In vitro calibration and in vivo validation of phenomenological corrosion models for resorbable magnesium-based orthopaedic implants

Metallic bioresorbable orthopaedic implants based on magnesium, iron and zinc-based alloys that provide rigid internal fixation without foreign-body complications associated with permanent implants have great potential as next-generation orthopaedic devices. Magnesium (Mg) based alloys exhibit excellent biocompatibility. However, the mechanical performance of such implants for orthopaedic applications is contingent on limiting the rate of corrosion in vivo throughout the bone healing process. Additionally, the surgical procedure for the implantation of internal bone fixation devices may impart plastic deformation to the device, potentially altering the corrosion rate of the device. The primary objective of this study was to develop a computer-based model for predicting the in vivo corrosion behaviour of implants manufactured from a Mg-1Zn-0.25Ca ternary alloy (ZX10). The proposed corrosion model was calibrated with an extensive range of mechanical and in vitro corrosion testing. Finally, the model was validated by comparing the in vivo corrosion performance of the implants during preliminary animal testing with the corrosion performance predicted by the model. The proposed model accurately predicts the in vitro corrosion rate, while overestimating the in vivo corrosion rate of ZX10 implants. Overall, the model provides a "first-line of design" for the development of new bioresorbable Mg-based orthopaedic devices. STATEMENT OF SIGNIFICANCE: Biodegradable metallic orthopaedic implant devices have emerged as a potential alternative to permanent implants, although successful adoption is contingent on achieving an acceptable degradation profile. A reliable computational method for accurately estimating the rate of biodegradation in vivo would greatly accelerate the development of resorbable orthopaedic implants by highlighting the potential risk of premature implant failure at an early stage of the device development. Phenomenological corrosion modelling approach is a promising computational tool for predicting the biodegradation of implants. However, the validity of the models for predicting the in vivo biodegradation of Mg alloys is yet to be determined. Present study investigates the validity of the phenomenological modelling approach for simulating the biodegradation of resorbable metallic orthopaedic implants by using a porcine model that targets craniofacial applications.

A case of necrotizing fasciitis initially misdiagnosed as cellulitis

INTRODUCTION AND IMPORTANCE

Necrotizing Fasciitis (NF) is a life-threatening, rapidly progressive infection of the skin and underlying soft tissues. Bacterial pathogens induce a toxic-shock reaction that reduces vascular flow, causing thrombosis, sepsis, and tissue necrosis. Treatment consists of immediate IV antibiotics and oftentimes surgical intervention. We present a case of acute NF that was misdiagnosed as cellulitis.

CASE PRESENTATION

A 17-year-old male was transferred to an emergency department from a rural hospital for further management of right lower extremity cellulitis and suspected sepsis. On examination, there was an ulcerated lesion on his right lower leg. Within 4 h, the patient underwent fasciotomy and debridement. The patient was hospitalized for 10 days, received a 3-week-course of Cefazolin, and underwent a meshed split-thickness skin graft. By the end of his hospital stay, he showed significant clinical improvement.

CLINICAL DISCUSSION

Misdiagnosis of NF will almost always lead to a poorer prognosis. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to differentiate NF from other soft tissue infections. Yet, other diagnostic clues such as presentation or pain out of proportion to physical findings may be more relevant clinical indicators for a NF diagnosis. Moreover, though imaging findings of NF may be relevant, surgical fascial examination must not be delayed for the purpose of imaging. It is also important to note that cellulitis and NF do share a disease spectrum.

CONCLUSION

A life-threatening NF infection may seem to be a benign-appearing case of cellulitis, and thus early detection is vital.

Development of a Novel Risk Stratification Score to Predict 30-Day Mortality in Cervical Trauma Patients: CLAAD Score

STUDY DESIGN

Case control.

OBJECTIVE

Traumatic cervical spine injuries are associated with a substantial risk of mortality. The aim of this study is to develop a novel mortality prediction model for patients with cervical trauma who require operative treatment.

SUMMARY OF BACKGROUND DATA

Patients with cervical spine trauma have a high risk of postoperative complications and mortality. There are few reliable systems that can accurately predict mortality after surgery for cervical spine trauma, and those that do exist are typically not specific to cervical trauma.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients undergoing surgery for cervical spine trauma. Univariate analyses were performed to identify variables associated with mortality. Variables that were found to be significant in the univariate models were compiled into a multivariable model. The final model was compared with the American Society of Anesthesiologists (ASA), a modified Charlson comorbidity index (mCCI), and the 5-factor modified frailty index (mFI-5) in respect to predicting 30-day mortality after cervical trauma. The score was then externally validated using the Nationwide Inpatient Sample (NIS) database.

RESULTS

Fifty-five (6.7%) of 822 patients did not survive 30 days after surgery. The final multivariable logistic regression model consisted of the following variables: circumferential fusion "C." long "L" fusion (more than 4 levels), anemia "A," age over 60 "A," and dialysis "D." The risk of mortality increased with increasing CLAAD score, with mortality rates of 0.9%, 3.1%, 7.4%, 22.7%, and 14.3% for scores of 0, 1, 2, 3, and 4, respectively. The CLAAD model had an AUC of 0.73 for predicting mortality after cervical trauma.

CONCLUSIONS

The CLAAD score is a simple and effective system that can help identify patients at risk of increased mortality within 30 days of cervical trauma.

LEVEL OF EVIDENCE

Level III.

A National Survey of Neonatologists' Perspectives on Probiotics Use in Neonatal Intensive Care Units in the U.S.A

Introduction: Most recent clinical reports from the American Academy of Pediatrics (AAP) concluded current evidence does not support routine universal administration of probiotics to preterm infants, particularly those with birth weight <1000 grams. Despite this, the use of probiotics is increasing in US neonatal intensive care units (NICU).Objectives: Collaborating with the Perinatal Neonatal Medicine of AAP, we conducted a national survey to obtain neonatologist opinion on probiotics use.Methods: Survey questionnaires were sent to 3000 neonatologists via email.Results: Of 3000 potential respondents, 249 (8.3 %) completed the survey. Seventy-five (30%) neonatologists working in 23 different NICUs reported using probiotics in their practice, while 168 (70%) neonatologists working in 54 different NICUs reported not using probiotics. Of those not currently use probiotics, 49% indicated they would consider using probiotics in the future vs. 12% indicating they would not use probiotics. The most common indication for probiotics use was average gestational age < 32 weeks and mean birth weight < 1500 grams. Probiotics were discontinued at mean gestational age of 35 weeks. Respondents who prescribe probiotics were more likely to work in a setting without fellowship or residency training (48% vs 20%). Probiotics users were more often from the West (29 % vs 7%) and less often from Northeast (5% vs 34%) compared to non-users. The proportion of those using probiotics did not significantly differ by NICU size, NICU level, or years working in a NICU. Similac Tri-Blend, Evivo, and Culturelle were the top three probiotics used in the respondent's NICU.Conclusion: Though a majority of respondents are not currently using probiotics in their NICU, a large number of nonusers are interested in using probiotics in the future. Differences continue to exist in the brand of probiotics used in US NICUs.

Increased Time to Fixation After Traumatic Spinal Cord Injury Influenced by Race and Insurance Status

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

Although the optimal timing of surgical intervention for traumatic spinal cord injury (TSCI) is controversial, early intervention has been recognized as being beneficial in several studies. The objective of this study was to evaluate the socioeconomic factors that may delay time to surgical fixation in the management of TSCI.

METHODS

The present study utilized the Trauma Quality Improvement Program (TQIP) dataset to identify patients aged greater than 18 undergoing spinal fusion for TSCI from 2007-2016. Patients were divided into subgroups based on race and insurance types. Multivariable linear regression was used to compare time to procedure based on race and payer type while adjusting for demographic and injury-specific factors. Significance was set at P < .05.

RESULTS

Using multivariable analysis, Hispanic and Black patients were associated with significantly increased time to fixation of 12.1 h (95% CI 5.5-18.7, P < .001), and 20.1 h (95% CI 12.1-28.1, P < .001), respectively compared to White patients. Other cohorts based on racial status did not have significantly different times to fixation (P > .05). Medicaid was associated with an increased time to fixation compared to private insurance (11.6 h, 95% CI 3.9-19.2, P = .003).

CONCLUSIONS

Black and Hispanic race and Medicaid were associated with statistically significant increases in time to fixation following TSCI, potentially compromising quality of patient care and resulting in poorer outcomes. More research is needed to elucidate this relationship and ensure equitable care is being delivered.

