Retrospective Comparative Analysis of Clinical and Functional Outcome After Arthroscopic Bankart Repair using All-Suture Anchor and Metal Anchor

Introduction

Both knotted all suture anchors and metal anchors are used for arthroscopic Bankart repair. We retrospectively evaluated and compared clinical and functional outcomes after arthroscopic Bankart repair using the knotted all-suture anchors and knotted metal anchors.

Materials and methods

In a retrospective cohort analysis, patients who underwent arthroscopic Bankart repair without any concomitant additional lesion repair using either all-suture anchors or metal anchors, between January 2015 and May 2018 were identified. Their pre- and post-operative functional and clinical outcomes were compared using Rowe and WOSI scores. The recurrence rate in the two groups was also compared.

Results

A total of 41 patients in all suture anchors group and 47 in the metal anchors group were identified as per inclusion and exclusion criteria. The demographic profile of both groups was comparable. There was no significant difference in clinical and functional outcome between the two suture anchor groups as per Rowe (pre-operative 40.13+6.51 vs 38.09+6.24 and post-operative 2 years 93.28+7.09 vs 92.55+9.2) and WOSI (pre-operative 943.05+216.64 vs 977.55+165.46 and post-operative 2 years 278.21+227.56 vs 270.94+186.25) scores. There was a significant improvement in both the groups between preoperative and post-operative ROWE and WOSI scores at 6 months and 2 years follow-up as compared to pre-operative scores (p<0.001). Re-dislocation rates were also comparable (4.8% vs 6.3%).

Conclusion

All-suture anchors showed comparable clinical and functional results as the metal anchors for arthroscopic Bankart repair at two-year follow-up.

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies.

RECENT FINDINGS

There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.

Impact of Patient Subgroups on the Efficacy and Safety of Methylnaltrexone for Opioid-Induced Constipation in Patients with Advanced Illness

Purpose

We evaluated the impact of baseline patient characteristics on safety and efficacy of methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, in patients with advanced illness with opioid-induced constipation (OIC).

Patients and Methods

This analysis pooled data from 2 randomized, double-blind, placebo-controlled studies (study 302: NCT00402038; study 4000: NCT00672477) in patients with advanced illness, including cancer, and OIC. Patients were randomized to receive subcutaneous methylnaltrexone (study 302: 0.15 mg/kg; study 4000: 8 or 12 mg based on weight) or placebo every other day for 2 weeks. The proportions of patients achieving rescue-free laxation within 4 or 24 hours after the first dose of study drug were assessed in patient subgroups stratified by baseline age, Eastern Cooperative Oncology Group (ECOG) performance status, cancer status, laxative type, and opioid requirement. Treatment-emergent adverse events (TEAEs) were evaluated.

Results

Overall, 363 patients were included in this analysis (methylnaltrexone, 178; placebo, 185). Mean (SD) age was 66.3 (13.7) years and 48.5% were men overall. A significantly greater proportion of patients receiving methylnaltrexone versus placebo achieved rescue-free laxation within 4 hours (111/178 [62.4%] vs 31/185 [16.8%]; P<0.0001) and 24 hours (135/178 [75.8%] vs 81/185 [43.8%]; P<0.0001) of the first dose. These trends were consistent across all subgroups. Most patients experienced ≥1 TEAE in the overall population (methylnaltrexone, 82.1%; placebo, 76.2%), which remained consistent when stratified by baseline characteristics. More than half of TEAEs were gastrointestinal in nature. Abdominal pain was more common in patients receiving methylnaltrexone than placebo across baseline characteristic subgroups.

Conclusion

Methylnaltrexone treatment was superior to placebo in achieving rescue-free laxation within 4 and 24 hours after the first dose, irrespective of patients' cancer status, baseline ECOG performance status, or baseline opioid or laxative use. The methylnaltrexone safety profile remained consistent across baseline characteristic subgroups.

An artificial intelligence-powered, patient-centric digital tool for self-management of chronic pain: a prospective, multicenter clinical trial

OBJECTIVE

To investigate how a behavioral health, artificial intelligence (AI)-powered, digital self-management tool affects the daily functions in adults with chronic back and neck pain.

DESIGN

Eligible subjects were enrolled in a 12-week prospective, multicenter, single-arm, open-label study and instructed to use the digital coach daily. Primary outcome was a change in Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores for pain interference. Secondary outcomes were changes in PROMIS physical function, anxiety, depression, pain intensity scores and pain catastrophizing scale (PCS) scores.

METHODS

Subjects logged daily activities, using PainDrainerTM, and data analyzed by the AI engine. Questionnaire and web-based data were collected at 6 and 12 weeks and compared to subjects' baseline.

RESULTS

Subjects completed the 6- (n = 41) and 12-week (n = 34) questionnaires. A statistically significant Minimal Important Difference (MID) for pain interference was demonstrated in 57.5% of the subjects. Similarly, MID for physical function was demonstrated in 72.5% of the subjects. A pre- to post-intervention improvement in depression score was also statistically significant, observed in 100% of subjects, as was the improvement in anxiety scores, evident in 81.3% of the subjects. PCS mean scores was also significantly decreased at 12 weeks.

CONCLUSION

Chronic pain self-management, using an AI-powered, digital coach anchored in behavioral health principles significantly improved subjects' pain interference, physical function, depression, anxiety, and pain catastrophizing over the 12-week study period.

