Improving the hepatitis C virus care cascade with the in-hospital Reflex tEsting ALarm-C (REAL-C) model

BACKGROUND

The World Health Organization (WHO) has set targets to eliminate viral hepatitis, including hepatitis C virus (HCV) infection, by 2030. We present the results of the in-hospital Reflex tEsting ALarm-C (REAL-C) model, which incorporates reflex HCV RNA testing and sending alerts to physicians.

METHODS

We conducted a retrospective study analysing the data of 1730 patients who newly tested positive for anti-HCV between March 2020 and June 2023. Three distinct periods were defined: pre-REAL-C (n = 696), incomplete REAL-C (n = 515) and complete REAL-C model periods (n = 519). The primary outcome measure was the HCV RNA testing rate throughout the study period. Additionally, we assessed the referral rate to the gastroenterology department, linkage time for diagnosis and treatment and the treatment rate.

RESULTS

The rate of HCV RNA testing increased significantly from 51.0% (pre-REAL-C) to 95.6% (complete REAL-C). This improvement was consistent across clinical departments, regardless of patients' comorbidities. Among patients with confirmed HCV infection, the gastroenterology referral rate increased from 57.1% to 81.1% after the REAL-C model. The treatment rate among treatment-eligible patients was 92.4% during the study period. The mean interval from anti-HCV positivity to HCV RNA testing decreased from 45.1 to 1.9 days. The mean interval from the detection of anti-HCV positivity to direct-acting antiviral treatment also decreased from 89.5 to 49.5 days with the REAL-C model.

CONCLUSION

The REAL-C model, featuring reflex testing and physician alerts, effectively increased HCV RNA testing rates and streamlined care cascades. Our model facilitated progress towards achieving WHO's elimination goals for HCV infection.

Outcomes of Liver Resection and Transarterial Chemoembolization in Patients with Multinodular BCLC-A Hepatocellular Carcinoma

Background

This study aimed to compare the outcomes of liver resection (LR) and transarterial chemoembolization (TACE) in patients with multinodular hepatocellular carcinoma (HCC) within the Milan criteria who were not eligible for liver transplantation.

Methods

We retrospectively analyzed 483 patients with multinodular HCC within the Milan criteria, who underwent either LR or TACE as an initial therapy between 2013 and 2022. The overall survival (OS) in the entire population and recurrence-free survival (RFS) in patients who underwent LR and TACE and achieved a complete response were analyzed. Propensity score (PS) matching analysis was also used for a fair comparison of outcomes between the two groups.

Results

Among the 483 patients, 107 (22.2%) and 376 (77.8%) underwent LR and TACE, respectively. The median size of the largest tumor was 2.0 cm, and 72.3% of the patients had two HCC lesions. The median OS and RFS were significantly longer in the LR group than in the TACE group (p <0.01 for both). In the multivariate analysis, TACE (adjusted hazard ratio [aHR], 1.81 and aHR, 2.41) and large tumor size (aHR, 1.43 and aHR, 1.44) were significantly associated with worse OS and RFS, respectively. The PS-matched analysis also demonstrated that the LR group had significantly longer OS and RFS than the TACE group (PS <0.05).

Conclusion

In this study, LR showed better OS and RFS than TACE in patients with multinodular Barcelona Clinic Liver Cancer stage A HCC. Therefore, LR can be considered an effective treatment option for these patients.

CRISPR-Cas9 and beyond: identifying target genes for developing disease-resistant plants

Throughout the history of crop domestication, desirable traits have been selected in agricultural products. However, such selection often leads to crops and vegetables with weaker vitality and viability than their wild ancestors when exposed to adverse environmental conditions. Considering the increasing human population and climate change challenges, it is crucial to enhance crop quality and quantity. Accordingly, the identification and utilization of diverse genetic resources are imperative for developing disease-resistant plants that can withstand unexpected epidemics of plant diseases. In this review, we provide a brief overview of recent progress in genome-editing technologies, including zinc-finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and clustered regularly interspaced short palindromic repeats (CRISPR)-associated protein 9 (Cas9) technologies. In particular, we classify disease-resistant mutants of Arabidopsis thaliana and several crop plants based on the roles or functions of the mutated genes in plant immunity and suggest potential target genes for molecular breeding of genome-edited disease-resistant plants. Genome-editing technologies are resilient tools for sustainable development and promising solutions for coping with climate change and population increases.

Effect of bimatoprost sustained-release intracameral implant on intraocular pressure and medication burden in patients with prior glaucoma surgery

The present retrospective study evaluated intraocular pressure (IOP) and medication burden after bimatoprost sustained-release (bimatoprost SR, Durysta, Allergan) implantation in patients with glaucoma. A secondary objective was to examine an effect of bimatoprost SR in a subset of patients with prior minimally invasive and incisional glaucoma surgery. A retrospective chart review of 122 eyes that received bimatoprost SR by 6 glaucoma specialists at Wills Eye Hospital between March 2020 and September 2021 was performed. One hundred and eighteen eyes from 84 patients had a reduction in IOP (18.5±5.7mmHg vs. 16.0±5.4mmHg, P<0.01) and required fewer glaucoma medications (2.1±1.4 vs. 1.2±1.2, P<0.01) after bimatoprost SR implantation. In 41 eyes from 31 patients who previously underwent glaucoma surgery (including iStent, goniotomy, trabeculectomy, Xen Gel Stent, or tube shunt surgery), medication burden was decreased after bimatoprost SR implantation (1.9±1.3 vs. 1.0±1.0, P<0.001). These data suggest that bimatoprost SR is an efficacious treatment modality for glaucoma, even in post-surgical patients.

Longitudinal changes in renal function in patients with chronic hepatitis B on antiviral treatment

BACKGROUND

Patients with chronic hepatitis B (CHB) on nucleos(t)ide analogues (NUCs) often experience renal function decline. Conflicting results regarding the impact of NUC use and renal function have recently been reported.

AIM

To examine longitudinal changes in renal function according to the NUC treatment type compared with untreated patients METHODS: From 2014 to 2022, we retrospectively analysed 10,642 patients with CHB. The primary outcome was chronic kidney disease (CKD) progression, which was defined as a minimum one-stage elevation. We applied propensity score (PS) matching for outcome comparisons.

RESULTS

In the PS-matched cohort of 1996 pairs, the NUC-treated group (7.6/100 person-years [PYs]) had a significantly higher CKD progression risk than the untreated group (4.4/100 PYs), with a hazard ratio (HR) of 1.70 (p < 0.001). The tenofovir disoproxil fumarate (TDF)-treated group (7.9/100 PYs) showed a 1.76-fold increased CKD progression risk compared with the untreated group (4.5/100 PYs) in the PS-matched cohort (p < 0.001). Both the entecavir- and tenofovir alafenamide (TAF)-treated groups showed CKD progression risks comparable to those of the untreated group in the PS-matched cohorts of 755 and 426 pairs, respectively (p = 0.132 and p = 0.120, respectively). No significant CKD progression risk was found between the entecavir- (6.0/100 PYs) and TAF-treated (5.2/100 PYs) groups in the PS-matched cohort of 510 pairs (p = 0.118).

