Validation and Implementation of molecular RT-PCR COVID-19 Testing Platforms

Introduction/Objective

COVID-19 is caused by the SARS-CoV-2 coronavirus that has led to a worldwide pandemic with an unprecedented need for fast and accurate testing under FDA Emergency Use Authorizations (EUA). Despite the promise of the Alinity-m as an upgrade from the Abbott m2000 for optimization of high throughput testing and random access for laboratory workflow, validation studies comparing Alinity-m to already used Abbott m2000 are sparse in the literature, particularly for the veteran population.

Methods/Case Report

The validation study for the Alinity m (Chicago IL) was performed in three parts 1) Method to method sample/patient correlation study, 2) precision study (at 250 virus copies/mL, 500 virus copies/mL and 1000 virus copies/mL versus 4 negatives), and 3) verification and confirmation of the accuracy of the assay at the lower limit of detection (LOD). For the validation study. The patient specimens were used side by side for both assays. The results from the Abbott m2000 (Chicago IL), which was already established in our lab, were used as a reference for validation.

Results (if a Case Study enter NA)

The validation with a method to method correlation included 157 valid specimens from which concordant results were obtained for all 157 specimens on both the Alinity-m and Abbott m2000. The precision or reproducibility of the Alinity-m was verified at all concentrations. The limit of detection verification on diluted samples determined the limit of detection to be 20 virus copies/mL (>95% of dilution samples agreed with positive results at this level), which confirmed even below the manufacturer provided LOD of 100 virus copies/mL.

Conclusion

Alinity m was validated for clinical use with study demonstrating that it is 1) equivalent in the method to method correlation, precision, and LOD determination. 2)The validation of Alinity m, holds great promise with its optimized throughput for testing of large numbers of specimens with less technician handling and random access, is a valuable addition to the literature of test validations under the FDA EUA. 3)The validation of tests under the FDA EUA is unprecedented and provides an important way to improve patient care during this extraordinary pandemic.

Challenges and visions for managing pain-related insomnia in primary care using the hybrid CBT approach: a small-scale qualitative interview study with GPs, nurses, and practice managers

Background

Chronic pain and insomnia have a complex, bidirectional relationship – addressing sleep complaints alongside pain may be key to alleviating patient-reported distress and disability. Healthcare professionals have consistently reported wanting to offer psychologically informed chronic pain management at the primary care level. Research in secondary care has demonstrated good treatment efficacy of hybrid CBT for chronic pain and insomnia. However, primary care is typically the main point of treatment entry, hence may be better situated to offer treatments using a multidisciplinary approach. In this study, primary care service providers’ perception of feasibility for tackling pain-related insomnia in primary care was explored.

Methods

The data corpus originates from a feasibility trial exploring hybrid CBT for chronic pain and insomnia delivered in primary care. This formed three in-depth group interviews with primary care staff (n = 9) from different primary care centres from the same NHS locale. All interviews were conducted on-site using a semi-structured approach. Verbal data was recorded, transcribed verbatim and analysed using the thematic analysis process.

Results

Eight themes were identified – 1) Discrepant conceptualisations of the chronic pain-insomnia relationship and clinical application, 2) Mismatch between patients’ needs and available treatment offerings, 3) Awareness of psychological complexities, 4) Identified treatment gap for pain-related insomnia, 5) Lack of funding and existing infrastructure for new service development, 6) General shortage of psychological services for complex health conditions, 7) Multidisciplinary team provision with pain specialist input, and 8) Accessibility through primary care. These mapped onto four domains - Current understanding and practice, Perceived facilitators, Perceived barriers, Ideal scenarios for a new treatment service – which reflected the focus of our investigation. Taken together these provide key context for understanding challenges faced by health care professionals in considering and developing a new clinical service.

Conclusions

Primary care service providers from one locale advocate better, multidisciplinary treatment provision for chronic pain and insomnia. Findings suggest that situating this in primary care could be a feasible option, but this requires systemic support and specialist input as well as definitive trials for success.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01552-3.

141 New Guidelines to Reduce Unnecessary Blood Tests, Delayed Discharge and Costs Following Robot Assisted Radical Prostatectomy

Objectives

Routine postoperative blood tests (POBT) following robot assisted radical prostatectomy (RARP) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed to form new guidelines. The new guidelines were prospectively validated in a sample of 300 patients.

Results

Derivation Dataset: 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 day due to delayed or incomplete blood tests. Validation Dataset: No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. Number of POBT requested reduced by 73% (p < 0.001). The new guidelines improved POBT sensitivity for complications from 98% to 100% and specificity from 0% to 74%. Discharge delays reduced from 6% to 0% (p = 0.008). Cost savings were £178 per patient.

Conclusions

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

100 Assessing the Admission Proforma: A Multi-Cycle Audit Evaluating the Quality of Documentation of The Burnsadmission Proforma At the Regional Mersey Burn Unit

Introduction

A thoroughly completed Burns Proforma can provide vital information for the effective management of a burn and enables the sharing of information with other members of the multidisciplinary team.

Aim

We aimed to assess the quality of record-keeping of the new Burns Proforma, compared it with the previous cycle, and identified areas of improvement.

Method

Data on 76 fields on version 4.0 of the Mersey Burns Proforma was collected for 92 patients between January and February 2020. The data was compared to cycle 1of the audit collected in July 2019.

