The Impact of Posterior Intervertebral Osteophytes on Patient-Reported Outcome Measures After L5-S1 Anterior Lumbar Interbody Fusion and Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

(1) To develop a reliable grading system to assess the severity of posterior intervertebral osteophytes and (2) to investigate the impact of posterior intervertebral osteophytes on clinical outcomes after L5-S1 decompression and fusion through anterior lumbar interbody fusion (ALIF) and minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF).

BACKGROUND

There is limited evidence regarding the clinical implications of posterior lumbar vertebral body osteophytes for ALIF and MIS-TLIF surgeries and there are no established grading systems that define the severity of these posterior lumbar intervertebral osteophytes.

PATIENTS AND METHODS

A retrospective analysis of patients undergoing L5-S1 ALIF or MIS-TLIF was performed. Preoperative and postoperative patient-reported outcome measures of the Oswestry Disability Index (ODI) and leg Visual Analog Scale (VAS) at 2-week, 6-week, 12-week, and 6-month follow-up time points were assessed. Minimal clinically important difference (MCID) for ODI of 14.9 and VAS leg of 2.8 were utilized. Osteophyte grade was based on the ratio of osteophyte length to foraminal width. "High-grade" osteophytes were defined as a maximal osteophyte length >50% of the total foraminal width.

RESULTS

A total of 70 consecutive patients (32 ALIF and 38 MIS-TLIF) were included in the study. There were no significant differences between the two cohorts in patient-reported outcome measures or achievement of MCID for Leg VAS or ODI preoperatively or at any follow-ups. On multivariate analysis, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with leg VAS or ODI scores at any follow-up time point. In addition, neither the surgical approach nor the presence of high-grade foraminal osteophytes was associated with the achievement of MCID for leg VAS or ODI at 6 months.

CONCLUSION

ALIF and MIS-TLIF are both valid options for treating degenerative spine conditions and lumbar radiculopathy, even in the presence of high-grade osteophytes that significantly occupy the intervertebral foramen.

LEVEL OF EVIDENCE

3.

Psoas Muscle Health is Correlated with Time to Achieve MCID in Patients with Predominant Axial Back Pain Following Decompression Surgery: Early Results

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the impact of psoas muscle health (cross-sectional area, CSA) on achieving minimal clinically important differences (MCID) in patient-reported outcome measures (PROMs) following laminectomy for patients with predominant back pain (PBP) and leg pain (PLP).

SUMMARY OF BACKGROUND DATA

Psoas muscle health is linked to postoperative outcomes in decompression patients, with MRI-based grading of psoas CSA correlating with these outcomes. However, evidence on its impact on symptomatic recovery, measured by PROMs, is lacking.

METHODS

106 patients with PBP (VAS back >VAS leg) and 139 patients with PLP (VAS leg >VAS back) who underwent laminectomy from 2017-2021 were included. Axial T2 MRI images were analyzed for psoas CSA using a validated method. Based on the lowest-quartile normalized total psoas area (NTPA) thresholds, patients were divided into "Good" and "Poor" muscle health groups. The correlation analyses were performed between the psoas CSA and changes in PROMs. Kaplan-Meier survival analysis was conducted to determine the probability of achieving MCID as a function of time.

RESULTS

Of 106 PBP patients, 83 (78.3%) had good muscle health, 23 (21.6%) had poor muscle health. Of 139 PLP patients, 54 (38.8%) had good muscle health, 85 (61.1%) had poor muscle health. In the PBP group, older age was associated with poor muscle health (69.70±9.26 vs. 59.92±15.01, P=0.0002). For both cohorts, there were no differences in the rate of MCID achievement for any PROMs between the good and poor muscle health groups. In the PBP group, Kaplan-Meier analysis showed patients with good psoas health achieved MCID-VAS back and Oswestry Disability Index (ODI) in median times of 14 and 42 days (P=0.045 and 0.015), respectively.

CONCLUSION

Good psoas muscle health is linked to faster attainment of MCID, especially in patients with PBP compared to PLP after decompression surgery.

LEVEL OF EVIDENCE

3.

Clinical and Radiological Predictors of Slower and Non-Improvement Following Surgical Treatment of L4-5 Degenerative Spondylolisthesis: Preliminary Results

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To identify the predictors of slower and non-improvement following surgical treatment of L4-5 degenerative lumbar spondylolisthesis (DLS).

SUMMARY OF BACKGROUND DATA

There is limited evidence regarding clinical and radiological predictors of slower and non-improvement following surgery for L4-5 DLS.

METHODS

Patients who underwent minimally invasive decompression or fusion for L4-5 DLS and had a minimum of 1-year follow-up were included. Outcome measures were: (1) minimal clinically important difference (MCID), (2) patient acceptable symptom state (PASS), and (3) global rating change (GRC). Clinical variables analyzed for predictors were age, gender, body mass index (BMI), surgery type, comorbidities, anxiety, depression, smoking, osteoporosis, and preoperative patient reported outcome measures (PROMs) (Oswestry Disability Index, ODI; Visual Analog Scale, VAS back and leg; 12-Item Short Form Survey Physical Component Score, SF-12 PCS). Radiological variables analyzed were slip percentage, translational and angular motion, facet diastasis/cyst/orientation, laterolisthesis, disc height, scoliosis, main and fractional curve Cobb angles, and spinopelvic parameters.

RESULTS

233 patients (37% decompression, 63% fusion) were included. At <3 months, high pelvic tilt (PT) (OR 0.92, P 0.02) and depression (OR 0.28, P 0.02) were predictors of MCID non-achievement and GRC non-betterment, respectively. Neither retained significance at >6 months and hence, were identified as predictors of slower improvement. At >6 months, low preoperative VAS leg (OR 1.26, P 0.01) and high facet orientation (OR 0.95, P 0.03) were predictors of MCID non-achievement, high L4-5 slip percentage (OR 0.86, P 0.03) and L5-S1 angular motion (OR 0.78, P 0.01) were predictors of GRC non-betterment, and high preoperative ODI (OR 0.96, P 0.04) was a predictor of PASS non-achievement.