CONCLUSIONS

NUC-treated patients, especially those on TDF, faced a higher CKD progression risk than untreated patients. Entecavir- and TAF-treated patients had comparable CKD progression risks to untreated patients. No difference was observed between entecavir and TAF in the risk of CKD progression.

Prediction of Hepatocellular Carcinoma Development in Korean Patients after Hepatitis C Cure with Direct-Acting Antivirals

Background/Aims

With the wide application of direct-acting antivirals (DAAs) for hepatitis C virus infection, the number of patients achieving a sustained virologic response (SVR) will continue to increase. However, no consensus has been achieved on exempting SVR-achieving patients from hepatocellular carcinoma (HCC) surveillance.

Methods

Between 2013 and 2021, 873 Korean patients who achieved SVR following DAA treatment were analyzed. We evaluated the predictive performance of seven noninvasive scores (PAGE-B, modified PAGE-B, Toronto HCC risk index, fibrosis-4, aspartate aminotransferase-to-platelet ratio index, albumin-bilirubin, and age male albumin-bilirubin platelet [aMAP]) at baseline and after SVR.

Results

The mean age of the 873 patients (39.3% males) was 59.1 years, and 224 patients (25.7%) had cirrhosis. During 3,542 person-years of follow-up, 44 patients developed HCC, with an annual incidence of 1.24/100 person-years. Male sex (adjusted hazard ratio [AHR], 2.21), cirrhosis (AHR, 7.93), and older age (AHR, 1.05) were associated with a significantly higher HCC risk in multivariate analysis. The performance of all scores at the time of SVR were numerically better than those at baseline as determined by the integrated area under the curve. Time-dependent area under the curves for predicting the 3-, 5-, and 7-year risk of HCC after SVR were higher in mPAGE-B (0.778, 0.746, and 0.812, respectively) and aMAP (0.776, 0.747, and 0.790, respectively) systems than others. No patients predicted as low-risk by the aMAP or mPAGE-B systems developed HCC.

Conclusions

aMAP and mPAGE-B scores demonstrated the highest predictive performance for de novo HCC in DAA-treated, SVR-achieving patients. Hence, these two systems may be used to identify low-risk patients that can be exempted from HCC surveillance.

Endometrial organoids: a reservoir of functional mitochondria for uterine repair

Background: Asherman's syndrome (AS) is a dreadful gynecological disorder of the uterus characterized by intrauterine adhesion with severe fibrotic lesions, resulting in a damaged basalis layer with infertility. Despite extensive research on overcoming AS, evidence-based effective and reproducible treatments to improve the structural and functional morphology of the AS endometrium have not been established. Methods: Endometrial organoids generated from human or mouse endometrial tissues were transplanted into the uterine cavity of a murine model of AS to evaluate their transplantable feasibility to improve the AS uterine environment. The successful engraftment of organoid was confirmed by detection of human mitochondria and cytosol (for human endometrial organoid) or enhanced green fluorescent protein signals (for mouse endometrial organoid) in the recipient endometrium. The therapeutic effects mediated by organoid transplantation were examined by the measurements of fibrotic lesions, endometrial receptivity and angiogenesis, and fertility assessment by recording the number of implantation sites and weighing the fetuses and placenta. To explore the cellular and molecular mechanisms underlying the recovery of AS endometrium, we evaluated the status of mitochondrial movement and biogenetics in organoid transplanted endometrium. Results: Successfully engrafted endometrial organoids with similar morphological and molecular features to the parental tissues dramatically repaired the AS-induced damaged endometrium, significantly reducing fibrotic lesions and increasing fertility outcomes in mice. Moreover, dysfunctional mitochondria in damaged tissues, which we propose might be a key cellular feature of the AS endometrium, was fully recovered by functional mitochondria transferred from engrafted endometrial organoids. Endometrial organoid-originating mitochondria restored excessive collagen accumulation in fibrotic lesions and shifted uterine metabolic environment to levels observed in the normal endometrium. Conclusions: Our findings suggest that endometrial organoid-originating mitochondria might be key players to mediate uterine repair resulting in fertility enhancement by recovering abrogated metabolic circumstance of the endometrium with AS. Further studies addressing the clinical applicability of endometrial organoids may aid in identifying new therapeutic strategies for infertility in patients with AS.

Cardiovascular risk in chronic hepatitis B patients treated with tenofovir disoproxil fumarate or tenofovir alafenamide

BACKGROUND/AIMS

Tenofovir disoproxil fumarate (TDF) is known to have a lipid-lowering effect. This is in contrast to tenofovir alafenamide (TAF), which has a lipid-neutral effect. Therefore, concerns have been raised as to whether these differences affect long-term cardiovascular risk. Here, we aimed to evaluate the long-term risk of cardiovascular events in chronic hepatitis B (CHB) patients treated with TAF or TDF.

METHODS

We retrospectively analyzed 4,124 treatment-naïve CHB patients treated with TDF (n=3,186) or TAF (n=938) between 2012 and 2022. The primary outcome was a composite endpoint of major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, and hospitalization for unstable angina or heart failure. Serial changes in lipid profiles between two treatments were also explored.

RESULTS

The median age of the patients was 50.6 years, and 60.6% of the patients were male. At baseline, 486 (11.8%) and 637 (15.4%) of the patients had dyslipidemia and fatty liver, respectively. A total of 42 MACE occurred, with an annual incidence of 0.2%/100 person-years (PYs). At 1, 3, and 5 years, the cumulative risk of MACE was 0.4%, 0.8%, and 1.2% in patients treated with TDF, and 0.2%, 0.7%, and 0.7% in patients treated with TAF, respectively (p=0.538). No significant differences in the risk of MACE were observed between TDF and TAF. A multivariable analysis found that current smoker and a history of cardiovascular events were risk factors associated with an increased risk of MACE.

CONCLUSION

Patients treated with TAF had comparable risks of cardiovascular outcomes, defined as MACE, as patients treated with TDF.

Fracture Resistance of Chairside CAD/CAM Lithium Disilicate-reinforced Ceramic Occlusal Veneers With and Without Margin and Full Coverage Crowns

OBJECTIVE

The aim of this investigation was to compare the fracture resistance of chairside computer-aided design and computer-aided manufacturing (CAD/CAM) lithium disilicate-reinforced ceramic occlusal veneers with and without margin and traditional full coverage premolar crowns.

