Paired analysis of tree ring width and carbon isotopes indicates when controls on tropical tree growth change from light to water limitations

Light and water availability are likely to vary over the lifespan of closed-canopy forest trees, with understory trees experiencing greater limitations to growth by light and canopy trees greater limitation due to drought. As drought and shade have opposing effects on isotope discrimination (Δ13C), paired measurement of ring width and Δ13C can potentially be used to differentiate between water and light limitations on tree growth. We tested this approach for Cedrela trees from three tropical forests in Bolivia and Mexico that differ in rainfall and canopy structure. Using lifetime ring width and Δ13C data for trees of up to and over 200 years old, we assessed how controls on tree growth changed from understory to the canopy. Growth and Δ13C are mostly anti-correlated in the understory, but this anti-correlation disappeared or weakened when trees reached the canopy, especially at the wettest site. This indicates that understory growth variation is controlled by photosynthetic carbon assimilation due to variation in light levels. Once trees reached the canopy, inter-annual variation in growth and Δ13C at one of the dry sites showed positive correlations, indicating that inter-annual variation in growth is driven by variation in water stress affecting stomatal conductance. Paired analysis of ring widths and carbon isotopes provides significant insight in what environmental factors control growth over a tree's life; strong light limitations for understory trees in closed-canopy moist forests switched to drought stress for (sub)canopy trees in dry forests. We show that combined isotope and ring width measurements can significantly improve our insights in tree functioning and be used to disentangle limitations due to shade from those due to drought.

Yusof MY, Vital E. AB0434 EFFICACY AND SAFETY OF OBINUTUZUMAB IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH SECONDARY NON-RESPONSE TO RITUXIMAB

Background

Secondary inefficacy characterized by infusion reactions and anti-drug antibodies occur in 14% of SLE patients treated with repeat rituximab courses(1). Obinutuzumab is a next-generation humanized type-2 anti-CD20 therapy licensed for hematological malignancies which may overcome this issue(2).

Objectives

We set out to evaluate the clinical efficacy and safety of obinutuzumab in a cohort of rituximab resistant SLE patients.

Methods

We collated data from SLE patients receiving obinutuzumab for secondary non-response to rituximab in BILAG centres. Disease activity was assessed using BILAG-2004, SLEDAI-2K and serology before, and 6 months after, obinutuzumab 2x1000mg infusions alongside methylprednisolone 100mg. Flow cytometry where possible was carried out using a multiple gating highly sensitive strategy.

Results

All 9 patients included in the study received obinutuzumab alongside concomitant oral immunosuppression. At 6 months post-obinutuzumab, there were significant reductions in median SLEDAI-2K from 12 to 6 (p=0.014) and total BILAG-2004 score from 21 to 2 (p=0.009). Complement C3 and dsDNA titres improved significantly (both p=0.04). Non statistically significant numerical improvements were seen in C4 levels.

Of 8/9 patients receiving concomitant oral prednisolone at baseline (all >10mg/day), 5/9 had their dose reduced at 6 months; 4/8 were on 5mg/day and were in Lupus Low Disease Activity State. After obinutuzumab, 6/9 patients with peripheral B-cell data achieved complete depletion including 4/4 assessed with highly sensitive assays. 1/9 obinutuzumab non-responder required cyclophosphamide therapy. 1 unvaccinated patient died from COVID-19.

Table 1.

Baseline characteristics, disease activity and steroid doses before and after last obinutuzumab/rituximab.