CONCLUSIONS

High PT and depression were predictors of slower improvement and low preoperative leg pain, high disability, high facet orientation, high slip percentage, and L5-S1 angular motion were predictors of non-improvement. However, these are preliminary findings and further studies with homogeneous cohorts are required to establish these findings.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To determine the impact of preoperative symptom duration on postoperative functional outcomes following cervical disc replacement (CDR) for radiculopathy.

SUMMARY OF BACKGROUND DATA

CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes following CDR is not well established.

METHODS

Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6 mo) and prolonged (≥6 mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included Neck Disability Index (NDI), Visual Analog Scale (VAS) Neck and Arm. Change in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3 mo) and late (6 mo-2 y) postoperative periods.

RESULTS

A total of 201 patients (43.6±8.7 y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared to the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P=0.001), VAS-Neck (87.0% vs. 56.0%, P<0.001), and VAS-Arm (90.5% vs. 70.7%, P=0.002). Prolonged preoperative symptom duration (≥6 mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P=0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P<0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P<0.001).

CONCLUSIONS

Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability.

LEVEL OF EVIDENCE

III.

Ninety Percent of Patients Are Satisfied With Their Decision to Undergo Spine Surgery for Degenerative Conditions

STUDY DESIGN

Cross-sectional survey and retrospective review of prospectively collected data.

OBJECTIVE

To explore how patients perceive their decision to pursue spine surgery for degenerative conditions and evaluate factors correlated with decisional regret.

SUMMARY OF BACKGROUND DATA

Prior research shows that one-in-five older adults regret their decision to undergo spinal deformity surgery. However, no studies have investigated decisional regret in patients with degenerative conditions.

METHODS

Patients who underwent cervical or lumbar spine surgery for degenerative conditions (decompression, fusion, or disk replacement) between April 2017 and December 2020 were included. The Ottawa Decisional Regret Questionnaire was implemented to assess prevalence of decisional regret. Questionnaire scores were used to categorize patients into low (<40) or medium/high (≥40) decisional regret cohorts. Patient-reported outcome measures (PROMs) included the Oswestry Disability Index, Patient-reported Outcomes Measurement Information System, Visual Analog Scale (VAS) Back/Leg/Arm, and Neck Disability Index at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) timepoints. Differences in demographics, operative variables, and PROMs between low and medium/high decisional regret groups were evaluated.

RESULTS

A total of 295 patients were included (mean follow-up: 18.2 mo). Overall, 92% of patients agreed that having surgery was the right decision, and 90% would make the same decision again. In contrast, 6% of patients regretted the decision to undergo surgery, and 7% noted that surgery caused them harm. In-hospital complications (P=0.02) and revision fusion (P=0.026) were significantly associated with higher regret. The medium/high decisional regret group also exhibited significantly worse PROMs at long-term follow-up for all metrics except VAS-Arm, and worse achievement of minimum clinically important difference for Oswestry Disability Index (P=0.007), Patient-Reported Outcomes Measurement Information System (P<0.0001), and VAS-Leg (P<0.0001).

CONCLUSIONS

Higher decisional regret was encountered in the setting of need for revision fusion, increased in-hospital complications, and worse PROMs. However, 90% of patients overall were satisfied with their decision to undergo spine surgery for degenerative conditions. Current tools for assessing patient improvement postoperatively may not adequately capture the psychosocial values and patient expectations implicated in decisional regret.

COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Limited Improvement with Minimally Invasive Lumbar Decompression Alone for Degenerative Scoliosis with Cobb Angle over 20 Degrees: The Impact of Decompression Location

STUDY DESIGN

Retrospective review of a prospectively collected multi-surgeon registry.

OBJECTIVE

To evaluate the outcomes of minimally invasive (MI) decompression in patients with severe degenerative scoliosis (DS) and identify factors associated with poorer outcomes.

SUMMARY OF BACKGROUND CONTEXT

MI decompression has gained widespread acceptance as a treatment option for patients with lumbar canal stenosis and DS. However, there is a lack of research regarding the clinical outcomes and the impact of MI decompression location in patients with severe DS exhibiting a Cobb angle exceeding 20 degrees.

MATERIALS AND METHODS

Patients who underwent MI decompression alone were included and categorized into the DS or control groups based on Cobb angle (>20 degrees). Decompression location was labeled as "scoliosis-related" when the decompression levels were across or between end vertebrae, and "outside" when the operative levels did not include the end vertebrae. The outcomes including Oswestry Disability Index (ODI) were compared between the propensity score-matched groups for improvement and minimal clinical importance difference (MCID) achievement at ≥1 year postoperatively. Multivariable regression analysis was conducted to identify factors contributing to the non-achievement of MCID in ODI of the DS group at the ≥1 year timepoint.

RESULTS

A total of 253 patients (41 DS) were included in the study. Following matching for age, gender, osteoporosis status, psoas muscle area, and preoperative ODI, the DS groups exhibited a significantly lower rate of MCID achievement in ODI (DS: 45.5% vs. control 69.0%, P=0.047). The "scoliosis-related" decompression (Odds ratio: 9.9, P=0.028) was an independent factor of non-achievement of MCID in ODI within the DS group.

CONCLUSION

In patients with a Cobb angle>20 degrees, lumbar decompression surgery, even in the MI approach, may result in limited improvement of disability and physical function. Caution should be exercised when determining a surgical plan, especially when decompression involves the level between or across the end vertebrae.

LEVEL OF EVIDENCE

3.

Measurement of the ^{13}C(α, n_{0})^{16}O Differential Cross Section from 0.8 to 6.5 MeV

The cross section of the ^{13}C(α,n)^{16}O reaction is needed for nuclear astrophysics and applications to a precision of 10% or better, yet inconsistencies among 50 years of experimental studies currently lead to an uncertainty of ≈15%. Using a state-of-the-art neutron detection array, we have performed a high resolution differential cross section study covering a broad energy range. These measurements result in a dramatic improvement in the extrapolation of the cross section to stellar energies potentially reducing the uncertainty to ≈5% and resolving long standing discrepancies in higher energy data.