METHODS AND MATERIALS

A total of 60 chairside CAD/CAM lithium disilicate-reinforced ceramic (Amber Mill, Hass Bio) restorations were designed and fabricated with a chairside CAD/CAM system (CEREC Dentsply Sirona). The restorations were divided into three groups (n=20): 1) occlusal veneer with 1.0-mm uniform occlusal thickness and with chamfer margin; 2) occlusal veneer with 1.0-mm uniform occlusal thickness and without margin; and 3) full coverage crown with uniform occlusal thickness and gingival margin. Occlusal veneers and crowns were cemented with dual cured resin luting cement (Multilink, Ivoclar Vivadent) to printed resin dies, load cycled (5 million load cycles at 1 Hz with 275 N force), and then loaded until fracture. Load at break (LB) and peak load (PL) until fracture were recorded. Scanning electron microscope images of the tested restorations on the abutments were obtained.

RESULTS

Fracture strengths were different depending on the design of the restoration. There was no significant difference in fracture strength between the two types of occlusal veneer (LB: 1132.45 N; PL: 1143.30 N for veneers with margin; LB: 1149.25 N; PL: 1219.05 N for veneers without margin). Full coverage crowns showed the lowest fracture resistance (LB: 936.26 N, PL: 976.42 N), which was significantly lower than both designs of occlusal veneer.

CONCLUSIONS

The fracture resistance of the CAD/CAM lithium disilicate-reinforced ceramic restorations was influenced by the design. Occlusal veneers with and without margin displayed higher fracture resistance than traditional crowns.

An abrupt shift in gross primary productivity over Eastern China-Mongolia and its inter-model diversity in land surface models

The terrestrial ecosystem in East Asia mainly consists of semi-arid regions that are sensitive to climate change. Therefore, gross primary productivity (GPP) in East Asia could be highly variable and vulnerable to climate change, which can significantly affect the local carbon budget. Here, we examine the spatial and temporal characteristics of GPP variability in East Asia and its relationship with climate factors over the last three decades. We detect an abrupt decrease in GPP over Eastern China-Mongolia region around the year 2000. This is attributed to an abrupt decrease in precipitation associated with the phase shift of the Pacific decadal oscillation (PDO). We also evaluate the reproducibility of offline land surface models to simulate these abrupt changes. Of the twelve models, eight were able to simulate this abrupt response, while the others failed due to the combination of an exaggerated CO2 fertilization effect and an underrated climate impact. For accurate prediction, it is necessary to improve the sensitivity of the GPP to changes in CO2 concentrations and the climate system.

Five-year on-treatment variables-based PPACS model predicts subsequent hepatocellular carcinoma in entecavir/tenofovir-treated patients

Considering the lower risk of hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients receiving long-term potent antiviral therapy, models predicting HCC after 5 years of therapy are needed. We conducted a multicenter retrospective cohort study to construct and validate a model predicting HCC after 5 years of entecavir (ETV) or tenofovir (TFV) therapy for CHB. The endpoint was HCC after 5 years of ETV/TFV therapy. Information on age, sex, liver cirrhosis (assessed by diagnosis code and confirmed by clinical findings) and type of antiviral agent was obtained at baseline (initiation of ETV/TFV). Laboratory values were collected at baseline and 5 years. Risk factors for HCC were identified in the training set and the final prediction model was validated using the test set. Among 7542 patients, 345 (4.6%) developed HCC after 5 years of ETV/TFV therapy. HCC risk after 5 years of ETV/TFV therapy was increased by 4-fold in patients with liver cirrhosis than in those without cirrhosis at baseline. Furthermore, Platelet counts and Prothrombin time at 5 years, Age at baseline and Sex were associated with risk of HCC and were incorporated into a prediction model, PPACS. PPACS showed a good performance with a time-dependent area under the curve of 0.80 (95% confidence interval, 0.75-0.85) at 8-year of ETV/TFV therapy, a Brier score of 0.031 and an integrated Brier score of 0.006 in the test set. In conclusion, the PPACS model provides a reliable assessment of HCC risk after 5 years of ETV/TFV therapy (https://ppacs.shinyapps.io/shiny_app_up/).

Disability competency training in medical education

PURPOSE

Lack of health care providers' knowledge about the experience and needs of individuals with disabilities contribute to health care disparities experienced by people with disabilities. Using the Core Competencies on Disability for Health Care Education, this mixed methods study aimed to explore the extent the Core Competencies are addressed in medical education programs and the facilitators and barriers to expanding curricular integration.

METHOD

Mixed-methods design with an online survey and individual qualitative interviews was used. An online survey was distributed to U.S. medical schools. Semi-structured qualitative interviews were conducted via Zoom with five key informants. Survey data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis.

RESULTS

Fourteen medical schools responded to the survey. Many schools reported addressing most of the Core Competencies. The extent of disability competency training varied across medical programs with the majority showing limited opportunities for in depth understanding of disability. Most schools had some, although limited, engagement with people with disabilities. Having faculty champions was the most frequent facilitator and lack of time in the curriculum was the most significant barrier to integrating more learning activities. Qualitative interviews provided more insight on the influence of the curricular structure and time and the importance of faculty champion and resources.

CONCLUSIONS

Findings support the need for better integration of disability competency training woven throughout medical school curriculum to encourage in-depth understanding about disability. Formal inclusion of the Core Competencies into the Liaison Committee on Medical Education standards can help ensure that disability competency training does not rely on champions or resources.

Association between statin use and the prognosis of hepatocellular carcinoma after resection: a nationwide cohort study

Background

The majority of patients with hepatocellular carcinoma (HCC) following hepatic resection experience tumor recurrence. Statin use is associated with a reduced risk of HCC development; however, the association between statin use and the prognosis of HCC after resection remains unclear. We aimed to investigate the effect of statin use on the prognosis after hepatic resection among patients with HCC.

Methods

A nationwide cohort study was performed with data from the National Health Insurance Service Database in Korea. Among 65,101 HCC patients who underwent hepatic resection between January 2002 and December 2017, we included 21,470 patients. For validation, a hospital-based cohort of 3366 patients with very early or early-stage HCC who received curative-intent hepatic resection between January 2010 and December 2018 was analyzed. Recurrence-free survival (RFS) and overall survival (OS) was compared between statin users and non-users.

Findings

Among the nationwide cohort of 21,470 patients, 2399 (11.2%) used statins and 19,071 (88.8%) did not. Among the hospital cohort of 3366 patients, 363 (10.8%) used statins and 3003 (89.2%) did not. In the propensity score-matched nationwide cohort, statin users had better RFS (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.56-0.64; P < 0.001) and OS (HR, 0.49; 95% CI, 0.45-0.53; P < 0.001), with a duration-response relationship. In the propensity score-matched validation hospital cohort, statin treatment was significantly associated with better RFS (HR, 0.73; 95% CI, 0.59-0.90; P = 0.003) and OS (HR, 0.48; 95% CI, 0.32-0.72; P < 0.001). The beneficial effects of statins were more prominent in non-cirrhotics, tumors sized ≥3 cm, tumors with microscopic vascular invasion, or early HCC recurrence (<2 years after resection).

