Routes to diagnosis for hepatocellular carcinoma patients: predictors and associations with treatment and mortality

BACKGROUND

Hepatocellular carcinoma (HCC) incidence has increased rapidly, and prognosis remains poor. We aimed to explore predictors of routes to diagnosis (RtD), and outcomes, in HCC cases.

METHODS

HCC cases diagnosed 2006-2017 were identified from the National Cancer Registration Dataset and linked to Hospital Episode Statistics and the RtD metric. Multivariable logistic regression was used to explore associations between RtD, diagnosis year, 365-day mortality and receipt of potentially curative treatment.

RESULTS

23,555 HCC cases were identified; 36.1% via emergency presentation (EP), 30.2% GP referral (GP), 17.1% outpatient referral, 11.0% two-week wait and 4.6% other/unknown routes. Odds of 365-day mortality was >70% lower via GP or OP routes than EP, and odds of curative treatment 3-4 times higher. Further adjustment for cancer/cirrhosis stage attenuated the associations with curative treatment. People who were older, female, had alcohol-related liver disease, or were more deprived, were at increased risk of an EP. Over time, diagnoses via EP decreased, and via GP increased.

CONCLUSIONS

HCC RtD is an important predictor of outcomes. Continuing to reduce EP and increase GP and OP presentations, for example by identifying and regularly monitoring patients at higher risk of HCC, may improve stage at diagnosis and survival.

The use of NovoSorb biodegradable temporising matrix in wound management: a literature review and case series

OBJECTIVE

NovoSorb (Poly-Novo Ltd, Australia) biodegradable temporising matrix (BTM) is a novel artificial dermal matrix. Previous literature is weighted towards its use in burns reconstruction; however, this paper describes its use within a range of wound aetiologies. The authors present one of the largest and most diverse case series to date, and aim to provide an independent benchmark of clinical practice.

METHOD

A retrospective observational study was performed. Patient demographics and clinical data (wound aetiology, site, total body surface area (TBSA), wound bed, number of debridements, time to BTM integration, time to skin grafting) were collected and subgroup analysis preformed.

RESULTS

The cohort consisted of 37 patients (acute trauma wounds, n=19; hard-to-heal wounds, n=9; acute infections, n=6; cancer, n=3). Successful BTM integration, allowing subsequent split-thickness skin grafting (STSG), occurred in 70% of cases, despite an overall complication rate of 51%. Mean time from BTM application to STSG was 53 days. There was no difference in STSG outcomes when grafting was performed either before or after the six-week BTM application period. There was no difference when various wound beds (fascia, tendon, periosteum) were compared. Patients >65 years of age were more likely to experience complications; however, this did not affect the speed of integration. The relation of diabetes and smoking to overall integration had no statistical significance.

CONCLUSION

In comorbid patients in particular, the time between BTM application and STSG may be longer than the manufacturer's recommendation. Furthermore, data suggest greater wound bed optimisation and closer interval monitoring in hard-to-heal/malignant wounds, and in older patients and patients with comorbidities. However, BTM appears robust (even in infection) and is showing promise as a useful reconstructive tool.

When the Cost of Vaping Is an Eye: A Case of an Open Globe and Superior Orbital Roof Fracture

The authors report a penetrating orbitocerebral vape pen injury necessitating a primary enucleation and craniotomy to remove the foreign body fragments. A 31-year-old male presented with acute right vision loss after a modifiable vape pen explosion launched multiple projectile fragments into his right eye. CT revealed a deformed globe with multiple radiodense curvilinear fragments in the superior orbital roof and intracranial space. A right frontal craniotomy and orbitotomy with removal of vape pen fragments, reconstruction of the orbital roof, primary enucleation, and eyelid repair were performed in conjunction with neurosurgery. To the best of the authors' knowledge, this is the first reported penetrating globe injury from a vape pen explosion.

Poverty and Frailty Are Not Related to Each Other with Regards to Outcomes in Middle Aged and Older Patients with Burn Injuries

The purpose of this study was to determine the relationship between frailty and poverty in burn patients >50 years-old, and their association with patient outcomes. This was a single-center retrospective chart review from 2009-2018 of patients >50 years old admitted with acute burn injuries. Frailty was assigned using the Canadian Study of Health and Aging Clinical Frailty Scale. Poverty was defined as a patient from a zip code that had >20% of people living in poverty. The relationship between frailty and poverty, as well as each variable independently on mortality, length of stay (LOS), and disposition location was examined. Of 953 patients, the median age was 61 years, 70.8% were male, and median total body surface area burn was 6.6%. Upon admission, 26.4% and 35.2% patients were frail and from impoverished neighborhoods, respectively. The mortality rate was 8.8%. Univariate analysis demonstrated that non-survivors had significantly higher chances of living in poverty (p=0.02) and were more likely to be frail compared to survivors. There was no significant correlation between poverty and frailty (p=0.08). Multivariate logistic regression confirmed the relationship between lack of poverty and mortality (OR 0.47 95% CI 0.25-0.89) and frailty and mortality OR 1.62 95%CI 1.24-2.12). Neither poverty (p=0.26) nor frailty (p=0.52) was associated with LOS. Both poverty and frailty were associated with a patient's discharge location (p=0.03; p<0.0001). Poverty and frailty each independently predict mortality and discharge destination in burn patients >50, but they are not associated with LOS nor each other.

Response to Besse et al. 2023

The authors of The Comprehensive Counseling Center (CCC) Model (2017) respond to The Holistic Prevention & Intervention Model: A public health approach to college mental health and suicide prevention, by Besse et al. (2023). We believe the article is based on misunderstanding of college counseling centers and the CCC Model. As such the authors simultaneously argue for duplication of models and the inappropriate diminishing of counseling centers.

Rhinitis associated with asthma is distinct from rhinitis alone: The ARIA-MeDALL hypothesis

Asthma, rhinitis and atopic dermatitis (AD) are interrelated clinical phenotypes that partly overlap in the human interactome. The concept of "one-airway-one-disease", coined over 20 years ago, is a simplistic approach of the links between upper- and lower-airway allergic diseases. With new data, it is time to reassess the concept. This article reviews (i) the clinical observations that led to Allergic Rhinitis and its Impact on Asthma (ARIA), (ii) new insights into polysensitisation and multimorbidity, (iii) advances in mHealth for novel phenotype definition, (iv) confirmation in canonical epidemiologic studies, (v) genomic findings, (vi) treatment approaches and (vii) novel concepts on the onset of rhinitis and multimorbidity. One recent concept, bringing together upper- and lower-airway allergic diseases with skin, gut and neuropsychiatric multimorbidities, is the "Epithelial Barrier Hypothesis". This review determined that the "one-airway-one-disease" concept does not always hold true and that several phenotypes of disease can be defined. These phenotypes include an extreme "allergic" (asthma) phenotype combining asthma, rhinitis and conjunctivitis. Rhinitis alone and rhinitis and asthma multimorbidity represent two distinct diseases with the following differences: (i) genomic and transcriptomic background (Toll-Like Receptors and IL-17 for rhinitis alone as a local disease; IL-33 and IL-5 for allergic and non-allergic multimorbidity as a systemic disease), (ii) allergen sensitisation patterns (mono- or pauci-sensitisation versus polysensitisation), (iii) severity of symptoms and (iv) treatment response. In conclusion, rhinitis alone (local disease) and rhinitis with asthma multimorbidity (systemic disease) should be considered as two distinct diseases, possibly modulated by the microbiome, and may be a model for understanding the epidemics of chronic and auto-immune diseases.

