Single vs. multiple fraction non-inferiority trial of stereotactic ablative radiotherapy for the comprehensive treatment of oligo-metastases/progression: SIMPLIFY-SABR-COMET

BACKGROUND

Radiotherapy delivery regimens can vary between a single fraction (SF) and multiple fractions (MF) given daily for up to several weeks depending on the location of the cancer or metastases. With limited evidence comparing fractionation regimens for oligometastases, there is support to explore toxicity levels to nearby organs at risk as a primary outcome while using SF and MF stereotactic ablative radiotherapy (SABR) as well as explore differences in patient-reported quality of life and experience.

METHODS

This study will randomize 598 patients in a 1:1 ratio between the standard arm (MF SABR) and the experimental arm (SF SABR). This trial is designed as two randomized controlled trials within one patient population for resource efficiency. The primary objective of the first randomization is to determine if SF SABR is non-inferior to MF SABR, with respect to healthcare provider (HCP)-reported grade 3-5 adverse events (AEs) that are related to SABR. Primary endpoint is toxicity while secondary endpoints include lesional control rate (LCR), and progression-free survival (PFS). The second randomization (BC Cancer sites only) will allocate participants to either complete quality of life (QoL) questionnaires only; or QoL questionnaires and a symptom-specific survey with symptom-guided HCP intervention. The primary objective of the second randomization is to determine if radiation-related symptom questionnaire-guided HCP intervention results in improved reported QoL as measured by the EuroQoL-5-dimensions-5levels (EQ-5D-5L) instrument. The primary endpoint is patient-reported QoL and secondary endpoints include: persistence/resolution of symptom reporting, QoL, intervention cost effectiveness, resource utilization, and overall survival.

DISCUSSION

This study will compare SF and MF SABR in the treatment of oligometastases and oligoprogression to determine if there is non-inferior toxicity for SF SABR in selected participants with 1-5 oligometastatic lesions. This study will also compare patient-reported QoL between participants who receive radiation-related symptom-guided HCP intervention and those who complete questionnaires alone.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05784428. Date of Registration: 23 March 2023.

Malignant spinal cord compression in the paediatric population-a systematic review, meta-analysis

BACKGROUND

Malignant spinal cord compression (MSCC) has been noted in 3-5% of children with primary tumours. MSCC can be associated with permanent neurological deficits and prompt treatment is necessary. Our aim was to perform a systematic review on MSCC in children < 18 years to help formulate national guidelines.

METHODS

A systematic review of the English language was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search criteria included 'MSCC in children, paediatric and metastases' for papers published between January1999 and December 2022. Isolated case reports/case series with < 10 patients were excluded.

RESULTS

From a total of 17 articles identified, a final 7 were analysed (Level III/IV). Neuroblastoma constituted the most common cause for MSCC in children (62.7%) followed by sarcoma (14.2%). Soft tissue sarcomas were the most frequent cause of MSCC in children > 5 years old, while for neuroblastomas, the mean age of presentation was 20 months. The median age at time of diagnosis for the entire cohort of patients was 50.9 months (14.8-139). The median follow-up duration was 50.7 months (0.5-204). Motor deficits were the presenting symptom in 95.6% of children followed by pain in 65.4% and sphincter disturbance in 24%. There was a delay of about 26.05 days (7-600) between the onset of symptoms and diagnosis. A multimodality approach to treatment was utilised depending on the primary tumour. The prognosis for neurological recovery was found to be inversely proportional to the degree of neurological deficits and duration of symptoms in four studies.

CONCLUSION

Neuroblastoma is the most common cause for MSCC in children (62.7%) followed by sarcoma (14.2%), whilst soft tissue sarcomas constituted the most frequent cause of MSCC in children > 5 years old. The majority of patients presented with motor deficit, followed by pain. In children with neuroblastoma /lymphoma, chemotherapy was the primary treatment. Early surgery should be a consideration with rapid deterioration of neurology despite chemotherapy. A multimodality approach including chemo-radiotherapy and surgery should be the treatment of choice in metastatic sarcomas. It is worth noting that multi-level laminectomy/decompression and asymmetrical radiation to the spine can lead to spinal column deformity in the future.

A multiscale orchestrated computational framework to reveal emergent phenomena in neuroblastoma

Neuroblastoma is a complex and aggressive type of cancer that affects children. Current treatments involve a combination of surgery, chemotherapy, radiotherapy, and stem cell transplantation. However, treatment outcomes vary due to the heterogeneous nature of the disease. Computational models have been used to analyse data, simulate biological processes, and predict disease progression and treatment outcomes. While continuum cancer models capture the overall behaviour of tumours, and agent-based models represent the complex behaviour of individual cells, multiscale models represent interactions at different organisational levels, providing a more comprehensive understanding of the system. In 2018, the PRIMAGE consortium was formed to build a cloud-based decision support system for neuroblastoma, including a multi-scale model for patient-specific simulations of disease progression. In this work we have developed this multi-scale model that includes data such as patient's tumour geometry, cellularity, vascularization, genetics and type of chemotherapy treatment, and integrated it into an online platform that runs the simulations on a high-performance computation cluster using Onedata and Kubernetes technologies. This infrastructure will allow clinicians to optimise treatment regimens and reduce the number of costly and time-consuming clinical trials. This manuscript outlines the challenging framework's model architecture, data workflow, hypothesis, and resources employed in its development.

