Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Spatiotemporally resolved transcriptomics reveals the subcellular RNA kinetic landscape

Spatiotemporal regulation of the cellular transcriptome is crucial for proper protein expression and cellular function. However, the intricate subcellular dynamics of RNA remain obscured due to the limitations of existing transcriptomics methods. Here, we report TEMPOmap-a method that uncovers subcellular RNA profiles across time and space at the single-cell level. TEMPOmap integrates pulse-chase metabolic labeling with highly multiplexed three-dimensional in situ sequencing to simultaneously profile the age and location of individual RNA molecules. Using TEMPOmap, we constructed the subcellular RNA kinetic landscape in various human cells from transcription and translocation to degradation. Clustering analysis of RNA kinetic parameters across single cells revealed 'kinetic gene clusters' whose expression patterns were shaped by multistep kinetic sculpting. Importantly, these kinetic gene clusters are functionally segregated, suggesting that subcellular RNA kinetics are differentially regulated in a cell-state- and cell-type-dependent manner. Spatiotemporally resolved transcriptomics provides a gateway to uncovering new spatiotemporal gene regulation principles.

A tailored COVID-19 vaccination pathway for children 5-11 years in Victoria, Australia

BACKGROUND

Procedural anxiety was anticipated in children 5-11 years during the COVID-19 vaccine rollout in Victoria, Australia, as children in this age group receive few routine vaccines. Therefore, the Victorian state government designed a tailored, child-friendly vaccine program. This study aimed to assess parental satisfaction with elements of the bespoke vaccination pathway.

METHODS

The Victorian government and state-run vaccination hubs in Victoria facilitated an online immunisation plan to help parents identify their child's support needs, and utilised experienced paediatric staff and additional supports for children with severe needle distress and/or disability. All parents/guardians of children 5-11 years who received a COVID-19 vaccine in a vaccination hub were sent a 16-item feedback survey via text message.

RESULTS

Between 9 February and 31 May 2022 there were 9203 responses; 865 children (9.4%) had a first language other than English, 499 (5.4%) had a disability or special needs, and 142 (1.5%) were Aboriginal or Torres Strait Islander. Most parents (94.4%; 8687/9203) rated their satisfaction with the program as very good or excellent. The immunisation plan was used by 13.5% (1244/9203) of respondents, with usage more common for Aboriginal or Torres Strait Islander children (26.1%; 23/88) or families with a first language other than English (23.5%; 42/179). The child-friendly staff (88.5%, 255/288) and themed environment (66.3%, 191/288) were the most valued measures for vaccination. Additional support measures were required by 1.6% (150/9203) of children in the general population and 7.9%, (17/261) of children with a disability and/or special needs.

CONCLUSION

A tailored COVID-19 vaccination program for children 5-11 years, with additional support for children with severe needle distress and/or disability, had high parental satisfaction. This model could be utilised for COVID-19 vaccination in pre-school children and for routine childhood vaccination programs to provide optimal support to children and their families.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

A Rare Case of Anaplastic Lymphoma Kinase-Positive Large B-Cell Lymphoma Involving Epidural Tissue

Introduction/Objective

Anaplastic lymphoma kinase-positive large B-cell lymphoma (ALK-positive LBCL) is a rare, aggressive type of non-Hodgkin’s B-cell lymphoma with characteristic rearrangements and overexpression of ALK. Diagnosis of ALK-positive LBCL is challenging because of its rarity and uncharacteristically low expression of B- lineage antigens usually needed for diagnosis of B-cell lymphomas. In this report, we describe a case of ALK-positive large B cell lymphoma involving epidural soft tissue in a young adult.

Methods/Case Report

29 year old presented to emergency department with a two week history of back pain and a three day history of worsening numbness and weakness in the lower extremities. MRI of the thoracic spine showed an epidural soft tissue mass posterior to T5, T6 and T7 vertebral bodies with abnormal signal in the T6 spinous process. Histological examination from the epidural mass revealed sheets of atypical lymphoid cells with abundant pale cytoplasm and round vesicular nuclei with prominent single to occasional multiple nucleoli. Immunohistochemical stains demonstrated neoplastic cell positivity for ALK, VS38c, CD138, EMA, MUM1, CD45, PAX5 and MCK. They were negative for CD3, CD20, CD19, CD79a, CD30, CD2, CD117, SOX10, HMB45, cytokeratin, synaptophysin and chromogranin. These overall findings were consistent with ALK-positive large B-cell lymphoma.

Results (if a Case Study enter NA)

NA.

