Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

AB0770 DESCRIBING A COHORT OF PATIENTS WITH PSORIATIC ARTHRITIS ACCORDING TO THE BODY MASS INDEX: EXPERIENCE IN A JOINT RHEUMATOLOGY-DERMATOLOGY CLINIC

Background:

Obesity is a predictor for the development of psoriatic arthritis (PsA) with a negative prognostic impact.

Objectives:

We aimed to describe and characterize patients with PsA according to the Body Mass Index (BMI) in a joint Rheumatology-Dermatology unit (PAIDER).

Methods:

We retrospectively reviewed patients diagnosed with PsA according to CASPAR criteria visited between May 2012 and May 2019 at the PAIDER clinic of our center. Data on demographic and anthropometric features, serologic findings, source of referral, cardiovascular risk factors and biological treatment were collected from clinical records. Patients were classified according to the WHO International Classification of nutritional status in normal weight (BMI 18.5-24.9 Kg/m2), overweight (BMI 25-29.9 Kg/m2) and obesity (BMI≥30 Kg/m2). A descriptive analysis was performed, and the differences between groups were evaluated using Chi2, T-Student and ANOVA tests. P-values <0.05 were accepted as significant.

Results:

During the study period 393 patients (50.6% women) with a mean age of 52.47 ± 13.21 years were evaluated. Baseline characteristics are shown in table 1.

Table 1.Baseline characteristicsTotaln=393Female, n (%)199 (50,6)Age, yrs, mean ±SD52,47 (13,21)Source of referral, n (%) Dermatology117 (29,8) Rheumatology219 (55,7) Primary Care and Others22 (5,6)Smoker, n (%)97 (25,8)High Blood Pressure (HBP), n (%)106 (27,7)Diabetes, n (%)48 (12,5)Hypercholesterolemia, n (%)98 (25,8)Hyperuricemia, n (%)32 (8,6)HLA-B27 positive, n (%)68 (21,6)BMI, Kg/m2, mean ±SD28,15 (5,87)Biological treatment, n (%)166 (43,2)

The mean BMI was 28.15 ± 5.87 kg/m2. 112 patients (32%) were overweight with a mean BMI of 27.46 ± 1.55 kg/m2and 118 patients (34%) were obese with a mean BMI of 34.42 ± 5.08 kg/m2. Of the obese patients, 80 (67.8%) had obesity grade 1, 28 (23.7%) grade 2 and 10 (8.5%) grade 3.

Characteristics of the patients according to BMI categories are shown in Table 2.

Table 2.Characteristics according to BMINormal weightn= 118Overweightn= 112Obesityn=118P valueFemale, n (%)66 (55,9)52 (46,4)62 (52,5)nsAge, yrs, mean ±SD47,92 (14,08)54,71 (11,75)54,48 (11,54)<0,001Source of referral, n (%)Ns Dermatology35 (33,7)37 (35,2)34 (30,9) Rheumatology63 (60,6)61 (58,1)70 (63,6) Primary Care and Others6 (5,8)7 (6,7)6 (5,5)Smoker, n (%)37 (33)23 (21,1)31 (26,7)nsHigh Blood Pressure (HBP), n (%)12 (10,5)37 (34,3)41 (35)<0,001Diabetes, n (%)7 (6)9 (8,3)30 (25,6)<0,001Hypercholesterolemia, n (%)19 (17)24 (22,2)45 (38,5)0,001Hyperuricemia, n (%)5 (4,4)7 (6,8)19 (16,7)0,004HLA-B27, n (%)27 (28,7)17 (17,9)13 (12,6)0,016BMI, Kg/m2, media ±DE22,58 (1,78)27,46 (1,55)34,42 (5,08)-Biological treatment, n (%)47 (41,2)45 (40,9)66 (55,9)0,032

We observed that mean age was significantly higher in obese patients (p <0.001), as well as the prevalence of cardiovascular risk factors such as HBP (p <0.001), Diabetes (p <0.001), dyslipidemia (p = 0.001) and hyperuricemia (p = 0.004). Obese patients also received more biological therapy (p=0.032). A higher prevalence of HLA-B27 was observed in patients with normal weight (p=0.016). No differences were found according to BMI regarding gender and source of referral.

Conclusion:

- Almost 70% of patients with PsA visited in the PAIDER clinic of our center have a BMI above normal and more than a third of them are obese, mostly grade 1.

- In our joint clinic there are no differences in BMI regarding the source of referral of the patients.

- Patients with obesity are older, have more cardiovascular comorbidities and receive more biological treatment significantly, which increases the complexity of their management and worsens the prognosis.

