795 A POSITIVE 4AT DELIRIUM ASSESSMENT TOOL SCORE ON HOSPITAL ADMISSION IS LINKED TO MORTALITY, LENGTH OF STAY AND ‘HOME TIME’: A STUDY OF 82,770 HOSPITAL ADMISSIONS IN EDINBURGH AND SALFORD

Introduction

Delirium is linked with poor outcomes but studies using large-scale routine data are scarce. The 4AT (www.the4AT.com) is a brief (~2 minutes), well-validated tool for detection of delirium and cognitive impairment. We performed a two-centre study (Edinburgh and Salford) of Electronic Health Record (EHR) 4AT scores and outcomes in 82,770 non-elective hospital admissions in patients aged ≥65. We determined relationships between 4AT scores 0 (no impairment), 1–3 (cognitive impairment but no delirium) and ≥ 4 (delirium), in relation to 30-day inpatient mortality, length of stay, and time at home (‘home time’) in the year following index admission.

Methods

We analysed EHR 4AT scores recorded within 24 hours of admission, and outcomes data were also derived from the EHR. The study period was between April 2016 (Edinburgh)/September 2017 (Salford) and April 2020 (both centres).

Results

4AT scores suggestive of delirium (≥4) were present in 25% in Salford, and 18% in Edinburgh. After adjustment for age and sex, 30-day inpatient mortality with 4AT ≥4 was 5.5-fold greater than the 4AT 0 group in Edinburgh (aOR 5.53, 95% confidence interval [CI] 4.99–6.13) and 3.4-fold greater in Salford (aOR 3.39, 95% CI 2.98–3.87). Length of stay was more than double in patients with any abnormal 4AT score compared to a 4AT score of 0. The median ‘home time’ at 1 year was reduced by 112 days (Edinburgh) and 61 days (Salford) in the 4AT ≥4 compared to 4AT 0 days.

Conclusions

This large study using routine clinical data confirms the relationships between delirium and poor outcomes previously reported in smaller research studies. Further, the results demonstrate the feasibility and value of using a brief clinical tool to identify delirium as a strong marker of adverse outcomes, and will be helpful in guiding policy development around patient safety including better treatment of delirium.

A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression

INTRODUCTION

Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT.

AREAS COVERED

The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed.

EXPERT OPINION

: The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.

Quantification of Kuramoto Coupling Between Intrinsic Brain Networks Applied to fMRI Data in Major Depressive Disorder

Organized patterns of system-wide neural activity adapt fluently within the brain to adjust behavioral performance to environmental demands. In major depressive disorder (MD), markedly different co-activation patterns across the brain emerge from a rather similar structural substrate. Despite the application of advanced methods to describe the functional architecture, e.g., between intrinsic brain networks (IBNs), the underlying mechanisms mediating these differences remain elusive. Here we propose a novel complementary approach for quantifying the functional relations between IBNs based on the Kuramoto model. We directly estimate the Kuramoto coupling parameters (K) from IBN time courses derived from empirical fMRI data in 24 MD patients and 24 healthy controls. We find a large pattern with a significant number of Ks depending on the disease severity score Hamilton D, as assessed by permutation testing. We successfully reproduced the dependency in an independent test data set of 44 MD patients and 37 healthy controls. Comparing the results to functional connectivity from partial correlations (FC), to phase synchrony (PS) as well as to first order auto-regressive measures (AR) between the same IBNs did not show similar correlations. In subsequent validation experiments with artificial data we find that a ground truth of parametric dependencies on artificial regressors can be recovered. The results indicate that the calculation of Ks can be a useful addition to standard methods of quantifying the brain's functional architecture.

Real-world experience of using combinatorial pharmacogenomic test in children and adolescents with depression and anxiety

OBJECTIVE

To evaluate the real-world impact of using a commercially available combinatorial pharmacogenomic (CPGx) test on medication management and clinical outcomes in children and adolescents treated at a tertiary care psychiatry practice.