Sleep Disturbance Among Adults With Overactive Bladder: A Cross-sectional Survey

OBJECTIVE

To examine differences in sleep disturbance, nocturia, and depression among adults with overactive bladder (OAB) by treatment type.

METHODS

A cross-sectional survey of adults with OAB assessed sleep disturbance, nocturia, and depression using patient-reported outcome measures, including the Patient Reported Outcomes Measurement Information System (PROMIS)-29 Profile v2.1 (Sleep Disturbance and Depression domains), Lower Urinary Tract Dysfunction Research Network Symptom Index-10, and PROMIS Sleep Disturbance Short Form 8B. Treatment groups included antimuscarinics, β-3 adrenergic agonists, and no treatment. Analysis of covariance (ANCOVA) was used to test for differences in study endpoints; Bonferroni-adjusted pairwise tests (P < .05/3) were performed to compare differences in least squares means between groups.

RESULTS

One hundred participants were included per treatment group. The overall mean (standard deviation) age across all groups was 47.8 (11.8) years. Symptom scores across all PROMIS domains in all three treatment groups were higher than the US general population. There were no statistically significant differences in outcomes across treatment groups.

CONCLUSION

Adults with OAB reported being affected by sleep disturbance and depression, regardless of treatment. The mirabegron group trended toward the lowest symptom impact across all outcomes, however, comparisons were not significant. Future research should examine temporal associations between OAB treatment, sleep disturbance, and outcomes.

Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Role of sex and stature on the biomechanics of normal and loaded walking: implications for injury risk in the military

Load carriage and marching 'in-step' are routine military activities associated with lower limb injury risk in service personnel. The fixed pace and stride length of marching typically vary from the preferred walking gait and may result in overstriding. Overstriding increases ground reaction forces and muscle forces. Women are more likely to overstride than men due to their shorter stature. These biomechanical responses to overstriding may be most pronounced when marching close to the preferred walk-to-run transition speed. Load carriage also affects walking gait and increases ground reaction forces, joint moments and the demands on the muscles. Few studies have examined the effects of sex and stature on the biomechanics of marching and load carriage; this evidence is required to inform injury prevention strategies, particularly with the full integration of women in some defence forces. This narrative review explores the effects of sex and stature on the biomechanics of unloaded and loaded marching at a fixed pace and evaluates the implications for injury risk. The knowledge gaps in the literature, and distinct lack of studies on women, are highlighted, and areas that need more research to support evidence-based injury prevention measures, especially for women in arduous military roles, are identified.

Kommerell's diverticulum: an unusual cause of unilateral vocal cord palsy?

Kommerell's diverticulum is a rare congenital anomaly of the aortic arch system in which there is a left- or right-sided aortic arch with an aberrant subclavian artery on the contralateral side. Patients with this anomaly can be asymptomatic or have features of tracheal or oesophageal compression. However, there is a rising suspicion that it may be a rare cause of unilateral vocal cord palsy through its compression of the recurrent laryngeal nerve. We describe a patient who had a long history of hoarse voice and left vocal cord palsy with no other obvious cause, who was found to have a Kommerell's diverticulum on a contrast-enhanced computed tomography scan.

A model to determine at-home restrictions for cats after treatment of hyperthyroidism with radioiodine

OBJECTIVES

Felinehyperthyroidism is the most common endocrine disease of older cats and radioiodine is considered to be the gold standard treatment. Isolation periods following treatment vary depending on both individual treatment facilities and the relevant legislation of the country; therefore, there is no recognised standardised protocol defining the length of isolation. This work describes how our institution validated that its owner restrictions met dose constraints by using a model of iodine retention to calculate the required duration and nature of owner restrictions.

MATERIALS AND METHODS

The retained radioactivity of cats at the point of discharge was used to simulate the radiation dose to owners in the 90 days following release. The model created was used to calculate the minimum duration of isolation for a range of administered activities and owner restrictions.

RESULTS

Using the model, it was found that when injected with the maximum dose used, 222 MBq radioiodine, it was possible to release cats after 14 days of isolation and keep owner doses below 0.30 mSv (whole-body effective dose constraint for a single radiation source) with some restrictions. It was possible to release after 23 days with no restrictions.

CLINICAL SIGNIFICANCE

The present study provides clinicians with a consistent and verified method in which they can calculate the isolation periods for radioiodine-treated cats.

What is the impact of dexamethasone on postoperative pain in adults undergoing general anaesthesia for elective abdominal surgery: a systematic review and meta-analysis

Background

Previous meta-analysis of heterogeneous surgical cohorts demonstrated reduction in postoperative pain with perioperative intravenous dexamethasone, but none have addressed adults undergoing elective abdominal surgery. The aim of this study was to determine the impact of intravenous perioperative dexamethasone on postoperative pain in adults undergoing elective abdominal surgery under general anaesthesia.

Methods

This review was prospectively registered on the international prospective register of systematic reviews (CRD42020176202). Electronic databases Medical Analysis and Retrieval System Online (MEDLINE), Exerpta Medica Database (EMBASE), (CINAHL) Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and trial registries were searched to January 28 2021 for randomised controlled trials, comparing dexamethasone to placebo or alternative antiemetic, that reported pain. The primary outcome was pain score, and secondary outcomes were time to first analgesia, opioid requirements and time to post-anaesthesia care unit (PACU) discharge.