Results

Assessing the 61 comparable fields between audit cycles, 58 fields (95%) improved while 3 (5%) deteriorated. 21 fields achieved a completion rate greater than 80%. Vital information such as history, comorbidities, and drug history achieved 100% completion, up from 94%, 94%, and 95%, respectively. Total body surface area (TBSA) increased to 93% from 83%, the use of the Lund & Browder chart remained the same, treatment plan documentation increased to 95% from 91%, documentation of admission increased from 24% to 51%, consultant confirmation of TBSA increased to 10% from 5%, but this requires further improvement. Comments stated the proforma was clearer and provided a flowchart layout which made documentation easier.

Conclusions

The Burns Admission Proforma has made significant improvements. Working with the nursing staff and consultant body, we aim to improve our completion rates of vital information further. It sets a high standard for data collection and presents itself as a useful tool for other Burns Units across the United Kingdom.

842 Teleurology; A Prospective Study of Patient’s Perception and Real Time Experience in A Tertiary UK Centre

Aim

To evaluate the clinical outcome and patient’s satisfaction of our real-time teleurology experience.

Materials

A prospective study, the whole cohort of face-to-face [FTF] clinics was shifted for telephone clinics. The data were collected prospectively for all appointments from 30th March to 3rd April. The primary objectives were clinic outcome and patient’s satisfaction evaluated using a validated questionnaire. The secondary objectives were number of non-attendance, percentage of face-to-face clinics and clinic demographics.

Results

Overall, 95 scheduled appointments for 7 consultants and 2 trainees. Telephone consultations performed for 75 patients, while 6 patients reviewed in FTF Clinics, and 14 patients classified as non-attendant. The non-attendance rate was 14.7%, with estimated 50% reduction in comparison to FTF rate prior to pandemic. The majority of patients (58%) treated conservatively while 14 (17.2%) patients commenced on medications, and 20 patients (24.6%) were listed for surgery. All patients but one (98.1%) agreed that cancelling FTF clinics was reasonable. The majority of the patients 94.2%, 96.2%, 84.6% found the telephone clinic was effective, long enough, and was easy to express their concerns over the phone, respectively. Approximately 90.4% and 100% satisfied with teleurology service and that clinicians were careful, respectively.

Conclusions

Our study elucidated the feasibility of teleurology in a real time setting and showed that it meets the tetrafecta of clinical outcomes, continuity of care, patient’s safety, and patient’s satisfaction. To our knowledge, this is the first study to assess patient’s perception of teleurology using a validated questionnaire.

283 Salvage Versus Primary Robot-Assisted Radical Prostatectomy: A Propensity-Matched Comparative Effectiveness Study from A High-Volume Tertiary Centre

Aim

Salvage Robot-Assisted Radical Prostatectomy (sRARP) is a potential treatment option for locally recurrent Prostate Cancer after non-surgical primary treatment. There are minimal data comparing outcomes between propensity-matched salvage and primary Robot-Assisted Radical Prostatectomy (RARP). We compare perioperative, oncological, and functional outcomes of sRARP with primary RARP and between sRARP post-whole and focal gland therapy.

Method

1:1 propensity-matched comparison of 146 sRARP with primary RARP from a cohort of 3,852 consecutive patients from a high-volume tertiary centre.

Results

There were no significant differences in patient characteristics between the salvage and primary RARP groups. Grade III-V Clavien-Dindo complication rates were 1.3% and 0% in the salvage and primary groups, respectively (p = 0.310). Median (IQR) follow-up was 16 (10,30) and 21 (13,33) months in the salvage and primary groups, respectively. BCR rates were 30.8% and 13.7% in the salvage and primary groups, respectively (p < 0.001). Pad-free continence rates were 79.1% and 85.4% at two years in the salvage and primary groups, respectively (p = 0.160). ED rates were 95.2% and 77.4% in the salvage and primary groups, respectively (p < 0.001). Comparing the whole gland and focal gland groups, BCR rates were 33.3% and 29.1%, respectively (p = 0.687), pad-free continence rates were 66% and 89.3%, respectively (p = 0.001), and ED rates were 98.3% and 93%, respectively (p = 0.145).

Conclusions

SRARP has similar perioperative but inferior oncological outcomes to primary RARP. Continence rates are similar to primary RARP, but potency is worse. Perioperative and oncological outcomes of sRARP after focal gland therapy are similar but continence outcomes are superior compared to sRARP after whole gland therapy.

81 VIRTUAL: Virtual Interactive Surgical Skills Classroom – An Ongoing Randomized Controlled Trial

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on year group and surgical skill confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention, and Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts. Change in confidence, time to completion and a granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed.

Results

Data collection will be completed in January 2021. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusions

To our knowledge, this will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the virtual classroom’s suitability as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

1420 ViRtual prOficiency Based prOgression for Robotic Training (VROBOT): A Prospective Cohort Study Protocol

Introduction

Robotic surgery is an evolving field that requires specialist training. Historically, robotic surgery training has lacked standardisation. Recently, training centres have introduced proficiency-based modules and curriculums to certify and progress the skills of novice robotic surgeons. However, training tends to be self-directed and non-interactive. Limited interactive teaching does exist but can be inaccessible and expensive. We aim to validate the effectiveness of the current Fundamentals of Robotic Surgery (FRS) training curriculum with the addition of interactive virtual classroom teaching.