Trend analysis and prediction of seasonal changes in milk composition from a pasture-based dairy research herd

The composition of seasonal pasture-produced milk is influenced by stage of lactation, animal genetics, and nutrition, which affects milk nutritional profile and processing characteristics. The objective was to study the effect of lactation stage (early, mid, and late lactation) and diet on milk composition in an Irish spring calving dairy research herd from 2012 to 2020 using principal component and predictive analytics. Crude protein, casein, fat, and solids increased from 2012 to 2020, whereas lactose concentration peaked in 2017, then decreased. Based on seasonal data from 2013 to 2016, forecasting models were successfully created to predict milk composition for 2017 to 2020. The diet of cows in this study is dependent upon grass growth rates across the milk production season, which in turn, are influenced by weather patterns, whereby extreme weather conditions (rainfall and temperature) were correlated with decreasing grass growth and increasing nonprotein nitrogen levels in milk. The study demonstrates a significant change in milk composition since 2012 and highlights the effect that seasonal changes such as weather and grass growth have on milk composition of pasture-based systems. The potential to forecast milk composition at different stages of lactation benefits processers by facilitating the optimization of in-process and supply logistics of dairy products.

Outcomes of liver transplantation in non-alcoholic steatohepatitis (NASH) versus non-NASH associated hepatocellular carcinoma

BACKGROUND

Non-alcoholic steatohepatitis (NASH)-associated hepatocellular carcinoma (HCC) is a rising indication for liver transplantation. This unique population, with multiple comorbidities, has potential for worse post-transplant outcomes. We compared post-transplant survival of NASH and non-NASH HCC patients using a large cohort.

METHODS

Adults transplanted for HCC between 2008 and 2018, from United Network for Organ Sharing (UNOS) and University Health Network (UHN) databases were divided into two populations: NASH and non-NASH. Recipient characteristics and post-transplant survival were compared. Subgroup analyses were performed within and beyond Milan criteria.

RESULTS

2071 of 20,672 (10.0%) patients underwent transplantation for NASH HCC, with annual proportional increase of 1.2%UHN (p = 0.02) and 1.3%UNOS (p < 0.001). The 1-,3-,5-year post-transplant survival were 90.8%, 83.9%, 76.3% NASH HCC versus 91.9%, 82.1%, 74.9% non-NASH HCC (p = 0.94). No survival differences were observed in populations within or beyond Milan. Competing-risk analysis demonstrated no differences in risk for cardiovascular-related death (HR1.24, 95%CI 0.87-1.55, p = 0.16), or HCC recurrence-related death (HR1.21, 95%CI 0.89-1.65, p = 0.23). NASH HCC patients had lower risk of liver-related deaths (HR0.57, 95%CI 0.34-0.98, p = 0.04).

DISCUSSION

NASH HCC is a rising indication for liver transplantation. Despite demographic differences, no post-transplantation survival differences were observed between NASH and non-NASH HCC. This justifies equivalent organ allocation, irrespective of NASH status.

Outcomes after liver transplantation using deceased after circulatory death donors: A comparison of outcomes in the UK and the US

BACKGROUND AND AIMS

Identifying international differences in utilization and outcomes of liver transplantation (LT) after donation after circulatory death (DCD) donation provides a unique opportunity for benchmarking and population-level insight.

METHODS

Adult (≥18 years) LT data between 2008 and 2018 from the UK and US were used to assess mortality and graft failure after DCD LT. We used time-dependent Cox-regression methods to estimate hazard ratios (HR) for risk-adjusted short-term (0-90 days) and longer-term (90 days-5 years) outcomes.

RESULTS

One-thousand five-hundred-and-sixty LT receipts from the UK and 3426 from the US were included. Over the study period, the use of DCD livers increased from 15.7% to 23.9% in the UK compared to 5.1% to 7.6% in the US. In the UK, DCD donors were older (UK:51 vs. US:33 years) with longer cold ischaemia time (UK: 437 vs. US: 333 min). Recipients in the US had higher Model for End-stage Liver Disease (MELD) scores, higher body mass index, higher proportions of ascites, encephalopathy, diabetes and previous abdominal surgeries. No difference in the risk-adjusted short-term mortality or graft failure was observed between the countries. In the longer-term (90 days-5 years), the UK had lower mortality and graft failure (adj.mortality HR:UK: 0.63 (95% CI: 0.49-0.80); graft failure HR: UK: 0.72, 95% CI: 0.58-0.91). The cumulative incidence of retransplantation was higher in the UK (5 years: UK: 11.9% vs. 4.6%; p < .001).

CONCLUSIONS

For those receiving a DCD LT, longer-term post-transplant outcomes in the UK are superior to the US, however, significant differences in recipient illness, graft quality and access to retransplantation were seen between the two countries.

Machine learning-based mortality prediction models using national liver transplantation registries are feasible but have limited utility across countries

Many countries curate national registries of liver transplant (LT) data. These registries are often used to generate predictive models; however, potential performance and transferability of these models remain unclear. We used data from 3 national registries and developed machine learning algorithm (MLA)-based models to predict 90-day post-LT mortality within and across countries. Predictive performance and external validity of each model were assessed. Prospectively collected data of adult patients (aged ≥18 years) who underwent primary LTs between January 2008 and December 2018 from the Canadian Organ Replacement Registry (Canada), National Health Service Blood and Transplantation (United Kingdom), and United Network for Organ Sharing (United States) were used to develop MLA models to predict 90-day post-LT mortality. Models were developed using each registry individually (based on variables inherent to the individual databases) and using all 3 registries combined (variables in common between the registries [harmonized]). The model performance was evaluated using area under the receiver operating characteristic (AUROC) curve. The number of patients included was as follows: Canada, n = 1214; the United Kingdom, n = 5287; and the United States, n = 59,558. The best performing MLA-based model was ridge regression across both individual registries and harmonized data sets. Model performance diminished from individualized to the harmonized registries, especially in Canada (individualized ridge: AUROC, 0.74; range, 0.73-0.74; harmonized: AUROC, 0.68; range, 0.50-0.73) and US (individualized ridge: AUROC, 0.71; range, 0.70-0.71; harmonized: AUROC, 0.66; range, 0.66-0.66) data sets. External model performance across countries was poor overall. MLA-based models yield a fair discriminatory potential when used within individual databases. However, the external validity of these models is poor when applied across countries. Standardization of registry-based variables could facilitate the added value of MLA-based models in informing decision making in future LTs.

Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada

BACKGROUND & AIMS

Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada.

METHODS

This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling.

RESULTS

A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 - US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 - in 2018 - US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28-1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59-2.02, p = 0.78).

CONCLUSIONS

The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation.

LAY SUMMARY

This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.

Time-varying Comparison of All-cause Mortality After Liver Transplantation Between Recipients With and Without Hepatocellular Carcinoma: A Population-based Cohort Study Using the United Kingdom Liver Transplant Registry

BACKGROUND

Accurately identifying time-varying differences in the hazard of all-cause mortality after liver transplantation (LT) between recipients with and without hepatocellular carcinoma (HCC) may inform patient selection and organ allocation policies as well as post-LT surveillance protocols.

METHODS

A UK population-based study was carried out using 9586 LT recipients. The time-varying association between HCC and post-LT all-cause mortality was estimated using an adjusted flexible parametric model (FPM) and expressed as hazard ratios (HRs). Differences in this association by transplant year were then investigated. Non-cancer-specific mortality was compared between HCC and non-HCC recipients using an adjusted subdistribution hazard model.

RESULTS

The HR comparing HCC recipients with non-HCC recipients was below one immediately after LT (1-mo HR = 0.76; 95% confidence interval [CI], 0.59-0.99; P = 0.044). The HR then increased sharply to a maximum at 1.3 y (HR = 2.07; 95% CI, 1.70-2.52; P < 0.001) before decreasing. The hazard of death was significantly higher in HCC recipients than in non-HCC recipients between 4 mo and 7.4 y post-LT. There were no notable differences in the association between HCC and the post-LT hazard of death by transplant year. The estimated non-cancer-specific subdistribution HR for HCC was 0.93 (95% CI, 0.80-1.09; P = 0.390) and not found to vary over time.

