Cytoreductive surgery plus hyperthermic intraoperative peritoneal chemotherapy for people with peritoneal metastases from colorectal, ovarian or gastric origin: A systematic review of randomized controlled trials

BACKGROUND

There is uncertainty in the relative benefits and harms of hyperthermic intraoperative peritoneal chemotherapy (HIPEC) when added to cytoreductive surgery (CRS) +/- systemic chemotherapy or systemic chemotherapy alone in people with peritoneal metastases from colorectal, gastric, or ovarian cancers.

METHODS

We searched randomized controlled trials (RCTs) in the medical literature until April 14, 2022 and applied methods used for high-quality systematic reviews.

FINDINGS

We included a total of eight RCTs (seven RCTs included in quantitative analysis as one RCT did not provide data in an analyzable format). All comparisons other than ovarian cancer contained only one trial. For gastric cancer, there is high uncertainty about the effect of CRS + HIPEC + systemic chemotherapy. For stage III or greater epithelial ovarian cancer undergoing interval cytoreductive surgery, CRS + HIPEC + systemic chemotherapy probably decreases all-cause mortality compared to CRS + systemic chemotherapy. For colorectal cancer, CRS + HIPEC + systemic chemotherapy probably results in little to no difference in all-cause mortality and may increase the serious adverse events proportions compared to CRS +/- systemic chemotherapy, but probably decreases all-cause mortality compared to fluorouracil-based systemic chemotherapy alone.

INTERPRETATION

The role of CRS + HIPEC in gastric peritoneal metastases is uncertain. CRS + HIPEC should be standard of care in women with stage III or greater epithelial ovarian cancer undergoing interval CRS. CRS + systemic chemotherapy should be standard of care for people with colorectal peritoneal metastases, with HIPEC given only as part of a RCT focusing on subgroups and regimes.

PROSPERO REGISTRATION

CRD42019130504.

Head injury in older adults presenting to the ambulance service: who do we convey to the emergency department, and what clinical variables are associated with an intracranial bleed? A retrospective case-control study

OBJECTIVE

Most older adults with traumatic brain injuries (TBI) reach the emergency department via the ambulance service. Older adults, often with mild TBI symptoms, risk being under-triaged and facing poor outcomes. This study aimed to identify whether sufficient information is available on the scene to an ambulance clinician to identify an older adult at risk of an intracranial haemorrhage following a head injury.

METHODS

This was a retrospective case-control observational study involving one regional ambulance service in the UK and eight emergency departments. 3545 patients aged 60 years and over presented to one regional ambulance service with a head injury between the 1st of January 2020 and the 31st of December 2020. The primary outcome was an acute intracranial haemorrhage on head computed tomography (CT) scan in patients conveyed to the emergency department (ED). A secondary outcome was factors associated with conveyance to the ED by the ambulance clinician.

RESULTS

In 2020, 2111 patients were conveyed to the ED and 162 patients were found to have an intracranial haemorrhage on their head CT scan. Falls from more than 2 m (adjusted odds ratio (aOR) 3.45, 95% CI 1.78-6.40), chronic kidney disease (CKD) (aOR 2.80, 95% CI 1.25-5.75) and Clopidogrel (aOR 1.98, 95% CI 1.04-3.59) were associated with an intracranial haemorrhage. Conveyance to the ED was associated with patients taking anticoagulant and antiplatelet medication or a visible head injury or head injury symptoms.

CONCLUSION

This study highlights that while most older adults with a head injury are conveyed to the ED, only a minority will have an intracranial haemorrhage following their head injury. While mechanisms of injury such as falls from more than 2 m remain a predictor, this work highlights that Clopidogrel and CKD are also associated with an increased odds of tICH in older adults following a head injury. These findings may warrant a review of current ambulance head injury guidelines.

Novel Role of Glycogen Synthase Kinase-3β in Determining Cancer Cell Response to Genotoxic Stress through Regulation of 53BP1 Function

PURPOSE/OBJECTIVE(S)

Glycogen synthase kinase-3β (GSK3β) is a multifunctional serine/threonine kinase involved in various cellular processes and signaling pathways. Accumulating evidence suggests GSK3β plays a role in cancer treatment with effects on tumorigenesis and treatment response. We have previously shown that inhibition of GSK3β protects neurons from ionizing radiation-induced apoptosis through upregulation of non-homologous end joining (NHEJ) mediated repair of double strand breaks (DSBs). Here, we investigate the molecular mechanism underlying GSK3β regulation of NHEJ.

MATERIALS/METHODS

Using biochemical, molecular, and genetic approaches, we investigated the physical and functional interaction between GSK3β and 53BP1. Cultured human tumor cells were utilized as model system to further characterize how GSK3β controls 53BP1 function in DNA DSB recognition and repair. Finally, we employed a cell biology approach to genetically and pharmacologically manipulate GSK3β activity and test how the GSK3β-53BP1 axis impacts tumor cytotoxic response to PARP inhibitor (PARPi) and radiation therapy.

RESULTS

We illustrate that GSK3β directly interacts with 53BP1 and phosphorylates 53BP1 at threonine 334 amino acid (T334) within a region heavily phosphorylated by several stress kinases. Phosphorylation at T334 inhibits 53BP1's function in recruitment to DNA DSB sites as well as canonical NHEJ. Furthermore, our results identify GSK3β regulation of 53BP1 function in NHEJ is achieved through suppression of downstream mediators, RIF1 and PTIP, and their function. In contrast, GSK3β enhances single strand DNA resection and promotes homologous recombination (HR) repair. Most importantly, genetic and pharmacologic inhibition of GSK3β-53BP1 signaling axis dramatically enhances the cytotoxic response of BRCA1-deficit cancer cells to PARPi. The assessment of the effect of GSK3β-53BP1 axis on tumor cell response to radiation treatment is underway.

CONCLUSION

This study establishes the connection between GSK3β and DSB repair through its phosphorylation and regulation of 53BP1 pathways. Moreover, it demonstrates that GSK3β kinase activity uniquely results in inhibition of 53BP1 as opposed to other kinases that enhance 53BP1 function. Importantly, this novel signaling axis provides a strategy for targeting cancer cell resistance to PARPi.

Follow-up strategies for patients with splenic trauma managed non-operatively: the 2022 World Society of Emergency Surgery consensus document

Background

In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved.

Methods

Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM.

Results

Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate ≥ 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I–II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II–III, AAST Grades III–V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries—WSES Class I, AAST Grades I–II) to 3 days (for high-grade splenic injuries—WSES Classes II–III, AAST Grades III–V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48–72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV–V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48–72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications.

Conclusion

This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.

Intracoronary Imaging in left main stent percutaneous coronary intervention has a clear survival benefit particularly in more complex patients

Background

Left Main Stem Disease (LMS) is prognostically important coronary artery disease that is managed either with coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI). Use of intracoronary imaging (ICI) modalities such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have been shown to improve outcomes with PCI revascularization.

The primary objective of this study was to evaluate the impact of ICI on outcomes following LMS PCI.

Methods

Retrospective observation study of 498 (5.1% of all PCI cases) patients who had undergone LMS PCI at our tertiary primary PCI centre hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records. Follow-up was also obtained through linkage with the Office of National Statistics.

Results

The mean age at the time of enrolment was 70.7±11.5 years. Majority of the patients were male 351 (70.5%). 353 (70.9%) of cases had acute coronary syndrome (ACS) presentation while the remainder were elective procedures. Mean follow-up duration was 3.75±3.06 years. Survival calculated by Kaplan-Meier was 70%. 87 patients (17.5%) deceased during first year of enrolment. 344 (69.1%) patients had ICI, with IVUS in 316 (63.5%) and OCT in 28 (5.6%) patients. IVUS comprised 91.9% of ICI procedures. Protected LMS (OR 0.175, 95% CI: 0.037–0.833, P-value=0.029) and the use of left ventricular mechanical support device (OR 0.324, 95% CI: 0.122–0.859, P-value=0.024) were associated with decreased odds of undergoing an ICI.

Patients undergoing ICI had significantly better survival compared to those without ICI (HR: 0.54, P<0.001). Moreover, OCT showed significantly better survival compared with IVUS (HR: 0.181, P=0.017). Use of ICI was associated with better survival in patients who had Rotablation (HR: 0.455, 95% CI: 0.232–0.892, P=0.022), ACS (HR: 0.523, 95% CI: 0.383–0.714, P<0.001) or comorbidities of diabetes and stroke (HR: 0.551, 95% CI: 0.337–0.807, P=0.002).