Preclinical Development and Characterization of Novel Adeno-Associated Viral Vectors for the Treatment of Lipoprotein Lipase Deficiency

Lipoprotein lipase deficiency (LPLD) results from mutations within the lipoprotein lipase (LPL) gene that lead to a complete lack of catalytically active LPL protein. Glybera was one of the first adeno-associated virus (AAV) gene replacement therapy to receive European Medicines Agency regulatory approval for the treatment of LPLD. However, Glybera is no longer marketed potentially due to a combination of economical, manufacturing, and vector-related issues. The aim of this study was to develop a more efficacious AAV gene therapy vector for LPLD. Following preclinical biodistribution, efficacy and non-Good Laboratory Practice toxicity studies with novel AAV1 and AAV8-based vectors in mice, we identified AAV8 pVR59. AAV8 pVR59 delivered a codon-optimized, human gain-of-function hLPLS447X transgene driven by a CAG promoter in an AAV8 capsid. AAV8 pVR59 was significantly more efficacious, at 10- to 100-fold lower doses, compared with an AAV1 vector based on Glybera, when delivered intramuscularly or intravenously, respectively, in mice with LPLD. Efficient gene transfer was observed within the injected skeletal muscle and liver following delivery of AAV8 pVR59, with long-term correction of LPLD phenotypes, including normalization of plasma triglycerides and lipid tolerance, for up to 6 months post-treatment. While intramuscular delivery of AAV8 pVR59 was well tolerated, intravenous administration augmented liver pathology. These results highlight the feasibility of developing a superior AAV vector for the treatment of LPLD and provide critical insight for initiating studies in larger animal models. The identification of an AAV gene therapy vector that is more efficacious at lower doses, when paired with recent advances in production and manufacturing technologies, will ultimately translate to increased safety and accessibility for patients.

Synthesis and characterization of nanostructured graphene-doped selenium

In this work, we explore various properties of elemental selenium glass (g-Se) by doping with graphene through the facile melt-quench technique. The structural information of the synthesized sample was found by X-ray diffraction (XRD), X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM), and Raman spectroscopy. The analyses confirm that the graphene-doped g-Se behaves like a glass-ceramic material. Electrical and dielectric measurements were performed to discover the consequences of graphene incorporation on the nano-structure of g-Se. The electrical measurements of the dielectric parameters (i.e., dielectric constant ε' and loss ε'') and conductivity (σ _ac) reveal that graphene incorporation causes a rise in the dielectric constant but simultaneously increases dielectric loss. The enhancement in ε' and ε'' values is thought to be a consequence of the interface effect between graphene and the host selenium glass. Calorimetric experiments were performed in a standard differential scanning calorimetry (DSC) unit on the glassy nanocomposite in non-isothermal mode. By measuring the kinetic temperatures at four heating rates, the kinetics of the crystallization/glass transition were studied. The results were examined to understand the role of graphene doping on the well-known phase transitions (i.e., glass transition and crystallization) of g-Se.

Thermal analysis of novel third-generation phase-change materials with zinc as a chemical modifier

The thermal analysis in the present work is done to analyze the glass/crystal phase transformation in a newly synthesized glassy system (i.e., glassy SeTeSnZn alloys) consisting of chalcogenides Se and Te as major elements, Sn as a third element of the parent alloy and Zn as a chemical modifier. The role of increasing the Zn concentration at the cost of Se has been understood by correlating the kinematics of structural relaxation during the glass transition phenomenon and devitrification during the crystallization phenomenon in the chalcogenide glasses (ChGs) of the quaternary STSZ [i.e., Se_78-x Zn _x Te₂₀Sn₂ (0 ≤ x ≤ 6)] system and their different physicochemical properties. A noticeable rise in the crystallization rate is observed after the addition of Zn in the parent SeTeSn glass. With the rise in the zinc content, the values of average heat of atomization and overall mean bond energy are found to be decreased with the decrease in cohesive energy of samples. An inverse correlation is observed between the thermal stability parameter and the enthalpy released during the glass/crystalline phase transformation.

A Review of Laser Therapy and Low-Intensity Ultrasound for Chronic Pain States

PURPOSE OF REVIEW

Chronic pain management therapies have expanded quickly over the past decade. In particular, the use of laser therapy and ultrasound in the management of chronic pain has risen in recent years. Understanding the uses of these types of therapies can better equip chronic pain specialists for managing complicated chronic pain syndromes. The purpose of this review was to summarize the current literature regarding laser radiation and ultrasound therapy used for managing chronic pain syndromes.

RECENT FINDINGS

In summary, there is stronger evidence supporting the usage of laser therapy for managing chronic pain states compared to low-intensity ultrasound therapies. As a monotherapy, laser therapy has proven to be beneficial in managing chronic pain in patients with a variety of pain syndromes. On the other hand, LIUS has less clear benefits as a monotherapy with an uncertain, optimal delivery method established. Both laser therapy and low-intensity ultrasound have proven beneficial in managing various pain syndromes and can be effective interventions, in particular, when utilized in combination therapy.

Effect of a Structured Stretching Exercise Program on Resolution of Myofascial Pain and Opioid Usage in "Legacy Pain" Patients: A Retrospective Cohort Study

OBJECTIVE

To determine if the implementation of a structured exercise stretching routine targeted at resolving myofascial pain is effective in improving outcomes of "legacy pain" patients.

DESIGN

Retrospective cohort study.

SETTING

Private community based interventional pain management practice.

SUBJECTS

"Legacy pain" patients, defined as patients on opioid therapy for greater than one year.

METHODS

Subjects were initiated on a structured home exercise stretching routine targeted at resolving myofascial pain consisting of 14 lumbar, 4 thoracic and 7 cervical stretches as appropriate. Daily morphine milligram equivalent, functional status (Oswestry Disability Index) and pain level (Numeric Rating Scale) were compared pre and post treatment at one year.

