Redefining CT perfusion-based ischemic core estimates for the ghost core in early time window stroke

BACKGROUND AND PURPOSE

In large vessel occlusion (LVO) stroke patients, relative cerebral blood flow (rCBF)<30% volume thresholds are commonly used in treatment decisions. In the early time window, nearly infarcted but salvageable tissue volumes may lead to pretreatment overestimates of infarct volume, and thus potentially exclude patients who may otherwise benefit from intervention. Our multisite analysis aims to explore the strength of relationships between widely used pretreatment CT parameters and clinical outcomes for early window stroke patients.

METHODS

Patients from two sites in a prospective registry were analyzed. Patients with LVOs, presenting within 3 hours of last known well, and who were successfully reperfused were included. Primary short-term neurological outcome was percent National Institutes of Health Stroke Scale (NIHSS) change from admission to discharge. Secondary long-term outcome was 90-day modified Rankin score. Spearman's correlations were performed. Significance was attributed to p-value ≤.05.

RESULTS

Among 73 patients, median age was 66 (interquartile range 54-76) years. Among all pretreatment imaging parameters, rCBF<30%, rCBF<34%, and rCBF<38% volumes were significantly, inversely correlated with percentage NIHSS change (p<.048). No other parameters significantly correlated with outcomes.

CONCLUSIONS

Our multisite analysis shows that favorable short-term neurological recovery was significantly correlated with rCBF volumes in the early time window. However, modest strength of correlations provides supportive evidence that the applicability of general ischemic core estimate thresholds in this subpopulation is limited. Our results support future larger-scale efforts to liberalize or reevaluate current rCBF parameter thresholds guiding treatment decisions for early time window stroke patients.

RAPID aneurysm accurately measures aneurysm size on CT angiography compared to three-dimensional digital subtraction angiography

BACKGROUND

Cerebral aneurysms are often identified and characterized on non-invasive CT Angiography (CTA) images, but digital subtraction angiography (DSA) is the gold standard for aneurysm evaluation.

OBJECTIVE

We compared cerebral aneurysm size measurements as measured from CTA processed by a semi-automated artificial intelligence software program (RAPID Aneurysm) and three-dimensional rotational DSA (3D-DSA).

METHODS

We performed a retrospective cohort study of consecutive patients with a cerebral aneurysm who underwent CTA and DSA with 3D reformations. CTA images were processed by RAPID Aneurysm to determine aneurysm height, width, and neck width. The reference standard was aneurysm measurements on 3D-DSA as measured by two neurointerventionalists. Both readers were blinded to RAPID Aneurysm measurements. Correlation and bias between these measurements were determined.

RESULTS

Results from 50 patients with 50 aneurysms were compared. 32 patients (64%) were female. Median age was 65 (IQR: 56.25-71.75). 37 patients (74%) presented with ruptured aneurysms. The aneurysms represented a range of aneurysm sizes (1.9-33.3 mm; IQR 3.6-7.2 mm). RAPID Aneurysm size measurements showed excellent correlation and low bias (correlation, mean difference) when compared to the reference standard for aneurysm height (0.98, -0.9 mm), width (0.98, 0.1 mm), and neck width (0.94, 1.1 mm). The inter-reader comparison between the two neurointerventionalists was similarly excellent for aneurysm height (0.97, -0.4 mm), width (0.98, -0.2 mm), and neck width (0.89, 0.8 mm).

CONCLUSION

RAPID Aneurysm measurement of cerebral aneurysm height, width, and neck width on CTA is strongly correlated to expert neurointerventionalist measurements on 3D-DSA.

Excellent Recanalization and Small Core Volumes Are Associated With Favorable AM-PAC Score in Patients With Acute Ischemic Stroke Secondary to Large Vessel Occlusion

Objective

To assess pretreatment and interventional parameters as predictors of favorable Activity Measure for Post-Acute Care (AM-PAC) scores for optimal discharge planning.

Design

In this prospectively collected, retrospectively reviewed multicenter study from 9/1/2017 to 9/22/2022, patients were dichotomized into favorable and unfavorable AM-PAC. Multivariate logistic regression and receiver operator characteristics analyses were performed for the identified significant variables. A P value of ≤.05 was significant.

Setting

Hospitalized care.

Participants

In total, 229 patients (mean ±SD 70.65 ±15.2 [55.9% women]) met our inclusion criteria. Inclusion criteria were (a) computed tomography (CT) angiography confirmed LVO from 9/1/2017 to 9/22/2022; (b) diagnostic CT perfusion; and (c) available AM-PAC scores.

Interventions

None.

Main Outcome Measures

Favorable AM-PAC, defined as a daily activity score ≥19 and basic mobility score of ≥17.

Results

Patients with favorable AM-PAC were younger (61.3 vs 70.7, P<.001), had lower admission glucose (mean, 124 vs 136, P=.042), lower blood urea nitrogen (mean, 15.59 vs 19.11, P<.001), and lower admission National Institutes of Health Stroke Scale (NIHSS) (mean, 10.58 vs 16.15, P<.001). No differences in sex were noted. Multivariate regression analyses revealed age, admission NIHSS, relative cerebral blood flow (rCBF) <30% volume, and modified thrombolysis in cerebral infarction (mTICI) score to be independent predictors of favorable AM-PAC (P<.047 for all predictors). The combined model revealed an area under the curve (AUC) of 0.83 (IQR 0.75-0.86).

Conclusion

Excellent recanalization, smaller core volumes, younger age, and lower stroke severity independently predict favorable outcomes as measured by AM-PAC.

Effect of Topical Platelet Extract Daily Serum as a Cosmetic Product to Reduce Facial Redness

Objective

The primary objective of this pilot study was to demonstrate the benefits of topical human platelet extract (plated)™ serum for the improvement of persistent facial redness.

Methods

This single-center, open-label pilot study evaluated six subjects using (plated)™ serum containing human platelet extract (HPE) with Renewosome™ technology twice daily for six weeks. The primary efficacy endpoint was a reduction in the Clinical Erythema Assessment (CEA) grade, and a reduction in Patient Subjective Assessment grade at six weeks. Secondary endpoints included an improvement in quality of life related to facial redness, and a reduction in redness by Mexameter™ spectrometry measurement. Safety data included monitoring for adverse events.

Results

Topical HPE serum demonstrated a statistically significant improvement in facial redness at Week 9 when averaging the Mexameter™ spectrometry results across nine regions of the face (p=0.0052). The primary and secondary endpoints were achieved. CEA grade at Week 6 demonstrated that all subjects improved by at least one grade, while one subject improved by two grades. One patient reported dryness. No other adverse effects were observed.

Limitations

Study limitations included a small sample size and lack of darker skin types (Fitzpatrick IV-VI).

Conclusion

This study demonstrates that topical HPE with Renewosome™ technology provides statistically significant reduction in facial redness and is safe and well-tolerated.

Childhood cancer incidence & survival in Aotearoa, New Zealand 2010-2019

OBJECTIVE

To provide updated estimates of childhood cancer incidence and survival in Aotearoa, New Zealand.

METHOD

Registrations for children under the age of 15 years diagnosed with cancer between 2010 and 2019 were extracted from the New Zealand Children's Cancer Registry. Cases were stratified by age, sex, prioritised ethnicity (Māori, Pacific peoples, and non-Māori) and cancer type. Age-standardised incidence rates (ASRs) per million person years and observed survival rates were calculated.

RESULTS

During the study period, 1522 children were diagnosed with cancer providing an ASR of 169.1 per million per year (95 % Confidence Interval, CI: 157.0-181.2). For all childhood cancers combined, survival at 5-years was 85.6 % (95 % CI 83.7-87.3). There was a gap in 5-year survival between Māori (80.9 %, 95 % CI 76.5-84.6), Pacific peoples (82.6 %, 95 % CI 75.6-87,7) and Non-Māori (87.8 %, 95 % CI 85.6-89.7) In both adjusted and unadjusted models, this difference in survival was most marked (p < 0.05) among children who were 10-14 years of age at diagnosis.

