“Clots and Failures” A Case of COVID-19 Causing STEMI and Persistent Cardiogenic Shock Ultimately Requiring LVAD

Introduction

We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation.

Case Report

57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10^th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20^th . She failed an extubation trial and underwent tracheostomy on July 23^rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1.

Summary

Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

Recurrence-free survival after total thyroidectomy and lobectomy in patients with papillary thyroid microcarcinoma

PURPOSE

The incidence of papillary thyroid microcarcinoma is increasing. We evaluated the recurrence-free survival following total thyroidectomy and lobectomy to identify the optimal surgical choice.

METHODS

A meta-analysis was performed using the National Library of Medicine and the National Institutes of Health PubMed database to identify eligible studies. Summary 5- and 10-year RFS estimates after TT versus LT were calculated using random effects models.

RESULTS

The literature search yielded 1117 studies (1990-2019). Nine studies met the inclusion criteria comprising 10,186 total thyroidectomy and 11,408 lobectomy patients. The 5-year recurrence-free survival was 98% [95% confidence interval (CI) 97-99%] after total thyroidectomy and 97% (95% CI 96-99%) after lobectomy, based on eight studies (9421 total thyroidectomy and 11,283 lobectomy patients); the 10-year recurrence-free survival was 95% (95% CI 92-98%) after total thyroidectomy and 92% (95% CI 86-96%) after lobectomy, based on eight studies (total thyroidectomy = 10,100, lobectomy = 11,389 patients).

CONCLUSION

The present meta-analysis demonstrates excellent, long-term recurrence-free survival following both total thyroidectomy and lobectomy surgery in patients with papillary thyroid microcarcinoma. The analysis also suggests that patients undergoing total thyroidectomy trended toward a slightly better long-term 10-year recurrence-free survival in comparison to patients undergoing lobectomy, a finding of potential, clinical significance in the management decision-making process.

ECMO for Critically Ill COVID-19 with ARDS: A Case Series

Introduction

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support

Case Report

We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases; case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics.

Summary

Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers; this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

Voices of Community Organizations: How Cancer Centers Can Support Communities in the Face of COVID-19

Purpose: As part of an ongoing effort to support the equitable delivery of cancer care to historically underserved communities in New York City (NYC), we examined the impact of COVID-19 on community outreach organizations working with an NCI-comprehensive cancer center Methods: We conducted 16 semi-structured interviews (30–90 minutes; July-September 2020) with stakeholders (SH) including patient navigators, patient advocates, faith-based leaders, community health, and non-profit organizations in NYC – the epicenter of the COVID-19 pandemic in the US. Using thematic analysis, we characterized experiences and challenges in supporting cancer care delivery during COVID-19. Results: Per SH, COVID-19 required organizations to shift priorities to address day-to-day needs exacerbated by COVID-19 (food insecurity, financial/housing instability, misinformation, emotional distress). Organizations adapted by leveraging existing partnerships, including the cancer center, and partnering with new local/state organizations to broaden their work scope (e.g., COVID-19 testing centers, food pantries, technology training), and disseminate reliable COVID-19 information to communities. All organizations transitioned to virtual platforms creating challenges for those with limited technical resources and often excluded older or isolated populations; thus, many organizations retained a socially distanced in-person component to remain visible and trustworthy within the community. Importantly, SH emphasized the importance of cancer center support via proactive involvement and communication with community members, providing a supportive infrastructure (funding, technical support, personnel), and incorporating community voices into new programs and projects during and beyond the COVID-19 pandemic. Conclusion: In addition to or in lieu of cancer care delivery efforts, community organizations are compelled to develop innovative approaches that address the more immediate needs of the community resulting from COVID-19. Cancer centers can support their community partners by being responsive and flexible to the community needs, building trust within the community, and strengthening community organizational capacity to reduce the long-term damage of COVID-19 and achieve equity.

A241 A REVIEW OF 101 CHILDREN WITH GASTRO-JEJUNAL FEEDING TUBES INCLUDING THEIR COMPLICATIONS AT BC CHILDREN’S HOSPITAL

Background

The use of GastroJejunal Tubes (GJTs) is an increasingly common method for providing post-pyloric enteral nutrition in pediatric patients.

Aims

To describe the patients with GJT including the indication, comorbidities including by system, as well as tube related complications.