Trends in Volume and Charges of Retinal Tear Patients in the Emergency Department

PURPOSE

To characterize retinal tears (RTs) and calculate the economic burden of RTs that present to the emergency department (ED) in the US.

METHODS

We used a large national ED database to retrospectively analyze RTs that presented to the ED from 2006 to 2019. Using extrapolation methods, national of the RT patient ED volume, demographics, comorbidities, disposition, inpatient (IP) charges, and ED charges were calculated.

RESULTS

During the period between 2006 and 2019, 15841 ED encounters had RT listed as the primary diagnosis. The average annual RT ED encounters was 2,640 ± 856 and comprised an average of 6.4 × 10 - 5 % of all ED visits annually. The number and ED percentage of RT encounters did not change during this time period (p = .22, p = .67, respectively). Most patients were males, Caucasian, paid with private insurance, and admitted to EDs in the Northeast. The most common comorbidities were hypertension (19%), a history of cataracts (15%), and diabetes (7.2%). During this time period, RTs charges added up to more than $79 million and $33 million in the ED and IP settings, respectively. Mean per-encounter ED and IP charges increased by 145% (p = .0008) and 86% (p = .0047), respectively.

CONCLUSION

Despite the stable number of RT patients presenting to the ED, RTs place a significant economic burden to the healthcare system, which increases yearly. We recommend physicians and policy makers to work together to pass laws that could prevent the increasing healthcare charges.

Prospective Comparative Study of Quality of Life in Bladder Cancer Patients Undergoing Cystectomy or Bladder Preservation

PURPOSE/OBJECTIVE(S)

Health-related Quality of life (HRQOL) may be decisive when different treatments yield comparable survival outcomes. We compared QOL in patients undergoing radical cystectomy with ileal conduit (RCIC) or bladder preservation (BP) with (chemo)radiotherapy for bladder cancer.

MATERIALS/METHODS

Patients with histological diagnosis of bladder cancer, stage T1-T4, N0-N1, M0 with a minimum follow-up of 6 months from the last treatment intervention (RCIC or BP) and alive without disease at the time of QOL assessment were eligible for inclusion. After ethics committee approval, two HRQOL instruments were translated, validated and administered: Bladder cancer index (BCI) for bladder cancer-specific HRQOL, which includes 36 items under three domains - bladder, bowel and sexual function and the EORTC QLQ C30 which includes 30 items under three domains - functional, symptom and global health. The mean QOL scores across various domains and specific questions were compared between the two treatment groups using the independent t-test.

RESULTS

Of the 104 patients enrolled, 56 had RCIC, and 48 received BP, and included 95 (91.3%) males. The median time from treatment completion to QOL assessment was 22 months (IQR 10-56). The median age for the entire cohort was 62 years (IQR 55-68), 65.5 years (IQR 55-71) in BP and 59.5 years (IQR 55-66) in RCIC. Overall, mean BCI urinary scores and bowel scores were high in both groups, with no significant difference in function or bother subdomains between the two groups (Table 1). Overall, BCI sexual scores were low in both the groups but significantly better after BP (BPmean 56.9, RCICmean 41.5, p = 0.01). Mean scores for sexual function BPmean 38.4 and RCIC mean 25 p (0.07) and sexual bother BPmean 81 RCICmean 62 (p 0.02) subdomains. There was no significant difference in EORTC QOL outcomes in functional (BPmean 91.4, RCICmean 88.7 p 0.23), symptom (BPmean 89.8, RCICmean 89, p = 0.68) and global health scale (BPmean 76.8, RCICmean 78.5, p = 0.69) in both groups. On question-wise assessment, the ability to perform an exercise (BPmean 94.2, RCICmean 85, p = 0.06) and urinary leakage at night time (BPmean 91.7, RCICmean 77.6, p = 0.01) were better in the BP group, while scores for blood in the urine (BPmean 89.1, RCICmean 97, p = 0.05) were better in the RCIC group compared to BP.

CONCLUSION

Overall, QOL was good in both groups in the urinary and bowel domains while it was low in the sexual domain. However, bladder preservation performed significantly better in the sexual domain than RCIC.

The Relationship between Circulating APOA-1 and Atherosclerosis Initiation and Progression in Psoriasis

APOA-1 is central to the high-density lipoprotein function of reverse cholesterol transport measured by cholesterol efflux capacity. Psoriasis is a systemic inflammatory disease associated with poor cholesterol efflux capacity and accelerated noncalcified coronary burden (NCB) as measured by coronary computed tomographic angiography. In this study, we characterized the relationship between APOA-1, cholesterol efflux capacity, and progression of NCB over 4 years. Consecutively recruited participants with psoriasis underwent coronary computed tomographic angiography for NCB quantification (Medis QAngio, Leiden, The Netherlands) at baseline (n = 310) and at four years (n = 124). Blood was assessed for cardiometabolic biomarkers. The lowest quartile of APOA-1 was associated with cardiometabolic blood markers (insulin, homeostatic model assessment for insulin resistance, and cholesterol efflux capacity) and higher NCB (P < 0.001). The low APOA-1 quartile had higher NCB at 4 years (β = -0.36, P = 0.02) in fully adjusted models. Finally, a 10-unit decrease of APOA-1 was associated with a 16% increase in NCB progression over 4 years (OR = 0.83, 95% confidence interval = 0.70-0.99, P = 0.04). In addition to being associated with cardiometabolic disease, low APOA-1 was associated with more NCB over time. These findings show that low APOA-1 is correlated with initiation and progression of coronary artery disease and may have clinical utility in identifying high-risk populations for development of cardiovascular disease.

A prospective observational study to correlate lung ultrasound with clinical severity and prognosis score in patients with primary pulmonary pathology on invasive ventilatory support

Background

Lung ultrasound (LUS) is a known imaging modality employed for monitoring patients in an intensive care unit. This study evaluates, LUS in assessing disease severity and prognosis, by correlating its score with the three commonly used clinical severity scoring systems (CSSS), namely, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE) II score, and simplified acute physiology score (SAPS) II.

Methods

This single-center prospective observational study included 54 adult patients of primary lung disease-induced acute respiratory distress syndrome (ARDS), on invasive ventilation. The primary objective was to correlate LUS score with SOFA score. Secondary objectives were to correlate LUS score with APACHE II and SAPS II scores. LUS score was also correlated with the estimated mortality derived from the above-mentioned scores. A subgroup analysis on COVID-19-positive cases was also carried out. All scores were calculated on the initiation of mechanical ventilation, daily for 7 days or mortality, whichever was earlier.

Results

A significant positive correlation (P < 0.001) was found between LUS and all three severity scores, as well as their corresponding estimated mortality percentages, for all days of the study period, in both non-COVID-19 ARDS patients and in COVID-19 patients. The merit of all four scores in differentiating between the survivor and mortality group for the duration of study also showed significant (P < 0.05) to very significant (P < 0.001) results.

Conclusion

Point-of-care LUS in conjunction with CSSS is a reliable tool for assessing the severity and progression of primary lung disease.

Study Protocol of the Bladder Adjuvant RadioTherapy (BART) Trial: A Randomised Phase III Trial of Adjuvant Radiotherapy Following Cystectomy in Bladder Cancer

AIMS

To assess the efficacy and safety of adjuvant radiotherapy in patients with high-risk muscle-invasive bladder cancer (MIBC) following radical cystectomy (RC) and chemotherapy.

MATERIALS AND METHODS

The BART (Bladder Adjuvant RadioTherapy) trial is an ongoing multicentric, randomised, phase III trial comparing the efficacy and safety of adjuvant radiotherapy versus observation in patients with high-risk MIBC. The key eligibility criteria include ≥pT3, node-positive (pN+), positive margins and/or nodal yield <10, or, neoadjuvant chemotherapy for cT3/T4/N+ disease. In total, 153 patients will be accrued and randomised, in a 1:1 ratio, to either observation (standard arm) or adjuvant radiotherapy (test arm) following surgery and chemotherapy. Stratification parameters include nodal status (N+ versus N0) and chemotherapy (neoadjuvant chemotherapy versus adjuvant chemotherapy versus no chemotherapy). For patients in the test arm, adjuvant radiotherapy to cystectomy bed and pelvic nodes is planned with intensity-modulated radiotherapy to a dose of 50.4 Gy in 28 fractions using daily image guidance. All patients will follow-up with 3-monthly clinical review and urine cytology for 2 years and subsequently 6 monthly until 5 years, with contrast-enhanced computed tomography abdomen pelvis 6 monthly for 2 years and annually until 5 years. Physician-scored toxicity using Common Terminology Criteria for Adverse Events version 5.0 and patient-reported quality of life using the Functional Assessment of Cancer Therapy - Colorectal questionnaire is recorded pre-treatment and at follow-up.