CONCLUSIONS

FPMs can provide a more precise comparison of post-LT hazards of mortality between HCC and non-HCC patients. The results provide further evidence that some HCC patients have extra-hepatic spread at the time of LT, which has implications for optimal post-LT surveillance protocols.

Trends in liver transplantation for autoimmune liver diseases: a Canadian study

Background:

To our knowledge, no analysis of data from liver transplantation registries exists in Canada. We aimed to describe temporal trends in the number of liver transplantation procedures, patient characteristics and posttransplantation outcomes for autoimmune liver diseases (AILDs) in Canada.

Methods:

We used administrative data from the Canadian Organ Replacement Register, which contains liver transplantation information from 6 centres in Canada. This study included transplantation information from 5 of the centres, as liver transplantation procedures in children were not included. We included adult (age ≥ 18 yr) patients with a diagnosis of primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH) or overlap syndrome (PBC–AIH or PSC–AIH) who received a liver transplant from 2000 to 2018.

Results:

Of 5722 primary liver transplantation procedures performed over the study period, 1070 (18.7%) were for an AILD: 489 (45.7%) for PSC, 341 (31.9%) for PBC, 220 (20.6%) for AIH and 20 (1.9%) for overlap syndrome. There was a significant increase in the absolute number of procedures for PSC, with a yearly increase of 0.6 (95% confidence interval 0.1 to 1.2), whereas the absolute number of procedures for PBC and AIH remained stable. The proportion of transplantation procedures decreased for PBC and AIH but remained stable for PSC. Recipient age at transplantation increased over time for males with PBC (median 53 yr in 2000–2005 to 57 yr in 2012–2018, p = 0.03); whereas the median age among patients with AIH decreased, from 53 years in 2000–2005 to 44 years in 2006–2011 (p = 0.03). The Model for Endstage Liver Disease score at the time of transplantation increased over time for all AILDs, particularly AIH (median 16 in 2000–2005 v. 24 in 2012–2018, p < 0.001). There was a trend toward improved survival in the PBC group, with a 5-year survival rate of 81% in 2000–2005 and 90% in 2012–2018 (p = 0.06).

Conclusion:

Between 2000 and 2018, the absolute number of liver transplantation procedures in Canada increased for PSC but remained stable for PBC and AIH; proportionally, PBC and AIH decreased as indications for transplantation. Posttransplantation survival improved only for the PBC group. An improved understanding of trends and outcomes on a national scale among patients with AILD undergoing liver transplantation can identify disparities and areas for potential health care improvement.

Quantum gravity at low energies

I provide a conceptually-focused presentation of 'low-energy quantum gravity' (LEQG), the effective quantum field theory obtained from general relativity and which provides a well-defined theory of quantum gravity at energies well below the Planck scale. I emphasize the extent to which some such theory is required by the abundant observational evidence in astrophysics and cosmology for situations which require a simultaneous treatment of quantum-mechanical and gravitational effects, contra the often-heard claim that all observed phenomena can be accounted for either by classical gravity or by non-gravitational quantum mechanics, and I give a detailed account of the way in which a treatment of the theory as fluctuations on a classical background emerges as an approximation to the underlying theory rather than being put in by hand. I discuss the search for a Planck-scale quantum-gravity theory from the perspective of LEQG and give an introduction to the Cosmological Constant problem as it arises within LEQG.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Survival After Liver Transplantation: An International Comparison Between the United States and the United Kingdom in the Years 2008-2016

BACKGROUND

Compared with the United States, risk-adjusted mortality in the United Kingdom has historically been worse in the first 90 d following liver transplantation (LT) and better thereafter. In the last decade, there has been considerable change in the practice of LT internationally, but no contemporary large-scale international comparison of posttransplant outcomes has been conducted. This study aimed to determine disease-specific short- and long-term mortality of LT recipients in the United States and the United Kingdom.

METHODS

This retrospective international multicenter cohort study analyzed adult (≥18 y) first-time LT recipients between January 2, 2008, and December 31, 2016, using the Organ Procurement and Transplantation Network/United Network for Organ Sharing and the UK Transplant Registry databases. Time-dependent Cox regression estimated hazard ratios (HRs) comparing disease-specific risk-adjusted mortality in the first 90 d post-LT, between 90 d and 1 y, and between 1 and 5 y.

RESULTS

Forty-two thousand eight hundred seventy-four US and 4950 UK LT recipients were included. The main LT indications in the United States and the United Kingdom were hepatocellular carcinoma (25.4% and 24.9%, respectively) and alcohol-related liver disease (20.3% and 27.1%, respectively). There were no differences in mortality during the first 90 d post-LT (reference: United States; HR, 0.96; 95% confidence interval [CI], 0.82-1.12). However, between 90 d and 1 y (HR, 0.71; 95% CI, 0.59-0.85) and 1 and 5 y (HR, 0.71; 95% CI, 0.63-0.81]) the United Kingdom had lower mortality. The mortality differences between 1 and 5 y were most marked in hepatocellular carcinoma (HR, 0.71; 95% CI, 0.58-0.88) and alcohol-related liver disease patients (HR, 0.64; 95% CI, 0.45-0.89).

CONCLUSIONS

Risk-adjusted mortality in the United States and the United Kingdom was similar in the first 90 d post-LT but better in the United Kingdom thereafter. International comparisons of LT may highlight differences in healthcare delivery and help benchmarking by identifying modifiable factors that can facilitate improved global outcomes in LT.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

Improving pharmacy students' empathy and attitudes regarding opioid overdose and substance use disorder in a skills-based learning environment

INTRODUCTION

Using a skills-based learning environment as a launch pad for developing empathy for patients with substance use disorder or at high risk for opioid overdose allows for learning continuity and early intervention. Empathy for this patient population may reduce bias and stigma associated with negative health outcomes. Previous studies have assessed empathy in pharmacy students, but not in the context of substance use disorder and opioid overdose harm reduction among first professional year pharmacy students in skills-based education. This cohort study aimed to measure the change in empathy and opioid overdose-related attitudes before and after a two-part skills-based learning activity that focused on drug diversion and opioid overdose treatment.

METHODS

First professional year pharmacy students were given a pre- and post-survey consisting of empathy and attitudes sections. The Kiersma-Chen Empathy Scale (KCES) and the Opioid Overdose Attitudes Scale (OOAS) were used. The intervention was a skills-based learning activity with two segments, one that focused on naloxone counseling and the other focused on drug diversion.

RESULTS

The aggregate mean change in KCES and OOAS scores of the cohort increased by 1.837 (P = .014) and 2.349 (P = .008), respectively. Of note, students with lower baseline empathy and attitudes scores showed more improvement in both KCES and OOAS scores.

CONCLUSIONS

Students showed improvement in empathy and attitudes regarding opioid overdose and substance use disorder. A larger magnitude of improvement was noted with lower baseline scores.

Epigenetic mechanisms in metal carcinogenesis

Many metals exhibit genotoxic and/or carcinogenic effects. These toxic metals can be found ubiquitously - in drinking water, food, air, general use products, in everyday and occupational settings. Exposure to such carcinogenic metals can result in serious health disorders, including cancer. Arsenic, cadmium, chromium, nickel, and their compounds have already been recognized as carcinogens by the International Agency for Research on Cancer. This review summarizes a wide range of epigenetic mechanisms contributing to carcinogenesis induced by these metals, primarily including, but not limited to, DNA methylation, miRNA regulation, and histone posttranslational modifications. The mechanisms are described and discussed both from a metal-centric and a mechanism-centric standpoint. The review takes a broad perspective, putting the mechanisms in the context of real-life exposure, and aims to assist in guiding future research, particularly with respect to the assessment and control of exposure to carcinogenic metals and novel therapy development.

