Recruitment Strategies in the Integration of Mobile Health Into Sickle Cell Disease Care to Increase Hydroxyurea Utilization Study (meSH): Multicenter Survey Study

BACKGROUND

Hydroxyurea is an evidence-based disease-modifying therapy for sickle cell disease (SCD) but is underutilized. The Integration of Mobile Health into Sickle Cell Disease Care to Increase Hydroxyurea Utilization (meSH) multicenter study leveraged mHealth to deliver targeted interventions to patients and providers. SCD studies often underenroll; and recruitment strategies in the SCD population are not widely studied. Unanticipated events can negatively impact enrollment, making it important to study strategies that ensure adequate study accrual.

OBJECTIVE

The goal of this study was to evaluate enrollment barriers and the impact of modified recruitment strategies among patients and providers in the meSH study in response to a global emergency.

METHODS

Recruitment was anticipated to last 2 months for providers and 6 months for patients. The recruitment strategies used with patients and providers, new recruitment strategies, and recruitment rates were captured and compared. To document recruitment adaptations and their reasons, study staff responsible for recruitment completed an open-ended 9-item questionnaire eliciting challenges to recruitment and strategies used. Themes were extrapolated using thematic content analysis.

RESULTS

Total enrollment across the 7 sites included 89 providers and 293 patients. The study acceptance rate was 85.5% (382/447) for both patients and providers. The reasons patients declined participation were most frequently a lack of time and interest in research, while providers mostly declined because of self-perceived high levels of SCD expertise, believing they did not need the intervention. Initially, recruitment involved an in-person invitation to participate during clinic visits (patients), staff meetings (providers), or within the office (providers). We identified several important recruitment challenges, including (1) lack of interest in research, (2) lack of human resources, (3) unavailable physical space for recruitment activities, and (4) lack of documentation to verify eligibility. Adaptive strategies were crucial to alleviate enrollment disruptions due to the COVID-19 pandemic. These included remote approaching and consenting (eg, telehealth, email, and telephone) for patients and providers. Additionally, for patients, recruitment was enriched by simplification of enrollment procedures (eg, directly approaching patients without a referral from the provider) and a multitouch method (ie, warm introductions with flyers, texts, and patient portal messages). We found that patient recruitment rates were similar between in-person and adapted (virtual with multitouch) approaches (167/200, 83.5% and 126/143, 88.1%, respectively; P=.23). However, for providers, recruitment was significantly higher for in-person vs remote recruitment (48/50, 96% and 41/54, 76%, respectively, P<.001).

CONCLUSIONS

We found that timely adaptation in recruitment strategies secured high recruitment rates using an assortment of enriched remote recruitment strategies. Flexibility in approach and reducing the burden of enrollment procedures for participants aided enrollment. It is important to continue identifying effective recruitment strategies in studies involving patients with SCD and their providers and the impact and navigation of recruitment challenges.

TRIAL REGISTRATION

ClinicalTrials.Gov NCT03380351; https://clinicaltrials.gov/study/NCT03380351.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16319.

The complex landscape of intracellular signalling in protein modification under hyperglycaemic stress leading to metabolic disorders

Hyperglycaemia is a life-threatening risk factor that occurs in both chronic and acute phases and has been linked to causing injury to many organs. Protein modification was triggered by hyperglycaemic stress, which resulted in pathogenic alterations such as impaired cellular function and tissue damage. Dysregulation in cellular function increases the condition associated with metabolic disorders, including cardiovascular diseases, nephropathy, retinopathy, and neuropathy. Hyperglycaemic stress also increases the proliferation of cancer cells. The major areas of experimental biomedical research have focused on the underlying mechanisms involved in the cellular signalling systems involved in diabetes-associated chronic hyperglycaemia. Reactive oxygen species and oxidative stress generated by hyperglycaemia modify many intracellular signalling pathways that result in insulin resistance and β-cell function degradation. The dysregulation of post translational modification in β cells is clinically associated with the development of diabetes mellitus and its associated diseases. This review will discuss the effect of hyperglycaemic stress on protein modification and the cellular signalling involved in it. The focus will be on the significant molecular changes associated with severe metabolic disorders.

Nano-therapeutics: The upcoming nanomedicine to treat cancer

Nanotechnology is considered a successful approach for cancer diagnosis and treatment. Preferentially, cancer cell recognition and drug targeting via nano-delivery system include the penetration of anticancer agents into the cell membrane to damage the cancer cell by protein modification, DNA oxidation, or mitochondrial dysfunction. The past research on nano-delivery systems and their target has proven the beneficial achievement in a malignant tumor. Modern perceptions using inventive nanomaterials for cancer management have been offered by a multifunctional platform based on various nano-carriers with the probability of imaging and cancer therapy simultaneously. Emerging nano-delivery systems in cancer therapy still lack knowledge of the biological functions behind the interaction between nanoparticles and cancer cells. Since the potential of engineered nanoparticles addresses the various challenges, limiting the success of cancer therapy subsequently, it is a must to review the molecular targeting of a nano-delivery system to enhance the therapeutic efficacy of cancer. This review focuses on using a nano-delivery system, an imaging system, and encapsulated nanoparticles for cancer therapy.

Multiple genetic loci influence vaccine-induced protection against Mycobacterium tuberculosis in genetically diverse mice

Mycobacterium tuberculosis (M.tb.) infection leads to over 1.5 million deaths annually, despite widespread vaccination with BCG at birth. Causes for the ongoing tuberculosis endemic are complex and include the failure of BCG to protect many against progressive pulmonary disease. Host genetics is one of the known factors implicated in susceptibility to primary tuberculosis, but less is known about the role that host genetics plays in controlling host responses to vaccination against M.tb. Here, we addressed this gap by utilizing Diversity Outbred (DO) mice as a small animal model to query genetic drivers of vaccine-induced protection against M.tb. DO mice are a highly genetically and phenotypically diverse outbred population that is well suited for fine genetic mapping. Similar to outcomes in people, our previous studies demonstrated that DO mice have a wide range of disease outcomes following BCG vaccination and M.tb. challenge. In the current study, we used a large population of BCG-vaccinated/M.tb.-challenged mice to perform quantitative trait loci mapping of complex infection traits; these included lung and spleen M.tb. burdens, as well as lung cytokines measured at necropsy. We found sixteen chromosomal loci associated with complex infection traits and cytokine production. QTL associated with bacterial burdens included a region encoding major histocompatibility antigens that are known to affect susceptibility to tuberculosis, supporting validity of the approach. Most of the other QTL represent novel associations with immune responses to M.tb. and novel pathways of cytokine regulation. Most importantly, we discovered that protection induced by BCG is a multigenic trait, in which genetic loci harboring functionally-distinct candidate genes influence different aspects of immune responses that are crucial collectively for successful protection. These data provide exciting new avenues to explore and exploit in developing new vaccines against M.tb.

Non-uniform fuel distribution and thermo-mechanical analysis of a 1 MW thermal power micronuclear heat pipe reactor

One of the goals in improving the design of compact portable micronuclear heat pipe reactors is to enhance their operating life so that they can generate maximum power within safe nuclear, thermal, and mechanical limits and with minimal human intervention. This work carries out an analysis to estimate the effect of non-uniform fuel enrichment and thermo-mechanical performance of a 1 MW thermal power uranium nitride fueled Micro Nuclear Heat Pipe Reactor (MNHPR). For neutronic and thermo-mechanical analyses, the open-source Monte Carlo code OpenMC and the COMSOL Multiphysics codes are used. The neutron flux distribution and subsequent fuel temperature, heat transport, stresses and strains are estimated. The analysis of core power distribution shows an uneven power distribution resulting in hot spots. The maximum fuel centerline temperature of 1353 K at the highest peaking factor 1.22 is within the safety limit. However, the high temperature results in higher thermal stress and subsequent displacement of 119 μ m that exceeds the 100 μ m fuel-clad gap. Power peaking thus significantly limits the maximum allowed operating power. In this study it is found that non-uniform placement of the fuel reduces power peaking and enhances the overall core performance. It is recommended to consider each fuel ring as a separate zone and gradually change the fuel enrichment in each zone. The non-uniform distribution of the fuel follows the gradual increase of enrichment from ring 1 to ring 5 with max enrichment in ring 5, and then a drop in the enrichment to mitigate any peaking in ring 6 due to its proximity to the reflector. From ring 1 to ring 6 fuel of 60-62-70-70-75-65 percent enrichment is recommended. The proposed fuel strategy mitigates power peaking in the core and enhances the maximum safe operating power level by 15 % from 775 kW to 893 kW without physical design change.