Method

16 novice surgical trainees will be assigned to two training groups. The interventions will be implemented following a one-week robotic skills induction. Both groups will receive access to the FRS curriculum for one week. The intervention group will additionally receive virtual classroom robotic skills training. The primary outcome will be the objective performance scores after training using a synthetic model based on task errors, time taken and contact pressure. In week 3, each group will receive the alternate intervention and objective performance scores will be measured to determine the trajectory of scores.

Results

Significant objective performance improvement following the intervention will be indicative of intervention quality.

Conclusions

This will be the first feasibility study evaluating the efficacy of interactive virtual robotic surgery training. It will determine the effect size of virtual classroom training on the development of basic robotic surgical skills in addition to the proficiency-based FRS curriculum. The findings will assist the development and implementation of further resource-efficient virtual robotic surgical skills training programs.

The Role of Temperature Change, Ambient Temperature, and Relative Humidity in Allergic Conjunctivitis in a US Veteran Population

PURPOSE

Studies have implicated temperature and humidity in the pathogenesis of allergic conjunctivitis (AC), as these conditions facilitate air particulate and aeroallergen dispersion and tear film instability. Research also suggests that variation in temperature is associated with risk of asthma, but similar data are limited for AC. This study examined associations between several meteorologic conditions, including temperature variation, and AC visit risk.

DESIGN

Retrospective, case-crossover study.

METHODS

Data on individuals diagnosed with AC (via International Classification of Diseases-Ninth Edition [ICD-9]) at a Veterans Affairs clinic from January 2010-December 2013 was extracted. Local climate data were obtained from the National Climactic Data Center. Utilizing a case-crossover design, all cases were assigned a random control date 90-250 days prior to diagnosis. Daily time-lagged exposures were computed for 30-day lags. The associations between temperature, temperature variation (standard deviation [SD] of temperature), relative humidity (RH), and temperature-RH interaction with visit risk were examined via multivariate logistic regression models both at the national level and across domestic climate regions.

RESULTS

Overall, 74,951 subjects made 116,162 visits for AC. Prevalence was highest in spring (>10% April-May) in the Northeast (NE) and Southeast (SE) (>15%), and lowest in winter (<6.1% December-February) in the Pacific Northwest (PNW) (<5%). AC visit risk was positively associated with temperature (OR 1.028, P < .001), SD of temperature (OR 1.054, P < .01), and temperature-RH interaction (OR 1.0003, P < .01), whereas it was negatively associated with RH (OR 0.998, P < .001). Regionally, the PNW, NE, and Lower Midwest (LMW) accounted for the strongest associations.

CONCLUSION

Temperature, temperature variation, and RH associated with AC visit risk. Observed associations were strongest in northern regions, like the PNW.

P–460 Impact of various cancers on semen parameters in a tertiary onco-fertility unit in India

Study question

This study evaluated differences in semen parameters in male cancer patients in our ethnic population who banked their sperms prior to cancer treatment

Summary answer

We found significant differences in semen concentration, motility and morphology between different types of cancers, especially testicular cancers

What is known already

Impaired spermatogenesis and abnormal semen parameters in cancer patients has been noted, however certain cancer types are more damaging than others. In testicular cancer, spermatogenesis impairment is more quantitative than qualitative with sperm morphology being the most affected parameter. Among non testicular cancers, lymphoma cases usually show the most significantly impaired semen parameters

Study design, size, duration

We conducted a retrospective study analyzing semen parameters in 49 cancer patients between October 2014 to January 2020 who presented to the onco-fertility unit, Max Multispeciality Hospitals, New Delhi.

Furthermore, we did our analysis based on total of 101 samples and were broadly divided into testicular (37 samples) and non testicular cancers (64 samples). Patients who had previously received any form of cancer treatment including chemotherapy or radiotherapy were not included in this study

Participants/materials, setting, methods

Testicular Cancer(TC) group was further subcategorized into Seminoma and Non Seminoma groups whereas Non Testicular Cancer (NTC) group was subcategorized into Lymphoma and Non Lymphoma groups. Semen was collected by masturbation and analysis was performed in keeping with the WHO criteria. Statistical analyses was performed using SPSS software. p values &lt;0.05 were considered to indicate statistical significance.

Main results and the role of chance

In Testicular cancer (TC), 92% samples (34/37) had abnormal semen parameters whereas only 24.4% samples (22/64) were abnormal in Non Testicular cancer (NTC). Additionally, there were significant differences in sperm concentration, motility and morphology between TC and NTC groups.

Individually,

TC: Oligozoospermia was seen in 73% (27/37) with subdivision between Seminoma and Non Seminoma groups being 81.3% (13/16) and 61.9% (13/21).

Asthenozoospermia was seen in 86.5% (32/37) samples with subdivision between Seminoma and Non Seminoma groups being 87.5% (14/16) and 81% (17/21).

Teratozoospermia was seen in 59.5% (22/37) samples with subdivision between Seminoma and Non Seminoma groups being 75% (12/16) and 42.86% (9/21).

Combined OATS observed in 59.5% (22/37) samples with subdivision between Seminoma and Non Seminoma groups being 75% (12/16) and 42.86% (9/21)

NTC: Oligozoospermia was seen in 18.8% (12/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.92% (7/26) and 26.32% (10/38).