RESULTS

After one year, exercise techniques reduced daily morphine milligram equivalent intake on average from 76.3 mg to 21.0 mg (p < 0.001) with 84.4% of patients decreasing their total opioid dose (p < 0.001) and 34.4% of patients being completely weaned off of opioids (p < 0.001). Numeric Rating Scale of pain and Oswestry Disability Indices were unchanged with treatment, 7.0 to 6.7 (p = 0.122) and 30.4 to 29.3 (p = 0.181), respectively.

CONCLUSIONS

The addition of a structured stretching exercise program focusing on the resolution of the myofascial pain in the treatment of "legacy pain" patients was shown to significantly reduce and often discontinue opioid use without adversely affecting pain score or functionality.

Opioid-Free Recovery After Hernia Repair with HTX-011 as the Foundation of a Non-Opioid, Multimodal Analgesia Regimen in a Real-World Setting: A Randomized, Open-Label Study

INTRODUCTION

Helping Opioid Prescription Elimination (HOPE) is a project designed to provide surgeons with practical, real-world solutions to effectively manage postoperative pain and eliminate the need for opioids using HTX-011 (extended-release bupivacaine/low-dose meloxicam). In phase 3 herniorrhaphy and bunionectomy studies, HTX-011 without multimodal analgesia (MMA) was superior to bupivacaine hydrochloride in reducing pain and opioid consumption. Here, we examine the HOPE Hernia-1 study, which was designed to compare alternating ibuprofen/acetaminophen with concurrent use as part of an HTX-011-based non-opioid MMA regimen in patients undergoing herniorrhaphy and to evaluate the effectiveness of a personalized opioid prescription algorithm.

METHODS

Patients undergoing outpatient open inguinal herniorrhaphy with intraoperative administration of HTX-011 (300 mg bupivacaine/9 mg meloxicam) were randomly assigned to receive a scheduled oral regimen of ibuprofen plus acetaminophen, either taken together every 6 hours or alternating every 3 hours, for 5 days following surgery, while awake. Based on the opioid prescription algorithm evaluated here, patients could receive an oxycodone prescription upon discharge only if they had a numeric rating scale pain score of ≥ 6 at discharge and/or had received a postoperative rescue opioid.

RESULTS

The majority of patients did not require an opioid prescription through 2 weeks following surgery, and this was similar between cohorts (alternating MMA, 89.1%; concurrent MMA, 93.6%). Patient satisfaction was high for both regimens, and 95% of patients had an opioid-free recovery. No patient discharged without a prescription called back to request one. Treatment was well tolerated, without evidence of nonsteroidal anti-inflammatory drug-related toxicity.

CONCLUSIONS

HTX-011, used with over-the-counter products ibuprofen/acetaminophen and personalized opioid prescription algorithm in a real-world environment, has the potential to reduce opioid use and opioid prescriptions after herniorrhaphy without compromising patient satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03237481.

Attrition of methylnaltrexone treatment-emergent adverse events in patients with chronic noncancer pain and opioid-induced constipation: a post hoc pooled analysis of two clinical trials

Background: Opioids prescribed for the management of chronic noncancer pain are associated with nausea, vomiting, and constipation. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, has demonstrated robust efficacy and was well-tolerated in treating opioid-induced constipation without affecting central analgesia. Our objective was to assess changes in the frequency of adverse events after the first or second dose of methylnaltrexone or placebo.

Methods: This post hoc analysis pooled data from two randomized, placebo-controlled clinical trials assessing methylnaltrexone for opioid-induced constipation in the outpatient setting. Patients received subcutaneous methylnaltrexone (12 mg once daily or 12 mg once every other day), oral methylnaltrexone (150, 300, or 450 mg daily), or placebo. Adverse events, opioid withdrawal symptoms, pain intensity, and rescue-free bowel movements (RFBMs) within 4 hours of the first dose (i.e., RFBM responders) were assessed. Associations between adverse event frequencies and RFBM response were also evaluated.

Results: The analysis included 1263 adult patients with chronic noncancer pain. Treatment-emergent adverse event rates declined from treatment day 1 to 2 (methylnaltrexone: 16.2%–5.3%; placebo: 6.6%−5.4%). Among methylnaltrexone-treated patients, significantly greater proportions of RFBM responders versus nonresponders reported gastrointestinal adverse events on day 1. No associations between RFBM response and the frequency of adverse events were observed in the placebo group. No meaningful changes in opioid withdrawal symptoms or pain intensity were observed.

Conclusions: Early-onset adverse events following methylnaltrexone treatment, particularly gastrointestinal adverse events, are at least partially due to laxation. Methylnaltrexone treatment effectively relieves opioid-induced constipation without affecting the central analgesic effects of opioids.

Attrition of methylnaltrexone treatment-emergent adverse events in patients with chronic noncancer pain and opioid-induced constipation: a post hoc pooled analysis of two clinical trials