Methods

The charts of 101 patients who had a GJT over a one-year period (2019–20) were retrospectively reviewed including demographics, medical diagnoses, information about tube placement, maintenance, and complications including malposition, balloon failure, blockages, and leakages / breaks.

Results

The top indications for GJT are aspiration and GERD. 73.3% have >3 system comorbidities (ie CNS, GI, Resp). Mean age of GJT placement was 43 months. 78% remain on a PPI and 24% are on a prokinetic. 24% continue to eat some amount orally. Over this one-year period, 92% continue with a GJT (mean duration 4 years, max 15), 4% have reverted back to a G-tube, 1% had a surgical J tube placed, and 3% died (not due to the GJT). Following initial placement, these 101 patients underwent 1194 GJT related procedures, (417 urgent changes, 777 routine changes) with 98.3% technical success. Patients needed an average of one urgent repair per year (3.2/1000 GJT days) and the majority of patients required >1 emergency visit. Those with routine GJT changes seem to have fewer urgent repairs (Figure 1).

Conclusions

Children with GJT represent a growing complex patient population. GJT are being used for the longer term. Routine maintenance seems supported by our data although doesn’t prevent the need for urgent repairs or other complications. Frameworks and guidelines are needed for this essential technology to improve clinical care.

Funding Agencies

None

Risk factors for the delayed diagnosis of extrapulmonary TB

BACKGROUND: Extrapulmonary TB (EPTB) is more difficult to diagnose than pulmonary TB. The delayed management of EPTB can lead to complications and increase the socio-economic burden.METHODS: Patients newly diagnosed with EPTB were retrospectively enrolled from 11 general hospitals in South Korea from January 2017 to December 2018. The basic characteristics of patients were described. Univariable and multivariable analyses were performed between early and delayed diagnosis groups to identify risk factors for delayed diagnosis and treatment in EPTB.RESULTS: In total, 594 patients were enrolled. Lymph node TB (28.3%) was the predominant form, followed by abdominal (18.4%) and disseminated TB (14.5%). Concurrent lung involvement was 17.8%. The positivity of diagnostic tests showed no significant difference between the two groups. Acute clinical manifestations in disseminated, pericardial and meningeal TB, and immunosuppression were associated with early diagnosis. Delayed diagnosis was associated with outpatient clinic visits, delayed sample acquisition and diagnostic departments other than infection or pulmonology.CONCLUSION: The delay in diagnosis and treatment of EPTB was not related to differences in microbiological characteristics of Mycobacterium tuberculosis itself; rather, it was due to the indolent clinical manifestations that cause referral to non-TB-specialised departments in the outpatient clinic and delay the suspicion of TB and diagnostic testing.

CERKL is upregulated in cutaneous squamous cell carcinoma and maintains cellular sphingolipids and resistance to oxidative stress

BACKGROUND

Ceramide kinase-like protein (CERKL) was originally described in retinal tissue. CERKL has been shown to protect cells from oxidative stress, and mutations in CERKL underlie the inherited disease retinitis pigmentosa. CERKL expression maintains cellular sphingolipids via an unknown mechanism.

OBJECTIVES

To determine whether CERKL is expressed in epidermis and cutaneous squamous cell carcinoma (cSCC) and whether CERKL expression affects cSCC sphingolipid metabolism and susceptibility to oxidative stress.

METHODS

CERKL expression was determined by RNA-Seq, quantitative polymerase chain reaction and immunohistochemistry. CERKL was knocked down in cSCC cells using small interfering RNA. Sphingolipid content was analysed by liquid chromatography-mass spectrometry. Oxidative stress was induced by treatment with H₂ O₂ , and apoptosis was measured using flow cytometry to determine annexin V binding.

RESULTS

CERKL mRNA and protein are highly expressed in actinic keratosis and cSCC in comparison with normal epidermis. CERKL is also expressed in metabolically active epithelial cells in normal hair bulbs and sebaceous glands. CERKL knockdown in cultured cSCC cells reduces cellular sphingolipid content and enhances susceptibility to oxidative stress.

CONCLUSIONS

These findings suggest that CERKL may be important in cSCC progression and could lead to novel strategies for prevention and treatment of cSCC.