Results

Fifty-two studies (5768 participants) were included in the meta-analysis. Pain scores ≤ 4 hour (h) were reduced in patients who received dexamethasone at rest (mean difference (MD), − 0.54, 95% confidence interval (CI) − 0.72 to − 0.35, I² = 81%) and on movement (MD − 0.42, 95% CI − 0.62 to − 0.22, I² = 35). In the dexamethasone group, 4–24 h pain scores were less at rest (MD − 0.31, 95% CI − 0.47 to − 0.14, I² = 96) and on movement (MD − 0.26, 95% CI − 0.39 to − 0.13, I² = 29) and pain scores ≥ 24 h were reduced at rest (MD − 0.38, 95% CI − 0.52 to − 0.24, I² = 88) and on movement (MD − 0.38, 95% CI − 0.65 to − 0.11, I² = 71). Time to first analgesia (minutes) was increased (MD 22.92, 95% CI 11.09 to 34.75, I² = 98), opioid requirements (mg oral morphine) decreased (MD − 6.66, 95% CI − 9.38 to − 3.93, I² = 88) and no difference in time to PACU discharge (MD − 3.82, 95% CI − 10.87 to 3.23, I² = 59%).

Conclusions

Patients receiving dexamethasone had reduced pain scores, postoperative opioid requirements and longer time to first analgesia. Dexamethasone is an effective analgesic adjunct for patients undergoing abdominal surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-022-00243-6.

Prostatitis and prostatic abscessation in dogs: retrospective study of 82 cases

OBJECTIVES

To describe clinical signs, diagnostics, treatments and outcomes of prostatitis and prostatic abscesses of dogs in a referral population.

ANIMALS

Eighty-two dogs diagnosed with prostatitis and/or prostatic abscesses from three referral hospitals.

PROCEDURES

Retrospective case series.

RESULTS

A total of 82 dogs were included, and the median age was nine years. Acute prostatitis was diagnosed in 63% of cases, chronic prostatitis in 37% of cases and 40% of cases had prostatic abscessation. Prostatomegaly was the most common ultrasonographic finding. Mineralisation was identified in 20% of cases. The results of urine and prostatic bacterial culture were concordant in only 50% of cases. Antimicrobial resistance was encountered commonly, with 29% of cultures resistant to one antimicrobial and 52% resistant to two or more antimicrobials. Abscesses were treated with either antimicrobials alone, ultrasound-guided needle drainage or surgical drainage.

CONCLUSIONS AND CLINICAL RELEVANCE

With antimicrobial treatment and castration, the prognosis for canine prostatitis appears good. Prostatic abscessation is commonly encountered and does not appear to infer a worse prognosis and antimicrobials alone, ultrasound-guided needle drainage and surgical drainage all appear to be reasonable treatment options. Antimicrobial resistance is commonly encountered, and the results of urine culture and susceptibility testing are frequently discordant with those from samples from the prostate. Sampling of the prostate is required to confirm a diagnosis and exclude other pathologies such as neoplasia, particularly as mineralisation is seen in a reasonable number of cases of dogs with prostatitis.

An afucosylated anti-CD32b monoclonal antibody induced platelet-mediated adverse events in a human Fcγ receptor transgenic mouse model and its potential human translatability

To assess the safety and tolerability of NVS32b, a monoclonal, afucosylated, anti-CD32b (FCGR2B) antibody we used a humanized transgenic (Tg) mouse model that expresses all human Fc gamma receptors (FCGRs) while lacking all mouse FCGRs. Prior to its use, we extensively characterized the model. We found expression of all human FCGRs in a pattern similar to humans with some exceptions, such as low CD32 expression on T cells (detected with the pan CD32 antibody but more notably with the CD32b-specific antibody), variation in the transgene copy number, integration of additional human genes, and overall higher expression of all FCGRs on myeloid cells compared to human. Unexpectedly, NVS32b induced severe acute generalized thrombosis in huFCGR mice upon iv dosing. Mechanistic evaluation on huFCGR and human platelets revealed distinct binding, activation and aggregation driven by NVS32b in both species. In huFCGR mice, the anti-CD32b antibody NVS32b binds platelet CD32a via both Fc and/or CDR (complementarity determining region) causing their activation while in human, NVS32b-binding requires platelet pre-activation and interaction of platelet CD32a via the Fc portion and an unknown platelet epitope via the CDR portion of NVS32b. We deemed the huFCGR mice to be over-predictive of the NVS32b-associated human thrombotic risk. Impact: In this study we elucidated the mechanism based on the thrombotic adverse events observed in huFCGR mice upon NVS32B dosing and were able to identify this safety liability which led to program termination. Therefore, this mouse model could be useful in research of immunotherapies targeting or involving FCGRs. Potential biological implications resulting from species differences in the FCGR expression pattern are nevertheless important to consider.