METHODS

A retrospective cohort study using our prospectively maintained database of patients undergoing CPGx testing was performed. Only patients with clinical data at the time of ordering CPGx test (pre-baseline), potential medication change visit (baseline) and 8-weeks follow-up (post-baseline) visit were included. Clinical Global Impression (CGI) scores for each visit were calculated. Appropriate statistical analysis, including one-sample t-test, paired t-test and Chi-square test was performed.

RESULTS

Based on the inclusion criteria, 281 (75.9%) of the 370 patients with CPGx testing were included. Their mean age was 15.8 ± 4.5 years (111 females; 39.5%). The average number of medications significantly increased to 2.4 ± 1.2 on the post-baseline visit [t(280) = 8.34, p < 0.001). Medications were added in 123 (43.7%), replaced in 92 (32.7%) patients and remained unchanged in rest. There was no significant association between medication-related adverse effects and psychotropic medication change group (p = 0.27). The study population showed a significant improvement (p < 0.001) in the CGI severity, efficacy, and global improvement indices.

CONCLUSION

In our experience of using CPGx test in a large cohort of children and adolescents during routine clinical practice, three-quarter of them underwent medication change. Additionally, we noted an improvement in clinical outcomes without impacting adverse effects. While the role of clinical judgement in medication changes in our cohort is likely, CPGx may supplement clinical decision making. However, the best use and benefit of CPGx in routine clinical practice needs further investigation.

Antimicrobial effectiveness of Nano Silver Fluoride Varnish in reducing Streptococcus mutans in saliva and plaque biofilm when compared with Chlorhexidine and Sodium Fluoride Varnishes

Background

This in vivo study was done to investigate the antimicrobial effectiveness of Nano Silver fluoride, Sodium fluoride and Chlorhexidine when used as a varnish on Streptococcus mutans (S.mutans) in saliva and plaque biofilm.

Material and Methods

120 caries free subjects, aged 8-10 years were randomly assigned to four different groups (n=30) - group I: Control, group II: Chlorhexidine varnish (CHX), group III: Sodium fluoride varnish (NaF), group IV: Nano Silver fluoride varnish (NSF). Varnish application was done once at baseline. Saliva and plaque samples were collected at baseline (T0), at the end of 1 month (T1) and 3 months (T3) to evaluate S.mutans levels by culture method, optical density and PCR. OHI-S Index was also recorded for clinical evaluation.

Results

NSF, CHX and NaF were effective against S.mutans activity. The intragroup comparision of CFU/ml and OD/ml count showed a highly significant reduction from baseline to 3 months for all the 3 varnish groups (p=0.001). PCR result revealed that maximum reduction was seen in NSF and CHX followed by NaF group.

Conclusions

NSF reduces S.mutans level in both saliva and plaque biofilm and it is more advantageous than CHX and NaF as it has dual properties of acting as an antibacterial as well as a remineralizing agent.

Key words:Chlorhexidine, Nano Silver fluoride, Sodium fluoride, S. mutans, varnish.

Clinical predictors of non-response to lithium treatment in the Pharmacogenomics of Bipolar Disorder (PGBD) study

BACKGROUND

Lithium is regarded as a first-line treatment for bipolar disorder (BD), but partial response and non-response commonly occurs. There exists a need to identify lithium non-responders prior to initiating treatment. The Pharmacogenomics of Bipolar Disorder (PGBD) Study was designed to identify predictors of lithium response.

METHODS

The PGBD Study was an eleven site prospective trial of lithium treatment in bipolar I disorder. Subjects were stabilized on lithium monotherapy over 4 months and gradually discontinued from all other psychotropic medications. After ensuring a sustained clinical remission (defined by a score of ≤3 on the CGI for 4 weeks) had been achieved, subjects were followed for up to 2 years to monitor clinical response. Cox proportional hazard models were used to examine the relationship between clinical measures and time until failure to remit or relapse.

RESULTS

A total of 345 individuals were enrolled into the study and included in the analysis. Of these, 101 subjects failed to remit or relapsed, 88 achieved remission and continued to study completion, and 156 were terminated from the study for other reasons. Significant clinical predictors of treatment failure (p < 0.05) included baseline anxiety symptoms, functional impairments, negative life events and lifetime clinical features such as a history of migraine, suicidal ideation/attempts, and mixed episodes, as well as a chronic course of illness.