CERKL is Upregulated in Cutaneous Squamous Cell Carcinoma and Maintains Cellular Sphingolipids and Resistance to Oxidative Stress

BACKGROUND

Ceramide Kinase-Like Protein (CERKL) was originally described in retinal tissue. CERKL has been shown to protect cells from oxidative stress, and mutations in CERKL underlie the inherited disease, retinitis pigmentosa. CERKL expression maintains cellular sphingolipids via an unknown mechanism.

OBJECTIVES

To determine whether CERKL is expressed in epidermis and cutaneous squamous cell carcinoma (cSCC) and whether CERKL expression affects cSCC sphingolipid metabolism and susceptibility to oxidative stress.

METHODS

CERKL expression was determined by RNA-Seq, qPCR and immunohistochemistry. CERKL was knocked down in cSCC cells using siRNA. Sphingolipid content was analyzed by liquid chromatography-mass spectrometry (LC-MS). Oxidative stress was induced by treatment with H2 O2 , and apoptosis was measured using flow cytometry to determine annexin v binding.

RESULTS

CERKL mRNA and protein are highly expressed in actinic keratosis and cSCC in comparison with normal epidermis. CERKL also is expressed in metabolically active epithelial cells in normal hair bulbs and sebaceous glands. CERKL knockdown in cultured cSCC cells reduces cellular sphingolipid content and enhances susceptibility to oxidative stress.

CONCLUSIONS

These findings suggest that CERKL may be important in cSCC progression and could lead to novel strategies for prevention and treatment of cSCC.

Using opportunistic screening with abdominal CT to identify osteoporosis and osteopenia in patients with diabetes

Opportunistic osteoporosis screening involves measuring the attenuation of L1 vertebrae on abdominal computed tomography (CT), which correlates with DXA T-score. We found that this approach is useful for detecting low bone mass in patients with diabetes and propose L1 attenuation ≤ 135 Hounsfield units (HU) as a threshold for which DXA should be strongly considered.

INTRODUCTION

Attenuation of the L1 vertebrae on computer tomography (CT) images done for other reasons ("Opportunistic Osteoporosis Screening") has been found to correlate well with DXA-derived T-score. However, the method and the thresholds have never been tested specifically in those with diabetes mellitus (DM), in whom the fracture risk is greater than explained by BMD.

METHODS

In a retrospective study of subjects with DM who had both abdominal CT and DXA within 6 months of each other, we compared L1 attenuation and DXA T-score to define the sensitivity and specificity of thresholds previously established in the general population.

RESULTS

There were 313 subjects among whom 18 (5.8%) had prior major osteoporotic fracture (MOF). Subjects with MOF had lower T-scores (- 2.3 ± 1.4 vs. - 0.9 ± 1.4, p < 0.001) and L1 attenuation (104 HU ± 46 vs. 149 HU ± 47, p < 0.001) than non-fracture subjects. L1 attenuation ≤ 160 HU was 91% sensitive for osteoporosis, while ≤ 110 HU was 80% specific. For a higher T-score of ≤ - 1.5, L1 attenuation ≤ 135 HU showed balanced sensitivity and specificity (65% and 69%, respectively).

CONCLUSION

Opportunistic osteoporosis screening with abdominal CT is useful in determining the need for DXA screening in subjects with diabetes. We propose L1 attenuation ≤ 135 HU as a reasonable threshold for detecting the T-score of ≤ - 1.5, which is likely associated with increased fragility in DM.

High bodyweight variability and increased risk of atrial fibrillation in patients with type 2 diabetes mellitus

Background

Bodyweight variability is a risk factor for atrial fibrillation (AF), but this has not been studied with a focus on patients with diabetes mellitus (DM).

Methods

A nationwide population-based cohort of 670,797 patients with type 2 DM from the Korean National Health Insurance Service database without a history of AF and with ≥3 measurements of body weight over a 5-year period were followed up for AF development. Intra-individual bodyweight variability was calculated using variability independent of mean (VIM), and high bodyweight variability was defined as the quintile with the highest variability with the lower four quintiles as reference.