Disclosure of Interests:

Andrea García-Guillén: None declared, Ana Laiz: None declared, Anna Lopez-Ferrer: None declared, HyeSang Park: None declared, Patricia Moya: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Ana Milena Millán Arciniegas: None declared, Cesar Díaz-Torné: None declared, Sicylle Jeria: None declared, Hector Corominas: None declared

AB0997 IS HEIGHT ADJUSTMENT NECESSARY IN PEDIATRIC DENSITOMETRY IN ALL CHILDREN?

Background:

The current guidelines of the International Society for Clinical Densitometry (1) recommend that in children with linear growth or maturational delay, Z score results should be adjusted. Height for age Z score (HAZ) adjustment is valid and can be calculated using the formula the formula proposed by Zemmel et al(2).

It is possible that pediatric populations without linear growth or maturational delay, also benefit from HAZ, to prevent bone size from influencing the final Z score.

Objectives:

To evaluate Z score variability adjusted and without adjusting for height for age.

Methods:

We analysed data from densitometry performed on patients 2-20 years of age, from 2016 to 2018, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for low bone mass/osteoporosis. The HAZ was calculated according to Zemel’s formula.

Results:

Data from 103 patients are presented. Its characteristics are summarized in Table 1

Table 1.Mean age9,8 yearsFemale52,4%Height Percentil ≤ 36,8%Height Percentil ≥ 974,9%LBM (Z score ≤ -2) spine8,2%LBM HAZ spine6,4%LBM whole body10,5%LBM HAZ whole body7,2%

The table shows that the proportion of patients with BMD decreases in both the spine region and the whole body when adjusting for HAZ.

When evaluating the relationship between densitometric measurements we found that spine Z score (ZsS) and whole body Z score (ZsWB) had a correlation coefficient of 0,73 (p<0,001). There were no differences between their averages (p=0,170).

At the LBM cut-off point (Z score ≤ -2) there were discrepancies in 7%, where 5% presented LBM in ZsWB but not in ZsS. The concordance index at this point was 0,557.

When comparing these measures with their HAZ adjusted equivalents, we observe:

Conclusion:

There are discrepancies at the LBM cut-off point depending on the HAZ adjustment.

The pediatric population without linear growth or maturational delay, can also benefit from HAZ adjustment, especially those with high height percentiles in which their size can hide a diagnosis of LBM.

References:

[1]Weber DR, Boyce A, Gordon C, Hogler W, Kecskemethy HH, Misra M, et al. The Utility of DXA Assessment at the Forearm, Proximal Femur, and Lateral Distal Femur, and Vertebral Fracture Assessment in the Pediatric Population: 2019 ISCD Official Position. Journal of clinical densitometry: the official journal of the International Society for Clinical Densitometry. 2019;22(4):567-89.

[2]Zemel BS, Leonard MB, Kelly A, Lappe JM, Gilsanz V, Oberfield S, et al. Height adjustment in assessing dual energy x-ray absorptiometry measurements of bone mass and density in children. The Journal of clinical endocrinology and metabolism. 2010;95(3):1265-73.

Disclosure of Interests:

None declared

AB0998 TRABECULAR BONE SCORE IN PEDIATRICS, IS IT USEFUL?

Background:

Bone fragility depends not only on bone mineral density (BMD), but also on bone microarchitecture. In adults, Trabecular Bone Score (TBS) is being used as an indirect marker of bone microarchitecture

It is a software that applicated to the vertebral image obtained by conventional densitometry, informs about the thickness of the trabeculae, the trabecular connectivity and the space between them. A high score indicates a better bone microstructure. In adults, a TBS equal to or greater than 1,350 is considered to represent a normal microarchitecture

Objectives:

To evaluate the usefulness of TBS in pediatric population with risk factors for Low Bone Mass (LBM)

Methods:

TBS was assessed by analyzing vertebral densitometries performed on patients from 4 to 20 years of age, assessed in the pediatric rheumatology office of our hospital for presenting risk factors for LBM, consecutively from 2016 until 2018

Data were compared with normal pediatric population

Results:

Data from 83 patients are shown, with an average age of 11.2 years, 62% female, 80% Caucasian

The main risk factors for LBM were (%): Insufficient calcium intake (84,5), medications with osteopenizing potential (31), corticosteroids (39), sedentary lifestyle (13,6), fractures of long or vertebral bones (12,6) and hypovitaminosis D (8,1)

Table 1.

TBS por age groups and in patients with and without LBM

Age groupsnMeanSDMinimum-MaximumScholars (4-9a)221,3210,0931,119-1,502Adolescence (10-17a)541,3090,0881,073-1,493Youth (18-20a)61,3590,0851,258-1,460Spine Z scorenMean (SD)pMinimum-Maximum ≤-281,270 (0,075)0,1261,419-1,162 >-2741,321 (0,090)1,502-1,073Whole Body Z score ≤-291,246 (0,060)0,0121,323-1,145 >-2731,324 (0,089)1,502-1,073Table 2.