CONCLUSIONS

In this PGBD Study of lithium response, several clinical features were found to be associated with failure to respond to lithium. Future validation is needed to confirm these clinical predictors of treatment failure and their use clinically to distinguish who will do well on lithium before starting pharmacotherapy.

The impact of age on the diagnosis of type 1 myocardial infarction using high-sensitivity cardiac troponin

Background

Cardiac troponin concentrations are influenced by age and comorbidities with values above the 99th centile diagnostic threshold more common in older patients without myocardial infarction. Despite this, rule-in thresholds for myocardial infarction are applied universally regardless of age or comorbidities.

Purpose

We sought to evaluate how age and cardiovascular comorbidities influence the diagnostic performance of high-sensitivity cardiac troponin I for myocardial infarction.

Methods

In a secondary analysis of a multi-centre randomised controlled trial, we identified 45,991 consecutive patients with suspected acute coronary syndrome without ST-segment elevation myocardial infarction. The diagnostic performance of high-sensitivity cardiac troponin I measured at presentation for type 1 myocardial infarction was evaluated for the sex-specific 99th centile and thresholds three and five times this value in patients stratified by age (under 50 years, between 50 and 75 years, and over 75 years). The effect of comorbidities on diagnostic accuracy was evaluated using regression modelling.

Results

Of the 45,991 patients, 8,187 (18%) had myocardial injury of which 7,677 (94%) had a presentation troponin above the sex-specific 99th centile. Mean age of those with myocardial injury was 74 years (range 18–108). The positive predictive value (PPV) of the 99th centile was 54.6% (95% confidence interval [CI] 50.6–58.8%), 58.8% (56.9–60.6%) and 36.6% (35.1–38.2%) in patients under 50 years, between 50 and 75 years, and over 75 years, respectively. Rule-in thresholds three and five-times the 99th centile gave a higher PPV in all age groups with a PPV of 45.5% (43.1–47.8%) and 50.4% (47.6–53.2%), respectively in those aged over 75 years (Table 1). Regardless of threshold, specificity and PPV was lowest in patients over 75 years and decreased with advancing age (Figure 1). Across all age groups, the presence of heart failure resulted in the greatest decrease in PPV (36.9% [34.6–39.2%] versus 50.6% [49.3–51.8%]). Adjusting for cardiovascular comorbidities resulted in modest change in the discrimination of cardiac troponin for myocardial infarction (area under curve 0.89 vs 0.90) and did not prevent a decline in diagnostic accuracy in older patients.

Conclusion

The specificity and PPV of high-sensitivity cardiac troponin I for myocardial infarction decreases with advancing age. Cardiovascular comorbidities impact the PPV of troponin, but do not explain the decline in diagnostic accuracy with age. Clinicians should be aware of these important differences in performance by age of the diagnostic and rule-in thresholds for myocardial infarction when interpreting troponin results in older patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): University of Edinburgh Figure 1

Trajectories of high-sensitivity cardiac troponin I in the two decades before cardiovascular death in Whitehall II

Background

High-sensitivity cardiac troponin may be a promising biomarker that could be used for personalised cardiovascular risk prediction and monitoring in the general population. Temporal changes in high-sensitivity cardiac troponin before cardiovascular death are largely unexplored.

Purpose

Using the longitudinal Whitehall II cohort, we evaluated whether three serial high-sensitivity cardiac troponin I measurements over 15 years improved prediction of cardiovascular death when compared to a single time point at baseline.

Methods

Whitehall II is an ongoing longitudinal observation cohort study of 10,308 civil servants, and we included participants who had at least one cardiac troponin measurement and outcome data available. We constructed time trajectories to evaluate the temporal pattern of cardiac troponin I in those who died from cardiovascular disease as compared to those who did not. Cox regression and joint models were used to investigate the association of cardiac troponin I in relation to cardiovascular death using single time point (at baseline) and repeated measurements (at baseline, 10 and 15 years), respectively. The discriminative ability was assessed by the concordance index.