Isolated systems and their symmetries, part I: General framework and particle-mechanics examples

Physical theories, for the most part, should be understood as modelling isolated subsystems of a larger universe; doing so, among other benefits, greatly clarifies the interpretation of the dynamical symmetries of those theories. I provide a detailed framework for analysing the subsystem structure of physical theories and applying it to the interpretation of their symmetries: the core concept is subsystem recursivity, whereby interpretative conclusions about a sector of a theory can be deduced from considering subsystems of other models of the same theory. I illustrate the framework by extensive examples from nonrelativistic particle mechanics, and in particular from Newtonian theories of gravity. A sequel to the paper will apply the framework to the local and global symmetries of classical field theory.

Isolated systems and their symmetries, part II: Local and global symmetries of field theories

Physical theories, for the most part, should be understood as modelling isolated subsystems of a larger universe; doing so, among other benefits, greatly clarifies the interpretation of the dynamical symmetries of those theories. Building on a general framework for the symmetries of isolated systems developed in the prequel to this paper, I apply that framework to field theory. The resultant analysis provides a general basis for interpreting the physical significance of symmetries according to their topological and asymptotic features: global symmetries in general, and local symmetries insofar as they preserve boundary conditions and are asymptotically nonvanishing and/or topologically nontrivial, can be understood as physical transformations of an isolated system against the assumed background of other systems. Other symmetries in general must be understood as mere redescription, though in certain circumstances even non-boundary-preserving local symmetries can be afforded physical significance. The analysis largely reproduces - and so can be seen as a theoretical justification for - general practice in contemporary physics.

National time trends in mortality and graft survival following liver transplantation from circulatory death or brainstem death donors

BACKGROUND

Despite high waiting list mortality rates, concern still exists on the appropriateness of using livers donated after circulatory death (DCD). We compared mortality and graft loss in recipients of livers donated after circulatory or brainstem death (DBD) across two successive time periods.

METHODS

Observational multinational data from the United Kingdom and Ireland were partitioned into two time periods (2008-2011 and 2012-2016). Cox regression methods were used to estimate hazard ratios (HRs) comparing the impact of periods on post-transplant mortality and graft failure.

RESULTS

A total of 1176 DCD recipients and 3749 DBD recipients were included. Three-year patient mortality rates decreased markedly from 19.6 per cent in time period 1 to 10.4 per cent in time period 2 (adjusted HR 0.43, 95 per cent c.i. 0.30 to 0.62; P < 0.001) for DCD recipients but only decreased from 12.8 to 11.3 per cent (adjusted HR 0.96, 95 per cent c.i. 0.78 to 1.19; P = 0.732) in DBD recipients (P for interaction = 0.001). No time period-specific improvements in 3-year graft failure were observed for DCD (adjusted HR 0.80, 95% c.i. 0.61 to 1.05; P = 0.116) or DBD recipients (adjusted HR 0.95, 95% c.i. 0.79 to 1.14; P = 0.607). A slight increase in retransplantation rates occurred between time period 1 and 2 in those who received a DCD liver (from 7.3 to 11.8 per cent; P = 0.042), but there was no change in those receiving a DBD liver (from 4.9 to 4.5 per cent; P = 0.365). In time period 2, no difference in mortality rates between those receiving a DCD liver and those receiving a DBD liver was observed (adjusted HR 0.78, 95% c.i. 0.56 to 1.09; P = 0.142).

CONCLUSION

Mortality rates more than halved in recipients of a DCD liver over a decade and eventually compared similarly to mortality rates in recipients of a DBD liver. Regions with high waiting list mortality may mitigate this by use of DCD livers.

General Anxiety, Academic Distress, and Family Distress Among Doctor of Pharmacy Students

Objective. To examine the prevalence of general anxiety among Doctor of Pharmacy (PharmD) students and the role of academic distress and family distress in causing general anxiety.Methods. A cross-sectional study was conducted among first, second, and third year PharmD students. All students received an online survey consisting of the Counseling Center Assessment of Psychological Symptoms-62 (CCAPS-62) questionnaire and sample characteristics. Variables from CCAPS-62 considered in this study included academic distress and family distress measured on a three-level scale: no, low, and high clinical level. Data on gender, race, work status, and physical activity were also collected. Descriptive and multinomial logistic regression were conducted to identify factors associated with general anxiety.Results. Of the 238 students who took the online survey (63% response rate), the majority were female (67%) and Asian (49%). Overall, 69 first year, 75 second year, and 94 third year students participated. The prevalence of general anxiety was 50%, with equal distribution (25% each) among high-clinical and low-clinical general anxiety groups. High academic distress and high family distress were associated with a greater probability of a student having high general anxiety.Conclusion. General anxiety was quite prevalent among pharmacy students. Identification and implementation of strategies to lower general anxiety as well as academic distress is of great importance. Also, understanding and enhancing the role of family members in students' lives is essential. College administrators can provide support for students as well as for family members to make improvements in these areas.

Inferior outcomes in young adults undergoing liver transplantation - a UK and Ireland cohort study

Graft loss incidence is reported to be inversely related to recipient age. We used a national cohort of liver transplant (LT) recipients from the United Kingdom and Ireland to compare the age-dependent risk of graft failure in different post-transplantation time-periods ('epochs'). A cohort of first-time LT recipients (1995-2016) were identified (11 006). Cox regression was used to estimate hazard ratios (HR) comparing graft loss between age-groups (18-29, 30-39, 40-49, 50-59 and 60-76 years) and graft loss in different post-transplant epochs: 0-90 days, 90 days-2 years and 2-10 years. The risk of graft failure was highest in those transplanted between age 18 and 29 (adjusted HR 1.25, 95% CI: 1.00-1.57, P = 0.04) and in those aged 30-39 (adjusted HR 1.31, 95% CI: 1.11-1.55, P = 0.02). Graft failure in those under the age of 40 was similar in the first 90 days but worse 2-10 years' post-LT (18-29 years HR 1.36, 95% CI: 0.96-1.93, P < 0.001). Graft failure because of chronic rejection (CR) was more common in recipients aged 18-29 (P < 0.001). Adults transplanted between age 18 and 39 are at risk of late graft loss. CR is a concern for young adults (18-29 years). Our data highlights the need for specialist young adult services within adult healthcare.

Meta-analyses of the efficacy of pharmacotherapies and sublingual allergy immunotherapy tablets for allergic rhinitis in adults and children

BACKGROUND

Treatment options for seasonal and perennial allergic rhinitis (SAR/PAR) include pharmacotherapies and allergy immunotherapy. These meta-analyses evaluated the efficacy of pharmacotherapies and sublingual immunotherapy tablets (SLIT-tablets) versus placebo on nasal symptoms associated with SAR and PAR.

METHODS

Randomized, double-blind, placebo-controlled trials were identified from systematic PubMED/EMBASE searches through 7/18/2019 (PROSPERO protocol CRD42018105632). The primary outcome was mean numerical difference in total nasal symptom score (TNSS; 0-12) between active treatment and placebo at the end of the assessment period. Random-effects meta-analyses estimated the mean difference for each medication group weighted by the inverse of the trial variance. Publication bias assessments and sensitivity analyses were conducted.