Background: Opioids prescribed for the management of chronic noncancer pain are associated with nausea, vomiting, and constipation. Methylnaltrexone, a peripherally acting µ-opioid receptor antagonist, has demonstrated robust efficacy and was well-tolerated in treating opioid-induced constipation without affecting central analgesia. Our objective was to assess changes in the frequency of treatment-emergent adverse events (TEAEs) after the first or second dose of methylnaltrexone or placebo. Methods: This post hoc analysis pooled data from two randomized, placebo-controlled clinical trials assessing methylnaltrexone for opioid-induced constipation in the outpatient setting. Patients received subcutaneous methylnaltrexone (12 mg once daily or 12 mg once every other day), oral methylnaltrexone (150, 300, or 450 mg daily), or placebo. TEAEs, opioid withdrawal symptoms, pain intensity, and rescue-free bowel movements (RFBMs) within 4 hours of the first dose (i.e., RFBM responders) were assessed. Associations between TEAE frequencies and RFBM response were also evaluated. Results: The analysis included 1263 adult patients with chronic noncancer pain. TEAE rates declined from treatment day 1 to 2 (methylnaltrexone: 16.2%-5.3%; placebo: 6.6%-5.4%). Among methylnaltrexone-treated patients, significantly greater proportions of RFBM responders versus nonresponders reported gastrointestinal TEAEs on day 1. No associations between RFBM response and the frequency of TEAEs were observed in the placebo group. No meaningful changes in opioid withdrawal symptoms or pain intensity were observed. Conclusions: Early-onset TEAEs following methylnaltrexone treatment, particularly gastrointestinal TEAEs, are at least partially due to laxation. Methylnaltrexone treatment effectively relieves opioid-induced constipation without affecting the central analgesic effects of opioids.

A systematic review of full endoscopic versus micro-endoscopic or open discectomy for lumbar disc herniation

Aim: Endoscopic discectomies provide several advantages over other techniques such as traditional open lumbar discectomy (OLD) including possibly decreased complications, shorter hospital stay and an earlier return to work. Methods: An electronic database search including MEDLINE/PubMed, EMBASE, Scopus, Cochrane Database of Systematic Reviews and Cochrane Controlled trials (CENTRAL) were reviewed for randomized controlled trials (RCTs) only. Results: A total of nine RCTs met inclusion criteria. Three showed benefit of endoscopic discectomy over the comparator with regards to pain relief, with the remaining six studies showing no difference in pain relief or function. Conclusion: Based on review of the nine included studies, we can conclude that endoscopic discectomy is as effective as other surgical techniques, and has additional benefits of lower complication rate and superior perioperative parameters.

AB0544 EFFICACY AND SAFETY OF TILDRAKIZUMAB IN PATIENTS WITH AND WITHOUT METABOLIC SYNDROME: 5-YEAR POOLED DATA FROM reSURFACE 1 AND reSURFACE 2

Background:

Patients with psoriasis and metabolic syndrome (MetS) may have reduced absolute Psoriasis Area and Severity Index (PASI) response and long-term drug survival. Tildrakizumab is approved for the treatment of moderate to severe plaque psoriasis in the US, EU, Australia, and Japan. Efficacy and safety of tildrakizumab were previously shown to be comparable in patients with vs without MetS after 1 and 3 years of treatment.1

Objectives:

This post hoc analysis of pooled data from reSURFACE 1 and reSURFACE 2 (NCT01722331/NCT01729754) assessed tildrakizumab efficacy and safety through up to 5 years of treatment in patients with psoriasis with and without MetS.

Methods:

reSURFACE 1 and 2 were 3-part, double-blind, randomized controlled phase 3 trials with long-term extensions evaluating tildrakizumab 100 or 200 mg monotherapy at Weeks 0, 4, and every 12 weeks thereafter in adults with moderate to severe plaque psoriasis.2 Patients who achieved ≥50% improvement from baseline PASI score (PASI 50 response) at both week 28 and at the end of the phase 3 studies could enter the long-term extension studies continuing the same dose of tildrakizumab.1 This post hoc analysis reports results from a pooled data analysis through up to 5 years of tildrakizumab exposure from patients with and without MetS by National Cholesterol Education Program-Adult Treatment Panel III criteria who continuously received the same dose of tildrakizumab throughout the base studies and entered the long-term extensions. Efficacy was assessed as change from baseline PASI score; missing data were handled using multiple imputation. Safety was assessed from exposure adjusted incidence rates of serious adverse events (SAEs) and treatment-emergent AEs of special interest.

Results:

Analyses included 70/265 patients with/without MetS receiving tildrakizumab 100 mg and 64/241 patients with/without MetS receiving tildrakizumab 200 mg. Median percentage change from baseline PASI score is shown in Figure 1. Among patients with/without MetS receiving tildrakizumab 100 mg, 78.6%/87.9% achieved PASI 75, 57.1%/63.8% achieved PASI 90, and 25.7%/32.5% achieved PASI 100 response at week 244; the PASI 75, PASI 90, and PASI 100 response rates at week 244 in patients with/without MetS receiving tildrakizumab 200 mg were 76.6%/85.1%, 46.9%/61.4%, and 26.6%/36.5%, respectively. Safety outcomes over the 5-year extension period were consistent with the known safety profile of tildrakizumab. Rates of SAEs were <8.5 per 100 patient-years among all patients, and there were no new safety signals in patients with vs without MetS (Table 1).

Table 1.

SAEs and TEAEs of special interest by MetS status through up to 5 years of tildrakizumab exposure

TIL 100 mgTIL 200 mgWithout MetSWithMetSWithout MetSWithMetSn = 265n = 70n = 241n = 64n (EAIR per 100 PY)1149.1 PY304.1 PY1057.1 PY287.6 PYSAEs53 (4.61)22 (7.23)52 (4.92)24 (8.35)TEAEs of special interest24 (2.09)6 (1.97)27 (2.55)15 (5.22)Infections and infestations10 (0.87)2 (0.66)13 (1.23)6 (2.09)Malignanciesa5 (0.44)1 (0.33)4 (0.38)3 (1.04)Nonmelanoma skin cancer3 (0.26)1 (0.33)6 (0.57)1 (0.35)Confirmed extended MACE3 (0.26)1 (0.33)3 (0.28)3 (1.04)Drug hypersensitivity2 (0.17)1 (0.33)1 (0.09)2 (0.70)Melanoma skin cancer2 (0.17)000Injection site reactionsb1 (0.09)000

Incidence rates reported as events per 100 PY.

aExcluding nonmelanoma and melanoma skin cancer.

bNot considered of special interest in the extension study.