Results

During a median of 7.0 years of follow-up, 22,019 patients (3.3%) were newly diagnosed with AF. Risk of incident AF was increased in those in the highest quintile of bodyweight variability, after adjustment for baseline body mass index (BMI), age, sex, lifestyle factors, comorbidities, number of oral anti-diabetic medication, insulin use, duration of DM, and fasting glucose (HR 1.16, 95% CI 1.12–1.20). High bodyweight variability was significantly associated with AF development regardless of baseline BMI group and direction of overall weight change. This association was stronger in subjects with lower BMI, those on insulin, and those with a DM duration of greater than 5 years.

Conclusions

High bodyweight variability was associated with AF development, independently of traditional cardiovascular risk factors and baseline BMI. This association was stronger in underweight patients and in advanced diabetic stage.

Funding Acknowledgement

Type of funding source: None

S, K.R. R, Anua S, Mastor N. Antimicrobial resistance profile of Salmonella present in organic farming in Selangor, Malaysia

Presence of Salmonella in organic farming may lead to contamination in fresh produce. This study was designed to detect Salmonella contamination in organic vegetable farm situated in Serdang and to evaluate the antibiotic susceptibility profiles of the isolates. A total of 460 samples of brinjal, cucumber, ladies’ fingers and soil were collected and examined for the presence of Salmonella. The obtained isolates were identified and confirmed by biochemical characterization and serotyping. Antibiotic sensitivity profiles of the isolates were determined by using agar disk diffusion method. Salmonella spp. was detected in brinjal (1.7%, n=2), cucumber (1.7%, n=2), ladies’ fingers (2.5%, n=3) and soil (5.0%, n=5) samples. The prevalent serovars were Salmonella enterica ser. Senftenberg, S. enterica ser. Weltevreden and S. enterica ser. Corvallis. All strains were resistance to penicillin and vancomycin, with multiple antibiotic resistance (MAR) index between 0.21 and 0.36, demonstrated here as multi-drug resistant (MDR) Salmonella. The result highlighted that organic vegetables constituted potential sources of Salmonella, informing continuous monitoring and tightened surveillance are necessary to ensure food safety.

Impact of Data Presentation on Physician Performance Utilizing Artificial Intelligence-Based Computer-Aided Diagnosis and Decision Support Systems

Ultrasound (US) is a valuable imaging modality used to detect primary breast malignancy. However, radiologists have a limited ability to distinguish between benign and malignant lesions on US, leading to false-positive and false-negative results, which limit the positive predictive value of lesions sent for biopsy (PPV3) and specificity. A recent study demonstrated that incorporating an AI-based decision support (DS) system into US image analysis could help improve US diagnostic performance. While the DS system is promising, its efficacy in terms of its impact also needs to be measured when integrated into existing clinical workflows. The current study evaluates workflow schemas for DS integration and its impact on diagnostic accuracy. The impact on two different reading methodologies, sequential and independent, was assessed. This study demonstrates significant accuracy differences between the two workflow schemas as measured by area under the receiver operating curve (AUC), as well as inter-operator variability differences as measured by Kendall’s tau-b. This evaluation has practical implications on the utilization of such technologies in diagnostic environments as compared to previous studies.

Age-related natural fertility outcomes in women over 35 years: a systematic review and individual participant data meta-analysis

STUDY QUESTION

What is the rate of natural conception leading to ongoing pregnancy or livebirth over 6–12 months for infertile women of age ≥35 years?

SUMMARY ANSWER

Natural conception rates were still clinically relevant in women aged 35 years and above and were significantly higher in women with unexplained infertility compared to those with other diagnoses.

WHAT IS KNOWN ALREADY

In recent years, increasing numbers of women have attempted to conceive at a later age, resulting in a commensurate increase in the need for ART. However, there is a lack of data on natural fertility outcomes (i.e. no interventions) in women with increasing age.

STUDY DESIGN, SIZE, DURATION

A systematic review with individual participant data (IPD) meta-analysis was carried out. PubMed, MEDLINE, EMBASE, the Cochrane Library, clinicaltrials.gov were searched until 1 July 2018 including search terms ‘fertility service’, ‘waiting list’, ‘treatment-independent’ and ‘spontaneous conception’. Language restrictions were not imposed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria were studies (at least partly) reporting on infertile couples with female partner of age ≥35 years who attended fertility services, underwent fertility workup (e.g. history, semen analysis, tubal status and ovulation status) and were exposed to natural conception (e.g. independent of treatment such as IVF, ovulation induction and tubal surgery). Studies that exclusively studied only one infertility diagnosis, without including other women presenting to infertility services for other causes of infertility, were excluded. For studies that met the inclusion criteria, study authors were contacted to provide IPD, after which fertility outcomes for women of age ≥35 years were retrieved. Time to pregnancy or livebirth and the effect of increasing age on fertility outcomes after adjustment for other prognostic factors were analysed. Quality of studies was graded with the Newcastle–Ottawa Scale (non-randomised controlled trials (RCTs)) or the Cochrane Risk of Bias tool (for RCTs).