Deciphering Intermediate Nugent scores: Utility of Real-time PCR for Bacterial Vaginosis diagnosis

PURPOSE

To optimize real-time PCR assays for diagnosis of Bacterial Vaginosis (BV) and determine cut-off loads by ROC analysis for Gardnerella vaginalis, Atopobium vaginae and Lactobacillus spp. as compared to Nugent scoring (Gold standard) in clinical samples.

RESULTS

Out of 125 women, 34 were positive, 26 intermediate and 65 negative for BV by Nugent scoring. All three real-time PCR assays were found to be highly sensitive & specific and AUC suggested excellent diagnostic accuracy. An optimal cut-off was >9.45 × 103 copies/ ml, >3.34 × 103 copies/ ml & ≤ 18.63 × 103 copies/ ml for G. vaginalis, A. vaginae and Lactobacillus spp. respectively, in BV positives. Gram staining and qPCR were discordant only in patients with intermediate scores (n = 26) where qPCR identified 15 (57.69%) as positive and 11 (42.3%) as negative.

CONCLUSION

PCR-based molecular BV diagnosis is more accurate and can be used for deciphering intermediate Nugent scores.

Effect of protective coating agents on microleakage and flexural strength of glass ionomer cement and zirconomer. an in vitro study

PURPOSE

The objective of this study was to assess the microleakage and flexural strength of glass ionomer cement (GIC) and modified GIC (Zirconomer) when coated with protective coating agents such as COAT-IT and G-COAT plus.

METHODS

Sixty tooth specimens were grouped into two groups based on the type of restorations (GIC (n = 30) and Zirconomer (n = 30)). The samples were further divided into three subgroups (n = 10) based on the protective coating agent (Petroleum jelly, G-COAT Plus, or COAT IT) applied. This study evaluated the microleakage at the occlusal and cervical margins of class V restoration after being subjected to dye penetration and sectioning. Each specimen was viewed under a 40 × microscope and was given scores based on the depth of dye penetration. They were statistically analyzed using the Kruskal-Wallis test and compared within the groups using the Mann- Whitney Test. In addition, flexural strength was assessed using standardized cuboid (25 × 2 × 2 mm) specimens of restorative materials with and without protective coating agents. The mean flexural strength data of all the subgroups were statistically evaluated using a one-way analysis of variance (ANOVA) and compared within the subgroups using the student t test.

RESULTS

A statistically significant difference was found when occlusal margin microleakage scores were evaluated with G-COAT Plus demonstrating the lowest occlusal margin microleakage when applied over GIC restoration. The increasing order of occlusal margin microleakage scores is as follows: GIC with G-COAT Plus, Zirconomer with COAT-IT, GIC with COAT-IT, GIC, Zirconomer with G-COAT Plus, and Zirconomer. However, the cervical margin microleakage scores revealed no significant difference. While flexural strength was found to be highest for the GIC group coated with G-COAT Plus, it was observed that there was a significant improvement in the flexural strength of both GIC and Zirconomer when coated with either of the protective coating agents.

CONCLUSION

Within the limitations of this in vitro study, it was observed that the application of protective coating agents can significantly reduce the potential microleakage and improve the flexural strength of the restorative material especially when zirconia-reinforced GIC is the restorative material.

Feasibility of Saphenous Nerve Somatosensory-Evoked Potential Intraoperative Monitoring during Lumbar Spine Surgery: Early Results

STUDY DESIGN

Retrospective review.

OBJECTIVE

Assess the feasibility of saphenous nerve somatosensory evoked potentials (SN-SSEP) monitoring in lumbar spine surgeries.

BACKGROUND CONTEXT

SN-SSEPs have been proposed for detecting lumbar plexus and femoral nerve injury during lateral lumbar surgery where tibial nerve (TN)SSEPs alone are insufficient. SN-SSEPs may also be useful in other types of lumbar surgery, as stimulation of SN below the knee derives solely from the L4 root and provides a means of L4 monitoring, whereas TN-SSEPs often do not detect single nerve root injury. The feasibility of routine SN-SSEP monitoring has not been established.

METHODS

A total of 563 consecutive cases using both TN and SN-SSEP monitoring were included. Anesthesia was at the discretion of the anesthesiologist, using an inhalant in 97.7% of procedures. SN stimulation was performed using 13 mm needle electrodes placed below the knee using 200-400 μsec pulses at 15-100 mA. Adjustments to stimulation parameters were made by the neurophysiology technician while obtaining baselines. Data were graded retrospectively for monitorability and cortical response amplitudes were measured by two independent reviewers.

RESULTS

98% of TN-SSEPs and 92.5% of SN-SSEPs were monitorable at baseline, with a mean response amplitude of 1.35 μV for TN-SSEPs and 0.71 μV for SN-SSEPs. A significant difference between the stimulation parameters used to obtain reproducible TN and SN-SSEPs at baseline was observed, with SN-SSEPs requiring greater stimulation intensities. Body mass index (BMI) is not associated with baseline monitorability. Out of 20 signal changes observed, 11 involved SN while TN-SSEPs were unaffected.

CONCLUSION

With adjustments to stimulation parameters, SN-SSEP monitoring is feasible within a large clinical cohort without modifications to the anesthetic plan. Incorporating SN into standard intraoperative neurophysiological monitoring (IONM) protocols for lumbar spine procedures may expand the role of SSEP monitoring to include detecting injury to the lumbar plexus.

LEVEL OF EVIDENCE

3.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively collected registry.

OBJECTIVE

The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS).

SUMMARY OF BACKGROUND DATA

There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery.

MATERIALS AND METHODS

Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified Frailty Index-11 (mFI-11) and Eat Assessment Tool 10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative time points (1-2 years).

RESULTS

Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative time point. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95% CI: 1.24-13.16; P =0.021), overcorrection of TS-CL after surgery (TS-CL, T1 slope minus C2-C7 lordosis; OR, 0.86; 95% CI: 0.79-0.95; P =0.003), and surgery at C3/C4 (OR, 12.38; 95% CI: 1.41-108.92; P =0.023) as factors associated with postoperative dysphagia.

