Five Dimensions of Needs for Help: The Efficacy of a Technology-Based Intervention Among Asian American Breast Cancer Survivors

Cancer survivors including Asian American breast cancer survivors have reported their high needs for help during their survivorship process. With the COVID-19 pandemic, the necessity of technology-based programs to address their needs for help without face-to-face interactions has been highlighted. The purpose of this randomized intervention study was to determine the efficacy of a technology-based program in reducing various types of needs for help among this specific population. This was a randomized clinical trial with repeated measures. A total of 199 participants were included in the data analysis. The recruitment settings included both online and offline communities/groups for Asian Americans. The needs for help were assessed using the Support Care Needs Survey-34 Short Form (SCNS) subscales measuring psychological, information, physical, support, and communication needs. Data analysis was conducted through an intent-to-treat approach. In the mixed effect models, psychological needs, information needs, physical needs, and communication needs decreased over time (P < .001). However, there were no significant group * time effects. Social support significantly mediated the effects of a technology-based intervention on psychological, information, and support needs at the pre-test and the post-1 month. This study supported significant decreases in the needs for help of Asian American breast cancer survivors by a technology-based intervention. Further studies are needed with other racial/ethnic groups of cancer survivors to confirm the efficacy of a technology-based intervention in reducing cancer survivors' needs for help during their survivorship process.

Turning brain MRI into diagnostic PET: 15O-water PET CBF synthesis from multi-contrast MRI via attention-based encoder-decoder networks

Accurate quantification of cerebral blood flow (CBF) is essential for the diagnosis and assessment of a wide range of neurological diseases. Positron emission tomography (PET) with radiolabeled water (15O-water) is the gold-standard for the measurement of CBF in humans, however, it is not widely available due to its prohibitive costs and the use of short-lived radiopharmaceutical tracers that require onsite cyclotron production. Magnetic resonance imaging (MRI), in contrast, is more accessible and does not involve ionizing radiation. This study presents a convolutional encoder-decoder network with attention mechanisms to predict the gold-standard 15O-water PET CBF from multi-contrast MRI scans, thus eliminating the need for radioactive tracers. The model was trained and validated using 5-fold cross-validation in a group of 126 subjects consisting of healthy controls and cerebrovascular disease patients, all of whom underwent simultaneous 15O-water PET/MRI. The results demonstrate that the model can successfully synthesize high-quality PET CBF measurements (with an average SSIM of 0.924 and PSNR of 38.8 dB) and is more accurate compared to concurrent and previous PET synthesis methods. We also demonstrate the clinical significance of the proposed algorithm by evaluating the agreement for identifying the vascular territories with impaired CBF. Such methods may enable more widespread and accurate CBF evaluation in larger cohorts who cannot undergo PET imaging due to radiation concerns, lack of access, or logistic challenges.

Are Commonly Used Geographically Based Social Determinant of Health Indices in Orthopaedic Surgery Research Correlated With Each Other and With PROMIS Global-10 Physical and Mental Health Scores?

BACKGROUND

Geographically based social determinants of health (SDoH) measures are useful in research and policy aimed at addressing health disparities. In the United States, the Area Deprivation Index (ADI), Neighborhood Stress Score (NSS), and Social Vulnerability Index (SVI) are frequently used, but often without a clear reason as to why one is chosen over another. There is limited evidence about how strongly correlated these geographically based SDoH measures are with one another. Further, there is a paucity of research examining their relationship with patient-reported outcome measures (PROMs) in orthopaedic patients. Such insights are important in order to determine whether comparisons of policies and care programs using different geographically based SDoH indices to address health disparities in orthopaedic surgery are appropriate.

QUESTIONS/PURPOSES

Among new patients seeking care at an orthopaedic surgery clinic, (1) what is the correlation of the NSS, ADI, and SVI with one another? (2) What is the correlation of Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 physical and mental health scores and the NSS, ADI, and SVI? (3) Which geographically based SDoH index or indices are associated with presenting PROMIS Global-10 physical and mental health scores when accounting for common patient-level sociodemographic factors?

METHODS

New adult orthopaedic patient encounters at clinic sites affiliated with a tertiary referral academic medical center between 2016 and 2021 were identified, and the ADI, NSS, and SVI were determined. Patients also completed the PROMIS Global-10 questionnaire as part of routine care. Overall, a total of 75,335 new patient visits were noted. Of these, 62% (46,966 of 75,335) of new patient visits were excluded because of missing PROMIS Global-10 physical and mental health scores. An additional 2.2% of patients (1685 of 75,335) were excluded because they were missing at least one SDoH index at the time of their visit (for example, if a patient only had a Post Office box listed, the SDoH index could not be determined). This left 35% of the eligible new patient visits (26,684 of 75,335) in our final sample. Though only 35% of possible new patient visits were included, the diversity of these individuals across numerous characteristics and the wide range of sociodemographic status-as measured by the SDoH indices-among included patients supports the generalizability of our sample. The mean age of patients in our sample was 55 ± 18 years and a slight majority were women (54% [14,366 of 26,684]). Among the sample, 16% (4381of 26,684) of patients were of non-White race. The mean PROMIS Global-10 physical and mental health scores were 43.4 ± 9.4 and 49.7 ± 10.1, respectively. Spearman correlation coefficients were calculated among the three SDoH indices and between each SDoH index and PROMIS Global-10 physical and mental health scores. In addition, regression analysis was used to assess the association of each SDoH index with presenting functional and mental health, accounting for key patient characteristics. The strength of the association between each SDoH index and PROMIS Global-10 physical and mental health scores was determined using partial r-squared values. Significance was set at p < 0.05.

RESULTS

There was a poor correlation between the ADI and the NSS (ρ = 0.34; p < 0.001). There were good correlations between the ADI and SVI (ρ = 0.43; p < 0.001) and between the NSS and SVI (ρ = 0.59; p < 0.001). There was a poor correlation between the PROMIS Global-10 physical health and NSS (ρ = -0.14; p < 0.001), ADI (ρ = -0.24; p < 0.001), and SVI (ρ = -0.17; p < 0.001). There was a poor correlation between PROMIS Global-10 mental health and NSS (ρ = -0.13; p < 0.001), ADI (ρ = -0.22; p < 0.001), and SVI (ρ = -0.17; p < 0.001). When accounting for key sociodemographic factors, the ADI demonstrated the largest association with presenting physical health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001) and mental health (regression coefficient: -0.13 [95% CI -0.14 to -0.12]; p < 0.001), as confirmed by the partial r-squared values for each SDoH index (physical health: ADI 0.04 versus SVI 0.02 versus NSS 0.01; mental health: ADI 0.04 versus SVI 0.02 versus NSS 0.01). This finding means that as social deprivation increases, physical and mental health scores decrease, representing poorer health. For further context, an increase in ADI score by approximately 36 and 39 suggests a clinically meaningful (determined using distribution-based minimum clinically important difference estimates of one-half SD of each PROMIS score) worsening of physical and mental health, respectively.

CONCLUSION

Orthopaedic surgeons, policy makers, and other stakeholders looking to address SDoH factors to help alleviate disparities in musculoskeletal care should try to avoid interchanging the ADI, SVI, and NSS. Because the ADI has the largest association between any of the geographically based SDoH indices and presenting physical and mental health, it may allow for easier clinical and policy application.

CLINICAL RELEVANCE

We suggest using the ADI as the geographically based SDoH index in orthopaedic surgery in the United States. Further, we caution against comparing findings in one study that use one geographically based SDoH index to another study's findings that incorporates another geographically based SDoH index. Although the general findings may be the same, the strength of association and clinical relevance could differ and have policy ramifications that are not otherwise appreciated; however, the degree to which this may be true is an area for future inquiry.

Understanding ChatGPT for evidence-based utilization in interventional radiology

Advancement in artificial intelligence (AI) has the potential to improve the efficiency and accuracy of medical care. New techniques used in machine learning have enhanced the functionality of software to perform advanced tasks with human-like capabilities. ChatGPT is the most utilized large language model and provides a diverse range of communication tasks. Interventional Radiology (IR) may benefit from the implementation of ChatGPT for specific tasks. This review summarizes the design principles of ChatGPT relevant to healthcare and highlights activities with the greatest potential for ChatGPT utilization in the practice of IR. These tasks involve patient-directed and physician-directed communications to convey medical information efficiently and act as a medical decision support tool. ChatGPT exemplifies the evolving landscape of new AI tools for advancing patient care and how physicians and patients may benefit with strategic execution.