MAIN RESULTS AND THE ROLE OF CHANCE

We included nine studies (seven cohort studies and two RCTs) (n = 4379 women of at least age 35 years), with the observed composite primary outcome of ongoing pregnancy or livebirth occurring in 429 women (9.8%) over a median follow-up of 5 months (25th to 75th percentile: 2.5–8.5 months). Studies were of moderate to high quality. The probability of natural conception significantly decreased with any diagnosis of infertility, when compared with unexplained infertility. We found non-linear effects of female age and duration of infertility on ongoing pregnancy and tabulated the predicted probabilities for unexplained infertile women aged 35–42 years with either primary or secondary infertility and with a duration of infertility from 1 to 6 years. For a 35-year-old woman with 2 years of primary unexplained infertility, the predicted probability of natural conception leading to ongoing pregnancy or livebirth was 0.15 (95% CI 0.11–0.19) after 6 months and 0.24 (95% CI 0.17–0.30) after 12 months. For a 42-year-old woman, this decreased to 0.08 (95% CI 0.04–0.11) after 6 months and 0.13 (95% CI 0.07–0.18) after 12 months.

LIMITATIONS, REASONS FOR CAUTION

In the studies selected, there were different study designs, recruitment strategies in different centres, protocols and countries and different methods of assessment of infertility. Data were limited for women above the age of 40 years.

WIDER IMPLICATIONS OF THE FINDINGS

Women attending fertility services should be encouraged to pursue natural conception while waiting for treatment to commence and after treatment if it is unsuccessful. Our results may aid in counselling women, and, in particular, for those with unexplained infertility.

STUDY FUNDING/COMPETING INTEREST(S)

S.J.C. received funding from the University of Adelaide Summer Research Scholarship. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437), B.W.M. reports consultancy for ObsEva, Merck, Merck KGaA, iGenomix and Guerbet. B.W.M. reports research support by Merck and Guerbet.

PROSPERO REGISTRATION NUMBER

CRD42018096552.

An epistatic interaction between pre-natal smoke exposure and socioeconomic status has a significant impact on bronchodilator drug response in African American youth with asthma

BACKGROUND

Asthma is one of the leading chronic illnesses among children in the United States. Asthma prevalence is higher among African Americans (11.2%) compared to European Americans (7.7%). Bronchodilator medications are part of the first-line therapy, and the rescue medication, for acute asthma symptoms. Bronchodilator drug response (BDR) varies substantially among different racial/ethnic groups. Asthma prevalence in African Americans is only 3.5% higher than that of European Americans, however, asthma mortality among African Americans is four times that of European Americans; variation in BDR may play an important role in explaining this health disparity. To improve our understanding of disparate health outcomes in complex phenotypes such as BDR, it is important to consider interactions between environmental and biological variables.

RESULTS

We evaluated the impact of pairwise and three-variable interactions between environmental, social, and biological variables on BDR in 233 African American youth with asthma using Visualization of Statistical Epistasis Networks (ViSEN). ViSEN is a non-parametric entropy-based approach able to quantify interaction effects using an information-theory metric known as Information Gain (IG). We performed analyses in the full dataset and in sex-stratified subsets. Our analyses identified several interaction models significantly, and suggestively, associated with BDR. The strongest interaction significantly associated with BDR was a pairwise interaction between pre-natal smoke exposure and socioeconomic status (full dataset IG: 2.78%, p = 0.001; female IG: 7.27%, p = 0.004)). Sex-stratified analyses yielded divergent results for females and males, indicating the presence of sex-specific effects.