PatientEthnicityDisease duration (Years)Age (Years)Total BILAG-2004 before ObiTotal BILAG-2004 after ObiSLEDAI-2K before ObiSLEDAI-2K after ObiPrednisolone before Obi (mg)Prednisolone after Obi (mg)1South Asian10.836.41821481052South Asian6.324.424212430103South Asian11.934.829110410104South Asian8.241.92116015155South Asian6.829.43221181450606White European17.537.0128881557White European16.930.01211281058Caribbean6.244.225213010159Caribbean2.621.092166105Median (Q1, Q3)NA8.2 (6, 12)34.8 (29,37)21 (12, 25)2 (1, 2)12 (10, 14)6 (4, 8)10 (10, 15)10 (5, 15)

Conclusion

Obinutuzumab appears to be effective and steroid-sparing in renal and non-renal SLE patients with secondary non-response to rituximab. Obinutuzumab was shown to be effective in patients with severe renal and non-renal disease. Therefore, in those with previous responsiveness to B-cell depletion, switching to humanised type-2 anti-CD20 therapy is a logical approach following loss off efficacy.

References

[1]Vital EM, Dass S, Buch MH, Henshaw K, Pease CT, Martin MF, et al. B cell biomarkers of rituximab responses in systemic lupus erythematosus. Arthritis Rheum [Internet]. 2011 Oct [cited 2020 Oct 12];63(10):3038–47. Available from: https://pubmed.ncbi.nlm.nih.gov/21618204/

[2]Hassan SU, Md Yusof MY, Emery P, Dass S, Vital EM. Biologic Sequencing in Systemic Lupus Erythematosus: After Secondary Non-response to Rituximab, Switching to Humanised Anti-CD20 Agent Is More Effective Than Belimumab. Front Med [Internet]. 2020 Aug 27 [cited 2020 Sep 2];7:498. Available from: https://www.frontiersin.org/article/10.3389/fmed.2020.00498/full

Disclosure of Interests

Jack Arnold: None declared, Shouvik Dass Consultant of: Roche, Abbvie, UCB & Chugai, Employee of: Honoraria from Roche, Abbvie, UCB & Chugai, Sarah Twigg: None declared, Colin Jones: None declared, Benjamin Rhodes: None declared, Peter Hewins: None declared, Mithun Chakravorty: None declared, Philip Courtney: None declared, Michael Ehrenstein Grant/research support from: GSK, Employee of: Has received honoraria from GSK, Md Yuzaiful Md Yusof: None declared, Edward Vital Employee of: Has received honoraria from Roche

POS0793 IMPROVED RELAPSE-FREE SURVIVAL WITH THE NORWICH PREDNISOLONE REGIMEN FOR GIANT CELL ARTERITIS

Background

Glucocorticoid therapy is the mainstay treatment for GCA. There is no consensus on the dose of prednisolone to be used. Prednisolone regimens used in clinical trials have reported relapse rates of 66 to 92%. The long-term follow-up of Tocilizumab and prednisolone for 1-year showed a relapse rate of 74% at 2 years. The Norwich Regimen is a bespoke prednisolone plan with an initial dose of 1mg/kg of lean body mass. It delivers 164.64 mg/kg of lean body mass in a logarithmic taper over 100 weeks. It was devised to reduce the risk of relapse and allow patients to be in control of their prednisolone reduction.

Objectives

To document drug-free survival at 150 weeks of people with GCA treated with a bespoke prednisolone taper

Methods

All patients were diagnosed by biopsy, ultrasonography or PET scan and provided with a printed prednisolone plan at diagnosis. All individuals were assessed at approximately 3-6 monthly intervals in addition to suspected relapse, toxicity or other need for course correction. Relapses were confirmed objectively using a modification of the Kerr criteria. Relapse free survival was recorded at 100 weeks. Patients were given an open invite to contact us in the event of a suspected relapse after coming off prednisolone. A notes review was done to record events at 150 weeks.

Results

150 consecutive people with objectively diagnosed GCA (mean age 74) since 10/01/2012 have completed 150 weeks since starting prednisolone. Drug-free, relapse-free survival at 100 weeks was met by 133/150 (89%). 7 individuals died and 20 relapsed. A further 5 died and 15 relapsed by week 150; 103/150 (69%) survivors were in prednisolone-free remission. Of the 12 deaths – 6 died of cancer, 1 subdural haemorrhage, 1 ischaemic bowel, 1 septicaemia, 1 general decline (aged 93). The cause of death was not available for 2 individuals who died in the community. The median time to relapse for the 35 individuals was 80 weeks (IQR 64,109).