Interpretation

Statin use was associated with a better prognosis in a population-based cohort of patients with HCC after hepatic resection, which was further validated in a large hospital-based cohort.

Funding

Asan Institute for Life Sciences and Corporate Relations; Korean Association for the Study of the Liver.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

A Comparison of Treatment Plan Adaptation Methods on PTV Margin Coverage in MR-Linac Prostate SBRT

PURPOSE/OBJECTIVE(S)

MRI-Linac guided radiotherapy is a novel treatment modality allowing for daily online adaptation of contours and treatment planning. MRI-Linac prostate SBRT (MRL-SBRT) has recently been shown to provide a tangible benefit in decreasing both acute and late toxicity, due to the ability to evaluate soft tissue contrast, directly monitor organ motion, and anatomical changes during the entire treatment course. Multiple MRI-Linac platforms are available, which provide different advantages with regards to imaging and motion management. We undertook this study to assess coverage of the clinical target volume with use of a standard PTV margin in patients receiving either adapt-to-position (ATP) only treatment or a combination of adapt-to-position and adapt-to-shape (ATP+ATS) on the Elekta Unity MR-Linac.

MATERIALS/METHODS

Data was collected retrospectively in patients who underwent prostate SBRT using a 1.5 T MR-Linac (Unity, Elekta AB, Stockholm, Sweden). Prior to each fraction, determination of ATP or ATS planning was at the discretion of the treating physician. Prostate and organs at risk (OAR's) were contoured on the reference MRI and daily MR image sets acquired prior to each fraction. The prostate PTV consisted of a 5mm margin, except 3mm posteriorly. Contours were merged to account for target and OAR volumes during all fractions. Target volumes from the reference plan were then compared to the clinical target volume (CTV) on pre-treatment MR-Linac imaging as well as intersection with OAR's.

RESULTS

Nineteen men, median age 72 years (range 67-75), with prostate cancer underwent treatment from May 2021 to January 2023 with MRL-SBRT. The average time for ATP vs ATP+ATS was 45 minutes (range 35-60) and 60 minutes (range 50-80), respectively. The mean CTV treated was 43.4cc (range 31-60) for ATP and 51.8cc (range 36-67) for ATP+ATS. Prior to plan adaptation, target volumes in 92.6% of fractions were not covered completely by the PTV. In the ATP cohort, 89% of fractions had a portion of the CTV uncovered with an average of 2.9cc. In the ATP+ATS cohort, 96.4% had a portion of the CTV uncovered, with an average of 6.9cc. There was no difference in the amount of PTV intersection for ATP or ATP+ATS plans with the rectum (1.1cc vs. 1.5cc) and bladder (9.2cc vs. 12.6cc), respectively. All patients completed the planned course of treatment.

CONCLUSION

Adaptive radiation therapy for prostate cancer utilizing an MR-Linac based approach with the Elekta Unity was feasible for patients requiring either ATP only or ATP+ATS plans. As expected, ATS plans required longer treatment time, allowing for improved coverage of the target when deemed clinically necessary. Despite a larger overall volume treated in ATS plans, there was no difference in overlap with OARs between ATP and ATS plans. Adaption for each daily fraction and intrafraction motion monitoring improved CT coverage with our pre-specified PTV margin.

Assessment of Daily Target Motion to Optimize ITV Margins in Online Adaptive Plan for Liver and Pancreatic SBRT on MR-LINAC

PURPOSE/OBJECTIVE(S)

Accurate measurement of daily target motion on online plan adaptation is essential for re-optimizing the internal target volume (ITV) margins. In this study, by analyzing 2D cine MR images acquired in a 1.5T MR-Linac, we assessed daily target motion and its inter-fractional variations, which is then used to customize ITV margins for MR-based online adaptive plan of liver and pancreatic stereotactic body radiotherapy (SBRT).

MATERIALS/METHODS

Twenty-threepatients, enrolled in this study, underwent MR-guided online adaptive SBRT on 1.5 T MR-Linac: liver (n = 12 without compression belt (CB), n = 2 with CB) and pancreas (n = 9 with CB). Target motion in a 2D coronal and sagittal MR images (> 200 cine images to cover multiple breathing cycles), as well as a set of 4D-CT images during the simulation, was analyzed to determine patient specific ITV margins for a reference plan. On every fraction of online adaptive SBRT, the 2D MR images were exported to commercially available software along with a planning MR images: a T1-wighted MR image set for pancreas and or a navigated T2-wighted MR image set for liver. Daily target motion was then measured by overlaying the orthogonal cine image set on the T1- or T2-wighted image set. The ITV margin was adjusted when required prior to online plan optimization RESULTS: Thisstudy successfully assessed the daily target motion and inter-fractional variations in 23 liver or pancreatic cancer patients. We found a discrepancy of daily target motion of orthogonal 2D cine MR images from that of 4D-CT, required to adjust the ITV margin for online plan adaptation. In liver SBRT without CB, 15 out of 45 fractions from 12 patients (33.3 %) went through adjusted ITV margin. The tumor motion was large up to a 2.2 cm along the inferior direction in a patient without CB and thus the patient was treated on a conventional Linac with the active breathing control (ABC) unit for breath-hold. On the other hand, no adjustments were necessary for 2 liver patients with CB. In 9 patients with pancreatic cancers, we found the inter-fractional ITV variations in 3 out of 45 fractions (6.7 %) adjusted the ITV margin. The daily target motion in the pancreatic patients with CB was more stable and relatively smaller than that of the liver patients.

CONCLUSION

Theorthogonal 2D cine MR images are evidently essential for assessing daily target motion to evaluate the inter-fractional variation and achieve daily ITV-customized liver and pancreatic SBRT in the 1.5 T MR-Linac. The customized ITV approach will improve the treatment outcome of the MR-guided online adaptive therapy.

Goals for girls: a cluster-randomized trial to investigate a school-based sexual health programme amongst female learners in South Africa

The delivery of comprehensive sexuality education to adolescents at school is recognized as a long-term strategy to support adolescent health. Suboptimal sexual and reproductive health (SRH) outcomes among South African adolescents necessitate the ongoing development and optimization of SRH education and promotion models. We conducted a cluster-randomized controlled trial amongst secondary schools (n = 38) in Cape Town, South Africa, to evaluate a sport-based, near-peer-led SRH curriculum, SKILLZ, amongst female learners (n = 2791). Biomedical (sexually transmitted infections [STIs], human immunodeficiency virus [HIV] and pregnancy) and socio-behavioural (social support, gender norms and self-concept) outcomes were assessed pre and post intervention. Attendance at SKILLZ was low and intervention participants did not show an improvement in SRH outcomes, with HIV and pregnancy incidence remaining stable and STI prevalence remaining high and increasing in both control and intervention arms. Although evidence of positive socio-behavioural measures was present at baseline, participants with high attendance showed further improvement in positive gender norms. SKILLZ did not demonstrate the capacity to significantly impact clinical SRH outcomes. Modest improvements in outcomes amongst high attenders suggest that the impact may be possible with improved attendance; however, in the absence of optimal attendance, alternative intervention strategies may be required to improve SRH outcomes amongst adolescents.