Simple Scattering: Lipid nanoparticle structural data repository

Lipid nanoparticles (LNPs) are being intensively researched and developed to leverage their ability to safely and effectively deliver therapeutics. To achieve optimal therapeutic delivery, a comprehensive understanding of the relationship between formulation, structure, and efficacy is critical. However, the vast chemical space involved in the production of LNPs and the resulting structural complexity make the structure to function relationship challenging to assess and predict. New components and formulation procedures, which provide new opportunities for the use of LNPs, would be best identified and optimized using high-throughput characterization methods. Recently, a high-throughput workflow, consisting of automated mixing, small-angle X-ray scattering (SAXS), and cellular assays, demonstrated a link between formulation, internal structure, and efficacy for a library of LNPs. As SAXS data can be rapidly collected, the stage is set for the collection of thousands of SAXS profiles from a myriad of LNP formulations. In addition, correlated LNP small-angle neutron scattering (SANS) datasets, where components are systematically deuterated for additional contrast inside, provide complementary structural information. The centralization of SAXS and SANS datasets from LNPs, with appropriate, standardized metadata describing formulation parameters, into a data repository will provide valuable guidance for the formulation of LNPs with desired properties. To this end, we introduce Simple Scattering, an easy-to-use, open data repository for storing and sharing groups of correlated scattering profiles obtained from LNP screening experiments. Here, we discuss the current state of the repository, including limitations and upcoming changes, and our vision towards future usage in developing our collective knowledge base of LNPs.

Thalamocortical organoids enable in vitro modeling of 22q11.2 microdeletion associated with neuropsychiatric disorders

Thalamic dysfunction has been implicated in multiple psychiatric disorders. We sought to study the mechanisms by which abnormalities emerge in the context of the 22q11.2 microdeletion, which confers significant genetic risk for psychiatric disorders. We investigated early stages of human thalamus development using human pluripotent stem cell-derived organoids and show that the 22q11.2 microdeletion underlies widespread transcriptional dysregulation associated with psychiatric disorders in thalamic neurons and glia, including elevated expression of FOXP2. Using an organoid co-culture model, we demonstrate that the 22q11.2 microdeletion mediates an overgrowth of thalamic axons in a FOXP2-dependent manner. Finally, we identify ROBO2 as a candidate molecular mediator of the effects of FOXP2 overexpression on thalamic axon overgrowth. Together, our study suggests that early steps in thalamic development are dysregulated in a model of genetic risk for schizophrenia and contribute to neural phenotypes in 22q11.2 deletion syndrome.

Association Between Vertebral Bone Quality Score and Dual-Energy X-ray Absorptiometry for the Assessment of Bone Mineral Density in Adolescent Patients

BACKGROUND

The MRI-based vertebral bone quality (VBQ) score is an assessment tool for bone mineral density (BMD) that has been validated in adults against the clinical standard of dual-energy X-ray absorptiometry (DEXA). However, VBQ has yet to be validated against DEXA for use in adolescents. This study evaluated the associations between adolescent VBQ scores, DEXA Z-scores, and BMD values.

METHODS

The radiographic records of 63 consecutive patients between the ages of 11 and 21 who underwent MRI of the abdomen and pelvis and DEXA of the spine and hip were retrieved. The collected radiographic data consisted of the MRI-based VBQ score, DEXA Z-score, and BMD values of the femoral neck, L1-4 vertebrae, and total body. The VBQ score was calculated by taking the median signal intensity (MSI) from L1-L4 and the SI of the L3 cerebrospinal fluid (CSF). The VBQ score was derived as the quotient of MSIL1-L4 divided by SICSF.

RESULTS

A mean VBQ score of 2.41 ± 0.29 was observed. Strong correlations of -0.749 (p<0.0001) and -0.780 (p<0.0001) were detected between the VBQ score and DEXA femoral neck and spine Z-scores, respectively. Correlations between VBQ score and DEXA femoral neck, spine, and total body BMD scores were -0.559 (p<0.0001), -0.611 (p<0.0001), and -0.516 (p<.0001), respectively. No significant correlations were found between the VBQ score and age, BMI, weight, or height. A mean difference in VBQ score of -0.155 (p=0.035) was observed between sexes. VBQ demonstrated moderate predictive ability for DEXA-derived Z-scores and BMD scores.

CONCLUSIONS

VBQ scores were strongly correlated with DEXA Z-scores and moderately correlated with BMD values. The VBQ score can also be used by adolescent patients as an accessory tool to assess bone health.

Correlations among Cervical, Thoracic, and lumbar Hounsfield Unit measurements for assessment of bone mineral density

OBJECTIVE

Bone mineral density assessment using Hounsfield Unit (HU) currently depends upon the availability of computed tomography (CT) of the lumbar spine. The primary aim of this study was to evaluate the associations among HU measurements of the cervical (CHU), thoracic (THU), and lumbar (LHU) spine. The secondary aim of this study was to analyze the influence of patient demographic and anthropometric characteristics on HU measurements.

METHODS

Radiographic records of 165 patients who underwent CT of the cervical, thoracic, and lumbar spine were retrieved. The CHU, THU, and LHU were calculated by obtaining the mean signal intensity from the medullary portions of C3-C7, T8-T12, and L1-L4 vertebral bodies.

RESULTS

Mean CHU, THU, and LHU values were 266.26 ± 88.69, 165.57 ± 55.06, and 166.45 ± 51.38. Significant differences of 100.69, 99.81, and 0.88 were observed between CHU and THU (p <.001), CHU and LHU (p <.001), and THU and LHU (p =.023). Correlations of 0.574, 0.488, and 0.686 were observed between CHU and THU (p <.001), CHU and LHU (p <.001), and THU and LHU (p <.001). No differences in HU based on sex, age, height, weight, or ethnicity were observed. Multivariate regression models demonstrated R2 values of 0.770 - 0.790 (p <.001) in prediction of LHU.

CONCLUSIONS

Hounsfield Unit measurements derived from the cervical and thoracic spine correlate with the validated lumbar Hounsfield Unit. Hounsfield Unit measurements do not vary based on sex, ethnicity, age, height, or weight.

Using machine learning in the prediction of symptomatic venous thromboembolism following ankle fracture

BACKGROUND

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the trauma setting, and both prediction and prevention of VTE have long been a concern for healthcare providers in orthopedic surgery. The purpose of this study was to evaluate the use of novel statistical analysis and machine-learning in predicting the risk of VTE and the usefulness of prophylaxis following ankle fractures.

METHODS

The medical profiles of 16,421 patients with ankle fractures were screened retrospectively for symptomatic VTE. In total, 238 patients sustaining either surgical or nonsurgical treatment for ankle fracture with subsequently confirmed VTE within 180 days following the injury were placed in the case group. Alternatively, 937 patients who sustained ankle fractures managed similarly but had no documented evidence of VTE were randomly chosen as the control group. Individuals from both the case and control populations were also divided into those who had received VTE prophylaxis and those who had not. Over 110 variables were included. Conventional statistics and machine learning methods were used for data analysis.

RESULTS

Patients who had a motor vehicle accident, surgical treatment, increased hospital stay, and were on warfarin were shown to have a higher incidence of VTE, whereas patients who were on statins had a lower incidence of VTE. The highest Area Under the Receiver Operating Characteristic Curves (AUROC) showing the performance of our machine learning approach was 0.88 with 0.94 sensitivity and 0.36 specificity. The most balanced performance was seen in a model that was trained using selected variables with 0.86 AUROC, 0.75 sensitivity, and 0.85 specificity.

CONCLUSION

By using machine learning, this study successfully pinpointed several predictive factors linked to the occurrence or absence of VTE in patients who experienced an ankle fracture. Training these algorithms using larger, more granular, and multicentric data will further increase their validity and reliability and should be considered the standard for the development of such algorithms.

LEVEL OF EVIDENCE

Case-Control study - 3.

Optimal trade-off control in machine learning-based library design, with application to adeno-associated virus (AAV) for gene therapy

Adeno-associated viruses (AAVs) hold tremendous promise as delivery vectors for gene therapies. AAVs have been successfully engineered-for instance, for more efficient and/or cell-specific delivery to numerous tissues-by creating large, diverse starting libraries and selecting for desired properties. However, these starting libraries often contain a high proportion of variants unable to assemble or package their genomes, a prerequisite for any gene delivery goal. Here, we present and showcase a machine learning (ML) method for designing AAV peptide insertion libraries that achieve fivefold higher packaging fitness than the standard NNK library with negligible reduction in diversity. To demonstrate our ML-designed library's utility for downstream engineering goals, we show that it yields approximately 10-fold more successful variants than the NNK library after selection for infection of human brain tissue, leading to a promising glial-specific variant. Moreover, our design approach can be applied to other types of libraries for AAV and beyond.

Experimenting with ASL-based arterialized cerebral blood volume as a novel imaging biomarker in grading glial neoplasms

BACKGROUND

Perfusion imaging is one of the methods used to grade glial neoplasms, and in this study we evaluated the role of ASL perfusion in grading brain glioma.