CONCLUSION

Childhood cancer incidence and survival rates in Aotearoa, New Zealand remain comparable to other high-income countries. Further research is required to understand the survival difference between ethnic groups.

Safety and efficacy of human platelet extract in skin recovery after fractional CO2 laser resurfacing of the face: A randomized, controlled, evaluator-blinded pilot study

BACKGROUND

Fractional carbon dioxide (CO2 ) laser resurfacing is used successfully for facial rejuvenation. Post procedure skincare is a variable that influences downtime caused by pain/tenderness, erythema, crusting, and bruising.

AIMS

The primary objective of this pilot study was to demonstrate the benefits of human platelet extract (HPE) (plated)™ CALM Serum, a new topical cosmetic product, following fractionated CO2 ablative laser resurfacing treatment to the entire face versus standard of care.

METHODS

In a single-center, randomized, evaluator-blinded pilot study, a total of 18 subjects were randomized into two groups, CO2 facial resurfacing followed by post-procedural standard of care (Stratacel silicone gel) or CO2 facial resurfacing with the addition of HPE renewosomes in the CALM Serum.

RESULTS

CALM Serum demonstrated statistically significant less crusting at Day 10 compared to the control group (p = 0.0193) with less downtime in the first 14 days (p = 0.03). Subjects treated with CALM Serum had statistically significant brighter appearing skin at 14 days (p = 0.007) and more youthful looking skin on Days 14 and 30 (p = 0.003 and 0.04, respectively).

CONCLUSIONS

This study demonstrates that Renewosome™ technology provides statistically significant post-laser clinical recovery over silicone gel for reducing crusting, and downtime. Subjects reported less diary days of symptoms of pain/tenderness, redness, crusting/flaking, bruising, and itching in the first 14 days compared to the control group. CALM also demonstrated statistically significant improvements in brighter and more youthful appearing skin. CALM is safe and well tolerated.

RAPID Aneurysm: Artificial intelligence for unruptured cerebral aneurysm detection on CT angiography

OBJECTIVES

Cerebral aneurysms may result in significant morbidity and mortality. Identification of these aneurysms on CT Angiography (CTA) studies is critical to guide patient treatment. Artificial intelligence platforms to assist with automated aneurysm detection are of high interest. We determined the performance of a semi-automated artificial intelligence software program (RAPID Aneurysm) for the detection of cerebral aneurysms.

MATERIALS AND METHODS

RAPID Aneurysm was used to detect retrospectively the presence of cerebral aneurysms in CTA studies performed between January 2019 and December 2020. The gold standard was aneurysm presence and location as determined by the consensus of three expert neuroradiologists. Aneurysm detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID Aneurysm were determined.

RESULTS

51 patients (mean age, 56±15; 24 women [47.1%]) with a single CTA were included. A total of 60 aneurysms were identified. RAPID Aneurysm had a sensitivity of 0.950 (95% CI: 0.863-0.983), specificity of 1.000 (95% CI: 0.996-1.000), a positive predictive value (PPV) of 1.000 (95% CI: 0.937-1.000), a negative predictive value (NPV) of 0.997 (95% CI: 0.991-0.999), and an accuracy of 0.997 (95% CI: 0.991-0.999) for cerebral aneurysm detection.

CONCLUSIONS

RAPID Aneurysm is highly accurate for the detection of cerebral aneurysms on CTA.

Abstract 3390: Preliminary results for a novel single extracellular vesicle assay for early stage ovarian cancer: The power of co-localized detection of surface biomarkers

Introduction: Ovarian cancer (OC) is one of the deadliest cancers, with 314,000 new cases and 207,000 deaths globally in 2020. Serum CA125 has been explored as an OC biomarker for the past 40 years, but lacks sensitivity for early stage OC and is not recommended for screening average-risk, asymptomatic women. We hypothesize that co-localization of biomarkers on the surface of individual extracellular vesicles (EVs), which are shed into the circulation by cancer cells, may lead to development of a blood test for early stage OC. We evaluated the potential of our approach in detecting early stage OC in clinical samples.

Methods: We isolated EVs using size-exclusion chromatography and immunoaffinity capture, and detected biomarkers co-localized on the surface of individual EVs with proximity ligation qPCR. Using this approach, we evaluated 49 antibody combinations recognizing 2 or more biomarkers. Each combination consisted of 1 capture antibody and 2 oligonucleotide-tagged detection antibodies. We tested plasma samples from women with early stage I/II high-grade serous ovarian carcinoma (HGSOC)(n=18; 48-80 yr, med 57) and late stage HGSOC (n=24; 37-80 yr, med 54). HGSOC samples were sourced from 2 commercial vendors. Controls comprised samples from women with benign ovarian masses (n=26; 23-76 yr, med 39.5) sourced from a single vendor, and samples prospectively collected by Mercy from healthy women with no cancer history (n=24; 22-72 yr, med 52.5). PCR cycle threshold (Ct) values were measured for each of 49 combinations and data was evaluated using univariate analysis. Performance was compared to plasma CA125 measured at Mercy by commercial ELISA.

Results: 8 of 49 combinations distinguished all stages of HGSOC relative to benign and healthy controls with AUCs ranging from 0.86 (95% CI 0.78-0.94) to 0.95 (95% CI 0.90-1.00), comparable to CA125 with an AUC of 0.87 (95% CI 0.79-0.95). One of the most effective combinations (STn, BST2, MUC1) had a sensitivity of 0.78 (95% CI 0.52-0.94) at a specificity of 0.96 (95% CI 0.87-0.99) in detecting early stage HGSOC. This combination also detected HGSOC in 6 of 11 women (3 early stage, 3 late stage) with normal CA125 (&lt; 25 U/mL) and correctly classified 7 of 8 women with benign masses and high CA125 (&gt; 25 U/mL).

Conclusions: These preliminary data suggest that co-localization of surface biomarkers in single EVs may provide an effective means to identify women with early stage HGSOC, including those with normal CA125, while avoiding false positives in women with benign masses and high CA125. Despite the inherent challenges associated with commercial samples, our finding that several combinations detected early stage HGSOC is promising. Statistically powered studies with curated repository specimens are underway to refine combinations and independently validate our assay for early stage OC detection.

Citation Format: Laura T. Bortolin, Daniel P. Salem, Sanchari Banerjee, Kelly M. Biette, Delaney M. Byrne, Anthony D. Couvillon, Peter A. Duff, Jonian Grosha, MacKenzie Sadie King, Christopher R. Sedlak, Ibukunoluwapo O. Zabroski, Claire Alexander, Karen Copeland, Daniel Gusenleitner, Emily S. Winn-Deen, Eric K. Huang, Bo R. Rueda, Joseph Charles Sedlak. Preliminary results for a novel single extracellular vesicle assay for early stage ovarian cancer: The power of co-localized detection of surface biomarkers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3390.

Abstract 2232: Preliminary results for a novel single extracellular vesicle assay for early lung cancer: The power of co-localized detection of surface biomarkers

Introduction: Screening for lung cancer (LC), the leading cause of cancer deaths, with helical computerized tomography lowers mortality but uptake is poor. Investigations into new approaches such as using circulating tumor cells and circulating tumor DNA for LC detection have soared in the last decade. However, the low abundance of these targets has limited the performance of these approaches as screening tools. We hypothesize that co-localization of biomarkers on the surface of individual extracellular vesicles (EVs), which are shed into the circulation by cancer cells, may lead to development of a blood test for early stage LC. We evaluated the potential of our approach in detecting early stage LC in clinical samples.