ENDPOINTS AND STATISTICS

The primary endpoint is 2-year locoregional recurrence-free survival. The sample size calculation was based on the estimated improvement in 2-year locoregional recurrence-free survival from 70% in the standard arm to 85% in the test arm (hazard ratio 0.45) using 80% statistical power and a two-sided alpha error of 0.05. Secondary endpoints include disease-free survival, overall survival, acute and late toxicity, patterns of failure and quality of life.

CONCLUSION

The BART trial aims to evaluate whether contemporary radiotherapy after standard-of-care surgery and chemotherapy reduces pelvic recurrences safely and also potentially affects survival in high-risk MIBC.

THE GUT-BRAIN AXIS: IMPLICATIONS FOR NEUROLOGICAL DISORDERS, MENTAL HEALTH, AND IMMUNE FUNCTION

A gut-brain axis (GBA) has a long history of conceptual development. Intestinal dysbiosis has now been recognized as a key player in the development of adult neurodevelopmental disorders, obesity, and inflammatory bowel disease. Recent developments in metagenomics suggest those nutrition and gut microbiotas (GM) are important regulators of the gut-brain communication pathways that cause neurodevelopmental and psychiatric problems in adulthood. Intestinal dysbiosis and neurodevelopmental disease outcomes in preterm newborns are being linked by recent research. Recent clinical investigations demonstrate that in critical care units, intestinal dysbiosis occurs before late-onset newborn sepsis and necrotizing enterocolitis. Strong epidemiologic data also shows a connection between necrotizing enterocolitis and extremely low birth weight babies' long-term psychomotor impairments and late-onset neonatal sepsis. The GBA theory suggests that intestinal bacteria may indirectly affect preterm newborns' developing brains. In this review, we emphasize the structure and function of the GBA and discuss how immune-microbial dysfunction in the gut affects the transmission of stress signals to the brain. Preterm babies who are exposed to these signals develop neurologic disorders. Understanding neuronal and humoral communication through the GBA may provide insight into therapeutic and nutritional strategies that may enhance the results of very low-birth-weight babies.

Operationalising targeted next-generation sequencing for routine diagnosis of drug-resistant TB

BACKGROUND

Phenotypic drug susceptibility testing (pDST) for Mycobacterium tuberculosis can take up to 8 weeks, while conventional molecular tests identify a limited set of resistance mutations. Targeted next-generation sequencing (tNGS) offers rapid results for predicting comprehensive drug resistance, and this study sought to explore its operational feasibility within a public health laboratory in Mumbai, India.

METHODS

Pulmonary samples from consenting patients testing Xpert MTB-positive were tested for drug resistance by conventional methods and using tNGS. Laboratory operational and logistical implementation experiences from study team members are shared below.

RESULTS

Of the total number of patients tested, 70% (113/161) had no history of previous TB or treatment; however, 88.2% (n = 142) had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB). There was a high concordance between resistance predictions of tNGS and pDST for most drugs, with tNGS more accurately identifying resistance overall. tNGS was integrated and adapted into the laboratory workflow; however, batching samples caused significantly longer result turnaround time, fastest at 24 days. Manual DNA extraction caused inefficiencies; thus protocol optimisations were performed. Technical expertise was required for analysis of uncharacterised mutations and interpretation of report templates. tNGS cost per sample was US$230, while for pDST this was US$119.

CONCLUSIONS

Implementation of tNGS is feasible in reference laboratories. It can rapidly identify drug resistance and should be considered as a potential alternative to pDST.

Adoption of cleaner technologies and reduction in fire events in the hotspots lead to global decline in carbon monoxide

Carbon Monoxide (CO) is not a greenhouse gas (GHG), but has the capacity to change atmospheric chemistry of other GHGs such as methane and ozone, and therefore indirectly affects Earth's radiative forcing of the GHGs and surface temperature. Here, we use the CO mixing ratio at 850 hPa from the Tropospheric Emission Spectrometer (TES) reanalysis and the Measurement of Pollution in the Troposphere (MOPITT) satellite measurements for the period 2005-2019 to examine the spatio-temporal changes in CO across the latitudes. We find a substantial decrease in global CO, about 0.21 ± 0.09 ppb/yr (0.23 ± 0.12%/yr) with the TES data and about 0.36 ± 0.07 ppb/yr (0.45 ± 0.08%/yr) with the MOPITT satellite measurements during the study period. The highest CO decreasing trend is observed in Eastern China (2.7 ± 0.37 ppb/yr) followed by Myanmar (2.142 ± 0.59 ppb/yr) and South America (1.08 ± 0.82 ppb/yr). This negative trend in CO is primarily due to the decrease in biomass burning and stringent environmental regulations in the respective regions and countries. The sources including road transport that account for about 33.6% of CO emissions, followed by industries (18.3%) and agricultural waste burning (8.8%), might also be responsible for the reduction in CO due to adaptation of improved emission control technology and regulations in the past decade from 2005 to 2019. Therefore, the study provides new insights on the current trends of global CO distribution and reasons for recent reduction in global CO emissions, which would be useful for future decision-making process to control air pollution.

Non-surgical organ preservation in laryngeal and hypopharyngeal cancers: an audit from the clinic

BACKGROUND

There is increasing concern regarding efficacy of organ preservation protocol in laryngeal and hypopharyngeal cancers.

METHOD

This study retrospectively assessed disease-related and functional outcomes of 191 patients with non-metastatic laryngeal or hypopharyngeal squamous cell carcinoma treated with curative intent (radiotherapy with or without chemotherapy).

RESULTS

Seventy-six patients (39.8 per cent) had a primary cancer in the larynx, and 115 patients (60.2 per cent) had a primary cancer in the hypopharynx. The median follow up was 39 months. The 3-year time to progression, overall survival, local control and laryngectomy free survival was 56.2 per cent, 76.3 per cent, 73.2 per cent and 67.2 per cent, respectively. At the time of analysis, 83 patients (43.5 per cent) were alive and disease free at their last follow up and did not require tube feeding or tracheostomy. The laryngo-oesophageal dysfunction-free survival was 61 per cent at 3 years.

CONCLUSION

Organ conservation protocols remain the standard of treatment in appropriately selected patients with laryngeal and hypopharyngeal cancers.

In Silico study on Targeting Human C-Reactive Protein Involved in Cardiovascular Disease using Quercetin

Cardiovascular disease is one of the leading causes of death and disability in humans. Quercetin (Que) and its analogs are found in plants naturally and have been shown to have promising bioactive effects. The relationship between “Human C-reactive protein (CRP)” and the cardiovascular system (CVD) has been extensively researched over the last several decades. Numerous studies have looked at Que's potential benefits for a wide variety of medical conditions, including diabetes, inflammation, microbial infection, arthritis, heart disease, and wound healing. In current study the binding affinity of Quercetin against the cardiovascular target protein was analyzed using molecular docking because of the significance of protein-ligand interactions in structure-based drug development. After downloading the CRP (Target Cardiovascular Protein) 3D structure from Protein Data Bank, the authors used the Autodock software to position it in its docking environment and it was reported that the binding energy of Quercetin molecule with CRP is -6.28 kcal/mol. Though more in-vitro studies are required to validate this research. The findings suggest that Quercetin may protect against cardiovascular disease and cancer.