PURPOSE

The aim is to evaluate the role of arterialized cerebral blood volume (aCBV) of multi-delay ASL perfusion for grading glial neoplasm.

MATERIALS AND METHODS

This study is a prospective observational study of 56 patients with glial neoplasms of the brain who underwent surgery, and only cases with positive diagnosis of glioma are included to evaluate the novel diagnostic parameter.

RESULTS

In the study, ASL-derived normalized aCBV (naCBV) and T2*DSC-derived normalized CBV (nCBV) are showing very high correlation (Pearson's correlation coefficient value of 0.94) in grading glial neoplasms. naCBV and nCBF are also showing very high correlation (Pearson's correlation coefficient value of 0.876). The study also provides cutoff values for differentiating LGG from HGG for normalized aCBV(naCBV) of ASL, normalized CBV (nCBV), and normalized nCBF derived from T2* DCS as 1.12, 1.254, and 1.31, respectively. ASL-derived aCBV also shows better diagnostic accuracy than ASL-derived CBF.

CONCLUSION

This study is one of its kind to the best of our knowledge where multi-delay ASL perfusion-derived aCBV is used as a novel imaging biomarker for grading glial neoplasms, and it has shown high statistical correlation with T2* DSC-derived perfusion parameters.

A deep learning approach using an ensemble model to autocreate an image-based hip fracture registry

Objectives

With more than 300,000 patients per year in the United States alone, hip fractures are one of the most common injuries occurring in the elderly. The incidence is predicted to rise to 6 million cases per annum worldwide by 2050. Many fracture registries have been established, serving as tools for quality surveillance and evaluating patient outcomes. Most registries are based on billing and procedural codes, prone to under-reporting of cases. Deep learning (DL) is able to interpret radiographic images and assist in fracture detection; we propose to conduct a DL-based approach intended to autocreate a fracture registry, specifically for the hip fracture population.

Methods

Conventional radiographs (n = 18,834) from 2919 patients from Massachusetts General Brigham hospitals were extracted (images designated as hip radiographs within the medical record). We designed a cascade model consisting of 3 submodules for image view classification (MI), postoperative implant detection (MII), and proximal femoral fracture detection (MIII), including data augmentation and scaling, and convolutional neural networks for model development. An ensemble model of 10 models (based on ResNet, VGG, DenseNet, and EfficientNet architectures) was created to detect the presence of a fracture.

Results

The accuracy of the developed submodules reached 92%-100%; visual explanations of model predictions were generated through gradient-based methods. Time for the automated model-based fracture-labeling was 0.03 seconds/image, compared with an average of 12 seconds/image for human annotation as calculated in our preprocessing stages.

Conclusion

This semisupervised DL approach labeled hip fractures with high accuracy. This mitigates the burden of annotations in a large data set, which is time-consuming and prone to under-reporting. The DL approach may prove beneficial for future efforts to autocreate construct registries that outperform current diagnosis and procedural codes. Clinicians and researchers can use the developed DL approach for quality improvement, diagnostic and prognostic research purposes, and building clinical decision support tools.

Soli-enabled noncontact heart rate detection for sleep and meditation tracking

Heart rate (HR) is a crucial physiological signal that can be used to monitor health and fitness. Traditional methods for measuring HR require wearable devices, which can be inconvenient or uncomfortable, especially during sleep and meditation. Noncontact HR detection methods employing microwave radar can be a promising alternative. However, the existing approaches in the literature usually use high-gain antennas and require the sensor to face the user's chest or back, making them difficult to integrate into a portable device and unsuitable for sleep and meditation tracking applications. This study presents a novel approach for noncontact HR detection using a miniaturized Soli radar chip embedded in a portable device (Google Nest Hub). The chip has a [Formula: see text] dimension and can be easily integrated into various devices. The proposed approach utilizes advanced signal processing and machine learning techniques to extract HRs from radar signals. The approach is validated on a sleep dataset (62 users, 498 h) and a meditation dataset (114 users, 1131 min). The approach achieves a mean absolute error (MAE) of 1.69 bpm and a mean absolute percentage error (MAPE) of [Formula: see text] on the sleep dataset. On the meditation dataset, the approach achieves an MAE of 1.05 bpm and a MAPE of [Formula: see text]. The recall rates for the two datasets are [Formula: see text] and [Formula: see text], respectively. This study represents the first application of the noncontact HR detection technology to sleep and meditation tracking, offering a promising alternative to wearable devices for HR monitoring during sleep and meditation.

A randomized controlled trial testing a virtual program for Asian American women breast cancer survivors

A culturally tailored virtual program could meet the survivorship needs of Asian American women breast cancer survivors (AABC). This study aims to determine the efficacy of a culturally tailored virtual information and coaching/support program (TICAA) in improving AABC's survivorship experience. A randomized clinical trial (NCT02803593) was conducted from January 2017 to June 2020 among 199 AABC. The intervention group utilized TICAA and the American Cancer Society [ACS] website while the control group used only ACS website for 12 weeks. The outcomes were measured using the SCNS-34SF (needs; primary), the MSAS-SF (symptoms; secondary), and the FACT-B (quality of life; secondary). The data were analyzed using an intent-to-treat approach. The intervention group showed significant reductions in their needs from the baseline (T0) to post 4 weeks (T1) and to post 12 weeks (T2). Although the changes were not statistically significant, the intervention group had decreased symptoms from T0 to T2 while the control group had an increase in their symptoms. The intervention group had a significant increase in their quality of life from T0 to T2. A culturally tailored virtual program could therefore improve quality of life in AABC patients. Trial Registration: To Enhance Breast Cancer Survivorship of Asian Americans (TICAA), NCT02803593, https://clinicaltrials.gov/ct2/show/NCT02803593?titles=TICAA&draw=2&rank=1.

Spatiotemporal molecular dynamics of the developing human thalamus

The thalamus plays a central coordinating role in the brain. Thalamic neurons are organized into spatially distinct nuclei, but the molecular architecture of thalamic development is poorly understood, especially in humans. To begin to delineate the molecular trajectories of cell fate specification and organization in the developing human thalamus, we used single-cell and multiplexed spatial transcriptomics. We show that molecularly defined thalamic neurons differentiate in the second trimester of human development and that these neurons organize into spatially and molecularly distinct nuclei. We identified major subtypes of glutamatergic neuron subtypes that are differentially enriched in anatomically distinct nuclei and six subtypes of γ-aminobutyric acid-mediated (GABAergic) neurons that are shared and distinct across thalamic nuclei.

Quantitative and Qualitative Impact of CT-Based Radiotherapy Dose Maps on Radiologists' Interpretation of Post-treatment Thoracic Surveillance Imaging

PURPOSE/OBJECTIVE(S)

For diagnostic radiologists, interpretation of surveillance imaging for oncology patients treated with radiation therapy (RT) can be challenging because (1) the imaging order may not adequately describe the radiation fields and (2) RT treatment effect and progression can appear similar. Volumetric dose visualization used for plan review is often inaccessible to radiologists. We hypothesize that displaying RT dose would improve radiologists' confidence and ability to correctly identify and distinguish irradiated targets and treatment effects.

MATERIALS/METHODS

CT images were read by a board-certified cardiothoracic radiologist and a diagnostic radiology resident. The readers interpreted pre-RT, treatment planning, and 3-4 month post-RT CT images in anonymized software sessions first without, then-after a 1 month "washout" period-with access to RT dose overlay. Six color-coded isodose lines ranging from 25% to 110% represented in absolute cGy were displayed along with a brief clinical history. RT fractionation schedules ranged in BED10 from 39 to 112.5 Gy. Readers were asked to label the treated lesion(s) and treatment effect(s), and record their confidence using a Likert scale of 1-5 and agreement with statements using yes/no responses.

RESULTS

Two readersindependently interpreted imaging for 32 patients who received thoracic RT to 1-5 lesion(s) for primary (24) or metastatic (8) cancer. Nineteen patients had 1 lesion and 13 patients had >1 lesion. Correct identification of all treated lesions significantly increased with the addition of dose visualization (61% to 81%; McNemar test, p = 0.00079), with the largest increase noted for cases with >1 lesion (15% to 54%; McNemar test, p = 0.0039). With the addition of dose information, the number of false negatives attributable to missed extranodal targets fell from 52% to 18%. Without dose information, 13% of labeled lesions and treatment effects fell outside of the 25% isodose lines, representing false positives. With the addition of dose information, false positives fell below 2% for both lesions and treatment effects. The readers' confidence that they had identified treated lesion(s) increased from a rating of 4.1 to 4.8 on a scale of 1-5 (Paired two-tail t test; p = 0.000005).

