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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Indicators for the evaluation of musculoskeletal trauma systems: A scoping review and Delphi study

BACKGROUND

Trauma is a leading cause of mortality and morbidity, disproportionately affecting low- and middle-income countries. Musculoskeletal trauma results in the majority of post-traumatic morbidity and disability globally. The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries.

STUDY OBJECTIVES

The purpose of this study was to establish a practical list of performance indicators to evaluate and monitor the quality and equity of musculoskeletal trauma care delivery in health systems worldwide.

METHODS

A scoping review was performed that identified performance indicators related to musculoskeletal trauma care. Indicators were organized by phase of care (general, prevention, pre-hospital, hospital, post-hospital) within a modified Donabedian model (structure, process, outcome, equity). A panel of 21 experts representing 45 countries was assembled to identify priority indicators utilizing a modified Delphi approach.

RESULTS

The scoping review identified 1,206 articles and 114 underwent full text review. We included 95 articles which reported 498 unique performance indicators. Most indicators related to the hospital phase of care (n = 303, 60%) and structural characteristics (n = 221, 44%). Mortality (n = 50 articles) and presence of trauma registries (n = 16 articles) were the most frequently reported indicators. After 3 rounds of surveys our panel reached consensus on a parsimonious list of priority performance indicators. These focused on access to trauma care; processes and key resources for polytrauma triage, patient stabilization, and hemorrhage control; reduction and immobilization of fractures and dislocations; and management of compartment syndrome and open fractures.

CONCLUSIONS

The literature has reported many performance indicators relating to trauma care, but few specific to musculoskeletal injuries. To create quality and equitable trauma systems, musculoskeletal care must be incorporated into development plans with continuous monitoring and improvement. The performance indicators identified by our expert panel and organized in a modified Donabedian model can serve as a method for evaluating musculoskeletal trauma care.

High Dielectric Constant Liquid Dielectrics Based on Magnetic Nanofluids

Magnetic nanofluids are increasingly finding new applications. They can be employed as liquid dielectrics. The advantage of having a liquid dielectric is that high dielectric constant can be achieved by a judicious choice of the base liquid. The dielectric constant can be tuned with the help of an external magnetic field too. Superparamagnetic iron oxide nanoparticles were dispersed in polar carriers, namely water, polyvinyl alcohol, ethylene glycol, and a nonpolar carrier like kerosene to obtain stable magnetic fluids after ensuring the crystallographic phase purity along with appropriate magnetic characteristics of the dispersant. The fluids were then subjected to dielectric studies using an automated homemade dielectric setup. The dielectric permittivity and dielectric loss at different frequencies with and without an external magnetic field were evaluated. The studies indicate that magnetic nanofluids based on polar carriers are excellent liquid dielectrics over a wide range of frequencies with the incorporation of iron oxide nanoparticles. The application of an external magnetic field enhances the dielectric constant considerably. These magnetic nanofluids can be employed as liquid dielectrics for applications. It has been found that kerosene based magneto fluids have a low dielectric constant while Polyvinyl alcohol based fluids exhibit the highest dielectric constant.

Reducing donor-site complications in DIEP flap breast reconstruction with closed incisional negative pressure therapy: A cost-benefit analysis

INTRODUCTION

Deep inferior epigastric perforator (DIEP) flaps are considered the gold standard for autologous breast reconstruction but create large abdominal incisions that risk donor-site morbidity during harvest. Closed incision negative pressure therapy (ciNPT) is emerging as an effective alternative to standard postoperative dressings, but there is a paucity of data in DIEP flap donor sites.

METHODS

We conducted a retrospective case-control study investigating the use of ciNPT in DIEP flap donor sites at a single institution between March 2017 and September 2021. Patients who underwent microsurgical autologous breast reconstruction with DIEP flaps were included. Patients were divided into those with donor incision sites managed with ciNPT (n = 24) and those with conventional postoperative wound dressings (n = 20). We compared patient demographics, wound drainage volumes and postoperative outcomes between the two groups. A cost-benefit analysis was employed to compare the overall costs associated with each complication and differences in length of stay between the two groups.