Conclusion

ALK-positive large B-cell lymphoma is a non-Hodgkin lymphoma associated with high morbidity and mortality. Absence of reliable B-cell marker expression in this B-cell lymphoma requires recognition of morphological findings to order confirmatory testing such as immunohistochemical stains for CD138 and ALK. This particular case also showed an unusual anatomic presentation in epidural tissue.

Subjective age and positive psychiatry: Identifying the positive characteristics associated with successful aging

Introduction

For older adults, feeling subjectively younger is associated with improvements in cognition, subjective well-being and depressive symptoms. Positive psychiatry is the field that focuses on patient strengths and the promotion of positive outcomes, rather than just mitigation of illness. Younger subjective age may be a useful measure of successful aging, but little is known about how subjective age is associated with positive psychosocial characteristics.

Objectives

Our objective is to characterize how subjective age is related validated positive psychosocial measures, with the goal of better understanding the determinants of successful aging.

Methods

The Successful Aging Evaluation (SAGE) longitudinal study recruited over 1,300 community-dwelling residents of San Diego County, CA, from age 21 to over 100. A single-item question asked “How old/young do you feel?” We used spearman correlations to assess the relationship between subjective age and validated positive psychosocial scales such as the Self-Rated Successful Aging, Life Orientation Test, Personal Mastery Scale, Connor-Davidson Resilience Scale, Satisfaction with Life Scale, Adult Hope Scale, and Social Support Index.

Results

Mean chronological age was 65.5, and mean subjective age was 53.6. Mean age discrepancy was 11.5 years. Younger subjective age was positively associated with most of the positive psychosocial characteristics measured, including self-rated successful aging, optimism, personal mastery, resilience, curiosity, hope, and social support.

Conclusions

There is a growing movement within psychiatry to understand the positive characteristics that lead to successful aging. This is one of the first studies demonstrating younger age identities are associated with positive psychosocial characteristics and successful aging.

Disclosure

No significant relationships.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Whole-patient conversations: Implementation of a practical positive psychiatry intervention for medical trainees

Introduction

Positive psychiatry is the science and practice of psychiatry seeking to promote overall well-being and understand the “positive” aspects of the patient’s life, such as resilience, social connections, and meaning and values in life. While positive psychiatry research has recently blossomed, the field lacks practical ways to integrate these overarching principles into clinical practice. Life review interventions are commonly used in palliative care, spiritual care, and geriatrics, and involve a healthcare team member interviewing a patient about their life.

Objectives

Our objective is to describe the implementation of a positive psychiatry-informed life story review initiative into medical education, with the goal of creating a structure for medical trainees to see the larger context of patients’ health, understand how past experiences influence current values, and improve patients’ overall well-being.

Methods

First- and third-year students at Alpert Medical School of Brown University are required to participate in at least one strengths-based life review with a patient in the community or inpatient setting, transcribe the story, and integrate the story into the electronic health record.

Results

Preliminary results demonstrate high acceptability and perceived development of patient-centered competencies, such as understanding patients as more complete human beings. While this is a low cost and sustainable intervention, barriers include buy-in from medical educators, hospital administrators, and trainees.

Conclusions

To our knowledge, this is one of the first positive psychiatry-informed interventions to be implemented into the required medical curricula. Life story reviews may allow providers to understand the “positive” aspects of patients’ lives and understand their patients better as people.

A systematic review and meta-analysis of treatment-related toxicities of curative and palliative radiation therapy in non-small cell lung cancer

Treatment-related toxicity is an important component in non-small cell lung cancer (NSCLC) management decision-making. Our aim was to evaluate and compare the toxicity rates of curative and palliative radiotherapy with and without chemotherapy. This meta-analysis provides better quantitative estimates of the toxicities compared to individual trials. A systematic review of randomised trials with > 50 unresectable NSCLC patients, treated with curative or palliative conventional radiotherapy (RT) with or without chemotherapy. Data was extracted for oesophagitis, pneumonitis, cardiac events, pulmonary fibrosis, myelopathy and neutropenia by any grade, grade ≥ 3 and treatment-related deaths. Mantel–Haenszel fixed-effect method was used to obtain pooled risk ratio. Forty-nine trials with 8609 evaluable patients were included. There was significantly less grade ≥ 3 acute oesophagitis (6.4 vs 22.2%, p < 0.0001) and any grade oesophagitis (70.4 vs 79.0%, p = 0.04) for sequential CRT compared to concurrent CRT, with no difference in pneumonitis (grade ≥ 3 or any grade), neutropenia (grade ≥ 3), cardiac events (grade ≥ 3) or treatment-related deaths. Although the rate of toxicity increased with intensification of treatment with RT, the only significant difference between treatment regimens was the rate of oesophagitis between the use of concurrent and sequential CRT. This can aid clinicians in radiotherapy decision making for NSCLC.