CONCLUSIONS

Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were overcorrection of TS-CL and surgery at C3/C4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

Living with Asthma in Low- and Middle-Income Countries in the Six WHO Regions

Living with AsthmaAsthma is a highly prevalent disease. Although most people with asthma can be treated effectively with certain inhaled medicines, accessing affordable care near their homes is a challenge for many people in low- and middle-income countries. We present stories from six men, women, and children living with asthma in such countries.

Implementing systematic melanoma risk assessment and risk-tailored surveillance in a skin cancer focussed dermatology clinic: A qualitative study of feasibility and acceptability to patients and clinic staff

BACKGROUND

International bodies recommend that melanoma risk assessment should be integrated into skin cancer care provision, but evidence to support implementation is lacking.

AIM

To explore the acceptability and feasibility of implementing personalised melanoma risk assessment and tailored patient education and skin surveillance within routine clinical care.

METHODS

This prospective qualitative implementation study was informed by the Theoretical Framework of Acceptability (TFA). Personalised, systematic melanoma risk assessment was implemented in the dermatology clinic at the Melanoma Institute Australia, Sydney, Australia February-May 2021. Pre- and post-implementation observations and semi-structured interviews with patients and staff were conducted (September 2020-March 2021). Observational notes and interview transcript data were analysed thematically using the TFA as a classifying framework.

RESULTS

A total of 37 h of observations were made, and 29 patients and 12 clinic staff were interviewed. We found that the delivery of personalised melanoma risk estimates did not impact on patient flow through the clinic. Dermatologists reported that the personalised risk information enhanced their confidence in assessing patient risk and recommending tailored surveillance schedules. Most patients reported that the risk assessment and tailored information were a beneficial addition to their care. Among patients whose risk deviated from their expectations, some reported feeling worried, confused or mistrust in the risk information, including those at lower risk who were recommended to decrease surveillance frequency.

CONCLUSIONS

It is feasible and acceptable to patients and clinic staff to calculate and deliver personalised melanoma risk information and tailored surveillance as part of routine clinical care within dermatology clinics.

Preoperative and Postoperative Segmental and Overall Range of Motion in Patients Undergoing Lumbar Spinal Fusion Using HA-Infused PEEK and HA-Treated Titanium Alloy Interbody Cages

STUDY DESIGN

Retrospective observational radiographic analysis.

OBJECTIVE

Determine how single level lumbar interbody fusion (LIF) alters segmental range of motion (ROM) at adjacent levels and decreases overall ROM.

METHODS

This study included 54 patients who underwent single-level anterior (ALIF, 39%), thoraco-LIF (TLIF, 26%), posterior LIF (PLIF, 22%), or lateral LIF (LLIF, 13%) (L2-3/L3-4/L4-5/L5-S1: 4%/13%/35%/48%). Segmental ROM from L1-2 to L5-S1 and the overall lumbar ROM (L1-S1) were assessed from preoperative and postoperative flexion-extension radiographs. K-means cluster analysis was used to identify ROM subgroups.

RESULTS

The overall L1-S1 ROM decreased 14% (25.5 ± 20.4° to 22.0 ± 17.2°, P = .104) postoperatively. ROM at the fusion level decreased 77% (4.8 ± 5.0° to 1.1 ± 1.1°, P < .001). Caudal adjacent segment ROM decreased 12% (5.2 ± 5.7° to 4.6 ± 4.4°, P = .345) and cranially ROM increased 34% (4.3 ± 5.0° to 5.7 ± 5.7°, P = .05). K-cluster analysis identified 3 distinct clusters (P < .05). Cluster 1 lost more ROM and had less improvement in patient-reported outcomes measures (PROMs) than average. Cluster 2 had less ROM loss than average with worse PROMs improvement. Cluster 3 did not have changes in ROM and better improvement in PROMs than average. Successful fusion was verified in 96% of all instrumented segments with >6 months follow-up (ROM <4°).

CONCLUSION

Following single-level L IF, patients should expect a loss of 3.3°, or 14% of overall lumbar motion with increases in ROM of the cranial segment. However, specific clusters of patients exist that experience different relative changes in ROM and PROMs.

Recovery Kinetics After Cervical Spine Surgery

STUDY DESIGN

Retrospective review of a prospectively maintained multisurgeon registry.

OBJECTIVE

To study recovery kinetics and associated factors after cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Few studies have described return to activities cervical spine surgery. This is a big gap in the literature, as preoperative counseling and expectations before surgery are important.

MATERIALS AND METHODS

Patients who underwent either anterior cervical discectomy and fusion (ACDF) or cervical disk replacement (CDR) were included. Data collected included preoperative patient-reported outcome measures, return to driving, return to working, and discontinuation of opioids data. A multivariable regression was conducted to identify the factors associated with return to driving by 15 days, return to working by 15 days, and discontinuing opioids by 30 days.

RESULTS

Seventy ACDF patients and 70 CDR patients were included. Overall, 98.2% of ACDF patients and 98% of CDR patients returned to driving in 16 and 12 days, respectively; 85.7% of ACDF patients and 90.9% of CDR patients returned to work in 16 and 14 days; and 98.3% of ACDF patients and 98.3% of CDR patients discontinued opioids in a median of seven and six days. Though not significant, minimal (odds ratio (OR)=1.65) and moderate (OR=1.79) disability was associated with greater odds of returning to driving by 15 days. Sedentary work (OR=0.8) and preoperative narcotics (OR=0.86) were associated with decreased odds of returning to driving by 15 days. Medium (OR=0.81) and heavy (OR=0.78) intensity occupations were associated with decreased odds of returning to work by 15 days. High school education (OR=0.75), sedentary work (OR=0.79), and retired/not working (OR=0.69) were all associated with decreased odds of discontinuing opioids by 30 days.

CONCLUSIONS

Recovery kinetics for ACDF and CDR are comparable. Most patients return to all activities after ACDF and CDR within 16 days. These findings serve as an important compass for preoperative counseling.

Risk factors for failure to achieve minimal clinically important difference following cervical disc replacement

BACKGROUND CONTEXT

While cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing CDR will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) postoperatively-risk factors for failure to achieve MCID in PROMs following CDR have not been established.