Conclusion

We report the first results of a bespoke prednisolone taper to be used in real life. The Norwich Regimen for the treatment of GCA results in drug-free relapse-free survival of 89% at 100 weeks and 69% at 150 weeks, which is superior to all other reports published so far.

References

[1]Mukhtyar, C, Cate, H, Graham, C, Merry, P, Mills, K, and Misra, A, 2019, ‘Development of an evidence-based regimen of prednisolone to treat giant cell arteritis – the Norwich regimen’ Rheumatology Advances in Practice, Volume 3, Issue 1, 2019, rkz001, https://doi.org/10.1093/rap/rkz001

[2]Hellmich B, Agueda A, Monti S, et al2018 Update of the EULAR recommendations for the management of large vessel vasculitis Annals of the Rheumatic Diseases 2020;79:19-30.

Disclosure of Interests

None declared

POS0810 FREQUENCY OF VISUAL MANIFESTATIONS IN GIANT CELL ARTERITIS IN NORFOLK

Background

The ophthalmic features of giant cell arteritis (GCA) involve a spectrum of severity from transient symptoms to bilateral visual loss from anterior ischaemic optic neuropathy or less commonly central retinal or cilioretinal artery occlusion. Reported ocular involvement varies between 10-70%.1,2. At the Norfolk and Norwich University Hospital an interdisciplinary fast track service is provided for potential GCA patients. This report aims provides a complete picture of the frequency and nature of ocular involvement in GCA.

Objectives

350 records of consecutive patients diagnosed objectively with GCA based on biopsy or imaging were reviewed. In our centre, the hospital pathway mandates all suspected GCA cases to have a formal ophthalmology assessment including visual acuity, pupil exam and full-dilated fundus assessment. Systemic and Ophthalmic symptoms and signs were recorded.

Methods

From January 2012 to September 2021, 350 individuals were diagnosed with GCA by biopsy, ultrasonography or positron emission tomography. The mean age was 74 ± 7.7 years. 235 (67%) of patients were females. 101 (29%) presenting with GCA had visual symptoms and/or signs. 42 of them had mono-ocular and 5 had binocular loss of vision. A summary of the key visual symptoms and signs are shown in Table 1. Only 6 patients with visual symptoms did not have any symptoms commonly associated with GCA.

Table 1.

Visual Symptoms and Signs (N=350 patients)

Visual Symptoms101Blurred Vision36Loss of vision47Double Vision27Ocular SignsRight CRAO11Left CRAO110Right AION219Left AION223Right extraocular muscle weakness6Left extraocular muscle weakness4

1 Central retinal artery occlusion 2 Anterior ischaemic optic neuropathy

Results

From January 2012 to September 2021, 350 individuals were diagnosed with GCA by biopsy, ultrasonography or positron emission tomography. The mean age was 74 ± 7.7 years. 235 (67%) of patients were females. 101 (29%) presenting with GCA had visual symptoms and/or signs. 42 of them had mono-ocular and 5 had binocular loss of vision. A summary of the key visual symptoms and signs are shown in Table 1. Only 6 patients with visual symptoms did not have any extra-ocular symptoms commonly associated with GCA.

Conclusion

We report the frequency of visual involvement in one of the largest cohorts of individuals with GCA. 29% have ocular symptoms. Partial or total field loss occurred in 13% of cases. 2% of patients presented with visual manifestations as the only feature of GCA. Rarely, permanent visual loss may occur without any other manifestation of GCA.

References

[1]Ivana Vodopivec, Joseph F Rizzo, III, Ophthalmic manifestations of giant cell arteritis, Rheumatology, Volume 57, Issue suppl_2, February 2018, Pages ii63–ii72.