Methods: EVs were purified from plasma using size-exclusion chromatography and immunoaffinity capture, and biomarkers co-localized on the EV surface were detected with proximity ligation qPCR. We used antibody combinations comprising 1 capture antibody and 2 oligonucleotide-tagged detection antibodies, recognizing 1, 2 or 3 unique biomarkers. We evaluated this approach by testing plasma samples from early stage I/II lung adenocarcinoma (LUAD) patients (15 smokers, 19 non-smokers), late stage III/IV LUAD patients (16 smokers, 18 non-smokers), and healthy donors (34 smokers, 33 non-smokers). Samples were from one vendor, processed using a standardized protocol. LUAD samples were sourced from a cancer research center and healthy samples from a primary care facility. PCR cycle threshold (Ct) values were generated for each combination and data was evaluated using univariate analysis.

Results: Combinations recognizing 3 biomarkers were better in detecting all stages of LUAD (AUC=0.83, 95% CI 0.77-0.90), as compared to combinations recognizing 2 biomarkers (AUC=0.71, 95% CI 0.63-0.80) or 1 biomarker (AUC=0.50, 95% CI 0.35-0.55), demonstrating greater accuracy with an increasing number of co-localized biomarkers. In detecting LUAD (all stages) at a specificity of 0.80 (95% CI 0.69-0.88), sensitivity improved as the number of co-localized biomarkers increased from 1 (0.08, 95% CI 0.03-0.18) to 2 (0.60, 95% CI 0.48-0.72) to 3 (0.76, 95% CI 0.65-0.86). In detecting early stage I/II LUAD, the most effective combination used 3 biomarkers (STn, MUC1, CEACAM6) and had a sensitivity of 0.56 (95% CI 0.38-0.73).

Conclusions: These preliminary data highlight the potential of detecting biomarkers co-localized on the surface of single EVs as an effective tool for early stage LC detection, and the benefit of using 3 biomarkers simultaneously. Despite inherent challenges associated with commercial samples, our finding that detection of co-localized EV surface biomarkers distinguished LUAD is promising. Additional studies with LC cohorts beyond LUAD are underway to refine combinations and independently validate our assay for early stage LC detection.

Citation Format: Daniel P. Salem, Laura T. Bortolin, Sanchari Banerjee, Kelly M. Biette, Delaney M. Byrne, Anthony D. Couvillon, Peter A. Duff, Jonian Grosha, Daniel Gusenleitner, MacKenzie Sadie King, Christopher R. Sedlak, Ibukunoluwapo O. Zabroski, Karen Copeland, Emily S. Winn-Deen, Eric K. Huang, Christine D. Berg, Joseph C. Sedlak. Preliminary results for a novel single extracellular vesicle assay for early lung cancer: The power of co-localized detection of surface biomarkers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2232.

Hereditary cancer risk assessment and genetic testing in the community urology practice setting

OBJECTIVES

To evaluate the feasibility of integrating a hereditary cancer risk assessment (HCRA) process in the community urology practice setting for patients with prostate cancer (PCa).

METHODS

In this prospective intervention, an HCRA process was implemented across six different community urology clinics between May 2019 and April 2020. The intervention included a process integration during which the workflow at each site was refined, a post-integration period during which HCRA was conducted in all patients with PCa, and a follow-up period during which healthcare providers and patients reported their satisfaction with the HCRA and genetic testing process.

RESULTS

Among patients who completed a family history assessment during the post-integration period, 23.6% met guideline criteria for genetic testing. Of all patients seen at the clinic during the post-integration period, 8.7% completed genetic testing; this was a twofold increase over the period immediately preceding process integration (4.2%), and a sevenfold increase over the same period 1 year prior (1.2%). The majority of providers reported that the HCRA was as important as other regularly performed assessments (61.0%) and planned to continue using the process in their practice (68.3%). Most patients believed that the genetic test results were important for their future cancer care (84.7%) and had already shared their test results with at least one family member (63.2%).

CONCLUSIONS

This study demonstrated that implementing an HCRA process in the community urology practice setting was feasible, generally favored by providers and patients, and resulted in an increase in the number of patients with PCa who completed genetic testing.

Hereditary cancer risk assessment in the community urology practice setting

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Background: Professional guidelines recommend hereditary cancer risk assessment (HCRA) for men with prostate cancer to inform both risk of cancer (primary or subsequent) and treatment decisions. The objectives of the study were to evaluate the feasibility of integrating a HCRA protocol in urology practice for patients with prostate cancer and determine the response of providers and patients to the HCRA protocol. Methods: This prospective study was divided into 4 segments: process integration (4 wks.), practice (4 wks.), post-integration (8 wks.), and follow up (10 wks.). Study site staff were trained to perform HCRA for men with prostate cancer (integration). The sites then incorporated recommendations from the integration process into their normal practice workflow (practice). During the post-integration period, the HCRA process was implemented with eligible patients consented to participate. Eligible patients were ≥18 years old, had a personal history of prostate cancer, and met National Comprehensive Cancer Network guidelines for genetic testing (2.2018). Patients and providers completed surveys regarding testing ≥ 8 weeks of test delivery or 1 week of end of data collection period, respectively (follow up). Results: In the 8 weeks prior to the study, 4.2% of patients completed testing at the study sites. During the study, 8.4% of patients completed testing, about 1/2 of eligible patients screened. Of all patients who completed testing and consented for their results to be summarized (N = 182), 10.4% (N = 19) tested positive for a single pathogenic variant (PV; monoallelic MUTYH N = 4; BRCA2 N = 3; ATM, BRCA1, BRIP1, CHEK2, HOXB13 N = 2 each; RAD51C, RAD51D N = 1 each). Not all men who tested positive or a PV reported a family history of cancer and not all PVs detected were in known prostate cancer risk genes. During follow up, most providers (61.0%) felt HCRA was as important as other assessments regularly performed and 68.3% planned to continue to use the HCRA process. In contrast, only 9.8% of providers did not believe HCRA was as important and 12.2% did not plan to continue to use the process. Of the patients that responded to the survey (N = 166), most had shared (62.0%) or planned to share (25.3%) their results with family members post-testing. Conclusions: Urologists and patients responded favorably to HCRA protocol integration. Based on this study, education around and incorporation of an HCRA process in a community urology practice setting for men with prostate cancer appears effective at increasing appropriate uptake of genetic testing. Clinical trial information: NCT04015102.

Abstract WP97: Automated Analysis For Detecting Large Vessel Occlusion On Non Contrast Ct In Acute Stroke

Background and Purpose: Rapid detection of large vessel occlusion (LVO) is essential for rapid triage for thrombectomy to salvage at-risk tissue. Early detection of LVO on noncontrast CT head (NCCT) could facilitate triage before advanced imaging is obtained. RAPID hyperdense vessel sign (HVS), a new fully automated software- tool for HVS detection is compared to experienced radiologists, for early LVO detection on NCCT, and validated with CTA.

Methods: Scans were selected from a database of 335 scans, of which 166 were selected by stratified random selection. Images were evaluated by the Rapid automated software, and six readers, two radiologists, and four neuroradiologists. The Rapid algorithm returns a score between zero and one, and a threshold of 0.5 was applied of HVS. Radiologists read each scan twice, 30 days apart. A scan rating confidence scale was used, from “very confident of absence,” to “very confident of HVS,” and a separate “technically inadequate” rating, and this was compared to the Rapid HVS score. “Very Confident,” or “Confident” rated scans were considered HVS positive.