Results

In total, we included 7,293 individuals (mean age of 58 years [SD 7] at baseline, 29.4% women). Of these, 5,818 (79.8%) and 4,045 (55.5%) individuals had a second and third cardiac troponin I concentration measured, respectively. Cardiovascular death occurred in 281 (3.9%) individuals during a median follow-up of 21.4 [IQR, 15.8 to 21.8] years. In the 21-year trajectories of cardiac troponin I, we observed higher baseline concentrations in those who died due to cardiovascular disease as compared to those who did not (median 5 [IQR, 2 to 9] ng/L versus 3 [IQR, 2 to 5] ng/L respectively, Figure). Cardiac troponin I was an independent predictor of cardiovascular death, and the hazard ratio (HR) derived from the joint model that included serial cardiac troponin measurements was higher than the HR derived from the single time point model (single time point model: adjusted HR 1.53, 95% Confidence Interval [CI] 1.37 to 1.70 per naturally log transformed unit of cardiac troponin I, versus repeated measurements model: adjusted HR 1.79, 95% CI 1.58 to 2.02). The discriminative ability of the cardiac troponin model improved when using repeated measurements (concordance index of unadjusted cardiac troponin models, single time point: 0.668 versus repeated measurements: 0.724).

Conclusions

Our study shows that cardiac troponin I trajectories were persistently higher among individuals who died from cardiovascular disease. Cardiac troponin I is a strong independent predictor of cardiovascular death, and incorporating repeated measurements of cardiac troponin improves cardiovascular risk prediction in the general population.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac troponin I measurements and analysis were supported by were supported by Siemens Healthineers. The study was supported by Health Data Research UK which receives its funding from HDR UK Ltd (HDR-5012) funded by the UK Medical Research Council, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Department of Health and Social Care (England), Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Health and Social Care Research and Development Division (Welsh Government), Public Health Agency (Northern Ireland), British Heart Foundation and the Wellcome Trust. NLM is supported by the British Heart Foundation through a Senior Clinical Research Fellowship (FS/16/14/32023), Programme Grant (RG/20/10/34966) and a Research Excellence Award (RE/18/5/34216). The funders had no role in the study and the decision to submit this work to be considered for publication.

Mechanisms of myocardial injury and clinical outcomes in patients hospitalised with suspected COVID-19

Background

Myocardial injury is associated with adverse outcomes in patients with COVID-19. However, the prognostic role of myocardial injury in COVID-19 compared to other acute illnesses and the underlying mechanisms of injury are poorly understood.

Methods

In a prospective, multi-centre, cohort study conducted in secondary and tertiary care hospitals in Scotland, all consecutive patients with suspected COVID-19 underwent cardiac troponin (ARCHITECTSTAT high-sensitive troponin I (hs-cTnI) assay; Abbott Laboratories) testing in plasma that was surplus to clinical requirements. The results were not reported unless required by the attending clinician. We evaluated the prevalence of myocardial injury, mechanisms and outcomes in all patients. In those with any hs-cTnI concentration above the sex-specific 99th centile the diagnosis was adjudicated according to the 4th Universal Definition of Myocardial Infarction. The primary outcome of all-cause mortality was compared in those with and without myocardial injury and COVID-19 by cox regression adjusted for age, sex, renal function and co-morbidities.

Results

A total of 2,916 (median age 69 [interquartile range, IQR 54–79] years, 53% women) consecutive patients with suspected COVID-19 were followed up for 228 [IQR 203–249] days. Myocardial injury occurred in 26% (750/2,916) with a median troponin concentration of 66 [35–178] ng/L; the prevalence was 41% (46/112) and 25% (704/2,804) in those with and without COVID-19, respectively. The most common mechanism was acute non-ischaemic myocardial injury occurring in 80% (37/46) and 71% (502/704) of patients with and without COVID-19, respectively. Type 1 myocardial infarction (2% and 4%), type 2 myocardial infarction (7% and 14%) and chronic myocardial injury (11% and 11%) were less common and only one patient had confirmed myocarditis. In patients with myocardial injury mortality was increased compared to those without (P&lt;0.001 log rank), whether they had COVID-19 (54% [25/46] versus 26% [17/66]) or not (35% [248/704] versus 14% [294/2100]). Myocardial injury was an independent predictor of death in all patients (adjusted hazard ratio [aHR] 2.04, 95% confidence interval [CI] 1.71 to 2.43), but this excess risk was not higher in patients with COVID-19 (aHR 1.58, 95% CI 0.75 to 3.15) compared to those without the condition (aHR 2.01, 95% CI 1.81 to 2.49).