Liver Cirrhosis Increases the Risk of Herpes Zoster: A Nationwide Population-Based Cohort Study

INTRODUCTION

Limited data are available regarding the association between liver cirrhosis (LC) and the risk of herpes zoster (HZ). This study aimed to determine the risk of HZ in patients with LC.

METHODS

HZ was defined as the presence of the International Classification of Diseases-10th revision code for HZ and concomitant prescription of antiviral medication. The incidence rates and standardized incidence ratios (SIRs) of HZ in patients with LC were analyzed using data from the Health Insurance Review and Assessment Service in Korea claims database from 2009 to 2019.

RESULTS

A total of 504,986 Korean patients with LC were included. The mean age was 52.4 years, and 60.8% were men. Chronic hepatitis B was the most common cause of LC. The incidence rates for HZ and HZ-related hospitalization were 21.6 of 1,000 and 1.81 of 1,000 person-years, respectively. The SIRs for HZ and HZ-related hospitalization were 1.09 (95% confidence interval [CI]: 1.08-1.09) and 1.48 (95% CI: 1.44-1.52), respectively, which were significantly higher than those in the general population. Patients with LC aged 20-29, 30-39, and 40-49 years had SIRs for HZ of 1.41 (95% CI: 1.33-1.48), 1.16 (1.13-1.19), and 1.17 (1.13-1.19), respectively. In multivariable analysis, woman (adjusted hazard ratio [AHR]: 1.48), steroid (AHR: 1.20), immunosuppressant use (AHR: 1.26), and combined comorbidities were associated with an increased risk of HZ among patients with LC.

DISCUSSION

Patients with LC, particularly those who are not currently recommended for HZ vaccination, were at an increased risk of HZ and HZ-related hospitalization compared with the general Korean population.

Clinical outcomes of immune checkpoint inhibitors in unresectable or metastatic combined hepatocellular-cholangiocarcinoma

PURPOSE

Immune checkpoint inhibitors (ICIs) have been demonstrated to be effective for unresectable or metastatic hepatocellular carcinoma (HCC) or cholangiocarcinoma (CCA) in prior prospective trials. However, the clinical outcomes of ICIs in patients with combined HCC-CCA (cHCC-CCA) have not been investigated. Accordingly, we retrospectively evaluated the effectiveness and safety of ICIs in patients with unresectable or metastatic cHCC-CCA.

METHODS

Among 101 patients with histologically documented cHCC-CCA who received systemic therapy, 25 received ICIs between January 2015 and September 2021 and were included in the current analysis. Overall response rate (ORR) per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1, progression-free survival (PFS), overall survival (OS), and adverse events (AEs) were retrospectively evaluated.

RESULTS

The median age was 64 years (range 38-83) and 84% (n = 21) of patients were males. Most patients had Child-Pugh A liver function (n = 22, 88%) and hepatitis B virus infection (17, 68%). Nivolumab (n = 17, 68%) was the most frequently used ICI, followed by pembrolizumab (n = 5, 20%), atezolizumab plus bevacizumab (n = 2, 8%), and ipilimumab plus nivolumab (n = 1, 4%). All patients, except one, had previously received systemic therapy; median two lines (1-5 lines) of systemic therapy were administered prior to ICIs. With a median follow-up duration of 20.1 months (95% CI 4.9-35.2 months), the median PFS was 3.5 months (95% CI 2.4-4.8 months), and the median OS was 8.3 months (95% CI 6.8-9.8 months). The ORR was 20.0% (n = 5, nivolumab for 2 patients, pembrolizumab for 1, atezolizumab plus bevacizumab for 1, and ipilimumab plus nivolumab for 1) and the duration of response was 11.6 months (95% CI 11.2-12.0 months).

CONCLUSIONS

ICIs displayed clinical anti-cancer effectiveness, aligning with the results of prior prospective studies for HCC or CCA. Further international studies are required to define the optimal strategies for managing unresectable or metastatic cHCC-CCA.

How important is it to avoid indices of deprivation that include health variables in analyses of health inequalities?

OBJECTIVES

This study aimed to quantify the difference in mortality inequalities using the Scottish Index of Multiple Deprivation (SIMD) and the Income and Employment Index (IEI; a subindex of SIMD, which excludes health) as ranking measures in Scotland.

STUDY DESIGN

This ecological study was a cross-sectional analysis of routine administrative data.

METHODS

Data from the 2020 SIMD and the subindex using data from only the Income and Employment domains, the IEI, were obtained. The correlation between data zones, percentage of data zones that changed deprivation tenth and differences in the Slope Index of Inequality (SII) and Relative Index of Inequality (RII) for Standardised Mortality Ratios (SMRs) across tenths were compared when data zones were ranked by SIMD and IEI.

RESULTS

There was a close correlation between data zones ranked by SIMD and IEI (R² = 0.96). When data zones were ranked by IEI, 18.7% of data zones moved to a lower deprivation tenth, and 20.8% of data zones moved to a higher deprivation tenth, compared with SIMD. However, only a negligible number of data zones moved two or more tenths. The SMRs across deprivation tenths were very similar between the SIMD and IEI, as were the summary health inequality measures of SII (87.3 compared with 85.7) and RII (0.88 and 0.86).

CONCLUSION

Although there is a logical problem in using deprivation indices that include health outcomes to rank areas to calculate the scale of health inequalities, the impact of using an alternative subindex containing only data from the income and employment domains is minimal. For population-wide analyses of health inequalities in Scotland, the SIMD does not introduce a substantial bias in the health inequalities summary measures despite substantial movement of small areas between ranked population tenths. Although not examined here, this is likely to be relevant to other similar indices across the United Kingdom.

Low Level of Hepatitis B Viremia Compared With Undetectable Viremia Increases the Risk of Hepatocellular Carcinoma in Patients With Untreated Compensated Cirrhosis

INTRODUCTION

The initiation of antiviral treatment in patients with chronic hepatitis B with compensated cirrhosis and low-level viremia (LLV; HBV DNA 15-2,000 IU/mL) remains controversial. We sought to compare the long-term outcomes of these untreated patients according to their viremic status.

METHODS

Six hundred twenty-seven untreated patients with chronic hepatitis B with compensated cirrhosis were analyzed retrospectively. The risk of hepatocellular carcinoma (HCC) and liver-related clinical events, including hepatic decompensation, were compared between patients with LLV and undetectable HBV DNA. Patients who received antiviral treatment were censored during treatment initiation.