Conclusion

ICI in LMS PCI has a significant survival benefit in our dataset. This is especially the case in patients presenting with ACS, those with comorbidities of Diabetes mellitus and stroke and those undergoing rotablation.

Funding Acknowledgement

Type of funding sources: None.

The 11-year outcome of PCI for treatment of left main stem disease

Background

Left Main Stem Disease (LMS) has historically been treated with coronary artery bypass surgery (CABG). However, not all patents with LMS are candidates for CABG due to co-morbidities. There is limited long-term follow-up of patients undergoing PCI in the real world. The primary objective of this study was to investigate the long-term mortality following LMS PCI.

Methods

We conducted a retrospective study of patients who had undergone PCI for LMS disease at our hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records and analyzed using Kaplain-Meier survival analysis. Follow-up was obtained through linkage with the Office of National Statistics.

Results

498 patients underwent LMS PCI (5.1% of the total PCI cases). The overall survival rate was 70%. Median survival following PCI was 1,196 days (IQR = 1,796). The mean age of the patients was 70.7 years; 70.5% were males. 70.9% of patients underwent PCI for Acute Coronary Syndrome (ACS), and 15.3% had STEMI. 33.7% of patients had a history of diabetes, 8% had stroke, 8.2% had COPD, and 8.8% had PVD. 51 patients went into cardiogenic shock, and 25 died prior to discharge.

Survival of the ACS group was significantly lower than the stable group (67% vs 77%, p<0.01); the STEMI group did not significantly differ from rest of the ACS group (62% vs 66%, p=0.87). Survival in those <60 years of age was significantly higher than in those >60 years (80% vs 68%; p<0.01). The presence of one or more co-morbidities was associated with higher survival compared to zero co-morbidities (74% vs 65%, p<0.01). Patients with a history of diabetes had a significantly lower survival rate than those without diabetes (63% vs 73%, p<0.01). Patients with an LV ejection fraction ≤35% had a significantly lower survival than those with an ejection fraction >35% (22% vs 29%, p<0.01); only 259 patients had data on LV function. Patients who developed cardiogenic shock had a significantly lower survival rate than those who did not develop shock (38% vs 70%; p<0.01). When these patients were excluded from the data set, the overall survival rate increased from 70% to 74%. Lastly, a multinomial analysis showed that the only independent predictors of mortality were age (p<0.01) and cardiogenic shock (p<0.01).

Conclusion

Our results show that the real world 10-year mortality rate following LMS PCI is influenced by multiple factors including age, shock, and LV function. The high mortality rate was potentially due to the significant number of acute cases (70.1%) in non-operable patients. While factors such as age and past medical history are considered in the decision-making process regarding CABG vs PCI, we saw that specific subgroups within these factors may have decreased the effectiveness of PCI as a treatment for LMS disease, suggesting that deeper analysis into these risk factors is required when deciding between CABG and PCI for LMS disease management.

Funding Acknowledgement

Type of funding sources: None.

Non-autonomous stomatal control by pavement cell turgor via the K+ channel subunit AtKC1

Stomata optimize land plants' photosynthetic requirements and limit water vapor loss. So far, all of the molecular and electrical components identified as regulating stomatal aperture are produced, and operate, directly within the guard cells. However, a completely autonomous function of guard cells is inconsistent with anatomical and biophysical observations hinting at mechanical contributions of epidermal origins. Here, potassium (K+) assays, membrane potential measurements, microindentation, and plasmolysis experiments provide evidence that disruption of the Arabidopsis thaliana K+ channel subunit gene AtKC1 reduces pavement cell turgor, due to decreased K+ accumulation, without affecting guard cell turgor. This results in an impaired back pressure of pavement cells onto guard cells, leading to larger stomatal apertures. Poorly rectifying membrane conductances to K+ were consistently observed in pavement cells. This plasmalemma property is likely to play an essential role in K+ shuttling within the epidermis. Functional complementation reveals that restoration of the wild-type stomatal functioning requires the expression of the transgenic AtKC1 at least in the pavement cells and trichomes. Altogether, the data suggest that AtKC1 activity contributes to the building of the back pressure that pavement cells exert onto guard cells by tuning K+ distribution throughout the leaf epidermis.

Patient-reported outcome (PRO) results from the AGITG DOCTOR trial: a randomised phase 2 trial of tailored neoadjuvant therapy for resectable oesophageal adenocarcinoma

Background

AGITG DOCTOR was a randomised phase 2 trial of pre-operative cisplatin, 5 fluorouracil (CF) followed by docetaxel (D) with or without radiotherapy (RT) based on poor early response to CF, detected via PET, for resectable oesophageal adenocarcinoma. This study describes PROs over 2 years.

Methods

Participants (N = 116) completed the EORTC QLQ-C30 and oesophageal module (QLQ-OES18) before chemotherapy (baseline), before surgery, six and 12 weeks post-surgery and three-monthly until 2 years. We plotted PROs over time and calculated the percentage of participants per treatment group whose post-surgery score was within 10 points (threshold for clinically relevant change) of their baseline score, for each PRO scale. We examined the relationship between Grade 3+ adverse events (AEs) and PROs. This analysis included four groups: CF responders, non-responders randomised to DCF, non-responders randomised to DCF + RT, and “others” who were not randomised.

Results

Global QOL was clinically similar between groups from 6 weeks post-surgery. All groups had poorer functional and higher symptom scores during active treatment and shortly after surgery, particularly the DCF and DCF + RT groups. DCF + RT reported a clinically significant difference (−13points) in mean overall health/QOL between baseline and pre-surgery. Similar proportions of patients across groups scored +/− 10 points of baseline scores within 2 years for most PRO domains. Instance of grade 3+ AEs were not related to PROs at baseline or 2 years.

Conclusions

By 2 years, similar proportions of patients scored within 10 points of baseline for most PRO domains, with the exception of pain and insomnia for the DCF + RT group. Non-responders randomised to DCF or DCF + RT experienced additional short-term burden compared to CF responders, reflecting the longer duration of neoadjuvant treatment and additional toxicity. This should be weighed against clinical benefits reported in AGITG DOCTOR. This data will inform communication of the trajectory of treatment options for early CF non-responders.

Trial registration

Australia New Zealand Clinical Trials Registry (ANZCTR), ACTRN12609000665235. Registered 31 July 2009.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09270-4.

Intravascular lithotripsy during percutaneous coronary intervention for calcified coronary lesions: analysis of patient and procedural characteristics and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Coronary artery calcification is frequently encountered during percutaneous coronary intervention (PCI). It can reduce PCI success and increase intra-procedural and post-procedural complications, including stent embolization, under-expansion and mal-apposition. Intravascular lithotripsy (IVL) is a new tool developed to treat calcified coronary lesions.

Purpose

Retrospective analysis of all cases of intravascular lithotripsy performed within our local health district to examine patient and procedural characteristics and clinical outcomes.

Methods

All patients undergoing PCI with intravascular lithotripsy between September 2019-August 2021 within our local health district were analysed. Patient and procedural characteristics and clinical outcomes were recorded.

Results

67 patients (50 men) were included with mean age 71.4 ± 8.7years. Risk factors prevalence included smoking (34%), hypertension (82%), dyslipidaemia (69%) and diabetes (46%). Trans-radial artery access was used in 38 patients (57%). IVL was performed most commonly in the left anterior descending artery (52%),[Figure 1]. IVL was utilised in 9 chronic total occlusions and 12 bifurcation lesions. Intracoronary (IC) imaging was performed in 59 patients (88%), intravascular ultrasound in 41(61%) and optical coherence tomography in 18 (27%). 41 (69%) patients had imaging performed pre and post IVL and post PCI.  IC imaging identified 14 cases with 270º calcification arc and 45 cases with 360º arc. Nine cases (13.4%) required rotational atherectomy prior to IVL (most commonly 1.75mm burr). Mean reference vessel diameter was 3.2 ± 0.3mm. Mean lesion length was 36.3 ± 16.5mm. Mean pre-PCI stenosis was 85.5 ± 10.8%. Drug eluting stents were successfully deployed in 57 cases (85%), 10 had balloon angioplasty alone. Mean stent length was 39.2 ± 17.8mm. Mean post-PCI stenosis was 4.5 ± 13.3% (median 0%). Figure 2 shows a statistically significant increase in minimum lumen diameter and minimum lumen area post-IVL and minimal-stent-area (MSA) post-PCI. Mean stent expansion was 83%. Mean screening time 35.8 ± 17.8 minutes with mean contrast used 207.3 ± 78.7mL. No sustained arrhythmias or side-branch loss occurred. Vessel rupture was recorded in one patient necessitating urgent cardiac surgery (due to oversized balloon) and in 4 cases the IVL balloon could not cross the lesion.