Structural perturbations induced by cumulative action of methylglyoxal and peroxynitrite on human fibrinogen: An in vitro and in silico approach

Methylglyoxal (MGO); a reducing sugar and a dicarbonyl; attaches to the biomolecules (proteins, lipids, and DNA) leading to glycation and accumulation of oxidative stress in cells and tissues. Superoxide anion formed under such conditions entraps free nitric oxide radical (NO) to form peroxynitrite (PON). Nitro-oxidative stress due to PON is well established. Human fibrinogen plays a key role in haemostasis and is a highly vulnerable target for oxidation. Modifications of fibrinogen can potentially disrupt its structure and function. Earlier evidence suggested that glycation and nitro-oxidation lead to protein aggregation by making it resistant to lysis. This study aims to reveal the structural perturbations on fibrinogen in the presence of MGO and PON synergistically. The in vitro glyco-nitro-oxidation of human fibrinogen by MGO and PON leads to substantial structural alterations, as evident by biophysical and biochemical studies. In-silico results revealed the formation of stable complexes. UV-visible, intrinsic fluorescence, and circular dichroism investigations confirmed the synergistic effect of MGO and PON caused micro-structural modifications leading to secondary structural alterations. AGEs formation in MGO-modified fibrinogen reduced the free lysine and free arginine residues which were quantified by TNBS and phenanthrenequinone assays. Enhanced oxidative status was confirmed by estimating carbonyl content. ANS fluorophore validated exposure of hydrophobic patches in modified protein and thioflavin-T showed maximum binding with synergistically modified fibrinogen, indicated the formation of β-sheet. Confocal and electron microscope results corroborated the formation of aggregates. This study, therefore, evaluated the impact of MGO and PON on the structural integrity, oxidative status and aggregate formation of fibrinogen that can aggravate metabolic complications.

Generation of autoantibodies against glycated fibrinogen: Role in diabetic nephropathy and retinopathy

The process of glycation, characterized by the non-enzymatic reaction between sugars and free amino groups on biomolecules, is a key contributor to the development and progression of both microvascular and macrovascular complications associated with diabetes, particularly due to persistent hyperglycemia. This glycation process gives rise to advanced glycation end products (AGEs), which play a central role in the pathophysiology of diabetes complications, including nephropathy. The d-ribose-mediated glycation of fibrinogen plays a central role in the pathogenesis of diabetes nephropathy (DN) and retinopathy (DR) by the generation and accumulation of advanced glycation end products (AGEs). Glycated fibrinogen with d-ribose (Rb-gly-Fb) induces structural changes that trigger an autoimmune response by generating and exposing neoepitopes on fibrinogen molecules. The present research is designed to investigate the prevalence of autoantibodies against Rb-gly-Fb in individuals with type 2 diabetes mellitus (T2DM), DN & DR. Direct binding ELISA was used to test the binding affinity of autoantibodies from patients' sera against Rb-gly-Fb and competitive ELISA was used to confirm the direct binding findings by checking the bindings of isolated IgG against Rb-gly-Fb and its native conformer. In comparison to healthy subjects, 32% of T2DM, 67% of DN and 57.85% of DR patients' samples demonstrated a strong binding affinity towards Rb-gly-Fb. Both native and Rb-gly-Fb binding by healthy subjects (HS) sera were non-significant (p > 0.05). Furthermore, the early, intermediate, and end products of glycation have been assessed through biochemical and physicochemical analysis. The biochemical markers in the patient groups were also significant (p < 0.05) in comparison to the HS group. This study not only establishes the prevalence of autoantibodies against d-ribose glycated fibrinogen in DN but also highlights the potential of glycated fibrinogen as a biomarker for the detection of DN and/or DR. These insights may open new avenues for research into novel therapeutic strategies and the prevention of diabetes-related nephropathy and retinopathy.

GCMS characterization and biological potential of the seeds and aerial part of Galium tricorne Stokes

Abstract Natural products have long been proven very effective against various challenging diseases including cancer and bacterial infections. Galium tricorne is one of the important source of natural products, which has not been explored till date in spite of its profound ethnomedicinal prominence. The current study has been designed to explore the biological potential of G. tricorne and to extract and isolate chemical constituents from its aerial part and seeds respectively along with identification of their chemical constituents. Phytochemical screening was performed to figure out the presence of secondary metabolite in G. tricorne. Crude Methanolic extract (Gt.Crd), which was obtained from the aerial part while the fatty acids were extracted from the seeds, which were later on analyzed by GCMS. Similarly, Well Diffusion and MTT method were used for antibacterial activity and cancer cell line assay respectively. To evaluate the cytotoxic potential, brine shrimps were used. Likewise, in Gas Chromatography-Mass Spectroscopy (GC-MS) analysis a total number of 23 compounds were identified in Gt.Crd extract out of which 7 compounds were sorted out to have some sort of toxicity profile. In the same fashion, 5 fatty acids were identified in the seeds of G. tricorne. Moreover, among the fractions, chloroform fraction (Gt.Chf) exhibited greater zone of inhibition (ZOI) 20.37 mm followed by Gt.Crd 18.40 mm against S. aureus and S. pyogenes respectively. In cytotoxicity Gt.Chf was more active followed by ethyl acetate fraction (Gt.Eta) by exhibiting 88.32±0.62% (LC50=60 µg/mL) and 73.95±2.25% (LC50=80 µg/mL) respectively at 1000 µg/mL concentration of the tested sample. Gt.Chf exhibited greater cell line inhibitory activity (IC50=61 µg/mL) against HeLa cell line. Similarly, Gt.Crd displayed IC50 values of 167.84 µg/mL and 175.46 µg/mL against HeLa and NIH/3T3 cell line respectively. Based on the literature review and screenings, it may be concluded that the aerial part and seeds of G. tricorne are the rich sources of bioactive compounds. The results of the current study also authenticate the scientific background for the ethnomedicinal uses of G. tricorne.

Numerical analysis of radiative hybrid nanomaterials flow across a permeable curved surface with inertial and Joule heating characteristics

The water-based Cu and CoFe2O4 hybrid nano liquid flow across a permeable curved sheet under the consequences of inertial and Lorentz forces has been reported in this analysis. The Joule heating and Darcy Forchheimer effects on fluid flow have been also examined. In the presence of copper (Cu) and cobalt iron oxide (CoFe2O4) nanoparticles, the hybrid nano liquid is synthesized. Radiation and heat source features are additionally incorporated to perform thermodynamics analysis in detail. The second law of thermodynamics is employed in order to estimate the overall generation of entropy. The nonlinear system of PDEs (partial differential equations) is transformed into a dimensionally-free set of ODEs (ordinary differential equations) by employing a similarity framework. The Mathematica built in package ND Solve method is applied to compute the resulting set of nonlinear differential equations numerically. Along with the velocity, and temperature profiles, skin friction and Nusselt number are also computed. Figures and tables illustrate the effects of flow factors on important profiles. Evidently, the outcomes reveal that hybrid nanofluid (Cu + CoFe2O4+H2O) is more progressive than nanofluid (Cu + H2O) and base fluid (H2O) in thermal phenomena. Furthermore, the velocity profile is improved with the greater values of curvature parameter, while the inverse trend is observed against the magnetic parameters. Also, the velocity and energy distribution of hybrid nano-liquid flow boosts with the inclusion of Cu and CoFe2O4 nanoparticles into the base fluid. Velocity distribution diminishes with the increment of volume friction. For high values of inertial factor, skin friction improve while velocity and Nusselt number declines.

Correlation of Transient Elastography with Liver Iron Concentration and Serum Ferritin Levels in Patients with Transfusion-Dependent Thalassemia Major from Oman

Aims

In a longitudinal study, we aimed to assess the correlation between ultrasound transient elastography (TE), serum ferritin (SF), liver iron content (LIC) by magnetic resonance imaging (MRI) T2* along with the fibrosis-4 (FIB-4) score as a screening tool to detect significant liver fibrosis among chronically transfusion-dependent beta-thalassemia (TDT) patients.

Methods

The study was conducted at a tertiary health center treating TDT patients. Transient elastography was performed within 3 months of Liver MRI T2* examinations at the radiology department over a median of one-year duration. T-test for independent data or Mann-Whitney U test was used to analyze group differences. Spearman correlation with linear regression analysis was used to evaluate the correlation between TE liver stiffness measurements, Liver MRI T2* values, and SF levels.

Results

In this study on 91 patients, the median age (IQR) of the subjects was 33 (9) years, and the median (IQR) body mass index was 23.8 (6.1) kg/m2. Median (IQR) TE by fibroscan, MRI T2*(3T), Liver iron concentration (LIC) by MRI Liver T2*, and SF levels were 6.38 (2.6) kPa, 32.4 (18) milliseconds, 7(9) g/dry wt., and 1881 (2969) ng/mL, respectively. TE measurements correlated with LIC g/dry wt. (rS =0.39, p=0.0001) and with SF level (rS =0.43, P=0.001) but not with MRI T2* values (rS =-0.24; P=0.98).

Conclusion

In TDT patients, liver stiffness measured as TE decreased significantly with improved iron overload measured as LIC by MRI and SF levels. However, there was no correlation of TE with the fibrosis-4 (FIB-4) score.

Post-COVID-19 vaccine uveitis: A case series

OBJECTIVE

With the recent emergence and worldwide distribution of COVID-19 vaccines, many side effects may be underreported and possibly unknown. Cases of vaccine-associated uveitis have been linked to almost all vaccines administered in the past; however, there is scarcity of literature providing insight into post-COVID-19 vaccine-associated uveitis. This case series documents patients presenting with uveitis after administration of the Pfizer and Moderna mRNA vaccines, in hope of advancing our current understanding of potential ocular complications of COVID-19 vaccines.

METHODS

Patients with ocular symptoms consistent with uveitis within 14 days after administration of the Pfizer or Moderna COVID-19 vaccines were included in this case series.

RESULTS

Eight patients with a mean age of 44.4 years (range, 19-83) were included. Six patients received a Pfizer, and 2 received a Moderna vaccine. Four patients presented after their first dose, 3 after their second dose, and 1 after both doses. The mean onset of ocular symptoms after the vaccine was 5.19 days (range, 1-14), and the mean BCVA was 0.678. Patients were diagnosed with bilateral anterior granulomatous uveitis (case 1), unilateral non-granulomatous anterior uveitis (case 2, 5-8), and bilateral non-granulomatous anterior uveitis (case 3-4).