Incidental Anaplastic Lymphoma in a Case of Herpetic Hepatitis

Introduction/Objective

The role of Herpes Simplex Virus (HSV) virus in the development of lymphomas is unclear and poses a diagnostic challenge along with limited literature explaining the relationship between HSV and Anaplastic large-cell lymphoma (ALCL).

Methods

A 26-year-old female admitted for intractable fever (103.7 F), chills, and dysuria; her urine analysis was suggestive of a mild urinary tract infection. During the admission, she developed abdominal pain with subsequent CT- scan showing thickening of the gallbladder and possible cholecystic fluid. Her liver function tests were: albumin 2.8 g/dL, AST 394 U/L, ALT 303 U/L, ALP 156 U/L, total bilirubin 0.3 INR 1. A subsequent Magnetic Resonance Cholangiopancreatography (MRCP) showed heterogeneous enhancement pattern of the liver without any masses following which she underwent cholecystectomy, during which her liver was abnormal along with an enlarged peri- cholic lymph node. Intraoperative biopsy of the liver showed patchy hepatocyte necrosis and occasional hepatocytes with ground-glass nuclei. The morphologic features were suggestive for Herpes Simplex Virus (HSV) hepatitis, and an HSV immunohistochemical stain confirmed this diagnosis. Removal of the lymph node showed a sinusoidal infiltrate of atypical lymphohistiocytic cells with abundant pale cytoplasm and large moderately irregular nuclei and occasional prominent amphophilic nucleoli. A few “hallmark”-like cells with curved nuclei were noted with rare mitosis. A panel of adequately controlled immunohistochemical stains showed positivity for CD4, CD30 (variable), and CD45. CD2, CD3, CD5, CD7, CD8, CD10, CD15, CD20, CD68 (positive in adjacent macrophages), BCL2, ALK1 were negative.

Results

Flow cytometry was negative for a neoplastic leukocyte population with a polytypic B-cell population. Taken together, a diagnosis of ALK1 negative, ALCL was made. A subsequent CT scan revealed borderline enlarged para- aortic lymph nodes along with an increased number of non-enlarged lymph nodes in the bilateral axillary, mediastinal, lower neck, and subpectoral regions. A bone marrow biopsy performed was negative for lymphoma.

Conclusion

Off note, her hepatitis serology panel, CMV, and HIV screens were negative. Thus, with her unusual presenting symptoms and no signs of malignancy led to numerous workups, which further led to an infectious cause, however, the patient was ultimately discovered to have an occult ALCL.

A Rare Case of Chronic Lymphoproliferative Disorder of NK Cells with an Unusual Expression of CD57

Introduction/Objective

Natural Killer cells (NK-cells) malignancies are extremely rare and the two NK-cell disorders involving the peripheral blood and bone marrow include chronic lymphoproliferative disorder of NK-cells (CLPDNK) and aggressive NK-cell leukemia (ANKL). ANKL is EBV associated with a prevalence in Asian adults and a fulminant clinical course leading to death within 2 months.

Methods

A 76-year-old female with a history of iron deficiency anemia presented for evaluation of lymphocytosis (78 TH/mm) and negative EBV with extreme fatigue, weight loss, and worsening weakness from the past 8 months.

Results

The peripheral and bone marrow aspirate showed an increase in granular lymphocytes with bland nuclei and abundant pale-staining cytoplasm containing fine to coarse azurophilic granules with no evidence of nuclear atypia. Flow cytometry demonstrated an atypical lymphocytic cell population comprising &gt;50% of total marrow and peripheral blood lymphocytes demonstrating loss of CD56 and diminished CD7 expression. The analysis showed atypical lymphocytes with the following immunophenotype: CD2, CD8 (the majority, at least 75%),CD7 (dim), CD38, CD11c (subset) with no expression of CD3, CD5, CD4, CD56, or CD11c. Flow cytometry is important as it helps in the phenotypic detection of aberrancy. A broad panel of immunohistochemical stains revealed scattered positivity for CD3, CD4, CD7, CD8, TIA-1, granzyme, perforin, and tryptase and negative for CD56 and CD57. Our top differential with a similar clinical course included T-cell large granular lymphocytic leukemia which is characterized by a clonal proliferation of mature cytotoxic T cells and also has an indolent course. They show CD3 positivity by flow cytometry along with co-expression of NK cell-associated markers (CD16 and CD57), and variable expression of other pan T cell markers such as CD2, CD5, CD7. It is found incidentally in patients having cytopenias with a persistent increase in circulating mature NK-cells. Of note, the PET scan revealed splenomegaly with no other significant findings.The patient was started on steroids and is currently doing well.