RESULTS

There was no statistically significant difference in age, body mass index (BMI), comorbidity burden or smoking status between the two groups. Both groups had similar lengths of stay and wound drainage volumes with no readmissions or reoperations in either group. There was a statistically significant reduction in donor-site complications (p = 0.018), surgical site infections (p = 0.014) and seroma formation (p = 0.016) in those with ciNPT. Upon cost-benefit analysis, the ciNPT group had a mean reduction in cost-per-patient associated with postoperative complications of £420.77 (p = 0.031) and £446.47 (p = 0.049) when also accounting for postoperative length of stay CONCLUSION: ciNPT appears to be an effective alternative incision management system with the potential to improve complication rates and postoperative morbidity in DIEP flap donor sites. Our analysis demonstrates improved cost-benefit outweighing the increase in costs associated with ciNPT. We recommend a multicentre prospective trial with formal cost-utility analysis to strengthen these findings.

Headache in Patients with Sellar Disease: Clinicomorphological Predictors of Headache and the Outcome of Endoscopic Transphenoidal Surgery

Objectives: Sellar pathologies are frequently found on imaging performed to investigate headache. However, both headache and incidental sellar lesions are common. Hence, this study prospectively examined headache prevalence, phenotype and severity in patients with sellar pathologies and the impact of transphenoidal surgery on headache. Methods: Patients undergoing transphenoidal resection of sellar lesions were consecutively recruited. At baseline, participants were defined as having headache or not and headache phenotype was characterised using validated questionnaires. Headache severity was assessed at baseline and 6-months postoperatively using the Headache Impact Test-6 (HIT-6) and Migraine Disability Assessment Score (MIDAS). Tumour characteristics were defined using radiological, histological and endocrine factors. Primary outcomes included baseline headache prevalence and severity and headache severity change at 6-months postoperatively. Correlation between headache and radiological, histological and endocrine characteristics was also of interest. Results: 60 participants (62% female, 47.1±18.6 years) were recruited. 63% possessed baseline headache. HIT-6 scores were higher in patients with primary headache risk factors, including younger age (R2 =-0.417, p=0.010), smoking history (63.31±7.93 vs 54.44±9.21, p=0.006) and family headache history (68.13±7.01 vs 54.94±9.11, p=0.003). Headaches were more common in patients with dural invasion (55.70±12.14 vs 47.18±10.15, p=0.027) and sphenoid sinus invasion (58.87±8.97 vs 51.29±10.97, p=0.007). Postoperative severity scores improved more with higher baseline headache severity (HIT-6: R2=-0.682, p<0.001, MIDAS: R2=-0.880, p<0.001) and dural invasion (MIDAS: -53.00±18.68 vs 12.00±17.54, p=0.003). Conclusions: Headaches in sellar disease are likely primary disorders triggered or exacerbated by sellar pathology. These may respond to surgery, particularly in patients with severe headache and dural invasion.

248. Change in Incidence of Multisystem Inflammatory Syndrome in Children Across the COVID-19 Pandemic in Chicago — March 2020 – March 2022

Background

Peak counts of multisystem inflammatory syndrome in children (MIS-C) have followed each COVID-19 peak by 2–5 weeks. Fewer cases of MIS-C occurred after the Delta-predominant period compared to early waves of the pandemic. The Chicago Department of Public Health analyzed the ratio of MIS-C to pediatric COVID-19 hospitalization by period of variant predominance from March 2020 – mid-March 2022 to evaluate differences by variant.

Methods

MIS-C in Chicago residents was reported using the standard CDC MIS-C case report form. Four periods of COVID-19 infection were identified with dates defined by variant predominance (≥50%); date ranges for corresponding MIS-C periods were defined as starting 21 days after the COVID-19 period (Table 1). MIS-C cases were compared to hospitalizations as a measure of COVID-19 disease activity in children (rather than case counts which are more subject biases inherent in disease testing) among confirmed and probable COVID-19 cases in children ≤21 years reported to CDPH. Ratios of MIS-C cases per 100 corresponding pediatric hospitalizations for each variant period were calculated. Proportions of MIS-C hospitalizations with intensive care unit (ICU) admission, mechanical ventilation (MV), and receipt of vasopressors (VP) were calculated as markers of disease severity in MIS-C for each wave.