Clinical utility of target-based next-generation sequencing for drug-resistant TB

BACKGROUND: In high TB burden countries, access to drug susceptibility testing is a major bottleneck. Targeted next-generation sequencing (tNGS) is a promising technology for rapid resistance detection. This study assessed the role of tNGS for the diagnosis of drug-resistant TB (DR-TB).METHODS: A total of 161 samples from bacteriologically confirmed TB cases were subjected to tNGS using the Deeplex^® Myc-TB kit and sequenced using the MiSeq platform. These samples were also processed for conventional phenotypic DST (pDST) using 13 drugs on Mycobacteria Growth Indicator Tube and line-probe assays (MTBDRplus and MTBDRsl).RESULTS: There were 146 DR-TB and 15 drug-susceptible TB (DS-TB) samples. About 70% of patients with DR-TB had no previous TB treatment history. Overall, 88.2% had rifampicin-resistant/multidrug-resistant TB (RR/MDR-TB), 58.5% pre-extensively drug-resistant TB (pre-XDR-TB) and 9.2% had XDR-TB as defined by the WHO (2020). Around 8% (n = 13) of samples were non-culturable; however, identified 8 were resistant to first and second-line drugs using tNGS. Resistance frequency was similar across methods, with discordance in drugs less reliable using pDST or with limited mutational representation within databases. Sensitivities were aligned with literature reports for most drugs. We observed 10% heteroresistance, while 75% of strains were of Lineages 2 and 3.CONCLUSIONS: Programme data supported tNGS in the diagnosis of DR-TB for early treatment using individualised regimens.

Fatal COVID-19 in a neonate after probable late intrauterine transmission

We report the case of a 35-week gestation infant girl born by emergent cesarean section for fetal distress in a woman with recent coronavirus disease 2019 (COVID-19). Tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using polymerase chain reaction (PCR) on the infant at 24 and 48 hours of life were negative. However, at 72 hours of life, the infant's respiratory status worsened, and a repeat SARS-CoV-2 PCR was positive. The infant developed leukopenia, thrombocytopenia, and progressive respiratory failure, and died on the ninth day of life. Pathologic examination of the placenta revealed findings consistent with COVID-19 placentitis, and SARS-CoV-2 RNA staining was positive, suggesting intrauterine transmission of the infection.

Surgically-induced deformation in biodegradable orthopaedic implant devices

The biocompatibility and mechanical performance of biodegradable metals (e.g. magnesium, iron, and zinc-based alloys) in orthopaedic-targeted applications are contingent on limiting the rate of corrosion in vivo throughout the bone healing. Concurrently, the surgical procedure for the implantation of internal bone fixation devices may impart plastic deformation to the device, potentially altering the corrosion rate of the device. However, the potential effect of the surgical implantation procedure on the mechanochemical performance of metallic degradable orthopaedic devices in vivo remains largely unresolved. The objective of the present study is to develop a robust technique that permits the quantification of the strain introduced due to surgical implantation of degradable orthopaedic devices. Specifically, a novel combined experimental-modelling approach based on 3D laser scanning in situ and the finite element method is utilised to quantify the plastic strain introduced to a bone fixation plate following surgical implantation in a cadaveric porcine model where the plate is based on a ternary magnesium-zinc-calcium alloy (ZX10). The magnitude of plastic strains determined by the above approach for the Mg craniofacial miniplate confirms that the surgical procedure itself has the potential to enhance the corrosion rate of the Mg alloy in an accelerated and potentially localised manner. STATEMENT OF SIGNIFICANCE: Biodegradable metallic orthopaedic implant devices have emerged as a potential alternative to permanent implants, although successful adoption is contingent on achieving an acceptable degradation profile. Plastic strain that is introduced to the device during surgical implantation may influence the resulting degradation behaviour of the implant. In the present work, 3D laser scanning is combined with computer simulation to estimate the level and distribution of surgically-induced plastic strain in a magnesium alloy (ZX10). Subsequently, clinically-relevant pre-strain is shown to influence the rate of corrosion of ZX10 in vitro, indicating the value of such an approach in the design of biodegradable metallic devices under multiaxial loading.

Sharps Injuries Related to Subdermal Needles in the Orbicularis Oris During Intraoperative Neurophysiologic Monitoring

PURPOSE

Little is known about the incidence and nature of sharps injuries caused by subdermal intraoperative neurophysiologic monitoring (IONM) needle electrodes. In their institution, the authors observed a series of sharps injuries attributed to placement of needles in the orbicularis oris (OO).

METHODS

One large academic institution's sharps injury monitoring database was queried for all reported events over 3 years. The de-identified list was filtered for sharps events occurring in the operating room, and the descriptions of the sharps injuries were individually evaluated. Interventions were performed to attempt to decrease the number of sharps injuries from IONM needles, particularly those placed in OO. Similar data were then collected for 3 months post-intervention.

RESULTS

Pre-intervention, 327 sharps injuries were reported over the span of 3 years, of which 13 (4.0%) were attributed to IONM needles not in OO and 5 (1.5%) were attributed to IONM needles in OO. Post-intervention, 41 sharps injuries were reported in 3 months, of which 5 (12.2%) were attributed to IONM needles not in OO and 1 (2.4%) was attributed to needles in OO.

CONCLUSIONS

The placement of subdermal needles in the OO presents a disproportionately high risk of sharps injury. Interventions were performed to attempt to decrease the rate of sharps injuries from needles in OO; the post-intervention increase in events was likely skewed by small sample sizes. The implementation of these changes and the ongoing surveillance of injury cases may be important data to help decrease the number of sharps injuries attributed to IONM needles.

TOLERABILITY OF GRADED CORONAVIRUS DISEASE 2019 MRNA VACCINE DOSING

Introduction

The rapid development of novel coronavirus disease 2019 (COVID-19) mRNA vaccines and their widespread use has raised concerns that they may cause allergic reactions at rates greater than conventional vaccines. Vaccine administration strategies in cases of prior COVID-19 vaccine reaction or patient hesitancy include full dose administration with close observation and graded dosing protocols.

Methods

Retrospective chart review of patients who were referred to an allergy clinic for observed COVID-19 vaccine administration with emphasis on demographic characteristics, atopic co-morbidities, prior vaccine reactions, and outcome of challenge.

Results

Data were available for 83 patients comprising 102 total COVID-19 vaccine challenges. All (n=102) challenges were successful; 21 experienced symptoms and 81 did not. The most reported symptoms were pruritus (n=5), headache (n=5), and chest tightness (n=3). No patient experienced vital sign changes during the protocol and there were no cases of anaphylaxis. The most common dosing protocols were either one-step (n=38) or two-step (n=36). The most common reasons for undergoing challenge were previous COVID-19 vaccine reaction (n=55) and concern for multiple drug allergies (n=21).

Conclusion

This review demonstrates that COVID-19 vaccine graded dosing protocols were highly tolerated and successful regardless of prior COVID-19 vaccine reactions or drug allergies. The presence of symptoms during the challenge did not preclude successful outcome, and no patients experienced anaphylaxis. Given the ongoing nature of the COVID-19 pandemic, it is important to recognize that graded challenge or full dose administration with observation may provide a safe means for patients who are hesitant to pursue COVID-19 vaccination.

Left ventricular unloading with Impella versus IABP in patients on VA-ECMO for cardiogenic shock

Background

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for circulatory support in shock is limited by increased left ventricular afterload. Impella and intra-aortic balloon pump (IABP) can be used in conjunction with VA-ECMO to help unload the left ventricle. Data comparing the two strategies are limited.

Purpose

We performed a systematic review and meta-analysis of published data to compare outcomes of patients with shock supported by VA-ECMO in conjunction with Impella versus IABP.

Methods

We conducted a search of Medline, Embase, and Cochrane databases to identify studies comparing the use of Impella versus IABP in patients on VA-ECMO. The primary outcome of interest was all-cause mortality (in-hospital or 30-day). Secondary outcomes included transition to destination therapy with left ventricular assist device (LVAD) or transplant, stroke, need for continuous renal replacement therapy (CRRT), bleeding, and hemolysis. Risk ratios (RR) with 95% confidence interval and the heterogeneity statistic I2 were reported for each outcome.

Results

Six observational studies with a total of 629 patients were included in the analysis. Of these, 205 (33%) and 424 (67%) patients were supported by Impella and IABP respectively, in addition to VA-ECMO. All six studies reported the primary outcome. No difference was observed in all-cause mortality between VA-ECMO with Impella and VA-ECMO with IABP (RR 1.02 [0.74–1.40], I2=74%). Similar rates were observed for transition to LVAD or transplant (RR 0.75 [0.45–1.27], I2=0%), stroke (RR 1.50 [0.80–2.83], I2=0%), and need for CRRT (RR 1.04 [0.82–1.32], I2=0%). However, use of VA-ECMO with Impella was associated with a higher risk of bleeding (RR 1.91 [1.28–2.86], I2=68%) and hemolysis (RR 4.61 [1.24–17.17], I2=66%) as compared with use of VA-ECMO with IABP.