RESULTS

The mean age of the patients was 54.7 years, 64.4% of whom were male. During the study period, 59 patients developed HCC (20 and 39 in the undetectable and LLV groups, respectively) with an annual incidence of 2.44/100 person-years. Multivariable analysis revealed that the LLV group was associated with a significantly higher risk of HCC (adjusted hazard ratio: 2.36, P = 0.002) than the undetectable group. In the 204 propensity score-matched cohort, the LLV group had a 2.16-fold greater risk of HCC than the undetectable group ( P = 0.014). Liver-related clinical events occurred in 121 patients with an annual incidence of 5.25/100 person-years. Despite not reaching statistical significance, the LLV group tended to have a higher risk of liver-related events in the propensity score-matched cohort (hazard ratio: 1.14, P = 0.50).

DISCUSSION

Compared with patients with undetectable HBV DNA, those with compensated cirrhosis and LLV had a significantly higher risk of HCC. Antiviral treatment should be advised for these patients.

Synthesis and Biological Evaluation of O6-Aminoalkyl-Hispidol Analogs as Multifunctional Monoamine Oxidase-B Inhibitors towards Management of Neurodegenerative Diseases

Oxidative catabolism of monoamine neurotransmitters by monoamine oxidases (MAOs) produces reactive oxygen species (ROS), which contributes to neuronal cells' death and also lowers monoamine neurotransmitter levels. In addition, acetylcholinesterase activity and neuroinflammation are involved in neurodegenerative diseases. Herein, we aim to achieve a multifunctional agent that inhibits the oxidative catabolism of monoamine neurotransmitters and, hence, the detrimental production of ROS while enhancing neurotransmitter levels. Such a multifunctional agent might also inhibit acetylcholinesterase and neuroinflammation. To meet this end goal, a series of aminoalkyl derivatives of analogs of the natural product hispidol were designed, synthesized, and evaluated against both monoamine oxidase-A (MAO-A) and monoamine oxidase-B (MAO-B). Promising MAO inhibitors were further checked for the inhibition of acetylcholinesterase and neuroinflammation. Among them, compounds 3aa and 3bc were identified as potential multifunctional molecules eliciting submicromolar selective MAO-B inhibition, low-micromolar AChE inhibition, and the inhibition of microglial PGE₂ production. An evaluation of their effects on memory and cognitive impairments using a passive avoidance test confirmed the in vivo activity of compound 3bc, which showed comparable activity to donepezil. In silico molecular docking provided insights into the MAO and acetylcholinesterase inhibitory activities of compounds 3aa and 3bc. These findings suggest compound 3bc as a potential lead for the further development of agents against neurodegenerative diseases.

Predictive Biomarkers for Immune-Checkpoint Inhibitor Treatment Response in Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) has one of the highest mortality rates among solid cancers. Late diagnosis and a lack of efficacious treatment options contribute to the dismal prognosis of HCC. Immune checkpoint inhibitor (ICI)-based immunotherapy has presented a new milestone in the treatment of cancer. Immunotherapy has yielded remarkable treatment responses in a range of cancer types including HCC. Based on the therapeutic effect of ICI alone (programmed cell death (PD)-1/programmed death-ligand1 (PD-L)1 antibody), investigators have developed combined ICI therapies including ICI + ICI, ICI + tyrosine kinase inhibitor (TKI), and ICI + locoregional treatment or novel immunotherapy. Although these regimens have demonstrated increasing treatment efficacy with the addition of novel drugs, the development of biomarkers to predict toxicity and treatment response in patients receiving ICI is in urgent need. PD-L1 expression in tumor cells received the most attention in early studies among various predictive biomarkers. However, PD-L1 expression alone has limited utility as a predictive biomarker in HCC. Accordingly, subsequent studies have evaluated the utility of tumor mutational burden (TMB), gene signatures, and multiplex immunohistochemistry (IHC) as predictive biomarkers. In this review, we aim to discuss the current state of immunotherapy for HCC, the results of the predictive biomarker studies, and future direction.

The therapeutic effects and optimal timing of granulocyte colony stimulating factor intrauterine administration during IVF-ET

Most of embryos fail to produce live offspring during In Vitro Fertilization-Embryo Transfer (IVF-ET) procedure. There is a dearth of research activity addressing this problem despite the significant population of women suffering from repeated implantation failure after transfer of high-quality of embryos. As a clinically accessible option, granulocyte colony stimulating factor (G-CSF) is often used for the treatment to improve the rates of embryo implantation. However, there are currently no evidence-based standardized protocol for the clinical use of G-CSF. G-CSF was administered into one side of mouse uterine horns and saline was infused into the other side of horns as a control. Intrauterine G-CSF administration showed maximal effects 24 h after administration in enhancing endometrial receptivity and subsequent increase of angiogenesis by demonstrating elevated integrin β3 and OPN and reduced cytotoxicity of NK cells. Furthermore, G-CSF administration 24 h prior to embryo transfer promoted the stability of attached embryos at the early stage of implantation in vitro. Our findings suggest as new consensus criteria providing a potential therapeutic strategy of the clinical use of G-CSF to achieve maximal effects of IVF-ET for patients who are suffering from repeated implantation failure with the problems with endometrial receptivity.

Telehealth Self-Management Support in Early Stroke Rehabilitation: A Feasibility Randomized Controlled Trial

BACKGROUND

Skills to manage the chronic effect of stroke are often not sufficiently addressed in early stroke rehabilitation.

OBJECTIVES

The study evaluated the feasibility of conducting a trial testing the efficacy of telehealth self-management support early in stroke recovery.

METHODOLOGY

Process, resources, and scientific feasibility was assessed for a randomized controlled trial comparing the effect of motivational interviewing and a group-based self-management program to treatment-as-usual with first-time stroke patients. Data were analyzed using descriptive statistics, effect sizes, and thematic analysis.

RESULTS

Fifteen stroke patients were enrolled, and 10 completed the study (intervention n = 6). 100% attendance was achieved with technical support, reminders, and schedule flexibility. Participants were satisfied with the intervention and reported emotional benefits and gain of new insights. Perceived recovery showed moderate effect (r = 0.54).

CONCLUSION

The findings support the feasibility of an efficacy trial as well as the potential benefit of integrating telehealth self-management support early in stroke rehabilitation.