Results

90 cases of MIS-C and 1,597 pediatric COVID-19 hospitalizations were reported (Table 2). The overall ratio was 5.6 MIS-C cases/100 pediatric COVID-19 hospitalizations. The first period with predominance of the original lineage had a ratio of 10.2; subsequent periods with variant predominance all had lower ratios. The Delta period had the second highest ratio which was 68% of the first period. Across waves, 74% of MIS-C patients were admitted to ICU (range, 67–82%); 11% underwent MV (range, 0–14%); and 52% received VP (range, 45–71%).

Conclusion

The ratio of MIS-C to pediatric COVID-19 hospitalizations varied by period of SARS-CoV-2 variant predominance. The ratio was highest in the early pandemic. There was no consistent change in MIS-C severity. Further study is needed to determine if the change in ratio is due to increased immunologic exposure (vaccination or previous infection) or if it is variant dependent.

Disclosures

All Authors: No reported disclosures.

[Clinical, diagnostic and evolutionary profile of peritoneal tuberculosis at the national reference general hospital of Ndjamena about 69 cases]

INTRODUCTION

Peritoneal tuberculosis is not uncommon in Chad. Its diagnosis of certainty is difficult and is based on the analysis of ascites fluid and abdominal ultrasound. Our aim was to contribute to the study of the various clinical, diagnostic and progressive aspects of peritoneal tuberculosis in the internal medicine department of the HGRN.

METHODOLOGY

This is a retrospective and prospective study spread over 39 months covering the period from January 2014 to March 2017 including all patients hospitalized for peritoneal tuberculosis in the internal medicine department of the HGRN. The diagnosis was made, on a bundle of anamnestic, clinical, ultrasound, cytological and evolutionary arguments.

RESULTS

During the study period, 69 patients were included, or 9.77% of all hospital admissions. The average age was 42 years (range 18 to 83 years). The female sex represented 52.2% of the cases. The main reasons for hospitalization were ascites (87% of cases), associated with fever (92.5% of cases). The clinical signs were dominated by abdominal pain, deterioration of general condition and transit disorders. The ascites fluid was citrus yellow, rich in lymphocytes (81.6% of cases) and protein (94.2% of cases). Abdominal ultrasound, performed in all patients, demonstrated ascites with deep, mesenteric lymphadenopathy, portal in 62.3% of cases and compartmentalized in 37.7% of cases. Tuberculosis treatment was started in all patients and the outcome was favorable in 65.2% of cases. We deplored 20.3% mortality; all were patients who were severely immunosuppressed with HIV.

CONCLUSION

Peritoneal involvement in tuberculosis is common in Chad. The diagnosis is not always easy, but the clinic associated with the exudative and lymphocytic characters of the ascites fluid as well as the abdominal ultrasound are elements which can direct towards a peritoneal localization of tuberculosis. The course is generally favorable under early treatment and well conducted.

Warm Autoimmune Hemolytic Anemia as the Initial Presentation of Systemic Lupus Erythematosus (SLE): A Case Report