Conclusion

In patients with shock requiring VA-ECMO, concurrent use of Impella and IABP had similar risk of mortality, transition to LVAD/transplant, stroke, and need for CRRT. However, Impella use was associated with higher risk of bleeding and hemolysis. Randomized trials are needed to identify the optimal strategy for left ventricular unloading in patients with cardiogenic shock on VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Psychiatry Residency Directors' Attitudes Toward and Uses of the Medical Student Performance Evaluation and Other Potential Tools for Residency Selection

OBJECTIVE

A survey was conducted to determine US psychiatry residency directors' attitudes regarding current measures of medical student performance and their preferences for the future.

METHODS

A team of psychiatry medical student educators and residency program directors developed a 23-question survey. In July 2021, links to the survey were sent out to all program directors registered with the American Association of Directors of Psychiatric Residency Training.

RESULTS

Seventy program directors out of 223 initiated the survey, resulting in a response rate of 31.4%. Forty percent of respondents reported that the most important use of the Medical Student Performance Evaluation (MSPE) is in screening out applicants for interviews, and only 26.1% reported that the MSPE in its current form could be trusted to provide a valid and reliable assessment of a student's medical school performance. Most respondents agreed that in the absence of United States Medical Licensing Examination (USMLE) step 1 numerical scores, the existing MSPE format/content requirements should be modified, use a set of ranking categories that are uniform across all medical schools, and be supplemented with additional measures of the student's character and ability specific to psychiatry.

CONCLUSIONS

US psychiatry program directors are eager for change when it comes to the MSPE and how it reports rankings, grades, and professionalism. The transition of the USMLE step 1 score reporting to pass/fail presents an opportunity to pursue this change and for stakeholders from all medical specialties to work together toward a shared goal of an improved residency selection process.

Retinal Haemorrhage in Newborns in Tertiary Care Hospital

Background Retinal haemorrhage in new-born is a clinically common neonatal fundus condition. Although, it usually does not affect the development of visual function, entities like macular haemorrhages may lead to amblyopia causing deterioration of visual function. Such scenario leads to downgrade in quality of life of the affected child. Objective To explore the underlying clinical factors associated with retinal haemorrhage in term new-borns. Method A cross sectional study was conducted involving 136 term neonates admitted in the neonatal intensive care unit of Dhulikhel Hospital. Fundus examination was performed within 2 weeks of delivery. Retinal haemorrhage was graded according to their location in three retinal zones. Result Out of 136 cases examined, 44 (32.35%) of the cases had one of the eyes with retinal haemorrhage. Where grade 1 retinal haemorrhage was accounted in majority of the cases. Birth weight, gestational age, mode of delivery, poor Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) Score in 1 and 5 minutes, birth asphyxia, neonatal sepsis and heavy work in antenatal period had statistically significant correlation with occurrence of retinal haemorrhage. Conclusion Our results suggest that spontaneous vaginal delivery, larger birth weight, higher gestational age, birth asphyxia, low Appearance, Pulse, Grimace, Activity, and Respiration score, are risk factors for occurrence of neonatal retinal haemorrhage. It is recommended that in neonates with above high-risk factors should undergo targeted fundus screening for early identification and needful interventions.

Meta-Analysis Comparing Venoarterial Extracorporeal Membrane Oxygenation With or Without Impella in Patients With Cardiogenic Shock

Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], I² = 0%, p = 0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], I² = 0%, p <0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], I² = 0%, p <0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], I² = 11%, p <0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], I² = 0%, p = 0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

Carpal Tunnel Syndrome: Pathophysiology and Comprehensive Guidelines for Clinical Evaluation and Treatment

In carpal tunnel syndrome (CTS), the median nerve is compressed at the level of the carpal tunnel in the wrist. This entrapment manifests as unpleasant symptoms, such as burning, tingling, or numbness in the palm that extends to the fingers. As the disease progresses, afflicted individuals also report decreased grip strength accompanied by hand weakness and restricted movement. The first half of this review elaborates on CTS pathology by providing readers with a comprehensive understanding of the etiology, relevant anatomy, and disease mechanism.

CTS is considered the most common entrapment neuropathy, affecting around 3-6% of the adult population. Further, CTS prevalence has seen a dramatic increase in the last few decades paralleling the growth of everyday technology usage. Despite how common it is to have CTS, it can be quite challenging for physicians to make a definite diagnosis due to differentials that present with overlapping symptoms. Even more difficult can be deciding on a course of treatment that is the most effective and considerate of patient needs. Thus arises the need for clear clinical direction, and hence we end with a discussion around such guidelines that serve as a starting point toward effective diagnoses and patient treatment.

Effect of treatment regimens in severe COVID pneumonia at an Indian tertiary care hospital: An observational, real-world study

Background

Corticosteroids have attracted attention as a treatment option for severe Coronavirus disease (COVID-19). However, published data on steroid therapy is debatable, and real-world data is lacking. This study evaluated the effect of treatment regimens, especially Pulse steroid therapy (Injection Methyl Prednisolone 250 mg iv once a day for three days) in severe-COVID-19 pneumonia at an Indian tertiary care hospital.

Methods

This observational cross-sectional study included severe COVID-19 pneumonia patients aged >18 years, requiring assisted ventilation. As part of the hospital protocol, patients received either pulse steroid therapy, remdesivir or tocilizumab in addition to the recommended steroid doses i.e., injection of dexamethasone 6 mg iv once a day. The association of factors and treatment regimens to patient outcomes was evaluated.

Results

Data of eighty-three patients were assessed, majority being above 60 years (n = 30, 36.14%) and males (n = 45/83, 54.21%). The commonest comorbidities were hypertension (n = 26), diabetes (n = 23) and obesity (n = 19), fifty-five patients (66.26%) reported at least one comorbidity. Sixty-one patients (73.49%) had received pulse steroid regimen, forty-eight patients (57.83%) were administered remdesivir-based regimen while twelve patients (14.46%) had received tocilizumab treatment. 54.1% patients managed with pulse steroid regimens were discharged after treatment, statistically similar to remdesivir-managed subgroup (62.5%, p > 0.05). On sub-group analysis, pulse steroids showed better outcomes in young males with no comorbidities. No comorbidity had significant relationship with patient outcomes (p > 0.05).

Conclusion

Pulse steroid therapy is an effective therapy in management of patients with severe COVID-19 pneumonia in a real-world setting, with better outcomes in young males without comorbidities. Pulse steroids can be considered a viable option for severe-COVID-19 pneumonia management.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Analysis of Perception of Students and Faculty on Case Based Early Clinical Exposure in First Year Medical Students

Early clinical exposure (ECE) is a novel strategy for medical colleges to bridge the gap between basic and clinical sciences. There are few studies that explain student's and faculty's perspective on ECE. This study compares the ECE models (Case-based and Video-based case) in terms of benefits and challenges. This cross-over comparative study with 120 medical students of MBBS Batch 2019 and 8 facilitators was conducted in Government medical college, Pali, Rajasthan, India from September 2020 to March 2021. Entire batch was divided into two groups. In a hospital environment, one group was taught by an actual case (patient) of a specific topic, while another group was taught in a classroom setting by a video-based case. The students' and faculty's perspectives on Case-Based Early Clinical Exposure (CBECE) were documented using a pre-tested questionnaire and evaluated on a Likert scale. Finally, both groups were given assessment questions and the process was repeated in the following session of case based early clinical exposure, but with switched groups. Majority of the students (98.3%) agreed CBECE as more effective for attentiveness, retention, correlation of clinical knowledge with theoretical knowledge and communication. Most of the students (43.0%) believed that learning is limited due to lack of repeatability as compare with video-based case. Most of the facilitators found CBECE as effective tool for the development of attitude and communication skills of the students. CBECE can be implemented with limited sessions for sensitization of students about health care setup, importance of empathetic behavior, communication skill and better correlation of preclinical subjects in the context of disease.

MicroRNA biomarkers of platelet function

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation (BHF), VASCage (Centre for Promoting Vascular Health in the Ageing Community) of the Austrian Research Promotion Agency FFG (COMET program - Competence Centers for Excellent Technologies)

Introduction

Antiplatelet therapy (APT) leads to reduced morbidity and mortality in patients with cardiovascular disease but some still have thrombotic events. Tailoring APT to platelet function is currently limited by a lack of suitable platelet function tests. It has been previously shown that different circulating microRNAs (miRNAs) are derived from platelets and their measurement could provide new markers of platelet reactivity.