Conclusion

Our experience shows that IVL is safe and effective and facilitates stent delivery and expansion. Intracoronary imaging is important to determine the need for calcium modification and evaluate its success prior to stent delivery and to confirm optimised stent expansion. Abstract Figure. Breakdown of PCI Artery  Abstract Figure. IC Dimensions Pre/Post IVL/Post PCI

Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service team

BACKGROUND

The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex created a designated critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers.

METHODS

Retrospective review of air critical care transfer service set up and case review of first 50 transfers.

RESULTS

We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. 94% of the transfer missions were conducted by road. The mean age of these patients was 58 years (29-83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 min (range 149-440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 min (31-158). The mean transfer transit time between referring and receiving units was 72 min (9-182).

CONCLUSION

Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air transfer, can be achieved safely with specific planning, protocols and precautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.

Dietary Patterns and Intrinsic Capacity in Community-Dwelling Older Adults: A Cross-Sectional Study

OBJECTIVES

Few studies have investigated the link between diet and intrinsic capacity (IC), and the potential sex difference in such association. This study examined the association between dietary patterns and IC and its sub-domains in Chinese community-dwelling older adults.

DESIGN

Cross-sectional analysis using baseline data from the MrOs and MsOs study.

SETTING

Community.

PARTICIPANTS

Chinese community-dwelling older adults aged ≥65 years in Hong Kong.

MEASUREMENTS

Dietary intake was assessed using a validated food frequency questionnaire and priori and posteriori dietary pattern scores were generated. IC including measures of cognitive, locomotor, vitality, sensory and psychological domains was assessed. Multiple logistic regression was performed to examine the associations between dietary pattern scores and the likelihood of greater IC and sub-domain scores with adjustment for sociodemographic and lifestyle factors.

RESULTS

Data of 3730 participants (aged 72.2±5.0 years, 50.4% men) was available. In men, higher Diet Quality Index-International (DQI-I) and Okinawan diet scores, and lower "meat-fish" pattern scores were associated with greater IC. A higher DQI-I score was associated with greater locomotion, whereas higher "snacks-drinks-milk products" pattern score was associated with a greater sensory function. In women, none of the dietary pattern scores was associated with IC. Higher DQI-I score, Mediterranean-DASH Intervention for Neurodegenerative Delay Diet (MIND) score and "vegetables-fruits" pattern score were associated with greater psychological function.

CONCLUSION

Various dietary patterns were associated with greater IC and its sub-domains in Chinese community-dwelling older adults, and more associations were observed in men than women. Strategies to improve diet and IC should take sex differences into account.

Towards Healthy Ageing: Using the Concept of Intrinsic Capacity in Frailty Prevention

OBJECTIVES

To examine whether intrinsic capacity (IC) could predict frailty, whether declines in specific domains of IC could lead to frailty, and whether different combinations of domains could represent different risks of developing frailty.

SETTING

Community.

PARTICIPANTS

Chinese people aged 65 years and older.

MEASUREMENTS

Using data from a prospective cohort study, we derived a summary score for IC and scores for the five domains (cognitive, locomotor, vitality, sensory, psychological) for each participant at baseline. Frailty was assessed according to the Fried's frailty phenotype at baseline, 2- and 4-year follow-ups. Participants were classified as frail if they had ≥3 of the following criteria: weight loss, self-rated exhaustion, weakness, slow walking speed, and low physical activity.

RESULTS

Four thousand participants were interviewed at baseline. Overall mean age was 72.5 years; 50% were women. Between baseline and the 2-year follow-up, 5.7% of non-frail participants developed frailty; between 2- and 4-year follow-ups, 5.7% of non-frail participants developed frailty. The average annual incidence rate of frailty was 2.9%. Higher scores on IC at baseline were associated with a lower risk of incident frailty at both follow-ups (year 2, odds ratio (OR)=0.64, 95% confidence interval (CI)=0.59-0.71); year 4, OR=0.64, 95%CI=0.58-0.71) after adjustment for age, sex, educational level, and chronic diseases. Across the five domains, vitality was the strongest predictor of incident frailty at each follow-up (year 2, OR=0.33, 95%CI=0.24-0.45; year 4, OR=0.33, 95%CI=0.23-0.46). Compared to other combinations of any two domains, having 'high' scores on both vitality and locomotor domains was associated with the lowest risk of incident frailty (year 2, OR=0.11, 95%CI=0.06-0.22, area under the curve (AUC)=0.770; year 4, OR=0.18, 95%CI=0.10-0.32, AUC=0.782).

CONCLUSION

This study provides evidence that IC was independently associated with incident frailty. It also finds that vitality was the domain most strongly associated with incident frailty. Finally, it suggests that optimizing multiple domains of IC, particularly vitality and locomotor, may prevent frailty.

Comorbidity of mental and musculoskeletal disorders in ageing women: A data linkage study using national registries

BACKGROUND

Mental disorders (MDs) and musculoskeletal disorders (MSDs) are the main causes of disability. Yet, their comorbidity has not received the deserved attention.

OBJECTIVE

To investigate the extent of the comorbidity between MDs and MSDs in ageing women using national registries on prescription medications and work disability pensions (DPs).

METHODS

The study included 7,809 Finnish women, born during 1932-41, from the population-based Kuopio Osteoporosis Risk Factor and Prevention Study (OSTPRE) cohort, established in 1989. Lifetime permanent DPs due to: 1) 'MDs only' (n = 359), 2) 'MSDs only' (n = 954), 3) 'MDs + MSDs' (n = 227), were recorded till 2003. The reference group was 'no DP' (n = 6,269). Data from the OSTPRE questionnaires was obtained in 1994. Use of medications was recorded in 1995 and 2003. The use of musculoskeletal or psychotropic medications by women having a DP or medication due to MD, or MSD diagnoses, respectively, was considered as an indicator of comorbidity.

RESULTS

In 1995, all DP groups had used psychotropic and musculoskeletal medications more often than the referents. Use of musculoskeletal medications was associated with a higher use of psychotropic medications, and vice versa (OR=2.45; 95% CI 2.17-2.77), compared with non-use. The 'MSDs only' group was more likely to use psychotropic (OR=1.79; 95% CI 1.50-2.12), and the 'MDs only' group musculoskeletal medications (OR=1.38; 95% CI 1.09-1.74), compared with those without DPs. The proportions of medication users were similar in 1995 and 2003; however, the amounts used increased.

CONCLUSIONS

There was strong evidence for comorbidity between MDs and MSDs in ageing women. Further research concerning their longitudinal relationships is warranted.

Can you trust clinical practice guidelines for laparoscopic surgery? A systematic review of clinical practice guidelines for laparoscopic surgery

BACKGROUND

Clinical practice guidelines aim to support clinicians in providing clinical care and should be supported by evidence. There is currently no information on whether clinical practice guidelines in laparoscopic surgery are supported by evidence.

METHODS

We performed a systematic review and identified clinical practice guidelines of laparoscopic surgery published in PubMed and Embase between March 2016 and February 2019. We performed an independent assessment of the strength of recommendation based on the evidence provided by the guideline authors. We used the 'Appraisal of Guidelines for Research & Evaluation II' (AGREE-II) Tool's 'rigour of development', 'clarity of presentation', and 'editorial independence' domains to assess the quality of the guidelines. We performed a mixed-effects generalised linear regression modelling.

RESULTS

We retrieved 63 guidelines containing 1905 guideline statements. The median proportion of 'difference in rating' of strength of recommendation between the guideline authors and independent assessment was 33.3% (quartiles: 18.3%, 55.8%). The 'rigour of development' domain score (odds ratio 0.06; 95% confidence intervals 0.01-0.48 per unit increase in rigour score; P value = 0.0071) and whether the strength of recommendation was 'strong' by independent evaluation (odds ratio 0.09 (95% confidence intervals 0.06-0.13; P value < 0.001) were the only determinants of difference in rating between the guideline authors and independent evaluation.