CONCLUSIONS

The pathogenesis of vaccine-induced uveitis is not properly understood; however, the outcomes of this case series will aid in establishing a temporal association between the Pfizer and Moderna COVID-19 vaccines and the onset of uveitis. As the rate of COVID-19 vaccinations increases globally, it is imperative for physicians to be aware of the possible association and presentation of these ocular findings and diagnoses in order to treat patients effectively.

Barriers and Facilitators of Premarital Genetic Counseling for Sickle Cell Disease in Northern Nigeria

In high-income countries, premarital genetic counseling for Sickle Cell Disease (SCD) is a standard practice. However, in Nigeria, there is no formal premarital genetic counseling program available for SCD. We conducted a series of focus group discussions with health care professionals, patients with SCD, and parents of the patients with or without SCD to gain an understanding of their attitudes and beliefs towards SCD/Sickle Cell Trait and premarital genetic counseling for SCD. Data were analyzed using Charmaz's constructivist grounded theory approach. Two themes were highlighted in the analysis as follows: (1) the difference between the perception of premarital sickle cell screening among individuals with SCD versus the general population, and (2) the personal beliefs and physical challenges that could lead to the avoidance of premarital screening within the general community. Lack of disease-related knowledge, testing facilities, transportation, and stigma associated with the disease were the most commonly perceived barriers to premarital testing. Also, a willingness to receive premarital testing for SCD exists within our community to reduce the spread of the disease and advocate for improved health-related quality of life of patients with SCD. The content and structure of a premarital genetic counseling program in Kano, Northern Nigeria, needs to be developed.

Preliminary construct validity of patient-reported outcomes to assess chronic pain in adults with sickle cell disease

Chronic pain affects 30% to 40% of individuals with sickle cell disease (SCD) and impairs patient functioning. Clinically meaningful, practical, and valid assessment tools for investigation, evaluation, and management of chronic pain are limited, representing a barrier for advancing SCD care. We sought to determine whether patient-reported outcomes (PROs) show preliminary construct validity in identifying individuals with SCD who were a priori defined as suggestive of having chronic pain based on previously published criteria. All individuals completed the Patient-Reported Outcomes Measurement Information System (PROMIS) domains: pain interference, pain behavior, pain quality (nociceptive, neuropathic), fatigue, sleep disturbance, depression, and anxiety; the Adult Sickle Cell Quality of Life Measurement Information System (ASCQ-Me) domains: pain impact and emotional impact; and the painDETECT questionnaire. Thirty-three adults living with SCD were enrolled, and 42.4% had chronic pain. Pain-related PROs scores distinctly differentiated individuals with chronic pain from those without. Individuals with chronic pain had significantly worse pain-related PROs scores: PROMIS pain interference (64.2 vs 54.3), PROMIS pain behavior (63.2 vs 50), and ASCQ-Me pain impact (42.9 vs 53.2). According to published PROMIS clinical cut scores for the pain-related domains, individuals with chronic pain were categorized as having moderate impairment, whereas those without chronic pain had mild or no impairment. Individuals with chronic pain had PRO pain features consistent with neuropathic pain and worse scores in fatigue, depression, sleep disturbance, and emotional impact. Pain-related PROs show preliminary construct validity in differentiating individuals with and without chronic SCD pain and could be used as valuable tools for research and clinical monitoring of chronic pain.

Intravenous BCG Vaccination of Diversity Outbred Mice Results in Moderately Enhanced Protection against Challenge with Mycobacterium tuberculosis Compared to Intradermal Vaccination

Tuberculosis is still the leading cause of death globally from any infectious disease, despite the widespread use of the live attenuated vaccine Bacille Calmette Guerin (BCG). While BCG has some efficacy against disseminated TB disease in children, protection wanes into adulthood resulting in over 1.8 million TB deaths per year. This has led to efforts to develop novel vaccine candidates that either replace or boost BCG, as well as to test novel delivery mechanisms to enhance BCG's efficacy. Traditional BCG vaccination is performed as an intradermal (ID) injection but delivering BCG by an alternate route may enhance the depth and breadth of protection. Previously, we demonstrated that phenotypically and genotypically disparate Diversity Outbred (DO) mice have heterogenous responses to M. tuberculosis challenge following intradermal BCG vaccination. Here, we utilize DO mice to examine BCG-induced protection when BCG is delivered systemically via intravenous (IV) administration. We find that DO mice vaccinated with IV BCG had a greater distribution of BCG throughout their organs compared to ID-vaccinated animals. However, compared to ID-vaccinated mice, M. tuberculosis burdens in lungs and spleens were not significantly reduced in animals vaccinated with BCG IV, nor was lung inflammation significantly altered. Nonetheless, DO mice that received BCG IV had increased survival over those vaccinated by the traditional ID route. Thus, our results suggest that delivering BCG by the alternate IV route enhances protection as detected in this diverse small animal model.

Evidence of Antineutrinos from Distant Reactors Using Pure Water at SNO

The SNO+ Collaboration reports the first evidence of reactor antineutrinos in a Cherenkov detector. The nearest nuclear reactors are located 240 km away in Ontario, Canada. This analysis uses events with energies lower than in any previous analysis with a large water Cherenkov detector. Two analytical methods are used to distinguish reactor antineutrinos from background events in 190 days of data and yield consistent evidence for antineutrinos with a combined significance of 3.5σ.

Paediatric tibial shaft fractures: an instructional review for the FRCS exam

This instructional review presents the literature and guidelines relevant to the classification, management and prognosis of paediatric tibial shaft fractures at a level appropriate for the FRCS exit examination in Trauma and Orthopaedic surgery.

Sickle cell disease and social determinants of health: A scoping review

Social determinants of health (SDoH) may impact outcomes in sickle cell disease (SCD). We conducted a comprehensive literature review of five electronic databases to elucidate the relationship between SDoH and SCD, and identify gaps in the literature. Our search yielded 59 articles, which we organized into five SDoH areas: Neighborhood and Built Environment, Health and Healthcare, Social and Community Context, Education, and Economic Stability. We found that social determinants, such as access to healthcare, were inconsistently evaluated. Improved recognition and understanding of SDoH should enhance the development of programs that directly address its detrimental effects on patients with SCD.

“Achieving Optimal Clinical Outcomes in Autologous Fat Grafting: A Systematic Review of Processing Techniques”

BACKGROUND

Autologous fat grafting (AFG) is a versatile technique in reconstructive and cosmetic surgery. Graft processing is a key source of variability resulting in unreliable clinical outcomes, with no consensus on the optimal methodology. This systematic review identifies the evidence base supporting different processing paradigms.

METHODS

A systematic literature search was conducted using the PubMed, Scopus and The Cochrane Foundation databases. Studies comparing AFG processing methods and reporting long-term patient outcomes were identified.

RESULTS

Twenty-four studies (2413 patients) were identified. Processing techniques evaluated included centrifugation, decantation, washing, filtration, gauze rolling, as well as commercial devices and adipose-derived stem/stromal cell (ASC) enrichment methods. Objective volumetric and subjective patient-reported outcomes were discussed. There was a variable reporting of complications and volume retention rates. Complications were infrequent; palpable cysts (0-20%), surgical-site infections (0-8%) and fat necrosis (0-58.4%) were the most reported. No significant differences in long-term volume retention between techniques were found in AFG in the breast. In head and neck patients, greater volume retention was documented in ASC enrichment (64.8-95%) and commercial devices (41.2%) compared to centrifugation (31.8-76%).

CONCLUSIONS

Graft processing through washing and filtration, including when incorporated into commercial devices, results in superior long-term outcomes compared to centrifugation and decantation methods. ASC enrichment methods and commercial devices seem to have superior long-term volume retention in facial fat grafting.

Impact of the COVID-19 Pandemic on the Implementation of Mobile Health to Improve the Uptake of Hydroxyurea in Patients With Sickle Cell Disease: Mixed Methods Study

BACKGROUND

Hydroxyurea therapy is effective for reducing complications related to sickle cell disease (SCD) and is recommended by National Health Lung and Blood Institute care guidelines. However, hydroxyurea is underutilized, and adherence is suboptimal. We wanted to test a multilevel mobile health (mHealth) intervention to increase hydroxyurea adherence among patients and improve prescribing among providers in a multicenter clinical trial. In the first 2 study sites, participants were exposed to the early phases of the COVID-19 pandemic, which included disruption to their regular SCD care.

OBJECTIVE

We aimed to describe the impact of the COVID-19 pandemic on the implementation of an mHealth behavioral intervention for improving hydroxyurea adherence among patients with SCD.

METHODS

The first 2 sites initiated enrollment 3 months prior to the start of the pandemic (November 2019 to March 2020). During implementation, site A clinics shut down for 2 months and site B clinics shut down for 9 months. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the implementation and effectiveness of the intervention. mHealth implementation was assessed based on patients' daily app use. Adherence to hydroxyurea was calculated as the proportion of days covered (PDC) from prescription records over the first 12 and 24 weeks after implementation. A linear model examined the relationship between app usage and PDC change, adjusting for baseline PDC, lockdown duration, and site. We conducted semistructured interviews with patients, health care providers, administrators, and research staff to identify factors associated with mHealth implementation and effectiveness. We used a mixed methods approach to investigate the convergence of qualitative and quantitative findings.