Asthenozoospermia was seen in 32.8% (21/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 34.62% (9/26) and 34.21% (13/38).

Teratozoospermia was seen in 17.2% (11/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.9% (7/26) and 23.68% (9/38).

Combined OATS observed in 17.2% (11/64) samples with subdivision between Lymphoma and Non Lymphoma groups being 26.9% (7/26) and 23.68% (9/38).

Limitations, reasons for caution

Study was conducted in a single institution with lesser overall number of patients. Duration, staging and grading of cancers were also not individually assessed, which could be a further limiting factor.

Wider implications of the findings: Testicular cancers, especially seminomas, have the most severe effect upon semen parameters. Among NTC patients, lymphomas have the worst impact. Knowing the varying effect of different cancers on semen parameters in our ethnic population helps ART specialists and oncologists to appropriately modify patient counseling and improve fertility outcomes.

Trial registration number

RMO13019

O43 Virtual: virtual interactive surgical skills classroom: a randomized controlled trial (protocol)

Introduction

High costs and inaccessibility are significant barriers to face-to-face basic surgical skills (BSS) training. Virtual classrooms enable the combination of computer-based learning with interactive expert instruction. They may optimise resources and increase accessibility, facilitating larger-scale training with a similar educational benefit. We aim to evaluate the efficacy of virtual BSS classroom training compared to both non-interactive video and face-to-face teaching.

Method

72 medical students will be randomly assigned to three equal intervention groups based on surgical skills experience and confidence. Interventions will be implemented following an instructional video. Group A will practice independently, Group B will receive face-to-face training, and Group C will attend a virtual classroom. Participants will be recorded placing three interrupted sutures with hand tied knots pre- and post-intervention. Objective Structured Assessment of Technical Skills (OSATS) will be blind marked by two experts.

Result

Change in confidence, time to completion and a novel granular performance score will also be measured. Each intervention’s feasibility and accessibility will be assessed. Significant improvement in OSATS within groups will be indicative of intervention quality. Difference in improvement between groups will determine the relative performance of the interventions.

Conclusion

This will be the largest randomised control trial investigating virtual BSS classroom training. It will serve as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and beyond.

Take-home Message

This is the first RCT assessing virtual basic surgical skill classroom training and serves as a comprehensive appraisal of the suitability of virtual classrooms as an alternative to face-to-face training. The findings will assist the development and implementation of further resource-efficient training programs during the COVID-19 pandemic and in the future.

O50 New guidelines to reduce unnecessary blood tests, delayed discharge and costs following robot assisted radical prostatectomy

Introduction

Routine postoperative blood tests (POBT) are used to evaluate the impact of surgery on pre-existing co-morbidities and to detect early complications. This practice dates back to an era of open surgery, when blood loss and complication rates were higher. We propose new guidelines to improve the specificity of POBT.

Method

The cases of 1040 consecutive patients who underwent a primary or salvage RARP at two large tertiary urology centres in the United Kingdom were retrospectively reviewed, and new guidelines were designed. The guidelines were prospectively validated in a cohort of 300 patients.

Result

Derivation Dataset 3% and 5% had intra- and post-operative Clavien-Dindo complications, respectively. 15% had clinical concerns postoperatively. 0.9% required perioperative transfusion. 78% had routine blood tests without clinical concerns, none of whom developed a complication. 98% of complications were suspected by clinical judgement. 6% of patients had a discharge delay of ≥ 1 days due to delayed or incomplete blood tests.

Validation Dataset No significant difference existed in complication, clinical concern or transfusion rates between the derivation and validation datasets. New guidelines improved sensitivity for complications from 98% to 100% and specificity from 0% to 74%. The number of blood tests requested reduced by 73% (P &lt; 0.001). Discharge delays reduced from 6% to 0% (P = 0.008). Cost savings were £178 per patient.

Conclusion

Postoperative complications and transfusion following RARP are rare. Routine POBT without clinical indication are unnecessary and inefficient. A guideline-based approach to POBT can reduce costs and optimise discharge without compromising patient safety or care.

Take-home Message

Routine postoperative blood tests following robot assisted radical prostatectomy are often unnecessary. A guideline-based approach can reduce costs and optimise patient care.

Comparison of femoro-popliteal plain balloon angioplasty for chronic limb threatening ischaemia in the BASIL trial and in a UK contemporary series

BACKGROUND

Since the turn of the millennium there has been a world-wide trend towards an endovascular first where possible revascularisation strategy for chronic limb threatening (CLTI). There is concern that this may be inappropriate and can result in net patient harm. The aim of this study, therefore, is to compare important clinical outcomes following femoro-popliteal plain balloon angioplasty (FP-PBA), with selective use of bare metal stents (BMS), in a contemporary series (CS) of patients treated in our unit between 2009 and 2014 with those observed following FP-PBA +/- BMS in the UK NIHR HTA-funded Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL-1, B1) trial (treated 1999-2004).

METHODS

Baseline and clinical outcome data (amputation free survival, AFS; overall survival, OS; limb salvage, LS; freedom from re-intervention, FF-R; freedom from major adverse limb events, FF-MALE) were obtained from prospectively gathered hospital data and B1 trial case record forms.