CONCLUSION

A considerable proportion of guideline statements in clinical practice guidelines in laparoscopic surgery are not supported by evidence. Guideline authors systematically overrated the strength of the recommendation (i.e., even when the evidence points to weak recommendation, guideline authors made strong recommendations).

Smartphone GPS signatures of patients undergoing spine surgery correlate with mobility and current gold standard outcome measures

OBJECTIVE

Patient-reported outcome measures (PROMs) are currently the gold standard to evaluate patient physical performance and ability to recover after spine surgery. However, PROMs have significant limitations due to the qualitative and subjective nature of the information reported as well as the impossibility of using this method in a continuous manner. The smartphone global positioning system (GPS) can be used to provide continuous, quantitative, and objective information on patient mobility. The aim of this study was to use daily mobility features derived from the smartphone GPS to characterize the perioperative period of patients undergoing spine surgery and to compare these objective measurements to PROMs, the current gold standard.

METHODS

Eight daily mobility features were derived from smartphone GPS data in a population of 39 patients undergoing spine surgery for a period of 2 months starting 3weeks before surgery. In parallel, three different PROMs for pain (visual analog scale [VAS]), disability (Oswestry Disability Index [ODI]) and functional status (Patient-Reported Outcomes Measurement Information System [PROMIS]) were serially measured. Segmented linear regression analysis was used to assess trends before and after surgery. The Student paired t-test was used to compare pre- and postoperative PROM scores. Pearson's correlation was calculated between the daily average of each GPS-based mobility feature and the daily average of each PROM score during the recovery period.

RESULTS

Smartphone GPS features provided data documenting a reduction in mobility during the immediate postoperative period, followed by a progressive and steady increase with a return to baseline mobility values 1 month after surgery. PROMs measuring pain, physical performance, and disability were significantly different 1 month after surgery compared to the 2 immediate preoperative weeks. The GPS-based features presented moderate to strong linear correlation with pain VAS and PROMIS physical score during the recovery period (Pearson r > 0.7), whereas the ODI and PROMIS mental scores presented a weak correlation (Pearson r approximately 0.4).

CONCLUSIONS

Smartphone-derived GPS features were shown to accurately characterize perioperative mobility trends in patients undergoing surgery for spine-related diseases. Features related to time (rather than distance) were better at describing patient physical and performance status. Smartphone GPS has the potential to be used for the development of accurate, noninvasive and personalized tools for patient mobility monitoring after surgery.

OP0194 GENERALIZED IMMUNE ACTIVATION IN STRUCTURES RELATED TO PMR OR GCA ON PET/CT ASSESSMENT DOES NOT OCCUR IN IMMUNE CHECKPOINT INHIBITOR-TREATED PATIENTS WHO DO NOT GO ON TO DEVELOP RHEUMATIC IMMUNE-RELATED ADVERSE EVENTS

Background:

The pathogenesis of rheumatic immune-related adverse events (irAEs) from checkpoint inhibitor cancer immunotherapy directed against programmed cell death protein 1 (PD-1) and programmed death ligand 1 (PD-L1) remains unknown, even though they are a consequence of pharmacologic inhibition of a specific immune mechanism. Given that some irAEs resemble polymyalgia rheumatica (PMR) or giant cell arteritis (GCA), a disease whose pathogenesis is poorly understood, observations regarding the pathogenesis of PMR-like or GCA-like irAEs are of significant interest. One proposed pathogenic mechanism involves generalized immune activation leading to a spectrum of subclinical disease. Interrogation of this hypothesis may be aided by PET/CT, which is frequently utilized for oncological staging purposes but is also useful in classical PMR or GCA diagnosis. If PMR or GCA irAEs merely represent a spectrum of generalized immune activation, low-grade subclinical PMR or GCA-related changes on PET/CT might be expected to be seen in patients who receive immunotherapy, irrespective of whether they develop clinically evident rheumatic irAEs.

Objectives:

This study investigated whether such changes occurred in patients receiving immunotherapy who did not develop clinically evident rheumatic irAEs.

Methods:

Consecutive patients exposed to PD-1 or PD-L1 inhibitor immunotherapy at a single center had scintigraphic uptake calculated by a nuclear medicine physician experienced in assessment of vasculitis. Patients were included if they had had 18F-fluorodeoxyglucose (18F-FDG) PET/CT imaging both within the two weeks prior to immunotherapy initiation and after at least eleven weeks of immunotherapy. Patients who went on to develop a rheumatic irAE were excluded, as were patients with scintigraphic evidence of liver metastases owing to their potential influence on scoring of uptake. Quantification of 18F-FDG uptake by maximum standardized uptake values (maximum standard unit value, SUVmax) was performed at sites relevant to PMR or GCA (17 sites relevant to PMR, 17 sites relevant to GCA) in paired scans, and the difference calculated.

Results:

Twenty-four patients receiving nivolumab, pembrolizumab or avelumab met the inclusion criteria, primarily for melanoma, non-small cell lung cancer, or lymphoma. The mean age was 67 at the time of the first scan, 71% were male, and 66% had a complete or partial oncological response at best response. No statistically or clinically significant difference in SUVmax was noted at any PMR or GCA-relevant anatomical site interrogated. Latent class analysis did not reveal clusters identifiable by cancer type, best response, or presence of combination therapy.

Conclusion:

Patients treated with PD-1/PD-L1 inhibitors without clinically evident rheumatic irAEs do not develop subclinical PMR or GCA-like changes on PET/CT. This supports the proposition that PMR-like and GCA-like irAEs are a distinct entity with stochastic onset, and do not simply represent generalized immune activation induced by immunotherapy.

Acknowledgements:

David Liew is the recipient of the Ronald John Gleghorn Bursary from the University of Melbourne.

Disclosure of Interests:

David Liew: None declared, Aurora Poon: None declared, Christopher McMaster: None declared, Claire Owen Speakers bureau: Roche, Jessica Leung Speakers bureau: GIlead, Novartis, Albert Frauman: None declared, Jonathan Cebon: None declared, Andrew Scott: None declared, Russell Buchanan: None declared

AB0371 PATIENTS WITH PROLONGED SYMPTOMS BEFORE GCA DIAGNOSIS DO NOT INCUR HIGHER RATES OF VISUAL LOSS

Background:

Giant cell arteritis (GCA), if left untreated, confers the threat of serious cranial ischaemic complications including permanent visual loss. Although achieving a prompt and accurate diagnosis remains challenging, early diagnosis is viewed as being paramount in preventing significant morbidity.1 This raises the question of whether GCA patients are at greater risk of developing visual sequelae if there is a longer window between symptom onset and presentation.

Objectives:

To compare the frequency of lasting visual loss in patients diagnosed with GCA undergoing temporal artery biopsy (TAB) within three months and after three months of symptom onset.

Methods:

Patients who underwent TAB from January 2011 to November 2020 were identified from the pathology database of an Australian rheumatology referral centre. The diagnosis of GCA was established for each patient based on either positive TAB or, in the setting of negative TAB, clinical diagnosis by a rheumatologist. Baseline demographics, symptoms and major confounders – including age, sex, history of polymyalgia rheumatica or inflammatory arthritis, headache, jaw pain, fatigue, temporal artery tenderness or diminished pulse, and number of 1990 American College of Rheumatology (ACR) classification criteria for GCA2 fulfilled – were manually extracted from electronic medical records, as was the duration between onset of GCA symptoms and TAB, and the presence of visual loss before and after TAB. Logistic regression log-likelihood tests were used to examine the two cohorts presenting before and after three months.

Results:

There were 167 patients who underwent TAB during the study period with accessible clinical information. Of these, 31 (19%) had a delayed presentation of greater than three months from symptom onset. There were no statistical differences in patient demographics between the two groups (Table 1). No patients with delayed presentation experienced lasting, objective visual loss. In contrast, there were three cases in the cohort of patients who presented more promptly; these included two patients who developed permanent unilateral blindness, and one who experienced unilateral vision loss with some improvement at three months of follow-up.

Table 1.

Patient characteristics by time from symptom onset to TAB.