RESULTS

The percentage of patients accessing the app decreased after March 15, 2020 from 86% (n=55) to 70% (n=45). The overall mean PDC increase from baseline to week 12 was 4.5% (P=.32) and to week 24 was 1.5% (P=.70). The mean PDC change was greater at site A (12 weeks: 20.9%; P=.003; 24 weeks: 16.7%; P=.01) than site B (12 weeks: -8.2%; P=.14; 24 weeks: -10.3%; P=.02). After adjustment, PDC change was 13.8% greater in those with increased app use after March 15, 2020. Interview findings indicated that site B's closure during COVID-19 had a greater impact, but almost all patients reported that the InCharge Health app helped support more consistent medication use.

CONCLUSIONS

We found significant impacts of the early clinic lockdowns, which reduced implementation of the mHealth intervention and led to reduced patient adherence to hydroxyurea. However, disruptions were lower among participants who experienced shorter clinic lockdowns and were associated with higher hydroxyurea adherence. Investigation of added strategies to mitigate the effects of care interruptions during major emergencies (eg, patient coaching and health navigation) may "insulate" the implementation of interventions to increase medication adherence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04080167; https://clinicaltrials.gov/ct2/show/NCT04080167.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/16319.

Paediatric distal radius fractures: an instructional review for the FRCS examination

An instructional review of the literature and guidelines relevant for the classification, management and prognosis of paediatric distal radius fractures. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Energetic and myocellular pathways in cardiac and skeletal muscle following anthracycline chemotherapy

Background

Anthracycline-related cardiac dysfunction is a recognised consequence of cancer therapies. Here we assess resting cardiac and skeletal muscle energic status as an early mechanistic pathway of myocyte derangement and explore molecular targets of skeletal myocyte metabolism, protein synthesis/degradation and mitochondrial biogenesis signalling.

Methods

We conducted a prospective, mechanistic, observational, longitudinal study of chemotherapy-naive breast cancer patients undergoing anthracycline-based chemotherapy, compared to a healthy control group. 31P-Magnetic Resonance spectroscopy in cardiac and skeletal muscle (phosphocreatine/gamma adenosine triphosphate (PCr/yATP) and inorganic phosphate/phosphocreatine (Pi/PCr) ratios respectively), cardiac magnetic resonance (CMR) imaging inclusive of T1 and T2 mapping, echocardiography-derived global longitudinal strain function, serum NT-pro-BNP and skeletal muscle biopsies from the right vastus lateralis were assessed before and after 3 cycles of Flurouracil, Epirubicin and Cyclophosphamide followed by 3 cycles of Docetaxel. Statistical significance was set at p&lt;0.05.

Results

Twenty-five female breast cancer patients (median age 53 years, range 32–74 years) receiving a mean epirubicin dose 307 mg/m2) and twenty-eight controls (median age 44 years, range 23–65) were recruited. All study assessments in breast cancer patients at pre-chemotherapy stage were comparable to the matched healthy controls. However, following chemotherapy, breast cancer patients demonstrated a small but significant reduction in cardiac function (global longitudinal strain −22.9±3.9 vs −19.1±3.3%, p=0.01 and CMR-derived ejection fraction 65±5 vs 62±4%, p=0.047), a mild increase in CMR-derived indexed left ventricular volumes (end diastolic 65±10 vs 74±11 ml/m2, p=0.014 and end systolic 23±5 vs 28±5 ml/m2, p=0.01) as well as an increase in left ventricular T1 and T2-mapping (1289±29 vs 1321±31 ms, p=0.004 and 50±4 vs 55±7 ms, p=0.027, respectively) and serum NT-Pro-BNP (49±25 vs 108±84 pg/m, p=0.008). After epirubicin, there was significant reduction in cardiac PCr/yATP ratio (2.0±0.7 vs 1.2±0.6, p=0.007) and a significant increase in skeletal muscle Pi/PCr ratio (0.13±0.04 vs 0.22±0.2, p=0.008) – Figure 1.

Following chemotherapy, there was significant upregulation of skeletal myocyte protein synthesis (mammalian target of rapamycin, 0.44±0.4 vs 0.53±0.2, p&lt;0.001) and degradation (Calcium/calmodulin dependent protein kinase II, 1.4±0.7 vs 2.7±1.1, p&lt;0.001), metabolism (peroxisome proliferator-activated receptor gamma, 0.35±0.2 vs 0.60±0.1, p&lt;0.001) and muscle mass regulator myostatin-2 (0.16±0.1 vs 0.24±0.1, p&lt;0.001).

Conclusion

Contemporary doses of epirubicin for breast cancer result in significant reduction of cardiac and skeletal muscle high energy 31P-metabolism alongside skeletal myocellular alterations of protein synthesis and metabolic regulation pathways.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Tenovus ScotlandNHS Grampian Endowment fund

Renin-angiotensin and endothelin systems in patients post takotsubo syndrome

Background

We investigate if renin-angiotensin and endothelin-1 response pathways follow the same pattern of recovery as left ventricular ejection fraction in patients with takotsubo syndrome.

Purpose

To provide better insight into the pathophysiology underlying this condition.

Methods

Ninety takotsubo syndrome patients [n=30 in each of “acute”, “convalescent” (3–5 months) and “recovered” (&gt;1 year) groups] who were on minimal or no medication and were free of any significant cardiac/metabolic co-morbidities, and 30 healthy controls were studied. Serum concentrations of renin, angiotensin converting enzyme, angiotensin II, big endothelin-1, endothelin-1 were measured using commercially available ELISA, and BNP was measured using an immunoassay.

Results

Left ventricular ejection fraction was 38±1.6% in acute, 63±2.0% in convalescent and 64±2.6% in recovered takotsubo syndrome patients. As shown in Figure 1, serum renin concentrations are persistently elevated after a takotsubo episode (p=0.03 vs controls). Angiotensin converting enzyme levels are significantly depressed during the acute phase compared to convalescent (p=0.004), recovered takotsubo (p=0.02) or controls (p=0.03). Angiotensin II is increased in takotsubo patients (p&lt;0.001 vs controls) remaining persistently elevated long-term in the recovered group (p=0.03 vs controls). B-type natriuretic peptide concentrations remain elevated after a Takotsubo episode compared to controls (p=0.003). Big endothelin-1 levels are unchanged, but endothelin-1 is significantly lower after takotsubo syndrome compared to controls (p=0.03).

Conclusions

Despite “normalisation” of the left ventricular ejection fraction, there is long-term maladaptive activation of renin-angiotensin system in takotsubo syndrome patients. This suggests therapy aimed at modulating this pathway may be beneficial in the long-term.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation

OUES from submaximal cardiopulmonary exercise

Introduction

Cardiopulmonary exercise testing (CPEX) provides valuable diagnostic and prognostic cardiopulmonary function data. However, in clinical setting a maximal test is not always achievable. The Oxygen Efficiency Uptake Slope (OUES) has been proposed as a possible submaximal measure of cardiopulmonary function as it remains relatively stable during the final quartile of the exercise test. This study explored the validity of OUES as a surrogate marker for cardiopulmonary function in the event of a submaximal test.

Methods

Four groups of subjects [128 healthy controls (73 M), 44 asymptomatic hypertensive (HT) patients (26 M), 67 adult cardiac congenital heart disease (ACHD) patients (44 M) and 35 Heart Failure with preserved Ejection Fraction (HFpEF) (10M) patients] were recruited after informed consent. All subjects underwent clinical assessment, resting ECG, blood pressure and spirometry prior to a treadmill CPEX to volitional exhaustion and a respiratory exchange ratio (RER) of at least 1.1 using the same testing protocol. Peak VO2 (ml/min) was recorded from the last 5s of the maximal test (RER=1.1) and OUES was calculated from complete (RER=1.1) and truncated (RER=0.9) gas exchange data. The linear relationships between absolute peak VO2 and OUES from complete and truncated gas exchange data were assessed using Pearson's correlation coefficient. Subsequently, the two correlations obtained in each patient group were compared. Statistical significance was set at p&lt;0.01.

Results

Mean and 95% confidence intervals of the peak VO2 for males and females in each decile of life examined in the 4 subject groups are shown in the Figure. Peak VO2 values achieved in each of the patient groups were significantly lower when matched for age and sex compared to healthy participants (HT p=0.006, ACHD patients p&lt;0.001 and HFpEF patients p&lt;0.001).

In all 4 groups there was a good correlation between absolute peak VO2 and the OUES at RER 1.1 (healthy volunteers r=0.910, p&lt;0.001, HT r=0.899, p&lt;0.001, ACHD r=0.816, p&lt;0.001 and HFpEF r=0.846, p&lt;0.001). Correlations were inferior for absolute peak VO2 and OUES at RER 0.9 (healthy volunteers r=0.74, p&lt;0.001, HT r=0.780, p&lt;0.001, ACHD r=0.651, p&lt;0.001 and HFpEF r=0.817, p&lt;0.001). Correlations between absolute peak VO2 vs OUES at RER of 1.1 and 0.9 were significantly different only for healthy controls (p=0.001, Z-score = −4.649), but not for HT (p=0.05, Z-score = −1.909), ACHD (p=0.04, Z-score = −2.080) or HFpEF (p=0.7, Z-score = −0.377) patients.

Conclusion

Our data support the use of submaximal OUES at an RER of 0.9 as a surrogate marker for absolute peak VO2 obtained at an RER of 1.1, especially in patients, in whom it can often be difficult to achieve maximal exercise.