Implementation of a novel antimicrobial stewardship strategy for rural facilities utilising telehealth

A significant portion of healthcare takes place in small hospitals, and many are located in rural and regional areas. Facilities in these regions frequently do not have adequate resources to implement an onsite antimicrobial stewardship programme and there are limited data relating to their implementation and effectiveness. We present an innovative model of providing a specialist telehealth antimicrobial stewardship service utilising a centralised service (Queensland Statewide Antimicrobial Stewardship Program) to a rural Hospital and Health Service. Results of a 2-year post-implementation follow-up showed an improvement in adherence to guidelines [33.7% (95% CI 27.0-40.4%) vs. 54.1% (95% CI 48.7-59.5%)] and appropriateness of antimicrobial prescribing [49.0% (95% CI 42.2-55.9%) vs. 67.5% (95% CI 62.7-72.4%) (P < 0.001). This finding was sustained after adjustment for hospitals, with improvement occurring sequentially across the years for adherence to guidelines [adjusted odds ratio (aOR) = 2.44, 95% CI 1.70-3.51] and appropriateness of prescribing (aOR = 2.48, 95% CI 1.70-3.61). There was a decrease in mean total antibiotic use (DDDs/1000 patient-days) between the years 2016 (52.82, 95% CI 44.09-61.54) and 2018 (39.74, 95% CI 32.76-46.73), however this did not reach statistical significance. Additionally, there was a decrease in mean hospital length of stay (days) from 2016 (3.74, 95% CI 3.08-4.41) to 2018 (2.55, 95% CI 1.98-3.12), although this was not statistically significant. New telehealth-based models of antimicrobial stewardship can be effective in improving prescribing in rural areas. Programmes similar to ours should be considered for rural facilities.

Dorsal mediastinal haemorrhage in dogs: four cases (2010-2018)

OBJECTIVE

This retrospective case series describes the clinical presentation and CT findings of dogs with presumed mediastinal haemorrhage with no apparent identifiable underlying cause.

MATERIALS AND METHODS

Medical records were searched for dogs with presumed or suspected mediastinal haemorrhage of non-thymic origin. For all dogs, data on signalment, history, physical examination, treatment and outcome were collected by reviewing the medical records. Follow-up information was collected by telephone interviews with the owners and/or their primary-care veterinarians.

RESULTS

Four dogs were included. All survived to discharge with apparent resolution of the mediastinal haemorrhage (based on repeat imaging and/or clinical signs) with supportive treatment alone. Follow-up information was available from 2 months to 5 years following discharge, and none of the patients showed a recurrence of clinical signs during this period.

CLINICAL SIGNIFICANCE

This case series highlights that presumed haemorrhage into the mediastinum can occur in dogs without an obviously identifiable cause and, whilst rare, should be considered as a cause of dorsal mediastinal masses and may be successfully managed with supportive care alone.

External validation of the Surgical Outcome Risk Tool (SORT) in 3305 abdominal surgery patients in the independent sector in the UK

Background

Assessing the risk of post-surgical mortality is a key component of pre-surgical planning. The Surgical Outcome Risk Tool (SORT) uses pre-operative variables to predict 30-day mortality. The aim of this study was to externally validate SORT in patients undergoing major abdominal surgery.

Methods

Data were collected from patients treated in five independent hospitals in the UK. Individualised SORT scores were calculated, and area under the receiver operating characteristic (AUROC) and precision-recall curves (PRC) plus 95% confidence intervals (CI) were drawn to test the ability of SORT to identify in-hospital death. Outcomes of patients with a SORT predicted risk of mortality of ≥ 5% (high risk) were compared to those with a predicted risk of < 5% (standard risk).

Results

The study population comprised 3305 patients, mean age 51 years, 2783 (84.2%) underwent elective surgery most frequently involving the colon (24.6%), or liver, pancreas or gallbladder (18.2%). Overall, 1551 (46.9%) patients were admitted to ICU and 29 (0.88%) died. The AUROC of SORT for discriminating patients at risk of death in hospital was 0.899 (95% CI 0.849 to 0.949) and the PRC 0.247. In total, 72 (2.18%) patients were stratified as high risk. There were more unplanned ICU admissions and deaths in this group compared to the standard risk group (25.0% and 3.3%, versus 3.1% and 0.5%, respectively).

Conclusion

We externally validated SORT in a large population of abdominal surgery patients. SORT performed well in patients with lower risk profiles, but underpredicted adverse outcomes in the higher risk group.

Blood culture quality assurance: what Australasian laboratories are measuring and opportunities for improvement

Blood cultures are among the most important specimen types received and processed by the microbiology laboratory. Several publications list which variables should be measured to ensure quality. We undertook a qualitative structured questionnaire of Australian and New Zealand clinical microbiology laboratories to document current blood culture practices and to determine whether expected quality standards are being met. Questions included a wide range of pre-analytical, analytical, and post-analytical aspects of blood cultures from adults. The responses from 71 laboratories were analysed. Compliance was high for use of a biological safety cabinet (90%), incubating for 5 days (86%), and commenting on likely contaminants (85%). While Gram stains were reported within 2 hours during normal hours (93%), reporting was slower after hours (59%), p<0.001. The volume of blood collected for a clinical episode was poorly monitored with only 11% (n=8) of laboratories regularly auditing the number of blood culture sets and 3% (n=2) monitoring adequacy of fill. Most laboratories received blood cultures from off-site with just 34% (n=21) meeting guidance for loading bottles onto the analyser within 4 hours. More laboratories met standards for loading bottles onto the analyser during working hours than after hours: 87% vs 56%, p<0.001. Most laboratories did not monitor the contamination rate, 56% (n=40), and only 27% (n=19) knew their rate was below the guidance threshold of less than -3%. Considerable opportunities exist to improve quality assurance of blood culture practice in Australia and New Zealand, especially for the most critical aspect affecting culture sensitivity, the volume of blood collected.