Conclusion

Thus, overall morphologic, immunophenotypic, and molecular results with negative expression of surface or cytoplasmic CD3 as well as the absence of TCR expression were most consistent with CLPD-NK with an unusual expression of CD57 expression detected in flow cytometry.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

FRI0096 CLINICAL BENEFITS REPORTED IN AMPLE TRIAL OBSERVED IN A REAL-WORLD (RW) COHORT OF US RHEUMATOID ARTHRITIS (RA) PATIENTS

Background:

Efficacy observed in controlled trials may not reflect RW effectiveness, given documented differences in patient populations and management.1

Objectives:

This study aimed to assess disease measures over time as measured in a trial setting (AMPLE) and in a separate RW observational setting, both among patients with RA treated with abatacept.

Methods:

The RW cohort comprised retrospective patient-level data abstracted by 31 community rheumatologists for adult RA patients treated with abatacept who had an anti-cyclic citrullinated peptide-2 titer ≥250 AU/mL. AMPLE was a phase III, randomized controlled trial of RA patients treated with abatacept that assessed disease measures over a 2-year follow-up. Data included demographics, treatments, labs, and disease measures (tender and swollen joint counts (TJC, SJC), C-reactive protein (CRP), American College of Rheumatology-20 (ACR20) and ACR50 at baseline and 3 and 6 months) and were summarized descriptively. Disease measures were evaluated across AMPLE and RW cohorts.

Results:

Of the 291 RW patients and 318 AMPLE patients, the majority were female (70%, 81%), white (72%, 81%), and RF-positive (91%, 76%), respectively (Table 1). The mean ages at abatacept initiation were 54.7 and 51.4 years old in RW and AMPLE, respectively. Concomitant corticosteroids (45%, 65%) and methotrexate (62%, 100%) were common in RW and AMPLE, respectively. All patients in AMPLE were biologic naïve, whereas 83% of RW patients had prior biologic use. AMPLE administered abatacept subcutaneously (SC), while 37% of RW patients received abatacept SC. Patients had median SJC and TJC of 6 and 8 in RW and 13 and 22 in AMPLE at abatacept initiation, respectively (Table 2). SJC (TJC) improved a median of 65% (60%) and 68% (66%) at 3 months and 75% (67%) and 76% (75%) at 6 months in RW and AMPLE, respectively (Fig 1). The majority of patients achieved ACR20 at 3 months (79% and 60%) and 6 months (88% and 66%) in RW and AMPLE, respectively, while 58% and 32% achieved ACR50 at 3 months and 67% and 45% at 6 months, respectively (Fig 2).

Table 1:

Patient Characteristics.

RW cohort(n=291)AMPLE cohort(n=318)Female (n, %)205 (70%)259 (81%)White (n, %)209 (72%)257 (81%Age at abatacept initiation, years (mean, SD)54.7 (14.8)51.4 (12.6)RF-positive* (n, %)249 (91%)240 (76%)Concomitant medications (n, %) Corticosteroids†132 (45%)207 (65%) Methotrexate179 (62%)318 (100%)Prior biologic use (n, %)241 (83%)0 (0%)Route of administration (n, %) Intravenous183 (63%)0 (0%) Subcutaneous108 (37%)318 (100%)

LEGEND: *among 274 with known RF status;†corticosteroids in AMPLE cohort at any time in the 2-year study period

Table 2.

Changes in Disease Activity.

RW cohort(n=291)AMPLE cohort(n=318)SJC (median) Baseline value613 3-month value24 6-month value13TJC (median) Baseline value822 3-month value37 6-month value25CRP, mg/dL (mean) Baseline value1.081.6 3-month value0.470.8 6-month value0.300.8ACR20 achieved (n, %) 3-month value194 (79%)191 (60%) 6-month value78 (88%)209 (66%)ACR50 achieved (n, %) 3-month value144 (58%)103 (32%) 6-month value60 (67%)144 (45%)

LEGEND: values soonest after 3 months and value between 6-9 months used for RW cohort; values at days 85 and 197 used for AMPLE cohort.