Results: Demographics: 54% were men. Ages ranged 23 - 94 with a median of 65. GE, Philips, Siemens, and Toshiba scanners are represented. Agreement with RAPID for HVS detection was 75% to 84%. Below a HVS score of 0.4 the proportion of LVO positive scans was 46% (indeterminate), between 0.4 and 0.6 the proportion was 62.5% (probable), and above 0.6 the proportion was 90% (likely). The scan rating confidence grade correlated with the Rapid HVS score. The software identified 53% of the LVOs, comparable to human readers (26-57%) A clinical practice simulation of RAPID followed by a reader identified 61.3% (p=0.02 vs readers alone). Among the 61 patients with no LVO on CTA, readers had a false positive rate of less than 7% as compared to 15% for the software. Median software processing time was 54 seconds.

Conclusions: Expert readers, and the Rapid software, detect an HVS in about 50% of CT head images with LVO on CTA. When Rapid software is used in tandem with an experienced reader, HVS can be detected in up to two thirds of patients with LVO on CTA. This high percentage of early LVO detection would facilitate faster triage of patients for more advanced imaging and/or therapeutic interventions.

Outcomes of rapid digital transformation of large-scale communications during the COVID-19 pandemic

Objective This study examined the content and impact of a new digital communication medium, called a VIDCAST, implemented at a large hospital and health service when the COVID-19 pandemic was announced, and the key concerns held by staff at the time when the health service was preparing for the COVID-19 pandemic to arrive in this health service. Methods A mixed-methods approach was used. Thematic analysis of 20 transcripts of daily VIDCASTS broadcast between 30 March and 24 April 2020 was undertaken, in addition to descriptive analysis of feedback from an anonymous online survey. Results Survey feedback from 322 staff indicated almost universal satisfaction with this new communication method. The VIDCASTS provided a new COVID-safe method for the Executive to connect to staff at a time of uncertainty. Thematic analysis of the content of the VIDCASTS revealed three themes: 'Accurate Information', 'Reassurance and Support' and 'Innovation'. The Executive was able to reassure staff about what the organisation was doing to safeguard the health and wellbeing of all, and enabled an effective response to the pandemic. Conclusions The digital communication channel of VIDCASTS, rapidly operationalised at a major Australian hospital and health service in March 2020, provided important information and support for staff as it prepared for the anticipated COVID-19 surge. What is known about the topic? When the COVID-19 pandemic began, traditional face-to-face staff meetings were disrupted and many hospitals and their staff were left scrambling for information, and for reassurance about their safety, as they prepared to receive increasing numbers of COVID-19 patients. What does this paper add? The implementation of a digital communication tool was able to address many of the concerns raised by hospital staff in other geographic locations dealing with surging COVID-19 cases and underpinned a globally leading COVID-19 response. What are the implications for practitioners? New digitised communication methods provided an effective vehicle to inform and support staff in the early stages of pandemic preparation.

Abstract P337: RAPID-LVO for Automated Detection of Intracranial Large Vessel Occlusion in Ct Angiography of the Brain

Background: Identification of large vessel occlusion (LVO) is paramount in the urgent evaluation of acute ischemic stroke (AIS). Emergent interpretation of large and high-complexity data sets, however, may impose strains upon imaging and clinical workflows, motivating development of fast and accurate computer-aided approaches to facilitate LVO detection in the emergency setting. This study investigates the performance of a fully automated LVO detection platform in a mixed cohort of stroke subjects with and without LVO on head and neck CT angiography (CTA).

Methods: CTA from two cerebrovascular trials were enriched with cases from eleven global sites. Imaging and clinical variables were balanced between populations including in LVO positivity and across demographic and imaging environments to the extent achievable. Independent and fully blinded review for intracranial ICA or MCA M1 LVO was performed by two subspecialty neuroradiologists. A novel, user-independent imaging analysis application ( RAPID-LVO , iSchemaview inc) was used to predict LVO presence, location, and overall performance relative to reader consensus. Any discordance between readers was adjudicated by a blinded tertiary reader with subspecialty training. Sensitivity, specificity, and receiver-operating characteristics were determined by an independent statistician. Performance thresholds were set a priori, including a lower bound of the 95% CI of sensitivity and specificity of ≥0.8 at mean times-to-notification <3.5 minutes.

Results: 217 CTA (median age 65.5, 53% male, 109 LVO(+)) were included. Lower confidence limits of sensitivity and specificity exceeded 90% (sensitivity 0.963, 95% CI 0.909-0.986; specificity 0.981, 95% CI 0.935-0.995), surpassing pre-specified performance benchmarks. Subgroup analyses revealed no decrement in performance relative to subject age or sex, vendor systems, or location of the examination within or outside the United States. The area under the receiver operating characteristics curve was 0.99 (95% CI: 0.971-0.999) and average time-to-notification was 3.18 minutes.

Conclusion: RAPID-LVO offers fast, highly accurate, and fully user-independent large vessel occlusion detection across all tested clinical and imaging environments.

Abstract P336: Assistance From Automated ASPECTS Software Improves Reader Performance

Purpose: To compare physicians’ ability to read Alberta Stroke Program Early CT Score (ASPECTS) in patients with a large vessel occlusion within 6 hours of symptom onset when assisted by a machine learning-based automatic software tool, RAPID ASPECTS, compared with their unassisted score.

Materials and Methods: 50 baseline CT scans selected from two prior studies (CRISP and GAMES-RP) were read by 3 experienced neuroradiologists who were provided access to a follow-up MRI. The average ASPECT score of these reads was used as the reference standard. Two additional neuroradiologists and 6 non-neuroradiologist readers then read the scans both with and without assistance from the RAPID ASPECTS software and reader improvement was determined. The primary hypothesis was that the agreement between typical readers and the consensus of 3 expert neuroradiologists would be improved with RAPID-assisted vs. unassisted reads. Agreement was based on the percentage of the individual ASPECT regions (50 cases, 10 regions each; N=500) where agreement was achieved.

Results: Typical non-neuroradiologist readers agreed with the expert consensus read in 72% of the 500 ASPECTS regions, evaluated without software assistance. The automated software alone agreed in 77%. When the typical readers read the scan in conjunction with the software, agreement improved to 78% (P<0.0001, test of proportions). RAPID ASPECTS alone achieved correlations for total ASPECT scores that were similar to the expert readers who had access to the follow-up MRI scan to help enhance the quality of their reads.

Conclusion: Typical readers had statistically significant improvement in their scoring of scans when the scan was read in conjunction with the automated RAPID ASPECTS software, achieving agreement rates that were comparable to neuroradiologists.

High-Performance Automated Anterior Circulation CT Angiographic Clot Detection in Acute Stroke: A Multireader Comparison

Background Identification of large vessel occlusion (LVO) is critical to the management of acute ischemic stroke and prerequisite to endovascular therapy in recent trials. Increasing volumes and data complexity compel the development of fast, reliable, and automated tools for LVO detection to facilitate acute imaging triage. Purpose To investigate the performance of an anterior circulation LVO detection platform in a large mixed sample of individuals with and without LVO at cerebrovascular CT angiography (CTA). Materials and Methods In this retrospective analysis, CTA data from recent cerebrovascular trials (CRISP [ClinicalTrials.gov NCT01622517] and DASH) were enriched with local repositories from 11 worldwide sites to balance demographic and technical variables in LVO-positive and LVO-negative examinations. CTA findings were reviewed independently by two neuroradiologists from different institutions for intracranial internal carotid artery (ICA) or middle cerebral artery (MCA) M1 LVO; these observers were blinded to all clinical variables and outcomes. An automated analysis platform was developed and tested for prediction of LVO presence and location relative to reader consensus. Discordance between readers with respect to LVO presence or location was adjudicated by a blinded tertiary reader at a third institution. Sensitivity, specificity, and receiver operating characteristics were assessed by an independent statistician, and subgroup analyses were conducted. Prespecified performance thresholds were set at a lower bound of the 95% CI of sensitivity and specificity of 0.8 or greater at mean times to notification of less than 3.5 minutes. Results A total of 217 study participants (mean age, 64 years ± 16 [standard deviation]; 116 men; 109 with positive findings of LVO) were evaluated. Prespecified performance thresholds were exceeded (sensitivity, 105 of 109 [96%; 95% CI: 91, 99]; specificity, 106 of 108 [98%; 95% CI: 94, 100]). Sensitivity and specificity estimates across age, sex, location, and vendor subgroups exceeded 90%. The area under the receiver operating characteristic curve was 99% (95% CI: 97, 100). Mean processing and notification time was 3 minutes 18 seconds. Conclusion The results confirm the feasibility of fast automated high-performance detection of intracranial internal carotid artery and middle cerebral artery M1 occlusions. © RSNA, 2021 See also the editorial by Kloska in this issue.