PURPOSE

To identify risk factors for failure to achieve MCID in Neck Disability Index (NDI, Visual Analog Scale (VAS) neck and arm following primary 1- or 2-level CDRs in the early and late postoperative periods.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

Patients who had undergone primary 1- or 2-level CDR for the treatment of degenerative cervical pathology at a single institution with a minimum follow-up of 6 weeks between 2017 and 2022.

OUTCOME MEASURES

Patient-reported outcomes: Neck disability index (NDI), Visual analog scale (VAS) neck and arm, MCID.

METHODS

Minimal clinically important difference achievement rates for NDI, VAS-Neck, and VAS-Arm within early (within 3 months) and late (6 months to 2 years) postoperative periods were assessed based on previously established thresholds. Multivariate logistic regressions were performed for each PROM and evaluation period, with failure to achieve MCID assigned as the outcome variable, to establish models to identify risk factors for failure to achieve MCID and predictors for achievement of MCID. Predictor variables included in the analyses featured demographics, comorbidities, diagnoses/symptoms, and perioperative characteristics.

RESULTS

A total of 154 patients met the inclusion criteria. The majority of patients achieved MCID for NDI, VAS-Neck, and VAS-Arm for both early and late postoperative periods-79% achieved MCID for at least one of the PROMs in the early postoperative period, while 80% achieved MCID for at least one of the PROMs in the late postoperative period. Predominant neck pain was identified as a risk factor for failure to achieve MCID for NDI in the early (OR: 3.13 [1.10-8.87], p-value: .032) and late (OR: 5.01 [1.31-19.12], p-value: .018) postoperative periods, and VAS-Arm for the late postoperative period (OR: 36.63 [3.78-354.56], p-value: .002). Myelopathy was identified as a risk factor for failure to achieve MCID for VAS-Neck in the early postoperative period (OR: 3.40 [1.08-10.66], p-value: .036). Anxiety was identified as a risk factor for failure to achieve MCID for VAS-Neck in the late postoperative period (OR: 6.51 [1.91-22.18], p-value: .003). CDR at levels C5C7 was identified as a risk factor for failure to achieve MCID in NDI for the late postoperative period (OR: 9.74 [1.43-66.34], p-value: .020).

CONCLUSIONS

Our study identified several risk factors for failure to achieve MCID in common PROMs following CDR including predominant neck pain, myelopathy, anxiety, and CDR at levels C5-C7. These findings may help inform the approach to counseling patients on outcomes of CDR as the evidence suggests that those with the risk factors above may not improve as reliably after CDR.

Preoperative Disability Influences Effectiveness of MCID and PASS in Predicting Patient Improvement Following Lumbar Spine Surgery

STUDY DESIGN

Retrospective cohort.

SUMMARY OF BACKGROUND DATA

Although minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) are utilized to interpret Oswestry Disability Index (ODI), it is unclear whether there is a clearly better metric between the two and if not, which metric should be utilized when.

OBJECTIVE

To compare the characteristics of MCID and PASS when interpreting ODI after lumbar spine surgery.

METHODS

Patients who underwent primary minimally invasive transforaminal lumbar interbody fusion or decompression were included. The ODI and global rating change data at 1 year were analyzed. The global rating change was collapsed to a dichotomous outcome variable-(a) improved, (b) not improved The sensitivity, specificity, positive predictive value and negative predictive value of MCID and PASS were calculated for the overall cohort and separately for patients with minimal, moderate, and severe preoperative disability. Two groups with patients who achieved PASS but not MCID and patients who achieved MCID but not PASS were analyzed.

RESULTS

Two hundred twenty patients (mean age 62 y, 57% males) were included. PASS (86% vs. 69%) and MCID (88% vs. 63%) had significantly greater sensitivity in patients with moderate and severe preoperative disability, respectively. Nineteen percent of patients achieved PASS but not MCID and 10% of patients achieved MCID but not PASS, with the preoperative ODI being significantly greater in the latter. Most of these patients still reported improvement with no significant difference between the 2 groups (93% vs. 86%).

CONCLUSION

Significant postoperative clinical improvement is most effectively assessed by PASS in patients with minimal or moderate preoperative disability and by MCID in patients with severe preoperative disability. Adequate interpretation of ODI using the PASS and MCID metrics warrants individualized application as their utility is highly dependent on the degree of preoperative disability.

Preoperative Disability Influences Effectiveness of Minimal Clinically Important Difference and Patient Acceptable Symptom State in Predicting Patient Improvement Following Cervical Spine Surgery

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare the characteristics of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) metrics when interpreting Neck Disability Index (NDI) following cervical spine surgery.

METHODS

Patients who underwent primary cervical fusion, discectomy, or laminectomy were included. NDI and global rating change (GRC) data at 6 months/1 year/2 years were analyzed. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of MCID and PASS in predicting improvement on GRC were calculated for the overall cohort and separately for patients with minimal (NDI <30), moderate (NDI 30 - 49), and severe (NDI ≥ 50) preoperative disability. Two groups with patients who achieved PASS but not MCID and patients who achieved MCID but not PASS were analyzed.

RESULTS

141 patients (206 responses) were included. PASS had significantly greater sensitivity for the overall cohort (85% vs 73% with MCID, P = .02) and patients with minimal disability (96% vs 53% with MCID, P < .001). MCID had greater sensitivity for patients with severe disability (78% vs 57% with PASS, P = .05). Sensitivity was not significantly different for PASS and MCID in patients with moderate preoperative disability (83% vs 92%, P = .1). 17% of patients achieved PASS but not MCID and 9% of patients achieved MCID but not PASS. Most of these patients still reported improvement with no significant difference between the 2 groups (89% vs 72%, P = .13).

CONCLUSION

PASS and MCID are better metrics for patients with minimal and severe preoperative disability, respectively. Both metrics are equally effective for patients with moderate preoperative disability.

Percutaneous Transforaminal Endoscopic Discectomy Learning Curve: A CuSum Analysis

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To describe the learning curve for percutaneous transforaminal endoscopic discectomy (PTED) and demonstrate its efficacy in treating lumbar disc herniation.

SUMMARY OF BACKGROUND DATA

The learning curve for PTED has not yet been standardized in the literature.