Conclusion:

Despite differences in patient characteristics, improvements in SJC and TJC, as well as high rates of ACR20 and ACR50, were observed in both trial setting and RW settings. These improvements in disease activity were observed at similar magnitudes in both settings, demonstrating that trial efficacy is achievable in RW clinical practice with abatacept treatment.

References:

[1]Kilcher G, Hummel N, Didden EM, et al. Rheumatoid arthritis patients treated in trial and real-world settings: comparison of randomized trials with registries.Rheumatology. 2018;57(2):354-369.

Disclosure of Interests:

Andrew Klink Employee of: I am employed by Cardinal Health., Xue Han Employee of: BMS, Francis Lobo Shareholder of: Bristol-Myers Squibb (US), Employee of: Bristol-Myers Squibb (US), Rick Szymialis Shareholder of: BMS, Employee of: BMS, Jenny Lam Shareholder of: A few shares in Gilead in IRA account, Grant/research support from: Currently, a BMS fellowship (not a full-time employee), Bruce Feinberg Employee of: I am employed by Cardinal Health.

Colorectal stenting in England: a cross-sectional study of practice

INTRODUCTION

UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England.

METHODS

All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty).

RESULTS

Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure.

CONCLUSIONS

All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

Canada's Prosthetic Coverage: a Review of Provincial Prosthetic Policy

The Canadian healthcare system serves as an example of equity and federal service to citizens across the world. However, it is not without its challenges. Prosthetic coverage across Canada is highly variable and largely unable to provide equal coverage for Canadian persons living with amputation. Many persons with limb loss are forced to rely upon personal resources, fundraising, or the charity of non-governmental organizations in order to meet this basic healthcare need. This disparity in the Canadian healthcare system is unusual and largely undescribed in the literature. We thus explore the nature of Canadian healthcare prosthetic coverage across Canada, investigating the variability in coverage, presence of prosthetic coverage policies, clarity of policy, eligibility criteria, and interval of prosthetic replacement. Our findings highlight potential areas for improvement within current Canadian healthcare policy.

Modular, tissue-specific, and biodegradable hydrogel cross-linkers for tissue engineering

Synthetic hydrogels are investigated extensively in tissue engineering for their tunable physicochemical properties but are bioinert and lack the tissue-specific cues to produce appropriate biological responses. To introduce tissue-specific biochemical cues to these hydrogels, we have developed a modular hydrogel cross-linker, poly(glycolic acid)-poly(ethylene glycol)-poly(glycolic acid)-di(but-2-yne-1,4-dithiol) (PdBT), that can be functionalized with small peptide-based cues and large macromolecular cues simply by mixing PdBT in water with the appropriate biomolecules at room temperature. Cartilage- and bone-specific PdBT macromers were generated by functionalization with a cartilage-associated hydrophobic N-cadherin peptide, a hydrophilic bone morphogenetic protein peptide, and a cartilage-derived glycosaminoglycan, chondroitin sulfate. These biofunctionalized PdBT macromers can spontaneously cross-link polymers such as poly(N-isopropylacrylamide) to produce rapidly cross-linking, highly swollen, cytocompatible, and hydrolytically degradable hydrogels suitable for mesenchymal stem cell encapsulation. These favorable properties, combined with PdBT's modular design and ease of functionalization, establish strong potential for its usage in tissue engineering applications.

Observation of an Unusual Upward-Going Cosmic-Ray-like Event in the Third Flight of ANITA

We report on an upward traveling, radio-detected cosmic-ray-like impulsive event with characteristics closely matching an extensive air shower. This event, observed in the third flight of the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload, is consistent with a similar event reported in a previous flight. These events could be produced by the atmospheric decay of an upward-propagating τ lepton produced by a ν_{τ} interaction, although their relatively steep arrival angles create tension with the standard model neutrino cross section. Each of the two events have a posteriori background estimates of ≲10^{-2} events. If these are generated by τ-lepton decay, then either the charged-current ν_{τ} cross section is suppressed at EeV energies, or the events arise at moments when the peak flux of a transient neutrino source was much larger than the typical expected cosmogenic background neutrinos.