Purpose

To compare the release of different platelet miRNAs in response to different platelet agonists.

Methods

Measurements of platelet function were performed by light transmission aggregometry (LTA) in participants of the 2015 follow-up of the Bruneck study (n=338), using the following agonists: arachidonic acid (1mM), adenosine diphosphate (5µM, 20µM), collagen (0.4 µg/ml, 4 µg/ml, 10µg/ml), TRAP-6 amide (25µM) and U46619 (10µM). LTA platelet releasates were then used for RT-qPCR measurements of five platelet-enriched miRNAs (miR-21, miR-126, miR-150, miR-197, miR-223). Platelet-poor plasma (PPP) served as negative control.

Results

Platelet activation led to aggregation and extracellular release of miRNAs, with aspirin users (n=155) showing significantly lower miRNA release than non-aspirin users (n=183). Agonist responsiveness differed among miRNAs, with miR-21 being hyperresponsive to arachidonic acid and miR-150 being hyperresponsive to adenosine diphosphate, whilst release of miR-126, miR-197 and miR-223 was strongest to collagen (10µg/ml). In non-aspirin users, inflammation markers such as granulocyte counts or C-reactive protein correlated positively with platelet-derived miRNAs measured in PPP, whilst they correlated negatively with platelet-derived miRNAs measured in releasates. These effects were absent in aspirin users.

Conclusions

MiRNAs released from activated platelets can be reliably detected in PPP and platelet releasates. Preferential release of miRNAs in response to specific agonists suggests a selective release mechanism. Elevated PPP levels and decreased releasate levels of platelet-derived miRNAs in inflammatory environments suggest platelet exhaustion ex vivo due to platelet pre-activation.

POS1443 IDENTIFYING THE NEW EMERGENCE OF RACIAL DISPARITIES IN GOUT OVER THE PAST 3 DECADES – US NATIONAL SURVEY AND PROSPECTIVE COHORT DATA

Background

Several studies published after 2010 reported a higher frequency of gout and hyperuricemia among US Blacks than Whites.1-4 However, Blacks (in the US and Africa) were previously thought to suffer gout less often than Whites.5 We hypothesized that the racial disparity in Blacks emerged over the past several decades, with flipped prevalence between the two races.

Objectives

To assess trends in racial differences in gout prevalence in the US using both national survey and cohort study data over the past 3 decades.

Methods

Using data from the NHANES (National Health and Nutrition Examination Survey) III (1988-1994) and latest decade (2007-2016), and data from 5 examination periods in the ARIC (Atherosclerosis Risk in Communities) Study between 1988 through 2013, we compared age- and sex-adjusted prevalences and odds ratios (OR) to determine the trend of racial differences in gout prevalence between Blacks and Whites. A time-race interaction term was used to assess differences in the rate of change between the two races.

Results

Among Whites, the sex- and age-standardised prevalence of gout in the NHANES rose from 2.8% (95% CI: 2.4 to 3.2) in 1988-94 to 3.7% (3.2 to 4.1) in 2007/16. Prevalence of gout among Blacks was lower than Whites in 1988-94 (2.6% [2.2 to 3.0]) but rose more sharply over the subsequent decades (p for race-time interaction=0.003), and in 2007/16 came to exceed that of Whites (5.0% [4.4 to 5.6]).

Corresponding age-sex-adjusted ORs for gout in Blacks vs. Whites were 0.93 (0.73 to 1.17) in 1988-94, increasing to 1.46 (1.22 to 1.74) in 2007/16 (Table 1). This disproportionate rise in gout prevalence among Blacks tended to be more prominent among women (OR 1.81 [1.29 to 2.53]) than men (OR 1.26 [1.02 to 1.55]; p for race-time interactions of 0.002 and 0.01, respectively). Similar trends were observed in the ARIC cohort, where the OR for gout among Blacks vs. Whites rose progressively from 0.82 (0.65 to 1.02) in 1987-89 to 1.81 (1.49 to 2.19) in 2011-13.

Table 1.

Temporal Trend of Racial Disparity in Gout Prevalence in NHANES Survey and the ARIC Study Cohort, overall and by sex

Odds Ratio (95% CI) for Gout Among Blacks vs. WhitesOVERALLNHANES1988-19942007-2016Age- and sex-adjusted0.93(0.73 to 1.17)1.46(1.22 to 1.74)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age- and sex-adjusted0.82(0.65 to 1.02)0.99(0.81 to 1.22)1.24(1.03 to 1.50)1.60(1.35 to 1.90)1.81(1.49 to 2.19)WOMENNHANES1988-19942007-2016Age-adjusted0.98(0.65 to 1.47)1.81(1.29 to 2.53)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age-adjusted0.92(0.64 to 1.32)1.14(0.82 to 1.59)1.45 (1.07 to 1.96)1.89 (1.45 to 2.46)2.28(1.73 to 3.01)MENNHANES1988-19942007-2016Age-adjusted0.91(0.68 to 1.21)1.26 (1.02 to 1.55)ARICVisit 1: 1987-89Visit 2: 1990-92Visit 3: 1993-95Visit 4: 1996-98Visit 5: 2011-13Age-adjusted0.73 (0.54 to 0.97)0.87 (0.66 to 1.14)1.03(0.79 to 1.33)1.29(1.02 to 1.64)1.34(1.00 to 1.78)

Conclusion

Gout prevalence tended to be lower in Blacks than Whites until late 80’s, then rose and surpassed that of Whites over the past several decades. These trends closely parallel the worsening obesity epidemic during this period,6 particularly in Blacks, partly due to enhanced Western lifestyle. Gout risk genetic profile change would not contribute to this emergence of racial differences, particularly among the same individuals in ARIC, although it remains to be clarified whether Blacks carry genetic profiles that enhance the effect of lifestyle risk factors for gout.

References

[1]PMID 22225548 (2012)

[2]PMID 24330409 (2013)

[3]PMID 24335384 (2014)

[4]PMID: 30618180 (2019)

[5]NEJM PMID: 15014177

[6]JAMA PMID: 12365955

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart., Grant/research support from: Ironwood and Horizon

POS0280 EXCESS RISK OF ALL-CAUSE AND CARDIOVASCULAR MORTALITY IN FEMALES WITH GOUT – A PROSPECTIVE COHORT STUDY OF 105,502 WOMEN

Background

Despite the disproportionately worsening disease burden of female gout in recent years1 and its frequent associations with key cardiovascular risk factors (more often than male gout2,3), there remains a paucity of specific data about female gout, particularly about its impact on mortality and fatal coronary heart disease (CHD).

Objectives

To prospectively examine the relation of female gout and risk of all-cause and cardiovascular and coronary heart disease-specific deaths.

Methods

Using data from the Nurses’ Health Study (NHS), an ongoing prospective cohort study in which female nurses in the United States completed detailed mailed questionnaires regarding their medical history, lifestyle, and other risk factors at baseline and every two years thereafter, we prospectively analyzed the relation between gout status at baseline and during the follow-up period and the risk of all-cause and cardiovascular mortality using Cox proportional hazards regression to adjust for cardiovascular risk factors such as comorbidities, body mass index, postmenopausal status, medication use, and dietary factors.

Results

The analysis included 105,502 women without gout and 1602 women with gout. Women with gout at baseline in 1982 tended to be older (mean age 54 vs. 50 years), and more likely to report a history of hypertension (44% vs. 22%), hypercholesterolemia (17% vs. 8%), and diabetes (11% vs. 6%). During 24 years of follow-up, we documented 15,255 deaths from all causes, including 3,128 deaths from cardiovascular disease (CVD) and 1,405 deaths from coronary heart disease (CHD). Compared to women without history of gout or CHD at baseline, the multivariable relative risks (RRs) among women with history of gout at baseline were 1.33 (95% CI, 1.21 to 1.46) for total mortality, 1.40 (95% CI, 1.17 to 1.67) for CVD deaths, and 1.49 (95% CI, 1.17 to 1.91) for fatal CHD (Table 1). The corresponding RRs for gout at baseline and during the follow-up were 1.33 (95% CI, 1.23 to 1.44), 1.43 (95% CI, 1.24 to 1.66), and 1.34 (95% CI, 1.08 to 1.66), respectively.

Table 1.

