Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

A novel approach using electroacupuncture for erectile dysfunction after radical prostatectomy: A case report

INTRODUCTION

Research shows that electrical stimulation to damaged peripheral nerves has promising effects on nerve regeneration and recovery of function.

DESCRIPTION

A 71 yr. old male, who was 12 months post left intrafacial and right incremental nerve sparing robotic radical prostatectomy received 6 sessions of sacral electroacupuncture/acupuncture at weekly intervals, commencing 12 months post operatively.

METHODS

CARE guidelines informed the case study report. Positive changes in erectile function after electroacupuncture was recorded using validated scores (IIEF-5 and EHS). Qualitative information was collected via a feedback box.

DISCUSSION

Given that current treatments for post radical prostatectomy erectile dysfunction are invasive and largely unsuccessful, further investigation into electroacupuncture for this population should be pursued.

A116 OPTIMIZING CROHN’S DISEASE ENDOSCOPIC SCORING OPERATING CHARACTERISTICS TO ASSIST WITH THE ADVENT OF ARTIFICIAL INTELLIGENCE

Background

To date, no studies have used Artificial Intelligence (AI) to produce standard endoscopic scores for Crohn’s Disease (CD). These scores are essential to clinical practice and have a major cost in clinical trials.

Purpose

We aimed to re-examine the components of the Simple Endoscopic Score for Crohn’s Disease (SES-CD) and Modified Multiplier (MM-SES-CD) to see if scoring of individual colonic segments could be combined while maintaining predictive value accuracy, thus simplifying scoring for AI.

Method

Data from 279 participants in the UNITI and EXTEND trials as well as an infliximab biosimilar trial (NCT02096861) were used in this retrospective study. The primary outcome was endoscopic remission (ER-1) of the colon, defined as absence of ulcers. Secondary outcomes included alternative definitions of colonic endoscopic remission including SES-CD score of 0 (ER-2), SES-CD <3 (ER-3), and SES-CD reduction by 50% or greater from baseline (colonic endoscopic response).

Result(s)

The mean baseline SES-CD score was 13.7 (SD 7.7) and the mean MM-SES-CD score was 22.8 (SD 12.4). Among all possible colonic segment combinations, the combination of Right + Rectum + worst of Left or Transverse performed best for prediction of one-year ER-1, with fair accuracy (AUC 0.71, 95% CI 0.65-0.78, p < 0.0001). Accuracy of prediction of one-year ER-2 was poor (AUC 0.68, 95% CI 0.62-0.75, p < 0.0001), ER-3 was fair (AUC 0.71, 95% CI 0.65-0.77, p < 0.0001), and prediction of endoscopic response was poor (AUC 0.64, 95% CI 0.56-0.72, p > 0.01). These results were very similar to conventional scoring (without combining any “worst of” segments) with all of the colonic MM-SES-CD scores, with AUCs of 0.70, 0.69, 0.71, and 0.61 for the respective outcomes. Assessing only for the presence of ulcers was as accurate as the full assessment and exclusion of scoring stenosis had minimal impact on scores.

Image

Conclusion(s)

By combining assessment of colonic segments accuracy was maintained compared with currently used endoscopic scoring. Assessing for features other than ulceration had no significant impact on overall scores. By combining colonic segments and limiting assessment to ulceration, it may be simpler to develop AI algorithms reliably scoring endoscopic severity of CD for clinical practice and trials.

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Disclosure of Interest

None Declared

1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM

Introduction

Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception.

Aim

We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards:

- Medication review at least once weekly;

- Documented rationale for choice of medication

- Specified timeframe review and outcome documentation

We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data.

Method

Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment.

Results

47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2

Conclusion

Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.

A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention

BACKGROUND

Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II.

METHODS

We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the 'early course' of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach.

RESULTS

From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course.

CONCLUSIONS AND RECOMMENDATIONS

While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.

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.