RESULTS

Rescue symptom-relieving pharmacotherapy was prohibited in most pharmacotherapy trials but was allowed in all SLIT-tablet trials. For adult/adolescent SAR, the mean numerical difference (95% CI) in TNSS versus placebo was: intranasal corticosteroids (INCS)=1.38 (1.18, 1.58; 39 trials); combination intranasal antihistamine/INCS=1.34 (1.15, 1.54; 4 trials); intranasal antihistamines=0.72 (0.56, 0.89; 13 trials); oral antihistamine=0.62 (0.35, 0.90; 18 trials); SLIT-tablets=0.57 (0.41, 0.73; 4 trials); and montelukast=0.48 (0.36, 0.60; 10 trials). For adult/adolescent PAR, mean difference in TNSS versus placebo (95% CI) was: INCS=0.82 (0.66, 0.97; 14 trials); SLIT-tablets=0.65 (0.42, 0.88; 3 trials); and oral antihistamine=0.27 (0.11, 0.42; 3 trials). The number of eligible trials limited meta-analyses for pediatric SAR/PAR.

CONCLUSIONS

All treatments significantly improved nasal symptoms versus placebo. SLIT-tablets provided improvement in TNSS despite access to rescue symptom-relieving pharmacotherapy. Extensive trial heterogeneity and strong indications of publication bias preclude the comparison of treatment effects among treatment classes.

The Impact of Performance Status on Length of Hospital Stay and Clinical Complications Following Liver Transplantation

BACKGROUND

Impaired pretransplant performance status (PS) is associated with chronic liver disease (CLD). We studied its impact on hospital length of stay (LOS), complications, and readmissions in the first year after liver transplantation.

METHODS

The Standard National Liver Transplant Registry was linked to a hospital administrative dataset, and all first-time liver transplant recipients with CLD aged ≥18 years in England were identified. A modified 3-level Eastern Cooperative Oncology Group score was used to assess PS. Linear- and logistic-fixed effect regression models were used to estimate the effect of specific posttransplant complications and readmissions in the first year after transplantation.

RESULTS

Six thousand nine hundred sixty-eight recipients were included. Impaired PS was associated with an increased LOS in the initial posttransplant period (comparing ECOG 1-3, adjusted difference 7.2 d; 95% confidence [CI], 4.8-9.6; P < 0.001) and in time spent on the ITU (adjusted difference 1.2 d; 95% CI, 0.4-2.0; P < 0.001). There was no significant association between ECOG status and total LOS of later admissions (adjusted difference, 2.5 d; 95% CI, -0.4-5.5; P = 0.23). Those with a poorer ECOG status had an increased incidence of renal failure (odds ratio, 1.5; 95% CI, 1.1-2.0; P = 0.004) and infection (odds ratio, 1.2; 95% CI, 1.1-1.4; P = 0.02) but not an increased incidence of readmission (odds ratio, 1.2; 95% CI, 0.9-1.5; P = 0.13).

CONCLUSIONS

In liver transplant recipients with CLD, impaired pretransplant PS is associated with prolonged LOS in the immediate posttransplant period but not with LOS of later admissions in the first year after transplantation. Impaired PS increased the risk of renal failure and infection.

Surviving an Extensive Burn Injury Using Advanced Skin Replacement Technologies

There have been significant improvements in the technology available for treating extensive burns in the past decade. This case presents two unique, skin replacement technologies that were used to treat an 86% surface area flame burn in a pediatric patient. A temporary dermal replacement, known as "Novosorb™ Biodegradable Temporizing Matrix" was first used to stabilize the burn injury and remained in place for approximately three months. Given the large burn size and lack of available donor skin for grafting, a permanent skin replacement product known as "Self-Assembled Skin Substitute (SASS)" was then utilized to cover the burns. SASS is a novel technology that was developed to replace skin as an autologous skin graft and is currently available in Canada through a clinical trial for major burns. Ultimately, the concurrent use of these two technologies allowed for the unprecedented survival of a child following an extensive and life-threatening burn injury.

A comparison of methods for measuring spatial access to health care

OBJECTIVE

To compare measures of spatial access to care commonly used by policy makers and researchers with the more comprehensive enhanced two-step floating catchment area (E2SFCA) method.

STUDY SETTING

Fourteen southwestern Pennsylvania counties.

STUDY DESIGN

We estimated spatial access to buprenorphine-waivered prescribers using three commonly used measures-Euclidean travel distance to the closest prescriber, travel time to the closest provider, and provider-to-population ratios-and the E2SFCA. Unlike other measures, the E2SFCA captures provider capacity, potential patient volume, and travel time to prescribers.

DATA COLLECTION/EXTRACTION METHODS

We measured provider capacity as the number of buprenorphine prescribers listed at a given address in the Drug Enforcement Agency's 2020 Controlled Substances Act Registrants Database, and we measured potential patient volume as the number of nonelderly adults in a given census tract as reported by the 2018 American Community Survey. We estimated travel times between potential patients and prescribers with Bing Maps and Mapbox application programming interfaces. We then calculated each spatial access measure using the R programming language. We used each measure of spatial access to identify census tracts in the lowest quintile of spatial access to prescribers.

PRINCIPAL FINDINGS

The Euclidean distance, travel time, and provider-to-population ratio measures identified 48.3%, 47.2%, and 69.9% of the census tracts that the E2SFCA measure identified as being in the lowest quintile of spatial access to care, meaning that these measures misclassify 30%-52% of study area census tracts as having sufficient spatial access to buprenorphine prescribers.

CONCLUSIONS

Measures of spatial access commonly used by policy makers do not sufficiently accurately identify geographic areas with relatively low access to prescribers of buprenorphine. Using the E2SFCA in addition to the commonly used measures would allow policy makers to precisely target interventions to increase spatial access to opioid use disorder treatment and other types of health care services.

Trends in indications and outcomes of liver transplantation in Canada: A multicenter retrospective study

The liver transplantation (LT) landscape is continuously evolving. We sought to evaluate trends in indications for LT in Canada and the impact of primary liver disease on post-LT outcomes using a national transplant registry. Adult patients who underwent a primary LT between 2000 and 2018 were retrospectively identified in the Canadian Organ Replacement Registry. Outcomes included post-LT patient and graft survival. A total of 5,722 LTs were identified. The number of LT per year increased from 251 in 2000 to 349 in 2018. The proportion of patients transplanted for HCV decreased from 31.5% in 2000 to 3.4% in 2018. In contrast, the percentage of transplants for HCC increased from 2.3% in 2000 to 32.4% in 2018, and those performed for NASH increased from 0.4% in 2005 to 12.6% in 2018. Year of transplant (per 1 year) was protective for both patient (HR:0.96,95%CI:0.94-0.97; P < 0.001) and graft survival (HR:0.97, 95%CI: 0.96-0.99; P = 0.001). Post-LT outcomes have improved over time in this nationwide analysis spanning 18 years. Moreover, trends in the indications for LT have changed, with HCC becoming the leading etiology. The decrease in the proportion of HCV patients and increase in those with NASH has implications on the evolving management of LT patients.

Primary liver cancer in the UK: Incidence, incidence-based mortality, and survival by subtype, sex, and nation

BACKGROUND & AIMS

The incidence of primary liver cancer (PLC) is increasing in Western Europe. To understand trends over time and the current burden in the UK, a detailed analysis of the epidemiology of PLC and its subtypes was conducted.

METHODS

Data on PLCs diagnosed during 1997-2017 were obtained from population-based, nationwide registries in the UK. European age-standardised incidence (ASR) and incidence-based mortality rates (ASMR) per 100,000 person-years were calculated overall and by sex and UK-nation. Annual percentage change in rates was estimated using Joinpoint regression. One-, 2-, and 5-year age-standardised net survival was estimated.