[2]Saleh M, Turesson C, Englund M, Merkel PA, Mohammad AJ. Visual Complications in Patients with Biopsy-proven Giant Cell Arteritis: A Population-based Study. J Rheumatol. 2016;43(8):1559-1565.

Disclosure of Interests

None declared

POS1523-HPR PATIENT SATISFACTION SURVEY OF A SPECIALIST PHARMACIST RUN RHEUMATOLOGY BIOLOGIC AND JAK INHIBITOR CLINIC

Background

Hereford Rheumatology Department, UK, treats over 850 patients on biologic disease-modifying anti-rheumatic drugs (bDMARDs) and JAK inhibitors (JAKi). The multidisciplinary team (MDT) includes a Specialist Rheumatology Pharmacist running clinics for all adult Rheumatology patients who have been identified for bDMARD or JAKi initiation or switch by their responsible Consultant. Patients can feel anxious during the pre-treatment screening process and require reassurance about medication safety. This innovative role has been a well-received asset to the Rheumatology MDT, but patients’ perceptions of the role are unknown. To our knowledge, there is no similar study within British Rheumatology practice.

Objectives

The survey aims to gauge patient satisfaction of the consultation from a pharmacist-run bDMARD and JAKi initiation and switch clinic.

Methods

A generic patient satisfaction survey was piloted with positive results. Following this, a bespoke survey was developed, specifically enquiring about patients’ perceptions of the consultation skills, clarity, education and reassurance provided by the pharmacist. A Likert scale was used where appropriate and a space for free text was included. The Trust’s Patient Experience Team was consulted to ensure clarity for patients. In consecutive weekly clinics from July 2021 to January 2022, the survey was given to all patients immediately following Specialist Rheumatology Pharmacist clinic. The majority of patients were seen face-to-face however the survey was posted to the patient if telephone consultation was necessary. Clinic staff collected the completed surveys to ensure patient anonymity.

Results

57 of 58 patients completed the survey, with 100% stating they were pleased to receive counselling from a pharmacist. Patients were asked to score their knowledge of the medication out of 10, before and after the consultation; they reported a mean increase in knowledge of 3.9/10. The remaining survey results show mostly positive feedback (Table 1).

Table 1.

Patient rating of experience in pharmacist clinic.

StatementNo answerStrongly disagreeDisagreeNeitherAgreeStrongly agreeThe pharmacist put me at ease00001146The information provided was easy for me to understand.10011342The pharmacist listened to what I had to say.0000948The pharmacist showed care and sensitivity to my Rheumatological condition.00001146The pharmacist appeared knowledgeable about the medication to be started.0000849I feel that the medication I am starting has been chosen for me as an individual.10011738I understand why we are starting the new medication.00021045I have been told about the side effects the medication could cause.00001146I feel that it is safe to start the new medication.10161534I was able to discuss my concerns and ask questions about the new medication.00001146I felt included in the decision to start or change to new medication.10021143Overall, my experience in the pharmacist clinic today was a positive one*40001043

*Statement excludes results from 4 patients who did not complete the second page of the survey.

Conclusion

The results demonstrate the high level of patient satisfaction attained from the Specialist Pharmacist clinic. A small number of patients remain sceptical about medication safety, despite discussion. Inclusion of a pharmacist is especially useful to manage the increasing number of patients starting these medications, maintaining excellent patient experience, reducing the workload for other Rheumatology staff, and ensuring a robust MDT.

References

Not applicable.