CONCLUSIONS

Our study identified novel interaction effects significantly, and suggestively, associated with BDR in African American children with asthma. Notably, we found that all of the interactions identified by ViSEN were "pure" interaction effects, in that they were not the result of strong main effects on BDR, highlighting the complexity of the network of biological and environmental factors impacting this phenotype. Several associations uncovered by ViSEN would not have been detected using regression-based methods, thus emphasizing the importance of employing statistical methods optimized to detect both additive and non-additive interaction effects when studying complex phenotypes such as BDR. The information gained in this study increases our understanding and appreciation of the complex nature of the interactions between environmental and health-related factors that influence BDR and will be invaluable to biomedical researchers designing future studies.

Sustaining tuberculosis preventive therapy scale-up through direct supportive supervision

Background

Tuberculosis preventive therapy (TPT) is recommended for tuberculosis (TB) prevention among people living with HIV (PLHIV) and other high-risk groups. The Nigerian Military HIV Program embarked on TPT-specific 'direct supportive supervision' (DSS) in May 2018 to increase TPT initiation and completion rates.

Methods

Interventional approaches included site visits to conduct root cause analysis, didactic teaching approach on the concepts of quality improvement and mentorship to address barriers. The DSS introduced TPT monitoring tools, sticker reminders on clients' folders, and bi-weekly data collection and review for decision making.

Results

TPT initiation increased from a monthly pre-intervention median of 323 clients to monthly medians of 2611 during the 'surge' and 1212 clients during the 'sustained' phases. Due to an isoniazid stock-out, a 'dip phase', with a median of 559 clients was recorded. Overall, 10 463 clients were started on TPT in fiscal year (FY) 2018 and 12 596 in FY2019, with an overall initiation rate of 79%. Completion rates were respectively 73% and 70% for FY2018 and FY2019.

Conclusion

With the implementation of a tailored DSS, programmatic barriers to TPT were easily identified and quickly addressed to increase initiation and completion rates.

AB0074 KRÜPPEL-LIKE FACTOR 10 IS A IMPORTANT MODULATORY FACTOR OF CHONDROCYTE HYPERTROPHY IN DEVELOPING SKELETON

Background:

To investigate the functional role of KLF10 as a modulator of chondrocyte hypertrophy in developmental skeleton, the developmental characteristics in the long bone of KLF10 knockout mice and characteristics of MSCs from KLF10 KO mice were investigated regarding chondrogenesis and osteogenesis. Delayed long bone growth and delayed formation of primary ossification center were observed in an early embryonic stage in KLF10 KO mouse along with very low Ihh expression in epiphyseal plate. While the chondrogenic potential of mMSCs appeared normal or slight decrerased in KLF10 KO mice, osteogenesis and hypertrophy were extensively suppressed. KLF10 was found to be a mediator of chondrocyte hypertrophy in developing skeleton. Suppression of KLF10 may be considered as a new strategy for preventing hypertrophy in cartilage regeneration using MSCs.

Objectives:

Investigated the functional role of KLF10 to present new insights into the transcriptional network regulating skeletal development and provide a novel strategy for preventing aberrant hypertrophic differentiation in cartilage regeneration strategies using MSCs.

Methods:

Generation of KLF10 KO mice and genotyping / Skeletal preparations, embryo heights, and mineralized bone length measurements / Histological and Fluorescent Immunohistochemical Analysis / ALP staining and activity / Alizarin red staining / Von Kossa staining and calcium salts quantification / Isolation and Establishment of Mouse Clonal MSC Lines / Chondrogenic pellet culture and differentiation of mMSCs / DNA Quantification and GAG Contents Analysis / Rq-PCR Analysis / Statistics

Results:

The overall results showed that mMSCs from KLF10 KO mice have significantly decreased osteogenic potential with very low Ihh expression while an increase in chondrogenic potential was not significant. In addition to Ihh promotor demonstrated in our previous study, KLF10 can activate Runx2 expression through its proximal-promoter region. Thus, KLF10 may indirectly stimulate Ihh expression upstream of Runx2 or directly bind to Ihh promoter and activate Ihh expression. As shown in this and out previous study, KLF10 also enhances Wnt/β-catenin signalling in MSCs. KLF10 modulates β-catenin sub-cellular localization and enhances Wnt signalling in osteoblasts.

Conclusion:

In conclusion, primary ossification in KLF10 KO mice was critically delayed during early endochondral bone development. KLF10 KO inhibited hypertrophy via reduced Ihh expression in developing skeleton. TGF-β-induced hypertrophy was inhibited during chondrogenesis of KLF10 KO mMSCs. Our findings present new insights into the transcriptional-network system of skeletal development and provide a novel strategy for suppressing hypertrophy in cartilage tissue engineering.