Presentation <3 monthsPresentation ≥3 monthsp-valueAge (years)73.45±10.0669.84±10.750.080Female92 (67.65%)20 (64.52%)0.738History of polymyalgia rheumatica23 (16.91%)4 (12.90%)0.586History of inflammatory arthritis6 (4.41%)2 (6.45%)0.633Headache110 (80.88%)23 (74.19%)0.406Jaw pain37 (27.21%)5 (16.13%)0.206Fatigue28 (20.59%)6 (19.35%)0.878Temporal artery tenderness or diminished pulse46 (33.82%)11 (35.48%)0.860ACR classification criteria2.83±0.992.58±0.890.199

Conclusion:

GCA patients with a lengthier course of symptoms before diagnosis did not experience any enduring visual loss. This may reflect a pattern of more aggressive disease leading to earlier presentation, but further study should explore whether longer symptom duration before diagnosis necessitates a higher degree of clinical concern.

References:

[1]Font C, Cid MC, Coll-Vinent B, López-Soto A, Grau JM. Clinical features in patients with permanent visual loss due to biopsy-proven giant cell arteritis. Br J Rheumatol. 1997 Feb;36(2):251-4. doi: 10.1093/rheumatology/36.2.251. PMID: 9133940.

[2]Hunder GG, Bloch DA, Michel BA, Stevens MB, Arend WP, Calabrese LH, Edworthy SM, Fauci AS, Leavitt RY, Lie JT, et al. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990 Aug;33(8):1122-8. doi: 10.1002/art.1780330810. PMID: 2202311.

Disclosure of Interests:

None declared

Validation of the Construct of Intrinsic Capacity in a Longitudinal Chinese Cohort

OBJECTIVES

We examined the structure and predictive ability of intrinsic capacity in a cohort of Chinese older adults.

METHODS

We used data from the MrOS and MsOS (Hong Kong) study, which was designed to examine the determinants of osteoporotic fractures and health in older Chinese adults. We analysed baseline and the 7-year follow-up data using exploratory factor analysis, confirmatory factor analysis (CFA), and mediation analysis.

RESULTS

The study consisted of 3736 participants at baseline (mean 72.2 years), with 1475 in the 7-year follow-up. Bi-factor CFA revealed five sub-factors labelled as 'cognitive', 'locomotor', 'vitality', 'sensory', and 'psychological' and one general factor labelled as 'intrinsic capacity'. The model fits the data well, with Root Mean Square Error of Approximation (RMSEA)=0.055 (90% CI=0.053-0.058) for the 5-factor model and RMSEA=0.031 (90% CI=0.028-0.035) for the bi-factor model. Significantly lower intrinsic capacity scores were found in older age groups, women, as well as those who had lower levels of education, lower subjective social status, reported more chronic diseases, or a higher number of IADL limitations (All p<0.0001). Intrinsic capacity had a direct effect in predicting incident IADL limitations at the 7-year follow-up (β=-0.21, p<0.001). The effect was larger than the direct effect of the number of chronic diseases on incident IADL limitations (β=0.05, not significant).

CONCLUSIONS

This study supports the construct and predictive validity of the proposed capacity domains of intrinsic capacity. The findings could inform the development of an intrinsic capacity score that would facilitate implementation of the concept of intrinsic capacity in clinical practice.

KRAS mutation effects on the 2-[18F]FDG PET uptake of colorectal adenocarcinoma metastases in the liver

Background

Deriving individual tumor genomic characteristics from patient imaging analysis is desirable. We explore the predictive value of 2-[18F]FDG uptake with regard to the KRAS mutational status of colorectal adenocarcinoma liver metastases (CLM).

Methods

2-[18F]FDG PET/CT images, surgical pathology and molecular diagnostic reports of 37 patients who underwent PET/CT-guided biopsy of CLM were reviewed under an IRB-approved retrospective research protocol. Sixty CLM in 39 interventional PET scans of the 37 patients were segmented using two different auto-segmentation tools implemented in different commercially available software packages. PET standard uptake values (SUV) were corrected for: (1) partial volume effect (PVE) using cold wall-corrected contrast recovery coefficients derived from phantom spheres with variable diameter and (2) variability of arterial tracer supply and variability of uptake time after injection until start of PET scan derived from the tumor-to-blood standard uptake ratio (SUR) approach. The correlations between the KRAS mutational status and the mean, peak and maximum SUV were investigated using Student’s t test, Wilcoxon rank sum test with continuity correction, logistic regression and receiver operation characteristic (ROC) analysis. These correlation analyses were also performed for the ratios of the mean, peak and maximum tumor uptake to the mean blood activity concentration at the time of scan: SUR_MEAN, SUR_PEAK and SUR_MAX, respectively.

Results

Fifteen patients harbored KRAS missense mutations (KRAS+), while another 3 harbored KRAS gene amplification. For 31 lesions, the mutational status was derived from the PET/CT-guided biopsy. The Student’s t test p values for separating KRAS mutant cases decreased after applying PVE correction to all uptake metrics of each lesion and when applying correction for uptake time variability to the SUR metrics. The observed correlations were strongest when both corrections were applied to SUR_MAX and when the patients harboring gene amplification were grouped with the wild type: p ≤ 0.001; ROC area under the curve = 0.77 and 0.75 for the two different segmentations, respectively, with a mean specificity of 0.69 and sensitivity of 0.85.

Conclusion

The correlations observed after applying the described corrections show potential for assigning probabilities for the KRAS missense mutation status in CLM using 2-[18F]FDG PET images.

2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

BACKGROUND

Acute calculus cholecystitis (ACC) has a high incidence in the general population. The presence of several areas of uncertainty, along with the availability of new evidence, prompted the current update of the 2016 WSES (World Society of Emergency Surgery) Guidelines on ACC.

MATERIALS AND METHODS

The WSES president appointed four members as a scientific secretariat, four members as an organization committee and four members as a scientific committee, choosing them from the expert affiliates of WSES. Relevant key questions were constructed, and the task force produced drafts of each section based on the best scientific evidence from PubMed and EMBASE Library; recommendations were developed in order to answer these key questions. The quality of evidence and strength of recommendations were reviewed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria (see https://www.gradeworkinggroup.org/ ). All the statements were presented, discussed and voted upon during the Consensus Conference at the 6th World Congress of the World Society of Emergency Surgery held in Nijmegen (NL) in May 2019. A revised version of the statements was voted upon via an online questionnaire until consensus was reached.

RESULTS

The pivotal role of surgery is confirmed, including in high-risk patients. When compared with the WSES 2016 guidelines, the role of gallbladder drainage is reduced, despite the considerable technical improvements available. Early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, even in subgroups of patients who are considered fragile, such as the elderly; those with cardiac disease, renal disease and cirrhosis; or those who are generally at high risk for surgery. Subtotal cholecystectomy is safe and represents a valuable option in cases of difficult gallbladder removal.

CONCLUSIONS, KNOWLEDGE GAPS AND RESEARCH RECOMMENDATIONS

ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.

SAT0279 FACTORS PREDICTIVE OF POSITIVE TEMPORAL ARTERY BIOPSY IN TWO AUSTRALIAN COHORTS

Background:

Temporal artery biopsy (TAB) is widely recognised as the diagnostic gold standard for GCA despite having a poor sensitivity due to the presence of ‘skip’ lesions. There is, however, a lack of consensus guiding TAB practice, particularly in relation to optimal length, need for bilateral specimens, and number of segments examined.

Objectives:

To investigate the impact of factors such as total biopsied length, laterality, segment number, and referral centre on histopathological outcomes in an Australian setting.

Methods:

Reports for all available biopsy specimens labelled “temporal artery” were extracted from the pathology service records of two rheumatology referral centres with adjacent geographic catchments. Each histopathology report was manually reviewed to establish length of biopsied artery, laterality, and number of segments, along with patient demographics such as age, sex, and referral centre. Key histopathological findings including intimal hyperplasia, disruption of the internal elastic lamina, presence of giant cells, and adventitial inflammation were recorded. Multivariable logistic regression with site-varying intercept was performed.

Results:

TAB reports from a total of 577 patients were captured, with results available from the two centres from 1999-2019 and 2010-2019 respectively. The mean age in this group was 73, and 69% were female (Table 1). A bilateral TAB was performed in 29%, and the mean total biopsy length was 2.5cm. Of these patients, 122 had positive biopsies (21%), with intimal hyperplasia reported in 100 (17%), giant cells in 83 (14%), and adventitial findings in 68 (12%). Positive biopsy weakly correlated with increased total length of biopsy in centimetres (OR 1.25 [1.06-1.47]) (Figure 1) and increased age in years (OR 1.02 [1.00-1.05]) but not laterality or sex (Table 2). There was a substantial difference between the two centres, which was incompletely accounted for once corrected for total biopsy length and calendar year of biopsy, suggesting either unmeasured differences in patient demographics or a difference in clinical practice. This change was preserved across analysis of different histopathological subtypes.

