POS0867 COMORBIDITY AND COMPLICATIONS PRIOR TO SYSTEMIC SCLEROSIS DIAGNOSIS: A RETROSPECTIVE COHORT ANALYSIS

Background

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by progressive microvascular damage, collagen deposition and subsequent fibrosis of the skin and internal organs which contributes to substantial morbidity and premature death.1-2

Objectives

The objective was to evaluate the disease burden of SSc patients prior to their SSc diagnosis.

Methods

Patients with SSc were identified in a claims dataset (IBM MarketScan Commercial Database, 2015-2019) using ICD 10 diagnosis codes for SSc. Eligible subjects were required to have > 1 inpatient or >2 outpatient/office claims with a scleroderma diagnosis code on separate days and > 24 months of continuous health plan enrollment without a SSc diagnosis before the first SSc claim (‘index date’) and > 12 months of enrollment after the index date. Overall comorbid disease burden was assessed via the Charlson Comorbidity Index (CCI) 13-24 and 12 months before and 12 months after index date. The prevalence of SSc-related complications for atherosclerosis, pulmonary arterial hypertension (PAH), pulmonary fibrosis (PF), Raynaud’s Phenomenon (RP), and gastrointestinal (GI) complications (e.g., GERD, dysphagia, etc.) were identified using ICD codes and reported as percentages for the aforementioned time intervals relative to patients’ index dates.

Results

902 eligible SSc patients were identified for analysis. The mean age at index SSc diagnosis was 54.3 years and 84.7% of patients were female. Mean CCI scores 13-24 months before, 12 months before, and 12 months after index SSc diagnosis were 0.84, 1.13 and 1.30, respectively. From the time points 13-24 months before, 12 months before, and 12 months after index SSc diagnosis, increasing rates were also observed of atherosclerosis, PAH, PF, RP, and GI complications (Table 1).

Table 1.

Charlson Comorbidity Index (CCI) and systemic sclerosis-related complications by time-interval

Clinical characteristic13-24 months before Index12 months before Index12 months after IndexMean CCI (std dev)0.84 (1.58)1.13 (1.71)1.30 (1.75)Systemic sclerosis-related complicationsAtherosclerosis7%9%14%Pulmonary arterial hypertension (PAH)1%4%12%Pulmonary fibrosis (PF)5%8%16%Raynaud’s Phenomenon (RP)13%29%43%GI complications23%32%46%

Conclusion

Results from this analysis suggests that SSc-related sequalae are present at least two years prior to SSc diagnosis and rates of these complications increased markedly over time. Patients’ overall comorbid disease burden also worsened substantially over this period, likely because of these complications. The internal organ involvement is likely under reported due to requirements to link each diagnosis with an ICD-10 code. These data indicate the significant burden of SSc, prior to and after diagnosis, highlighting the need for awareness, prompt diagnosis, and effective therapies for SSc and its related complications.

References

[1]Cutolo M, et al. Expert Rev Clin Immunol. 2019;15(7):753-764.

[2]Steen VD, Medsger TA. Ann Rheum Dis. 2007;66(7):940-944.

Disclosure of Interests

Dinesh Khanna Consultant of: Horizon Therapeutics, Daniel Furst Consultant of: Horizon Therapeutics, Justin W. Li Grant/research support from: Horizon Therapeutics, Saloni Shah Grant/research support from: Horizon Therapeutics, Tamara Lesperance Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Farah Ali Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Stephanie Taylor Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

Comparative evaluation of different techniques for herniorrhaphy in calves

Umbilical hernia is one of the most common problems in young calves. This problem occurs in dairy sector as well as in the local farmers. Present study was conducted to compare outcomes of four different techniques of herniorrhaphy. Twenty four young calves (n=24) were divided in 4 groups (A, B, C, and D) which underwent four different surgical techniques. Group A underwent vicryl plus suture material and pants-over-west technique, Group B underwent mesh application with Dexon suture material by using simple interrupted suture pattern, Group C underwent closed method with Nylon No. 3 suture material by using vertical mattress suture pattern and Group D underwent clamp application method with Silk No. 2 suture material by using simple interrupted suture pattern. The result showed that mesh application method was comparatively better with respect to feed intake, body weight gain and healing time. There was no reoccurrence with non-significant hematological changes (p≤0.05). It is concluded that mesh application method is safer than other three techniques and there are no systemic effects of this surgical intervention on calves' health.

