuss alcohol and aggression and seek to distance themselves from 'shabby bar men', rural men, and male football hooligans who drink and fight, outgroups that are marked as working-class in the participants' narratives.

CONCLUSION

Two general discursive patterns were identified: discursive bridging across gender and discursive othering across class. For the participants, drinking norms are not as much about general gender differences as they are about the 'dysfunctional' drinking of certain groups of working-class men. These findings contribute to a more specific understanding of the reconstitution of gender boundaries in relation to drinking norms.

Development and validation of a Bayesian survival model for inclusion body myositis

BACKGROUND

Associations between disease characteristics and payer-relevant outcomes can be difficult to establish for rare and progressive chronic diseases with sparse available data. We developed an exploratory bridging model to predict premature mortality from disease characteristics, and using inclusion body myositis (IBM) as a representative case study.

METHODS

Candidate variables that may be potentially associated with premature mortality were identified by disease experts and from the IBM literature. Interdependency between candidate variables in IBM patients were assessed using existing patient-level data. A Bayesian survival model for the IBM population was developed with identified variables as predictors for premature mortality in the model. For model selection and external validation, model predictions were compared to published mortality data in IBM patient cohorts. After validation, the final model was used to simulate the increased risk of premature death in IBM patients. Baseline survival was based on age- and gender-specific survival curves for the general population in Western countries as reported by the World Health Organisation.

RESULTS

Presence of dysphagia, aspiration pneumonia, falls, being wheelchair-bound and 6-min walking distance (6MWD in meters) were identified as candidate variables to be used as predictors for premature mortality based on inputs received from disease experts and literature. There was limited correlation between these functional performance measures, which were therefore treated as independent variables in the model. Based on the Bayesian survival model, among all candidate variables, presence of dysphagia and decrease in 6MWD [m] were associated with poorer survival with contributing hazard ratios (HR) 1.61 (95% credible interval [CrI]: 0.84-3.50) and 2.48 (95% CrI: 1.27-5.00) respectively. Excess mortality simulated in an IBM cohort vs. an age- and gender matched general-population cohort was 4.03 (95% prediction interval 1.37-10.61).

CONCLUSIONS

For IBM patients, results suggest an increased risk of premature death compared with the general population of the same age and gender. In the absence of hard data, bridging modelling generated survival predictions by combining relevant information. The methodological principle would be applicable to the analysis of associations between disease characteristics and payer-relevant outcomes in progressive chronic and rare diseases. Studies with lifetime follow-up would be needed to confirm the modelling results.

Association between sella turcica bridging and congenitally missing maxillary lateral incisors

Background/purpose

Sella turcica bridging (STB) and its association with dental anomalies has been investigated and reported in literature. This is the first study that exclusively compared STB among the orthodontic patients with congenital missing maxillary lateral incisors (CMMLI) and individuals with complete dentition.

Materials and methods

The retrospective study has recruited 49 patients with CMMLI (13 males and 36 females aged between 12 and 43 years) and 49 patients with complete dentition. Sella dimensions and association of STB with CMMLI were evaluated and the results were analysed using descriptive and inferential statistics.

Results

The comparison of mean diameter, length, and depth of sella between groups showed reduction in length among the CMMLI (p = 0.04). CMMLI group has shown a significant higher (p < 0.05) number of subjects (69.4%) with calcification when compared to control group (46.9%). The odds of having sella's bridging in patients with CMMLI were 2.5 times greater than patients with full set of teeth. Age showed a significant (p < 0.001) positive correlation with sella's width only in CMMLI.

Conclusion

Patients with CMMLI tend to have an increased frequency of STB, and decreased sella turcica length.

Long-term outcomes of hepatocellular carcinoma that underwent chemoembolization for bridging or downstaging

BACKGROUND

Prospective study of 200 patients with hepatocellular carcinoma (HCC) that underwent liver transplant (LT) after drug-eluting beads transarterial chemoembolization (DEB-TACE) for downstaging versus bridging. Overall survival and tumor recurrence rates were calculated, eligibility for LT, time on the waiting list and radiological response were compared. After TACE, only patients within Milan Criteria (MC) were transplanted. More patients underwent LT in bridging group. Five-year post-transplant overall survival, recurrence-free survival has no difference between the groups. Complete response was observed more frequently in bridging group. Patients in DS group can achieve post-transplant survival and HCC recurrence-free probability, at five years, just like patients within MC in patients undergoing DEB-TACE.

AIM

To determine long-term outcomes of patients with HCC that underwent LT after DEB-TACE for downstaging vs bridging.

METHODS

Prospective cohort study of 200 patients included from April 2011 through June 2014. Bridging group included patients within MC. Downstaging group (out of MC) was divided in 5 subgroups (G1 to G5). Total tumor diameter was ≤ 8 cm for G1, 2, 3, 4 (n = 42) and was > 8 cm for G5 (n = 22). Downstaging (n = 64) and bridging (n = 136) populations were not significantly different. Overall survival and tumor recurrence rates were calculated by the Kaplan-Meier method. Additionally, eligibility for LT, time on the waiting list until LT and radiological response were compared.

RESULTS

After TACE, only patients within MC were transplanted. More patients underwent LT in bridging group 65.9% (P = 0.001). Downstaging population presented: higher number of nodules 2.81 (P = 0.001); larger total tumor diameter 8.09 (P = 0.001); multifocal HCC 78% (P = 0.001); more post-transplantation recurrence 25% (P = 0.02). Patients with maximal tumor diameter up to 7.05 cm were more likely to receive LT (P = 0.005). Median time on the waiting list was significantly longer in downstaging group 10.6 mo (P = 0.028). Five-year post-transplant overall survival was 73.5% in downstaging and 72.3% bridging groups (P = 0.31), and recurrence-free survival was 62.1% in downstaging and 74.8% bridging groups (P = 0.93). Radiological response: complete response was observed more frequently in bridging group (P = 0.004).