AE, adverse event; EAIR, exposure adjusted incidence rate; MACE, major adverse cardiovascular events; MetS, metabolic syndrome; PY, patient-years; SAE, serious AE; TEAE, treatment-emergent AE; TIL, tildrakizumab.

Conclusion:

The efficacy and safety of tildrakizumab were maintained in patients with and without MetS following 5 years of treatment.

References:

[1]Lebwohl, M et al. JAAD. 2020;S0190-9622(20)32637-2.

[2]Reich K, et al. Lancet. 2017;390:276–88.

Disclosure of Interests:

Alice B Gottlieb Shareholder of: Xbiotech (only stock options, which she has not used)., Consultant of: Anaptyps Bio, Avotres Therapeutics; Beiersdorf; Boehringer Ingelheim; Bristol-Myers Squibb Co.; Eli Lilly; Janssen; LEO Pharma; Novartis; Sun Pharmaceutical Industries, Inc.; UCB; and Xbiotech, Grant/research support from: Boehringer Ingelheim; Janssen; Novartis; Sun Pharmaceutical Industries, Inc.; UCB; and Xbiotech., Nehal Mehta Grant/research support from: Grants to the NIH from AbbVie, Celgene, Janssen, and Novartis., Employee of: Full-time employee of the US government., Alan Menter Speakers bureau: AbbVie, Abbott Labs, Amgen, Anacor, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen Biotech, LEO Pharma, Merck & Co., Novartis, Sienna, and UCB., Consultant of: AbbVie, Abbott Labs, Amgen, Anacor, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen Biotech, LEO Pharma, Merck & Co., Novartis, Sienna, and UCB., Grant/research support from: AbbVie, Abbott Labs, Amgen, Anacor, Boehringer Ingelheim, Celgene, Eli Lilly, Janssen Biotech, LEO Pharma, Merck & Co., Novartis, Sienna, and UCB., Alan M Mendelsohn Shareholder of: Has individual shares in Johnson and Johnson, and as part of retirement account/mutual funds, Employee of: Sun Pharmaceutical Industries, Inc., Stephen Rozzo Employee of: Sun Pharmaceutical Industries, Inc., Mark Lebwohl Consultant of: Aditum Bio; Allergan; Almirall; Arcutis; Avotres Therapeutics; BirchBioMed, Inc.; BMD Skincare; Boehringer Ingelheim; Bristol-Myers Squibb; Cara Therapeutics; Castle Biosciences; Corrona; Dermavant Sciences; Evelo; Facilitate International Dermatologic Education; Foundation for Research and Education in Dermatology; Inozyme Pharma; Kyowa Kirin; LEO Pharma; Meiji Seika Pharma; Menlo; Mitsubishi; Neuroderm; Pfizer; Promius/Dr. Reddy’s Laboratories; Serono; Theravance; and Verrica., Grant/research support from: AbbVie; Amgen; Arcutis; Boehringer Ingelheim; Dermavant; Eli Lilly; Incyte; Janssen Research & Development, LLC; LEO Pharma; Ortho Dermatologics; Pfizer; and UCB.

POS1063 RHEUMATOLOGIST AND PATIENT PERSPECTIVES ON IMPLEMENTING CARDIOVASCULAR RISK PREVENTION IN THE MANAGEMENT OF PSORIASIS: A QUALITATIVE STUDY

Background:

Psoriatic arthritis (PsA) is an immune-mediated musculoskeletal disease associated with excess risk for cardiovascular disease (CVD). New US-based guidelines recognize psoriasis as a CVD risk enhancer; however, patients with PsA often do not have CVD risk factors identified nor managed.

Objectives:

This study examines strategies to improve CVD prevention care from the perspective of rheumatologists and patients with PsA.

Methods:

Semi-structured qualitative interviews were conducted using an interview guide based on the Consolidated Framework for Implementation Research to examine the perspectives of rheumatologists (N = 8) and patients with psoriatic arthritis managed by rheumatologists (N = 8) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity facilitated by NVivo software.

Results:

Most rheumatologists confirmed that they were not regularly engaging in CVD prevention care with psoriatic arthritis patients. Providers reported sometimes counseling and screening for CVD risk, but they were not regularly prescribing statins and not as willing to do so. Reasons included a lack of familiarity or comfort with guidelines, concern about working outside of their scope of practice, confusing boundaries between other clinicians, and time constraints. Most patients confirmed that it was uncommon for their rheumatologists to engage them in CVD prevention care but expressed desire for their rheumatologists inform them of the risk, and were open to CVD prevention care from them.

Conclusion:

We identified several potentially modifiable barriers to CVD screening and management. These findings will inform the design of a clinical trial comparing the effectiveness of rheumatologist implementation of CVD guideline-based counseling, screening and prescribing statins when appropriate in patients with PsA.

Figure 1.

Barriers to CVD screening and management among patients with PsA in a rheumatology practice setting and potential strategies to address those barriers. Abbreviations: CV = cardiovascular; SOC = standard of care.