Funding Acknowledgement

Type of funding sources: None.

Assessment of skeletal relationships in cleft palate with or without cleft lip: A cone-beam computed tomography study in a pakistani population

BACKGROUND

Understanding the different skeletal relationships in orofacial clefts by using cone-beam computed tomography (CBCT) may eventually lead to developing better diagnosis and treatment protocols for facial deformities.

AIMS

The objective of this study was to investigate the different skeletal relationships in the cleft palate with or without cleft lip (CP ± L), using CBCT scans. This is a retrospective study conducted at the Orthodontics and Oral Radiology department, CMH-Lahore medical college and Institute of dentistry. In the current study, 4,152 CBCT scans (dcm format) were collected from a radiology center in Lahore, Pakistan between February 2015 and February 2018. All CBCT scans were imported to the Romexis Viewer, version 4.4.0 (Planmeca, Finland). Data sorting was performed to identify age, sex, cleft phenotype, unilateral cleft quadrant, sagittal skeletal relationship, and facial soft tissue involvement.

MATERIALS AND METHODS

Statistics were generated, using the Chi-square test. A P value <0.05 was considered statistically significant.

RESULTS

We identified 73 cases of CP ± L in the sample. The male-to-female ratio was 1.21:1. Bilateral cleft lip and palate (BCLP) mostly affected males (60%), whereas unilateral cleft lip and palate (UCLP) mainly affected females (57.6%), with a left-side female predominance. The different cleft phenotypes do not show any statistically significant difference regarding skeletal relationships and sex (P > 0.05).

CONCLUSIONS

Skeletal class III relationships were found to be predominant in both sexes, followed by class II, and class I skeletal relationships. Henceforth, such CP ± L patients should be pre-emptively screened in early life to avoid such skeletal complications.

No significant increase in Guillain-Barré syndrome after COVID-19 vaccination in adults: A vaccine adverse event reporting system study

Objective

To investigate the association between Guillain-Barré syndrome (GBS) and COVID-19 vaccination.

Background

On July 13, 2021, the US Food and Drug Administration (FDA) released a new warning that Johnson & Johnson COVID-19 vaccine could increase the risk of developing GBS.

Methods

The reporting rate of adult GBS after COVID-19 vaccination, ascertained with Brighton criteria, was compared with the reporting rate after other vaccinations during the same time period, and also compared with the reporting rate during control periods. Statistical methods such as proportion tests, and Pearson’s chi-squared test were utilized to identify significant relationships. Self-controlled and case centered analyses were conducted. A machine learning model was utilized to identify the factors associated with a worse outcome defined as emergency room (ER) or doctor visits, hospitalizations, and deaths.

Results

The reporting rate of GBS after COVID-19 vaccination was significantly higher than after influenza and other vaccinations (49.7, 0.19, 0.16 per 10 million, p < 0.0001). However, the reporting rate was within the incidence range of GBS in the general population. Using self-controlled and case centered analyses, there was a significant difference in the reporting rate of GBS after COVID-19 vaccination between the risk period and control period (p < 0.0001). There was an estimated 0.7–1.7 per million excess reports of GBS within 6 weeks of COVID-19 vaccination. Machine learning model demonstrated that female gender and age between 18 and 44 are associated with worse outcome. No association was found between the onset interval of GBS and its prognosis.

Conclusions

Although the reporting rate of GBS after COVID-19 vaccination was not statistically different than that of the general population, the increased reporting of GBS within the first 6 weeks after COVID-19 vaccination, more so than with other vaccinations, suggests that some cases of GBS are temporally associated with COVID-19 vaccination. However, there is a reduction in the reporting rate of GBS after other vaccines, compared to reporting rates pre-COVID-19, highlighting limitations inherent in any passive surveillance system. These findings warrant continuous analysis of GBS after COVID-19 vaccination. Further improvement of the machine learning model is needed for clinical use.

9 Complications of Bone-Anchored Hearing Aids (BAHA) in Patients

Aim

BAHA implants utilise bone conduction to treat hearing loss. The aim of the study was to understand the complication rate of patients receiving the implant compared to other studies and to identify any causative factor. Recommendations would therefore be made to reduce these complications.

Methodology

A retrospective cohort study was undertaken on 134 patients who received a BAHA implant performed by a single surgeon at Salford Royal NHS Foundation Trust between 01/01/2016 to 31/12/2018. Data collected identified complications of the surgery, whether or not the abutment was still in situ and whether the patient had any comorbidities or history of smoking

Results

33.6% of the patients had no complications after surgery with the remaining 66.4% having at least one complication. BAHA connect devices had a 67.2% complication rate, attract devices had a 33% complication rate. 13.6% of BAHAs were extruded. There was no positive correlation between either smoking or diabetes and poorer complication rate.

Conclusion

Implant extrusion can be prevented with irrigation cooling of the drill site. Immobilisation of the implant, proper wound care with brushing and using an Allevyn Acticoat 7 wound dressing improves outcomes. Attract systems have fewer complications rates so must be maximised where appropriate.

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.

POS0198 COVID-19 OUTCOMES IN PATIENTS WITH DERMATOMYOSITIS: A REGISTRY-BASED COHORT ANALYSIS

Background

Dermatomyositis (DM) patients have fewer risks of COVID-19 infection compared to the general population, however, certain subgroups with DM have worse outcomes. Men. African Americans, those with interstitial lung disease, exhibited higher risks of severe COVID-19. DMARD and glucocorticoid use was associated with frequent hospitalisations and severe sepsis.

Objectives

Rheumatic diseases (RDs) like DM, are previously known to be vulnerable towards various types of infections due to its aggressive activity mandating high dose immunosuppressive therapy. The severity of COVID-19 in RDs is limited in literature due to the heterogeneous nature of the condition. Therefore, specific details on mortality is essential to navigate any precautions required in the treatment.

Methods

Retrospective data of individuals with DM and COVID-19 and the general population with COVID-19 between January 2020 to August 2020 was retrieved from the TriNetX database. A one-to-one matched COVID-19 positive control was selected using propensity score (PS) matching. We assessed COVID-19 outcomes such as mortality, hospitalisation, ICU admission, severe COVID-19, mechanical ventilation (MV), acute kidney injury (AKI), venous thromboembolism (VTE), ischemic stroke, acute respiratory distress syndrome (ARDS), renal replacement therapy (RRT) and sepsis. Subgroup analyses included gender, race, ILD, cancer patients, disease-modifying rheumatic drugs (DMARDs) use, and glucocorticoids (GC) use (Figure 1).

Figure 1.

Overview of study

Results

We identified 5,574 DM patients with COVID-19, and 5,574 general population with COVID-19 (controls). DM with COVID-19 had a lower risk of mortality in comparison to controls [RR 0.76], hospitalisation [RR 0.8], severe COVID-19 [RR 0.76], AKI [RR 0.83], and sepsis [RR 0.73]. Males and African Americans were more likely to develop AKI [RR 1.35, 1.65], while African Americans had higher odds for severe COVID-19 [RR 1.62] and VTE [RR 1.54]. DM with ILD group also experienced higher odds for severe COVID-19 infection [RR 1.64], and VTE [RR 2.06] (Figure 1).

DM patients receiving DMARDs and glucocorticoids had higher odds for hospitalisation [RR 1.46, 2.12], and sepsis [RR 3.25] Subgroup analysis of neoplasms amongst DM patients with COVID-19 was inadequate for meaningful comparison (Figure 1).

Conclusion

DM patients are protected for certain aspects of COVID-19 disease, including severe COVID-19, hospitalization, and mortality. The African American race, male gender, ILD, DMARDS and glucocorticoid users, are associated with poor outcomes.

Disclosure of Interests

Latika Gupta: None declared, Haig Pakhchanian: None declared, Hiba Khan: None declared, Rahul Raiker: None declared, Maryam Abbasi: None declared, Charles DeYoung: None declared, Sinan Kardes Grant/research support from: SK has received congress travel, accommodation, and participation fee support (12th Anatolian Rheumatology Days) from Abbvie, Sakir Ahmed Speakers bureau: SA has received honorarium as speaker for Pfizer, Chengappa Kavadichanda: None declared, Parikshit Sen: None declared, Rohit Aggarwal Consultant of: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant., Grant/research support from: RA has/had a consultancy relationship with and/or has received research funding from the following companies-Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, and Abbvie, Janssen, Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant.

POS1421 AROMATASE INHIBITORS AND SKELETAL HEALTH – NATURAL HISTORY AND INTERVENTIONAL EPIDEMIOLOGY

Background

Breast cancer remains the most common cancer diagnosed in women worldwide. Aromatase inhibitors (AI) are employed for hormone sensitive disease in mainly postmenopausal women. AI related bone loss (AIBL) is a known complication; although data regarding the natural history in the real-world, long-term outcomes and the role of bone active therapy in fracture prevention is sparse.

Objectives

Our aim was to determine the real-world impact of AIBL and whether bone sparing therapy utilising standard risk stratification model is sufficient for fracture prevention.

Methods

We undertook a longitudinal study of patients prescribed AI for breast cancer over a seven-year period at our university teaching hospital. All the data was recorded electronically with full access to demographics, disease parameters, investigations and drug management. DEXA scans performed prior to initiation of AI were compared with subsequent imaging over a mean follow up of 3 years. Outcome data for cancer and all fractures was collected. Statistical analysis was done to investigate significant relationships amongst the variables of interest.