Relative Risks of Death from All-Causes, Cardiovascular Disease, and Coronary Heart Disease According to Gout Status at Baseline in 1982 in the Nurses’ Health Study

No CHDNo GoutGoutDeaths from all causesCases, n14,810445Age-adjusted RR (95% CI)1.01.58 (1.43, 1.73)Multivariable-adjusted* RR (95% CI)1.01.33 (1.21, 1.46)All cardiovascular deathsCases, n3,001127Age-adjusted RR (95% CI)1.02.06 (1.72, 2.46)Multivariable-adjusted* RR (95% CI)1.01.40 (1.17, 1.67)Fatal CHDCases, n1,33570Age-adjusted RR (95% CI)1.02.53 (1.99, 3.22)Multivariable-adjusted* RR (95% CI)1.01.49 (1.17, 1.91)

*Adjusted for age (continuous), history of hypertension, history of hypercholesterolemia, history of diabetes, aspirin use (yes, no), diuretic use (yes, no), smoking (never, past, current <15, current ≥15 cigarettes/day), body mass index (<23, 23-24.9, 25-29.9, 30-34.9, ≥35), physical activity (quintile), alcohol intake (nondrinker, <5, 5-9, 10-29, ≥30g/day), family history of MI (yes, no), menopausal status (premenopause, post menopause), hormone replacement therapy use (premenopause, never user, current user, past user). total energy intake (quintile), trans fat (quintile), dietary cholesterol (quintile), protein (quintile), linoleic fatty acid (quintile), and ratio of polyunsaturated fat/saturated fat.

CHD = coronary heart disease; CI = confidence interval; RR = relative risk.

Conclusion

These prospective data indicate that women with gout have a higher risk of all-cause mortality, which is primarily driven by higher risk of CVD deaths. These findings closely agree with the UK general population data of both sexes that showed unclosing mortality gap over the past two decades.4 Together, these findings provide support for rigorous cardiovascular risk factor modification specifically in female gout to help curtail the rising disease burden of gout worldwide.1

References

[1]Xia et al., PMID 31624843

[2]Puig et al., PMID 2012455

[3]Harrold et al., PMID 16644784

[4]Fisher et al., PMID 28122760

Disclosure of Interests

Chio Yokose: None declared, Natalie McCormick: None declared, Na Lu: None declared, Amit Joshi: None declared, Gary Curhan Consultant of: AstraZeneca, Allena Pharmaceuticals, Shire/Takeda, Dicerna, and Orfan, Grant/research support from: Decibel Therapeutics, Employee of: Chief Medical Officer at OM1, Inc., Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart, Grant/research support from: Ironwood and Horizon

POS0155 WHAT DRIVES RACIAL DISPARITIES IN GOUT IN THE US? – POPULATION-BASED, SEX-SPECIFIC, CASUAL MEDIATION ANALYSIS

Background

Traditionally viewed as a disease of White men, global frequency and disability burden of female gout are rising disproportionately to male gout.1 Moreover, emerging US cohort data suggest gout and hyperuricemia impart larger burdens on Black adults than Whites.2 These racial disparities may be largely attributable to differences in non-genetic, mainly modifiable gout risk factors e.g., BMI, diet,3,4 and chronic kidney disease (CKD). However, national-level, general population data on racial differences in burden of gout, and potential mediators, are lacking.

Objectives

To determine and quantify sex-specific mediators of racial disparities in gout prevalence among a nationally representative sample of US adults.

Methods

Using recent decadal data (2007-2016) on physician-diagnosed gout and hyperuricemia from the National Health and Nutrition Examination Survey, we compared contemporary sex- and race-specific prevalences and conducted sequential causal mediation analysis (adjusting for upstream mediators following causal pathways)5 to determine the proportion of the racial differences attributable to 7 potentially mediating social and clinical factors (see DAG in Figure 1): low education, poverty, body mass index (BMI), alcohol, poor quality diet (poor DASH adherence), diuretic use, and CKD (eGFR <60 mL/min, using the latest equations that do not include a coefficient for Black race6, per National Kidney Foundation and American Society of Nephrology recommendations.7)

Results

Age standardised prevalence of gout was 3.5% and 2.0% in Black and White women, respectively (age-adjusted OR =1.8 [95% CI: 1.3 to 2.5]), and 7.0% and 5.4% in Black and White men (age-adjusted OR =1.3 [1.0 to 1.6]). Most risk factors were more frequent/elevated in Blacks than Whites, except alcohol consumption, which was lower in Blacks (both sexes). BMI levels and poverty were higher in Black women, but similar between Black and White men.

Largest mediating factor of excess gout cases among Black women was excess BMI, accounting for 56% of the racial difference (independent of education, poverty, diet, and alcohol), followed by CKD (24%), poverty (17%), and poor diet (12%) (see Table 1).

Table 1.

Indirect (mediation) effects of potential mediators, using sequential mediation analysis, for the association between Black race and odds of gout in US women and men.

WOMENMENEffect Estimate (OR), 95% CIProportion Mediated, %Effect Estimate (OR), 95% CIProportion Mediated, %Indirect (Mediation) EffectEducation (high school or less)1.01 (0.98 to 1.03)2.4%1.01 (0.98 to 1.03)3.3%Poverty1.07 (1.04 to 1.10)16.9%1.00 (0.99 to 1.00)0.53%Alcohol consumption (# drinks/week, continuous)0.99 (0.96 to 1.01)-3.4%0.99 (0.98 to 1.00)-4.5%DASH diet score (continuous; higher scores = ↓ adherence)1.05 (0.96 to 1.01)12.0%1.05 (1.01 to 1.10)19.8%Body mass index (continuous)1.25 (1.14 to 1.37)55.9%1.03 (1.02 to 1.04)11.9%Diuretic use1.03 (1.01 to 1.05)7.6%1.04 (1.02 to 1.06)14.2%Chronic kidney disease1.10 (1.04 to 1.16)23.9%1.12 (1.08 to 1.17)45.6%Direct Effect0.94 (0.68 to 1.30)a−15.2%1.02 (0.83 to 1.26)b9.2%Total Effect1.49 (1.12 to 1.98)100%1.29 (1.05 to 1.57)100%

DASH=Dietary Approaches to Stop Hypertension;

ap=0.52,

bp=0.83

Among men, CKD was the largest mediator (46%), followed by poor diet (20%) and diuretic use (14%). BMI (12%) and poverty (0.5%) mediated smaller proportions of the racial difference among men compared to women. Mediators of racial differences in hyperuricemia closely agreed with gout results.

Conclusion

Contrasting with historical views, gout is more frequent among Black adults in the US than their White counterparts, especially women (two-times greater in Black women vs. White). Culturally informed efforts to reduce these disparities should focus on excess adiposity, diet quality, and kidney disease while recognising the impact of poverty in female gout.

References

[1]Xia; PMID 31624843

[2]PMID 24335384

[3]Rai BMJ PMID 28487277

[4]Yokose JAMA IM (2022)

[5]VanderWeele; PMID 25580377

[6]NEJM PMID 34554658

[7]JASN PMID 34556489

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Tony Merriman: None declared, Kenneth Saag Consultant of: Arthrosi, Atom Bioscience, Horizon Therapeutics, LG Pharma, Mallinkrodt, SOBI, Takeda, Grant/research support from: Horizon Therapeutics, SOBI, Shanton, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart.

Grant/research support from: Ironwood, Horizon

OP0166 CHRONIC KIDNEY DISEASE AND AMPLIFICATION OF SERUM URATE IMPACT ON GOUT RISK: POPULATION-BASED STUDY OF > 450,000 UK BIOBANK PARTICIPANTS

Background

Serum urate (SU) is a necessary causal factor for development of gout, while chronic kidney disease (CKD) is associated with increased inflammatory biomarkers, cytokines, and reduced AMPK activity levels. Furthermore, CKD has been found to be associated with an increased risk of incident gout, even beyond (i.e., independent of) SU levels. As such, the impact of SU may be enhanced by presence of CKD, but this hypothesis has not been evaluated.

Objectives

To prospectively examine whether CKD modifies the relation between SU levels and risk of incident gout.