RESULTS

A total of 82,024 PLCs were diagnosed. Both hepatocellular carcinoma (HCC) incidence and mortality rates trebled (ASR 1.8-5.5 per 100,000, ASMR 1.3-4.0). The rate of increase appeared to plateau around 2014/2015. Scottish men consistently had the highest HCC incidence rates. PLC survival increased, driven by a substantial increase in the proportion that are HCC (as prognosis is better than other PLCs) and in HCC survival (change in 1-year survival 24-47%). Intrahepatic cholangiocarcinoma was the most common PLC in women and 1-year survival improved from 22.6% to 30.5%.

CONCLUSIONS

PLC incidence has been increasing rapidly but, as most risk factors are modifiable, it is largely a preventable cancer. This rate of increase has slowed in recent years, possibly attributable to effective treatment for hepatitis C. As other risk factors such as obesity and diabetes remain prevalent in the UK, it is unlikely the considerable burden of this disease will abate. While improvements in survival have been made, over half of patients are not alive after 1 year, therefore further progress in prevention, early detection, and treatment innovation are needed.

LAY SUMMARY

Many more people are getting liver cancer, particularly the subtype hepatocellular carcinoma, than 20 years ago. Men in Scotland are most likely to get liver cancer and to die from it. Survival after liver cancer diagnosis is getting longer but still less than half are alive after 1 year.

Genome-wide surveillance of transcription errors in response to genotoxic stress

Mutagenic compounds are a potent source of human disease. By inducing genetic instability, they can accelerate the evolution of human cancers or lead to the development of genetically inherited diseases. Here, we show that in addition to genetic mutations, mutagens are also a powerful source of transcription errors. These errors arise in dividing and nondividing cells alike, affect every class of transcripts inside cells, and, in certain cases, greatly exceed the number of mutations that arise in the genome. In addition, we reveal the kinetics of transcription errors in response to mutagen exposure and find that DNA repair is required to mitigate transcriptional mutagenesis after exposure. Together, these observations have far-reaching consequences for our understanding of mutagenesis in human aging and disease, and suggest that the impact of DNA damage on human physiology has been greatly underestimated.

Treatment of allergic rhinitis during and outside the pollen season using mobile technology. A MASK study

Background

The analysis of mobile health (mHealth) data has generated innovative insights into improving allergic rhinitis control, but additive information is needed. A cross-sectional real-world observational study was undertaken in 17 European countries during and outside the estimated pollen season. The aim was to collect novel information including the phenotypic characteristics of the users.

Methods

The Allergy Diary–MASK-air–mobile phone app, freely available via Google Play and App, was used to collect the data of daily visual analogue scales (VASs) for overall allergic symptoms and medication use. Fluticasone Furoate (FF), Mometasone Furoate (MF), Azelastine Fluticasone Proprionate combination (MPAzeFlu) and eight oral H1-antihistamines were studied. Phenotypic characteristics were recorded at entry. The ARIA severity score was derived from entry data. This was an a priori planned analysis.

Results

9037 users filled in 70,286 days of VAS in 2016, 2017 and 2018. The ARIA severity score was lower outside than during the pollen season. Severity was similar for all treatment groups during the pollen season, and lower in the MPAzeFlu group outside the pollen season. Days with MPAzeFlu had lower VAS levels and a higher frequency of monotherapy than the other treatments during the season. Outside the season, days with MPAzeFlu also had a higher frequency of monotherapy. The number of reported days was significantly higher with MPAzeFlu during and outside the season than with MF, FF or oral H1-antihistamines.

Conclusions

This study shows that the overall efficacy of treatments is similar during and outside the pollen season and indicates that medications are similarly effective during the year.

Dissecting the Financial Relationship Between Industry and Academic Neurosurgery

BACKGROUND

Established by the Centers for Medicare and Medicaid Services (CMS), the Open Payments Database (OPD) has reported industry payments to physicians since August 2013.

OBJECTIVE

To evaluate the frequency, type, and value of payments received by academic neurosurgeons in the United States over a 5-yr period (2014-2018).

METHODS

The OPD was queried for attending neurosurgeons from all neurosurgical training programs in the United States (n = 116). Information from the OPD was analyzed for the entire cohort as well as for comparative subgroup analyses, such as career stage, subspecialty, and geographic location.

RESULTS

Of all identified neurosurgeons, 1509 (95.0%) received some payment from industry between 2014 and 2018 for a total of 106 171 payments totaling $266 407 458.33. A bimodal distribution was observed for payment number and total value: 0 to 9 (n = 438) vs > 50 (n = 563) and 0-$1000 (n = 418) vs >$10 000 (n = 653), respectively. Royalty/License was the most common type of payment overall (59.6%; $158 723 550.57). The median number (40) and value ($8958.95) of payments were highest for mid-career surgeons. The South-Central region received the most money ($117 970 036.39) while New England received the greatest number of payments (29 423). Spine surgeons had the greatest median number (60) and dollar value ($20 551.27) of payments, while pediatric neurosurgeons received the least (8; $1108.29). Male neurosurgeons received a greater number (31) and value ($6395.80) of payments than their female counterparts (11, $1643.72).

CONCLUSION

From 2014 to 2018, payments to academic neurosurgeons have increased in number and value. Dollars received were dependent on geography, career stage, subspecialty and gender.

Assessing the Time-Dependent Impact of Performance Status on Outcomes After Liver Transplantation

BACKGROUND AND AIMS

Identifying how the prognostic impact of performance status (PS) differs according to indication, era, and time period ("epoch") after liver transplantation (LT) could have implications for selection and treatment of patients on the waitlist. We used national data from the United Kingdom and Ireland to assess impact of PS on mortality separately for HCC and non-HCC recipients.

APPROACH AND RESULTS

We assessed pre-LT PS using the 5-point modified Eastern Cooperative Oncology Group scale and used Cox regression methods to estimate hazard ratios (HRs) that compared posttransplantation mortality in different epochs of follow-up (0-90 days and 90 days to 1 year) and in different eras of transplantation (1995-2005 and 2006-2016). 2107 HCC and 10,693 non-HCC patients were included. One-year survival decreased with worsening PS in non-HCC recipients where 1-year survival was 91.9% (95% confidence interval [CI], 88.3-94.4) in those able to carry out normal activity (PS1) compared to 78.7% (95% CI, 76.7-80.5) in those completely reliant on care (PS5). For HCC patients, these estimates were 89.9% (95% CI, 85.4-93.2) and 83.1% (95% CI, 61.0-93.3), respectively. Reduction in survival in non-HCC patients with poorer PS was in the first 90 days after transplant, with no major effect observed between 90 days and 1 year. Adjustment for donor and recipient characteristics did not change the findings. Comparing era, post-LT mortality improved for HCC (adjusted HR, 0.55; 95% CI, 0.40-0.74) and non-HCC recipients (0.48; 95% CI, 0.42-0.55), but this did not differ according to PS score (P = 0.39 and 0.61, respectively).

CONCLUSIONS

Impact on mortality of the recipient's pretransplant PS is principally limited to the first 3 months after LT. Over time, mortality has improved for both HCC and non-HCC recipients and across the full range of PS.

Emerging Links between Cadmium Exposure and Insulin Resistance: Human, Animal, and Cell Study Data

Recent research has helped clarify the role of cadmium (Cd) in various pathological states. We have demonstrated Cd involvement in pancreatic cancer, as well as the bioaccumulation of Cd in the pancreas. Bioaccumulation and increased toxicity suggest that Cd may also be involved in other pancreas-mediated diseases, like diabetes. Cd falls into the category of "hyperglycemic" metals, i.e., metals that increase blood glucose levels, which could be due to increased gluconeogenesis, damage to β-cells leading to reduced insulin production, or insulin resistance at target tissue resulting in a lack of glucose uptake. This review addresses the current evidence for the role of Cd, leading to insulin resistance from human, animal, and in vitro studies. Available data have shown that Cd may affect normal insulin function through multiple pathways. There is evidence that Cd exposure results in the perturbation of the enzymes and modulatory proteins involved in insulin signal transduction at the target tissue and mutations of the insulin receptor. Cd, through well-described mechanisms of oxidative stress, inflammation, and mitochondrial damage, may also alter insulin production in β-cells. More work is necessary to elucidate the mechanisms associated with Cd-mediated insulin resistance.