Disclosure of Interests:

Alexis Ogdie Consultant of: Abbvie, Amgen, BMS, Celgene, Corrona, Gilead, Janssen, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Pfizer to Penn, Novartis to Penn, Amgen to Forward/NDB, Alix Gustafson: None declared, Adina Lieberman: None declared, Jennifer Mason: None declared, April Armstrong: None declared, Nehal Mehta Consultant of: Amgen, Eli Lilly, and Leo Pharma receiving grants/other payments, Grant/research support from: AbbVie, Celgene, Janssen Pharmaceuticals, Inc, and Novartis receiving grants and/or research funding and as a principal investigator for the National Institute of Health receiving grants and/or research funding., Employee of: NNM is a full-time US government employee, Rinad Beidas Consultant of: Camden Coalition of Healthcare Providers in the past 3 years. She currently is a consultant for United Behavioral Health. She serves on the Optum Behavioral Health Clinical and Scientific Advisory Council. Dr. Beidas receives royalties from Oxford University Press., Joel Gelfand Shareholder of: Dr Gelfand is a co-patent holder of resiquimod for treatment of cutaneous T-cell lymphoma, and he is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology., Paid instructor for: CME work related to psoriasis that was supported indirectly by Eli Lilly and Company and Ortho Dermatologics, Consultant of: Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline, Janssen Biologics, Novartis Corp, UCB (Data Safety and Monitoring Board), Sanofi, and Pfizer Inc, Grant/research support from: research grants (to the Trustees of the University of Pennsylvania) from AbbVie, Janssen, Novartis Corp, Celgene, OrthoDermatologics, and Pfizer Inc.

Inelastic Scattering of a Photon by a Quantum Phase Slip

Spontaneous decay of a single photon is a notoriously inefficient process in nature irrespective of the frequency range. We report that a quantum phase-slip fluctuation in high-impedance superconducting waveguides can split a single incident microwave photon into a large number of lower-energy photons with a near unit probability. The underlying inelastic photon-photon interaction has no analogs in nonlinear optics. Instead, the measured decay rates are explained without adjustable parameters in the framework of a new model of a quantum impurity in a Luttinger liquid. Our result connects circuit quantum electrodynamics to critical phenomena in two-dimensional boundary quantum field theories, important in the physics of strongly correlated systems. The photon lifetime data represent a rare example of verified and useful quantum many-body simulation.

Recurrent giant retroperitoneal liposarcoma: Review of literature and a rare case report

Introduction and importance

Retroperitoneal liposarcomas (RPLS) are usually grow large with frequent recurrences. Complete surgical excision remains the gold standard treatment for primary and even recurrent tumours. Their prognosis depends on their histological type and grade. We report a recurrent giant de-differentiated RPLS weighing 18.55 kg which was completely excised. To the best of our knowledge, this is one of the largest liposarcoma reported in the literature.

Case presentation

A 40 year old female presented with a gradually progressing large abdominal lump for 1year. She had had a similar large lump twice in the past and undergone excision of the tumour elsewhere. Firm non-tender mass felt all over abdomen with edema noted over abdominal wall and bilateral lower limbs. PET CT showed large heterogeneously enhancing mass occupying almost the entire abdominopelvic cavity. 50 × 40 × 40cm tumour was completely excised and biopsy showed grade 2 dedifferentiated liposarcoma (DDLS). She is under close follow up with no recurrence at 12months.

Clinical discussion

DDLS have lower risk of distant metastases but have a high risk of local recurrence. The most important favourable prognostic factor in these tumours is complete resection with negative margins. Because of the ineffectiveness of current chemotherapy and the requirement of intolerably high radiation doses, surgical excision remains the most effective treatment even for the localized recurrences of RPLS.

Conclusion

The dedifferentiated subtype should be suspected in locally aggressive RPLS. Close follow up with early detection of recurrences and prompt excision with negative margins lowers the risk of recurrences and improves survival.

miR299a-5p promotes renal fibrosis by suppressing the antifibrotic actions of follistatin

Caveolin-1 (cav-1), an integral protein of the membrane microdomains caveolae, is required for synthesis of matrix proteins by glomerular mesangial cells (MC). Previously, we demonstrated that the antifibrotic protein follistatin (FST) is transcriptionally upregulated in cav-1 knockout MC and that its administration is protective against renal fibrosis. Here, we screened cav-1 wild-type and knockout MC for FST-targeting microRNAs in order to identity novel antifibrotic therapeutic targets. We identified that miR299a-5p was significantly suppressed in cav-1 knockout MC, and this was associated with stabilization of the FST 3'UTR. Overexpression and inhibition studies confirmed the role of miR299a-5p in regulating FST expression. Furthermore, the profibrotic cytokine TGFβ1 was found to stimulate the expression of miR299a-5p and, in turn, downregulate FST. Through inhibition of FST, miR299a-5p overexpression augmented, while miR299a-5p inhibition diminished TGFβ1 profibrotic responses, whereas miR299a-5p overexpression re-enabled cav-1 knockout MC to respond to TGFβ1. In vivo, miR299a-5p was upregulated in the kidneys of mice with chronic kidney disease (CKD). miR299a-5p inhibition protected these mice against renal fibrosis and CKD severity. Our data demonstrate that miR299a-5p is an important post-transcriptional regulator of FST, with its upregulation an important pathogenic contributor to renal fibrosis. Thus, miR299a-5p inhibition offers a potential novel therapeutic approach for CKD.

Shorter drug testing intervals are associated with improved drug misuse rates

OBJECTIVE

The Centers for Disease Control and Prevention (CDC) recommend that clinicians prescribing opioids for chronic pain should consider at least annual urine drug testing (UDT). We evaluated whether shorter intervals for repeat UDT are associated with decreased rates of drug misuse.

DESIGN

Retrospective analysis of deidentified serial UDT and matched prescribing data.

SETTING

We analyzed Quest Diagnostics 2016-2017 UDT results from new patients being monitored for prescription drug adherence, in nonsubstance use disorder (SUD) treatment environments.

MAIN OUTCOME MEASURES

Drug misuse was defined as the absence of a prescribed substance or the presence of a nonprescribed substance. Patients with ≥3 sets of the UDT results were included.