Table 1.

Patient characteristics by biopsy result.

Negative(n = 455)Positive(n = 122)Total(n = 577)Age (years) Mean (SD)72 (± 11)75 (± 8.9)73 (± 10)Sex Female310 (68%)88 (72%)398 (69%) Male145 (32%)34 (28%)179 (31%)Maximum biopsy length (cm) Mean (SD)1.8 (± 0.86)2.0 (± 1.10)1.9 (± 0.92)Total biopsy length (cm) Mean (SD)2.4 (± 1.6)2.8 (± 2.1)2.5 (± 1.7)Mean biopsy length (cm) Mean (SD)1.7 (± 0.78)1.9 (± 0.97)1.7 (± 0.83)Laterality Bilateral130 (29%)39 (32%)169 (29%) Unilateral325 (71%)83 (68%)408 (71%)Table 2.

Associations with positive TAB on multivariable logistic regression.

Overall positive findingIntimal hyperplasiaGiant cellsAdventitial inflammationTotal biopsy length (cm)1.25(1.06-1.47)1.18(0.98-1.40)1.21(1.00-1.46)1.07(0.87-1.31)Unilateral (vs. bilateral)1.56(0.82-3.07)1.12(0.56-2.30)1.28(0.61-2.77)0.82(0.38-1.82)Age (years)1.02(1.00-1.05)1.02(1.00-1.04)1.03(1.00-1.05)1.00(0.98-1.03)Male (vs. female)0.83(0.52-1.29)0.63(0.37-1.05)0.59(0.32-0.92)0.75(0.41-1.31)Centre 2 (vs. centre 1)0.54(0.34-0.84)0.41(0.24-0.68)0.55(0.32-0.92)0.46(0.25-0.82)Figure 1.

The effect of total biopsy length on result, stratified by laterality.

Conclusion:

Total biopsy length was weakly associated with a positive TAB result, but differences in results between referral centres independent of biopsy length suggest other selection factors may be important in determining TAB yield. Examination of differences in results between a greater number of referral centres would assist in determining the extent of this variability.

Disclosure of Interests:

None declared

Who Rules the Cell? An Epi-Tale of Histone, DNA, RNA, and the Metabolic Deep State

Epigenetics refers to the mode of inheritance independent of mutational changes in the DNA. Early evidence has revealed methylation, acetylation, and phosphorylation of histones, as well as methylation of DNA as part of the underlying mechanisms. The recent awareness that many human diseases have in fact an epigenetic basis, due to unbalanced diets, has led to a resurgence of interest in how epigenetics might be connected with, or even controlled by, metabolism. The Next-Generation genomic technologies have now unleashed torrents of results exposing a wondrous array of metabolites that are covalently attached to selective sites on histones, DNA and RNA. Metabolites are often cofactors or targets of chromatin-modifying enzymes. Many metabolites themselves can be acetylated or methylated. This indicates that the acetylome and methylome can actually be deep and pervasive networks to ensure the nuclear activities are coordinated with the metabolic status of the cell. The discovery of novel histone marks also raises the question on the types of pathways by which their corresponding metabolites are replenished, how they are corralled to the specific histone residues and how they are recognized. Further, atypical cytosines and uracil have also been found in eukaryotic genomes. Although these new and extensive connections between metabolism and epigenetics have been established mostly in animal models, parallels must exist in plants, inasmuch as many of the basic components of chromatin and its modifying enzymes are conserved. Plants are chemical factories constantly responding to stress. Plants, therefore, should lend themselves readily for identifying new endogenous metabolites that are also modulators of nuclear activities in adapting to stress.

Patients' Reports of Traumatic Experience and Posttraumatic Stress in Psychiatric Settings

OBJECTIVE

To determine the prevalence of traumatic experience (TE) among patients in psychiatric settings in Hong Kong and the associations between TE and levels of distress and anxiety and depressive symptoms.

METHODS

129 patients who have received inpatient psychiatric services were recruited. Their lifetime TE was assessed using the Life Event Checklist (LEC), and TE in psychiatric settings using the Psychiatric Experiences Questionnaire (PEQ). Their level of distress symptoms was assessed using the Impact of Event Scale-Revised (IES-R), and the level of anxiety and depressive symptoms using the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The prevalence of direct and indirect TE was 84.5%, as was the prevalence of TE in psychiatric settings. Common TE in psychiatric settings included witnessing another patient being taken down (61.2%), being put in restraints of any kind (41.1%), and witnessing another patient being physically assaulted by another patient (36.4%). TE in psychiatric settings associated with high prevalence of severe or extreme distress 1 week after the event included being forced to take medication against their will (52.2%), being threatened with physical violence (52.2%), and experiencing a physical assault (50.0%). Lifetime TE (the total number of LEC items reported) was associated with severity of distress and anxiety and depressive symptoms, whereas TE in psychiatric settings (the total number of PEQ items reported) was associated with severity of distress only. The total number of LEC items reported is the only predictor of levels of distress and anxiety and depressive symptoms.

CONCLUSIONS

Lifetime TE and TE in psychiatric settings are common among patients with SMI. Trauma-informed care is suggested for mental health services.

Induction immunosuppression in adults undergoing liver transplantation: a network meta-analysis

BACKGROUND

Liver transplantation is considered the definitive treatment for people with liver failure. As part of post-liver transplantation management, immunosuppression (suppressing the host immunity) is given to prevent graft rejections. Immunosuppressive drugs can be classified into those that are used for a short period during the beginning phase of immunosuppression (induction immunosuppression) and those that are used over the entire lifetime of the individual (maintenance immunosuppression), because it is widely believed that graft rejections are more common during the first few months after liver transplantation. Some drugs such as glucocorticosteroids may be used for both induction and maintenance immunosuppression because of their multiple modalities of action. There is considerable uncertainty as to whether induction immunosuppression is necessary and if so, the relative efficacy of different immunosuppressive agents.

OBJECTIVES

To assess the comparative benefits and harms of different induction immunosuppressive regimens in adults undergoing liver transplantation through a network meta-analysis and to generate rankings of the different induction immunosuppressive regimens according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until July 2019 to identify randomised clinical trials in adults undergoing liver transplantation.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults undergoing liver transplantation. We excluded randomised clinical trials in which participants had multivisceral transplantation and those who already had graft rejections.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio (OR), rate ratio, and hazard ratio (HR) with 95% credible intervals (CrIs) based on an available case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 25 trials (3271 participants; 8 treatments) in the review. Twenty-three trials (3017 participants) were included in one or more outcomes in the review. The trials that provided the information included people undergoing primary liver transplantation for various indications and excluded those with HIV and those with renal impairment. The follow-up in the trials ranged from three to 76 months, with a median follow-up of 12 months among trials. All except one trial were at high risk of bias, and the overall certainty of evidence was very low. Overall, approximately 7.4% of people who received the standard regimen of glucocorticosteroid induction died and 12.2% developed graft failure. All-cause mortality and graft failure was lower with basiliximab compared with glucocorticosteroid induction: all-cause mortality (HR 0.53, 95% CrI 0.31 to 0.93; network estimate, based on 2 direct comparison trials (131 participants; low-certainty evidence)); and graft failure (HR 0.44, 95% CrI 0.28 to 0.70; direct estimate, based on 1 trial (47 participants; low-certainty evidence)). There was no evidence of differences in all-cause mortality and graft failure between other induction immunosuppressants and glucocorticosteroids in either the direct comparison or the network meta-analysis (very low-certainty evidence). There was also no evidence of differences in serious adverse events (proportion), serious adverse events (number), renal failure, any adverse events (proportion), any adverse events (number), liver retransplantation, graft rejections (any), or graft rejections (requiring treatment) between other induction immunosuppressants and glucocorticosteroids in either the direct comparison or the network meta-analysis (very low-certainty evidence). However, because of the wide CrIs, clinically important differences in these outcomes cannot be ruled out. None of the studies reported health-related quality of life.

FUNDING

the source of funding for 14 trials was drug companies who would benefit from the results of the study; two trials were funded by neutral organisations who have no vested interests in the results of the study; and the source of funding for the remaining nine trials was unclear.