Conclusion

Myocardial injury is common in hospitalised patients with suspected COVID-19 whether or not COVID-19 was the cause of their presentation. The majority of patients had acute non-ischaemic myocardial injury rather than a defined cardiac condition. Despite this the presence of myocardial injury was an independent predictor of death in all hospitalised patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): British Heart Foundation Kaplan-Meier curve for all-cause death

Snapshots quiz

A 25-year old gentleman, treated one year previously for a signet ring mid rectal adenocarcinoma, presented with facial swelling and multiple nodular swellings on the neck and back. What is the diagnosis?

Neutrophil to lymphocyte ratio as a prognostic marker for non-metastatic renal cell carcinoma - does it add to what we already know?

AIM

To study the correlation of pre-operative neutrophil to lymphocyte ratio (NLR) with pathological stage, Fuhrman grade, sarcomatoid differentiation, tumor necrosis and lymph node positivity and its prognostic role in non-metastatic renal cell carcinoma (non-mRCC).

MATERIALS AND METHODS

This retro-prospective, observational study was done at a tertiary care center in Mumbai, India. All patients with non-mRCC from July 2015 to April 2018 were included. Patients with co-existing systemic infection, prior immunotherapy, and long-term steroids were excluded. NLR closest to surgery, but within one month prior to surgery was used. Patients were stratified as NLR ≥ 3.0 or < 3. NLR was correlated with known prognostic factors by Pearson's correlation.

RESULTS

113 patients, aged 18-81 years (83 males and 30 females) were included. 75% had clear cell RCC. 62% had stage 1 disease. 58% patients had Fuhrman Grade 2. 10 patients had lymph node metastasis, 6 had sarcomatoid differentiation, 40 had tumor necrosis. The NLR was < 3 in 72 patients. Statistically significant correlation between NLR and tumor stage (p = 0.0054) as well as NLR and tumor necrosis (p = 0.0128) was shown.

CONCLUSIONS

NLR correlates significantly with higher T stage and tumor necrosis. NLR may be integrated with well-established prognostic markers to improve the accuracy of prognostic scores.

Optimization based ECG watermarking in RDWT-SVD domain

With the increase in point of care services, communication of digital patient records through open network has multi-folded. This digital data is used to obtain the remote medical assistance from the smart healthcare centres. Protecting this data during transmission is a very big challenge. One of the most important medical data is electrocardiogram (ECG) signal which detects the cardiovascular diseases and any alteration in the signal may affect the diagnosis. In this work, an ECG watermarking based on redundant discrete wavelet transform (RDWT) and singular value decomposition (SVD) is developed. First, the ECG signal is converted into 2-D matrix using pan-tompkins algorithm. Then, we use the hybrid of RDWT and SVD to conceal the patient data and logo image into the 2-D ECG image. We also use hybrid of optimization scheme to improve the robustness of the watermark. Preliminary experimental results indicate the optimal invisibility and robustness result is more effective up to 97.89% than the traditional schemes respectively, which makes it suitable for ownership authentication of ECG signal.

Juvenile Generalized Myasthenia Gravis: Presented as Unilateral Blepharoptosis and Successfully Managed with Pulse Intravenous Methylprednisolone

Myasthenia Gravis is a rare autoimmune disorder of childhood and this is rarer in South Asia. We present a pre-pubertal 7 year old female child of seropositive Generalized Juvenile Myasthenia Gravis. She presented with unilateral blepharoptosis and later generalized symptoms appeared. Ice-pack test, Neostigmine challenge test and acetylcholine receptor antibody test were positive. Serum muscle specific tyrosine kinase antibody test was normal. She did not have thymic abnormalities. She did not respond to high dose (26 mg/kg/day) of Pyridostigmine and oral Prednisolone (2 mg/kg/day), but was successfully treated with a combination of pulse intravenous Methylprednisolone (30 mg/kg once a month for 6 months) and daily doses of oral Prednisolone (2 mg/kg/day) along with Pyridostigmine without significant side effects. This combination can be considered a potential inexpensive treatment for Juvenile Myasthenia Gravis in a resource limited area where other immunosuppressive treatments such as intravenous immunoglobulin is expensive and unaffordable.