TBS in healthy population and study population for age

Healthy girls (n=2535)Healthy boys (n=1459)Study girls (n=47)Study boys (n=36)Age (y)Spine BMDTBSSpine BMDTBSTBSTBS1-20,401,3250,371,2722-30,511,3630,461,2671,1273-40,521,3460,511,2641,2044-50,601,3460,601,2671,2371,2435-60,601,2880,561,2691,3301,3686-70,651,2800,601,2321,3181,4227-80,671,2680,641,2441,3391,3458-90,711,2660,681,2281,2449-100,751,2780,701,2081,2531,34110-110,81,2850,731,2311,2291,29211-120,841,3370,761,2501,3031,31512-130,991,3550,811,2481,3811,36813-141,061,3860,891,2731,3941,33814-151,101,3980,991,3031,4741,28515-161,141,4051,081,3111,3681,40616-171,171,4051,151,3341,3321,37117-181,171,4041,201,3281,3741,28518-191,171,4041,161,314

Conclusion:

TBS was lower in the patients with LBM by whole body Z score, but not in those with LBM by spine Z score. We observed a decrease in TBS in adolescence, not corresponding with a decrease in BMD, and that should not be interpreted as a pathological finding

Similar results have been described in other pediatric populations (1, 2), but larger studies are needed to evaluate this phenomenon. We hypothesize that it may be due to a higher rate of growth in adolescence, with a lower rate of calcium apposition into the osteoid material

References:

[1]Del Rio DS, Winthenrieth R. BONE MICROARCHITECTURE (TBS) AND BONE MASS DEVELOPMENT DURING CHILDHOOD AND ADOLESCENCE IN A SPANISH POPULATION GROUP. . WCO-IOF-ESCEO; Seville2014.

[2]Shawwa K, Arabi A, Nabulsi M, et al. Predictors of trabecular bone score in school children. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2016;27(2):703-10.

Disclosure of Interests:

None declared

AB0489 BETA 2 MICROGLOBULIN AS A PROGNOSTIC FACTOR IN CRYOGLOBULINEMIA NON ASSOCIATED WITH HEPATOTROPIC VIRUSES

Background:

Cryoglobulinemia (CG) is a rare phenomenon related to haematological disorders, infections and autoimmune diseases. Age and renal involvement are known prognostic markers.

Objectives:

To describe the differential clinical features and the prognostic factors in a cohort of patients diagnosed with CG non-associated with hepatotropic viruses.

Methods:

A descriptive, retrospective study of a cohort comprised of 252 cryoglobulin positive samples, obtained from the immunology laboratory database of a tertiary hospital attending 450,000 people over 1 year. 186 patients with CG positive samples were included, 87 of which were not associated with neither hepatitis B nor C virus. Demographic, clinical, serological and pathological data were collected. Nonparametric variables were compared using a Wilcoxon test.

Results:

Out of 186 reviewed patients, 87 (46.7%) are included in this study. The mean age at CG diagnosis was 60 (± 16) years. Mixed CG was the predominant subtype, detected in 66 (75.9%) patients, 10 of which (11.5%) were associated with glomerulonephritis (GN) with compatible biopsy, 17 (19.5%) with peripheral neuropathy (PN), 29 (33.3%) with non-erosive arthritis and 10 (11.5%) with leukocytoclastic vasculitis confirmed by skin biopsy. The clinical, epidemiological and serological characteristics of the sample are summarized in Table 1.

Figure 1.

Ing et al’s Nomogram of parsimonious model.

Table 1.

Clinical, epidemiological and serical characteristics of patients with CG

Sex, female / male, n (%)65/22 (74.7/25.3)Age at diagnosis, years ± SD60 ± 16CG subtype, n (%)- Type 1, n (%)27 (30)- Mixed, n (%)61 (70)ASSOCIATED DISEASES- pSS, n (%)37 (42,5)- LES, n (%)9 (10,3)- SSc, n (%)7 (8,05)CLINICAL CHARACTERISTICS- Skin, n (%)30 (34,5)- Purpura, n (%)14(16)- Ulcers, n (%)5 (5,7)- Acral ischemia, n (%)2 (2,3)- Acrocyanosis by cold, n (%)7 (8)- Raynaud, n (%)19 (21,8)- Peripheric Neuropathy, n (%)17 (19,5)- Non-erosive arthritis, n (%)29 (33,3)- Glomerulonephritis, n (%)10 (11,5)LABORATORY- β2M +(>1.8 mg/L) mean3.9- RCP (mg/L) p503.7- ESR (mm/hour) p5028- RF + (>20 UI/mL) p50124- Anti Ro52 + /Anti Ro60 + n, (%)42 (48.3)- Low C3 n, (%)48 (55.1)- Low C4 n, (%)36 (41.4)

In the comparative analysis of patients with CG and Beta 2 microglobulin (β2M), CG and rheumatoid factor (RF), those with high β2M (>1.8 mg / L) presented significantly more GN (p0.016) and PN (p0.013). However, the association of RF with either GN (p0.948) or PN (p0.645) was not significant. Also, high β2M was significantly related to complement consumption of C4 (p: 0.015) but not of C3 (p: 0.063). In the 30 (34.5%) patients with skin manifestations, high β2M showed no statistically significant association. The main systemic autoimmune diseases associated were primary Sjögren’s Syndrome (pSS) 37 (42.5%), Systemic Lupus Erythematosus (SLE) 9 (10.3%) and Systemic Sclerosis (SSc) 7 (8.05%).