Analyzing the impact of Сovid-19 on the hotel industry in Nepal

COVID-19 pandemic has significantly affected the tourism and hospitality sectors across the globe. Due to the increase in the number of COVID positive cases, governments of countries have imposed strict lockdown globally as a precautionary measure to control the spread of the coronavirus, which has led to restrictions on travel and mobility of individuals from one place to the other. One of the countries that have been severely affected due to the lockdown is the economy of Nepal. Being a tourist-friendly nation, every year, Nepal’s tourism and hospitality sector contributes significantly to its GDP. With a restriction on travel and cancellation of bookings, one of the most important departments under this sector, the hotel industry, is currently struggling to survive due to loss of revenue. The present study tries to understand the challenges and strategies planned by the hotel industry stakeholders in Nepal. A primary survey conducted with hoteliers from 10 hotels reveals major concerns about maintaining a steady financial performance and expectations for government aid to help this sector come back to normalcy.

Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p<0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p<0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p<0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.

Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p<0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p<0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.

Should Q-CT Be the Gold Standard for Detecting Spinal Osteoporosis?

STUDY DESIGN

Prospective comparative study.

OBJECTIVE

Refinement of the guidelines for screening of osteoporosis and considering quantitative computed tomography (Q-CT) for detecting spinal osteoporosis.

SUMMARY OF BACKGROUND DATA

Spinal osteoporosis is often underestimated and under-evaluated due to either lack of availability of the diagnostic modality or lack of awareness about the possibility of overestimation by dual X-ray absorptiometry (DXA) scan. There is a need for reconsidering osteoporosis evaluation with a site specific and patient specific inclination.

METHODS

Post-menopausal women that underwent bone mineral density (BMD) evaluation from January-2018 to December-2020 with either Q-CT or DXA were evaluated. Comparison studies of the distribution of age and T-scores of the bone densities obtained from the two study groups: age-matched, sex-matched, and common skeletal site of interest (L1-4 vertebrae) were performed. Mann-Whitney U test, correlation and regression analyses were performed and bell curves were plotted.

RESULTS

Of the 718 women evaluated, 447 underwent Q-CT and 271 underwent DXA. There was no significant difference among the age distribution of the two study groups (P-value > 0.05). The mean and mode T-scores obtained by Q-CT and DXA were found to be -2.71, -3.8 and -1.63, -1.7 respectively. A highly significant difference in the T-scores was observed in the Q-CT and DXA groups (P-value < 0.0001). Among those who were screened by Q-CT, 58.16% were osteoporotic, 37.58% were osteopenic, and 4.25% were normal. The respective percentages in the DXA group were 30.63%, 49.82%, and 19.55%.

CONCLUSION

Q-CT provides more precise estimation of cancellous bone mineral density than DXA. With the reliance on DXA for spinal BMD estimation being questionable, new standards have to be established for spinal osteoporosis evaluation. Q-CT can be a better alternative to replace DXA as the gold standard for the evaluation of spinal osteoporosis.Level of Evidence: 2.

Cylindrospermopsin impairs zebrafish (Danio rerio) embryo development

Cyanotoxins are among common contaminants that can impair human, animal, and environmental health. Cylindrospermopsin (CYN) is an abundant form of cyanotoxins elevated following algal bloom in the water worldwide. Previous studies have described CYN effects on several organs in mammals. However, little is known about its toxicity mechanisms in other vertebrates. This study aims to characterize the developmental effects of CYN using zebrafish larvae as an aquatic model organism. A wide range of CYN concentrations (0-2000 μg/L) was tested using a morphometric approach for survival, hatching, various growth and developmental abnormalities. We also investigated the expression of genes related to oxidative stress, osmoregulation, and thyroid function. Exposure to CYN resulted in decreased growth, increased developmental abnormalities such as pericardial and yolk sac edema as well as swim bladder absence. In addition, CYN increased tr1a, and decreased dio1 and dio3 transcript levels which are involved in thyroid-mediated function. It also increased transcript levels related to oxidative stress, including hsp70, ahr1a, cyp1a, gpx and cat. Lastly, CYN exposure increased aqp3a and decreased dab2, which are involved in osmoregulation with a threshold of 10 μg/L. The present study demonstrates multiple effects of exposure to environmentally relevant CYN concentrations in zebrafish embryos.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Forest yield prediction under different climate change scenarios using data intelligent models in Pakistan