Automated Cerebral Hemorrhage Detection Using RAPID

BACKGROUND AND PURPOSE

Intracranial hemorrhage (ICH) is an important event that is diagnosed on head NCCT. Increased NCCT utilization in busy hospitals may limit timely identification of ICH. RAPID ICH is an automated hybrid 2D-3D convolutional neural network application designed to detect ICH that may allow for expedited ICH diagnosis. We determined the accuracy of RAPID ICH for ICH detection and ICH volumetric quantification on NCCT.

MATERIALS AND METHODS

NCCT scans were evaluated for ICH by RAPID ICH. Consensus detection of ICH by 3 neuroradiology experts was used as the criterion standard for RAPID ICH comparison. ICH volume was also automatically determined by RAPID ICH in patients with intraparenchymal or intraventricular hemorrhage and compared with manually segmented ICH volumes by a single neuroradiology expert. ICH detection accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and positive and negative likelihood ratios by RAPID ICH were determined.

RESULTS

We included 308 studies. RAPID ICH correctly identified 151/158 ICH cases and 143/150 ICH-negative cases, which resulted in high sensitivity (0.956, CI: 0.911-0.978), specificity (0.953, CI: 0.907-0.977), positive predictive value (0.956, CI: 0.911-0.978), and negative predictive value (0.953, CI: 0.907-0.977) for ICH detection. The positive likelihood ratio (20.479, CI 9.928-42.245) and negative likelihood ratio (0.046, CI 0.023-0.096) for ICH detection were similarly favorable. RAPID ICH volumetric quantification for intraparenchymal and intraventricular hemorrhages strongly correlated with expert manual segmentation (correlation coefficient r = 0.983); the median absolute error was 3 mL.

CONCLUSIONS

RAPID ICH is highly accurate in the detection of ICH and in the volumetric quantification of intraparenchymal and intraventricular hemorrhages.

Impact of Preanalytical Factors During Histology Processing on Section Suitability for Digital Image Analysis

Digital image analysis (DIA) is impacted by the quality of tissue staining. This study examined the influence of preanalytical variables-staining protocol design, reagent quality, section attributes, and instrumentation-on the performance of automated DIA software. Our hypotheses were that (1) staining intensity is impacted by subtle differences in protocol design, reagent quality, and section composition and that (2) identically programmed and loaded stainers will produce equivalent immunohistochemical (IHC) staining. We tested these propositions by using 1 hematoxylin and eosin stainer to process 13 formalin-fixed, paraffin-embedded (FFPE) mouse tissues and by using 3 identically programmed and loaded immunostainers to process 5 FFPE mouse tissues for 4 cell biomarkers. Digital images of stained sections acquired with a commercial whole slide scanner were analyzed by customizable algorithms incorporated into commercially available DIA software. Staining intensity as viewed qualitatively by an observer and/or quantitatively by DIA was affected by staining conditions and tissue attributes. Intrarun and inter-run IHC staining intensities were equivalent for each tissue when processed on a given stainer but varied measurably across stainers. Our data indicate that staining quality must be monitored for each method and stainer to ensure that preanalytical factors do not impact digital pathology data quality.

Clinical Immunoassay for Human Hepcidin Predicts Iron Deficiency in First-Time Blood Donors

BACKGROUND

Serum markers currently used as indicators of iron status have clinical limitations. Hepcidin, a key regulator of iron homeostasis, is reduced in iron deficiency (ID) and increased in iron overload. We describe the first CLIA-validated immunoassay with excellent accuracy and precision to quantify human serum hepcidin. Its diagnostic utility for detecting ID in first-time blood donors was demonstrated.

METHODS

A monoclonal competitive ELISA (C-ELISA) was developed for the quantitation of human hepcidin and validated according to CLIA guidelines. Sera from nonanemic first-time blood donors (n = 292) were analyzed for hepcidin, ferritin, transferrin, and serum iron. Logistic regression served to determine the utility of hepcidin as a predictor of ID.

RESULTS

The C-ELISA was specific for human hepcidin and had a low limit of quantitation (4.0 ng/mL). The hepcidin concentration measured with the monoclonal C-ELISA was strongly correlated with a previously established, extensively tested polyclonal C-ELISA (Blood 2008;112:4292-7) (r = 0.95, P < 0.001). The area under the receiver operating characteristic curve for hepcidin as a predictor of ID, defined by 3 ferritin concentration thresholds, was >0.9. For predicting ID defined by ferritin <15 ng/mL, hepcidin <10 ng/mL yielded sensitivity of 93.1% and specificity of 85.5%, whereas the same hepcidin cutoff for ferritin <30 ng/mL yielded sensitivity of 67.6% and specificity of 91.7%.

CONCLUSION

The clinical measurement of serum hepcidin concentrations was shown to be a potentially useful tool for diagnosing ID.

Diagnostic accuracy of combined WBC, ANC and CRP in adult emergency department patients suspected of acute appendicitis

OBJECTIVES

To assess the sensitivity, specificity, and negative predictive value (NPV) of normal total white blood cell count (WBC) and normal absolute neutrophil count (ANC) combined with a normal proprietary C-reactive protein (pCRP) level in adult emergency department (ED) patients with abdominal pain suspected of possible acute appendicitis.

METHODS

We prospectively enrolled patients ≥18 years of age at seven U.S. emergency departments with ≤72 h of abdominal pain and other signs and symptoms suggesting possible acute appendicitis. Sensitivity, specificity, and NPV for normal WBC and ANC combined with normal pCRP were correlated with the final diagnosis of acute appendicitis.

RESULTS

We enrolled 422 patients with a prevalence of acute appendicitis of 19.1%. The combination of normal WBC and pCRP exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), an NPV of 98.8% (95% CI, 95.9-99.7%) and a specificity of 50.0% (95% CI, 44.7-55.3%) for acute appendicitis. Normal ANC and pCRP resulted in a sensitivity of 100% (95% CI, 95.4-100%), a negative predictive value of 100% (95% CI, 97.5-100%) and a specificity of 44.4% (95% CI, 39.2-49.7%) for acute appendicitis. Normal WBC and pCRP correctly identified 171 of 342 (50.0%) patients who did not have appendicitis with 2 (2.5%) false negatives, while normal ANC and pCRP identified 150 of 338 (44.3%) of patients without appendicitis with no false negatives.

CONCLUSION

The combination of normal WBC and ANC with normal pCRP levels exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult patient cohort. Confirmation and validation of these findings with further study using commercially available CRP assays is needed.