Detrusor urethral dyssynergy in dogs: 35 cases (2007-2019)

OBJECTIVES

To evaluate clinical presentation, diagnosis, treatment and outcome of dogs diagnosed with detrusor urethral dyssynergy.

MATERIALS AND METHODS

Multicentre (n = 3 UK referral clinics), retrospective, observational study. Database searches were performed (2007 to 2019) to identify dogs with detrusor urethral dyssynergy. Dogs with structural abnormalities or detectable neurological disorders affecting micturition were excluded. Clinical presentation, diagnostic procedures, treatment and outcome were evaluated.

RESULTS

Thirty-five dogs were included. Middle-aged, large-breed, male neutered dogs were most frequently documented. Four female dogs were included. Fifteen breeds, including Labrador retrievers (8/35; 22.9%), golden retrievers (5/35;14.3%) and cross-breeds (5/35; 14.3%) were identified. Median duration of clinical signs was 152 days (range 0 to 1095). All dogs were dysuric at presentation with 17/35 (48.6%) reported to have an altered stream of urine and 17/35 (48.6%) to be stranguric. Follow-up data were available for 34 dogs (median 136 days, range 4 to 2188). Response was classified as good (20/34; 58.8%), partial (7/34; 20.5%) or poor (7/34; 20.5%). Overall time to response was known for 21 of 34 dogs (partial n = 6, good n = 15) with a median of 11 days (range 1 to 155). Four dogs had surgical intervention (castration n = 4, cystostomy tube n = 2). Three dogs were euthanased due to partial (n = 1) or poor (n = 2) response. Medications were discontinued in 11 of 20 (55.0%) dogs with a good response to therapy, two of these relapsed.

CLINICAL SIGNIFICANCE

Detrusor urethral dyssynergy is an uncommon micturition disorder in dogs, in particular females. Medical therapy with or without surgery resulted in a favourable prognosis in the majority of dogs, although many require long-term medication.

A randomized comparison trial of culturally adapted HIV prevention approaches for Native Americans reducing trauma symptoms versus substance misuse: The Healing Seasons protocol

Native Americans (NA) experience interrelated risks of trauma exposure, substance use, and HIV risk behaviors that put them at increased risk for HIV infection. Despite these known risk factors, there are very few published randomized trials testing interventions to reduce trauma-related symptoms and substance misuse among NA.

METHODS

The Healing Seasons study is a randomized comparsion trial of two counseling strategies, Narrative Exposure Therapy (NET) addressing PTSD or Motivational interviewing with cognitive behavioral therapy skills training (MIST) addressing substance misuse as a means to prevent HIV among NA. Using a community-based participatory research approach, we adapted both evidence-based interventions to be specific to the risk contexts and realities of NA and to include psychoeducational and skill-building components that include cultural-specific stories, virtues, and traditional treatment strategies. Participants, 16 years and older, were recruited from a Pacific Northwest tribal community, screened over the phone, enrolled in person, and randomized in equal numbers to NET or MIST. We stratified by age (16-29 years and 30 or older) and gender (male or female identified) to ensure balance between treatment arms. The primary outcomes were number of sex partners and frequency of sexual acts (with and without condoms), sex under the influence of substances, frequency of substance use, and PTSD severity.

DISCUSSION

Behavioral interventions for NA are needed to prevent HIV risk behaviors when faced with trauma symptoms and substance misuse. This study will provide evidence to determine feasibility and efficacy of addressing related risk factors as part of counseling-based HIV prevention intervention to reduce sexual risk among this population.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT03112369, registered April 12, 2017.

FRI0139 FILGOTINIB PROVIDED RAPID AND SUSTAINED RELIEF OF PAIN AND FATIGUE AND IMPROVED HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS AND INADEQUATE RESPONSE TO BIOLOGIC DMARDS: RESULTS FROM THE FINCH 2 STUDY

Background:

EULAR guidelines recommend a treat-to-target approach focusing on reducing inflammation to prevent joint damage, physical disability, and mortality.1However, patients consider reduction in pain and fatigue, along with maintenance of physical function, and improvement in health-related quality of life (HRQoL) important areas for improvement with RA treatment.2In the FINCH 2 study, filgotinib (FIL)—a potent, selective, oral small molecule Janus kinase 1 inhibitor—in combination with conventional synthetic (cs)DMARD therapy significantly improved the signs and symptoms of rheumatoid arthritis (RA) in patients with an inadequate response to a biologic (b)DMARD compared with placebo (PBO).3In addition, patients experienced significant improvements in HAQ-DI at week (W)12 and W24 with FIL 100 mg (p <0.001, p = 0.003) or 200 mg (p <0.001 for both) compared with PBO.3

Objectives:

To evaluate the rate and magnitude of change in patient-reported outcomes (PROs) from FINCH 2 assessing pain, HRQoL, and fatigue.