This study aimed to develop and evaluate data driven models for prediction of forest yield under different climate change scenarios in the Gallies forest division of district Abbottabad, Pakistan. The Random Forest (RF) and Kernel Ridge Regression (KRR) models were developed and evaluated using yield data of two species (Blue pine and Silver fir) as an objective variable and climate data (temperature, humidity, rainfall and wind speed) as predictive variables. Prediction accuracy of both the models were assessed by means of root mean squared error (RMSE), mean absolute error (MAE), correlation coefficient (r), relative root mean squared error (RRMSE), Legates-McCabe's (LM), Willmott's index (WI) and Nash-Sutcliffe (NSE) metrics. Overall, the RF model outperformed the KRR model due to its higher accuracy in forecasting of forest yield. The study strongly recommends that RF model should be applied in other regions of the country for prediction of forest growth and yield, which may help in the management and future planning of forest productivity in Pakistan.

Diffuse Idiopathic Neuroendocrine Cell Hyperplasia (DIPNECH) on Electromagnetic Navigation Bronchoscopy (EMN) Guided Fine Needle Aspiration (FNA): A Case Report

Introduction/Objective

DIPNECH is a clinicopathological diagnosis characterized by abnormal proliferation of single or clusters of neuroendocrine cells in the bronchial mucosa. The World health organization includes DIPNECH as a preinvasive lesion to carcinoid tumors of the lung. Diagnosis is often delayed or missed due to insidious presentation and rarity of the disease. High degree of suspicion in the appropriate clinical and radiological context is important for early diagnosis. We describe a unique case of DIPNECH diagnosed by EMN guided aspiration cytology in the setting of multiple incidental lung nodules and confirmed on surgical resection.

Methods/Case Report

A 69-year-old female with history of insidious cough was referred to pulmonology clinic for multiple incidental bilateral lung nodules detected by CT scan, largest involving the right middle lobe. Although the main diagnostic consideration was pulmonary metastasis, several radiological features, including diffuse mosaic attenuation pattern, prompted the possibility of a diffuse neuroendocrine process. Electromagnetic navigation bronchoscopy (ENB) guided fine needle aspiration cytology was performed. Air-dried and Papanicolaou stained smears were scant but showed dispersed and clusters of small cells with fine chromatin with minimal cytoplasm. No necrosis or mitosis were seen. A cell block was prepared that showed rare clusters of tumor cells positive for immunostains synaptophysin, chromogranin, CD56, with a Ki-67 of 1%. In the appropriate clinical and radiological context findings were consistent with a well differentiated neuroendocrine process such as DIPNECH. Right middle lobe resection confirmed extensive DIPNECH with multiple typical carcinoid tumors and tumorlets.

Results (if a Case Study enter NA)

NA

Conclusion

It is essential to be familiar with the clinical and radiological findings of DIPNECH and include it in the differential diagnosis of its mimickers. Although the diagnosis is challenging on limited specimens, this report indicates that EMN guided aspiration cytology can be used as a valuable early tool for accurate diagnosis and timely management of DIPNECH.

1600 Assessing Necessity and Cost-Effectiveness of Routine Pre-Thyroidectomy Group and Save Tests

Aim

To determine the necessity and cost effectiveness of routine blood group and save tests (G&S) before thyroidectomy

Background

Sub-total or total thyroidectomy is the mainstay of treatment for several thyroid disorders. The incidence of post-thyroidectomy haemorrhage has been reported between 0.36% and 4.3% in the literature. Many patients undergo routine G&S testing in anticipation of a peri-operative haemorrhage requiring blood transfusion.