RESULTS

There were 237 CS and 218 B1 patients. CS patients were older (77 vs 73 years, p=.0002). B1 patients were more likely to be current smokers, less likely to be on best medical therapy, and underwent more extensive endovascular interventions. CS had more hospital admissions (4 vs 2, p<.0001) before they reached their primary endpoint (AFS). Immediate technical success was non-significantly higher in the CS patients (87% vs 83%, p=0.2). BMS were used in 20 (8%) CS and 2 (1%) B1 patients (p=.0002). AFS (HR = 0.64, 95%CI: 0.49 to 0.82, p = .0005) and OS (HR = 0.58, 95% CI: 0.44 to 0.76, p = .0001) were significantly worse in the CS cohort. There was no significant difference in LS, FF-R or FF-MALE.

CONCLUSIONS

CLTI patients managed in our unit (2009-2014) by means of a FP-PBA +/- BMS first where possible revascularisation strategy experience significantly worse AFS and OS than patients treated with FP-PBA +/- BMS in the B1 trial ten years earlier (1999-2004).

Primary results from IMpassion131, a double-blind, placebo-controlled, randomised phase III trial of first-line paclitaxel with or without atezolizumab for unresectable locally advanced/metastatic triple-negative breast cancer

BACKGROUND

In the phase III IMpassion130 trial, combining atezolizumab with first-line nanoparticle albumin-bound-paclitaxel for advanced triple-negative breast cancer (aTNBC) showed a statistically significant progression-free survival (PFS) benefit in the intention-to-treat (ITT) and programmed death-ligand 1 (PD-L1)-positive populations, and a clinically meaningful overall survival (OS) effect in PD-L1-positive aTNBC. The phase III KEYNOTE-355 trial adding pembrolizumab to chemotherapy for aTNBC showed similar PFS effects. IMpassion131 evaluated first-line atezolizumab-paclitaxel in aTNBC.

PATIENTS AND METHODS

Eligible patients [no prior systemic therapy or ≥12 months since (neo)adjuvant chemotherapy] were randomised 2:1 to atezolizumab 840 mg or placebo (days 1, 15), both with paclitaxel 90 mg/m² (days 1, 8, 15), every 28 days until disease progression or unacceptable toxicity. Stratification factors were tumour PD-L1 status, prior taxane, liver metastases and geographical region. The primary endpoint was investigator-assessed PFS, tested hierarchically first in the PD-L1-positive [immune cell expression ≥1%, VENTANA PD-L1 (SP142) assay] population, and then in the ITT population. OS was a secondary endpoint.

RESULTS

Of 651 randomised patients, 45% had PD-L1-positive aTNBC. At the primary PFS analysis, adding atezolizumab to paclitaxel did not improve investigator-assessed PFS in the PD-L1-positive population [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.60-1.12; P = 0.20; median PFS 6.0 months with atezolizumab-paclitaxel versus 5.7 months with placebo-paclitaxel]. In the PD-L1-positive population, atezolizumab-paclitaxel was associated with more favourable unconfirmed best overall response rate (63% versus 55% with placebo-paclitaxel) and median duration of response (7.2 versus 5.5 months, respectively). Final OS results showed no difference between arms (HR 1.11, 95% CI 0.76-1.64; median 22.1 months with atezolizumab-paclitaxel versus 28.3 months with placebo-paclitaxel in the PD-L1-positive population). Results in the ITT population were consistent with the PD-L1-positive population. The safety profile was consistent with known effects of each study drug.

CONCLUSION

Combining atezolizumab with paclitaxel did not improve PFS or OS versus paclitaxel alone. CLINICALTRIALS.GOV: NCT03125902.

Alternative therapies for dry eye disease

PURPOSE OF REVIEW

Dry eye disease (DED) is a multifactorial disease affecting approximately 5-50% of individuals in various populations. Contributors to DED include, but are not limited to, lacrimal gland hypofunction, meibomian gland dysfunction (MGD), ocular surface inflammation, and corneal nerve dysfunction. Current DED treatments target some facets of the disease, such as ocular surface inflammation, but not all individuals experience adequate symptom relief. As such, this review focuses on alternative and adjunct approaches that are being explored to target underlying contributors to DED.

RECENT FINDINGS

Neuromodulation, stem cell treatments, and oral royal jelly have all been studied in individuals with DED and lacrimal gland hypofunction, with promising results. In individuals with MGD, devices that provide eyelid warming or intense pulsed light therapy may reduce DED symptoms and signs, as may topical Manuka honey. For those with ocular surface inflammation, naturally derived anti-inflammatory agents may be helpful, with the compound trehalose being farthest along in the process of investigation. Nerve growth factor, blood-derived products, corneal neurotization, and to a lesser degree, fatty acids have been studied in individuals with DED and neurotrophic keratitis (i.e. corneal nerve hyposensitivity). Various adjuvant therapies have been investigated in individuals with DED with neuropathic pain (i.e. corneal nerve hypersensitivity) including nerve blocks, neurostimulation, botulinum toxin, and acupuncture, although study numbers and design are generally weaker than for the other DED sub-types.

SUMMARY

Several alternatives and adjunct DED therapies are being investigated that target various aspects of disease. For many, more robust studies are required to assess their sustainability and applicability.