Neuroimaging gender dysphoria: a novel psychobiological model

Gender identity development is complex and involves several key processes. Transgender people experience incongruence between their biological and identified gender. This incongruence can cause significant impairment in overall functioning and lead to gender dysphoria (GD). The pathophysiology of GD is complex and is poorly understood. A PubMed search based on predetermined eligibility criteria was conducted to review neuropsychiatric articles focused on neurological, biological and neuroimaging aspects of gender development, transgender identity and GD. The information obtained from the literature was then used to formulize a GD model. Distinct gray matter volume and brain activation and connectivity differences were found in individuals with GD compared to controls, suggesting a neurobiological basis of GD; which leads to the concept of brain gender. Individuals with GD encounter a recurrent conflict between their brain gender and the societal feedback; which causes recurrent and ongoing cognitive dissonance, finally leading to GD and functional connectivity and activation changes in the transgender brain. GD has neurobiological basis, but it is closely associated with the individuals' interaction with the external world, their self-perception and the feedback received in return. We propose a novel model where the development of GD includes cognitive dissonance, involving anterior cingulate cortex and ventral striatum as the key brain structures. This model can be used to generate testable hypotheses using behavioral and neuroimaging techniques to understand the neuropsychobiology of GD.

Intrinsic functional connectivity during continuous maintenance and suppression of emotion in bipolar disorder

Resting-state connectivity studies, which examine unconstrained low frequency BOLD fluctuations, have reported inconsistent abnormalities in bipolar disorder (BP). In this study, we investigated intrinsic brain connectivity under the constraints of a Continuous Emotion Regulation Task (CERT) in BP patients in depressed (BPD) and manic (BPM) states, along with healthy control participants. Medication-free participants, with either a diagnosis of BP (BPD = 27, BPM = 30) or healthy controls (N = 33) were included. We collected 2 fMRI scans using the CERT paradigm, in which participants continuously watched negative pictures and either maintained emotions (MAINTAIN) or suppressed emotion using reappraisal techniques (SUPPRESS). Network-based statistic and graph theory analyses were examined for (i) the main effect of condition (within-group) and (ii) group and condition interactions. In healthy participants, MAINTAIN largely involved occipital and parietal cortices (p < .001), whereas SUPPRESS also recruited the frontal and cingulate cortices (p = .023). The interaction between group (BPD vs. BPM) and condition revealed a network involving the inferior frontal lobe which was stronger during MAINTAIN for BPD and during SUPPRESS for BPM (p = .037). Graph theory properties (i.e., clustering coefficient) for key nodes also evidenced significant group by condition interactions. We observed BP-related changes in network properties involved in normal and abnormal emotion regulation, which provide insights into the neural bases for affective disturbances in BP.

Evaluation of mechanical properties of Ti-25Nb BCC porous cell structure and their association with structure porosity: A combined finite element analysis and analytical approach for orthopedic application

Ti-based alloys have been commonly employed in manufacturing implants for orthopedic applications. Binary Titanium-Niobium (Ti-25Nb) alloy is a promising material for potential applications in orthopedics because of their lower elastic moduli and superior biocompatibility than the conventional Ti-based alloys. Implants with porous structures encourage bone ingrowth and reduce the effect of stress-shielding further. This study is aimed at establishing the relationship between the mechanical performance and structural parameters of porous body-centered-cubic (BCC) structures made up of Ti-25Nb (25% by wt.). Solid models of BCC porous structures were constructed (unit cell size: 2 mm; overall size: 8 × 8 × 8 mm³). Finite element analysis (FEA) of the BCC structures with porosity ranging from 29% to 79% (seven porosities) was conducted under tension, bending, and torsional loads. The Gibson-Ashby model and Exponential regression model were also employed to determine the stiffness of the above porous structures. The functional relationships between effective Young's modulus, effective yield strength, and porosity generated from both the models were found to match the FEA results well. Results indicated that porosity in the range of 50%-70% can be used to design graded porous stems to mimic the mechanical properties of cortical bone.