BACKGROUND Autoimmune hemolytic anemia is an acquired disorder resulting in the presence of antibodies against red blood cell (RBC) antigens causing hemolysis. Autoimmune hemolytic anemia is of 2 types, Warm antibody mediated and cold agglutinin disease. Warm autoimmune hemolytic anemia (warm agglutinin disease) usually presents with fatigue and other constitutional symptoms and is diagnosed by the presence of IgG antibodies. The disease can occur as idiopathic or secondary to other autoimmune diseases, infections, or even malignancies. The systemic lupus erythematosus (SLE) is an autoimmune disease prevalent in young females. Autoimmune hemolytic anemia can occur as a part of the SLE spectrum however warm autoimmune hemolytic anemia as the initial manifestation of SLE is extremely rare. CASE REPORT Here, we describe a unique case of a 32-year-old woman who presented with vague clinical presentation found to have warm autoimmune hemolytic anemia and further immunological and inflammatory work-up during and after hospitalization lead to the diagnosis of systemic lupus erythematosus. CONCLUSIONS The systemic lupus erythematosus (SLE) is an autoimmune chronic inflammatory disease with unclear etiology affecting multi organs. Variable presentation in addition to the lack of definite pathognomonic features or tests makes the diagnosis of SLE challenging. On the whole autoimmune hemolytic anemia can not only be part of other disease processes but can be an initial presentation, highlighting the importance of thorough work-up in patients presenting with autoimmune hemolytic anemia to aid in timely diagnosis and management of underlying secondary conditions. It is important for providers to be aware of various disease spectrums that contain autoimmune hemolytic anemia for day-to-day clinical practice.

Analysis of Facial Electromyography Signals Using Linear and Non-Linear Features for Human-Machine Interface

In this work, an attempt has been made to analyze the facial electromyography (facial EMG) signals using linear and non-linear features for the human-machine interface. Facial EMG signals are obtained from the publicly available, widely used DEAP dataset. Thirty-two healthy subjects volunteered for the establishment of this dataset. The signals of one positive emotion (joy) and one negative emotion (sadness) obtained from the dataset are used for this study. The signals are segmented into 12 epochs of 5 seconds each. Features such as sample entropy and root mean square (RMS) are extracted from each epoch for analysis. The results indicate that facial EMG signals exhibit distinct variations in each emotional stimulus. The statistical test performed indicates statistical significance (p<0.05) in various epochs. It appears that this method of analysis could be used for developing human-machine interfaces, especially for patients with severe motor disabilities such as people with tetraplegia.

455 A Case of An Unusual Penetrating Brain Injury

Introduction

Penetrating brain injuries (PBI) are less common than closed head traumas. Interest in frontal lobe injuries dates back to 1848’s famous Phineas Gage incident. Here, we report a case of a construction worker, who showed a remarkable neuropsychiatric outcome following a workplace accident.

Case Presentation

45year old gentleman came with complaint of a foreign body accidentally lodged in his forehead. He had no neurological deficits or CSF leak. X-ray revealed that a 5.5cm metallic screw was penetrating his skull, headfirst; CT revealed that approximately 3cm of the screw was in the frontal sinus. He was given antiepileptics and antibiotics prophylactically. Surgically the screw was removed by raising a bone flap and mobilizing the screw carefully by cutting the dura and adequate irrigation, causing minimal damage to the brain parenchyma. The dural deficits were repaired and the frontal sinus was canalized, then a drain was placed, and the patient was shifted to ICU for postoperative monitoring.

Discussion

It is important to prognosticate PBI as they can have neurological deficits that may be lifelong. Understanding the mechanism of injury, aggressive medical management and immediate surgical intervention may lead to improved outcomes. A foreign object of the size of 5.5cm, completely penetrating the skull would have otherwise resulted in extensive parenchymal damage. Literature suggests that no two people have an identical frontal sinus. In our patient the size the frontal sinus has served the purpose of protection against PBI and has resulted in minimal parenchymal injury (of only about 1cm).

426 PREVALENCE OF, AND RISK FACTORS FOR, DEMENTIA IN ADULT OUTPATIENT REFERRALS TO A REGIONAL REFERRAL HOSPITAL IN ARUSHA, TANZANIA

Introduction

The global burden of dementia is increasing, with the greatest increase predicted to occur in sub-Saharan Africa (SSA). Despite this there are limited previous data on the prevalence of, and risk factors for, dementia in SSA. This study aimed to estimate the prevalence of dementia, and investigate its associations, in those aged 60 years and older attending the outpatient department of Mount Meru Hospital in northern Tanzania. This is the first hospital-based outpatient dementia prevalence and risk factors study to be conducted in an east African population.