PATIENTS AND METHODS

Consecutive patients who underwent lumbar PTED by a single surgeon between December 2020 and 2022 were included. Cumulative sum analysis was applied to operative and fluoroscopy time to assess the learning curve. Inflection points were used to divide cases into early and late phases. The 2 phases were analyzed for differences in operative and fluoroscopy time, length of stay, complications, and patient-reported outcome measures (PROMs). Patient characteristics and operative levels were also compared. PROMs entailed the Oswestry Disability Index, Patient-Reported Outcomes Measurement Information System, Visual Analog Scale Back/Leg, and 12-item Short Form Survey at preoperative, early postoperative (<6 mo), and late postoperative (≥6 mo) time points. PROMs between PTED cases and a comparable cohort of tubular microdiscectomy cases, performed by the same surgeon, were compared.

RESULTS

Fifty-five patients were included. Cumulative sum analysis indicated that both operative and fluoroscopy time diminished rapidly after case 31, suggesting a learning curve of 31 cases (early phase: n = 31; late phase: n = 24). Late-phase cases exhibited significantly lower operative times (85.7 vs . 62.2 min, P = 0.001) and fluoroscopy times (131.0 vs . 97.2 s, P = 0.001) compared with the early-phase cases. Both early and late-phase cases showed significant improvement in all PROMs. There were no differences in PROMs between the patients who underwent PTED and tubular microdiscectomy.

CONCLUSION

The PTED learning curve was found to be 31 cases and did not impact PROMs or complication rates. Although this learning curve reflects the experiences of a single surgeon and may not be broadly applicable, PTED can serve as an effective modality for the treatment of lumbar disc herniation.

Surgeon Experience Influences Robotics Learning Curve for Minimally Invasive Lumbar Fusion: A Cumulative Sum Analysis

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the learning curves of three spine surgeons for robotic minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

Although the learning curve for robotic MI-TLIF has been described, the current evidence is of low quality with most studies being single-surgeon series.

MATERIALS AND METHODS

Patients who underwent single-level MI-TLIF with three spine surgeons (years in practice: surgeon 1: 4, surgeon 2: 16, and surgeon 3: two) using a floor-mounted robot were included. Outcome measures were operative time, fluoroscopy time, intraoperative complications, screw revision, and patient-reported outcome measures. Each surgeon's cases were divided into successive groups of 10 patients and compared for differences. Linear regression and cumulative sum (CuSum) analyses were performed to analyze the trend and learning curve, respectively.

RESULTS

A total of 187 patients were included (surgeon 1: 45, surgeon 2: 122, and surgeon 3: 20). For surgeon 1, CuSum analysis showed a learning curve of 21 cases with the attainment of mastery at case 31. Linear regression plots showed negative slopes for operative and fluoroscopy time. Both learning phase and postlearning phase groups showed significant improvement in patient-reported outcome measures. For surgeon 2, CuSum analysis demonstrated no discernible learning curve. There was no significant difference between successive patient groups in either operative time or fluoroscopy time. For surgeon 3, CuSum analysis demonstrated no discernible learning curve. Even though the difference between successive patient groups was not significant, cases 11 to 20 had an average operative time of 26 minutes less than cases 1-10), suggesting an ongoing learning curve.

CONCLUSIONS

Surgeons who are well-experienced can be expected to have no or minimal learning curve for robotic MI-TLIF. Early attendings are likely to have a learning curve of around 21 cases with the attainment of mastery at case 31. Learning curve does not seem to impact clinical outcomes after surgery.

LEVEL OF EVIDENCE

Level 3.

Improvement in predominant back pain following minimally invasive decompression for spinal stenosis

OBJECTIVE

The objective of this study was to assess the outcomes of patients with predominant back pain (pBP) undergoing minimally invasive decompression surgery compared with patients with nonpredominant back pain (npBP).

METHODS

This was a retrospective cohort study. Patients were divided into two groups based on the presenting complaint: 1) pBP, defined as visual analog scale (VAS) back pain score > VAS leg pain score; and 2) npBP. Changes in patient-reported outcome measures (PROMs) were compared at the early (< 6 months) and late (≥ 6 months) postoperative time points. Outcomes measures were: 1) PROMs (Oswestry Disability Index [ODI], VAS back and leg pain scores, 12-Item Short-Form Health Survey Physical Component Score [SF-12 PCS], and Patient-Reported Outcomes Measurement Information System Physical Function [PROMIS PF]), and 2) minimal clinically important difference (MCID) achievement rate and time. For the late MCID achievement point, a second analysis was conducted restricting VAS back and leg pain scores only to patients with preoperative scores ≥ 5.

RESULTS

Three hundred ninety patients were included (126 with pBP and 264 with npBP). There were no differences in patient demographics and operated levels. There were no differences in preoperative ODI, SF-12 PCS, and PROMIS PF scores. The pBP cohort had a significantly greater preoperative VAS back pain score than the npBP cohort, whereas the npBP cohort had a significantly greater preoperative VAS leg pain score than the pBP cohort. There were no differences in the absolute values or changes in ODI, VAS back pain, SF-12 PCS, and PROMIS PF scores at any time point. There was a significant difference in the early VAS leg pain scores (greater in npBP) that disappeared by the late postoperative time point. There was no difference in the MCID achievement rate in the ODI, SF-12 PCS, or PROMIS PF scores. By the late postoperative time point, 51.2% and 55.3% achieved an MCID on the ODI, 58.1% and 62.7% on the SF-12 PCS, 60% and 67.6% on the PROMIS PF, 81.1% and 73.2% on VAS back pain scores for those with preoperative scores ≥ 5, and 72% and 83.6% on VAS leg pain scores for those with preoperative scores ≥ 5 for the pBP and npBP cohorts, respectively. Additionally, there were no differences in time to MCID achievement for any PROMs.

CONCLUSIONS

The pBP and npBP cohorts showed similar improvement in PROMs and MCID achievement rates. This result shows that minimally invasive laminectomy is equally effective for patients presenting with pBP or npBP.