CONCLUSION

Whendiagnostic radiologists have access to dose visualization, correct identification rate of irradiated lesions and treatment effects, as well as confidence in these identifications significantly increased. The decrease in false negatives could reduce potential missed identification of tumor progression while the decrease in false positives could reduce inaccurate identification of treatment failure in a new or stable lesion. Our results demonstrate that adding volumetric visualization of dose to imaging could improve quality of surveillance care for patients with irradiated thoracic malignancies.

Comparative Bleeding Risk in Patients with Atrial Fibrillation with Cancer versus Without Cancer from Nationwide Prospective Cohort

Comparison of the bleeding risk for long-term oral anticoagulation (OAC) in patients with nonvalvular atrial fibrillation (AF) with and without cancers has been inconsistent. This study aimed to clarify the differences in the bleeding risk in patients with AF with cancers and those without cancers during the long-term OAC.The CODE-AF prospective registry enrolled 5,902 consecutive patients treated for AF at 10 tertiary referral centers in Korea. Of the enrolled patients, 464 (7.8%) were diagnosed with cancers and were followed for all stroke and bleeding events (net composite events).The age, CHA2DS2-VASC, and HAS-BLED scores were similar between AF patients with and without cancers. Male population greatly comprised patients with AF with cancers. They were equally prescribed with direct OAC compared to those without cancers. The incidence rate for clinically relevant nonmajor (CRNM) bleeding events was higher in the patients with AF with cancers than in those without cancers (4.4 per 100 person-years versus 2.8 per 100 person-years, P = 0.023), and net composite events were also more frequent in patients with AF with cancers than in those without cancers (6.4 per 100 person-years versus 4.0 per 100 person-years, P = 0.004). Patients with AF with cancers showed a significantly higher rate of CRNM bleeding (hazard ratio [HR] 1.54, confidence interval [CI] 1.05-2.25, P = 0.002) than those without cancers.Based on the AF cohort, AF with cancers could face a significantly higher risk for CRNM bleeding events in the long-term OAC than those without cancers.

Spatiotemporal molecular dynamics of the developing human thalamus

The thalamus plays a central coordinating role in the brain. Thalamic neurons are organized into spatially-distinct nuclei, but the molecular architecture of thalamic development is poorly understood, especially in humans. To begin to delineate the molecular trajectories of cell fate specification and organization in the developing human thalamus, we used single cell and multiplexed spatial transcriptomics. Here we show that molecularly-defined thalamic neurons differentiate in the second trimester of human development, and that these neurons organize into spatially and molecularly distinct nuclei. We identify major subtypes of glutamatergic neuron subtypes that are differentially enriched in anatomically distinct nuclei. In addition, we identify six subtypes of GABAergic neurons that are shared and distinct across thalamic nuclei.

One-Sentence Summary

Single cell and spatial profiling of the developing thalamus in the first and second trimester yields molecular mechanisms of thalamic nuclei development.

Characteristics of direct-to-consumer platforms offering erectile dysfunction treatment

Background

Due to the sensitivity and potential embarrassment of discussing erectile dysfunction (ED) in person, men are seeking treatment online.

Aims

We sought to compare offerings of direct-to-consumer (DTC) platforms for ED treatment with respect to consultation, pricing, services, and privacy policy.

Methods

Google was queried to identify DTC platforms offering ED treatment with the keywords: "telehealth erectile dysfunction," "telemedicine erectile dysfunction," and "online erectile dysfunction." Inclusion criteria were as follows: serving a majority of U.S. states, existing online only, providing both the consultation and prescription for phosphodiesterase type 5 inhibitors, and delivering the prescription to the patient.

Results

Fifteen DTC platforms met criteria. Ten provided free consultations; 4 bundled the consultation fee with the first month of the prescription, with 1 of these functioning as a subscription service. Fourteen (93%) relied on online intake forms and 10 (67%) advertised review by the prescriber within 2 business days. Only 4 (27%) platforms explicitly advertised physician-only consults. Direct contact with the prescriber would only occur if needed or if required by state law at 8 (53%) platforms. Purchasing sildenafil and tadalafil was advertised on all platforms. Minimum prices of sildenafil ranged from $0.50 to $35/pill (mean $5.16/pill, median $2.65/pill); tadalafil ranged from $0.50 to $9.80/pill (mean $4.70/pill, median $3.21/pill). In addition to ED therapy, 13 (86%) platforms offered treatment for other men's health issues. All platforms included a website privacy policy, but only 10 (67%) mentioned Health Insurance Portability and Accountability Act compliance, with 2 of these claiming to not be covered entities.

Conclusion

Although DTC platforms are transparent with phosphodiesterase type 5 inhibitor medication and subscription pricing information, few offer direct contact with a physician to further discuss issues related to ED after completion of the online intake form. For comprehensive evaluation of ED in Health Insurance Portability and Accountability Act-compliant settings, in-person or telemedicine visits should be arranged with men's physicians.

Rubella virus tropism and single-cell responses in human primary tissue and microglia-containing organoids

Rubella virus is an important human pathogen that can cause neurological deficits in a developing fetus when contracted during pregnancy. Despite successful vaccination programs in the Americas and many developed countries, rubella remains endemic in many regions worldwide and outbreaks occur wherever population immunity is insufficient. Intense interest since rubella virus was first isolated in 1962 has advanced our understanding of clinical outcomes after infection disrupts key processes of fetal neurodevelopment. Yet it is still largely unknown which cell types in the developing brain are targeted. We show that in human brain slices, rubella virus predominantly infects microglia. This infection occurs in a heterogeneous population but not in a highly microglia-enriched monoculture in the absence of other cell types. By using an organoid-microglia model, we further demonstrate that rubella virus infection leads to a profound interferon response in non-microglial cells, including neurons and neural progenitor cells, and this response is attenuated by the presence of microglia.

Prevalence and Impact of Poorly Controlled Modifiable Risk Factors Among Patients Who Underwent Atrial Fibrillation Ablation

Managing atrial fibrillation (AF) risk factors (RFs) improves ablation outcomes in obese patients. However, real-world data, including nonobese patients, are limited. This study examined the modifiable RFs of consecutive patients who underwent AF ablation at a tertiary care hospital from 2012 to 2019. The prespecified RFs included body mass index (BMI) ≥30 kg/m², >5% fluctuation in BMI, obstructive sleep apnea with continuous positive airway pressure noncompliance, uncontrolled hypertension, uncontrolled diabetes, uncontrolled hyperlipidemia, tobacco use, alcohol use higher than the standard recommendation, and a diagnosis-to-ablation time (DAT) >1.5 years. The primary outcome was a composite of arrhythmia recurrence, cardiovascular admissions, and cardiovascular death. In this study, a high prevalence of preablation modifiable RFs was observed. More than 50% of the 724 study patients had uncontrolled hyperlipidemia, a BMI ≥30 mg/m², a fluctuating BMI >5%, or a delayed DAT. During a median follow-up of 2.6 (interquartile range 1.4 to 4.6) years, 467 patients (64.5%) met the primary outcome. Independent RFs were a fluctuation in BMI >5% (hazard ratio [HR] 1.31, p = 0.008), diabetes with A_1c ≥6.5% (HR 1.50, p = 0.014), and uncontrolled hyperlipidemia (HR 1.30, p = 0.005). A total of 264 patients (36.46%) had at least 2 of these predictive RFs, which was associated with a higher incidence of the primary outcome. Delayed DAT over 1.5 years did not alter the ablation outcome. In conclusion, substantial portions of patients who underwent AF ablation have potentially modifiable RFs that were not well controlled. Fluctuating BMI, diabetes with hemoglobin A_1c ≥6.5%, and uncontrolled hyperlipidemia portend an increased risk of recurrent arrhythmia, cardiovascular hospitalizations, and mortality after ablation.

Knockout of TSC2 in Nav1.8+ neurons predisposes to the onset of normal weight obesity

OBJECTIVE

Obesity and nutrient oversupply increase mammalian target of rapamycin (mTOR) signaling in multiple cell types and organs, contributing to the onset of insulin resistance and complications of metabolic disease. However, it remains unclear when and where mTOR activation mediates these effects, limiting options for therapeutic intervention. The objective of this study was to isolate the role of constitutive mTOR activation in Nav1.8-expressing peripheral neurons in the onset of diet-induced obesity, bone loss, and metabolic disease.

METHODS

In humans, loss of function mutations in tuberous sclerosis complex 2 (TSC2) lead to maximal constitutive activation of mTOR. To mirror this in mice, we bred Nav1.8-Cre with TSC2fl/fl animals to conditionally delete TSC2 in Nav1.8-expressing neurons. Male and female mice were studied from 4- to 34-weeks of age and a subset of animals were fed a high-fat diet (HFD) for 24-weeks. Assays of metabolism, body composition, bone morphology, and behavior were performed.