Influence of the first wave of COVID-19 on asthma inhaler prescriptions

In the beginning of the COVID-19 pandemic, there were major concerns regarding the huge demand for asthma inhalers. Using the primary-care medical records for 614,700 asthma patients between January and June 2020, we found that there was a substantial increase in inhalers solely in March 2020. Patients significantly associated with receiving higher inhaled corticosteroid prescriptions were younger, of higher socioeconomic status, and had milder asthma.

Prevalence and Disparities in Folate and Vitamin B12 Deficiency Among Preschool Children in Guatemala

BACKGROUND AND OBJECTIVE

Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6-59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers.

OBJECTIVE

To describe national and regional post-fortification folate and vitamin B12 status of children aged 6-59 months in Guatemala.

METHODS

A multistage, cluster probability study was carried out with national and regional representation of children aged 6-59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148-221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest.

RESULTS

The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3-46.6%) and was significantly higher among children 6-11 months and 12-23 months (46.6 and 37.0%, respectively), compared to older children aged 48-59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6-42.0%) and geographic region (27.2-46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively.

CONCLUSIONS

In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children.

POS0670 ROUTINE ASSESSMENT OF PATIENT INDEX DATA 3 (RAPID3) IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH LONG-TERM UPADACITINIB THERAPY

Background:

Routine Assessment of Patient Index Data 3 (RAPID3) is a pooled index of 3 patient-reported measures: patient global assessment, pain, and physical function. RAPID3 was shown to correlate with other composite measures of disease activity1 and is recommended by the American College of Rheumatology for use in clinical practice.2

Objectives:

To evaluate the impact of upadacitinib (UPA) versus comparators on RAPID3 over 60 weeks, as well as the correlation of RAPID3 scores with other disease measures in the UPA phase 3 SELECT clinical program.

Methods:

This post hoc analysis included placebo-controlled (SELECT-NEXT, -BEYOND, and -COMPARE) and active comparator-controlled (SELECT-EARLY, -MONOTHERAPY, and -COMPARE) trials. Patients received UPA as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Mean change from baseline in RAPID3 and the proportion of patients reporting RAPID3 remission (≤3), low (LDA, >3 to ≤6), moderate (MDA, >6 to ≤12), and high disease activity (HDA, >12) were assessed. Correlations between absolute scores for RAPID3 and Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), and 28-joint Disease Activity Score with C-reactive protein (DAS28[CRP]) were assessed using Spearman correlation coefficients. All data are as observed.

Results:

A total of 661, 498, 648, 1629, and 945 patients were included from SELECT-NEXT, -BEYOND, -MONOTHERAPY, -COMPARE, and -EARLY. At baseline, the majority of patients across all studies were in RAPID3 HDA (mean baseline RAPID3 [across all studies], 17.2–19.2) (Table 1 and Figure 1). Improvements from baseline in RAPID3 were observed with UPA 15 mg and 30 mg through Week 60, with numerically greater improvements observed with UPA compared with active comparators (Table 1). Across studies, mean improvements in RAPID3 exceeded the minimal clinically important difference (MCID) with UPA and adalimumab (ADA) treatment (MCID=3.83). By Week 60, approximately one-half of UPA-treated patients were in RAPID3 remission or LDA, with only 10–25% remaining in HDA, except for the more refractory population in SELECT-BEYOND, in which ~38% of patients remained in HDA (Figure 1). RAPID3 scores moderately to strongly correlated with CDAI (ρ=0.69–0.83), SDAI (ρ=0.69–0.82), and DAS28(CRP) (ρ=0.58–0.77), across all studies, at Week 60 (all p<0.001).

Conclusion:

UPA, as monotherapy or in combination with csDMARDs, was associated with improvements in patient-reported disease activity, pain, and physical function, as assessed by RAPID3 over 60 weeks in the phase 3 SELECT clinical program. RAPID3 continues to be an important tool in clinical practice to assess disease activity, as it was shown to correlate to other disease activity measures and allows for rapid scoring.

References:

[1]Pincus T, et al. Arthritis Care Res (Hoboken) 2010;62:181–9.

[2]England BR, et al. Arthritis Care Res (Hoboken) 2019;71:1540–55.

[3]Ward MM, et al. J Rheumatol 2019;46:27–30.

Table 1.