RESULTS

UDT results from 49,601 patients (148,803 specimens) were tested. Declines in misuse between the first and second UDT were highest for those tested at the shortest intervals: approximately weekly, 19 percent; monthly, 15 percent; bimonthly, 12 percent; quarterly, 9 percent; semiannually, 3 percent; misuse rates increased by 1 percent for patients tested annually. Declines in misuse were more pronounced for opioids than other drug groups. Substantial declines in positivity were noted for heroin (32 percent) and nonprescribed fentanyl (10 percent). Declines in misuse between the second and third UDT followed a similar pattern.

CONCLUSIONS

UDT intervals of ≤ quarterly were associated with marked declines, but testing annually or semiannually was not associated with consistent decreases. Our findings suggest that clinical strategies that include serial testing conducted quarterly or sooner may be instrumental in decreasing drug misuse. Testing more frequently than "at least once annually" should be considered by clinicians monitoring potential drug misuse.

Failure of SCS MR-Conditional Modes Due to High Impedance: A Review of Literature and Case Series

Introduction

Magnetic resonance imaging (MRI) conditional modes are a novel feature for certain Food and Drug Administration (FDA)-approved spinal cord stimulation (SCS) devices. However, there is a paucity of literature around the limitation of MRI-conditional modes (“MRI safe”), specifically in clinical scenarios where urgent MRIs may be needed. One such limitation is load impedance, referring to the circuit’s resistance to the current being generated by the system. High impedance can limit the MRI-conditional mode capability, presenting potential harm to a patient undergoing an MRI or make an MRI unable to be completed.

Methods

Three cases were identified, and informed consent was obtained. All information was obtained via retrospective chart review.

Results

In this case series of three patients where MRI-conditional SCS systems were unable to be placed in “MRI safe” settings, preventing timely MRI study completion in the setting of high impedance, all three were required to undergo alternative imaging including CT scans, and two patients ultimately had the system explanted and one chose to be re-implanted after completion of scans.

Conclusion

This case series highlights the need for further investigation of impedance in SCS systems and potential limitations for future MRI usage. The review of literature of impedance in SCS shows both device- and physiologic-related etiologies for changes in impedance that warrant consideration by the implanting physician.

Cardiovascular severe maternal morbidity in pregnant and postpartum women: development and internal validation of risk prediction models

OBJECTIVES

To develop and internally validate risk prediction models identifying women at risk for cardiovascular severe maternal morbidity (CSMM).

DESIGN

A retrospective cohort study.

SETTING

An obstetric teaching hospital between 2007 and 2017.

POPULATION

A total of 89 681 delivery hospitalisations.

METHODS

We created and evaluated two models, one predicting CSMM at delivery (delivery model) and the other predicting CSMM postpartum following discharge from delivery hospitalisation (postpartum CSMM). We assessed model discrimination and calibration and used bootstrapping for internal validation.

MAIN OUTCOME MEASURES

Cardiovascular severe maternal morbidity comprised the following confirmed conditions: pulmonary oedema/acute heart failure, myocardial infarction, aneurysm, cardiac arrest/ventricular fibrillation, heart failure/arrest during surgery or procedure, cerebrovascular disorders, cardiogenic shock, conversion of cardiac rhythm and difficult-to-control severe hypertension.

RESULTS

The delivery model contained 11 variables and 3 interaction terms. The strongest predictors were gestational hypertension, chronic hypertension, multiple gestation, cardiac lesions or valvular heart disease, maternal age ≥40 years and history of poor pregnancy outcome. The postpartum model comprised eight variables. The strongest predictors were severe pre-eclampsia, non-Hispanic Black race/ethnicity, chronic hypertension, gestational hypertension, non-severe pre-eclampsia and maternal age ≥40 years at delivery. The delivery and postpartum models had an area under the receiver operating characteristic curve of 0.87 (95% CI 0.85-0.89) and 0.85 (95% CI 0.80-0.90), respectively. Both models were adequately calibrated and performed well on internal validation.

CONCLUSIONS

These tools may help providers to identify women at highest risk of CSMM and enable future prevention measures.

TWEETABLE ABSTRACT

Risk assessment tools for cardiovascular severe maternal morbidity were developed and internally validated.

Neuromodulation and the Epidemiology of Magnetic Resonance Utilization for Lung, Breast, Colon, and Prostate Cancer

BACKGROUND

Neuromodulation is a growing therapeutic modality for the treatment of chronic pain. Determining whether a patient is an appropriate candidate for implantation of a neuromodulatory device and whether the device requires an MRI conditional feature necessitates understanding the patient's likelihood of requiring an MRI. Active treatment of cancer represents known high-risk clinical scenarios for MRI. However, the growth of MRI as a tool for diagnosis of cancer also warrants consideration by implanting physicians when assessing high-risk patients.

MATERIALS AND METHODS

Here, we conduct a systematic review of the literature to determine the epidemiology for MR utilization for breast, lung, prostate, and colon cancer. Out of 126 papers reviewed, 39 were ultimately analyzed to determine the relative likelihood of an MRI in the course of oncologic care.

RESULTS

We find that there is a low likelihood for MRI to be utilized as part of any screening process and a variable likelihood during the staging and surveillance phases across all cancer subtypes depending on the clinical circumstances. Certain populations present special consideration for MRI screening, such as the high at-risk breast cancer population, and MRI surveillance and staging, such as aging males (>50 years old) at risk for prostate cancer or individuals diagnosed with rectal cancers.

CONCLUSION

High likelihood of MRI within the oncologic context represents important distinction criteria for neuromodulation as patients may benefit from implantation of an MR conditional system.