RESULTS

By lineage tracing, Nav1.8-Cre targeted peripheral sensory neurons, a subpopulation of postganglionic sympathetics, and several regions of the brain. Conditional knockout of TSC2 in Nav1.8-expressing neurons (Nav1.8-TSC2KO) selectively upregulated neuronal mTORC1 signaling. Male, but not female, Nav1.8-TSC2KO mice had a 4-10% decrease in body size at baseline. When challenged with HFD, both male and female Nav1.8-TSC2KO mice resisted diet-induced gains in body mass. However, this did not protect against HFD-induced metabolic dysfunction and bone loss. In addition, despite not gaining weight, Nav1.8-TSC2KO mice fed HFD still developed high body fat, a unique phenotype previously referred to as 'normal weight obesity'. Nav1.8-TSC2KO mice also had signs of chronic itch, mild increases in anxiety-like behavior, and sex-specific alterations in HFD-induced fat distribution that led to enhanced visceral obesity in males and preferential deposition of subcutaneous fat in females.

CONCLUSIONS

Knockout of TSC2 in Nav1.8+ neurons increases itch- and anxiety-like behaviors and substantially modifies fat storage and metabolic responses to HFD. Though this prevents HFD-induced weight gain, it masks depot-specific fat expansion and persistent detrimental effects on metabolic health and peripheral organs such as bone, mimicking the 'normal weight obesity' phenotype that is of growing concern. This supports a mechanism by which increased neuronal mTOR signaling can predispose to altered adipose tissue distribution, adipose tissue expansion, impaired peripheral metabolism, and detrimental changes to skeletal health with HFD - despite resistance to weight gain.

Immunotherapy reverses glioma-driven dysfunction of immune system homeostasis

BACKGROUND

Glioma-induced immune dysregulation of the hematopoietic system has been described in a limited number of studies. In this study, our group further demonstrates that gliomas interrupt the cellular differentiation programming and outcomes of hematopoietic stem and progenitor cells (HSPCs) in the bone marrow. HSPCs from glioma-bearing mice are reprogrammed and driven towards expansion of myeloid lineage precursors and myeloid-derived suppressor cells (MDSCs) in secondary lymphoid organs. However, we found this expansion is reversed by immunotherapy. Adoptive cellular therapy (ACT) has been demonstrably efficacious in multiple preclinical models of central nervous system (CNS) malignancies, and here we describe how glioma-induced dysfunction is reversed by this immunotherapeutic platform.

METHODS

The impact of orthotopic KR158B-luc glioma on HSPCs was evaluated in an unbiased fashion using single cell RNAseq (scRNAseq) of lineage- cells and phenotypically using flow cytometry. Mature myeloid cell frequencies and function were also evaluated using flow cytometry. Finally, ACT containing total body irradiation, tumor RNA-pulsed dendritic cells, tumor-reactive T cells and HSPCs isolated from glioma-bearing or non-tumor-bearing mice were used to evaluate cell fate differentiation and survival.

RESULTS

Using scRNAseq, we observed an altered HSPC landscape in glioma-bearing versus non-tumor-bearing mice . In addition, an expansion of myeloid lineage subsets, including granulocyte macrophage precursors (GMPs) and MDSCs, were observed in glioma-bearing mice relative to non-tumor-bearing controls. Furthermore, MDSCs from glioma-bearing mice demonstrated increased suppressive capacity toward tumor-specific T cells as compared with MDSCs from non-tumor-bearing hosts. Interestingly, treatment with ACT overcame these suppressive properties. When HSPCs from glioma-bearing mice were transferred in the context of ACT, we observed significant survival benefit and long-term cures in orthotopic glioma models compared with mice treated with ACT using non-glioma-bearing HSPCs.

Single-Incision Laparoscopic Cholecystectomy Using the Marionette Transumbilical Approach Is Safe and Efficient with Careful Patient Selection: A Comparative Analysis with Conventional Multiport Laparoscopic Cholecystectomy

Objectives  The "marionette technique" for transumbilical laparoscopic cholecystectomy (m-TLC) offers improved cosmesis and possibly shorter postoperative recovery for patient undergoing laparoscopic cholecystectomy versus the four-port conventional laparoscopic cholecystectomy (CLC). We compared the outcomes of m-TLC and CLC at a tertiary care facility in New York. Methods  A retrospective chart review was conducted and data on patients who underwent m-TLC and CLC were retrieved. Hospital length of stay (LOS), operative time, and complications were compared between the two groups using linear and logistic regression, as appropriate. Results  M-TLC group patients were significantly younger, predominantly females with lower body mass index. They were less likely to have previous abdominal surgery and more likely to have noninflammatory pathology ( p  < 0.05 for all). Nonadjusted LOS (1 vs. 3 days, p -value < 0.0001) and operative time (50 vs. 56 minutes, p -value = 0.007) were significantly lower among patients who underwent m-TLC; however, there was no significant difference on multivariate analysis. In multivariate analysis, there was no difference in the overall complication rate (odds ratio: 1.63; 95% confidence interval 0.02-2.39). Conclusion  With careful patient selection, m-TLC offers better cosmesis with comparable safety outcomes. Level of evidence  Level III.

EXTH-70. IMMUNOTHERAPY REVERSES GLIOMA-DRIVEN DYSFUNCTION OF IMMUNE SYSTEM HOMEOSTASIS

BACKGROUND

Glioma-induced immune disfunction has been described in a limited number of studies, and here we further demonstrate that gliomas also interrupt the cellular differentiation programming and outcomes of hematopoietic stem cells (HSC) in the bone marrow. HSCs from glioma-bearing mice are re-programmed and driven towards expansion of myeloid lineage precursors myeloid-derived suppressor cells (MDSC) in secondary lymphoid organs. However, we found this is reversed by immunotherapy. Adoptive cellular therapy (ACT) has been demonstrably efficacious in multiple preclinical models of CNS malignancies, and here we describe how glioma-induced disfunction is reversed by this immunotherapeutic platform.

METHODS

The impact of orthotopic KR158B glioma on HSCs was evaluated in an unbiased fashion using single cell RNAseq of lineage- cells and phenotypically using flow cytometry. Mature myeloid cell frequencies and function were also evaluated using flow cytometry. Finally, ACT containing total body irradiation, tumor-specific dendritic cells, tumor-reactive T cells, and HSCs isolated from glioma-bearing or non-tumor-bearing mice was used to evaluate cell fate differentiation and survival.

RESULTS

We observed differential gene expression of HSCs in tumor-bearing versus healthy mice coupled with an expansion of myeloid lineage subsets in glioma-bearing mice. Interestingly, MDSCs from glioma-bearing mice demonstrated hyper suppressive capacity as compared to MDSCs from non-tumor-bearing hosts. Interestingly, treatment with ACT overcame the suppressive properties of glioma-bearing HSCs. When HSCs from tumor-bearing mice were transferred with ACT, we observed significant survival benefit and long-term cures in orthotopic glioma models compared with mice treated with ACT using non-glioma-bearing HSPCs.

CONCLUSIONS

These findings demonstrate the suppressive disposition in HSCs from glioma-bearing hosts can be redirected using ACT for significant survival benefit. Collectively, these data demonstrate gliomas impact the hematopoietic compartment at the progenitor level to promote expansion of suppressive myeloid cells and their progenitors. However, ACT can overcome this bias and provide lasting anti-tumor effects.

EXTH-38. NEOADJUVANT PD1 BLOCKADE ALTERS THE TUMOR IMMUNE MICROENVIRONMENT AFTER SURGERY IN A PRECLINICAL MODEL OF RECURRENT GLIOBLASTOMA

SIGNIFICANCE

Promising clinical trials for glioblastoma are evaluating the efficacy of neoadjuvant immunotherapy in the context of recurrent tumor surgery.

OBJECTIVE

We investigated the effects of neoadjuvant PD1 blockade on the glioma tumor microenvironment after surgery in a clinically relevant murine model of recurrent tumor.

RESULTS

Using a mouse resection model of KR158 glioblastoma that we established, we show that neoadjuvant PD1 inhibition and surgery enhance mouse survival and enhance the recruitment of CD8+ and CD4+ T cells at recurrent tumor sites following bulk tumor resection when compared with surgery followed by adjuvant immunotherapy. Transcriptome and spatial genomic analyses reveal alterations in immune exhaustion and activation pathway signaling genes after neoadjuvant anti-PD1 treatment when compared with adjuvant anti-PD1-treatment or surgery alone.

CONCLUSIONS

These studies provide insights into the effects of neoadjuvant PD1 blockade on the tumor microenvironment after surgery and uncover additional treatment targets that could be used in combination with this neoadjuvant therapy.

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Background

Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit.

Purpose

This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice.

Methods

This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI &gt;5% prior to ablation, mean systolic/diastolic blood pressure &gt;125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) &gt;6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed.

Results

The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI &gt;5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c &gt;6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1.