Change from BL in RAPID3 at Week 60 (as observed)

Phase 3 studyGroupnaMean (SD) BL scoreMean (SD) change from BLbSELECT-EARLYc(MTX-naïve)MTX23618.5 (5.6)−9.6 (7.5)UPA 15 mg QD26918.9 (5.6)−12.0 (7.6)UPA 30 mg QD25318.2 (5.6)−13.4 (7.2)SELECT-NEXT(csDMARD-IR)UPA 15 mg QD17217.7 (5.1)−11.1 (7.3)UPA 30 mg QD17217.6 (5.3)−10.4 (6.8)SELECT-MONOTHERAPY(MTX-IR)UPA 15 mg QD17217.4 (5.8)−9.6 (7.4)UPA 30 mg QD18017.2 (5.9)−10.6 (7.2)SELECT-COMPAREc(MTX-IR)UPA 15 mg QD55218.5 (5.5)−10.2 (7.1)ADA 40 mg EOW26418.7 (5.4)−8.8 (6.7)SELECT-BEYOND(bDMARD-IR)UPA 15 mg QD13319.2 (5.1)−8.6 (6.8)UPA 30 mg QD11818.5 (5.3)−9.3 (7.3)

b, biologic; BL, baseline; EOW, every other week; IR, inadequate response; MTX, methotrexate; QD, once daily; SD, standard deviation

aNumber of patients with RAPID3 values at both BL and Week 60. bNegative values indicate improvement from BL. cObserved data include patients rescued to UPA and/or ADA; treatment effect may include both the randomized and switch treatments in these patients

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Martin Bergman Shareholder of: Johnson & Johnson, Speakers bureau: AbbVie, Celgene, GSK, MSD, Novartis, Pfizer, and Sanofi/Regeneron, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Genentech/Roche, Gilead, Horizon, Janssen, MSD, Novartis, Pfizer, Sandoz, Sanofi/Regeneron, and Scipher, Maya H Buch Consultant of: AbbVie, Eli Lilly, Merck-Serono, Pfizer, Sandoz, and Sanofi, Grant/research support from: Pfizer, Roche, and UCB, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Mitsubishi Tanabe, Novartis, Pfizer, Sanofi, Takeda, UCB, and YL Biologics, Grant/research support from: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, MSD, Ono, Taisho Toyama, and Takeda, Gustavo Citera Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genzyme, Pfizer, and Roche, Sami Bahlas: None declared, Ernest Wong Consultant of: AbbVie, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Chugai, Novartis, and UCB, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Namita Tundia Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Celltrion, Eli Lilly, Gilead, Ichnos, Inmedix, Janssen, Kiniksa, MSD, Myriad Genetics, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Scipher, Setpoint, and UCB.

Direct-to-consumer marketing (DTC) of internet-based cognitive behavioral therapy (iCBT) using brief promotional video: Mapping modifiable mechanisms in pre-treatment acceptance

Introduction

Given the suboptimal acceptance of iCBT for depression, finding ways to increase the acceptance and uptake is crucial for its dissemination. Moreover, it remains unknown to what extend the Unified Theory of Acceptance and Use of Technology (UTAUT) could aid the design of DTC in psychological service.

Objectives

To explore whether the regulatory processes theorized in the UTAUT (Performance Expectancy, Effort Expectancy, Social Influence, and Facilitating Condition) could be modified and mediate the change of acceptance of iCBT.

Methods

This randomized controlled trial recruited 219 individuals with at least mild level of depression. Upon completion of pre-assessment, participants were randomly allocated to an intervention (IG) and a control group (CG). The IG received a 7-minute UTAUT-driven promotion video, while the CG received a video of same length on general psychoeducation. Both groups completed a post-assessment.

Results

Repeated measures ANOVA revealed a significant time by group effect on treatment acceptance. The video in IG was perceived to be clearer and more persuasive. Mediation analysis showed that the intervention effect was mediated by increase in perceived performance expectancy of iCBT, and the indirect effect was conditional on dispositional help seeking stigma.