Disclosure of Interests

Claire Jones Speakers bureau: Presented to rheumatology pharmacists at King’s College hospital London, Dec 2017. Purpose: to share my role to aid their development. Paid by UCB: £1000., Consultant of: Focus group for Fresenius Kabi Sept 2021. Received £500 honorarium, Jeanette Trickey: None declared

Tailored Immersion: Implementing Personalized Components Into Virtual Reality for Veterans With Post-Traumatic Stress Disorder

Introduction

With the application of virtual reality (VR), tailored interventions can be created that mirror the traumatic experiences of veterans with post-traumatic stress disorder (PTSD). Visual elements can be mimicked, and auditory and other senses stimulated. In doing so, the degree of immersion can be adjusted to optimize the therapeutic process. Objectively measuring the sensory immersion is key to keep subjects within their personal window of tolerance. Based on this information the therapist can decide manipulate the sensory stimulation embedded in the treatment.

Objectives

The objectives of this study are to explore the different immersive design aspects of VRET that can be modified to influence the experienced presence in veterans with PTSD, and to discuss possible methods of measuring the emotional response facilitated by immersive design aspects and experienced presence.

Methods

Four design aspects are discussed: system, sensory cues, narrative and challenge. We also report on a user experiment in three veterans that informed on quality and depth of immersion.

Results

Believability of the neutral virtual environment was important for maintaining the veterans’ presence within the VR experience. The immersive design aspects that were personalized and supportive in the narrative of the veteran such as music and self-selected images appeared to have a strong influence on recall and reliving of the traumatic events.

Conclusions

Finally, in order to increase the therapeutic effect in veterans with PTSD, the highlighted design aspects should be recognized and tailored to maximize immersion in virtual reality exposure therapy.

Disclosure

No significant relationships.

The association of pre-existing autoimmune disease and immune-related adverse events secondary to immune checkpoint inhibition therapy in a UK multicenter cohort

2522

Background: Pre-existing autoimmune disease (AID) potentially increases the propensity for the development of immune related adverse events (irAE) in response to oncological immune checkpoint inhibitors (ICIs) is biologically plausible and clinically observed. However, due to consistent clinical trial exclusion of those with pre-existing AID, the impact on the frequency and severity of irAEs is uncertain. Here we analyse this relationship in a large, real-world, UK multi-centre cohort. Methods: A retrospective analysis of 2049 patients treated with ICIs over a two year period was undertaken across 12 National Health Service centres by the UK National Oncology Trainees Collaborative for Healthcare Research (NOTCH). Patients received ICIs as standard of care for malignant melanoma, non-small cell lung cancer and renal cell carcinoma. The presence of pre-existing AIDs was assessed and classified as either autoantibody driven or autoinflammatory then correlated with clinically significant irAEs (i.e. ≥grade 2 or all-grade endocrinopathies). Statistical analyses included T-test, Mann-Whitney and Chi-squared. For overall survival (OS) Kaplan-Meier and log-rank tests were utilised. Results: Pre-existing AID were present in 13% (n = 257) of the overall cohort. Pre-existing endocrinopathies (30%; n = 76) were most common followed by rheumatological AIDs (18%; n = 46). In the pre-existing AID cohort there was a female predominance (48% vs 39%; p = 0.006) but no difference in smoking history (p = 0.074) or ethnicity (p = 0.12). There was no difference in ICI treatment between those with and without pre-existing AID (p = 0.2800). IrAEs occurred in 45% (n = 117) patients with pre-existing AID vs 33% (n = 583) without (p£0.001). The median time to onset of irAEs was similar. IrAEs with an increased incidence in the pre-existing AID cohort were colitis (p = < 0.001), arthralgia (p = 0.008) and dermatological irAEs (p = 0.014). There was no difference in the incidence of irAEs in patients with autoantibody driven vs autoinflammatory pre-existing AID (44.0 % vs 44.8%, p = 0.905). In the overall cohort, those with pre-existing AIDs had a median OS of 20.4 months (95% CI: 19.4-21.7) vs 14.1 months (95% CI: 12.8-16.3) in those without pre-existing AID (p = 0.004). Conclusions: This large multi-centre ICI-treated cohort demonstrates that pre-existing AID is a predisposing factor for the development of irAEs, however the incidence is lower than previously quoted. The pathological basis of pre-existing AID did not differentially affect irAE manifestation. Patients with pre-existing AID had improved OS compared to those without which has not been observed in previously reported studies. ICI treatment should be considered in those with pre-existing AID but further studies are needed to determine how best to optimise outcomes whilst mitigating the impact of irAEs.