Figure.

Acknowledgments:

This research was supported by the National Research Foundation of Korea (NRF-2019R1H1A2039685 and 2019R1I1A1A01043778).

Disclosure of Interests:

None declared

THU0058 ENHANCEMENT OF CARTILAGE REGENERATION EFFICIENCY WITH HUMAN ADIPOSE STEM CELL THREE-DIMENSIONAL SPHEROID

Background:

3D (three-dimensional) cell culture technology has been researched steadily because of its high potential of biocompatibility compared to single cells since 1990s, and is being developed to 3D spheroids recently. Spheroids are considered to reflect the natural organization of cells better than 2D cell cultures, and stem cells spheroids have been studied extensively in therapeutic transplantation. Stem cells were considered as a method of replacing autologous chondrocyte in regenerative treatment of articular cartilage. Compared to conventional single cells, 3D cell culture is artificially created an environment similar to a living body in vitro so that all cells collectively, a cell culture model that allows growth or interaction with the environment. Therefore, the findings of this study indicate that enhancement of treatment efficiency of stem cells caused by potential of survival and proliferation of hASC spheroid in Osteoarthritis. In conclusion, spheroid positive subpopulation of hASCs has high cell proliferation and survival but not apoptosis and cell death potential, which may contribute to successful cartilage regeneration and the development of stem cell therapies in the future.

Objectives:

Studied for 3D spheroids to investigate the mechanism of enhancement of survival and proliferationof hASC (human adipose stem cells) spheroid, which may contribute to successful improvement of therapeutic efficacy of stem cells.

Methods:

Cell isolation and culture / 3D cell culture dish preparation / hASCs culture on 3D cell culture dish / Real-time PCR analysis / Western blotting / Alcian blue staining / ACLT + MM (Anterior cruciate ligament transection with Medial meniscectomy) model / In vivo fluorescence for cell tracking / In vivo effects of spheroids in OA joint / Histological analysis / Enzyme-linked immunosorbent assay (ELISA) results for inflamma -tory cytokines in rat synovial fluid / Statistical Analysis

Results:

In order to see how the spheroid showed more residual than single, and how effective it was in actual cartilage regeneration, the result of paraffin tissues were confirmed by safranin O staining for each condition. The tendency of cartilage regeneration efficiency was good for spheroid. Although the differences between the single and spheroid groups were small, they reaffirmed that they could somewhat protect cartilage and help regeneration treatment. However, immunohistochemistry of HN(Human nucleic antigen) staining showed that cells of single and spheroid were not observed in the wound but disappeared by the paracrine effect.

Conclusion:

Spheroids do not exhibit differentiation characteristics, but they could be seen as a result of expression of related genes such as Bax, Bcl-XL and Alcian blue staining. Spheroids tend to have low potential of cell death rather than proliferation and reduction in the proliferation. So, we conclude the fact that instead of hASCs going directly to the surgical site to regenerate cartilage, they can help catrilage regeneration.

Acknowledgments:

This research was supported by the National Research Foundation of Korea (NRF-2019R1H1A2039685 and 2019R1I1A1A01043778).

Disclosure of Interests:

None declared

Preimplantation genetic diagnosis for retinoblastoma survivors: a cost-effectiveness study

This study aimed to investigate the cost-effectiveness of preimplantation genetic diagnosis (PGD) for the reproductive choices of patients with heritable retinoblastoma. The study modelled the costs of three cycles of in-vitro fertilization (IVF) and PGD across all uptake rates of PGD, number of children affected with retinoblastoma at each uptake rate and the estimated quality-adjusted life years (QALYs) gained. Cost-effectiveness analysis was conducted from the Australian public healthcare perspective. The intervention was the use of three cycles (one fresh and two frozen) of IVF and PGD with the aim of live births unaffected by the retinoblastoma phenotype. Compared with the standard care pathway (i.e. natural pregnancy), IVF and PGD resulted in a cost-saving to 18 years of age of AUD$2,747,294 for a base case of 100 couples with an uptake rate of 50%. IVF and PGD resulted in fewer affected (n = 56) and unaffected (n = 78) live births compared with standard care (71 affected and 83 unaffected live births), and an additional 0.03 QALYs per live birth. This modelling suggests that the use of IVF and PGD to achieve an unaffected child for patients with heritable retinoblastoma resulted in an overall cost-saving. There was an increase in QALYs per baby across all uptake rates. However, in total, fewer babies were born following the IVF and PGD pathway.