Phase 2 study of anastrozole in patients with estrogen receptor/progesterone receptor positive recurrent low-grade endometrial stromal sarcomas: The PARAGON trial (ANZGOG 0903)

BACKGROUND

Aromatase inhibitors are standard of care for low-grade endometrial stromal sarcomas (LGESS), based on very high response rates reported in retrospective studies. We evaluated the activity of anastrozole in recurrent/metastatic LGESS patients enrolled in PARAGON, a basket trial of anastrozole in estrogen receptor (ER±)/progesterone receptor (PR+) gynecological cancers.

METHOD

An investigator-initiated, single-arm, prospective open-label trial of anastrozole 1 mg/day in patients with ER ± PR + ve LGESS with measurable disease, treated until progressive disease or unacceptable toxicity. Primary endpoint was clinical benefit (complete/partial response + stable disease) rate (CBR) at 3 months. Secondary endpoints include progression-free survival (PFS), quality of life and toxicity.

RESULTS

15 eligible patients were enrolled. CBR at 3 months was 73% (95% CI: 48-89.1%); unchanged at 6 months. Best response was 26.7%, including complete response in one (6.7%; 95% CI 1.2-29.8%), partial response in three (20%, 95% CI 7.1-45.2%) and stable disease in seven (46.7%). Four patients ceased treatment by 3 months due to progression. Median PFS was not reached (25th percentile: 2.9 months (95% CI: 1.2-NR)). PFS was 73.3%, 73.3% and 66% at 6, 12, and 18 months, respectively. Six patients remained on treatment for an average of 44.2 months (range 34.5-63.6) up until data cut. Toxicity was as expected, with 3 patients stopping due to adverse effects.

CONCLUSION

The 26.7% objective response rate with anastrozole is lower than reported in retrospective series, but the CBR was high and durable. The results underscore the importance of prospective trials in rare cancers.

33 Diagnostic Test Accuracy of the 4AT for Delirium Detection: Systematic Review and Meta-Analysis

Introduction

Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short (&lt;2 min) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.

Methods

We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.

Results

17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good.

Conclusions

The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.

29 Predicting Unplanned Readmission and Death After Hospital Discharge: How Do Frailty Tools Compare to Electronic Health Record Frailty Markers?

Introduction

Numerous frailty tools and definitions have been described. Amongst hospitalised patients, the validity of face-to-face instruments may be confounded by acute illness. However, patient assessment after recovery at the point of hospital discharge, or recognition of electronic health record (EHR) frailty markers, may overcome this issuep.

Methods

In a consented, prospective observational cohort study, we recruited patients ≥70 years old within 24 hours of expected discharge from the cardiology ward of the Royal Infirmary of Edinburgh. Three established frailty instruments were tested: the Fried phenotype, Short Physical Performance Battery and nurse-administered Clinical Frailty Scale (CFS). An unweighted 32-item EHR score was generated using frailty markers (e.g. falls risk, continence, cognition) recorded within mandated admission documentation. Comorbidity was assessed by count of chronic health conditions. Outcomes were a 90-day composite of unplanned readmission or death and 12-month mortality. Adjusted Cox modelling determined the hazard ratio (HR) per standard deviation increase in each frailty score.

Results

186 patients (mean age 79 ± 6 years, 64% male) were included, of whom 55 (30%) had a 90-day composite outcome, and 21 (11%) died within 12 months. All four frailty tools were moderately correlated with age and comorbidity (Pearson’s r 0.21 to 0.43, all p &lt; 0.05). The Fried phenotype (HR 1.47, 95% CI 1.18–1.81), CFS (HR 1.24, 95% CI 1.01–1.51) and EHR score (HR 1.26, 95% CI 1.03–1.55) independently predicted 90-day readmission or death, after adjustment for age, sex and comorbidity. All frailty instruments were independent predictors of 12-month mortality, with age, sex and comorbidity losing predictive power (p &gt; 0.05) once frailty was included in modelling.