A9 INTESTINAL ORGANOID TRANSPLANTATION REVERSED THE INTESTINAL EPITHELIUM DAMAGE IN EXPERIMENTAL NECROTIZING ENTEROCOLITIS

NOT PUBLISHED AT AUTHOR’S REQUEST

Subclassification of advanced-stage hepatocellular carcinoma with macrovascular invasion: combined transarterial chemoembolization and radiotherapy as an alternative first-line treatment

Background/Aim

The Barcelona Clinic Liver Cancer (BCLC) guidelines recommend systemic therapy as the only first-line treatment for patients with BCLC stage C hepatocellular carcinoma (HCC) despite its heterogeneity of disease extent. We aimed to identify patients who might benefit from combined transarterial chemoembolization (TACE) and radiation therapy (RT) by subclassifying BCLC stage C.

Methods

A total of 1,419 treatment-naïve BCLC stage C patients with macrovascular invasion (MVI) who were treated with combined TACE and RT (n=1,115) or systemic treatment (n=304) were analyzed. The primary outcome was overall survival (OS). Factors associated with OS were identified and assigned points by the Cox model. The patients were subclassified into three groups based on these points.

Results

The mean age was 55.4 years, and 87.8% were male. The median OS was 8.3 months. Multivariate analysis revealed a significant association of Child-Pugh B, infiltrative-type tumor or tumor size ≥10 cm, main or bilateral portal vein invasion, and extrahepatic metastasis with poor OS. The sub-classification was categorized into low (point ≤1), intermediate (point=2), and high (point ≥3) risks based on the sum of points (range, 0-4). The OS in the low, intermediate, and high-risk groups was 22.6, 8.2, and 3.8 months, respectively. In the low and intermediate-risk groups, patients treated with combined TACE and RT exhibited significantly longer OS (24.2 and 9.5 months, respectively) than those who received systemic treatment (6.4 and 5.1 months, respectively; P<0.0001).

Conclusions

Combined TACE and RT may be considered as a first-line treatment option for HCC patients with MVI when classified into low- and intermediate-risk groups.

How well do area-based deprivation indices identify income- and employment-deprived individuals across Great Britain today?

BACKGROUND

Area-based deprivation indices are used in many countries to target interventions and policies to populations with the greatest needs. Analyses of the Carstairs deprivation index applied to postcode sectors in 2001 identified that less than half of all deprived individuals lived in the most deprived areas.

OBJECTIVE

This article examines the specificity and sensitivity of deprivation indices across Great Britain in identifying individuals claiming income- and employment-related social security benefits.

STUDY DESIGN

This was a descriptive analysis of cross-sectional administrative data.

METHODS

The data sets for the 2020 Scottish Index of Multiple Deprivation, Scottish Income and Employment Index, the 2019 English Index of Multiple Deprivation and the 2019 Welsh Index of Multiple Deprivation were obtained. For each data set, small areas were ranked by increasing overall deprivation, and the cumulative proportions of individuals who were income and employment deprived were calculated. Receiver operating characteristic curves were plotted to show the sensitivity and specificity of each index, and the percentages of income- and employment-deprived individuals captured at different overall deprivation thresholds were calculated.

RESULTS

Across all indices, the sensitivity and specificity for detecting income- and employment-deprived individuals were low, with less than half living in the most deprived 20% of areas. Between 55% and 62% of income-deprived people and between 56% and 63% of employment-deprived people were missed across the indices at the 20% deprivation threshold. The sensitivity and specificity were slightly higher for income deprivation than employment deprivation across indices and slightly higher for the Scottish Index of Multiple Deprivation and Scottish Income and Employment Index than for the English Index of Multiple Deprivation and Welsh Index of Multiple Deprivation.

CONCLUSION

Area-based deprivation measures in Great Britain have limited sensitivity and specificity for identifying individuals who are income or employment deprived. Place-based policies and interventions are unlikely to be effective at reducing inequalities as a result. Creation of individually linked data sets and interventions that recognise the social and economic relationships between social groups are likely to be more effective.

Comparison of survival between de novo stage IV and recurrent stage IV gastric cancer

304

Background: The characteristics and prognosis of de novo metastatic gastric cancer and recurrent metastatic gastric cancer have not yet been elucidated. Here, we compare prognosis and characteristics of patients with de novo versus recurrent gastric cancer. Methods: This retrospective study included 301 advanced pathologically confirmed gastric cancer patients who received palliative chemotherapy between 2012 and 2022. The de novo cohort was included of patients who presented with distant metastasis at diagnosis and recurrent metastatic cohort was composed of patients with metastasis after curative gastrectomy. We analyzed prognostic association by Cox regression and compared survival time of both cohorts using the Kaplan-meire method. Results: A total of 167 de novo and 112 recurrent patients were included. There were no differences noted among the patients with de novo disease and recurrent metastatic disease with respect to age, sex, ECOG, primary cancer location and pathologic features. Patients in the recurrent group versus de novo group were longer duration of chemotherapy (1.16 ± 1.18 years versus 0.85 ± 0.84, P = 0.01) and lower mean body mass index. (20.22 ± 2.78 versus 21.93 ± 3.38, p < 0.001) The median overall survival in the de novo group was 11.6 versus s 14.4 months in the recurrent group. ( P = 0.02) In a multivariate analysis, the age of 70 years or older at the time of stage 4 diagnosis was independently associated with shorter survival. Conclusions: De novo and recurrent metastatic gastric cancer characterize distinguished subpopulations. And advanced gastric cancer with distant recurrence has significantly better survival versus those with de novo cohort. This differences between de novo and recurrent gastric cancer could facilitate discussions about patient selection of clinical trial and help with advanced personalized treatment. [Table: see text]

Case Report: Single-port laparoscopic total gastrectomy for gastric cancer in patient with situs inversus totalis

Situs inversus totalis (SIT) is a rare anatomical condition, where all the viscera appear in its reverse position. Although minimally invasive surgery has evolved to achieve totally laparoscopic gastrectomy for gastric cancer patients with SIT, it is difficult to perform lymphadenectomy in such a transposed anatomical condition. Recently, we performed a single-port laparoscopic total gastrectomy (SPTG) for gastric cancer in a patient with SIT. No postoperative complications or dietary problems were observed. Based on this experience, we are to design a safe strategy to perform D2 lymphadenectomy during SPTG in patients with SIT.

Inequitable care delivery toward COVID-19 positive people of color and people with disabilities

This study aimed to explore provider observations of inequitable care delivery towards COVID-19 positive patients who are Black, Indigenous, and Other People of Color (BIPOC) and/or have disabilities and to identify ways the health workforce may be contributing to and compounding inequitable care. We conducted semi-structured interviews between April and November 2021 with frontline healthcare providers from Washington, Florida, Illinois, and New York. Using thematic analysis, major themes related to discriminatory treatment included decreased care, delayed care, and fewer options for care. Healthcare providers' bias and stigma, organizational bias, lack of resources, fear of transmission, and burnout were mentioned as drivers for discriminatory treatment. COVID-19 related health system policies such as visitor restrictions and telehealth follow-ups inadvertently resulted in discriminatory practices towards BIPOC patients and patients with disabilities. As patients experience lower quality healthcare during the pandemic, COVID-19-related restrictions and policies compounded existing inequitable care for these populations.