Conclusions

Pre-treatment acceptance of iCBT can be improved by brief DTC promotion video. The finding casts light that performance expectancy was the most modifiable and mediatable regulatory process on iCBT acceptance, although such relation could be attenuated by high help-seeking stigma. In sum, DTC marketing could aid implementation of Internet-based interventions, effort in stigma reduction should continue to encourage uptake of effective treatment.

Disclosure

No significant relationships.

A catalog of associations between rare coding variants and COVID-19 outcomes

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease-19 (COVID-19), a respiratory illness that can result in hospitalization or death. We investigated associations between rare genetic variants and seven COVID-19 outcomes in 543,213 individuals, including 8,248 with COVID-19. After accounting for multiple testing, we did not identify any clear associations with rare variants either exome-wide or when specifically focusing on (i) 14 interferon pathway genes in which rare deleterious variants have been reported in severe COVID-19 patients; (ii) 167 genes located in COVID-19 GWAS risk loci; or (iii) 32 additional genes of immunologic relevance and/or therapeutic potential. Our analyses indicate there are no significant associations with rare protein-coding variants with detectable effect sizes at our current sample sizes. Analyses will be updated as additional data become available, with results publicly browsable at https://rgc-covid19.regeneron.com.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

1202 Validation Of A Novel Wearable Home Sleep Testing Device For Assessment Of Obstructive Sleep Apnea

Introduction

There is a substantial need for an accurate and easy-to-use tool for obstructive sleep apnea (OSA) assessment. Belun Ring Platform (BRP), a novel photoplethysmography (PPG)-based home sleep apnea testing system with a proprietary deep learning algorithm, has been shown to have good sensitivity and specificity in predicting OSA in subjects without significant comorbidities and medications known to affect heart rate (HR). In this study, we further tested its performance in subjects referred for in-lab polysomnography (PSG) assessment of sleep disorders without excluding those with non-arrhythmia comorbidities or the subjects on HR-affecting medications.

Methods

PSG was recorded simultaneously with the Ring in the sleep lab and the studies were manually scored by certified sleep technicians according to the AASM Scoring manual version 2.4. Exclusion criteria include age &lt;18, unstable cardiopulmonary status, recent hospitalization within 30 days, significant arrhythmias, baseline HR &lt;50 or &gt;100, home oxygen use, pacemaker/defibrillator, post-cardiac transplantation or Left ventricular assist device.

Results

A cohort of 78 individuals (26 males and 52 females, age 50.5) were studied with 26 taking HR-affecting medications. Of these, 35 (45%) had AHI &lt; 5; 14 (18%) had AHI 5-15; 15 (19%) had AHI 15-30; 14 (18%) had AHI &gt; 30. The Ring-REI correlated well with the PSG-AHI (r =0.83, P &lt;0.001). The accuracy, sensitivity, specificity in categorizing AHI &gt;15 were 0.808, 0.931, and 0.735 respectively. The positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were 0.675, 0.947, 3.509, and 0.094 respectively. The use of HR-affecting medications did not significantly affect the sensitivity and specificity of BRP in predicting OSA (P =0.16 and 0.44 respectively).

Conclusion

BRP is promising as a reasonable tool for OSA assessment and can potentially be incorporated into a broad spectrum of clinical practices for identification of patients with OSA.

Support

This study is supported by a Grant from Belun Technology Company Limited.

Comment on the European position paper on diagnostic tools in rhinology â€" computational fluid dynamics

We read with interest the excellent paper authored by Rimmer et al. (1) entitled The European Position Paper on Diagnostic Tools in Rhinology. The authors are to be commended for their comprehensive, up-to-date and thorough summary of available tests in the assessment of rhinologic function. The paper describes traditional tools used in nasal airway obstruction (NAO); including subjective patient reported outcome measure questionnaires (PROMs) such as the NOSE scale; tests that are subjective to the clinician, such as clinical examination, nasendoscopy and imaging; and objective tests such peak nasal inspiratory flow (PNIF), rhinomanometry (RM) and acoustic rhinometry (AR). Unfortunately, each of these readily available, traditional tools fail to meet several accepted criteria of an ideal diagnostic test (Table 1), as outlined (2,3). In our opinion, these limitations restrict the capacity of Rhinology to develop as a discipline founded on sound evidence-based science.