Methods:

Patients in this double-blind, randomised study (NCT02873936) received FIL 200 mg, FIL 100 mg, or PBO while continuing csDMARD therapy. PROs were collected prospectively on day 1 and at the W2, W4, W8, W12, W14, W16, W20, and W24 visits for assessment of pain (VAS pain scale) and on day 1 and at W4, W12, and W24 for assessment of fatigue (FACIT-Fatigue) and HRQoL (SF-36). Changes from baseline for each PRO at each time point up to W24 were analysed longitudinally using a mixed-effects model for repeated measures. P values for the difference between each FIL arm and PBO at each time point were calculated.

Results:

Among the 448 patients randomised and treated (FIL 200 mg, n = 147; FIL 100 mg, n = 153; PBO, n = 148) 381 (85.0%) completed the study. Baseline mean (SD) VAS pain scale was 67 (21.0), SF-36 physical component summary (PCS) was 31.1 (7.89), SF-36 mental component summary (MCS) was 44.3 (11.6), and FACIT-Fatigue score was 24.4 (11.6); baseline values did not vary between treatment groups. Significantly greater improvements in VAS pain scores began at W2 and were maintained through W24 for patients who received either dose of FIL vs PBO (Fig 1A). FIL also significantly improved patients’ fatigue at W4, W12, and W24 compared with PBO for those receiving 200 mg doses, and at W4 and W12 for those receiving 100 mg doses (Fig 1B). HRQoL related to physical functioning (SF-36 PCS) was significantly enhanced at W4, W12, and W24 with both doses of FIL as compared with PBO (Fig 2A). Improvements to mental-health-related QoL (SF-36 MCS) were reported for FIL as early as W4 and maintained through W24, with statistically significant improvements at W4 and W12 for FIL 200 mg vs PBO (Fig 2B).

Conclusion:

In a patient population with refractory disease that had inadequate response to prior bDMARDs and had significant disease at baseline, FIL treatment—coadministered with csDMARD therapy—was able to provide rapid and sustained improvements in key measures of pain, HRQoL, and fatigue as reported by patients.

References:

[1]Smolen, et al.Ann Rheum Dis. 2017;76:960–77.

[2]Fautrel, et al.Rheumatol Int.2018;38:935–47.

[3]Genovese, et al.JAMA. 2019;322(4):315–25.

Disclosure of Interests:

David Walker Grant/research support from: Gilead, Consultant of: Gilead, Lilly, Pfizer, Roche, Speakers bureau: Lilly, Pfizer, Roche, Tsutomu Takeuchi Grant/research support from: AbbVie, Asahikasei Pharma Corp., Astellas Pharma, Inc., Chugai Pharmaceutical Co, Ltd., Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Nipponkayaku Co. Ltd., Shionogi & Co., Ltd., Takeda Pharmaceutical Co., Ltd., UCB Japan, Consultant of: Astellas Pharma, Inc., Chugai Pharmaceutical Co, Ltd., Eli Lilly Japan,, Speakers bureau: Abbvie, AYUMI Pharmaceutical Corp., Bristol-Myers Squibb, Chugai Pharmaceutical Co, Ltd., Daiichi Sankyo Co., Ltd., Eisai Co., Ltd., Eli Lilly Japan, Gilead Sciences, Inc., Mitsubishi-Tanabe Pharma Corp., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd, Beatrix Bartok Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Shangbang Rao Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., I-Heng Lee Shareholder of: Gilead Sciences Inc., Employee of: Gilead Sciences Inc., Robin Besuyen Shareholder of: Galapagos, Employee of: Galapagos, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Mark C. Genovese Grant/research support from: Abbvie, Eli Lilly and Company, EMD Merck Serono, Galapagos, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, Pfizer Inc., RPharm, Sanofi Genzyme, Consultant of: Abbvie, Eli Lilly and Company, EMD Merck Serono, Genentech/Roche, Gilead Sciences, Inc., GSK, Novartis, RPharm, Sanofi Genzyme

SAT0609-HPR DELPHI CONSENSUS FOR THE OPTIMAL TREATMENT & MANAGEMENT OF COMPLEX RHEUMATOID ARTHRITIS (RA) PATIENTS

Background:

A significant proportion of patients with rheumatoid arthritis (RA) have additional considerations that must be taken into account for managing their disease.1These include; co-morbidities, extra-articular manifestations and poor prognostic factors.2-5Tailored management could reduce the burden on patients, the health system and wider society.

The ‘complex’ RA patient group is ill-defined and no specific recommendations exist for their optimal management and treatment.

Objectives:

A group of UK Rheumatology experts aimed to provide a set of recommendations to support consistent and high quality management, grounded in current evidence, expert opinion and best practice.

Methods:

A steering group meeting identified priority topics associated with complex RA.

Table 1.

Topics for consensus

TopicNo. of statementsDefinition of ‘complex’ RA from a medical perspective19Definition of patient factors that may contribute to ‘complex’ RA3Outcomes for RA patients with co-morbidities and/or extra articular manifestations5Prescribing options for ‘complex’ RA8Evidence vs. best practice requirements4Burden of ‘complex’ RA4TOTAL NUMBER OF STATEMENTS43

For each topic, the group defined statements they all agreed with. Delphi methodology was used to ratify these statements with rheumatology peers.