Inequitable Care Delivery for COVID-19 Positive People of Color and People With Disabilities

Research Objectives

To explore provider observations of inequitable care delivery towards COVID-19 positive patients who are Black, Indigenous, and People of Color (BIPOC) and/or have disabilities and to identify ways health providers may be contributing to and compounding inequitable care.

Design

Qualitative research design using thematic analysis of data collected via individual semi-structured interviews between April and November 2021.

Setting

Hospitalized and ambulatory care.

Participants

A total of 19 pandemic frontline health care providers including nine physicians, five nurses, three rehabilitation professionals, and two nurse practitioners from Washington, Florida, Illinois, and New York were recruited through convenience and snowball sampling. The majority of participants were female (n=12) and White (n=11).

Interventions

Not applicable.

Main Outcome Measures

A semi-structured interview guide included questions regarding equity in treatments among COVID-19 patients who are BIPOC or have disabilities and perceptions around stigma related to COVID-19.

Results

Discriminatory treatment included decreased care (i.e., less explanation due to communication barriers, less interaction with health care providers, no access to telehealth follow-ups), delayed care, and fewer options for care. Health care providers’ bias and stigma (racism, ableism, and ageism), patient mistrust and provider-patient disconnect, lack of resources (e.g., staff, interpreter services, funding, or collaboration across health systems), fear of transmission, and burnout were mentioned as drivers for discriminatory treatment. COVID-19 related health system policies such as visitor restrictions and telehealth follow-ups also inadvertently resulted in discriminatory practices towards BIPOC patients and patients with disabilities.

Conclusions

BIPOC patients and patients with disabilities may experience lower quality of healthcare related to COVID-19 due to factors such as providers’ biases, fear, burnout, and lack of needed resources in their work settings. In addition, COVID-19-related restrictions and policies compounded existing inequitable care for these populations.

Author(s) Disclosures

Authors do not have conflicts to disclose.

Co-Responses of Soil Organic Carbon Pool and Biogeochemistry to Different Long-Term Fertilization Practices in Paddy Fields

Long-term application of soil organic amendments (SOA) can improve the formation of soil organic carbon (SOC) pool as well as soil fertility and health of paddy lands. However, the effects of SOA may vary with the input amount and its characteristics. In this work, a descriptive field research was conducted during one cropping season to investigate the responses of various SOC fractions to different long-term fertilization practices in rice fields and their relationships with soil biogeochemical properties and the emission of greenhouse gases (GHG). The field sites included two conventional paddies applied with chemical fertilizer (CF) or CF + rice straw (RS) and six organic agriculture paddies applied with oilseed cake manure (OCM) + wheat straw (WS), cow manure (CM) + WS, or CM + RS. The two paddy soils treated with CM + RS had significantly higher concentrations of recalcitrant to labile C forms, such as loss-on-ignition C (LOIC; 56-73 g kg^-1), Walkley-Black C (WBC; 20-25 g kg^-1), permanganate oxidizable C (POXC; 835-853 mg kg^-1), and microbial biomass carbon (MBC; 133-141 mg kg^-1), than soils treated with other SOA. Likewise, long-term application of CM + RS seemed to be the best for regulating soil fertility parameters, such as ammonium (11-141 mg kg^-1); phosphate (61-106 mg kg^-1); and soluble Ca, K, and Mg (7-10, 0.5-1.2, and 1.9-3.8 mg kg^-1, respectively), although the results varied with the location and soil properties of rice fields. Additionally, the two paddy sites had the largest cumulative methane emission (754-762 kg ha^-1), seemingly attributed to increased microbial biomass and labile C fractions. The significant correlations of most SOC fractions with soil microbial biomass, trophic factors, and methane emissions were confirmed with multivariate data analysis. It was also possible to infer that long-term SOA application, especially with CM + RS, enhanced interaction in belowground paddy fields, contributing to soil fertility and rice production sustainability. Based on our findings, we suggest the need for analysis of various types of SOC fractions to efficiently manage soil fertility and quality of paddy fields, C sequestration, and GHG emissions.

Patterns of anticoagulant prescribing and renal function changes in patients with atrial fibrillation

Background

The prevalence of atrial fibrillation (AF) is nearly three times higher in patients with chronic kidney disease (CKD) than the general population. These patients have an increased risk of stroke and systemic thromboembolism (SSE) as well as bleeding. The role for direct oral anticoagulants (DOACs) in those with advanced CKD and AF remains controversial. Studies show that patients on DOACs for AF with advanced CKD have similar risk of SSE and bleeding compared to those on warfarin, but these failed to account for changes in renal function over time.

Purpose

We sought to evaluate the pattern of oral anticoagulant prescribing, class switching, discontinuation and renal function trajectory in patients with AF in the last decade, coinciding with the development of DOACs.

Methods

Using linked administrative databases, we assessed patients 66 years of age and older with a new diagnosis of non-valvular AF between April 1, 2012 and March 31, 2020 who were started on oral anticoagulation within 90 days of diagnosis. Participants required a baseline serum creatinine (Cr) measurement in the year preceding AF diagnosis. Cr values were used to calculate the estimated glomerular filtration rate (eGFR) using the CKD Epidemiology Collaboration equation. Kidney function was tracked at baseline and longitudinally among patients prescribed DOACs versus warfarin using the Laboratories Information System. Anticoagulant class switching was tracked and discontinuation was defined if a new prescription for anticoagulation was not filled after 90 days of their last prescription ending.

Results

A total of 57,574 participants were included in the study; 48,662 were started on DOACs and 8,912 were started on warfarin. In April 2012, 83.8% of patients were prescribed warfarin; however, the proportion of first prescriptions significantly evolved over time to DOACs (Figure 1). Of those started on DOACs, 13,383 (27.5%) discontinued therapy, 34,918 (71.8%) remained on therapy and 361 (0.7%) switched to warfarin. The rate of discontinuation among those started on warfarin was higher with 4,144 (46.5%) stopping, 3,172 (35.6%) continuing therapy and 1,596 (17.9%) switching to DOACs. Most patients (75.6%) who switched to DOACs from warfarin remained on DOACs until the occurrence of dialysis, renal transplantation, death, or the last follow-up date (March 31, 2020). At baseline, the mean eGFR in the warfarin group was 56.2 compared with 66.3 mL/min/1.73 m2 in the DOAC group (p&lt;0.01). Over the course of study, more than half of the subjects in both groups had a 20% or more decline in eGFR (Figure 2).

Conclusion

Given the degree of renal function decline and frequency of anticoagulant class switching in our cohort, existing observational studies comparing DOACs to warfarin in patients with AF and CKD may be limited. In order to better compare DOACs to warfarin in this population, time-varying covariates like renal function should be included in modelling.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIHR Foundation Grant