Diagnostic criteria for temporomandibular disorders: Diagnostic accuracy for general dentistry procedure without mandatory commands regarding myalgia, arthralgia and headache attributed to temporomandibular disorder

The clinical examination in diagnostic criteria for temporomandibular disorders (DC/TMD) is a strict procedure and comprises mandatory commands. However, learning and using these mandatory commands in general practice have proven to be difficult and their use of DC/TMD is minimal. To investigate whether reliability on a diagnostic level for DC/TMD diagnoses differs between examiners using the mandatory commands or not. Six examiners were divided into two groups: one using the mandatory commands in DC/TMD for the clinical examination and one who did not use the mandatory commands. A reliability assessment was performed twice, one occasion for each group of examiners. The assessment was performed according to the guidelines from the International Network for Orofacial Pain and Related Disorders Methodology. Each group of examiners thereby examined 16 subjects (11 TMD patients and 5 healthy individuals) each, and the diagnostic agreement (reliability) as compared to diagnoses derived by a reference standard examiner was calculated with Cohen' s kappa coefficient. The DC/TMD diagnoses myalgia, arthralgia and headache attributed to TMD were included in the reliability assessment. There was no significant difference regarding diagnostic agreement reliability between the examiners using or not using the mandatory DC/TMD commands. This study indicates that not using the mandatory commands in DC/TMD in general practice does not impair the diagnostic reliability regarding the diagnoses myalgia, arthralgia and headache attributed to TMD compared to including the commands.

Partial correlation analysis reveals abnormal retinotopically organized functional connectivity of visual areas in amblyopia

Amblyopia is a prevalent developmental visual disorder of childhood that typically persists in adults. Due to altered visual experience during critical periods of youth, the structure and function of adult visual cortex is abnormal. In addition to substantial deficits shown with task-based fMRI, previous studies have used resting state measures to demonstrate altered long-range connectivity in amblyopia. This is the first study in amblyopia to analyze connectivity between regions of interest that are smaller than a single cortical area and to apply partial correlation analysis to reduce network effects. We specifically assess short-range connectivity between retinotopically defined regions of interest within the occipital lobe of 8 subjects with amblyopia and 7 subjects with normal vision (aged 19–45). The representations of visual areas V1, V2, and V3 within each of the four quadrants of visual space were further subdivided into three regions based on maps of visual field eccentricity. Connectivity between pairs of all nine regions of interest in each quadrant was tested via correlation and partial correlation for both groups. Only the tests of partial correlation, i.e., correlation between time courses of two regions following the regression of time courses from all other regions, yielded significant differences between resting state functional connectivity in amblyopic and normal subjects. Subjects with amblyopia showed significantly higher partial correlation between para-foveal and more eccentric representations within V1, and this effect associated with poor acuity of the worse eye. In addition, we observed reduced correlation in amblyopic subjects between isoeccentricity regions in V1 and V2, and separately, between such regions in V2 and V3. We conclude that partial correlation-based connectivity is altered in an eccentricity-dependent pattern in visual field maps of amblyopic patients. Moreover, results are consistent with known clinical and psychophysical vision loss. More broadly, this provides evidence that abnormal cortical adaptations to disease may be better isolated with tests of partial correlation connectivity than with the regular correlation techniques that are currently widely used.

•

Cortical functional connectivity abnormalities exist in amblyopia at a scale finer than previously reported.

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Connectivity changes within primary visual cortex are consistent with known loss of function.

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Connectivity changes between visual areas are consistent with concept of deafferentation.

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Partial correlation differentiates patients from controls, whereas correlation does not.

Characteristics of Four Upward-Pointing Cosmic-Ray-like Events Observed with ANITA

We report on four radio-detected cosmic-ray (CR) or CR-like events observed with the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload. Two of the four were previously identified as stratospheric CR air showers during the ANITA-I flight. A third stratospheric CR was detected during the ANITA-II flight. Here, we report on characteristics of these three unusual CR events, which develop nearly horizontally, 20-30 km above the surface of Earth. In addition, we report on a fourth steeply upward-pointing ANITA-I CR-like radio event which has characteristics consistent with a primary that emerged from the surface of the ice. This suggests a possible τ-lepton decay as the origin of this event, but such an interpretation would require significant suppression of the standard model τ-neutrino cross section.

Accelerator Measurements of Magnetically Induced Radio Emission from Particle Cascades with Applications to Cosmic-Ray Air Showers

For 50 years, cosmic-ray air showers have been detected by their radio emission. We present the first laboratory measurements that validate electrodynamics simulations used in air shower modeling. An experiment at SLAC provides a beam test of radio-frequency (rf) radiation from charged particle cascades in the presence of a magnetic field, a model system of a cosmic-ray air shower. This experiment provides a suite of controlled laboratory measurements to compare to particle-level simulations of rf emission, which are relied upon in ultrahigh-energy cosmic-ray air shower detection. We compare simulations to data for intensity, linearity with magnetic field, angular distribution, polarization, and spectral content. In particular, we confirm modern predictions that the magnetically induced emission in a dielectric forms a cone that peaks at the Cherenkov angle and show that the simulations reproduce the data within systematic uncertainties.