Hand fine motor control in classic galactosemia

Classic galactosemia (CG) is a rare inborn error of metabolism that results from profound deficiency of galactose-1-P uridylyltransferase (GALT). Despite early detection and rapid and lifelong dietary restriction of galactose, which is the current standard of care, most patients grow to experience a broad range of complications that can include motor difficulties. The goal of this study was to characterize hand fine motor control deficit among children and adults with classic galactosemia (CG). Specifically, we used Neuroglyphics software to collect digital Archimedes spiral drawings on a touch screen from 57 volunteers with CG (cases) and 80 controls. Hand fine motor control was scored as root mean square (RMS) of spirals drawn relative to an idealized template. Presence of tremor was defined as a peak in periodicity of changes in drawing speed or direction in the 4-8 Hz range. We observed a highly significant difference (P < .001) in RMS scores between cases and controls, with almost 51% of cases showing at least 1 of 4 spirals scoring outside the 95th percentile for controls. The corresponding prevalence for controls was 10%. Similarly, more than 35% of cases, and almost 14% of controls, showed at least 1 of 4 spirals with a tremor amplitude above the 95th % cutoff for controls. Our results both confirm and extend what is known about hand fine motor control deficit among children and adults with CG and establish digital assessment as a useful approach to quantify this outcome.

Iodide-induced sialadenitis following percutaneous coronary intervention: A case report

Iodide-induced sialadenitis is a rapid, painless enlargement of salivary glands following administration of iodine-based contrast agents. It has been reported numerous times in the literature; however, the pathogenesis remains unclear. This case report demonstrates how this may present following a coronary angiogram.

The rare C9 P167S risk variant for age-related macular degeneration increases polymerization of the terminal component of the complement cascade

Age-related macular degeneration (AMD) is a complex neurodegenerative eye disease with behavioral and genetic etiology and is the leading cause of irreversible vision loss among elderly Caucasians. Functionally significant genetic variants in the alternative pathway of complement have been strongly linked to disease. More recently, a rare variant in the terminal pathway of complement has been associated with increased risk, Complement component 9 (C9) P167S. To assess the functional consequence of this variant, C9 levels were measured in two independent cohorts of AMD patients. In both cohorts, it was demonstrated that the P167S variant was associated with low C9 plasma levels. Further analysis showed that patients with advanced AMD had elevated sC5b-9 compared to those with non-advanced AMD, although this was not associated with the P167S polymorphism. Electron microscopy of membrane attack complexes (MACs) generated using recombinantly produced wild type or P167S C9 demonstrated identical MAC ring structures. In functional assays, the P167S variant displayed a higher propensity to polymerize and a small increase in its ability to induce hemolysis of sheep erythrocytes when added to C9-depleted serum. The demonstration that this C9 P167S AMD risk polymorphism displays increased polymerization and functional activity provides a rationale for the gene therapy trials of sCD59 to inhibit the terminal pathway of complement in AMD that are underway.

Epithelioid hemangioendothelioma, an ultra-rare cancer: a consensus paper from the community of experts

Epithelioid hemangioendothelioma (EHE) is an ultra-rare, translocated, vascular sarcoma. EHE clinical behavior is variable, ranging from that of a low-grade malignancy to that of a high-grade sarcoma and it is marked by a high propensity for systemic involvement. No active systemic agents are currently approved specifically for EHE, which is typically refractory to the antitumor drugs used in sarcomas. The degree of uncertainty in selecting the most appropriate therapy for EHE patients and the lack of guidelines on the clinical management of the disease make the adoption of new treatments inconsistent across the world, resulting in suboptimal outcomes for many EHE patients. To address the shortcoming, a global consensus meeting was organized in December 2020 under the umbrella of the European Society for Medical Oncology (ESMO) involving >80 experts from several disciplines from Europe, North America and Asia, together with a patient representative from the EHE Group, a global, disease-specific patient advocacy group, and Sarcoma Patient EuroNet (SPAEN). The meeting was aimed at defining, by consensus, evidence-based best practices for the optimal approach to primary and metastatic EHE. The consensus achieved during that meeting is the subject of the present publication.

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This consensus paper provides key recommendations on the management of epithelioid hemangioendothelioma (EHE).

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Recommendations followed a consensus meeting between experts and a representative of the EHE advocacy group and SPAEN.

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Authorship includes a multidisciplinary group of experts from different institutions from Europe, North America and Asia.