Conclusion:

A direct association between presence of elevated levels of β2M and the existence of progression to glomerulonephritis and peripheral neuropathy is found in our cohort. No correlation is found between the presence of CG and other serological markers of autoimmunity except low C4. CG with elevated β2M does not associate with greater skin involvement or arthritis.

References:

[1]A.C. Desbois et al. Cryoglobulinemia: An update in 2019. Joint Bone Spine (2019)

[2]Cacoub P, Cryoglobulinemia Vasculitis, The American Journal of Medicine (2015)

Disclosure of Interests:

None declared

SAT0217 PERFORMANCE OF ACR/EULAR 2019, SLICC 2012 AND ACR 1997 CLASSIFICATION CRITERIA IN A COHORT OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS WITH LONGSTANDING DISEASE

Background:

Systemic lupus erythematosus (SLE) is an autoimmune disease with variable clinical features and a complex physiopathology. In 2019, EULAR and ACR have jointly developed new classification criteria with both high sensitivity and specificity. These criteria have the particularity of including the presence of ANA as an obligatory entry criterion and the existence of clinical and immunological domains with weighted scores.

Objectives:

To evaluate the performance and characteristics of the ACR/EULAR 2019, SLICC 2012 and ACR 1997 classification criteria in a cohort of SLE patients with longstanding disease.

Methods:

Descriptive observational study that enrolled a cohort of SLE patients with longstanding disease followed in a tertiary level hospital. Demographic and clinical data were gathered along with the fulfillment of classification criteria. The sensitivity of each classification criteria and the statistically significant associations between criteria fulfillment and clinical and immunological data were calculated. Statistical analyses were performed using the Chi2, T-student and ANOVA tests. Statistical significance was assumed in p values <0.05.

Results:

A total of 79 patients (88.6% women) with a mean age of 51.8±14 years, disease duration of 15.2±11.5 years and SLEDAI of 2.65±2.1 were included. The sensitivity of the different classification criteria was 51.9% for ACR 1997, 87.3% for SLICC 2012 and 86.1% for ACR/EULAR 2019 (Table 1).

Table 1.

Sensitivity and average scores.

ACR/EULAR 2019SLICC 2012ACR 1997Sensitivity (%)86.187.351.9Average score of patients classified as SLE(±SD)18.6±5.85.3±1.45±0.9Average score of patients NOT classified as SLE(±SD)6.1±2.52.8±0.42.8±0.8

51.9% of patients met all three classification criteria, 29.1% met SLICC 2012 and ACR/EULAR 2019, 5% only met SLICC 2012 and 3.7% exclusively met ACR/EULAR 2019. 11.4% of patients did not meet any classification criteria and were characterized by having a low SLEDAI (0.6±0.9) and fulfilling only skin domains (alopecia or oral ulcers), antiphospholipid antibodies or hypocomplementemia.

Statistically significant associations were found between meeting ACR/EULAR 2019 classification criteria and the presence of low C3 and C4 (p<0.04), DNA (p<0.001), lupus nephritis III-IV (p<0.05) and arthritis (p<0.001), highlighting that all patients with arthritis met these criteria.

In the SLICC 2012 evaluation, significant associations were found between meeting these criteria and the presence of arthritis (p<0.01), renal involvement (p<0.04), leukopenia/lymphopenia (p=0.05), DNA (p<0.03) and hypocomplementemia (p=0.02).

Fullfilment of ACR 1997 was associated to the presence of malar rash (p<0.001), discoid lupus (p<0.05), photosensitivity (p<0.001) and oral ulcers (p<0.04), as well as arthritis (p<0.001), serositis (p=0.02), renal (p<0.05) and hematologic (p=0.05) involvement.

The Kappa concordance coefficient among classification criteria is detailed in Table 2.

Table 2.

Kappa concordance coefficient.

ACR/EULAR 2019 - SLICC 2012ACR/EULAR 2019 - ACR 1997SLICC 2012 - ACR 1997Kappa concordance coefficient0.610.270.30

Conclusion:

The ACR/EULAR 2019 classification criteria maintain a high sensitivity similar to the SLICC 2012 in SLE patients with longstanding disease, both of which are much higher than ACR 1997. Patients with serological, articular or renal involvement are more likely to meet SLICC 2012 or ACR/EULAR 2019 criteria. It is noteworthy the relevance of dermatological manifestations in ACR1997 classification criteria against the increased weight that a better understanding of SLE physiopathology has provided to analytic and immunological criteria in the subsequent classification criteria.