A cross-sectional analysis of the relationships of FAM components and their effects on quality of life in Chinese patients with chronic musculoskeletal pain

Introduction

A body of evidence has accrued supporting the Fear-Avoidance Model (FAM) of chronic pain which postulated the mediating role of pain-related fear in the relationships between pain catastrophizing and pain anxiety in affecting pain-related outcomes. Yet, relatively little data points to the extent to which the FAM be extended to understand chronic pain in Chinese population and its impact on quality of life (QoL).

Objective

This study explored the relationships between FAM components and their effects on QoL in a Chinese sample.

Methods

A total of 401 Chinese patients with chronic musculoskeletal pain completed measures of three core FAM components (pain catastrophizing, pain-related fear, and pain anxiety) and QoL. Cross-sectional structural equation modeling (SEM) assessed the goodness of fit of the FAM for two QoL outcomes, Physical (Model 1) and Mental (Model 2). In both models, pain catastrophizing was hypothesized to underpin pain-related fear, thereby influencing pain anxiety and subsequently QoL outcomes.

Results

Results of SEM evidenced adequate data-model fit (CFI30.90) for the two models tested (Model 1: CFI = 0.93; Model 2: CFI = 0.94). Specifically, pain catastrophizing significantly predicted pain-related fear (Model 1: stdb = 0.90; Model 2: stdb = 0.91), which in turn significantly predicted pain anxiety (Model 1: stdb = 0.92; Model 2: stdb = 0.929) and QoL outcomes in a negative direction (Model 1: stdb = −0.391; Model 2: stdb = −0.651) (all P < 0.001) (Table 1, Fig. 1).

Conclusion

Our data substantiated the existing FAM literature and offered evidence for the cross-cultural validity of the FAM in the Chinese population with chronic pain.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The net suppression effect of pain catastrophic cognition on anxiety sensitivity

Introduction

The existing literature on chronic pain points to the effects anxiety sensitivity, pain hypervigilance, and pain catastrophizing on pain-related fear; however, the nature of the relationships remains unclear. The three dispositional factors may affect one another in the prediction of pain adjustment outcomes. The addition of one disposition may increase the association between another disposition and outcomes, a consequence known as suppressor effects in statistical terms.

Objective

This study examined the possible statistical suppressor effects of anxiety sensitivity, pain hypervigilance and pain catastrophizing in predicting pain-related fear and adjustment outcomes (disability and depression).

Methods

Chinese patients with chronic musculoskeletal pain (n = 401) completed a battery of assessments on pain intensity, depression, anxiety sensitivity, pain vigilance, pain catastrophizing, and pain-related fear. Multiple regression analyses assessed the mediating/moderating role of pain hypervigilance. Structural equation modeling (SEM) was used to evaluate suppression effects.

Results

Our results evidenced pain hypervigilance mediated the effects of anxiety sensitivity (Model 1: Sobel z = 4.86) and pain catastrophizing (Model 3: Sobel z = 5.08) on pain-related fear. Net suppression effect of pain catastrophizing on anxiety sensitivity was found in SEM where both anxiety sensitivity and pain catastrophizing were included in the same full model to predict disability (Model 9: CFI = 0.95) and depression (Model 10: CFI = 0.93) (all P < 0.001) (see Figs. 3 and 4, Figs. 1 and 2).

Conclusions

Our findings evidenced that pain hypervigilance mediated the relationship of two dispositional factors, pain catastrophic cognition and anxiety sensitivity, with pain-related fear. The net suppression effects of pain catastrophizing suggest that anxiety sensitivity enhanced the effect of pain catastrophic cognition on pain hypervigilance.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A Comparison of the Diagnostic Accuracy and Reliability of Subjective Grading and Computer-Aided Assessment of Intranodal Vascularity in Differentiating Metastatic and Reactive Cervical Lymphadenopathy

PURPOSE

Ultrasound is a well-established imaging modality in the assessment of malignant cervical lymphadenopathy. With the use of Doppler ultrasound, intranodal vascularity can be evaluated. However, the major limitation of ultrasound is operator dependency. Therefore, this study aimed to evaluate and compare the diagnostic accuracy and reliability of the subjective grading and computer-aided approach in assessing intranodal vascularity for the differentiation of benign and malignant lymph nodes.

MATERIALS AND METHODS

The present study retrospectively assessed 99 power Doppler ultrasound images of cervical lymph nodes and evaluated the degree of intranodal vascularity using qualitative subjective grading (QSG) and quantitative computer-aided (QCA) methods. The diagnostic accuracy of the two methods in distinguishing metastatic and reactive nodes and their inter- and intra-rater reliability in assessing intranodal vascularity were evaluated and compared.