AUTHORS' CONCLUSIONS

Based on low-certainty evidence, basiliximab induction may decrease mortality and graft failure compared to glucocorticosteroids induction in people undergoing liver transplantation. However, there is considerable uncertainty about this finding because this information is based on small trials at high risk of bias. The evidence is uncertain about the effects of different induction immunosuppressants on other clinical outcomes, including graft rejections. Future randomised clinical trials should be adequately powered, employ blinding, avoid post-randomisation dropouts (or perform intention-to-treat analysis), and use clinically important outcomes such as mortality, graft failure, and health-related quality of life.

High Protein Intake Is Associated with Lower Risk of All-Cause Mortality in Community-Dwelling Chinese Older Men and Women

OBJECTIVES

To examine the association of the quantity and the source of protein intake with mortality risk in Chinese older adults.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Community-dwelling Chinese adults aged >=65 (1,480 men, 1,540 women) in Hong Kong.

MEASUREMENTS

Food frequency questionnaire was used to capture baseline dietary intakes including protein, fiber, total grains, vegetables and fruit intakes. Primary outcome measures, identified from the death registry, were death from all causes, cancer and cardiovascular disease (CVD). Other demographic and lifestyle risk factors were also collected. Multivariate Cox proportion hazards regression was used to examine the association of protein intake with mortality risk.

RESULTS

During a median of 13.8 follow-up years, 963 all-cause deaths, 336 cancer deaths, and 205 CVD deaths were identified. Among men in the highest quintile of total protein intake, all-cause mortality and cancer mortality decreased by 29% [95% confidence interval (CI): 0.55-0.92, p-trend=0.017] and 38% [95% CI: 0.39-0.97, p-trend=0.041] respectively compared with men in the lowest quintile after adjustment for demographics, lifestyle factors and medical conditions. Men in the highest quintile of animal protein intake showed 20% reduced risk of all-cause mortality than men in the lowest quintile (p-trend=0.042). Women in the highest quintile of plant protein intake showed 39% decreased risk of all-cause mortality [95% CI: 0.44-0.85, p-trend=0.019] than those in the lowest quintile. In women, protein intake was not associated with cancer mortality. In both men and women, protein intake was not associated with CVD morality. Further adjustment for other dietary variables attenuated the significant associations.

CONCLUSIONS

Contrary to findings from Caucasian populations of all ages, among Chinese older adults, higher total protein intake was associated with lower all-cause and cancer mortality in Chinese older men. While higher animal protein intake was associated with reduced all-cause mortality in Chinese older men, higher plant protein intake was protective against all-cause mortality in Chinese women. The attenuated associations between protein intake and mortality risk after adjustment for other dietary variables also highlight the role of whole diet approach in mortality risk reduction among older adults.

PP27 Pre-hospital lactate monitoring: a worthy adjunct to systolic blood pressure and shock index in triggering blood product administration in patients with suspected traumatic haemorrhage?

Introduction

Pre-hospital identification of patients with suspected occult traumatic haemorrhage is problematic. Physiological parameters and clinical gestalt are inadequate surrogates for ongoing haemorrhage. Lactate monitoring may hold stronger predictive clinical utility to identify patients with suspected traumatic haemorrhage above other physiological parameters.

Methods

A single centre, service evaluation of pre-hospital lactate monitoring. A point of care test was introduced into a Helicopter Emergency Medical Service in the United Kingdom. Clinicians adhered to strict education and governance, supported by standard operating procedure. Systolic blood pressure (SBP) and shock index (SI) was measured in patients that received pre-hospital transfusion therapy. A predetermined ‘cut off’ value of lactate >2.5 mmol was acknowledged. In-hospital follow up established further transfusion therapy.

Results

Wilcoxon rank sum compared pre-lactate (n=22) and post-lactate (n=6) groups. Monte Carlo permutations were used to obtain exact probabilities. No statistically significant differences were found between groups for: SBP, p=0.955; and, SI, p=0.401. Univariate logistic regression identified the odds ratio (OR) and confidence interval (CI) for each continuous variable as: SBP, 0.97 (CI 0.94 to 1.01); SI, 26.91 (CI 1.11 to 652.48) and lactate >2.5 mmol, 2.33 (CI 0.23 to 23.91). Multivariate logistic regression identified OR as: SBP, 0.99 (CI 0.95 to 1.04); SI, 22.98 (CI 0.56 to 946.44); and lactate >2.5 mmol, 3.05 (CI 0.14 to 65.86).

Conclusion

Lactate monitoring has been successfully introduced into an enhanced care service. The Results confirm SBP is not predictive of further transfusion. The OR for SI shows greater predictive power. Limited by a small dataset, the Results are hypothesis-generating only.

How Dietary Patterns are Related to Inflammaging and Mortality in Community-Dwelling Older Chinese Adults in Hong Kong - A Prospective Analysis

INTRODUCTION

Studies examining dietary patterns and inflammageing in relation to mortality are limited.

OBJECTIVE

We examined the influence of various dietary patterns on all-cause and cardiovascular disease (CVD) mortality, taking into account demographics, lifestyle factors, and serum inflammatory markers.

METHODS

We conducted multivariate Cox regression analyses using data from a cohort of community-dwelling older Chinese adults (1,406 men, 1,396 women) in Hong Kong. Baseline interviewer administered questionnaires covered dietary intake estimation and dietary pattern generation from the food frequency questionnaire, demographic and lifestyle factors, cognitive function and depressive symptoms. Serum high-sensitivity C-reactive protein (hsCRP) and 25-hydroxyvitamin D (25OHD) were measured. All-cause and CVD mortality data at 14-year follow up were retrieved from an official database.

RESULTS

In men, higher hsCRP level was associated with lower Diet Quality Index-International (DQI-I) score, Mediterranean-DASH Intervention for Neurodegenerative Delay Diet (MIND) score, Okinawan diet score, "vegetables-fruits" pattern score and "snacks-drinks-milk" pattern score. Higher serum 25OHD level was associated with higher Mediterranean Diet Score (MDS) but lower "snacks-drinks-milk" pattern score. None of the dietary pattern scores was associated with all-cause or CVD mortality after adjusting for all covariates. In women, hsCRP level and serum 25OHD level were not associated with any dietary patterns. Higher DQI-I score (HR=0.77 (95% CIs: 0.59, 0.99) highest vs. lowest tertile, p-trend=0.038) and Okinawan diet score (HR=0.78 (95% CIs: 0.61, 1.00) highest vs lowest tertile, p-trend=0.046) was associated with a lower risk of all-cause mortality, whereas higher MIND score (HR=0.63 (95% CI: 0.36, 1.09) highest vs. lowest tertile, p-trend=0.045) was associated with a reduced risk of CVD morality in the multivariate adjusted model.

CONCLUSION

Higher DQI-I score and Okinawan diet score were associated with a lower risk of all-cause mortality, and higher adherence to the MIND diet was related to a reduced risk of CVD mortality in community-dwelling Chinese older women.

Breath-Hold Blood Oxygen Level-Dependent MRI: A Tool for the Assessment of Cerebrovascular Reserve in Children with Moyamoya Disease

BACKGROUND AND PURPOSE

There is a critical need for a reliable and clinically feasible imaging technique that can enable prognostication and selection for revascularization surgery in children with Moyamoya disease. Blood oxygen level-dependent MR imaging assessment of cerebrovascular reactivity, using voluntary breath-hold hypercapnic challenge, is one such simple technique. However, its repeatability and reliability in children with Moyamoya disease are unknown. The current study sought to address this limitation.

MATERIALS AND METHODS

Children with Moyamoya disease underwent dual breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging of cerebrovascular reactivity in the same MR imaging session. Within-day, within-subject repeatability of cerebrovascular reactivity estimates, derived from the blood oxygen level-dependent signal, was computed. Estimates were associated with demographics and intellectual function. Interrater reliability of a qualitative and clinically applicable scoring scheme was assessed.

RESULTS

Twenty children (11 males; 12.1 ± 3.3 years) with 30 MR imaging sessions (60 MR imaging scans) were included. Repeatability was "good" on the basis of the intraclass correlation coefficient (0.70 ± 0.19). Agreement of qualitative scores was "substantial" (κ = 0.711), and intrarater reliability of scores was "almost perfect" (κ = 0.83 and 1). Younger participants exhibited lower repeatability (P = .027). Repeatability was not associated with cognitive function (P > .05). However, abnormal cerebrovascular reactivity was associated with slower processing speed (P = .015).