Disclosure of Interests:

David Lobo Prat: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, HyeSang Park: None declared, Patricia Moya: None declared, Ignasi Gich: None declared, Ana Laiz: None declared, Cesar Díaz-Torné: None declared, Ana Milena Millán Arciniegas: None declared, Susana P. Fernandez-Sanchez: None declared, Hector Corominas: None declared

FRI0442 APPROPRIATE USE OF SEROLOGY TESTS FOR THE DIAGNOSIS OF LYME DISEASE. EXPERIENCE IN AN URBAN AREA

Background:

Lyme disease (LD) is a multisystemic animal-borne disease caused by spirochetes of theBorrelia burgdorferi s.lcomplex and transmitted by ticks of the speciesIxodes ricinus. In Spain, most cases occur in rural areas of the north-east region with a peak of maximum incidence between spring and early autumn. The diagnosis is based on a history of potential exposure to ticks, the recognition of characteristic clinical manifestations and serological testing.

Objectives:

To assess the suitability of serological study for the diagnosis of LD in an urban area.

Methods:

Retrospective observational study that included all LD serology tests made between April 2017 and September 2019 at a tertiary hospital in Barcelona covering a population of 450,000 people. Demographic data and the medical department that requested the serology test were collected along with serology test results. The medical records of patients with positive serology were consulted to identify which patients were finally diagnosed with LD along with their clinical manifestations, treatment and outcome.

Results:

A total of 574 serological tests were included and 78 (13.59%) of them were positive. Only 1.04% (6) of all serological tests belonged to patients finally diagnosed with LD. The department that made most requests was Neurology (37.3%) followed by Infectious Diseases (21%), Internal Medicine (14.5%), Emergency Medicine (4.7%), Dermatology (4.5%), Critical Care Medicine (2.3%) and Rheumatology (2.1%). 50% of the diagnosed patients were women with a mean age of 57.7±7.7DE years. In 50% of diagnosed cases, patients remembered a tick bite during activities in the mountain or rural areas. The most common clinical manifestations were erythema migrans (67%), non-inflammatory arthralgias (50%), fatigue and malaise (67%), together with one case of meningoencephalitis and one of knee monoarthritis. All diagnosed patients received antibiotic treatment with ceftriaxone (33%) or doxycycline (66%). Only one patient presented post-Lyme syndrome.

The serological test for LD in our center had a total individual cost of 15.75 eur, so the cost of the 574 requests was 9,040.5 eur. 7,812 eur corresponded to negative results and 1,134 eur to false positive results.

Conclusion:

Our study indicates the overuse of diagnostic testing for LD with implications for patient care and cost-effective health management. In the absence of a history of potential exposure to infected vector ticks or characteristic clinical manifestations, unnecessary microbiological tests should not be performed.

Disclosure of Interests:

David Lobo Prat: None declared, Luís Sainz Comas: None declared, Virginia Pomar: None declared, Ana Milena Millán Arciniegas: None declared, HyeSang Park: None declared, Andrea García-Guillén: None declared, Sicylle Jeria: None declared, Ana Laiz: None declared, Berta Magallares: None declared, Ivan Castellví Consultant of: Boehringer Ingelheim, Actelion, Kern Pharma, Speakers bureau: Boehringer Ingelheim, Actelion, Bristol-Myers Squibb, Roche, Patricia Moya: None declared, Cesar Díaz-Torné: None declared, Susana P. Fernandez-Sanchez: None declared, Hector Corominas: None declared

0724 Altered Brain Network Organization in Patients With Obstructive Sleep Apnea

Introduction

Previous functional MRI (fMRI) studies have reported altered brain networks in patients with obstructive sleep apnea (OSA), but the extent of such abnormal connectivity was inconsistent across studies. Moreover, despite the important role of the cerebellum in respiration and OSA, connections of the cerebellum to the cerebral cortex have been rarely assessed. Here, we investigated functional network changes in cerebral and cerebellar cortices of OSA patients.

Methods

Resting-state fMRI, polysomnography and neuropsychological (NP) tests data were acquired from 74 treatment naïve OSA patients (age: 45.8±10.7 years, apnea-hypopnea index: 46.4±18.5 /h) and 33 normal controls (39.6±9.3 years). Connectivity matrices were extracted by computing correlation coefficients from various ROIs, and Fisher r-to-z transformations. ROIs consisted of 234 regions matched to 17 functional networks, including 200 parcels of the cortex, and 34 parcels of the cerebellum. Between-group connectivity with age as a covariate was analyzed, and threshold for FDR correction was set at q&lt;0.05. In the functional connections that showed the significant group differences, linear regression was conducted to examine the association between connectivity and composite score of NP tests in OSA patients.