SARS-CoV-2 Spike Protein Expression In Vitro and Hematologic Effects in Mice Vaccinated With AZD1222 (ChAdOx1 nCoV-19)

Severe COVID-19 can be associated with a prothrombotic state, increasing risk of morbidity and mortality. The SARS-CoV-2 spike glycoprotein is purported to directly promote platelet activation via the S1 subunit and is cleaved from host cells during infection. High plasma concentrations of S1 subunit are associated with disease progression and respiratory failure during severe COVID-19. There is limited evidence on whether COVID-19 vaccine-induced spike protein is similarly cleaved and on the immediate effects of vaccination on host immune responses or hematology parameters. We investigated vaccine-induced S1 subunit cleavage and effects on hematology parameters using AZD1222 (ChAdOx1 nCoV-19), a simian, replication-deficient adenovirus-vectored COVID-19 vaccine. We observed S1 subunit cleavage in vitro following AZD1222 transduction of HEK293x cells. S1 subunit cleavage also occurred in vivo and was detectable in sera 12 hours post intramuscular immunization (1x10¹⁰ viral particles) in CD-1 mice. Soluble S1 protein levels decreased within 3 days and were no longer detectable 7–14 days post immunization. Intravenous immunization (1x10⁹ viral particles) produced higher soluble S1 protein levels with similar expression kinetics. Spike protein was undetectable by immunohistochemistry 14 days post intramuscular immunization. Intramuscular immunization resulted in transiently lower platelet (12 hours) and white blood cell (12–24 hours) counts relative to vehicle. Similarly, intravenous immunization resulted in lower platelet (24–72 hours) and white blood cell (12–24 hours) counts, and increased neutrophil (2 hours) counts. The responses observed with either route of immunization represent transient hematologic changes and correspond to expected innate immune responses to adenoviral infection.

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

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

Radiographic Incidence and Functional Outcomes of Distal Radius Fractures Undergoing Volar Plate Fixation With Concomitant Scapholunate Widening: A Prospective Analysis

Background: Scapholunate (SL) ligament injuries can occur concomitantly with distal radius fractures (DRFs), and the management of acute SL injury in the setting of DRFs remains controversial. The purpose of the study is to identify the radiographic incidence of SL widening in DRF treated with volar plate fixation and to determine the functional outcomes of DRF with concomitant radiographic SL-widening. Methods: One hundred and seventeen patients with DRFs, with and without radiographic SL-widening, and treated with volar locked plating, were prospectively enrolled. No SL ligament repairs or reconstructions were performed in any cases. Patients with DRFs with radiographic criteria for SL widening were compared to those without. Patients were evaluated at 3 months and 1 year postoperatively with Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation (PRWE) questionnaires. Results: Thirty-one patients (26.5%) were found to have radiographic evidence of SL widening. Patients with concomitant SL widening had less wrist extension at 3 months (52.4 degrees vs 60.8, P = .034) and at 1 year (64.5 degrees vs 71.8, P = .023). The group with SL widening had greater articular step off at 3 months (0.33 vs 0.06, P = .042), but no difference at 1 year (0.11 vs 0.05, P = .348). There were no differences in wrist flexion, supination, pronation, volar tilt, radial inclination, radial height, ulnar variance, PRWE scores, and Quick Dash scores at 3 months and 1 year. Conclusions: Radiographic SL-widening is a common finding associated with DRFs undergoing surgical repair. There are similar clinical outcomes between those with untreated SL widening compared to those without an SL widening at 1-year postoperatively.