Heat Exposure and Multiple Sclerosis-A Regional and Temporal Analysis

Multiple sclerosis (MS) is a neurological disorder that progressively distorts the myelination of axons within the central nervous system (CNS). Increased core body temperature or metabolism as a result of exercise are common causes of short-term exacerbations of neurological symptoms in MS. About 60–80% of patients with MS experience a worsening of their symptoms when exposed to heat. In comparison, less data are available on the relationship between ambient meteorological conditions (e.g., temperature and relative humidity (RH)) and fluctuations in such variables in relation to MS symptoms. Thus, this study examined associations between time-lagged exposure to meteorological conditions and risk of a clinic visit due to MS among US veterans between 2010 and 2013. This study leveraged data from the Veterans Affairs (VA) and National Climactic Data Center (NCDC) for the continental US, partitioned into eight climate zones. We used a case crossover design to assess the risk of a MS clinic visit with respect to several meteorological conditions. Location-specific time-lagged daily (ambient) exposure to temperature, RH, and temperature variations (standard deviation (SD) of temperature) were computed (up to 30 days) for each case (i.e., day of MS visit) and control (a randomly assigned date ± 90–270 days prior to visit). Statistical analyses were conducted to examine independent associations between the selected meteorological conditions and risk of MS visits at the national and regional levels. A total of 533,066 patient visits received a MS diagnosis (International Classifications of Diseases (ICD)-9 code = 340). The Northeast (NE) and Upper Midwest (UMW) regions reported the highest frequency of clinic visits due to MS. Clinic visits were 9% more likely to occur in the spring, summer, and fall months (March–October) than in the winter (OR = 1.089; 95% CI = 1.076–1.103; p < 0.01). In the univariate analyses, the SD of temperature, temperature, and temperature–RH interaction were positively associated with an elevated risk of a MS clinic visit, while the RH was negatively associated with the risk for a clinic visit. In multivariate analyses, the strongest association of a MS clinic visit was observed with the SD of the temperature (OR = 1.012; 95% CI 1.008–1.017; p < 0.01). These associations between MS clinic visits and meteorological conditions varied across climate regions, with the strongest associations being observed in the LMW, UMW, DSW, and NE zones. The SD of the temperature was again the strongest associated predictor when examined regionally. Temperature variations and temperature–RH interactions (a proxy of the heat index) showed significant associations with MS clinic visits. These associations varied across climate regions when examined geographically. Our findings have implications for the management of MS in severe or recurrent cases, especially considering the impending changes in the daily temperature variations and intensity of the heatwaves expected with the intensification of global warming.

AB0573 DUPILUMAB-INDUCED ENTHESITIS/ARTHRITIS IN PATIENTS WITH ATOPIC DERMATITIS: A RETROSPECTIVE OBSERVATIONAL STUDY

Background:

Atopic dermatitis (AD) is a common skin condition with a prevalence of 2–10% in adults1. IL-4 and IL-13 play a key role in the pathogenesis. Dupilumab, a human IgG4 monoclonal antibody binding the alpha subunit of the IL-4 receptor, blocking IL-4 and IL-13 signaling, has important efficacy in this difficult to treat disease. We first reported a musculoskeletal (MSK) adverse effect of enthesis/arthritis developing in 3 patients in 20192.

Objectives:

To report the ongoing experience at our centre of this new clinical paradigm, incidence and patient progress including clinical presentation, imaging and management.

Methods:

Clinical and radiological data was collected from electronic case records of all cases presenting with features of enthesitis/arthritis between October 2018 and January 2021.

Results:

Since initiation of dupilumab at GSTT, approximately 400 adults with moderate-to-severe AD have received at least one dose. Of these, 23 patients (14 men, 9 women) had the clinical syndrome of inflammatory enthesitis/tenosynovitis/arthritis. Nine patients had both enthesitis and arthritis, 10 enthesitis, 3 enthesitis and tenosynovitis and 1 arthritis only. Four of these also reported new onset inflammatory back pain symptoms. None had a preceding history of arthritis or enthesitis. Median onset of symptoms following initiation of dupilumab was 4 months. However, onset of symptoms ranged between 2 weeks and 48 months. Imaging (US/MRI) was performed in 18 patients, 11 with Doppler US positive enthesitis confirming clinical findings. Most common sites were lateral epicondyles, achilles and patella tendons. Two patients with more disabling symptoms had MRI confirmed gluteus medius and hamstring enthesitis and arthritis. Spine and SI joint MRI in 4 patients was negative. Most patients had normal inflammatory markers except 2; CRP 117, ESR 96 and CRP 13, ESR 10. All patients had very good AD response to dupilumab, average EASI score before and after Dupilumab was 21 and 4.2 respectively. One patient developed skin manifestations of guttate psoriasis, with subsequent disabling arthritis/enthesitis. Due to the life-changing beneficial effect of dupilumab therapy most patients did not want to stop therapy. We used NSAID therapy, etoricoxib/celecoxib/naproxen for symptom relief which was usually partly effective allowing continuation of dupilumab treatment in most. Five patients with severe MSK symptoms stopped Dupilumab completely. Some patients temporarily paused therapy but re-started as their AD became worse, often changing from the usual 2 weekly to 4 weekly dosing. Most patients continuing dupilumab had persistent MSK symptoms. Four patients who stopped dupilumab were treated with baricitinib, which has potential efficacy for both MSK symptoms and AD. Two did not tolerate it and remained on NSAID therapy.

Conclusion:

These data further characterize a new syndrome of enthesitis and/or arthritis induced by Dupilumab. In those with mild MSK symptoms use of NSAIDs allows continuation of full-dose dupilumab, in moderate cases reducing dupilumab dose frequency plus NSAID therapy maintains function. Most patients had on-going MSK symptoms. In more severe cases JAKi therapy may be an effective strategy. Our initial hypothesis that inhibition of IL-4/13 by dupilumab triggers an IL-17/23/TNF-mediated inflammatory MSK syndrome in some patients is supported by a recent in vitro study3.

References:

[1]Beck L et al. Dupilumab Treatment in Adults with Moderate-to-Severe Atopic Dermatitis. July 10, 2014. N Engl J Med 2014; 371:130-139

[2]Willsmore ZN et al. Development of inflammatory arthritis and enthesitis in patients on dupilumab: a case series. Br J Dermatol 2019; 0. doi:10.1111/bjd.18031.