Subjective speckle suppression for 3D measurement using one-dimensional numerical filtering

Laser speckle projection is a reliable method to generate statistical illumination patterns for 3D reconstruction purposes as in stereo photogrammetry. This type of pattern has several advantages compared to incoherent methods. However, the biggest disadvantage is given by the coherent noise, the so-called "subjective speckles," developing when a coherently illuminated surface is imaged by a lens system. Some experimental techniques have been published already, being costly in measurement time or leading to loss in light intensity and/or depth of field. In this work we want to present numerical one-dimensional filtering techniques that reduce this kind of noise and increase the performance of 3D reconstruction, while no experimental changes to the classical speckle projection technique have to be made. Therefore, a model describing the expectable contrast reduction is derived, the dependency between filter orientation and setup geometry is investigated, and results from simulations and real experiments are shown. It is found that for small filter sizes the results can be improved independent of the filter, but that in the general case a vertical orientation of the filter towards the setup geometry is most useful.

Correction: Exploring pre-surgery and post-surgery substance use disorder and alcohol use disorder in bariatric surgery: a qualitative scoping review

In the original Article, Leo Akioyamen's surname was misspelled as "Aikiyomen." This has been updated in the XML, PDF and HTML versions of this Article.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Author Correction: Chemotherapy with radiotherapy influences time-to-development of radiation-induced sarcomas: a multicenter study

Since the publication of this paper, the authors noticed an error in Fig. 1. The X-axis on all the figure panels should read 'Time (years)', not 'Time (months)'. The corrected Fig. 1 is shown below.

Abstract P2-03-03: A multicenter clinical study of Xpert® breast cancer STRAT4 demonstrates high concordance with central lab ER, PgR, HER2, and Ki67 IHC and HER2 FISH tests in FFPE breast tumor tissues

The Xpert® Breast Cancer STRAT4 (STRAT4) is a CE-IVD marked, semi-quantitative, cartridge-based RT-qPCR assay for the detection of ESR1, PGR, ERBB2 (HER2), and MKi67 mRNAs from formalin fixed, paraffin embedded (FFPE) breast tumors. The assay is fast (&lt; 2 hrs), reproducible, robust, and easy to perform.

The aim of this multicenter clinical study was to assess the performance characteristics of the STRAT4 assay relative to central lab immunohistochemistry (IHC) for ER, PgR, HER2, and Ki67 and to fluorescence in situ hybridization (FISH) for HER2 gene amplification.

Methods: A total of 200 archived primary invasive breast cancer FFPE blocks were sourced from Indivumed for this study. From each block, twelve (12) adjacent tissue sections (4-µm thickness) on slides were prepared for pathological H&E confirmation to define tumor area, and for testing by STRAT4, IHC (ER, PgR, HER2,Ki67), and HER2 FISH. Standard STRAT4 lysate preparation using a single unstained slide per specimen and testing on N=84, N=68, and N=48 samples was performed at 3 independent sites, respectively (2 US and 1 EU). A single slide from each specimen was also processed using the recommended concentrated lysate procedure for STRAT4 testing at Cepheid. All IHC and FISH testing was performed by a central academic reference laboratory in the US. For a given sample, STRAT4 data generated using the standard lysate procedure was included for concordance analysis when all target gene test results were valid. In cases where the standard lysate preparation yielded indeterminate test results for any target, data from the concentrated lysate preparation was used for the data analysis. Receiver Operating Characteristic (ROC) analysis, overall percent agreement (OPA), positive percent agreement (PPA), and negative percent agreement (NPA) between STRAT4 and IHC (IHC/FISH for HER2) were determined for ESR1,PGR, ERBB2, and MKi67.

Results: Of the 200 samples tested by STRAT4, all samples generated valid results for ESR1 and ERBB2, 199 of 200 samples were valid for PGR, and 198 of 200 samples were valid for MKi67 using the standard or concentrated lysate preparation protocol. One sample failed to generate results for both ER and PgR IHC. Twelve samples failed to yield HER2 FISH results.