Cancer risks associated with the HOXB13 c.251G> A variant in men and women referred for hereditary cancer genetic testing

e13653

Background: The HOXB13 c.251G > A (p.G84E) variant is associated with increased prostate cancer risk, possibly at younger ages. Studies on this variant have focused primarily on men, although genetic testing for hereditary cancer risk is most often performed in women. There remains a need to assess whether male and female carriers of this variant have increased risk for other cancers. Methods: We identified male and female carriers of the HOXB13 c.251G > A (p.G84E) variant among individuals referred for hereditary cancer panel genetic testing from October 2018 – December 2019. Non-carriers had no pathogenic variants in any gene or variants of uncertain significance in HOXB13. Personal and family (1st- and 2nd-degree relative) cancer histories were obtained from provider-completed test request forms. Multivariable logistic regression (MLR) models were conducted separately for males and females to estimate cancer risks for the variant as odds ratios (ORs), and 95% Wald confidence intervals (CIs) adjusted for age, ancestry and personal/family cancer history. Results: The analysis included 197,978 patients: 4.5% (8,998/197,978) male and 95.5% (188,980/197,978) female. The HOXB13 variant was present in 0.44% (40/8,998) of tested males, 45% (18/40) of whom had a diagnosis of prostate cancer. The variant was present in 0.32% (621/188,980) of tested females. Male carriers with prostate cancer were diagnosed at younger ages (median, 56; Interquartile ratio [IQR], 52, 62) than non-carriers (median, 63; IQR, 57,70), but this difference was not statistically significant. The MLR model calculated a 3.30 OR for prostate cancer in male carriers of c.251C > A ( P = 0.01; 95% CI 1.30-8.39). In an analysis combining males and females, carriers were significantly more likely to report prostate cancer in a family member than non-carriers ( P = 3.5 x 10−7; OR 1.61, 95% CI 1.34-1.93). There was no apparent association with increased risk for other cancers among carriers versus non-carriers, or among relatives of carriers compared with relatives of non-carriers. Conclusions: The HOXB13 c.251G > A (p.G84E) variant was associated with significantly increased risk of prostate cancer, confirming previously published studies. We found no evidence of association with other cancers. For unaffected male carriers, who may frequently be identified through testing of a female relative, identification of this HOXB13 variant provides an opportunity for more precise prostate cancer risk stratification and screening.

Optical density-based image analysis method for the evaluation of hematoxylin and eosin staining precision

Staining quality and reproducibility are essential factors to monitor laboratory quality assurance. In the last decade, there has been an increase in the use of digital pathology and image analysis. While the adoption of these tools provides a potential means to track staining precision by optical density (OD), it also presents challenges. Results from image analysis are more sensitive to variations in staining than microscopic evaluation by a pathologist. There are two goals with this study. The first was to track the precision of hematoxylin and eosin (H&E) staining, in both nuclear and cytoplasmic components by OD. The second was to determine the impact of different pre-analytical and analytical variables on the OD results. Specifically, the endpoints investigated were quality parameters including impacts of section thickness, protocol manipulation, expired hematoxylin on staining precision and reproducibility of staining over time. Our results show that image analysis of H&E-stained tissue sections is a viable tool for assessing and verifying staining quality. We also show that OD analysis results for H&E-stained sections are affected by changing pre-analytical and/or reagent variables. These authors chose a graphical rather than fully statistical analysis of the results to highlight the utility of visual aids in demonstrating H&E staining reproducibility.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Use of deep neural network ensembles to identify embryonic-fetal transition markers: repression of COX7A1 in embryonic and cancer cells

Here we present the application of deep neural network (DNN) ensembles trained on transcriptomic data to identify the novel markers associated with the mammalian embryonic-fetal transition (EFT). Molecular markers of this process could provide important insights into regulatory mechanisms of normal development, epimorphic tissue regeneration and cancer. Subsequent analysis of the most significant genes behind the DNNs classifier on an independent dataset of adult-derived and human embryonic stem cell (hESC)-derived progenitor cell lines led to the identification of COX7A1 gene as a potential EFT marker. COX7A1, encoding a cytochrome C oxidase subunit, was up-regulated in post-EFT murine and human cells including adult stem cells, but was not expressed in pre-EFT pluripotent embryonic stem cells or their in vitro-derived progeny. COX7A1 expression level was observed to be undetectable or low in multiple sarcoma and carcinoma cell lines as compared to normal controls. The knockout of the gene in mice led to a marked glycolytic shift reminiscent of the Warburg effect that occurs in cancer cells. The DNN approach facilitated the elucidation of a potentially new biomarker of cancer and pre-EFT cells, the embryo-onco phenotype, which may potentially be used as a target for controlling the embryonic-fetal transition.

A Retrospective Chart Review of Chronic Wound Patients Treated with Topical Oxygen Therapy

Objective: Topical oxygen devices are Food and Drug Administration (FDA) cleared for the following indications for use of various etiologies: skin ulcerations due to diabetes, venous stasis, postsurgical infections and gangrenous lesions, decubitus ulcers; amputations/infected stumps; skin grafts; burns; and frostbite. The goal of this study was to understand the impact of topical oxygen therapy (TOT) on patient outcomes, including amputation and healing rates.

Approach: This retrospective chart review included records collected between January 1, 2007, and July 18, 2016, from male and female patients ranging in age from 4 years to 105 years. All wounds were at least 1 cm² and were treated with at least one separate modality before treatment with TOT and then treated with TOT for a minimum of 2 weeks in compliance with the FDA-approved indications. All records were from wounds that were no longer being treated with TOT.

Results: In this study, TOT was associated with an overall rate of 59.4% for a reduction in chronic wound size, while 41.6% of wounds had no healing. The overall amputation rate was 2.4% for wounds in this study.

Innovation: To our knowledge, this retrospective chart review represents one of the largest data sets (4,127 total wounds) collected over one of the longest time periods (9.5 years) to evaluate patient outcomes following TOT.

Conclusion: This study revealed healing and amputation rates similar to those reported in controlled clinical studies using TOT to treat chronic wounds.

Abstract P5-03-05: Development of a panel of serum-based protein biomarkers for the non-invasive detection of breast cancer in BI-RADS category 4 patients

Background: Current breast cancer screening guidelines call for annual mammography for asymptomatic women age 45 to 54 and once every two years for women age 55 and older. Women with suspicious screening mammograms are recommended for a diagnostic mammogram and may also undergo MRI or ultrasound. Ultimately, suspicious findings unresolved by imaging typically result in the recommendation of a breast biopsy. Approximately 10% of suspicious diagnostic mammograms are recommended for breast biopsies and 67% to 95% of these biopsies yield negative results. With the goal of reducing the number of patients with benign pathology undergoing invasive biopsies, we conducted a screen for serum protein biomarkers and identified a novel panel for the non-invasive detection of breast cancer.

Methods: Serum samples were collected at two sites from women with suspicious diagnostic mammogram findings (primarily BI-RADS category 4) undergoing biopsy for the evaluation of a potential malignancy. Serum samples from 100-patients (50 benign pathology and 50 malignant pathology) were evaluated on the SOMAscan Assay 1.3k, which measures levels of 1,310 different protein analytes. Statistical screening methodologies, such as individual t-tests with control for false discovery, were used to identify markers with the potential to distinguish benign from malignant pathology. The candidate markers were further studied and combined using generalized linear modeling to develop three potential diagnostic models. K-fold cross validation was used to guard against over fitting of the models.

Results: A 15-marker model resulted in an AUC of 0.92 with a sensitivity of 90% and specificity of 76%. Two 6-marker models (with 4 markers in common) each resulted in AUC of 0.85, yielding a sensitivity of 90% with a specificity of 56% or 64%.

Conclusions: This study reveals a novel panel of serum protein biomarkers that may allow for the non-invasive and sensitive detection of breast cancer in BI-RADS category 4 patients. A multicenter study is underway to further refine and validate this panel in a larger set of prospectively collected patient samples.

Citation Format: Chapman KB, Copeland K, Kidd J, Qiu L, Sheibani N, Tam O, Friedman L, Korn R, Fiorica J, Lourenco A, Suthers S, Hesterberg L. Development of a panel of serum-based protein biomarkers for the non-invasive detection of breast cancer in BI-RADS category 4 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-05.