[3]Bridegwood C et al. Regulation of entheseal IL-23 expression by IL-4 and IL-13 as an explanation for arthropathy development under dupilumab therapy. Rheumatology (Oxford). 2020 Nov 30:keaa568. doi: 10.1093/rheumatology/keaa568

Disclosure of Interests:

Joseph Nathan: None declared., Catherine Hughes Speakers bureau: Presented for Abbvie, Samir Patel: None declared., Libin Mathew: None declared., Catherine Smith Grant/research support from: Grants/research support; Professor Smith is a PI/CoPI on a number of commercially supported studie (Abbvie, Janssen, Leo, Sanofi)., Andrew Pink Paid instructor for: Speaker or advisor to Lilly, Abbvie, Sanofi, Leo, Almirall, Novartis, Janssen, UCB, Galderma, BMS, La-Roche Posay, Richard Woolf: None declared., Bina Menon Speakers bureau: Presented for Abbvie, L Bruce Kirkham Grant/research support from: Professor Kirkham has received honoraria and/or research funding from AbbVie, Eli Lilly, Gilead, Janssen, Novartis, Pfizer and UCB.

Direct measurement of the triple spin flip rate in dynamic nuclear polarization

A previous study of the effect of Gadolinium doping on the dynamic polarization (DNP) of ¹³C using trityls showed that the rate at which the polarization builds up is almost independent of the Gadolinium concentration, while the electron spin-lattice relaxation rate varies over an order of magnitude. In this paper we analyze the polarization build-up in detail and show that in this case DNP is due to the cross-effect (CE) and that the build-up rate can be quantitatively interpreted as the rate of the triple spin flips responsible for the CE. Thus this build-up rate presents a direct measurement of this triple spin flip rate.

236 Novel Guidelines to Avoid Routine Blood Tests After Robotic Assisted Radical Prostatectomy (RARP)

Introduction

Patients undergoing RARP commonly require routine post-operative blood tests. This practice dates from an era of open surgery, with increased blood loss and complications. We aim to improve specificity of blood test requests with novel guidelines.

Method

1039 consecutive RARP patients at two tertiary urology centres in the UK were audited. Novel guidelines constructed based on risk stratified evidence from the initial audit were used to prospectively audit 133 patients.

Results

16% had clinical concerns post-operatively. 1% and 4% had an intra- and post-operative complication. Intra- or post-operative clinical judgement flagged post-operative complications in 99.9%. 80% had routine blood tests with no clinical concerns. 6% had delayed discharge due to delayed processing of blood tests. 0.9% received a peri-operative transfusion.

Re-Audit Novel guidelines reduced the number of blood tests requested from 100% to 36%. Specificity in diagnosing a complication improved from 0% to 67%. Discharge delays reduced from 6% to 0% and no post-operative complications were missed (sensitivity 100%).

Conclusions

Routine blood tests, without an indication, did not flag any additional post-operative complications. Blood transfusion is rare for RARP. Novel guidelines to request post-operative blood tests will reduce costs and discharge delays whilst maintaining appropriate patient safety and care.

Pathophysiology and Imaging Findings of COVID-19 Infection: An Organ-system Based Review

BACKGROUND

COVID-19 commonly presents with upper respiratory symptoms; however, studies have shown that SARS-CoV-2 infection affects multiple organ systems. Here, we review the pathophysiology and imaging characteristics of SARS-CoV-2 infection in organ systems throughout the body and explore commonalities.

OBJECTIVE

Familiarity with the underlying pathophysiology and imaging characteristics is essential for the radiologist to recognize these findings in patients with COVID-19 infection. Though pulmonary findings are the most prevalent presentation, COVID-19 may have multiple manifestations and recognition of the extrapulmonary manifestations is especially important because of the potential serious and long-term effects of COVID-19 on multiple organ systems.

Untangle those stethoscopes; never too early to start reflecting! Qualitative review of a reflective practice group for clinical undergraduate medical students

Introduction

Equipping our medical students with as many tools as possible to cope with the challenges that they will inevitably face has never been more important than it is today.

Objectives

The aim of this study was to examine the effectiveness of a reflective practice (RP) group for medical students, particularly with adaptation to COVID-19 and transition to video.

Methods

A pilot programme of RP for 3^rd year medical students commencing their clinical placement was run by the Sligo Medical Academy, NUIG in Ireland between January – April 2020. This group for nine students was initially run face-to-face but pivoted to an online group in March 2020 with the COVID-19 pandemic. Data was collected through one-to-one interviews with all student participants and the facilitator (n=10). Interviews were recorded and transcribed. Data were analysed using thematic content analysis.

Results

Our analysis identified four main discussion themes: transition to clinical environment, gender in the workplace, building professional identity and family and support systems. The students who continued the RP group over zoom during the COVID-19 pandemic particularly identified with the theme of support systems and solidarity. The smooth transition to zoom and its effectiveness in a time of social distancing were discussed. Identified challenges related primarily to timing of the RP group, particularly after a full day of placements or time differences for international students overseas.

Conclusions

Reflective practice programmes are not routinely offered to medical students in Ireland currently and this study gives recommendations on implementing and improving experiences of undergraduate training based on RP.

Disclosure

No significant relationships.