The STRAT4 success rate and results concordance with IHC were comparable across study sites. OPA between STRAT4 and IHC was 97% for ESR1, 88.9% for PGR, 93.3% for HER2 (92.4% for IHC and FISH), and 90.7% for MKi67 (excluding IHC 10-20% staining). Areas under the ROC curves were 0.9922 for ESR1, 0.9509 for PGR, 0.9958 for ERBB2, and 0.9395 for MKi67.

Conclusion: STRAT4 measurements for ESR1, PGR, ERBB2 and MKi67 mRNA expression are robust and highly concordant with IHC (IHC/FISH for HER2). The technical portion of the assay is easily performed in &lt; 2 hrs including hands-on time using standard FFPE tissue sections. Xpert STRAT4 offers local pathology labs an alternative to centralized, subjective IHC/FISH tests that require a higher level of expertise. Further investigations correlating STRAT4 markers directly with clinical outcomes in independent cohorts are in progress.

Citation Format: Wu NC, Wong E, Acca B, Birkmeier J, Tran L, Zhao S, Wong W, Chu VC, Ho K, Malek M, Lu C, Ge G, David K, Quigley NB, Beqaj SS, Davenport S, Weidler J, Bates M, Press M. A multicenter clinical study of Xpert® breast cancer STRAT4 demonstrates high concordance with central lab ER, PgR, HER2, and Ki67 IHC and HER2 FISH tests in FFPE breast tumor tissues [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-03.

A Case of Risperidone-Associated Neuroleptic Malignant Syndrome in a Patient Receiving Long-Term Haloperidol Treatment

We report a case of risperidone-associated neuroleptic malignant syndrome. A 53-year-old gentleman with mental retardation, psychosis and hypertension who was on long term haloperidol, lorazepam and atenolol treatment presented to the Department of Emergency Medicine of the Singapore General Hospital with hyperthermia, generalised rigidity, impaired consciousness and diaphoresis five weeks after adding on risperidone. Biochemical investigations revealed hyponatremia, raised creatine kinase levels and myoglobinuria. Chest X-ray showed consolidative changes in the right upper and middle zones and left middle zone. He was diagnosed as neuroleptic malignant syndrome with rhabdomyolysis, and aspiration pneumonia. He was discharged well after 13 days.

Focused Assessment with Sonography in Trauma (FAST): Experience of a Tertiary Hospital in Southeast Asia

Objective

This study compares the positive predictive value (PPV) and negative predictive value (NPV) of focused assessment with sonography in trauma (FAST) versus abdominal-pelvic computed tomography scans (CTAP) after blunt abdominal injury as well as the need for abdominal surgery. We also sought to determine if any false negative ultrasound studies were associated with significant morbidity. The results were compared with other studies.

Design

Retrospective cross-sectional study.

Setting

A tertiary hospital.

Methods

Cases were retrieved from the trauma registry and electronic medical records in a tertiary hospital in Singapore over a two year period from 1 January 2009 to 31 December 2010. Exclusion criteria included penetrating trauma and burns. The sonographic finding, computed tomography finding, and the outcome of the patients were retrieved. Diagnostic characteristics including predictive values were calculated.

Results

A total of 476 patients were enrolled. Four hundred fifty-nine patients had FAST performed with fifty (10.9%) being positive. Forty-nine patients (21.7%) out of 226 patients had CTAP which showed abnormalities and nineteen (4.0%) patients underwent surgery. Comparing FAST to detect abnormalities on CTAP, the PPV and NPV were 0.590 and 0.863 respectively. Comparing FAST with the need for surgery, the PPV and NPV were 0.280 and 0.990 respectively. Four patients (0.98%) had negative FAST but required surgery. There were no significant adverse outcomes or surgical intervention in patients with normal vital signs, normal initial physical examination and negative FAST findings but who did not have a CTAP.