Comparison of Robotics and Navigation for Clinical Outcomes After Minimally Invasive Lumbar Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare navigation and robotics in terms of clinical outcomes after minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

SUMMARY OF BACKGROUND DATA

Although robotics has been shown to have advantages like reduced radiation exposure, greater screw size, and slightly better accuracy over navigation, none of the studies has compared these two modalities in terms of clinical outcomes.

METHODS

Patients who underwent single-level MI-TLIF using robotics or navigation and had a minimum of 1-year follow-up were included. The robotics and navigation groups were compared for improvement in patient-reported outcome measures (PROMs), minimal clinically important difference, patient-acceptable symptom state, response on the global rating change scale, and screw-related complication and reoperation rates.

RESULTS

A total of 278 patients (143 robotics, 135 navigation) were included. There was no significant difference between the robotics and navigation groups in the baseline demographics, operative variables, and preoperative PROMs. Both groups showed significant improvement in PROMs at below six and six months or above, with no significant difference in the magnitude of improvement between the two groups. Most patients achieved minimal clinically important difference and patient-acceptable symptom state and reported feeling better on the global rating change scale, with no significant difference in the proportions between the robotics and navigation groups. The screw-related complication and reoperation rates also showed no significant difference between the two groups.

CONCLUSIONS

Robotics did not seem to lead to significantly better clinical outcomes compared with navigation following MI-TLIF. Although the clinical outcomes may be similar, robotics offers the advantages of reduced radiation exposure, greater screw size, and slightly better accuracy over navigation. These advantages should be considered when determining the utility and cost-effectiveness of robotics in spine surgery. Larger multicenter prospective studies are required in the future to further investigate this subject.

Frequency-Dependent Squeezed Vacuum Source for the Advanced Virgo Gravitational-Wave Detector

In this Letter, we present the design and performance of the frequency-dependent squeezed vacuum source that will be used for the broadband quantum noise reduction of the Advanced Virgo Plus gravitational-wave detector in the upcoming observation run. The frequency-dependent squeezed field is generated by a phase rotation of a frequency-independent squeezed state through a 285 m long, high-finesse, near-detuned optical resonator. With about 8.5 dB of generated squeezing, up to 5.6 dB of quantum noise suppression has been measured at high frequency while close to the filter cavity resonance frequency, the intracavity losses limit this value to about 2 dB. Frequency-dependent squeezing is produced with a rotation frequency stability of about 6 Hz rms, which is maintained over the long term. The achieved results fulfill the frequency dependent squeezed vacuum source requirements for Advanced Virgo Plus. With the current squeezing source, considering also the estimated squeezing degradation induced by the interferometer, we expect a reduction of the quantum shot noise and radiation pressure noise of up to 4.5 dB and 2 dB, respectively.

The role of dexmedetomidine in post cranioplasty refractory status epilepticus

Cranioplasty, specifically a repair of the skull defect resulting from a previous decompressive craniectomy, is a relatively simple procedure associated with a minimal rate of complications. Even though seizures are seen in up to 30% of the patients postoperatively, status epilepticus is not commonly described. Cerebral oedema, ischaemia and neuro-inflammation have been reported as putative causes of seizures in this population. Here, we report a case of refractory status epilepticus unresponsive to standard anti-epileptic and anaesthetic agents. The use of dexmedetomidine helped terminate the episode and led to a favourable outcome. Most of the standard anti-epileptic and anaesthetic agents act through potentiation of GABAergic transmission or sodium channel blockade and postsynaptic adrenoceptor activation by dexmedetomidine may help potentiate their effect. Further studies are needed to investigate its anticonvulsant effect on post-traumatic brain injury and elaborate on optimal dosage.

Automated Segmentation of Intracranial Thrombus on NCCT and CTA in Patients with Acute Ischemic Stroke Using a Coarse-to-Fine Deep Learning Model

BACKGROUND AND PURPOSE

Identifying the presence and extent of intracranial thrombi is crucial in selecting patients with acute ischemic stroke for treatment. This article aims to develop an automated approach to quantify thrombus on NCCT and CTA in patients with stroke.

MATERIALS AND METHODS

A total of 499 patients with large-vessel occlusion from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial were included. All patients had thin-section NCCT and CTA images. Thrombi contoured manually were used as reference standard. A deep learning approach was developed to segment thrombi automatically. Of 499 patients, 263 and 66 patients were randomly selected to train and validate the deep learning model, respectively; the remaining 170 patients were independently used for testing. The deep learning model was quantitatively compared with the reference standard using the Dice coefficient and volumetric error. The proposed deep learning model was externally tested on 83 patients with and without large-vessel occlusion from another independent trial.

RESULTS

The developed deep learning approach obtained a Dice coefficient of 70.7% (interquartile range, 58.0%-77.8%) in the internal cohort. The predicted thrombi length and volume were correlated with those of expert-contoured thrombi (r = 0.88 and 0.87, respectively; P < .001). When the derived deep learning model was applied to the external data set, the model obtained similar results in patients with large-vessel occlusion regarding the Dice coefficient (66.8%; interquartile range, 58.5%-74.6%), thrombus length (r = 0.73), and volume (r = 0.80). The model also obtained a sensitivity of 94.12% (32/34) and a specificity of 97.96% (48/49) in classifying large-vessel occlusion versus non-large-vessel occlusion.

CONCLUSIONS

The proposed deep learning method can reliably detect and measure thrombi on NCCT and CTA in patients with acute ischemic stroke.

Poor Muscle Health and Low Preoperative ODI are Independent Predictors for Slower Achievement of MCID After Minimally Invasive Decompression

BACKGROUND CONTEXT

Although some previous studies have analyzed predictors of non-improvement, most of these have focused on demographic and clinical variables and have not accounted for radiological predictors. In addition, while several studies have examined the degree of improvement after decompression, there is less data on the rate of improvement.

PURPOSE

To identify the risk factors and predictors (both radiological and non-radiological) for slower as well as non-achievement of minimal clinically important difference (MCID) after minimally invasive decompression.

DESIGN

Retrospective cohort PATIENT SAMPLE: Patients who underwent minimally invasive decompression for degenerative lumbar spine conditions and had a minimum of 1-year follow-up were included. Patients with preoperative Oswestry Disability Index (ODI) <20 were excluded.