THU0582 EFFECTIVE MANAGEMENT OF REFRACTORY GOUT: EFFECT OF ONLINE CONTINUING EDUCATION ON RHEUMATOLOGISTS’ KNOWLEDGE

Background:

Gout is a chronic condition with a considerable effect on patient health and quality of life. Despite the availability of multiple pharmacologic treatments and evidence-based management guidelines, treatment targets are often not achieved in patients with gout. Identification and optimal management of patients with severe or refractory gout is specially challenging.

Objectives:

The objective of this study was to determine if an online, continuing education activity could improve knowledge of rheumatologists regarding strategies to ensure effective and safe use of urate-lowering therapies in the management of patients with refractory gout.

Methods:

Educational design included an online, 30-minute, video-based discussion among two faculty experts with synchronized slides. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design using 3 knowledge questions and 1 confidence question, in which each individual served as his/her own control. A chi-squared test assessed differences from pre- to post-assessment. P values <.05 are statistically significant. Cramer’s V was used to calculate the effect size (<0.06 modest effect; 0.06-0.15 noticeable effect; 0.16-0.26 considerable effect; >0.26 extensive effect). The activity launched May 1, 2019, with data collected through December 30, 2019.

Results:

The analysis set consisted of responses from rheumatologists (n=300) who answered all assessment questions during the study period. Analysis of pre- vs post-intervention responses demonstrated a significant improvement in overall knowledge of rheumatologists with considerable educational impact (V = .201, P<.001). Average correct responses increased from 54% pre to 74% post education. Specific areas of improvement in knowledge include:

•Optimal strategies for reducing the risk for immunogenicity associated with the use of pegloticase in patients with refractory gout (40% pre, 73% post; P<.001; V = .326)

•Serum uric acid targets to optimize management of the patient with severe or refractory gout (45% pre, 57% post; P<.05; V = .120)

•Selection of pegloticase for rapid decreases in tophi and serum uric acid in patients with refractory gout (77% pre, 91% post; P<.001; V = .187)

Post-education, 32% of rheumatologists were more confident in their ability to manage patients with refractory gout.

Conclusion:

This study demonstrated the success of online, 30-minute, video-based discussion among two faculty experts with synchronized slides on improving the knowledge of rheumatologists regarding appropriate management of patients with refractory gout.

Disclosure of Interests:

None declared

Using Evidence-Based Dentistry in the Clinical Management of Methadone Maintenance Therapy Patients

AIMS AND OBJECTIVES

There is an increased interest to incorporate interprofessional educational models in the academic dental institutions to serve both student education and patient care. The aim of this report is to integrate evidence-based dentistry (EBD) with an interprofessional approach to treat methadone maintenance therapy (MMT) patients. Current example illustrates the case of a 26-year-old man receiving MMT who presented at Tufts University School of Dental Medicine with the chief complaint of "I want to fix my teeth." He presented with a collapsed vertical dimension of occlusion, extensive partial edentulism on both arches with bone loss, and a past history of drug abuse since the age of 16 years.

MATERIALS AND METHODS

The 5-step (ask, acquire, appraise, apply, assess) framework for the EBD process was used. First, the PICO (population, intervention, comparison, and outcome) question was asked, and then the literature was acquired and appraised. An expert librarian assisted in finding articles on the effects of methadone on the oral cavity and consequences that will affect dental treatment. The search was conducted on PubMed, using the following keywords: oral health, dentistry, dental health, and methadone. The search was performed from 1/1/2005 to 1/1/2018. After appraisal, the studies were applied in the clinical setting and treatment outcomes were assessed both subjectively and objectively.

RESULTS

The initial search identified there is sparse evidence on the topic. Only 34 articles were acquired. Based on the scientific evidence published, the interprofessional expertise of the clinical care team, and patient's perspective, 4 treatment plan options were proposed. The selected treatment plan was considered the best option considering an EBD person-centered approach. Progress of treatment, outcomes, and lessons learned were assessed.

CONCLUSIONS

This study demonstrates that incorporating EBD concepts and an interprofessional approach, MMT patients can be successfully treated. Future studies on this topic are recommended, specially considering the growth of the opioid epidemic in the past years and the need to treat the MMT patients and educate students.

Liver transplantation outcomes after transarterial chemotherapy for hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) awaiting liver transplantation is widespread, although evidence that it improves outcomes is lacking and there exist concerns about morbidity. The impact of TACE on outcomes after transplantation was evaluated in this study.

Methods

Patients with HCC who had liver transplantation in the UK were identified, and stratified according to whether they received TACE between 2006 and 2016. Cox regression methods were used to estimate hazard ratios (HRs) for death and graft failure after transplantation adjusted for donor and recipient characteristics.

Results

In total, 385 of 968 patients (39·8 per cent) received TACE. Five-year patient survival after transplantation was similar in those who had or had not received TACE: 75·2 (95 per cent c.i. 68·8 to 80·5) and 75·0 (70·5 to 78·8) per cent respectively. After adjustment for donor and recipient characteristics, there were no differences in mortality (HR 0·96, 95 per cent c.i. 0·67 to 1·38; P = 0·821) or graft failure (HR 1·01, 0·73 to 1·40; P = 0·964). The number of TACE treatments (2 or more versus 1: HR 0·97, 0·61 to 1·55; P = 0·903) or the time of death after transplantation (within or after 90 days; P = 0·291) did not alter the outcome. The incidence of hepatic artery thrombosis was low in those who had or had not received TACE (1·3 and 2·4 per cent respectively; P = 0·235).

Conclusion

TACE delivered to patients with HCC before liver transplant did not affect complications, patient death or graft failure after transplantation.