Results

OSA subjects showed decreased attention, executive function, verbal fluency and verbal memory compared to controls. Resting-state functional connectivity was increased between regions involved in the default mode network (DMN), including left medial prefrontal, ventrolateral prefrontal and lateral temporal cortices. In OSA, the connectivity changes between these DMN areas negatively correlated with attention/executive function and verbal fluency. Multiple cerebellar regions showed reduces in connectivity with cerebral cortical areas including frontal eye field, temporoparietal junction, temporo-occipital gyrus, and parieto-occipital association cortex.

Conclusion

OSA affects mainly the DMN and cerebello-cerebral pathway. The disruption of function in these two networks are known to relate to sleep deprivation and respiratory abnormality. The abnormal DMN found in OSA patients further related to their cognitive impairment.

Support

This research was supported by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, ICT & Future Planning, Republic of Korea (2017R1A2B4003120) and by Samsung Biomedical Research Institute grant (OTC1190671)

0779 Circadian Entrainment in 12h Night Shift Workers: The Environmental Lights Matter?

Introduction

Shift workers frequently suffer sleep disturbance in relation with the atypical work schedules. In particular, night shift workers are exposed to inevitable sunlight or bright indoor lights during the morning hours that may disturb their daytime sleep. We aimed to find out the optimal environmental lights to facilitate circadian entrainment of 12h-shift workers by assessing melatonin profiles in the morning and daytime sleep quality.

Methods

We enrolled 12h-shift female nurses working at one hospital (n=10, mean age 29.4±3.5 years). The schedules of participants are identical such as day-day-night-night shifts and four consecutive off days. Participants admitted to the laboratory at 9:00 following 2nd night shift schedule. Saliva melatonin was taken six times every 30 minute from 10:00 to 12:30 under two different lighting conditions with organic light emitting diodes (OLED) or light emitting diodes (LED) with 150 lux of light intensity. Dim light condition (10 lux) was conducted as controls. Three sessions were randomly ordered with 8-10 days intervals. Participants were allowed to sleep after 12:30 with light off and woke up ad libitum.

Results

Melatonin concentration had decreased gradually from 10.6±11.4 to 5.0±8.2 pg/ml. Among three different lighting conditions, there were no statistical differences in salivary melatonin and sleep parameters recorded by polysomnography. Circadian entrainment in night shift workers was defined as that salivary melatonin concentration had maintained above 5 pg/ml at the time to bed. 20% of sessions (6/30) were classified as circadian entrainment (CE) and 80% (24/30) were as non-entrainment (NE). Mean melatonin concentration was 22.1±11.2 in CE and 3.9±4.1 pg/ml in NE (p&lt;.001). CE showed significantly shorter sleep latency (0.5±0.3 vs. 1.5±1.4 min, p=.025) and wakefulness after sleep onset (13.6±6.3 vs. 27.9±16.8%, p=.015), and higher sleep efficiency (94.6±2.6 vs. 88.7±6.3%, p=.011) than NE. The number of each lighting condition was not different between CE and NE (p=.847).

Conclusion

This is a preliminary study with small number of participants. We found that environmental lights including dim light did not affect daytime sleep of 12h shift workers. Instead, daytime sleep quality was influenced by circadian entrainment with higher melatonin concentration in the morning.

Support

 

Measurement of R(D) and R(D^{*}) with a Semileptonic Tagging Method

The experimental results on the ratios of branching fractions R(D)=B(B[over ¯]→Dτ^{-}ν[over ¯]_{τ})/B(B[over ¯]→Dℓ^{-}ν[over ¯]_{ℓ}) and R(D^{*})=B(B[over ¯]→D^{*}τ^{-}ν[over ¯]_{τ})/B(B[over ¯]→D^{*}ℓ^{-}ν[over ¯]_{ℓ}), where ℓ denotes an electron or a muon, show a long-standing discrepancy with the standard model predictions, and might hint at a violation of lepton flavor universality. We report a new simultaneous measurement of R(D) and R(D^{*}), based on a data sample containing 772×10^{6}  BB[over ¯] events recorded at the ϒ(4S) resonance with the Belle detector at the KEKB e^{+}e^{-} collider. In this analysis the tag-side B meson is reconstructed in a semileptonic decay mode and the signal-side τ is reconstructed in a purely leptonic decay. The measured values are R(D)=0.307±0.037±0.016 and R(D^{*})=0.283±0.018±0.014, where the first uncertainties are statistical and the second are systematic. These results are in agreement with the standard model predictions within 0.2, 1.1, and 0.8 standard deviations for R(D), R(D^{*}), and their combination, respectively. This work constitutes the most precise measurements of R(D) and R(D^{*}) performed to date as well as the first result for R(D) based on a semileptonic tagging method.