FRI0067 ALL-CAUSE AND CAUSE-SPECIFIC MORTALITY OF PATIENTS WITH RHEUMATOID ARTHRITIS IN KOREA: A NATION-WIDE POPULATION-BASED STUDY

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with excess mortality.

Objectives:

To compare all-cause and cause-specific mortality between RA patients versus general population, using a nationally representative cohort from Korea National Health Insurance Service database (KNHIS).

Methods:

Patients with RA aged ≥ 40 years were identified from 2010-2016 KNHIS database and their annual cohorts were constructed per each calendar year. RA patients of each cohort were required to have prevalent RA on January 1stof the given calendar year. The KNHIS were linked with Korea national mortality data to obtain cause of death information and to estimate expected deaths of RA patients in reference to mortality data of the general population in Korea. Standardized mortality ratio (SMR) with a 95% confidence interval (CI) was calculated to compare mortality of RA patients and general population.

Results:

A total of 6,404 deaths occurred among 79,440 RA patients during 2011-2016 period, showing all-cause SMR (95% CI) of 1.45 (1.42-1.49) compared to general population. The SMR was 1.72 (1.59-1.85) for biologics users and 1.43 (1.39-1.46) for non-users, versus general population. The annual SMR of RA patients showed a growing trend of mortality over time particularly among biologics users (Table 1). The SMRs for common causes of death among RA patients showed approximately tripled risk of dying due to pulmonary and infectious causes compared to general population (Table 2). There was approximately 20% increased risk of cardiovascular deaths but 8% decreased risk of cancer-related deaths among RA patients compared to general population (Table 2).

Table 1.

Annual all-cause SMR of RA patients compared to 2010 general population

Calendar year1RA patientsBiologics usersBiologics non-users20111.00 (0.92−1.07)1.13 (0.87−1.39)0.98 (0.90−1.06)20121.13 (1.06−1.21)0.98 (0.75−1.22)1.15 (1.07−1.23)20131.22 (1.14−1.30)1.29 (1.04−1.54)1.21 (1.13−1.29)20141.30 (1.23−1.38)1.53 (1.26−1.79)1.28 (1.20−1.36)20151.45 (1.38−1.53)1.81 (1.53−2.09)1.41 (1.33−1.50)20161.45 (1.37−1.52)1.94 (1.66−2.22)1.39 (1.31−1.47)

CI, confidence interval; RA, rheumatoid arthritis; SMR, standardized mortality ratio

12010 data were used to identify RA diagnosis dates but were not included for SMR estimation since diagnosis dates of RA were unclear for those who had RA in 2010.

Table 2.

Cause-specific SMR comparing RA patients versus general population

Cause of deathRA patientsBiologics usersBiologics non-usersInfection3.12 (2.93−3.13)4.12 (3.36−4.88)3.03 (2.83−3.23)Cancer0.92 (0.87−0.97)0.98 (0.81−1.14)0.91 (0.85−0.96)Respiratory13.14 (2.97−3.32)4.64 (3.89−5.38)3.01 (2.83−3.19)Cardiovascular21.18 (1.12−1.25)1.26 (1.03−1.50)1.18 (1.11−1.25)

CI, confidence interval; RA, rheumatoid arthritis; SMR, standardized mortality ratio

1Includes pulmonary infections and chronic lung diseases (J00-J98, U04);2Includes atherosclerotic and non-atherosclerotic deaths (I00-I99).

Conclusion:

The all-cause mortality of RA patients during 2011-2016 was overall 45% greater than that of general Korean population, which increased annually over the study period. The increased mortality was more prominent among biologics users than non-users. The risk of infectious and respiratory deaths were tripled among RA patients compared to general population.

References:

[1]Sokka T, et al. Mortality in rheumatoid arthritis: 2008 update. Clin Exp Rheumatol. 2008;26(5 Suppl 51):S35-61.

Acknowledgments:

None

Disclosure of Interests:

None declared