Methods

We conducted a prospective cohort analysis of UK Biobank participants with urate and creatinine levels available from baseline blood samples (2006-2010), and no prior diagnosis of gout or urate lowering therapy use. CKD Stage ≥ 3 status (eGFR <60 mL/min) was determined from latest CKD-Epi equations (NEJM 2021; JASN 2021).1,2 Incident cases of gout were ascertained from linked hospitalisation, primary care, and death records. Participants were followed from baseline up to 10 years or until gout diagnosis, death, or end of study period (Dec 31/19).

We calculated 10-year cumulative incidence of gout according to baseline SU category and CKD status and evaluated their individual and joint impact on gout risk using multivariable Cox proportional hazards models.

We further assessed for additive and multiplicative interactions3 between levels of SU and inverted eGFR, on a standardized continuous scale per SD.

Results

We included 458,244 individuals (45% male, mean age 56.5 years), of whom 6,559 had CKD at baseline, and documented 5,847 cases of incident gout over 4,442,866 person-years.

10-year cumulative incidence of gout ranged from 0.2% (baseline SU < 5 mg/dL) to 33% (baseline SU ≥ 10 mg/dL), and in each category incidence was higher for those with CKD than without (Table 1; Figure 1-left), Multivariable hazard ratio (HR) for the joint effect of CKD and highest SU level (≥ 10 mg/dL), compared to non-CKD and lowest SU (<5mg/dL), was 242 (95% CI: 189 to 309) (Figure 1-right).

Table 1.

Cumulative incidence and hazard ratio (HR) of incident gout according to baseline serum urate levels and CKD status

CKD Stage ≥ 3Hyperuricemia (Dichotomous)Serum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0N cases6152895150104874943610-Year Cumulative Incidence0.6%1.1%1.7%7.6%19.1%28.0%42.0%1.2%16.6%Incidence Rate Ratio1.0 (Ref)1.72.712.333.856.1107.71.0 (Ref)15.2No CKDSerum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0N cases393446105617691251363841,8953,46710-Year Cumulative Incidence,0.2%0.4%1.4%6.0%15.6%23.5%27.5%0.5%8.8%Incidence Rate Ratio1.0 (Ref)2.18.034.696.9155.9198.81.0 (Ref)20.2Joint Effect of Serum Urate and CKDSerum urate, mg/dL<55.0 to < 6.06.0 to < 7.07.0 to < 8.08.0 to < 9.09.0 to < 10.0≥10<7.0≥7.0Age-, Sex-, and Race- Adjusted HRNo CKD1.0 (Ref)1.97.029.883.0133.3170.31.0 (Ref)15.7CKD3.25.17.834.193.3155.9302.32.530.5Fully adjusted HR*No CKD1.0 (Ref)1.86.425.869.4108.7132.91.0 (Ref)12.5CKD3.14.76.828.975.2121.1241.82.322.4

*Adjusted for age, sex, race, body mass index, hypertension, diuretic use, smoking, and consumption of alcohol, coffee, meat, fish, poultry, and milk.

There was a significant additive interaction between continuous SU and eGFR (relative excess risk due to interaction=0.16 [0.09 to 0.24], p < 0.001), with HRs of 3.7 (3.6 to 3.8) per SD increase of SU, 1.2 (1.2 to 1.3) per SD increase of inverted eGFR, and 4.1 (3.9 to 4.2) for their joint effect. Their multiplicative interaction was also significant (p < 0.001).

Conclusion

These large prospective cohort data suggest CKD presence enhances the effect of elevated SU levels on risk of incident gout. They support roles of CKD-associated factors beyond SU in developing gout, such as reduced AMPK activity levels and altered inflammatory factors in CKD, which warrant further investigation.

References

[1]PMID 34554658

[2]PMID 34556489

[3]ARD (2021) PMID 34857519

Disclosure of Interests

Natalie McCormick: None declared, Leo Lu: None declared, Chio Yokose: None declared, Amit Joshi: None declared, Yuqing Zhang: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, and Vaxart., Grant/research support from: Ironwood and Horizon

OP0164 A POPULATION-BASED, PROSPECTIVE METABOLOMICS STUDY IN THE UK BIOBANK IDENTIFIES GLYCOPROTEIN ACETYLS AS A NOVEL BIOMARKER OF INCIDENT GOUT

Background

Serum urate (SU) level is the strongest known causal predictor of clinical gout, but only ~20% with prolonged hyperuricemia develop gout, motivating the need for additional biomarkers for risk prediction and stratification. The metabolome represents a compelling intermediate trait between genome and phenome to elucidate disease mechanisms. Multiple cross-sectional studies of prevalent gout from men in Asia have been conducted, but no prospective data for incident gout (prediagnostic metabolome) are available.

Objectives

Our objectives were to (1) conduct a discovery-based metabolome-wide study to identify novel biomarkers of incident gout; and (2) replicate novel metabolomic biomarkers of gout in independent samples.

Methods

We conducted a prospective cohort analysis of 105,703 UK Biobank (UKB) participants (46% males, mean age 57.2 years) with targeted NMR metabolomic profiling (N=168 metabolites, including routine lipids and amino acids) available from baseline samples (2006-10), and no prior diagnosis of gout or urate lowering therapy use. Incident cases of gout were documented from linked medical records until gout diagnosis, death, or end of study period (Dec 31/19). We used Cox proportional hazard models to obtain hazard ratios (HR) and 95% confidence intervals (CIs) per standard deviation (SD) increase in each of the 168 metabolites to determine associations with incident gout.

To replicate our findings, we assessed association of metabolome-wide significant metabolites in a replication set, restricted to 4,804 non-overlapping participants who provided blood in the repeat assessment visit (2012-13).

Results

During a median 10.4 years follow-up, we documented 1,367 cases of incident gout in the discovery set. After correction for multiple comparisons, glycoprotein acetyls (GlycA) were positively associated with risk of incident gout (multivariable HR per 1SD increase = 1.34 (1.27 to 1.41), P = 9.04x 10-28) after adjusting for age, sex, and lifestyle and clinical covariates (Table 1). This association persisted even after SU adjustment (HR 1.07, P = 0.0091). In the replication set, among 4,804 participants followed for a median of 6.8 years, we documented 22 cases. In this dataset, we replicated GlycA association with incident gout (multivariable HR per 1SD increase =1.56 (1.08 to 2.25), P = 0.017).

Table 1.

Association of glycoprotein acetyls (GlycA) with risk of incident gout in the UK Biobank

ModelUnivariable HR, (95% CI)PMultivariable HR, (95% CI)PDiscovery (N= 105,703)Per Standard deviation:GlycA, per SD1.48 (1.41 to 1.60)3.7x10-591.34 (1.27 to 1.41)9.04x 10-28Categorized as quintiles:GlycA, Q11.0 Ref1.0 RefGlycA, Q21.43 (1.13 – 1.80)0.0021.30 (1.03 – 1.64)0.0252GlycA, Q32.06 (1.66 – 2.56)4.88 x 10-111.73 (139 – 2.15)7.64 x 10-07GlycA, Q42.53 (2.05 – 3.12)4.15 x 10-181.98 (1.60 – 2.45)3.96 x 10-10GlycA, Q53.70 (3.02 – 4.52)3.21 x 10-372.63 (2.12 – 3.23)2.01 x 10-19Replication (N= 4804)Per Standard deviation:GlycA, per SD1.65 (1.19 to 2.29)0.00271.56 (1.08 to 2.25)0.0172

1 Hazard ratios (HR) and 95% confidence intervals (CIs) obtained after adjusting for the first 4 genomic principal components (controlling for population stratification), age, sex, fasting (<4 hrs, 4-8 hrs and ≥8 hrs), smoking (never, former, current), freq of alcohol, BMI, diabetes (yes/no) and hypertension at baseline (yes/ no).

Conclusion

In this large-scale, prospective metabolomics study, we identified and independently replicated our findings that plasma levels of GlycA are associated with incident gout in UKB participants. GlycA is novel for gout, though this pro-inflammatory biomarker has predicted risk of other cardiometabolic-inflammatory phenotypes, independent of CRP.1 These findings may provide insight into the metabolic-inflammatory pathogenesis of gout, with implications for risk prediction, even beyond SU, but call for further investigation with more extensive metabolome profiling and external replication.

References

[1]Kettunen; PMID 30571186

Disclosure of Interests

Amit Joshi: None declared, Natalie McCormick: None declared, Chio Yokose: None declared, Na Lu: None declared, Hyon Choi Consultant of: Ironwood, Selecta, Horizon, Takeda, Kowa, Vaxart, Grant/research support from: Ironwood, Horizon