CONCLUSION

Tumors initially exceeding the MC down-staged after DEB-TACE, can achieve post-transplant survival and HCC recurrence-free probability, at five years, just like patients within MC in patients undergoing DEB-TACE.

Liver transplantation for hepatocellular carcinoma: Where do we stand?

Hepatocellular carcinoma represents an important cause of morbidity and mortality worldwide. It is the sixth most common cancer and the fourth leading cause of cancer death. Liver transplantation is a key tool for the treatment of this disease in human therefore hepatocellular carcinoma is increasing as primary indication for grafting. Although liver transplantation represents an outstanding therapy for hepatocellular carcinoma, due to organ shortage, the careful selection and management of patients who may have a major survival benefit after grafting remains a fundamental question. In fact, only some stages of the disease seem amenable of this therapeutic option, stimulating the debate on the appropriate criteria to select candidates. In this review we focused on current criteria to select patients with hepatocellular carcinoma for liver transplantation as well as on the strategies (bridging) to avoid disease progression and exclusion from grafting during the stay on wait list. The treatments used to bring patients within acceptable criteria (down-staging), when their tumor burden exceeds the standard criteria for transplant, are also reported. Finally, we examined tumor reappearance following liver transplantation. This occurrence is estimated to be approximately 8%-20% in different studies. The possible approaches to prevent this outcome after transplant are reported with the corresponding results.

[Perioperative handling of anticoagulation]

A growing number of patients in Germany receive a long-term prophylactic anticoagulation with phenprocoumone or one of the novel direct oral anticoagulants (NOAC), such as dabigatran, rivaroxaban or apixaban. The most common indication for an oral anticoagulant therapy is atrial fibrillation (approximately 75%) where the anticoagulant therapy can reduce the risk for an embolic event, particularly stroke by 60%. Operations carried out during such a therapy can result in major bleeding complications. On the other hand, suspending anticoagulant therapy can lead to an increased risk of thromboembolisms. Thus, the preoperative assessment should address the bleeding risk of the planned operation, the individual risk of thromboembolism, as well as other factors, such as patient age and renal function. If the individual assessment shows a substantial risk of perioperative bleeding when anticoagulant treatment is continued and a substantial risk of thromboembolism if the treatment is suspended, then a perioperative bridging, for example with low molecular weight heparin, is necessary. Perioperative bridging also leads to an increased risk of perioperative bleeding. Thus, undifferentiated bridging for all patients with atrial fibrillation with anticoagulant treatment is not recommended. Instead, the indications for a perioperative bridging should be decided according to individual risk profiles.

Periprocedural Bridging in Patients with Venous Thromboembolism: A Systematic Review

BACKGROUND

Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population.

METHODS

We performed a systematic review searching the PubMed and Embase databases from inception to December 7, 2017 for randomized and nonrandomized studies that included adults with previous venous thromboembolism requiring VKA interruption to undergo an elective procedure, and that reported venous thromboembolism or bleeding outcomes. Quality of evidence was graded by consensus.

RESULTS

We included 28 cohort studies (20 being single-arm cohorts) with, overall, 6915 procedures for analysis. In 27 studies reporting perioperative venous thromboembolism outcomes, the pooled incidence of recurrent venous thromboembolism with bridging was 0.7% (95% confidence interval [CI], 0.4%-1.2%) and 0.5% (95% CI, 0.3%-0.8%) without bridging. Eighteen studies reported major or nonmajor bleeding outcomes. The pooled incidence of any bleeding was 3.9% (95% CI, 2.0%-7.4%) with bridging and 0.4% (95% CI, 0.1%-1.7%) without bridging. In bridged patients at high thromboembolic risk, the pooled incidence for venous thromboembolism was 0.8% (95% CI, 0.3%-2.5%) and 7.5% (95% CI, 3.1%-17.4%) for any bleeding. Quality of available evidence was very low, primarily due to a high risk of bias of included studies.

CONCLUSIONS

Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.

Perioperative bridging of vitamin K antagonist treatment in patients with atrial fibrillation: only a very small group of patients benefits

AIMS

Bridging anticoagulation in atrial fibrillation (AF) patients who need to interrupt vitamin K antagonists for procedures is a clinical dilemma. Currently, guidelines recommend clinicians to take the stroke and bleeding risk into consideration, but no clear thresholds are advised. To aid clinical decision making, we aimed to develop a model in which periprocedural bridging therapy is compared with withholding anticoagulation in AF patients, for several bleeding and stroke risk groups.

METHODS AND RESULTS

A model was developed to simulate both a bridge and a non-bridge cohort, using simulated international normalized ratio (INR) values for patients on warfarin, acenocoumarol, and phenprocoumon. For both clinical strategies, stroke and bleeding risks were included and outcomes were stratified by CHA2DS2-VASc or CHADS2 and HAS-BLED groups. Quality-adjusted life expectancy was the main outcome considered. Our analyses show bridging to only be beneficial for patients with HAS-BLED scores equal or lower to 2 and with CHA2DS2-VASc scores of 6 or higher. For patients using acenocoumarol bridging may be beneficial starting at a CHA2DS2-VASc score of 7. Post-procedural time to therapeutic INR has a significant influence on the results: no significant benefit of bridging was found for patients reaching therapeutic INR values within 5 days.

CONCLUSION

When deciding whether to bridge anticoagulation, clinicians should consider the patient's individual stroke and bleeding risk, while also considering the patient's post-procedural INR management. In practice, only a small subset of patients is expected to benefit from bridging anticoagulation treatment.