Outcomes of Patients Suspended From the National Kidney Transplant Waiting List in the United Kingdom Between 2000 and 2010

BACKGROUND

In the United Kingdom, 1 in 3 patients on the National Kidney Transplant Waiting List (NKTWL) is suspended from the list at least once during their wait. The mortality of this large cohort of patients remains underreported and poorly described.

METHODS

We linked patient records from the UK transplant registry to mortality data from the Office of National Statistics and evaluated the impact of a clinically induced suspension event by estimating hazard ratios (HRs) that compared mortality and graft survival between those who had experienced a suspension event and those who had not.

RESULTS

Between January 1, 2000, and December 31, 2010, 16.7% (2221/13 322) of all patients registered on the NKTWL were suspended. Forty-eight percent (588/1225) of those who were suspended and who were never transplanted died, most often from cardiothoracic causes. A suspension event was associated with increased mortality from the time of listing (adjusted HR [aHR], 1.79; 1.64-1.95) and from the time of transplantation (aHR, 1.20; 1.06-1.37; P = 0.005). Graft survival was also poorer in those who had been suspended (aHR, 1.13; 1.01-1.28; P = 0.04).

CONCLUSIONS

Patients suspended on the NKTWL have a significantly higher rate of mortality both on the waiting list and following transplantation. Earlier prioritization of patients at risk of experiencing a suspension event may improve their outcomes.

Complex Feed-Forward and Feedback Mechanisms Underlie the Relationship Between Traumatic Brain Injury and the Gut-Microbiota-Brain Axis

Traumatic brain injury (TBI) contributes to nearly 1 in 3 injury-related deaths in the United States and accounts for a substantial public health burden and cost. The current literature reports that physiologic responses in the gastrointestinal system after TBI include, but are not limited to, epithelial barrier dysfunction, microbiota changes, and immunologic transformations. Recent evidence suggests gut alterations after TBI modify the homeostasis of the bidirectional gut-microbiota-brain axis, resulting in altered immune responses in the periphery and the brain. This cascade possibly contributes to impaired central nervous system (CNS) healing. Although attention to the gut-brain-microbiota axis has been increasing in the literature, the precise mechanisms underlying the changes observed after TBI remain unclear. The purpose of this review are to describe our current understanding regarding alterations to the gut-microbiota-brain axis after TBI, highlight the pathophysiologic changes involved, and evaluate how these variations modify healing in the CNS or even contribute to secondary injury. We also discuss current investigations into potential medical therapies directed at the gut-microbiota-brain axis, which might offer improved outcomes after TBI.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Shunt Failure-The First 30 Days

BACKGROUND

Incontrovertible predictors of shunt malfunction remain elusive.

OBJECTIVE

To determine predictors of shunt failure within 30 d of index surgery.

METHODS

This was a single-center retrospective cohort study from January 2010 through November 2016. Using a ventricular shunt surgery research database, clinical and procedural variables were procured. An "index surgery" was defined as implantation of a new shunt or revision or augmentation of an existing shunt system. The primary outcome was shunt failure of any kind within the first 30 days of index surgery. Bivariate models were created, followed by a final multivariable logistic regression model using a backward-forward selection procedure.

RESULTS

Our dataset contained 655 unique patients with a total of 1206 operations. The median age for the cohort at the time of first shunt surgery was 4.6 yr (range, 0-28; first and third quartile, .37 and 11.8, respectively). The 30-day failure rates were 12.4% when analyzing the first-index operation only (81/655), and 15.7% when analyzing all-index operations (189/1206). Small or slit ventricles at the time of index surgery and prior ventricular shunt operations were found to be significant covariates in both the "first-index" (P < .01 and P = .05, respectively) and "all-index" (P = .02 and P < .01, respectively) multivariable models. Intraventricular hemorrhage at the time of index surgery was an additional predictor in the all-index model (P = .01).

CONCLUSION

This study demonstrates that only 3 variables are predictive of 30-day shunt failure when following established variable selection procedures, 2 of which are potentially under direct control of the surgeon.

Treatment-related calvarial lesions in pediatric brain tumor survivors

BACKGROUND

Despite improved survival, many pediatric brain tumor survivors receiving radiation therapy (RT) experience late effects.

PROCEDURE

To study calvarial lesions in this population, we retrospectively reviewed records of patients undergoing neurosurgical evaluation for calvarial bone lesions detected in posttreatment follow-up imaging at St. Jude Children's Research Hospital. Primary tumor diagnosis, treatment, imaging, surgical intervention, and histopathology from patients with radiographic evidence of lesions followed for ≥2 years post-RT were studied.

RESULTS

For 17 patients with 18 index lesions, median time to lesion manifestation was 2.34 years. Medulloblastoma patients developed lesions at a shorter interval from RT than ependymoma patients (P = .05). Twelve of 14 lesions requiring surgery were benign fibro-osseous or sclerotic. Two malignant lesions distinct from the primary tumor had genetic predisposition to malignancy.

CONCLUSION

Most calvarial lesions arising post-RT are benign and fibro-osseous. Serial imaging is recommended, and high index of suspicion for malignant lesions is warranted for patients genetically predisposed to cancer.

OP0045 DELINEATION OF A PROINFLAMMATORY CYTOKINE PROFILE TARGETED BY JAK1/2 INHIBITION USING BARICITINIB IN A PHASE 2 SLE TRIAL

Background:

Given the unmet clinical needs in systemic lupus erythematosus (SLE), including poor disease control and drug toxicities, new therapies are needed. In a phase 2, randomized, placebo-controlled, double-blind study (JAHH), once-daily baricitinib (bari) resulted in significant clinical improvement in patients (pts) with active SLE versus PBO. Bari inhibits JAK1 and JAK2 signalling, and in turn may affect STAT1, STAT2, STAT4 pathways. Therefore, bari has the potential to simultaneously impact several pro-inflammatory immune cytokines implicated in the pathogenesis of SLE, including IFN-α, IFN-γ, IL-6, IL-12, and IL-23.

Objectives:

The objectives of the current study were: 1) to examine baseline serum cytokines in the JAHH phase 2 clinical trial for correlations with clinical or immunologic assessments; 2) to determine if changes in serum cytokine levels were associated with bari treatment.

Methods:

Pts enrolled in the JAHH phase 2 trial received daily treatment with PBO, bari 2 mg, or bari 4 mg through week 24. Serum samples were collected at baseline (week [wk] 0), wk 12, and wk 24) from SLE pts (n=270) and 50 sex- and age-matched controls. Samples were analyzed for: IL-2, IL-3, IL-5, IL-6, IL-10, IL-17A, IL-21, IL-12/23p40, IL-12p70, GM-CSF, IFN-α and IFN-γ using ultrasensitive quantitative assays. IFN gene signature, autoantibodies, C3 and C4 were measured as previously described [1].

Results:

At wk 0, serum IL-17A, IL-12/23p40, IL-6, IFN-γ and IFN-α were readily detectable. IL-12/23p40 was detectable in 100% of pts vs. 100% of controls, IFN-γ in 89% of pts vs. 66% of controls, IL-6 in 53% of pts vs. 12% of controls and in IFN-α 41% of pts vs. 2% of controls; detection of serum IL-2, GM-CSF, IL-5, IL-10 and IL-17A was variable (Fig 1). At baseline (wk 0), IL-12/23p40 was positively correlated with SLEDAI and IFN gene signature and negatively correlated with serum C4. IL-6 was positively correlated with joint swelling, joint tenderness, IFN-γ and C3. Serum IFN-α was positively correlated with serum IFN-γ, anti-Sm and anti-RNP, and the IFN gene signature (Fig 2). Treatment with bari 4 mg (Fig 1B) significantly decreased serum IL12/23p40 and IL-6 cytokine levels at wk 12 (p<0.05) but not serum IFN-α or IFN-γ levels (Fig 1B).