Results

1001 women were identified during the study period. The mean age of the cohort was 64 years (range 29-93). 929 (93%) were Caucasian, 57 (6%) were Asian and 15 (1%) were Afro-Caribbean. 723 women (72%) were diagnosed with invasive ductal carcinoma and 863 women (86%) were postmenopausal. At diagnosis, 428 women (43%) had node positive disease and 35 women (4%) had metastases. 91 women (9%) had sustained fractures prior to their breast cancer diagnosis.

All women had a baseline DEXA: 496 (49.6%) had osteopenia, 151 (15%) had osteoporosis and 354 (35.4%) had a normal result. 478 (48%) of women had a repeat scan available. Overall, there was a decline (from a mean of 0.888 g/cm2 to 0.858 g/cm2, p<0.0001) in left neck of femur (LNOF) bone mineral density (BMD) over time (mean of 3 years, with a range of 1-6).

334 (33%) were prescribed bone active therapy with 276 women (83%) given oral bisphosphonates. This group had an improvement in BMD by 0.4% (LNOF mean BMD of 0.785 g/cm2 at baseline compared to LNOF mean BMD of 0.788 at repeat DEXA, p=0.82).

Women who were not offered any treatment (n=667, 66%), showed a significant decline in bone density with the decline being -5%. (LNOF mean BMD of 0.939 g/cm2 at baseline compared to LNOF mean BMD of 0.888 g/cm2 at repeat DEXA, p< 0.0001).

The rate of fractures remained the same between the treatment (19 fractures, 5.67%) and non-treatment group (38 fractures, 5.70%)

Conclusion

Our study provides long term data for AIBL and confirms a significant decline in BMD over seven years. It confirms that bone sparing therapy is effective in reducing the pace of decline in BMD. However standard risk stratification model such as FRAX based intervention thresholds in mainly those with WHO defined osteoporosis (T ≤-2.5) is ineffective in fracture prevention in keeping with prior literature. Since our study period overlaps with publication of newer guidelines recommending different T score-based risk model, further studies are required to confirm their utility.

References

[1]https://www.wcrf.org/dietandcancer/worldwide-cancer-data/. Date accessed: 26.01.2022

[2]R. Coleman, J.J. Body, M. Aapro, et al., Bone health in cancer patients: ESMO clinical practice guidelines, Ann. Oncol. 25 (Suppl 3) (2014) iii124–iii137.

[3]E. Amir, B. Seruga, S. Niraula, et al., Toxicity of adjuvant endocrine therapy in postmenopausal breast cancer patients: a systematic review and meta-analysis, J. Natl. Cancer Inst. 103 (2011) 1299–1309.

Disclosure of Interests

None declared

OP0244 AROMATASE INHIBITORS AND FRACTURE PREVENTION – DO NEW GUIDELINES WORK IN REAL WORLD?

Background

2,261,419 women were diagnosed with breast cancer worldwide in 2020. For postmenopausal women with hormone sensitive disease, aromatase inhibitors (AI) are recommended for their mortality benefit. However, AI bone loss (AIBL) is a recognised adverse event with resultant increase in fracture risk. In 2017, a consensus statement of 7 international bone and cancer societies was published proposing an algorithm based on clinical risk factors and different bone mineral density (BMD) threshold for bone active therapeutic intervention.

Objectives

To determine the real-world impact of the 2017 consensus guidelines on AIBL and whether bone sparing therapy utilising proposed risk stratification model is effective in fracture prevention.

Methods

Over a 7-year study period, 1001 women were prescribed AI at our university teaching hospital. The new guidelines were adopted in July 2017. We split the participants in two groups: 361 (36%) women had commenced their AI prior to the adoption of guidelines and 640 (64%) were in the post implementation group.

First group were offered bone active treatment based on NOS 2009 guidelines whereas the second group followed the 2017 consensus guidelines. Women with osteoporosis were all offered treatment, however the difference in guideline is pertinent to osteopenia and we compared the results of that group.

Results

1001 women were included. Mean age was 64 years (range 29-93). 929 (93%) were Caucasian, 57 (6%) were Asian and 15 (1%) were Afro-Caribbean. 723 women (72%) had invasive ductal carcinoma and 863 women (86%) were postmenopausal. At diagnosis, 428 women (43%) had node positive disease and 35 women (4%) had metastases. 91 women (9%) had sustained fractures prior to their cancer diagnosis.

276 women (28%) were offered oral bisphosphonates based on DEXA result, with 58 (6%) offered parenteral therapy.

First group: 361 women had a baseline DEXA with a mean left neck of femur (LNOF) BMD of 0.888 g/cm2 (range 0.552-1.222). 143 (40%) women had a normal DEXA, 174 (48%) had osteopenia and 44 (12%) had osteoporosis.

Of the women with osteopenia, 44 (25%) women were offered treatment and 33 women had a repeat DEXA after a mean of 4 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.814 g/cm2 to 0.812 g/cm2 at the repeat DEXA (p= 0.94).

Of the 174 women with osteopenia, 22 (13%) women had a fracture.

Second group: 640 women had a baseline DEXA with a mean LNOF BMD of 0.888 g/cm2 (range 0.512-1.390). 216 (33%) women were normal, 322(50%) had osteopenia and 107 (17%) had osteoporosis.

Of the women with osteopenia, 127 (39%) women were offered treatment and 56 women had a repeat DEXA after a mean of 3 years. In the treatment group, LNOF mean BMD remained relatively unchanged from 0.822 g/cm2 to 0.829 g/cm2 at the repeat DEXA (p= 0.6169).

Of the 322 women with osteopenia, 8 (2.5%) women had a fracture.

Conclusion

Our study provides real world evidence of the success of 2017 consensus statement in lowering fracture risk. Though there has been data for positive impact on BMD decline with this approach, evidence for fracture prevention has been limited. This study showcases the success of lowering bone active therapy threshold employing alternative risk modelling strategy for women with breast cancer commenced on AI. A significant reduction in fractures pre (13%) and post guidelines change (2.5%) was demonstrated (absolute risk reduction of 10.5%) which has implications for healthcare systems worldwide as we have demonstrated this approach can reduce morbidity.

References

[1]https://www.wcrf.org/dietandcancer/worldwide-cancer-data/. Accessed: 26.01.2022.

[2]Reid DM, Doughty J, Eastell R, et al. Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group. Cancer Treat Rev. 2008;34 Suppl 1:S3-S18.

[3]Hadji P, Aapro MS, Body JJ, et al. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol. 2017;7:1-12.

Disclosure of Interests

None declared

Mathematical calculation of COVID-19 disease in Pakistan by emergency response modeling based on complex Pythagorean fuzzy information

The new emerged infectious disease that is known the coronavirus disease (COVID-19), which is a high contagious viral infection that started in December 2019 in China city Wuhan and spread very fast to the rest of the world. This infection caused millions of infected cases globally and still poses an alarming situation for human lives. Pakistan in Asian countries is considered the third country with higher number of cases of coronavirus with more than 649824. Recently, some mathematical models have been constructed for better understanding the coronavirus infection. Mostly, these models are based on classical integer-order derivative using real numbers which cannot capture the fading memory. So at the current position it is a challenge for the world to understand and control the spreading of COVID-19. Therefore, the aim of our paper is to develop some novel techniques, namely complex Pythagorean fuzzy weighted averaging (abbreviated as CPFWA) operator, complex Pythagorean fuzzy ordered weighted averaging (abbreviated as CPFOWA) operator, complex Pythagorean fuzzy hybrid averaging (abbreviated as CPFHA) operator, induced complex Pythagorean fuzzy ordered weighted averaging (abbreviated as I-CPFOWA) operator and induced complex Pythagorean fuzzy hybrid averaging (abbreviated as I-CPFHA) operator to analysis the spreading of COVID-19. At the end of the paper, an illustrative the emergency situation of COVID-19 is given for demonstrating the effectiveness of the suggested approach along with a sensitivity analysis, showing the feasibility and reliability of its results.

Intriguing interfacial characteristics of the CS contact with MX2 (M = Mo, W; X = S, Se, Te) and MXY ((X ≠ Y) = S, Se, Te) monolayers

Using (hybrid) first principles calculations, the electronic band structure, type of Schottky contact and Schottky barrier height established at the interface of the most stable stacking patterns of the CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH are investigated. The electronic band structures of CS–MX₂ and CS–MXY MS vdWH seem to be simple sum of CS, MX₂ and MXY monolayers. The projected electronic properties of the CS, MX₂ and MXY layers are well preserved in CS–MX₂ and CS–MXY MS vdWH. Their smaller effective mass (higher carrier mobility) render promising prospects of CS–WS₂ and CS–MoSeTe as compared to other MS vdWH in nanoelectronic and optoelectronic devices, such as a high efficiency solar cell. In addition, we found that the effective mass of holes is higher than that of electrons, suggesting that these heterostructures can be utilized for hole/electron separation. Interestingly, the MS contact led to the formation of a Schottky contact or ohmic contact, therefore we have used the Schottky Mott rule to calculate the Schottky barrier height (SBH) of CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH. It was found that CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) (in both model-I and -II) MS vdWH form p-type Schottky contacts. These p-type Schottky contacts can be considered a promising building block for high-performance photoresponsive optoelectronic devices, p-type electronics, CS-based contacts, and for high-performance electronic devices.

Electronic band structure, type of Schottky contact and Schottky barrier height established at the interface of the CS–MX₂ (M = Mo, W; X = S, Se, Te) and CS–MXY ((X ≠ Y) = S, Se, Te) MS vdWH.