Conclusions

At hospital discharge, the Fried phenotype and CFS added to age and comorbidity in risk prediction for future unplanned readmission or death. EHR frailty markers appeared comparable to face-to-face assessment. An automated trigger for high-risk patients using routine EHR data merits prospective evaluation.

Neuroimaging correlates of emotional response-inhibition discriminate between young depressed adults with and without sub-threshold bipolar symptoms (Emotional Response-inhibition in Young Depressed Adults)

BACKGROUND

Many subjects with major depression (MDD) exhibit subthreshold mania symptoms (MDD+). This study investigated, for the first time, using emotional inhibition tasks, whether the neural organization of MDD+ subjects is more similar to bipolar depression (BDD) or to MDD subjects without subthreshold bipolar symptoms (MDD-).

METHOD

This study included 118 medication-free young adults (15 - 30 yrs.): 20 BDD, 28 MDD+, 41 MDD- and 29 HC subjects. Participants underwent fMRI during emotional and non-emotional Go/No-go tasks during which they responded for Go stimuli and inhibited response for happy, fear, and non-emotional (gender) faces No-go stimuli. Univariate linear mixed-effects (LME) analysis for group effects and multivariate Gaussian Process Classifier (GPC) analyses were conducted.

RESULTS

MDD- group compared to both the BDD and MDD+ groups, exhibited significantly lower activation in parietal, temporal and frontal regions (cluster-wise corrected p <0.05) for emotional inhibition conditions vs. non-emotional condition. GPC classification of emotional (happy + fear) vs. non-emotional response-inhibition activation pattern showed good discrimination between BDD and MDD- subjects (AUC: 0.70; balanced accuracy: 70% (corrected p = 0.018)) as well as between MDD+ and MDD- subjects (AUC: 0.72; balanced accuracy: 67% (corrected p = 0.045)) but less efficient discrimination between BDD and MDD+ groups (AUC: 0.68; balanced accuracy: 61% (corrected p = 0.273)). Notably, classification of the MDD- group was weighted for left amygdala activation pattern.

LIMITATIONS

Results also need to be tested in a different independent dataset.

CONCLUSION

Using an fMRI emotional Go-Nogo task, MDD- subjects can be discriminated from BDD and MDD+ subjects.

Identification and stratification of systemic lupus erythematosus patients into two transcriptionally distinct clusters based on IFN-I signature

OBJECTIVE

Despite the significant advancement in the understanding of the pathophysiology of systemic lupus erythematosus (SLE) variable clinical response to newer therapies remain a major concern, especially for patients with lupus nephritis and neuropsychiatric systemic lupus erythematosus (NPSLE). We performed this study with an objective to comprehensively characterize Indian SLE patients with renal and neuropsychiatric manifestation with respect to their gene signature, cytokine profile and immune cell phenotypes.

METHODS

We characterized 68 Indian SLE subjects with diverse clinical profiles and disease activity and tried to identify differentially expressed genes and enriched pathways. To understand the temporal profile, same patients were followed at 6 and 12-months intervals. Additionally, auto-antibody profile, levels of various chemokines, cytokines and the proportion of different immune cells and their activation status were captured in these subjects.

RESULTS

Multiple IFN-related pathways were enriched with significant increase in IFN-I gene signature in SLE patients as compared to normal healthy volunteers (NHV). We identified two transcriptionally distinct clusters within the same cohort of SLE patients with differential immune cell activation status, auto-antibody as well as plasma chemokines and cytokines profile.

CONCLUSIONS

Identification of two distinct clusters of patients based on IFN-I signature provided new insights into the heterogeneity of underlying disease pathogenesis of Indian SLE cohort. Importantly, patient within those clusters retain their distinct expression dynamics of IFN-I signature over the time course of one year despite change in disease activity. This study will guide clinicians and researchers while designing future clinical trials on Indian SLE cohort.