Prospective Randomized Study Examining Preoperative Opioid Counseling on Postoperative Opioid Consumption after Upper Extremity Surgery

Background: Rates of opioid addiction and overdose continue to climb in the United States, increasing pressure on prescribers to identify solutions to decrease postoperative opioid consumption. Hand and upper extremity surgeries are high-volume surgeries with a predilection for inadvertent overprescribing. Recent investigations have shown that preoperative opioid counseling may decrease postoperative opioid consumption. In order to test this hypothesis, a prospective randomized trial was undertaken to determine the effect of preoperative opioid counseling on postoperative opioid consumption. Methods: Eligible patients undergoing outpatient upper extremity surgery were randomized to either receive preoperative opioid counseling or to receive no counseling. Surgeons were blinded to their patient's counseling status. Preoperatively, patient demographics, surgical and prescription details were recorded. Postoperatively, patients' pain experience including opioid consumption, pain levels, and satisfaction was recorded. Results: There were 131 total patients enrolled, with 62 in the counseling group and 69 in the control group. Patients receiving counseling consumed 11.8 pills compared to 17.4 pills in the control group (P = .007), which translated to 93.7 Morphine Equivalent Units (MEU) in the counseling group compared to 143.2 MEU in the control group (P = .01). There was no difference in pain scores at any time point between groups. Among all study patients a total of 3767 opioid pills were prescribed with approximately 50% left unused. Conclusion: Patients receiving preoperative counseling consumed significantly fewer opioids postoperatively. Inadvertant overprescribing remains high. Routine use of preoperative counseling should be implemented along with prescribing fewer opioids overall to prevent overprescribing.

Demonstrating the Clinical Impact of Continuous Glucose Monitoring Within an Integrated Healthcare Delivery System

BACKGROUND

Approximately 30 million Americans currently suffer from diabetes, and nearly 55 million people will be impacted by 2030. Continuous glucose monitoring (CGM) systems help patients manage their care with real-time data. Although approximately 95% of those with diabetes suffer from type 2, few studies have measured CGM's clinical impact for this segment within an integrated healthcare system.

METHODS

A parallel randomized, multisite prospective trial was conducted using a new CGM device (Dexcom G6) compared to a standard of care finger stick glucometer (FSG) (Contour Next One). All participants received usual care in primary care clinics for six consecutive months while using these devices. Data were collected via electronic medical records, device outputs, exit surveys, and insurance company (SelectHealth) claims in accordance with institutional review board approval.

RESULTS

Ninety-nine patients were randomized for analysis (n = 50 CGM and n = 49 FSG). CGM patients significantly decreased hemoglobin A1c (p = .001), total visits (p = .009), emergency department encounters (p = .018), and labs ordered (p = .001). Among SelectHealth non-Medicare Advantage patients, per member per month savings were $417 for CGM compared to FSG, but $9 more for Medicare Advantage. Seventy percent of CGM users reported that the technology helped them better understand daily activity and diet compared to only 16% for FSG.

DISCUSSION

Participants using CGM devices had meaningful improvements in clinical outcomes, costs, and self-reported measures compared to the FSG group. Although a larger study is necessary to confirm these results, CGM devices appear to improve patient outcomes while making treatment more affordable.

Practical Application of Rodent Transporter Knockout Models to assess Brain Penetration in Drug Discovery

BACKGROUND & OBJECTIVE

Compound X is a drug candidate for the treatment of neurodegenerative diseases. Its brain distribution was evaluated as part of the lead identification and optimization of early drug discovery.

METHODS

The brain distribution of compound X was studied in genetic transporter knockout rodent models, in vivo models with a chemical inhibitor and in vitro transporter cell systems.