Methods

This was a one-phase cross-sectional study. Adults aged 60 years and over attending medical outpatients were screened for dementia using The Identification and Intervention for Dementia in Elderly Africans cognitive screening tool. Those who scored ≤9 were clinically assessed using the DSM-IV criteria. Demographic, medical comorbidity and lifestyle information were collected during a clinical assessment.

Results

Prevalence of dementia was 5.0% (95% confidence interval: 3.7–6.3). Binary logistic regression found female sex (odds ratio (OR) = 2.778), having no formal education (OR = 6.088), quantity of alcohol consumption (units/week) (OR = 1.080), uncorrected visual impairment (OR = 4.260), body mass index &lt;18.5 kg/m2 (OR = 6.588) and stroke (OR = 15.790 with wide 95% confidence interval (3.48–74.475)) to be significantly, independently associated with dementia.

Conclusions

The prevalence of dementia in this population is lower than previously reported community-based rates in Tanzania, and similar to those in high-income countries. This is the first time the association between uncorrected visual impairment and dementia has been reported in SSA. Other associations identified are in keeping with previous literature. Further research on the management of dementia and its risk factors, and the support and education of carers and patients in east African populations is required.

Current status quo on COVID-19 including chest imaging

With each day the number coronavirus disease 2019 (COVID-19) cases continue to rise rapidly and our imaging knowledge of this disease is expeditiously evolving. The role of chest computed tomography (CT) in the screening or diagnosis of COVID-19 remains the subject of much debate. Despite several months having passed since identifying the disease, and numerous studies related to it, controversy and concern still exists regarding the widespread use of chest CT in the evaluation and management of COVID-19 suspect patients. Several institutes and organizations around the world have released guidelines, recommendations and statements against the use of CT for diagnosing or screening COVID-19 infection and advocating its use only for those cases with a strong clinical suspicion of complication or an alternate diagnosis. However, these guidelines and recommendations are in disagreement with majority of the widely available literature, which strongly favour CT as a pivotal tool in the early diagnosis, management and even follow-up of COVID-19 infection. This article besides comprehensively reviewing the current status quo on COVID-19 disease in general, also writes upon the current consensus statements/recommendations on the use of diagnostic imaging in COVID-19 as well as highlighting the precautions and various disinfection procedures being employed world-wide at the workplace to prevent the spread of infection.

Recurrence of Endometrial Stromal Sarcoma, Two Decades Post-Treatment

Endometrial stromal cell sarcomas (ESS) are a unique subtype of uterine malignancy. Recurrent low grade endometrial stromal sarcomas (LESS) is identified in half of the patients. Here, we discuss a case of a 76-year-old Asian female with a past medical history of adenomyosis and hypertension who presented to the outpatient clinic with a chief complaint of painless hematuria for one day. Computed tomography scan of abdomen and pelvis with contrast showed a new right-sided mixed cystic and solid pelvic mass measuring up to 6 cm, obstructing and invading the distal right ureter, which was concerning for malignancy. Positron emission tomography (PET scan) demonstrated a right pelvic mass with increased radiotracer activity consistent with malignancy. She underwent laparotomy with excision of the right-sided pelvic mass with an abdominal washout and at the same time, also underwent cystoscopy with right ureteral stent placement. Tissue pathology was consistent with spindle cell neoplasm with staining and histologic features consistent with a recurrent stromal cell sarcoma. Uterine sarcomas tend to have an aggressive nature but there are key features about ESS that distinguish it from other uterine sarcomas. ESS has a more indolent clinical course and can reoccur years after initial diagnosis. They usually relapse locally, although relapses in extra-uterine sites have also been reported. Treatment of ESS depends on the grade and stage at the time of diagnosis. The main line of treatment for ESS consists of a total abdominal hysterectomy (TAH) and salpingo-oophorectomy (BSO). The significance of this case demonstrates that, although remission can be obtained after the initial diagnosis, recurrence can happen. Even when patients seem to be disease-free, clinicians should follow them closely; early diagnosis is important as treatment for this type of entity has a high survival rate.