Duodenal volvulus: a rare cause of small bowel obstruction

Small bowel volvulus is a rare but life-threatening emergency. Volvulus of the duodenum is even rarer without the presence of predisposing factors. The clinical presentation is vague, including abdominal pain, nausea and vomiting, prompt diagnosis of volvulus therefore relies heavily on radiographs. The treatment options lie between conservative or surgical management, where the decision is influenced by the patient and their presentation. This case is of a 100-year-old female with an extensive surgical and medical background presenting with signs of small bowel obstruction. With the help of imaging, a rare case of duodenal volvulus was diagnosed but managed conservatively due to the patient's background, age and personal wishes.

Mathematical modeling and thermodynamics of Prandtl-Eyring fluid with radiation effect: a numerical approach

Main concern of current research is to develop a novel mathematical model for stagnation-point flow of magnetohydrodynamic (MHD) Prandtl-Eyring fluid over a stretchable cylinder. The thermal radiation and convective boundary condition are also incorporated. The modeled partial differential equations (PDEs) with associative boundary conditions are deduced into coupled non-linear ordinary differential equations (ODEs) by utilizing proper similarity transformations. The deduced dimensionless set of ODEs are solved numerically via shooting method. Behavior of controlling parameters on the fluid velocity, temperature fields as well as skin friction and Nusselt number are highlighted through graphs. Outcome declared that dimensionless fluid temperature boosts up for both the radiation parameter and Biot number. It is also revealed that the magnitude of both heat transfer rate and skin friction enhance for higher estimation of curvature parameter. Furthermore, comparative analysis between present and previous reports are provided for some specific cases to verify the obtained results.

Synthesis, characterization and urease inhibitory activities of Zn(II) complexes bearing C1-symmetric ligands derived from (R)-phenylethanamine

ABSTRACT. A series of Zn(II) complexes, supported with N-substituted phenylethanamine derivatives, [LnZnCl2] (where Ln = LA ((R)-1-phenyl-N-(thiophene-2-ylmethyl)ethanamine; LB (R)-N-(5-meyhylthiophene-2-yl)methyl-1-phenylethanamine; LC ((R)-N-(furan-2-ylmeththyl)-1-phenylethanamine and LD (R)-N-((5-methylfuran-2-yl)methyl)-1-phenylethanamine) were synthesized and characterized. The urease inhibitory activities of these complexes were determined against selected urease inhibitors where [LBZnCl2] was found to be the most prominent inhibitor of Jack bean urease (J. B. urease) (IC50 = 10.39±0.78 μM), whereas the activity of Bacillus pasteurii urease (B. P. urease) was predominantly inhibited by [LAZnCl2] (IC50 = 8.68±0.7 μM). Additionally, MOE-Dock program was used to affirm the probable binding modes of these complexes into the crystal structure of J. B. urease which certainly verified the inhibitory mechanism of these novel complexes.                     KEY WORDS: Zn(II) complexes, (R)-Phenylethanamine, Urease inhibition, Molecular docking   Bull. Chem. Soc. Ethiop. 2021, 35(2), 301-314. DOI: https://dx.doi.org/10.4314/bcse.v35i2.7

Synthesis, characterization, POM analyses and biological evaluation of n-[(2-methoxy-5- nitrophenyl)]-4-oxo-4-[oxy] butenamide based zinc(II) carboxylate complexes

ABSTRACT. The aim of medicinal chemistry is to links many scientific disciplines and allows the scientists in researching and developing new drugs with enhance and targeted properties. In this article we are exploring the preparation of four new zinc(II) carboxylate complexes based on N-[(2-methoxy-5-nitrophenyl)]-4-oxo-4-[oxy]butenamide which were characterized through FT-IR and EDX studies. The DNA binding ability and binding type of complexes were assessed by spectroscopic (UV-Visible) and viscosity measurements, exhibiting an intercalative pattern of interaction. The synthesized compounds were also assessed to know theoretically about their nature by molecular docking studies resulting also in intercalation mode. Analysis of the complexes for biological applications such as anti-microbial, anti-leishmanial, cytotoxicity and DNA damage activities showed that these complexes carries good anti-microbial, anti-leishmanial activity with no toxicity to human blood thyrocytes and DNA. The bioavailability prediction and drug likeness score has also been evaluated through Insilco studies.                     KEY WORDS: Zn(II) carboxylate complex, DNA binding, Anti-leishmanial activity, Cytotoxicity, Docking study   Bull. Chem. Soc. Ethiop. 2021, 35(2), 365-380. DOI: https://dx.doi.org/10.4314/bcse.v35i2.11

57 A Closed Loop Audit of Post-Operative Driving Advice Documentation

Aim

The Driving and Vehicle Licensing Agency state post-operatively it is between the patient and doctor to establish when would be safe to resume driving, providing recovery does not exceed three months. This audit aimed to assess and improve the documentation rate of driving advice in the discharge summaries given to patients post abdominal surgery.

Method

Retrospective data collection from electronic records over the months of August and September 2020. 132 discharge summaries were screened to assess the baseline rate of verbal/documented driving advice given on discharge. Following the 1st cycle, posters encouraging the inclusion of driving advice and demonstrating how to access driving advice to discharge summaries were developed and distributed across the surgical wards. A 2nd cycle re-audit was conducted in October 2020 to measure the effect of change, and a further 3rd cycle audit was conducted in November 2020.

Results

1st cycle included 132 patients. 62% had documented advice on their discharge summaries, while 38% had no proof of driving advice. After intervention, 2nd cycle included 30 patients. Results showed a significant increase in advice documentation (80%). A 3rd cycle was carried out with 47 patients. This showed a reduction in advice documentation (66%).

Conclusions

Driving advice on discharge in post-operative patients is crucial part of patient safety. Implementation of intervention has increased the documentation of driving advice showing enhancing patient safety. However, 3rd cycle after registrar’s changeover showed a decrease in the rate of documentation. A teaching session is planned for new doctors followed by 4th cycle.

951 More Than A Checkbox: Importance of Role-Modelling and Visibility Initiatives in Improving Perceptions of Diversity in Surgical Leadership

Introduction

The Royal College of Surgeons of England have committed themselves to championing diversity in surgery in light of recent socio-political events. Although there are now more trainees from underrepresented backgrounds entering the profession, this is not reflected in leadership roles which are key in establishing attitudes and cultures. This study evaluated whether an event showcasing surgeons from underrepresented groups holding leadership positions could improve student perceptions of diversity in surgical leadership.

Method

Participants attended an online event hosted by a student surgical society, where speakers with surgical leadership experience from a range of marginalised backgrounds highlighted topics of diversity and discrimination in surgery. Pre- and post-event questionnaires comprising Likert scales were completed to evaluate student perceptions of surgeons holding a leadership role from the following underrepresented groups: women (or gender non-conforming), BAME, LGBTQ+ and individuals with disabilities. Statistical significance was assessed using a Mann-Whitney U test with p &lt; 0.05 denoting significance throughout.

Results

The event significantly increased attendee confidence in the idea of a surgeon being seen in a leadership role from all underrepresented groups evaluated: 9.3% for female/gender non-conforming individuals (p &lt; 0.01), 12.3% for BAME individuals (p &lt; 0.01), 7.5% for non-heterosexual individuals (p = 0.04) and 16.0% for individuals with a disability (p &lt; 0.01).

Conclusions

Attendees felt significantly more confident in the belief that surgeons from underrepresented backgrounds could hold leadership positions following the event, indicating the benefit of such role-modelling initiatives. More investment is necessary in exploring factors dissuading specific underrepresented groups from pursuing surgical careers and for novel strategies to support these communities accordingly.

The dynamics of genome size and GC contents evolution in genus Nicotiana

Hybridization and Polyploidization are most common of the phenomenon observed in plants, especially in the genus Nicotiana leading to the duplication of genome. Although genomic changes associated with these events has been studied at various levels but the genome size and GC content variation is less understood because of absence of sufficient genomic data. In this study the flow cytometry technique was used to uncover the genome size and GC contents of 46 Nicotiana species and we compared the genomic changes associated with the hybridization events along evolutionary time scale. The genome size among Nicotiana species varied between 3.28 pg and 11.88 pg whereas GC contents varied between 37.22% and 51.25%. The tetraploid species in genus Nicotiana including section Polydiclae, Repandae, Nicotiana, Rustica and Sauveolentes revealed both up and downsizing in their genome sizes when compared to the sum of genomes of their ancestral species. The genome sizes of three homoploid hybrids were found near their ancestral species. Loss of large genome sequence was observed in the evolutionary more aged species (>10 Myr) as compared to the recently evolved one's (<0.2 Myr). The GC contents were found homogenous with a mean difference of 2.46% among the Nicotiana species. It is concluded that genome size change appeared in either direction whereas the GC contents were found more homogenous in genus Nicotiana.

Computing locating-total domination number in some rotationally symmetric graphs

Let G = ( V , E ) be a connected graph. A locating-total dominating set in a graph G is a total dominating set S of a G, for every pair of vertices i , j ∈ V ( G ) ∖ S , such that N ( i ) ∩ S ≠ N ( j ) ∩ S . The minimum cardinality of a locating-total dominating set is called locating-total domination number and represented as γ t L . In this paper, locating-total domination number is determined for some cycle-related graphs. Furthermore, some well-known graphs of convex polytopes from the literature are also considered for the locating-total domination number.