Effects of smoking and different BMI cutoff points on surgical site infection after elective open ventral hernia repair

PURPOSE

BMI > 40 kg/m² and smoking have been identified as risk factors for surgical site infections (SSIs) after ventral hernia repair, however, the relationship with lower BMI values has not been described. The objective of this study was to analyze the relationship between different BMI thresholds, smoking, and SSI after open ventral hernia repair.

METHODS

All patients who underwent an elective non-emergent open ventral hernia repair with mesh were extracted from the 2011 to 2016 NSQIP database. Bivariate, multivariate logistic regression, and Classification and Regression Tree (CART) analyses were used.

RESULTS

Of 55,240 patients, 2,620 (4.7%) developed SSIs (superficial: 58.5%, deep:27%, organ-space: 16%). BMI (OR: 1.035; 95% CI:1.03-1.04; p < 0.001) and smoking (OR:1.51; 95% CI:1.37-1.67; p < 0.001) were identified in logistic regression analysis as the two most modifiable risk factors independently associated with SSIs. CART analysis demonstrated that the lowest SSI rate belonged to non-smokers with BMI < 24.2 kg/m² (1.9%), and the highest SSI to smokers with BMI > 42.3 kg/m² (12%). Between these values, there was a stepwise increase in SSI rate as BMI increased, while smoking added additional risk in each group.

CONCLUSION

Following open hernia repair, the association between SSI and being overweight starts at a BMI of 24.2, a threshold lower than previously described. The risk of SSI increases in a stepwise fashion as BMI increases and is augmented by smoking. Future studies are needed to determine if SSI reduction can be achieved with a combination of smoking cessation and weight loss using these BMI thresholds.

Search for an Invisibly Decaying Z^{'} Boson at Belle II in e^{+}e^{-}→μ^{+}μ^{-}(e^{±}μ^{∓}) Plus Missing Energy Final States

Theories beyond the standard model often predict the existence of an additional neutral boson, the Z^{'}. Using data collected by the Belle II experiment during 2018 at the SuperKEKB collider, we perform the first searches for the invisible decay of a Z^{'} in the process e^{+}e^{-}→μ^{+}μ^{-}Z^{'} and of a lepton-flavor-violating Z^{'} in e^{+}e^{-}→e^{±}μ^{∓}Z^{'}. We do not find any excess of events and set 90% credibility level upper limits on the cross sections of these processes. We translate the former, in the framework of an L_{μ}-L_{τ} theory, into upper limits on the Z^{'} coupling constant at the level of 5×10^{-2}-1 for M_{Z^{'}}≤6  GeV/c^{2}.

Radiomics Study of Thyroid Ultrasound for Predicting BRAF Mutation in Papillary Thyroid Carcinoma: Preliminary Results

BACKGROUND AND PURPOSE

It is not known how radiomics using ultrasound images contribute to the detection of BRAF mutation. This study aimed to evaluate whether a radiomics study of gray-scale ultrasound can predict the presence or absence of B-Raf proto-oncogene, serine/threonine kinase (BRAF) mutation in papillary thyroid cancer.

MATERIALS AND METHODS

The study retrospectively included 96 thyroid nodules that were surgically confirmed papillary thyroid cancers between January 2012 and June 2013. BRAF mutation was positive in 48 nodules and negative in 48 nodules. For analysis, ROIs from the nodules were demarcated manually on both longitudinal and transverse sonographic images. We extracted a total of 86 radiomics features derived from histogram parameters, gray-level co-occurrence matrix, intensity size zone matrix, and shape features. These features were used to build 3 different classifier models, including logistic regression, support vector machine, and random forest using 5-fold cross-validation. The performance including accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve, of the different models was evaluated.

RESULTS

The incidence of high-suspicion nodules diagnosed on ultrasound was higher in the BRAF mutation-positive group than in the mutation-negative group (P  =  .004). The radiomics approach demonstrated that all classification models showed moderate performance for predicting the presence of BRAF mutation in papillary thyroid cancers with an area under the curve value of 0.651, accuracy of 64.3%, sensitivity of 66.8%, and specificity of 61.8%, on average, for the 3 models.

CONCLUSIONS

Radiomics study using thyroid sonography is limited in predicting the BRAF mutation status of papillary thyroid carcinoma. Further studies will be needed to validate our results using various diagnostic methods.

Observation of the Radiative Decays of ϒ(1S) to χ_{c1}

We report the first observation of the radiative decay of the ϒ(1S) into a charmonium state. The significance of the observed signal of ϒ(1S)→γχ_{c1} is 6.3 standard deviations including systematics. The branching fraction is calculated to be B[ϒ(1S)→γχ_{c1}]=[4.7_{-1.8}^{+2.4}(stat)_{-0.5}^{+0.4}(sys)×10^{-5}]. We also searched for ϒ(1S) radiative decays into χ_{c0,2} and η_{c}(1S,2S), and set upper limits on their branching fractions. These results are obtained from a 24.9  fb^{-1} data sample collected with the Belle detector at the KEKB asymmetric-energy e^{+}e^{-} collider at a center-of-mass energy equal to the ϒ(2S) mass using ϒ(1S) tagging by the ϒ(2S)→ϒ(1S)π^{+}π^{-} transitions.