Conclusion

Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c &gt;6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

Correlation of Statins Use with the Incidence of Venous Thromboembolism in Patients with Ankle Fracture

Category:

Ankle; Other

Introduction/Purpose:

Finding factors that can exacerbate or ameliorate the incidence of Venous thromboembolism (VTE) can affect the process of making decision on whether to start prophylaxis or not, especially when on the verge of whether to-give or not-to-give prophylaxis. Among each patient's profile, medications are of the most important factors influencing surgeon's decision on the prophylactic methods in VTE-vulnerable patients. Among medications, Statins were shown to reduce the incidence of VTE in patients who were receiving them for hyperlipidemia and cardiovascular conditions. However, none of the current VTE prediction methods, particularly in orthopaedic practice, have considered statins protective. Herein we aimed to determine any correlations between statin consumption and the incidence of VTE in ankle fractures and whether to include statins in prediction models of VTE.

Methods:

In this case-control machine learning-based study, approved by the Institutional Review Board (IRB), the ICD and CPT codes were used to identify the patients who were diagnosed with ankle fracture in the Mass General Brigham database from 2004 to end of May 2021. After screening approximately 16,421 patients with ankle fractures, a total of 1,176 patients who were suspect VTE according to their signs and symptoms were recruited, 239 had confirmed VTE (case group) and 937 did not have VTE (controls). Forty-nine cases and 396 controls were statin users. Using a semi-automated machine learning-based algorithm, patients' demographics, past medical and surgical history, fracture characteristics and weber classification, and statin consumption status were obtained, and values were organized in a numerical analyzable manner in the dataset. We used chi-squared and Pearson correlation tests where applicable, and outcomes were displayed and interpreted using p-value (p<0.05 considered significant) and odds ratio (OR).

Results:

The mean age and BMI in our case group were 55.1+-17.0 y/o and 30.0+-6.0, respectively; age and BMI in the controls were 69.4+-13.2 (p=0.09 vs. cases) and 29.2+-6.6 (p=0.12 vs. cases), respectively. Gender distribution is depicted in table 1. In addition, we found that in our population, a total of 239 patients had VTE, from which 49 (21%) were taking Statins and 190 (79%) were not. Out of the 937 patients who did not develop VTE, 396 (42%) were taking Statins whereas 541 (58%) were not. We found that patients taking statins had lower incidence of VTE after their ankle fracture, compared with patients not taking statins (OR=0.36, p <0.001). The distribution of statin users/non-users among cases and controls is shown in table 2. Moreover, using our machine learning algorithm, conditions that would necessitate the use of statins including cardiovascular diseases and hyperlipidemia showed negative significant correlation with VTE (p<=0.02).

Conclusion:

Several studies have suggested that hyperlipidemic blood is prone to a greater generation of thrombin, endothelial dysfunction, and higher platelet activity. By disturbing these mechanisms, statins play a protective role against VTE. Herein, using machine learning algorithms together with statistical analysis, we found that Statins were significantly associated with a lower rate of VTE in patients with an ankle fracture. These findings can be considered in future prediction models that are built based on patient-specific factors. Knowing the protective effect of statins can also help clinicians with deciding on prophylaxis administration in at VTE-risk patients.fig

Prediction of Venous Thromboembolism after Ankle Fractures using Machine Learning: To Give Prophylaxis or Not to Give, That is the Question

Category:

Ankle; Other

Introduction/Purpose:

The risk of venous thromboembolism (VTE) after foot and ankle surgery is significantly lower than rates after hip/knee arthroplasty, but it isn't zero. Specific subgroups of patients may be at higher risk, forcing patients and clinicians to navigate the risks and benefits of chemoprophylaxis with insufficient data. Efforts have been made to add clarity to such decision making using conventional data-analysis and risk-scoring methods, but none of these methods were patient-specific or built on robust models of a given patient's individual characteristics. In this study we used machine-learning to determine the potential risk factors for VTE after ankle fracture. We aimed to develop a patient-specific predictive model to assist clinicians and patients in deciding upon the use of postoperative chemoprophylaxis after foot and ankle surgery.

Methods:

In this preliminary machine-learning-based case-control study, 16,421 patients with ankle fractures were recruited retrospectively. We used an automated-string search method to find patients who were clinically suspected to have developed VTE. Among 1176 such patients, 239 had confirmed VTE within 180 days of sustaining an ankle fracture (cases) and 937 did not (controls). Groups were further sub-divided in patients who had been receiving chemoprophylaxis and those who hadn't. Over 110 factors and variables including patient demographics, past-medical and surgical history, fracture characteristics, treatment, medications, and laboratory values were included in our machine-learning dataset. Three analytical algorithms were used in our machine-learning methods including backward-logistic-regression, decision-tree-classifier (depth=5), and neural networks (two dense layers (n=16 and 4), two drop-out layers, and a sigmoid classifier). Conventional statistics were also used to compare the case and control groups (chi-squared, t-test, p<0.05 considered significant), and the odds-ratio (OR) was calculated for significant parameters.

Results:

Based on overall performance scores including specificity, sensitivity, area under the ROC curve, accuracy, PPV, NPV, F- 1 score, among the 3 machine-learning methods, the Backward-Logistic-Regression model was superior in predicting VTE post ankle fracture and in determining whether administering prophylaxis can be beneficial for the patient or not (Tables 1 and 2). Other than the previously suggested risk factors, our algorithms showed a positive correlation between the incidence of VTE and smoking (OR=2.09, p<0.001), age <55 y/o (p=0.001), open fracture (OR=2.49, p<0.001), male sex (OR=1.98, p<0.001), surgical versus nonoperative treatment (OR=1.88, p=0.001), and multiple fractures at the time of trauma (OR=1.9, p=0.001). Factors that showed negative correlation with VTE include statins use (OR=0.36, p<0.001), hypertension (OR=0.53, p=0.001), vitamin D (OR=0.43, 0.002), calcium supplementation (OR= 0.43, p= 0.01), hyperlipidemia (OR=0.55, p=0.006), cataract (OR=0.19, p=0.01), osteoporosis (OR=0.36, p=0.02), cardiovascular diseases (OR=0.54, p=0.02), hypokalemia (OR=0.26, p=0.03), and proton pump inhibitor use (OR=0.5, p=0.03).

Conclusion:

Our machine learning algorithms showed that factors such as tobacco use, younger age, open fracture, multi-trauma, operative treatment, as well as male sex heightened the risk of VTE. In contrast, certain factors such as vitamin D supplementation had negative correlation with VTE. Machine learning algorithms acted in a more complex manner and incorporated more factors in decision-making compared to conventional methods. External validation using larger and more granular datasets as well as using the algorithms in trial modes (shadow modes) are needed to build trust in this algorithm to assist clinicians in predicting/preventing VTE after foot and ankle surgeries.

Tropism of SARS-CoV-2 for human cortical astrocytes

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) readily infects a variety of cell types impacting the function of vital organ systems, with particularly severe impact on respiratory function. Neurological symptoms, which range in severity, accompany as many as one-third of COVID-19 cases, indicating a potential vulnerability of neural cell types. To assess whether human cortical cells can be directly infected by SARS-CoV-2, we utilized stem-cell-derived cortical organoids as well as primary human cortical tissue, both from developmental and adult stages. We find significant and predominant infection in cortical astrocytes in both primary tissue and organoid cultures, with minimal infection of other cortical populations. Infected and bystander astrocytes have a corresponding increase in inflammatory gene expression, reactivity characteristics, increased cytokine and growth factor signaling, and cellular stress. Although human cortical cells, particularly astrocytes, have no observable ACE2 expression, we find high levels of coronavirus coreceptors in infected astrocytes, including CD147 and DPP4. Decreasing coreceptor abundance and activity reduces overall infection rate, and increasing expression is sufficient to promote infection. Thus, we find tropism of SARS-CoV-2 for human astrocytes resulting in inflammatory gliosis-type injury that is dependent on coronavirus coreceptors.

Ethmoidal and maxillary nerve block versus systemic opioid administration during rhinoscopy in dogs: a non-randomised clinical trial

OBJECTIVES

This study aimed to evaluate the clinical effects of ethmoidal and maxillary nerve blocks during rhinoscopy in dogs.

MATERIALS AND METHODS

Fourteen dogs underwent rhinoscopy. Under general anaesthesia with isoflurane, ethmoidal and maxillary nerve blocks were applied bilaterally using 2% lidocaine before rhinoscopy in eight dogs (EM group). Six dogs were premedicated with hydromorphone (0.05 mg/kg) as a substitute for local nerve block (H group). During rhinoscopy, the heart rate, arterial blood pressure and end-tidal isoflurane concentration were recorded. The vaporizer setting was adjusted to increase the end-tidal isoflurane concentration when reflex movement was caused by nasal stimulation.