RESULTS

Compound X was found to be a substrate for human Breast Cancer-Resistance Protein (BCRP) in vitro (efflux ratio 8.1) and rodent Bcrp in vivo (Kp,uuKO/Kp,uuWT = 0.15/0.057 = 2.7, p < 0.05) but not a substrate for human P-glycoprotein (P-gp) in vitro (efflux ratio 1.0) nor rodent P-gp in vivo (Kp,uuKO/Kp,uuWT = 0.056/0.051 = 1.1, p > 0.05). When both transporters were knocked out in vivo, Kp,uu increased to 0.51 ± 0.02. Similar patterns observed across compounds with related chemistry corroborated structure-activity relationship.

CONCLUSION

While in vitro assays showed compound X to be a substrate for human BCRP and not P-gp, in vivo studies indicated a synergistic effect between rodent efflux transporters. However, this only accounted for ~50% of restricted BBB-transport, suggesting involvement from other efflux transporters. Given Kp,uu is a key criterion for assessing technical quality of CNS candidates before progression into clinical development, it is important to identify relevant screening assays for a better understanding of low Kp,uu and brain distribution in pre-clinical models for translation to humans.

Reliability of the Calgary depression scale for schizophrenia: A meta-analysis

BACKGROUND

A challenge for clinicians working with individuals diagnosed with schizophrenia is distinguishing depressive symptoms from negative symptoms of schizophrenia. The Calgary Depression Scale for Schizophrenia (CDSS) was developed for this purpose. No review has previously explored its reliability across multiple studies using advanced statistical means.

OBJECTIVES

This meta-analysis aimed to quantify the CDSS' internal consistency, inter-rater reliability (IRR) and test-retest reliability.

METHOD

A systematic literature search was conducted to find articles reporting on the CDSS' reliability. Articles were screened against the inclusion and exclusion criteria, with data extracted from 40 studies. Overall meta-analytic effects were calculated, and for internal consistency and IRR coefficients subsequent analyses explored between-study variation. The small test-retest reliability dataset limited analysis.

FINDINGS

The internal consistency meta-analytic effect was 0.83 (95% CI:0.82-0.84). Higgins I² indicated an acceptable level of variation between studies' alpha estimates. This suggests all items in the CDSS are measuring the same construct (i.e. symptoms of depression). The IRR meta-analytic effect was 0.88 (95% CI:0.86-0.91), with Higgins I² indicating high levels of heterogeneity. This was not deemed problematic variance as it is within levels expected for psychometric measures and, therefore, considered acceptable for this literature. This reflects high level of agreement between different raters when using the CDSS on the same client.

CONCLUSIONS

This review suggests the CDSS has good internal consistency and excellent IRR. Further research will help understand its test-retest reliability.

Incidence of Operating Room Fires During Hand Surgical Procedures

BACKGROUND

The purpose of the present study is to report the incidence of operating room fires during hand surgical procedures.

METHODS

The clinic and OR electronic medical records of seven fellowship-trained orthopedic hand surgeons at a single, large practice were retrospectively reviewed. All upper extremity procedures performed between June 2014 to June 2019 in both hospital and surgery center settings were included in the review. Demographic data was collected. The incidence of operating room fires was determined.

RESULTS

A total of 18,819 hand and upper extremity surgical procedures were included. There were 16,767 (89.1%) cases performed in a surgery center, while 2,052 (10.9%) of cases were performed in a hospital. There were 12,691 (67.4%) soft tissue procedures and 6,127 (32.6%) bony procedures performed. Chlorhexidine gluconate preparation solution was used in 9607 cases (51%). Chloraprep solution was used in 6280 cases (33.4%). Betadine was used in 2,932 cases (15.6%). One surgeon has monopolar electrocautery only available during cases. Five surgeons have bipolar available, and one has both mono and bipolar electrocautery available. There were no fires (0%) identified during the study period.

CONCLUSION

The incidence of operating room fires during hand surgical procedures is extremely low. While hand surgeons can be reassured that the likelihood of an operating room fire is minimal, surgeons should not become complacent and should maintain a high level of vigilance to prevent these potentially devastating occurences.

Realizing topologically ordered states on a quantum processor

[Figure: see text].