The utility of Magnetoencephalography in multiple sclerosis - A systematic review

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We conducted a Systematic Review of studies, looking at 30 studies from 13 centres.

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MS patients had reduced power in some induced responses (motor beta, visual gamma).

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Increased latency and reduced connectivity were seen for somatosensory evoked fields.

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There was an association between upper alpha connectivity and cognitive function.

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MEG shows promise, although work is too preliminary to recommend current clinical use.

Introduction

Magnetoencephalography (MEG), allows for a high degree temporal and spatial accuracy in recording cortical oscillatory activity and evoked fields. To date, no review has been undertaken to synthesise all MEG studies in Multiple Sclerosis (MS). We undertook a Systematic Review of the utility of MEG in MS.

Methods

We identified MEG studies carried out in MS using EMBASE, Medline, Cochrane, TRIP and Psychinfo databases. We included original research articles with a cohort of minimum of five multiple sclerosis patients and quantifying of at least one MEG parameter. We used a modified version of the JBI (mJBI) for case-control studies to assess for risk of bias.

Results

We identified 30 studies from 13 centres involving at least 433 MS patients and 347 controls. We found evidence that MEG shows perturbed activity (most commonly reduced power modulations), reduced connectivity and association with altered clinical function in Multiple Sclerosis. Specific replicated findings were decreased motor induced responses in the beta band, diminished increase of gamma power after visual stimulation, increased latency and reduced connectivity for somatosensory evoked fields. There was an association between upper alpha connectivity and cognitive measures in people with MS. Overall studies were of moderate quality (mean mJBI score 6.7).

Discussion

We find evidence for the utility of MEG in Multiple Sclerosis. Event-related designs are of particular value and show replicability between centres. At this stage, it is not clear whether these changes are specific to Multiple Sclerosis or are also observable in other diseases. Further studies should look to explore cognitive control in more depth using in-task designs and undertake longitudinal studies to determine whether these changes have prognostic value.

Traditional knowledge about medicinal plant in the remote areas of Wari Tehsil, Dir Upper, Pakistan

Traditional medicine is cheaper and easily available to local people, to care for most frequent diseases in the Northern parts of Pakistan. Our study aimed at inventorying medicine from local plants, documenting their uses, and assessing their market value in 2015-2018 during spring, summer, and winter seasons. A total of 15 trips were made, 5 in each season. Semi-structured interviews with 165 inhabitant's age range between 20-80 years were conducted, analyzed the data is analyzed using Relative frequency of citation(RFC), Use Value(UV), Fidelity Level(FL), Informants consensus factor(ICF), and Jaccard index(JI) to find the most frequent and well-known used species in the area. A total of 86 species belonging to 39 vascular plant families, 33 genera were documented as medicinally important. Family Asteraceae was observed as the dominant family among all the families with 10 species, the leaf was the most used parts and decoction 36% was the most preferred preparation type. Herb was the predominant life form (67%). The maximum UV (0.92) was demonstrated by J. adhatoda L. species, while A. sativum L. shows maximum RFC (0.58), the highest ICF value represented by diarrhea and dermatitis 0.92, and high FL value is recorded 100%. According to our collections, wild species were 45%, invasive species were 38% and cultivated 17% recorded, dicots species were recorded more 81%. Seven 7 medicinal species is being economically important and export to the local and international market of the world, whereas P. integrima L. species were the most exported species according to the local dealers. The investigated area is rural and the local people depend on the area's plants for their health needs, and other uses like a vegetable, fuelwood, fodder, etc. The current result of RFC, UV, ICF, FL, and JI shows that medicinal flora needs to be pharmacologically and phytochemically investigated to prove their efficacy. The documentation of medicinal knowledge is important to preserve this precious old knowledge before it is lost forever, due to technological and environmental changes in the world.

Physiologic Specialization and Genetic Differentiation of Puccinia triticina Causing Leaf Rust of Wheat on the Indian Subcontinent During 2016 to 2019

Wheat is the second most cultivated cereal crop in the world and is an important crop in India. Leaf (brown) rust, caused by Puccinia triticina, was the most prevalent among the three rusts found in all the wheat-growing areas of India, Bhutan, and Nepal during 2016 to 2019. Leaf rust samples from wheat crops in these countries were pathotyped using the wheat differential genotypes and binomial Indian system of nomenclature. To facilitate international communication, each pathotype identified was also tested using the North American differentials. A total of 33 pathotypes were identified from 1,086 samples, including three new pathotypes: 61R47 (162-5 = KHTPM) and 93R49 (49 = NHKTN) from India and 93R57 (20-1 = NHKTN) from Nepal. Two pathotypes, 121R60-1 (77-9/52 = MHTKL) and 121R63-1 (77-5 = THTTM), accounted for 79.46% of the population. Virulence on Lr19 was identified in 0.27% of the samples from Nepal only. The proportion of pathotype 121R60-1 (77-9 = MHTKL) increased to 57.55% during these years. Virulence was not observed on Lr9, Lr24, Lr25, Lr28, Lr32, Lr39, Lr45, and Lr47 in the population of the Indian subcontinent. Eighteen polymorphic simple sequence repeat (SSR) primer pairs tested on the isolates amplified 48 alleles with an average of 2.66 alleles per primer pair. Based on SSR genotyping, these pathotypes could be grouped into two clades with another two subclades each. Many of the Lr genes present in Indian wheat germplasm (Lr1, Lr3a, Lr10, Lr11, Lr14a, Lr15, Lr16, Lr17, Lr20, Lr23, and Lr26) were ineffective for a majority of pathotypes. Most of these varieties possessed a high degree of leaf rust resistance. The field resistance of wheat varieties could be attributed to the interaction of genes, unknown resistance, or adult plant resistance.

Association of clinical factors and recent anticancer therapy with COVID-19 severity among patients with cancer: a report from the COVID-19 and Cancer Consortium

BACKGROUND

Patients with cancer may be at high risk of adverse outcomes from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We analyzed a cohort of patients with cancer and coronavirus 2019 (COVID-19) reported to the COVID-19 and Cancer Consortium (CCC19) to identify prognostic clinical factors, including laboratory measurements and anticancer therapies.

PATIENTS AND METHODS

Patients with active or historical cancer and a laboratory-confirmed SARS-CoV-2 diagnosis recorded between 17 March and 18 November 2020 were included. The primary outcome was COVID-19 severity measured on an ordinal scale (uncomplicated, hospitalized, admitted to intensive care unit, mechanically ventilated, died within 30 days). Multivariable regression models included demographics, cancer status, anticancer therapy and timing, COVID-19-directed therapies, and laboratory measurements (among hospitalized patients).

RESULTS

A total of 4966 patients were included (median age 66 years, 51% female, 50% non-Hispanic white); 2872 (58%) were hospitalized and 695 (14%) died; 61% had cancer that was present, diagnosed, or treated within the year prior to COVID-19 diagnosis. Older age, male sex, obesity, cardiovascular and pulmonary comorbidities, renal disease, diabetes mellitus, non-Hispanic black race, Hispanic ethnicity, worse Eastern Cooperative Oncology Group performance status, recent cytotoxic chemotherapy, and hematologic malignancy were associated with higher COVID-19 severity. Among hospitalized patients, low or high absolute lymphocyte count; high absolute neutrophil count; low platelet count; abnormal creatinine; troponin; lactate dehydrogenase; and C-reactive protein were associated with higher COVID-19 severity. Patients diagnosed early in the COVID-19 pandemic (January-April 2020) had worse outcomes than those diagnosed later. Specific anticancer therapies (e.g. R-CHOP, platinum combined with etoposide, and DNA methyltransferase inhibitors) were associated with high 30-day all-cause mortality.

CONCLUSIONS

Clinical factors (e.g. older age, hematological malignancy, recent chemotherapy) and laboratory measurements were associated with poor outcomes among patients with cancer and COVID-19. Although further studies are needed, caution may be required in utilizing particular anticancer therapies.

CLINICAL TRIAL IDENTIFIER

NCT04354701.

289 Blood Loss in Robotic-Assisted Knee Arthroplasty: A Retrospective Analysis

Introduction

Significant blood loss is associated with a delayed postoperative recovery in joint arthroplasty. Emerging evidence suggests robotic-assisted knee arthroplasty reduces soft-tissue trauma, length of stay, and can facilitate a faster recovery. This study compares the total blood loss in patients undergoing robotic-assisted knee arthroplasty compared to conventional methods.

Method

Patients undergoing robotic-assisted total knee arthroplasty (TKA) or unicomparmental knee arthroplasty (UKA) were identified using patient records. Robotic-assisted groups were compared against contemporary sex-matched controls undergoing jig-based arthroplasty. The mean total blood loss was estimated using the Gross equation. Statistical significance was identified using the Student's t-test and Mann-Whitney U test for parametric and non-parametric data, respectively.

Results

Robotic TKA and UKA groups were successfully matched to contemporary controls (n = 50 in all groups). No differences in preoperative haematological parameters or blood volume were found between the robotic-assisted and control groups. Robotic TKA experienced 23.7% less blood loss compared to control TKA (911.0ml vs 1193.7ml, p &lt; 0.01) which was found to be statistically significant. There was a non-significant difference in mean total blood loss in robotic UKA compared to control UKA (821.7ml vs 854.7ml, p = 0.69).

Conclusions

The use of a robotic surgical system reduces blood loss in TKA but not UKA in knee arthroplasty.