Method

Retrospective review identified 276 patients undergoing an elective total or sub-total thyroidectomy at a London University Teaching Hospital between February 2018 and August 2020. Electronic medical and transfusion department records were audited to identify patients who had pre-operative G&S tests, pre-operatively reserved blood products and peri-operative transfusions.

Results

261 (94.6%) patients had a valid pre-operative group and save test. 17 (6.16%) patients had a total of 61 units of blood products ordered pre-operatively. Only 2 patients required transfusion.

Conclusions

The blood transfusion rate for elective thyroidectomies at this centre was 0.72%. Routine G&S tests cost the trust thousands of pounds and create unnecessary burden on healthcare providers’ time and hospital resources. We propose that routine pre-operative G&S tests are unnecessary for elective thyroidectomies.

111 The Systemic Effects of Intra-Articular Steroid Injections- Should COVID-19 Change Our Practice?

Aim

The COVID-19 pandemic prompted us to review and often suspend services, while patients continue to suffer with painful musculoskeletal conditions. The diagnostic and therapeutic value of intra-articular corticosteroid injections (IACSI) cannot be denied. Current BOA guidelines advise giving the lowest effective dose for inflammatory arthritis and limit use in osteoarthritis to patients with high levels of pain and disability. We aimed to evaluate the literature pertaining to the use of IACSI and the potential systemic immunosuppressive effects.

Method

We searched Medline, using the terms “systemic effects of intra-articular steroid” and “clinical course of Coronavirus infection in patients with steroid use”, between 1997 and 2020.

Results

No studies specifically looked at the systemic effects of intra-articular steroids in the presence of COVID-19 infection; however, four studies were identified which concluded that intra-articular steroid injections resulted in sufficient systemic absorption to cause suppression of the hypothalamic-pituitary-adrenal axis and endogenous cortisol production. These effects are dose dependent and are more common in patients with inflammatory joint diseases. A further four RCT’s, including one systematic review, showed that suppressed cortisol concentration was associated with a significant increase in mortality.

Conclusions

There is a lack of evidence in relation to the use of intra-articular steroids in COVID-19. However, evidence suggests that intra-articular steroids can result in systemic absorption and suppression of endogenous cortisol production thus increasing the potential risk of complications of COVID-19. We therefore support cautious use of low dose steroid injections in patients with inflammatory arthritis, where no alternative treatment is available.

Barriers and enablers to participating in regular screening programmes for women with cerebral palsy: A qualitative life course study

AIMS

To determine the barriers and enablers to regular, women-oriented screening programmes for women with cerebral palsy (CP); and to discuss the participants' suggestions for change.

DESIGN

Qualitative life course approach.

METHODS

Twenty-five life course interviews were conducted with women in 2020 who identified as having a diagnosis of CP. Interviews were conducted in person or using electronic platforms. Framework analysis was used to interpret the data.

FINDINGS

Access and utilization of regular screening programmes for women with CP across the life course are determined by multiple socioecological factors. Three themes are discussed focusing particularly on cervical and breast screening: 1. barriers, 2. enablers and 3. women's suggestions for change. Some women chose to opt out of sexual health checks for fear they would be too uncomfortable or the procedure would be too difficult. Practitioner attitudes towards disability in general, as well as the extent to which they understood the effects of CP for women, was highlighted as a barrier. Accessibility and adaptability of the environment also influenced women's uptake of screening.

CONCLUSION

Women with CP face many challenges to their sexual and reproductive healthcare. These can deter them from participating in regular women-oriented screening programmes, which puts them at higher risk of preventable diseases. Understanding the lifelong effects of CP for women, and the interaction with their reproductive health could help to reduce unmet needs and increase participation in relevant screening across the life course.

IMPACT

Knowledge of the challenges to regular screening programmes experienced by women with CP across the life course is crucial to provide appropriate preventative healthcare for women with CP across different stages of life. Elements of this knowledge could have benefits for the care of all disabled women.