Figure 1.

* p = 0.015; ** p = 0.001; Abbreviations: LLOQ, Lower limit of quantification.

Figure 2.

Abbreviations: Anti-dsDNA, Anti-double stranded DNA; Anti-RNP, Anti-ribonucleoprotein; CLASI, Cutaneous lupus erythematosus disease area and severity index; SLEDAI, SLE disease activity index.

Conclusion:

Bari 4 mg treatment was associated with statistically significant decreases of serum IL-12/23p40 and IL-6 at week 12 which continued through week 24. Serum IFN-α or IFN-γ were not reduced with bari treatment. Thus, bari 4 mg simultaneously impacted multiple pro-inflammatory cytokines implicated in the pathogenesis of SLE.

References:

[1]Hoffman RW, et al.Arthritis Rheumatol.2017;69(3):643-654.

Disclosure of Interests:

Thomas Dörner Grant/research support from: Janssen, Novartis, Roche, UCB, Consultant of: Abbvie, Celgene, Eli Lilly, Roche, Janssen, EMD, Speakers bureau: Eli Lilly, Roche, Samsung, Janssen, Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Michelle A Petri Grant/research support from: GSK, Eli Lilly and Company, Consultant of: Eli Lilly and Company, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Daniel Wallace Consultant of: Amgen, Eli Lilly and Company, EMD Merck Serono, and Pfizer, Brenda Crowe Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Ernst Dow Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Richard E Higgs Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Guilherme Rocha Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Robert Benschop Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Maria Silk Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Stephanie de Bono Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Robert Hoffman Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Damiano Fantini Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company

1097 Sleep Disturbances, Sleep Burden, And Depressive Symptoms In US Hispanics/Latinos: Results From The HCHS/SOL Sueño Study

Introduction

While sleep disturbances and depression often co-occur, these associations are understudied among Hispanics/Latinos. We examined the associations of sleep disturbances and sleep burden with depressive symptoms among Hispanic/Latino adults in the United States.

Methods

We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos Sueño Ancillary study (2010-2013). The study enrolled 2072 adults (ages 18-64; 51.5% females) who completed one-week wrist-actigraphy and sleep questionnaires. Sleep burden was operationalized as the total count of sleep disturbances across six domains (duration, efficiency, midpoint, variability, insomnia, sleepiness). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression scale (CESD-10). We used weighted survey linear regressions to evaluate the association of sleep disturbances and sleep burden with elevated depressive symptoms (CESD≥10) in individual models adjusted for age, gender, site, heritage, nativity, education, income, and employment. Sensitivity analyses further adjusted for behavioral health risk factors and apnea-hypopnea index.

Results

An estimated 28.3% had elevated depressive symptoms, 8.0% had short sleep duration (&lt;6 hours of sleep), 10.9% had long sleep duration (&gt;9 hours), 45.2% exhibited a later sleep midpoint (≥4:00AM), 38.4% had high sleep timing variability (upper third tertile for between day sleep midpoint), 15.3% had insomnia (ISI≥10), 17.3% had excessive daytime sleepiness (ESS ≥10), 21.5% had poor sleep efficiency (&lt;85%), and 77.4% had a total sleep burden count of ≥0. Insomnia (ß=0.49,95%CI:.43,.56), later sleep timing (ß=0.10,95%CI:.04,.16), excessive daytime sleepiness (ß=0.19,95%CI:.11,.27), poor sleep efficiency (ß=0.09,95%CI:.02,.17), high variability (ß=0.07, 95%CI:.01,.12), and sleep burden (ß=0.11,95%CI:.09,.13), were each positively associated with elevated depressive symptoms in individual adjusted models and sensitivity analyses. Extreme sleep durations were not associated with elevated depressive symptoms.

Conclusion

Multiple inter-related sleep disturbances, particularly those pertaining to sleep quality and timing, are associated with depression and may be targets for future interventions aimed at improving mood among Hispanics/Latinos.

Support

HL127307, HL098927, HL125748

0551 Longitudinal Measurement Invariance of the Insomnia Severity Index in Veterans with Sleep Apnea

Introduction

The Insomnia Severity Index is a commonly used instrument to assess the presence of insomnia symptoms as well as an outcome measure following an intervention. Longitudinal measurement invariance is a necessary property of an assessment instrument when it is repeated over time. The validity of conclusions regarding change in the construct ‘insomnia severity’ depend on scale equivalence at each measurement timepoint. Assessment of measurement invariance of the ISI in sleep apnea patients has never been performed.

Methods

Veterans with sleep apnea (n=654; AHI=36±28; 93% male; age=52±12; BMI=33±6) completed the ISI on the night of their overnight PSG and again when they picked up their PAP device. Invariance was determined by imposing a series of more restrictive equivalence constraints on a 2-factor model of the ISI. The series of constraints tested for configural, weak, strong and strict invariance. Invariance testing was modeled with exploratory structural equation modeling in Mplus (v. 7.0).

Results

The 2-factor model that emerged from the analysis showed items relating to nighttime symptoms loading on factor 1 and daytime symptoms loading on factor 2. The sleep ‘satisfaction’ item, however, had weak but similar loadings on both factors. The increasingly restrictive constraints imposed on the model revealed no decrement in model fit (RMSEA=.039 to.043; CFI=.987 to .980; TLI=.981-.977; SRMR=.027-.041).

Conclusion

The ISI met strict criteria for longitudinal measurement invariance demonstrating that it is a valid instrument to be used in repeated measures study designs of insomnia in sleep apnea patients. Change over time on the ISI is not due to the changing measurement characteristics of the ISI but to true changes in the ‘insomnia severity’ construct.

Support

None

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America

BACKGROUND

Bibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve.

OBJECTIVE

To calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs.

METHODS

During May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity.

RESULTS

The median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity.

CONCLUSION

This study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.

Liver transplantation outcomes after transarterial chemotherapy for hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) awaiting liver transplantation is widespread, although evidence that it improves outcomes is lacking and there exist concerns about morbidity. The impact of TACE on outcomes after transplantation was evaluated in this study.

Methods

Patients with HCC who had liver transplantation in the UK were identified, and stratified according to whether they received TACE between 2006 and 2016. Cox regression methods were used to estimate hazard ratios (HRs) for death and graft failure after transplantation adjusted for donor and recipient characteristics.

Results

In total, 385 of 968 patients (39·8 per cent) received TACE. Five-year patient survival after transplantation was similar in those who had or had not received TACE: 75·2 (95 per cent c.i. 68·8 to 80·5) and 75·0 (70·5 to 78·8) per cent respectively. After adjustment for donor and recipient characteristics, there were no differences in mortality (HR 0·96, 95 per cent c.i. 0·67 to 1·38; P = 0·821) or graft failure (HR 1·01, 0·73 to 1·40; P = 0·964). The number of TACE treatments (2 or more versus 1: HR 0·97, 0·61 to 1·55; P = 0·903) or the time of death after transplantation (within or after 90 days; P = 0·291) did not alter the outcome. The incidence of hepatic artery thrombosis was low in those who had or had not received TACE (1·3 and 2·4 per cent respectively; P = 0·235).

Conclusion

TACE delivered to patients with HCC before liver transplant did not affect complications, patient death or graft failure after transplantation.