RESULTS

The H group, compared to the EM group, had an increase in HR that was 18 beats/minute (95% CI: 11 to 26) higher, an increase in SAP that was 22 mmHg (12 to 31) higher, an increase in MAP that was 15 mmHg (7 to 23) higher, an increase in DAP that was 12 mmHg (5 to 19) higher, and an increase in end-tidal isoflurane concentration that was 0.4% (0.3 to 0.5) higher. Head movement due to endoscope insertion was observed in 5/6 dogs (83.3%) in the H group and 1/8 dogs (12.5%) in the EM group (odds ratio, 0.029; ra95% CI, 0.001-0.574).

CLINICAL SIGNIFICANCE

Compared with administration of 0.05 mg/kg hydromorphone, concurrent block of the ethmoidal and maxillary nerves can reduce the cardiovascular response, reflex movement and anaesthetic requirement during rhinoscopy in dogs.

Fate mapping of neural stem cell niches reveals distinct origins of human cortical astrocytes

Progenitors of the developing human neocortex reside in the ventricular and outer subventricular zones (VZ and OSVZ, respectively). However, whether cells derived from these niches have similar developmental fates is unknown. By performing fate mapping in primary human tissue, we demonstrate that astrocytes derived from these niches populate anatomically distinct layers. Cortical plate astrocytes emerge from VZ progenitors and proliferate locally, while putative white matter astrocytes are morphologically heterogeneous and emerge from both VZ and OSVZ progenitors. Furthermore, via single-cell sequencing of morphologically defined astrocyte subtypes using Patch-seq, we identify molecular distinctions between VZ-derived cortical plate astrocytes and OSVZ-derived white matter astrocytes that persist into adulthood. Together, our study highlights a complex role for cell lineage in the diversification of human neocortical astrocytes.

AB0922 Psoriatic Arthritis Disease Activity Differs by Race/Ethnicity

Background

Psoriatic arthritis (PsA) affects up to 30% of individuals with psoriasis. Studies have demonstrated that the presenting disease severity and quality of life impact of psoriasis differs by race/ethnicity in patients with and without PsA, but little is known about disease activity among different racial/ethnic groups [1-3].

Objectives

The objective of our study was to evaluate disease activity by race/ethnicity among patients with PsA.

Methods

We performed a cross-sectional study of adult (≥18 years old) patients with PsA who had at least one outpatient visit within the University of Pennsylvania health system between 2010 and 2019. Patients with PsA were identified by the presence of at least two International Classification of Diseases (ICD)-9 or ICD-10 codes for PsA associated with two different healthcare encounters. The primary outcome was disease activity as measured by the Routine Assessment of Patient Index Data 3 (RAPID3) assessment. The RAPID3 score is a validated patient-reported measure of physical function, pain, and global status [4]. RAPID3 scores range from 0 to 30, with higher scores indicating greater disease activity. Patients were included if they had at least one documented RAPID3 score. For patients with multiple RAPID3 scores, the median value was used. The primary independent variable was race/ethnicity categorized as White (reference), Black, Asian, Hispanic, or other race. Multivariable linear regression was used to assess the relationship between race/ethnicity and RAPID 3 score.

Results

The study population included 742 patients. Mean (standard deviation [SD]) age was 47.2 (13.3) years and 57.4% were female. The racial/ethnic distribution was 79.4% White, 7.0% Black, 5.0% Asian, 3.1% Hispanic, 2.6% other race, and 3.0% missing race/ethnicity. The means of the median Rapid3 scores were statistically significantly different across racial/ethnic groups (p<.001): White mean (SD) 9.79 (6.02), Black mean (SD) 14.86 (14.86), Asian mean (SD) 9.79 (5.44), Hispanic mean (SD) 15.09 (7.11), other race mean (SD) 10.57 (6.91). In an adjusted multivariable model controlling for other sociodemographic factors, body mass index, treatment history, and medical comorbidity, Hispanic patients had higher RAPID3 scores compared to White patients, indicating greater disease activity (β 3.36; 95% confidence interval [CI] 1.04 – 5.67, p <.005). In exploratory stratified analyses to evaluate effect modification by sex, among males, Black (β 3.43; 95% CI 0.23 – 6.63, p=.04) and Hispanic (β 5.94; 95% CI 2.18 – 9.70, p <.005) patients had higher RAPID3 scores than White patients. Among females, no significant racial/ethnic differences in RAPID3 scores were identified.

Conclusion

Black and Hispanic patients report greater disease activity as indicated by higher RAPID3 scores compared to White patients. Larger studies are necessary to confirm our findings and understand the causes of racial/ethnic differences in disease activity among patients with PsA.

References

[1]Abrouk M, Lee K, Brodsky M, Nakamura M, Singh R, Zhu TH, et al. Ethnicity affects the presenting severity of psoriasis. J Am Acad Dermatol. 2017;77(1):180-2.

[2]Shah SK, Arthur A, Yang YC, Stevens S, Alexis AF. A retrospective study to investigate racial and ethnic variations in the treatment of psoriasis with etanercept. J Drugs Dermatol. 2011;10(8):866-72.

[3]Takeshita J, Augustin M, de Jong E, Lafferty K, Langholff W, Langley R, Leonardi C, Menter A, Alexis A. Psoriasis-Related Quality-of-Life Differs by Race/Ethnicity. J Invest Dermatol. 2019; 139(5S, Supplement 1):S148.

[4]Coates LC, Tillett W, Shaddick G, Pincus T, Kavanaugh A, Helliwell PS. Value of the Routine Assessment of Patient Index Data 3 in Patients With Psoriatic Arthritis: Results From a Tight-Control Clinical Trial and an Observational Cohort. Arthritis Care Res (Hoboken). 2018;70(8):1198-1205.

Disclosure of Interests

Fahad Ahmed: None declared, Alexis Ogdie Consultant of: A. Ogdie has received consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, CorEvitas (formerly Corrona), Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB., Grant/research support from: A. Ogdie has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Abbvie (University of Pennsylvania), Pfizer (University of Pennsylvania), Amgen (FORWARD), and Novartis (FORWARD)., Robert Fitzsimmons: None declared, Daniel Shin: None declared, Junko Takeshita Consultant of: JT has served as a consultant for Pfizer Inc. and Janssen Biotech receiving honoraria., Grant/research support from: JT has received a research grant (to the Trustees of the University of Pennsylvania) from Pfizer Inc.

POS1049 ASSESSING TREATMENT PATTERNS WITH DISEASE-MODIFYING ANTIRHEUMATIC DRUGS AND PREDNISONE FOR PSORIATIC ARTHRITIS BY RACE/ETHNICITY

Background

Psoriatic arthritis (PsA) is a comorbidity commonly associated with psoriasis. Studies have demonstrated delays in the diagnosis and treatment of PsA[1] that may disproportionately affect racial/ethnic minority patients as indicated by one study that found Black Medicaid patients with PsA to be less likely to receive disease-modifying antirheumatic drugs [DMARDs] than White Medicaid patients with PsA [2]. Yet much remains unknown about potential racial/ethnic disparities in PsA management.

Objectives

The objective of our study was to evaluate treatment patterns for PsA by race/ethnicity.

Methods

We performed a cross-sectional study of adult (≥18 years old) patients with PsA who had at least one outpatient visit within the University of Pennsylvania health system between 2010 and 2019. Patients with PsA were identified by the presence of at least two International Classification of Diseases (ICD)-9 or ICD-10 codes for PsA associated with two different healthcare encounters. The primary outcomes were receipt of a prescription for: (i) an oral DMARD, (ii) a biologic DMARD, and (iii) prednisone. Oral DMARDs included apremilast, methotrexate, sulfasalazine, leflunomide, azathioprine, cyclosporine, tofacitinib, hydroxychloroquine, and upadacitnib. Biologic DMARDs included abatacept, adalimumab, brodalumab, certolizumab, etanercept, golimumab, guselkumab, infliximab, ixekixumab, secukinumab, ustekinumab, and risankizumab. The primary independent variable was race/ethnicity categorized as White (reference), Black, Asian, Hispanic, or other race. Multivariable logistic regression was used to assess the relationship between race/ethnicity and each treatment outcome.

Results

The study population included 1781 patients with PsA who were a mean age of 50.7 (SD 14.3), 54.6% female, and 72.5% commercially insured. The racial/ethnic distribution was 81.9% White, 5.6% Black, 4.0% Asian, 3.0% Hispanic, 2.5% other race, and 3.1% missing race/ethnicity. Of these patients, 64.3% were prescribed an oral DMARD, 55.6% were prescribed a biologic, and 44.1% were prescribed prednisone. There were no statistically significant differences across race/ethnicity for prescription of either oral or biologic DMARDs. However, prescription of prednisone did differ by race/ethnicity (p<.005) with Black (54.6%) and Hispanic (56.6%) patients being more likely to receive prednisone prescriptions and Asian (32.4%) patients being less likely to receive prednisone prescriptions than White (44.2%) patients. In adjusted logistic regression models controlling for sociodemographic and other factors, Hispanic patients were more likely to receive a prednisone prescription (OR 1.79, 95% CI 1.01 – 3.20, p=0.05) while Asian (OR 0.58, 95% CI 0.34 – 0.97, p=0.04) patients were less likely to receive a prednisone prescription compared to White patients.