High levels of agreement (over 70%) were achieved in the first round, the group proceeded to formulate the recommendations.

Figure 1.

Responses received (n=163)

Figure 2.

Consensus Plot (total responses n=163)

Conclusion:

These recommendations are offered:

References:

[1]Uhlig T, Moe RH, Kvien TK. The burden of disease in rheumatoid arthritis. Pharmacoeconomics 2014;32:841–51

[2]Dougados M, et al. Ann Rheum Dis 2014;73:62–68.

[3]Parodi M et al,Rheumatism, 2005, 57(3): 154-60.

[4]Young A & Koduri G. Best Pract Res Clin Rheumatol. 2007 Oct;21(5):907-27.

[5]Holroyd CR, et al. Rheumatology 2019;58:e3-e42

Acknowledgments:

Support for medical writing/editorial assistance, provided by Tim Warren at Triducive was funded by Roche Products Ltd. & Chugai Pharma Ltd. in accordance with Good Publication Practice (GPP3) guidelines (http://www.ismpp.org/gpp3).

Disclosure of Interests:

Gurdeep Dulay Grant/research support from: Educational grants to attend congress meetings/conferences from Roche, Chugai, UCB, Internis, Pfizer, Lilly, Sandoz, Consultant of: Honoraria for advisory board services from Roche, Chugai, Novartis, Speakers bureau: Speaker fees from Roche, Chugai, Novartis, Amgen, Lilly, Sandoz, Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Theresa Barnes Consultant of: Ad boards for Roche, Actelion and Abbvie, Speakers bureau: Speaker for MSD, UCB, Pfizer, Abbvie, Actelion, Roche and BMS, Debbie Chagadama Consultant of: Roche, Chugai, BI, Speakers bureau: Roche, Chugai, BI, Zoe Cole Consultant of: Consultancy work for Roche, Lilly, Gilead, Abbvie, Pfizer, UCB, Speakers bureau: Lilly, BMS, Abbvie, Pfizer, UCB, Janssen, Anshuman Malaviya Consultant of: Roche, Chugai, MSD, Pfizer, Novartis, Lily, BMS, Speakers bureau: Roche, BMS, Pfizer, MSD, Sandra Robinson Consultant of: Eli Lilly for Education Nurse Meeting, David Walker Grant/research support from: Gilead, Consultant of: Gilead, Lilly, Pfizer, Roche, Speakers bureau: Lilly, Pfizer, Roche, Chris Daly Employee of: Roche, Nicola Savill Employee of: Roche, Tim Warren Consultant of: Roche, Employee of: AstraZeneca, Nick Williams Shareholder of: MSD, Consultant of: Roche, Employee of: MSD

The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists

Background

In 2014, the Royal College of Anaesthetists (RCoA) launched the Perioperative Medicine Programme to facilitate the delivery of best preoperative, intraoperative and postoperative care through implementation of evidence-based medicine to reduce variation and improve postoperative outcomes. However, variation exists in the establishment of perioperative medicine services in the UK. This survey explored attitudes and behaviours of anaesthetists towards perioperative medicine, described current anaesthetic-led perioperative medicine services across the UK and explored barriers to anaesthetic involvement in perioperative medicine.

Methods

Survey content based on the RCoA vision document was refined and validated using an expert panel. An anonymous electronic survey was then sent by email to the members of the RCoA.

Results

Seven hundred fifty-eight UK anaesthetists (4.5% of the RCoA mailing list) responded to the survey. Of these, 64% considered themselves a perioperative doctor, with 65% having changed local services in response to the RCoA vision. Barriers to developing perioperative medicine included insufficient time (75%) and inadequate training (51%). Three quarters of respondents advocate anaesthetists leading the development of perioperative medicine.

Conclusions

Despite evidence of emerging services, this survey describes barriers to ongoing development of perioperative medicine. Facilitators may include increased clinical exposure, targeted education and training and collaborative working with other specialties.

Diabetic foot ulcer incidence and survival with improved diabetic foot services: an 18-year study

AIMS

To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing.

METHODS

Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios.

RESULTS

The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten-year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65-74 years and 25% for those aged 75-81 years (P < 0.0001). In those with peripheral vascular disease 5-year survival was 35% (P <0.001).

CONCLUSIONS

Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease.

First Measurement of the Total Neutron Cross Section on Argon between 100 and 800 MeV

We report the first measurement of the neutron cross section on argon in the energy range of 100-800 MeV. The measurement was obtained with a 4.3-h exposure of the Mini-CAPTAIN detector to the WNR/LANSCE beam at LANL. The total cross section is measured from the attenuation coefficient of the neutron flux as it traverses the liquid argon volume. A set of 2631 candidate interactions is divided in bins of the neutron kinetic energy calculated from time-of-flight measurements. These interactions are reconstructed with custom-made algorithms specifically designed for the data in a time projection chamber the size of the Mini-CAPTAIN detector. The energy averaged cross section is 0.91±0.10(stat)±0.09(syst)  b. A comparison of the measured cross section is made to the GEANT4 and FLUKA event generator packages, where the energy averaged cross sections in this range are 0.60 and 0.68 b, respectively.