CONCLUSIONS

Breath-hold hypercapnic challenge blood oxygen level-dependent MR imaging is a repeatable technique for the assessment of cerebrovascular reactivity in children with Moyamoya disease and is reliably interpretable for use in clinical practice. Standardization of such protocols will allow further research into its application for the assessment of ischemic risk in childhood cerebrovascular disease.

The role of previous falls in major osteoporotic fracture prediction in conjunction with FRAX in older Chinese men and women: the Mr. OS and Ms. OS cohort study in Hong Kong

Falls are a major concern in terms of fracture risk. Although awareness rising for the absence of falls in the FRAX algorithm, our study only identified the independent predictive role of previous recurrent falls and their better conjunction use with FRAX for major osteoporotic fracture prediction in older Chinese men.

Abstract P4-02-04: Quantitative MRI features analysis for differentiation of triple negative and HER2 positive subtypes of breast cancer

Objective: The aim of this study was to evaluate ability of quantitative analysis of MRI features to distinguish triple negative (TN) and HER2 positive (HER2+) subtypes of breast cancer, which have different biological characteristics, exhibiting different growth patterns and response to treatment.

Materials and Method: Breast cancer patients, who had MRI exam of the breast in our institution at the time of staging for breast carcinoma and who subsequently had surgery (segmentectomy or mastectomy) from January 1, 2008 through December 31, 2015 were identified. All lesions were evaluated by radiologists in accordance with the BI-RADS lexicon. The patient's age, breast cancer histology, multifocality/multicentricity (MF/MC), lesion size, axillary lymphadenopathy (LAN), MRI morphologic and enhancement characteristics were documented. Quantitative MRI feature analysis was performed using shape, texture, and histogram based features. Machine-learning-based (Xgboost) models were used to predict subtypes, and Leave-one-out cross-validation (LOOCV) was used to avoid model overfitting. Statistical significance was determined using the Student's t-test.

Results: Total of 105 patients, 51 patients with TN and 54 patients with HER2+ breast cancer were included in analysis. Mean age for TN was 50 (range 29-79)) years old and for HER2+ was 49 (range 25-70) years old. Axillary LAN and MF/MC disease was seen more commonly in HER2+ patients when compared to TN patients, but didn't reach statistical significance (13 vs 7, p=0.9; and 31 vs 20, p=0.06, respectively). Mass rim enhancement was associated with TN subtype and irregular mass enhancement was associated with HER2+ subtype of breast cancer (p&lt;0.05). Quantitative analysis showed that six out of the top 10 ranked MRI features: surface to volume ratio, difference variance, difference entropy, inverse difference moment, 75 percentile in histogram and sum average, were significantly different between these 2 subtypes with p&lt;0.05. When the significant features were incorporated to distinguish TN and HER+ subtypes, use of the top 2 features achieved the best accuracy on LOOCV of 0.69.

Conclusion: The quantitative MRI features show promise in distinguishing TN and HER2+ breast cancer subtypes reflecting their underlying biological characteristics and may be used as predictive quantitative biological markers. Further studies in a larger cohort evaluating associations with treatment response are underway.

FeatureIndexP-valueSurface to volume ratioShape30.005Difference VarianceGLCM110.005Difference EntropyGLCM100.009Inverse Difference MomentGLCM50.01875 percentile in histogramHistogram50.043Sum AverageGLCM60.044Median in histogramHistogram 30.08025 percentile in histogramHistogram 40.095VolumeShape10.104Max in histogramHistogram 10.105

Citation Format: Rauch GM, Li H, Zhu H, Adrada BE, Santiago L, Candelaria RP, Wang H, Leung J, Thompson A, Litton J, Wu Y, Lim B, Moulder S, Mittendorf EA, Yang W. Quantitative MRI features analysis for differentiation of triple negative and HER2 positive subtypes of breast cancer [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 P4-02-04.

Abstract PD2-09: Association of quantitative MRI features with tumor infiltrating lymphocytes and treatment response prediction in HER2 positive subtype of breast cancer

Objectives: To evaluate associations between qualitative and quantitative MRI features and tumor infiltrating lymphocytes (TIL) levels in HER2+ subtype of breast cancer, as potential prognostic non-invasive imaging markers for treatment response prediction.

Materials and Methods: Retrospective review of breast cancer patients who had MRI at staging, neoadjuvant chemotherapy and surgery from January 1, 2008 through December 31, 2015 was performed. BI-RADS lexicon was used for lesion evaluation. Demographic, imaging, and pathologic data including TIL levels were documented. Quantitative MRI texture analysis was performed using 3 types of textural features (TF): local binary patterns (LBP), gray-level co-occurrence matrix (GLCM), and threshold adjacency statistics (TAS). Associations between MRI quantitative TF, TIL levels, and pathologic complete response (pCR) were evaluated by Pearson correlation and logistic regression.

Results: There were 50 HER2+ patients (median age 51 years, range 29-59) with pretreatment MRI and TIL status for analysis; 27 patients had pCR at surgery. Qualitative MRI analysis showed that mass rim-enhancement (p&lt;0. 05) and fast early enhancement kinetics (p&lt;0.01) were associated with higher TIL levels. No association between qualitative MRI features and pCR was found. Nine TF significantly correlated with pCR (p&lt;0.05): angular 2nd moment (GLCM), 75 percentile (LBP), standard deviation (GLCM), adjacency 0-5 (TAS). This is indicative of association of tumor heterogeneity with pCR. Three TF were significantly associated with high TIL levels (p&lt;0.05): standard deviation, adjacency 1 and 2. Additional four TF had high association with TIL (p&lt;0.1): sum entropy, adjacency 0, 3 and 4. These findings showed that increased heterogeneity, complexity and entropy were associated with high TIL level. Three TF were significantly associated with both, pCR and TIL (p&lt;0.05): 75 percentile, standard deviation, adjacency 8.

Conclusion: Quantitative tumor texture analysis based on statistical modeling showed specific nine TF indicative of tumor heterogeneity associated with pCR; and seven TF indicative of increased heterogeneity, complexity, and entropy associated with high TIL levels in HER2+ breast cancer. Analysis of associations of MRI quantitative TF with pCR and TIL in HER2+ breast cancer may help to develop prognostic non-invasive imaging markers for treatment response prediction.

Citation Format: Rauch GM, Zhu H, Li H, Adrada BE, Santiago L, Candelaria RP, Wang H, Leung J, Litton J, Wu Y, Murthy R, Mittendorf EA, Yang W. Association of quantitative MRI features with tumor infiltrating lymphocytes and treatment response prediction in HER2 positive subtype of breast cancer [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 PD2-09.

The role of previous falls in major osteoporotic fracture prediction in conjunction with FRAX in older Chinese men and women: the Mr. OS and Ms. OS cohort study in Hong Kong

Falls are a major concern in terms of fracture risk. Although awareness rising for the absence of falls in the FRAX algorithm, our study only identified the independent predictive role of previous recurrent falls and their better conjunction use with FRAX for major osteoporotic fracture prediction in older Chinese men.

INTRODUCTION

Although the association of falls with fracture has been widely explored, the impact of previous falls is not included in the FRAX algorithm currently. Our aim was to examine the FRAX-independent associations between falls in the previous year and subsequent fracture risk, as well as the conjunctive use of falls and the FRAX score for major osteoporotic fracture (MOF) prediction in older Chinese people.

METHODS

Four thousand community older men and women aged 65 years or older were followed up for 9.9 ± 2.7 and 8.8 ± 1.5 years, respectively. The associations between falls in the previous 1 year and MOF risk by follow-up years were evaluated using the Fine and Gray model. New prediction scores were calculated by incorporating the falls and FRAX scores using the Fine and Gray model, or developed by adjusting the FRAX scores by 30% increased risk for each fall in the previous year. The predictive powers for MOF risk between the new scores and FRAX scores were evaluated by the area under the curve (AUC) and category-based net reclassification improvement index (NRI).

RESULTS

During the follow-up period, 139 (7.0%) men and 236 (11.8%) women had at least one incident MOF. One previous fall significantly predicted the first year incident MOF in men [hazard ratio (HR) (95%CI), 3.47 (1.02, 11.80)]. Previous recurrent falls significantly predicted a 10-year incident MOF in men [HR (95%CI), 2.42 (1.30, 4.51)]. In men, the fall-adjusting FRAX scores showed significant improvement on total net reclassification of fracture (3-6%). No improved predictive accuracy shown in women.

CONCLUSION

Falls in the previous year are likely to provide some predictive power to FRAX for MOF risk assessment in older Chinese men, but not women.