Diagnostic performance of a biomarker panel as a negative predictor for acute appendicitis in adult ED patients with abdominal pain

OBJECTIVES

Evaluate the diagnostic accuracy of the APPY1TM biomarker panel, previously described for use in pediatric patients, for identifying adult ED patients with abdominal pain who are at low risk of acute appendicitis.

METHODS

This study prospectively enrolled subjects >18years of age presenting to seven U.S. emergency departments with <72hours of abdominal pain suggesting possible acute appendicitis. The APPY1 panel was performed on blood samples drawn from each patient at the time of initial evaluation and results were correlated with the final diagnosis either positive or negative for acute appendicitis.

RESULTS

431 patients were enrolled with 422 completing all aspects of the study. The APPY1 biomarker panel exhibited a sensitivity of 97.5% (95% CI, 91.3-99.3%), a negative predictive value of 98.4% (95% CI, 94.4-99.6%), a negative likelihood ratio of 0.07 (95% CI, 0.02-0.27), with a specificity of 36.5% (95% CI, 31.6-41.8%) for acute appendicitis. The panel correctly identified 125 of 342 (36.6%) patients who did not have appendicitis with 2 (2.5%) false negatives. The CT utilization rate in this population was 72.7% (307/422). Of 307 CT scans, 232 were done for patients who did not have appendicitis and 79 (34%) of these patients were correctly identified as negative with "low risk" biomarker panel results, representing 26% (79/307) of all CT scans performed.

CONCLUSION

This biomarker panel exhibited high sensitivity and negative predictive value for acute appendicitis in this prospective adult cohort, thereby potentially reducing the dependence on CT for the evaluation of possible acute appendicitis.

Placental transfusion strategies in extremely preterm infants: the next piece of the puzzle

Evidence is growing on the potential value of enhancing placental-fetal transfusion at birth, with recent endorsement of the practice by the World Health Organization and American College of Gynecologists. However, these recommendations provide clinicians with little guidance on the optimal practice among infants born extremely premature (<28 weeks gestation) and those requiring immediate resuscitation. The goals of this review are to: 1) provide rationale for better outcomes among extremely preterm infants following delayed cord clamping or umbilical cord "milking" than with immediate cord clamping; 2) describe clinical situations that warrant immediate cord clamping following delivery and explore the controversy regarding optimal cord clamping practice among extremely premature infants, including those requiring immediate resuscitation; 3) discuss the quality of evidence in this subgroup of infants; 4) consider areas for future research, with a focus on characterizing if placental-fetal transfusion affects the magnitude or timing of variables associated with physiological transition. The review provided herein suggests that delayed cord clamping or umbilical cord milking can be applied safely to infants born prior to 28 weeks gestation, but the lack of evidence on the best practice among infants born severely depressed and requiring immediate resuscitation, who comprise a greater proportion of infant deliveries at the lowest gestational ages, is recognized. Future studies using well-defined physiologic outcome measures are needed to understand the role of placental transfusion in premature infants' adaptations to extrauterine life.

Needle-free jet injection for administration of influenza vaccine: a randomised non-inferiority trial

BACKGROUND

Administration of vaccines by needle-free technology such as jet injection might offer an alternative to needles and syringes that avoids the issue of needle phobia and the risk of needle-stick injury. We aimed to assess the immunogenicity and safety of trivalent influenza vaccine given by needle-free jet injector compared with needle and syringe.

METHODS

For this randomised, comparator-controlled trial, we randomly assigned (1:1) healthy adults (aged 18-64 years) who attended one of four employee health clinics in the University of Colorado health system, with stratification by site, to receive one dose of the trivalent inactivated influenza vaccine Afluria given either intramuscularly with a needle-free jet injector (Stratis; PharmaJet, Golden, CO, USA) or with needle and syringe. Randomisation was done with a computer-generated randomisation schedule with a block size of 100. Because of the nature of the study, masking of participants was not possible. Immunogenicity was assessed by measurement of the hemagglutination inhibition antibody titres in serum for the three viral strains included in the vaccine. We included six coprimary endpoints: three strain-specific geometric mean titre ratios and the absolute differences in three strain-specific seroconversion rates. The immune response of the jet injector group was regarded as non-inferior to that of the needle and syringe group if both the upper bound of each of the three 95% CIs for the strain-specific geometric mean titre ratios was 1.5 or less, and the upper bound of the three 95% CIs for the strain-specific seroconversion rate differences was less than 10 percentage points. We used t test for group comparison. This study is registered with ClinicalTrials.gov, number NCT01688921.

FINDINGS

During the 2012-13 influenza season of the northern hemisphere, we allocated 1250 participants to receive vaccination by needle-free jet injector (n=627) or needle and syringe (n=623). In the intention-to-treat immunogenicity population, all participants with two serum samples were included (575 in the jet injector group and 574 in the needle and syringe group). The immune response to Afluria when given by needle-free jet injector met the criteria for non-inferiority for all six coprimary endpoints. The jet injector group met the geometric mean titre criterion for non-inferiority for the A/H1N1, A/H3N2, and B strains (upper bound of the 95% CI for the geometric mean titre ratios were 1·10 for A/H1N1, 1·17 for A/H3N2, and 1·04 for B strains). The jet injector group met the seroconversion rate criterion for non-inferiority for the A/H1N1, A/H3N2, and B strains (upper bound of the 95% CI of the seroconversion rate differences were 6·0% for A/H1N1, 7·0% for A/H3N2, and 5·7% for B strains). We recorded serious adverse events in three participants, none of which were study related.

INTERPRETATION

The immune response to influenza vaccine given with the jet injector device was non-inferior to the immune response to influenza vaccine given with needle and syringe. The device had a clinically acceptable safety profile, but was associated with a higher frequency of local injection site reactions than was the use of needle and syringe. The Stratis needle-free jet injector device could be used as an alternative method of administration of Afluria trivalent influenza vaccine.

FUNDING

Biomedical Advanced Research and Development Authority (BARDA), PATH, bioCSL, and PharmaJet.

Implementing SBAR across a large multihospital health system

BACKGROUND

Communication problems among health care personnel during critical clinical situations can jeopardize patient safety. SBAR, a structured-communication technique, has been adapted from aviation and the military as a strategy for clear communication based on a statement of the situation, background, assessment, and recommendations related to a critical issue. Nurses' use of SBAR and physician perception of communication quality after SBAR implementation was assessed at a 13-hospital health care system.

METHODS

Baylor Health Care System initiated a campaign to implement SBAR and train staff in SBAR techniques across its hospitals. Nurse surveys and physician audits were conducted.

FINDINGS

Of 156 nurses interviewed, 152 (97.4%) had been educated about SBAR, and 91 (58.3%) used SBAR for critical communication. Of 84 nurses whose proficiency with SBAR was assessed, 72.6% demonstrated good or high proficiency. Of the 155 physicians who responded to the physician survey, 121 (78.1%) said that the last report they received was adequate to make clinical decisions. Of the 27 who indicated that the last report was not adequate to make clinical decisions, 25 (92.6%) had not received the report in SBAR format.

CONCLUSIONS

SBAR was generally well understood. Challenges included inconsistent uptake across facilities, lack of physician education about SBAR, and a tendency to view SBAR as a document rather than a verbal technique. Future research will address the need for refresher education with nurses after initial SBAR education, the need for formal physician education about SBAR use, and the possibility of conducting annual competency validation of the utilization of SBAR. Research should also examine the effect of SBAR on quality of care and patient outcomes in controlled trials.