Direct Evidence of the Competing Nature between Electronic and Lattice Breathing Order in Rare-Earth Nickelates

Correlated electrons give rise to both exotic electronic and magnetic properties in rare-earth nickelates. Here we present evidence of the interfacial coupling between two nickelate systems, EuNiO_{3} (ENO) and LaNiO_{3} (LNO), with different electronic and magnetic properties but with compatible structural registry giving rise to an electrostructural transition, unobserved in each constituent. Nominally, LNO remains in a paramagnetic-metallic R3[over ¯]c phase while orthorhombic ENO undergoes antiferromagnetic and insulating transitions. However, the ENO/LNO heterostructure displays a uniform rotational symmetry set by an entwined interface. This leads to an anomalous reduction of bond disproportionation in the ENO layer through the metal to insulator transition and concomitantly charge disproportionation opens the gap accompanied by antiferromagnetic ordering. Our results resolve a long-standing question in the physics of rare-earth nickelates, herein demonstrating that charge and bond disproportionation are competing mechanisms for the charge localization process in the rare-earth nickelate system.

Infertility treatment and autism risk using the Modified Checklist for Autism in Toddlers (M-CHAT)

STUDY QUESTION

Are toddlers conceived by fertility treatment at higher risk of failing a screening tool for autism spectrum disorders (ASD) than toddlers not conceived by treatment?

SUMMARY ANSWER

Compared with children not conceived by infertility treatment, children conceived by any infertility treatment, ovulation induction with or without intrauterine insemination (OI/IUI), or assisted reproductive technologies (ART) appeared to have had higher odds of failing an ASD screening; however, results were inconclusive and need replication.

WHAT IS KNOWN ALREADY

Although most of the studies which have examined risk of ASD after ART show no association, the results are mixed. Thus, further studies are needed to clarify this association.

STUDY DESIGN SIZE, DURATION

The Upstate KIDS Study is a population-based, prospective cohort study of children born in New York State between 2008 and 2010. Children were screened for ASD using the Modified Checklist for Autism in Toddlers (M-CHAT) at ages 18 and 24 months.

PARTICIPANTS/MATERIALS, SETTING, AND METHODS

The New York State live-birth registry was used to identify newborns conceived with and without fertility treatment with a 1:3 ratio, frequency matched on region of birth. At 18 and 24 months, 3183 and 3063 mothers, respectively, completed the M-CHAT questionnaire. The current analysis included 2586 singletons and 1296 twins with M-CHAT information at 18 and/or 24 months. Multivariable logistic regression with generalized estimating equations (GEE) was used to estimate odds ratios (aOR) and 95% confidence intervals (CI) after adjustment for covariates such as maternal age, education and plurality.

MAIN RESULTS AND THE ROLE OF CHANCE

We found that 200 (5.2%) and 115 (3.0%) children failed the M-CHAT at 18 and 24 months, respectively. The associations between use of infertility treatment and failing the M-CHAT at 18 and/or 24 months were positive but inconclusive as they failed to exclude no association (18 months aOR 1.71, 95% CI: 0.81-3.61; 24 months aOR 1.78, 95% CI: 0.66-4.81; and both 18 and 24 months aOR 1.53, 95% CI: 0.78-2.99). The relationships between OI/IUI and ART with M-CHAT failure at 18 and/or 24 months were similar to those of using any fertility treatment. In vitro fertilization with intracytoplasmic sperm injection was not consistently positively or inversely associated with M-CHAT failure at each time point (18 months aOR 1.20, 95% CI: 0.51-2.83; 24 months aOR 0.93, 95% CI: 0.37-2.31; and both 18 and 24 months aOR 1.09, 95% CI: 0.50-2.60).

LIMITATIONS REASONS FOR CAUTION

The M-CHAT is a screening tool used for ASD risk assessment, and therefore, M-CHAT failure does not indicate ASD diagnosis. In addition, we did not have power to detect associations of small magnitude. Finally, non-response to follow-up may bias the results.

WIDER IMPLICATIONS OF THE FINDINGS

Despite lack of precision, the positive associations between ART and M-CHAT failure suggest that larger population-based studies with longer follow-up are needed.

STUDY FUNDING/COMPETING INTEREST(S)

Supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD; contracts HHSN275201200005C, HHSN267200700019C). The sponsor played no role in the study design, data collection, data analysis or interpretation, writing of the manuscript or decision to submit the article for publication. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.