Conclusion

We found Hispanic patients with PsA to be more likely to receive prednisone prescriptions than White patients with PsA but did not identify any racial/ethnic differences in prescription patterns for oral or biologic DMARDs for PsA. Greater use of prednisone among Hispanic patients may reflect different diseases trajectories (e.g., more disease flares or greater disease severity) or other factors that affect prescription patterns that require further study.

References

[1]Favier G, Gladman DD, Merola JF, Armstrong AW, Boehncke WH, Helliwell PS. Benchmarking Care in Psoriatic Arthritis - The QUANTUM Report: A Report from the GRAPPA 2016 Annual Meeting. J Rheumatol. 2017;44(5):674-678.

[2]Ogdie A, Matthias W, Thielen RJ, Chin D, Saffore CD. Racial Differences in Prevalence and Treatment for Psoriatic Arthritis and Ankylosing Spondylitis by Insurance Coverage in the USA. Rheumatol Ther. 2021;8(4):1725-1739.

Disclosure of Interests

Fahad Ahmed: None declared, Alexis Ogdie Consultant of: A. Ogdie has received consulting fees from Amgen, AbbVie, Bristol Myers Squibb, Celgene, CorEvitas (formerly Corrona), Gilead, Janssen, Lilly, Novartis, Pfizer, and UCB., Grant/research support from: A. Ogdie has received grant support from the National Institutes of Health/National Institute of Arthritis and Musculoskeletal and Skin Diseases, Rheumatology Research Foundation, National Psoriasis Foundation, Abbvie (University of Pennsylvania), Pfizer (University of Pennsylvania), Amgen (FORWARD), and Novartis (FORWARD)., Robert Fitzsimmons: None declared, Daniel Shin: None declared, Junko Takeshita Consultant of: JT has served as a consultant for Pfizer Inc. and Janssen Biotech receiving honoraria., Grant/research support from: JT has received a research grant (to the Trustees of the University of Pennsylvania) from Pfizer Inc.

Pre-ablation interatrial conduction delay or block predicts atrial fibrillation recurrence after ablation among obese patients

Funding Acknowledgements

Type of funding sources: None.

Background

Obesity is associated with greater risk of atrial fibrillation (AF) recurrence post-ablation and higher incidence of conduction delay compared to non-obese patients. Pre-ablation P-wave duration (PWD) and morphology (PWM) indicating interatrial delay are easily assessed in the clinic and may predict AF recurrence post-ablation in these patients.

Purpose

Evaluate the predictive value of PWD and PWM on AF recurrence post-ablation in obese patients.

Methods

Pre-ablation PWD and PWM (negative P-wave in lead II or III) were analyzed on consecutive patients with BMI ≥30 kg/m2 who underwent initial AF ablation from 2012–19. The primary outcome was recurrent AF after a 3-month post-ablation blanking period. Multivariate analysis adjusted for baseline characteristics was performed.

Results

For 205 patients (61.0±9.5 years old, 39.0% female), mean BMI was 36.9±5.7 kg/m2 and 71.7% had persistent AF pre-ablation. Recurrent AF post-ablation occurred in 115 (56.1%) during a median follow up of 491 (270, 1001) days. PWD &gt;130 ms was significantly associated with higher AF recurrence (AHR of 1.62, 95%CI 1.04-2.57, p=0.03) after adjusting for age, persistent AF and left atrial volume index (LAVI). In a subgroup with LAVI &lt;42 mL/m2 (n=112), PWD &gt;130 ms and negative P-waves in lead II or III were independently associated with increased risk of recurrent AF (AHR 2.06, 95%CI 1.12-3.91; p=0.019 and AHR 1.94, 95% CI 1.00-3.56; p=0.05, respectively) (Figure 1).

Conclusion

AF recurred in &gt;50% of obese patients within 1.5 years of ablation. Pre-ablation PWD &gt;130 ms and negative P-waves in lead II or III independently predicted recurrent AF post-ablation in this cohort of obese patients. These easily assessed findings add predictive value to other risk factors.

Development of machine learning algorithms to predict achievement of minimal clinically important difference for the KOOS-PS following total knee arthroplasty

As cost-effective measures become increasingly implemented in the US healthcare system, changes in patient-reported outcome measure (PROM) scores can be utilized to indicate patient satisfaction following procedures including total knee arthroplasty (TKA). The primary aim of this study was to develop and evaluate machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS) at 1-year following TKA. A retrospective review of primary TKA patients between 2016 and 2018 was performed. Variables considered for prediction included demographics and preoperative PROMs. The KOOS-PS MCID was calculated via a distribution-based method. Five machine learning algorithms were developed and tested by discrimination, calibration, Brier score, and decision curve analysis. Among the 744 patients who met the inclusion criteria, 385 (72.8%) patients achieved the MCID. The elastic-net penalized logistic regression model was selected as the best performing model (c-statistic 0.77, calibration intercept -0.02, calibration slope 1.15, and Brier score 0.14). The most important variables for MCID achievement were preoperative KOOS-PS score, preoperative VAS Pain, preoperative opioid use, preoperative PROMIS global mental health score, age, and sex. Algorithms were incorporated into an open-access digital application available at https://sorg-apps.shinyapps.io/tka_koos_mcid/. This study is the first to predict the probability of achieving the KOOS-PS MCID following TKA using a machine learning-based approach. The results were used to develop a clinical decision aid based on commonly collected predictive variables to preoperatively predict an individual patient's likelihood of attaining an acceptable outcome following TKA.

Natural language processing for prediction of readmission in posterior lumbar fusion patients: which free-text notes have the most utility?

BACKGROUND CONTEXT

The increasing volume of free-text notes available in electronic health records has created an opportunity for natural language processing (NLP) algorithms to mine this unstructured data in order to detect and predict adverse outcomes. Given the volume and diversity of documentation available in spine surgery, it remains unclear which types of documentation offer the greatest value for prediction of adverse outcomes.

STUDY DESIGN/SETTING

Retrospective review of medical records at two academic and three community hospitals.

PURPOSE

The purpose of this study was to conduct an exploratory analysis in order to examine the utility of free-text notes generated during the index hospitalization for lumbar spine fusion for prediction of 90-day unplanned readmission.

PATIENT SAMPLE

Adult patients 18 years or older undergoing lumbar spine fusion for lumbar spondylolisthesis or lumbar spinal stenosis between January 1, 2016 and December 31, 2020.

OUTCOME MEASURES

The primary outcome was inpatient admission within 90-days of discharge from the index hospitalization.

METHODS

The predictive performance of NLP algorithms developed by using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, medical doctor (MD) (resident or attending), and allied practice professional (APP) (nurse practitioner or physician assistant) notes were assessed by discrimination, calibration, overall performance.

RESULTS

Overall, 708 patients were included in the study and 83 (11.7%) had 90-day inpatient readmission. In the independent testing set of patients (n=141) not used for model development, the area under the receiver operating curve of NLP algorithms for prediction of 90-day readmission using discharge summary notes, operative notes, nursing notes, physical therapy notes, case management notes, MD/APP notes was 0.70, 0.57, 0.57, 0.60, 0.60, and 0.49 respectively.

CONCLUSION

In this exploratory analysis, discharge summary, physical therapy, and case management notes had the most utility and daily MD/APP progress notes had the least utility for prediction of 90-day inpatient readmission in lumbar fusion patients among the free-text documentation generated during the index hospitalization.

Human microglia states are conserved across experimental models and regulate neural stem cell responses in chimeric organoids

Microglia are resident macrophages in the brain that emerge in early development and respond to the local environment by altering their molecular and phenotypic states. Fundamental questions about microglia diversity and function during development remain unanswered because we lack experimental strategies to interrogate their interactions with other cell types and responses to perturbations ex vivo. We compared human microglia states across culture models, including cultured primary and pluripotent stem cell-derived microglia. We developed a "report card" of gene expression signatures across these distinct models to facilitate characterization of their responses across experimental models, perturbations, and disease conditions. Xenotransplantation of human microglia into cerebral organoids allowed us to characterize key transcriptional programs of developing microglia in vitro and reveal that microglia induce transcriptional changes in neural stem cells and decrease interferon signaling response genes. Microglia additionally accelerate the emergence of synchronized oscillatory network activity in brain organoids by modulating synaptic density.