Characterisation and outcome of idiopathic pyogranulomatous lymphadenitis in 64 English springer spaniel dogs

OBJECTIVES

To describe the history, clinicopathological abnormalities, diagnostic imaging findings, lymph node cytological/histological appearance, treatment and outcome of English springer spaniels diagnosed with idiopathic pyogranulomatous lymphadenitis.

MATERIALS AND METHODS

In this retrospective UK-based multicentre study, 64 dogs were recruited from 10 referral centres, 32 first-opinion practices and three histopathology/cytology laboratories, between 2010 and 2016.

RESULTS

The median age at presentation was 6 years (range: 0.17 to 11.75). Neutered females were frequently affected. Pyrexia (83.8%), peripheral lymphadenomegaly (78.4%), dermatological lesions (72.9%), lethargy (67.6%), hyporexia (54%), diarrhoea (29.7%), coughing (24.3%), epistaxis, sneezing or nasal discharge (21.6%), ocular signs (21.6%) and vomiting (16.2%) were reported in dogs for which the history and physical examination records were available. Popliteal (45.3%), superficial cervical (35.9%) and submandibular (37.5%) lymphadenomegaly were frequently reported. Haematology and serum biochemistry revealed non-specific changes. When undertaken, testing for infectious diseases was negative in all cases. Lymph node cytology, histopathology or both demonstrated mixed inflammatory (27%), pyogranulomatous (24%), neutrophilic (20%) or granulomatous (11%) lymphadenitis. Treatment details were available for 38 dogs, with 34 receiving prednisolone for a median duration of 15 weeks (range: 1 to 28 weeks). A good to excellent clinical response was reported in all but one case. Ten dogs relapsed after discontinuing prednisolone.

CLINICAL SIGNIFICANCE

Idiopathic pyogranulomatous lymphadenitis should be considered as a differential diagnosis for lymphadenopathy and pyrexia in English springer spaniels. The characteristics of the disease, absence of identifiable infectious aetiology and response to glucocorticoid therapy suggest an immune-mediated aetiology.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A learning health systems approach to improving the quality of care for patients in South Asia

Poor quality of care is a leading cause of excess morbidity and mortality in low- and middle- income countries (LMICs). Improving the quality of healthcare is complex, and requires an interdisciplinary team equipped with the skills to design, implement and analyse setting-relevant improvement interventions. Such capacity is limited in many LMICs. However, training for healthcare workers in quality improvement (QI) methodology without buy-in from multidisciplinary stakeholders and without identifying setting-specific priorities is unlikely to be successful. The Care Quality Improvement Network (CQIN) was established between Network for Improving Critical care Systems and Training (NICST) and University College London Centre for Perioperative Medicine, with the aim of building capacity for research and QI. A two-day international workshop, in collaboration with the College of Surgeons of Sri Lanka, was conducted to address the above deficits. Innovatively, the CQIN adopts a learning health systems (LHS) approach to improving care by leveraging information captured through the NICST electronic multi-centre acute and critical care surveillance platform. Fifty-two delegates from across the CQIN representing clinical, civic and academic healthcare stakeholders from six countries attended the workshop. Mapping of care processes enabled identification of barriers and drivers to the delivery of care and facilitated the selection of feasible QI methods and matrices. Six projects, reflecting key priorities for improving the delivery of acute care in Asia, were collaboratively developed: improving assessment of postoperative pain; optimising sedation in critical care; refining referral of deteriorating patients; reducing surgical site infection after caesarean section; reducing surgical site infection after elective general surgery; and improving provision of timely electrocardiogram recording for patients presenting with signs of acute myocardial infarction. Future project implementation and evaluation will be supported with resources and expertise from the CQIN partners. This LHS approach to building capacity for QI may be of interest to others seeing to improve care in LMICs.

Systemic Yersinia pseudotuberculosis as a Cause of Osteomyelitis in a Captive Ring-tailed Lemur (Lemur catta)

Yersinia pseudotuberculosis and Yersinia enterocolitica are ubiquitous pathogens with wildlife and domestic animal reservoirs. Outbreaks of 'non-plague' yersiniosis in man and non-human primates are reported frequently (including zoological specimens and research breeding colonies) and are usually characterized by enteritis, mesenteric lymphadenitis and occasionally organ abscessation. In people, non-septic reactive arthritis is a common sequela to yersiniosis. However, there have been rare reports in people of septic arthritis and osteomyelitis because of active systemic infection with Y. pseudotuberculosis. Osteomyelitis has also been reported rarely in historical yersiniosis outbreaks in farmed turkeys in England and the USA. This paper reports the first case of osteomyelitis caused by systemic infection with Y. pseudotuberculosis O:1 in a non-human primate, a captive ring-tailed lemur (Lemur catta). The lemur had a short clinical history of hyporexia and weight loss with reduction in mobility, especially of the left hindlimb. On post-mortem examination there was evidence of multi-organ abscessation. In addition, severe necrosis, inflammation and large bacterial colonies were present in the musculature, periosteum and bone marrow in the hip, ribs and a vertebra at the cervicothoracic junction. Osteomyelitis should be considered as a rare clinical presentation in non-human primates with systemic Y. pseudotuberculosis infection.