Effectiveness of Computer-Based Dysphagia Training for Direct Patient Care Staff

Speech-language pathologists (SLPs) in medical settings are responsible for evaluating patients' feeding and swallowing. Once an evaluation is completed, nursing staff typically provides hands-on care and supervision of meals. SLPs seek to improve outcomes for individuals with dysphagia by educating direct-care staff. This project sought to determine whether a computer-based swallowing safety module could produce changes in knowledge levels of nursing staff. This module was designed to replace inservices conducted by staff SLPs. Nursing staff would be required to complete the training when hired and as an annual assessment. The training module was designed and pilot-tested along with a pre- and posttest to assess changes in knowledge. Participants in the experimental group took the pretest, completed the computer training module, and then took the posttest. Participants in the control group took the pre- and posttest with no intervening training. Statistically significant differences were found between the two groups on posttest scores. Participants in the experimental group demonstrated increased test scores, while the scores of the control group did not change significantly. This study indicates that computer-based training for nursing staff related to swallowing safety and dysphagia is effective.

World-wide radiation dosage calculations for air crew members

A greatly improved version of the computer program to calculate radiation dosage to air crew members is now available. Designated CARI-6, this program incorporates an updated geomagnetic cutoff rigidity model and a revision of the primary cosmic ray spectrum based on recent work by Gaisser and Stanev (1998). We believe CARI-6 provides the most accurate available method for calculating the radiation dosage to air crew members. The program is now utilized by airline companies around the world and provides unification for subsequent world-wide studies on the effects of natural radiation on aircrew members.

Prevention and early detection of type 2 diabetes in children and adolescents

Type 2 ("adult-onset") diabetes in young adults and children has become increasingly common over the last 10 years, and has been described as an "emerging epidemic." The financial and societal ramifications of such a development are substantial and demand a prompt and aggressive public health response. Emphasis must be placed upon preventive behaviors and early detection, and creation of new public policy to address the related societal issues. Recommendations for prevention and screening of high-risk children and adolescents are provided.

Effect of low-dose estrogen on hemodynamic response to stress

OBJECTIVE

To determine the effect of low-dose esterified estrogen on hemodynamic responses at rest and during stress in postmenopausal women, and to compare the changes with those seen with conjugated equine estrogen.

DESIGN

Open-label study of esterified estrogen compared with a double-blind, placebo-controlled investigation of conjugated equine estrogen.

SETTING

Healthy volunteers in an academic research environment.

PATIENT(S)

Postmenopausal women with normal endometrium, not currently using hormones.

INTERVENTION(S)

Cardiovascular parameters at rest and in response to stressors were assessed in 11 postmenopausal women before and 6 months after receiving 0.3 mg esterified estrogen. Responses were compared with 42 postmenopausal women randomized to 0.625 mg conjugated equine estrogen or placebo.

MAIN OUTCOME MEASURE(S)

Changes in mean arterial pressure (MAP) and vascular resistance index from before to after treatment.

RESULT(S)

At rest, MAP increased 3.3 +/- 1.5 mm Hg (+/-SD) in the placebo group, while declining 2.3 +/- 1.5 mm Hg and 4.8 +/- 1.4 mm Hg, respectively, in the esterified estrogen and conjugated equine estrogen groups after treatment. During mental stressors, MAP dropped significantly in both treatment groups. At rest and during mental stressors, vascular resistance index decreased with estrogen treatment.

CONCLUSION(S)

Low-dose esterified estrogen improved hemodynamic patterns similar to standard doses of conjugated equine estrogen in postmenopausal women.

Radiation exposure during air travel: guidance provided by the Federal Aviation Administration for air carrier crews

Air carrier crews are occupationally exposed to ionizing radiation, principally from galactic cosmic radiation. To promote radiation safety in aviation the Federal Aviation Administration has: issued educational material on the nature of the radiation received during air travel; recommended radiation exposure limits for pregnant and nonpregnant aircrew members; developed computer programs that estimate for a given flight profile the amount of galactic radiation received on a current flight or on one flown at any time back to January 1958; published tables that enable aircrew members to estimate possible health risks associated with their occupational exposure to radiation; and conducted research on effects of radiation during pregnancy. References for this material are given in the article. In addition, graphic and tabular data in the article show how galactic radiation levels and the composition of the galactic radiation has changed between 1958 and 1999. Also given are estimates of effective doses received by air travelers on a wide variety of air carrier flights.

Cognitive correlates of long-term cannabis use in Costa Rican men

BACKGROUND

Cognitive correlates of long-term cannabis use have been elusive. We tested the hypothesis that long-term cannabis use is associated with deficits in short term memory, working memory, and attention in a literate, westernized culture (Costa Rica) in which the effects of cannabis use can be isolated.

METHODS

Two cohorts of long-term cannabis users and nonusers were studied. Within each cohort, users and nonusers were comparable in age and socioeconomic status. Polydrug users and users who tested positive for the use of cannabis at the time of cognitive assessment after a 72-hour abstention period were excluded. The older cohort (whose age was approximately 45 years) had consumed cannabis for an average of 34 years, and comprised 17 users and 30 nonusers, who had been recruited in San José, Costa Rica, and had been observed since 1973. The younger cohort (whose age was approximately 28 years) had consumed cannabis for an average of 8 years, and comprised 37 users and 49 nonusers. Short-term memory, working memory, and attentional skills were measured in each subject.

RESULTS

Older long-term users performed worse than older nonusers on 2 short-term memory tests involving learning lists of words. In addition, older long-term users performed worse than older nonusers on selective and divided attention tasks associated with working memory. No notable differences were apparent between younger users and nonusers.

CONCLUSION

Long-term cannabis use was associated with disruption of short-term memory, working memory, and attentional skills in older long-term cannabis users.

The risk and efficacy of chorionic villus sampling in multiple gestations

Chorionic villus sampling (CVS) in the first trimester of pregnancy provides a safe and effective method for the early prenatal diagnosis of cytogenetic abnormalities in multiple gestations. In this multicentre study involving 126 twin and 2 triplet gestations primarily at risk because of advanced maternal age, the overall success rate of obtaining an adequate villus sample from each fetus was 99.2 per cent. For women of advanced maternal age, the rate of combined losses of chromosomally normal fetuses due to spontaneous abortion, stillbirths, and neonatal deaths was 5.0 per cent, compared with a 4.0 per cent total loss rate following CVS in singleton pregnancies derived from the same population (Rhoads et al., 1989). There was a 100 per cent success rate in obtaining a cytogenetic analysis; a cytogenetic abnormality was present in five of the multiple gestations (3.9 per cent) and involved seven fetuses (2.7 per cent). There were no diagnostic errors and no cases of normal cytogenetic diagnosis followed by the birth of a cytogenetically abnormal newborn. Based on cases of XX/XY admixture, cell contamination derived either from maternal decidua or the other twin occurred in 6 of 256 samples (2.3 per cent), giving an overall estimate of the frequency of cell contamination of 4.6 per cent; these cases did not present a diagnostic problem. However, there were two cases (0.8 per cent) in which the fetal sex was incorrect, due either to complete maternal cell contamination or to the possibility that in error one twin was sampled twice.

Pharmacokinetics and biotransformation of the cyclosporine metabolite M-17 in the rabbit

The monohydroxylated cyclosporine (CsA) metabolite M-17 was isolated from bile of human liver transplant recipients by preparative HPLC. The structure and purity of the metabolite were confirmed by fast atom bombardment-mass spectroscopy and proton NMR. The isolated metabolite was administered iv to three rabbits at a dose of 1.0 mg/kg with the following mean pharmacokinetic parameters being determined: half-life (t1/2B) 2.22 hr, volume of distribution (Vss) 1.44 liters/kg, and clearance 11.07 ml/min/kg. These are not significantly different from those obtained for CsA. In bile and urine obtained from rabbits administered M-17, the CsA metabolites M-8, M-18, and M-26 were found, indicating that M-17 is further metabolized. The latter data support the proposed biotransformation pathways for M-17.