RESULTS

The results showed that the QCA method was more accurate than the QSG method with a significantly higher sensitivity (67.8 % and 61.9 %, respectively, p < 0.05) and specificity (73.3 % and 57.3 %, respectively, p < 0.05). Using the intranodal vascularity index as determined by the QCA approach, the optimum cut-off to differentiate metastatic and reactive cervical lymph nodes was 32 %. The QCA method showed higher inter- and intra-rater reliability than the QSG method.

CONCLUSION

In the assessment of the degree of intranodal vascularity, the QCA method was more accurate and reliable than the QSG method in distinguishing metastatic and reactive lymph nodes.

A rapid, flexible method for incorporating controlled antibiotic release into porous polymethylmethacrylate space maintainers for craniofacial reconstruction

Severe injuries in the craniofacial complex, resulting from trauma or pathology, present several challenges to functional and aesthetic reconstruction. The anatomy and position of the craniofacial region make it vulnerable to injury and subsequent local infection due to external bacteria as well as those from neighbouring structures like the sinuses, nasal passages, and mouth. Porous polymethylmethacrylate (PMMA) "space maintainers" have proven useful in staged craniofacial reconstruction by promoting healing of overlying soft tissue prior to reconstruction of craniofacial bones. We describe herein a method by which the porosity of a prefabricated porous PMMA space maintainer, generated by porogen leaching, can be loaded with a thermogelling copolymer-based drug delivery system. Porogen leaching, space maintainer prewetting, and thermogel loading all significantly affected the loading of a model antibiotic, colistin. Weeks-long release of antibiotic at clinically relevant levels was achieved with several formulations. In vitro assays confirmed that the released colistin maintained its antibiotic activity against several bacterial targets. Our results suggest that this method is a valuable tool in the development of novel therapeutic approaches for the treatment of severe complex, infected craniofacial injuries.

Risk factors for contact lens-related microbial keratitis in Singapore

PURPOSE

To investigate independent risk factors for contact lens-related microbial keratitis in Singapore and estimate their impact on disease load.

METHODS

Cases were contact lens wearers presenting to Singapore National Eye Centre with microbial keratitis between 2008 and 2010. Community contact lens wearers were recruited as controls. All wearers completed a previously validated questionnaire describing contact lens wear history, hygiene and compliance habits, and demographics. Risk factors significant in univariate analysis (P<0.2) were evaluated in a multivariate model.

RESULTS

In all, 58 cases of microbial keratitis and 152 contemporaneous controls were identified. When controlling for other variables, Chinese had a 7 × lower risk compared with other races (95% CI: 2.3-21.3, P=0.001). Those aged between 25 and 44 years were at 3 × increased risk compared with younger wearers (95% CI: 1.1-9.6, P=0.04). Occasional overnight contact lens wear (less often than one night per week) was associated with a 4 × higher risk (95% CI: 1.2-15.4, P=0.03) compared with daily use. Not washing hands before handling was associated with a 13 × increased risk (95% CI: 1.9-84.8, P=0.008). Use of multipurpose solution A carried a 16 × higher risk compared with hydrogen peroxide (95% CI: 1.5-174.0, P=0.02). The combined PAR% for modifiable risk factors (occasional overnight wear, not washing of hands, and MPS A) was 82%.

CONCLUSIONS

Consistent with previous findings, independent risk factors for contact lens-related microbial keratitis include poor hand hygiene, occasional overnight wear, and type of lens care solution. Prolonged overnight or extended contact lens use was infrequent in this population.

Magnetic trapping of cold bromine atoms

Magnetic trapping of bromine atoms at temperatures in the millikelvin regime is demonstrated for the first time. The atoms are produced by photodissociation of Br2 molecules in a molecular beam. The lab-frame velocity of Br atoms is controlled by the wavelength and polarization of the photodissociation laser. Careful selection of the wavelength results in one of the pair of atoms having sufficient velocity to exactly cancel that of the parent molecule, and it remains stationary in the lab frame. A trap is formed at the null point between two opposing neodymium permanent magnets. Dissociation of molecules at the field minimum results in the slowest fraction of photofragments remaining trapped. After the ballistic escape of the fastest atoms, the trapped slow atoms are lost only by elastic collisions with the chamber background gas. The measured loss rate is consistent with estimates of the total cross section for only those collisions transferring sufficient kinetic energy to overcome the trapping potential.