Conclusions

In patients with an initial normal physical examination and negative FAST, emergent CTAP may be avoided. (Hong Kong j.emerg.med. 2014;21:230-236)

Canadian Computed Tomography Head Rule and Its Impact on Singaporean Practice

Introduction

We aim to determine the usefulness of the Canadian Computed Tomography (CT) Head Rule in patients who present with minor and minimal head injury to the emergency department.

Methods

Clinical information was retrospectively collected and the need for CT head was evaluated. The primary outcome measure was the requirement for neurological intervention. The secondary outcome measure was brain injury requiring admission or neurological follow-up.

Results

A total of 1127 cases were reviewed. About 6.3% had clinically important brain injury; and 1.2% required neurological intervention. The high-risk factors were 45.2% sensitive (95% confidence interval [CI]=27.8-63.7%) and 76.2% specific (95% CI=73.5-78.7%) for predicting need for neurological intervention. All seven risk factors were 73.2% sensitive (95% CI=61.2-82.7%) and 69.8% specific (95% CI=66.9-72.5%) for predicting clinically important brain injury. Overall, the rule had a positive predictive value of 14.0 (95% CI=10.7-18.1) and negative predictive value of 97.5 (95% CI=96.0-98.4).

Conclusions

In this retrospective validation of the Canadian CT Head Rule in the Singaporean context, we conclude that the lower sensitivity of the rule could be attributed to local neurosurgical practice, lack of application of the rule among clinicians and inclusion of patients with minimal head injury. Practically, the high NPV will mean that patients who do not fulfill the rule can be safely discharged with head injury advice, without the need for a scan. The judicious use of CT head can achieve savings for our health-care system. (Hong Kong j.emerg.med. 2015;22:359-363)

Knowledge and Beliefs of Parents of Asthmatic Children Presenting to an Emergency Department

This is a survey on the knowledge and beliefs of 100 parents or guardians of asthmatic children presenting to the emergency department with an asthmatic attack and staying in the observation ward for treatment. The parents were asked to fill in a questionnaire on their knowledge and beliefs about asthma. Demographic data and data related to routine asthma care were also collected. The mean age of the children was 6.2± 3.2. The mean duration of asthma was 3.4 year (±2.6). In the preceding 6 months the mean attendance frequency at our accident and Energency department was 1.5±1.4. The majority of respondent (79%) agreed that asthma is caused by bronchoconstriction but only 42% understood that mucosal oedema is involved during an acute attack. Many people (82%) believed that asthma is just sensitive bronchus. Less than half (40%) believes asthma is a hereditary disease. It was a common belief that asthmatic attack can be precipitated by a change of weather (89%) and cold food/drink (77%). Over 75% agreed that carpet in the house is undesirable for an asthmatic child. The majority of parents (69%) disagreed that an asthmatic child should avoid physical exercise and only 13 would not allow the child to attend physical exercise class. Over half (54%) of the respondents believed that asthma could be cured. Only a minority (17%) believed that antibiotics are useful in shortening the attack. Thirty (30%) respondents also used alternative means of therapy for example crocodile meat. Parents' knowledge of preventive medication was inadequate. Understanding common beliefs among parents is beneficial in patient and parental education.

Nephrotic syndrome as a complication of chronic graft-versus-host disease after allogeneic haemopoietic stem cell transplantation

Nephrotic syndrome (NS) is a rare complication following allogeneic haemopoietic stem cell transplantation (allo-HSCT), with limited current understanding of its pathogenesis. Here, we describe four cases of NS following allo-HSCT diagnosed at our institutions to identify key clinical and pathological features. In addition, a PubMed search was performed to identify existing reports that were pooled together with our cases for analysis. NS occurred as a late complication following allo-HSCT, with median onset 19.5 months after transplant (range: 3.9-84 months). The most common histopathology observed was membranous nephropathy; however, cases of minimal change disease have also been reported. There is a high incidence of prior extra-renal graft-versus-host disease (GvHD), with all four of our cases and 82% of published cases having prior GvHD. Glucocorticosteroids are the most common treatment, with variable degrees of response. Responses to immunosuppression with calcineurin inhibitors and rituximab have been described in steroid-refractory cases.