The Perfect Storm: A Case of Ischemic Stroke in the Setting of Thyroid Storm

Mortality in thyroid storm, without appropriate treatment, can rise as high as 100%. Thyroid storm coexisting with ischemic stroke is a rare presentation that further increases the risk of mortality. Early recognition and appropriate management are critical to the prevention of mortality and morbidity. Here, we review the case of a 63-year-old male presenting with new neurological deficits who was found to have thyroid storm; appropriate management of the co-existing conditions are also reviewed.

P2866Automated ultrasound ablation parameters predict lesion depth in a perfused thigh model

Background

The accuracy and safety of lesions created during catheter ablation of cardiac tissue rely on the user's ability to predict the size of lesions that form under variable conditions during treatment. A user-directed robotic system was developed that uses Low-Intensity Collimated Ultrasound (LICU) for cardiac imaging and to produce linear lesions without tissue contact. Molecular absorption of mechanical energy induced in the tissue by LICU causes a temperature rise resulting in thermal tissue necrosis.

Purpose

By varying the speed of the LICU beam as it traces the desired lesion path, while considering the beam intensity, distance from catheter tip to tissue, and relative motion of the target tissue, we demonstrate the capability to deposit lesions of known depth according to a predictive model.

Methods

The LICU catheter was mounted in a servo-controlled, 3 axis stage suspended above a perfused porcine thigh that simulates the thermodynamic properties of the myocardium such as acoustic attenuation, thermal conduction, and specific heat capacity. Therapy was delivered along a linear path while varying the distance to tissue, speed of the beam, and motion of the catheter relative to the tissue in 3 dimensions. Programmed relative motion was representative of typical and extreme motion in humans. Pathological analysis after necropsy was used to quantify lesion depth which was then compared to lesion depth as predicted by a mathematical model from approx. 4–12 mm.

Results

Data from 66 samples were categorized according to typical and extreme motion at 4 different distances (3, 8, 9 and 13 mm). Measured vs predicted lesion depth was well correlated (R = 0.898) with 98.5% of the samples within ±2 mm.

Assessment of LICU lesion depth

Conclusion

Lesion depth using LICU is well controlled in an animal model for the range of distances and relative motion typically encountered in a human subject. The range of acoustic beam speeds and acoustic power density with LICU predictably produces lesions up to 12 mm deep. The LICU thermal model may be useful to create lesions of known depth thus ensuring transmurality of lesions while potentially avoiding unintended extra-cardiac injury.

Health Outcomes of Youth in Clinical Pediatric Weight Management Programs in POWER

OBJECTIVE

To describe treatment outcomes of children and adolescents enrolled in the Pediatric Obesity Weight Evaluation Registry, a consortium of multicomponent pediatric weight management programs in the US.

STUDY DESIGN

This multicenter prospective observational cohort study, established in 2013, includes youth (2-18 years of age) with obesity enrolled from 31 Pediatric Obesity Weight Evaluation Registry (POWER) sites over a 2-year period and followed up to 12 months. Weight status was evaluated by the percentage of the 95th percentile for body mass index (%BMIp95). Associations of weight status outcomes with patient characteristics and program exposure were analyzed with multivariable mixed effects modeling.

RESULTS

We included 6454 children and adolescents (median age, 11 years; IQR, 9-14 years; 53% white, 32% Hispanic; 73% with severe obesity) who were enrolled in POWER. Median changes in %BMIp95 for this cohort were -1.88 (IQR, -5.8 to 1.4), -2.50 (IQR, -7.4 to 1.8), -2.86 (IQR, -8.7 to 1.9), at 4-6, 7-9, and 10-12 of months follow-up, respectively (all P < .05). Older age (≥12 years), greater severity of obesity, and Hispanic race/ethnicity were associated with better improvement in %BMIp95. A 5-percentage point decrease in %BMIp95 was associated with improvement in cardiometabolic risk factors.

CONCLUSIONS

Overall, treatment in pediatric weight management programs is associated with a modest median decrease in BMI as measured by change in %BMIp95. Further studies are needed to confirm these findings, as well as to identify additional strategies to enhance the effectiveness of these multicomponent interventions for youth with severe obesity.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02121132.