OUTCOME MEASURE

MCID achievement in ODI (cut off 12.8).

METHODS

Patients were stratified into two groups (achieved MCID, did not achieve MCID) at two timepoints (early ≤3 months, late ≥6 months). Non-radiological (age, gender, BMI, comorbidities, anxiety, depression, number of levels operated, preoperative ODI, preoperative back pain) and radiological (MRI - Schizas grading for stenosis, dural sac cross-sectional area, Pfirrmann grading for disc degeneration, psoas cross-sectional area and Goutallier grading, facet cyst/effusion; X-ray - spondylolisthesis, lumbar lordosis, spinopelvic parameters) variables were assessed with comparative analysis to identify risk factors and with multiple regression models to identify predictors for slower achievement of MCID (MCID not achieved by ≤3 months) and non-achievement of MCID (MCID not achieved at ≥6 months).

RESULTS

338 patients were included. At ≤3 months, patients who did not achieve MCID had significantly lower preoperative ODI (40.1 vs. 48.1, p<0.001) and worse psoas Goutallier grading (p=0.048). At ≥6 months, patients who did not achieve MCID had significantly lower preoperative ODI (38 vs. 47.5, p<0.001), higher age (68 vs. 63 years, p=0.007), worse average L1-S1 Pfirrmann grading (3.5 vs. 3.2, p=0.035), and higher rate of pre-existing spondylolisthesis at the operated level (p=0.047). When these and other probable risk factors were put into a regression model, low preoperative ODI (p=0.002) and poor Goutallier grading (p=0.042) at the early timepoint and low preoperative ODI (p<0.001) at the late timepoint came out as independent predictors for MCID non-achievement.

CONCLUSION

After minimally invasive decompression, low preoperative ODI and poor muscle health are risk factors and predictors for slower achievement of MCID. For non-achievement of MCID, low preoperative ODI, higher age, greater disc degeneration, and spondylolisthesis are risk factors and low preoperative ODI is the only independent predictor.

Weissella confusa Causing Vancomycin-Resistant Septicemia Infection in a Pediatric Patient: A Case Report From a University Teaching Hospital in North India

Weissella confusa is a Gram-positive coccus usually found in the microbiota of humans and the environment. Different studies quote that it has caused infections in humans under unfavourable conditions. A case report causing septicemia in an 11-year-old male patient diagnosed with acute pancreatitis and having acute respiratory distress syndrome (ARDS) is presented. The patient was successfully treated with ceftazidime and a piperacillin-tazobactam combination after confirmation of bacteria by matrix-assisted laser desorption and ionisation-time of flight (MALDI-TOF-MS) and antimicrobial sensitivity testing (AST) performed as per the latest Clinical and Laboratory Standard Institute (CLSI) guidelines. The patient was discharged asymptomatically after drainage of fluid and was managed conservatively. Correct identification by the automated method is important for this species and also to find its mode of infection. Because of its similarities to other vancomycin-resistant cocci, isolates of this species might be difficult to identify, leading to drug resistance. A literature review in tabulated form is summarised.

Asthma management and control in children, adolescents, and adults in 25 countries: a Global Asthma Network Phase I cross-sectional study

BACKGROUND

Asthma is one of the most common non-communicable diseases globally. This study aimed to assess asthma medicine use, management plan availability, and disease control in childhood, adolescence, and adulthood across different country settings.

METHODS

We used data from the Global Asthma Network Phase I cross-sectional epidemiological study (2015-20). A validated, written questionnaire was distributed via schools to three age groups (children, 6-7 years; adolescents, 13-14 years; and adults, ≥19 years). Eligible adults were the parents or guardians of children and adolescents included in the surveys. In individuals with asthma diagnosed by a doctor, we collated responses on past-year asthma medicines use (type of inhaled or oral medicine, and frequency of use). Questions on asthma symptoms and health visits were used to define past-year symptom severity and extent of asthma control. Income categories for countries based on gross national income per capita followed the 2020 World Bank classification. Proportions (and 95% CI clustered by centre) were used to describe results. Generalised structural equation multilevel models were used to assess factors associated with receiving medicines and having poorly controlled asthma in each age group.

FINDINGS

Overall, 453 473 individuals from 63 centres in 25 countries were included, comprising 101 777 children (6445 [6·3%] with asthma diagnosed by a doctor), 157 784 adolescents (12 532 [7·9%]), and 193 912 adults (6677 [3·4%]). Use of asthma medicines varied by symptom severity and country income category. The most used medicines in the previous year were inhaled short-acting β2 agonists (SABA; range across age groups, 29·3-85·3% participants) and inhaled corticosteroids (12·6-51·9%). The proportion of individuals with severe asthma symptoms not taking inhaled corticosteroids (inhaled corticosteroids alone or with long-acting β2 agonists) was high in all age groups (934 [44·8%] of 2085 children, 2011 [60·1%] of 3345 adolescents, and 1142 [55·5%] of 2058 adults), and was significantly higher in middle-to-low-income countries. Oral SABA and theophylline were used across age groups and country income categories, contrary to current guidelines. Asthma management plans were used by 4049 (62·8%) children, 6694 (53·4%) adolescents, and 3168 (47·4%) adults; and 2840 (44·1%) children, 6942 (55·4%) adolescents, and 4081 (61·1%) adults had well controlled asthma. Independently of country income and asthma severity, having an asthma management plan was significantly associated with the use of any type of inhaled medicine (adjusted odds ratio [OR] 2·75 [95% CI 2·40-3·15] for children; 2·45 [2·25-2·67] for adolescents; and 2·75 [2·38-3·16] for adults) or any type of oral medicine (1·86 [1·63-2·12] for children; 1·53 [1·40-1·68] for adolescents; and 1·78 [1·55-2·04] for adults). Poor asthma control was associated with low country income (lower-middle-income and low-income countries vs high-income countries, adjusted OR 2·33 [95% CI 1·32-4·14] for children; 3·46 [1·83-6·54] for adolescents; and 4·86 [2·55-9·26] for adults).

INTERPRETATION

Asthma management and control is frequently inadequate, particularly in low-resource settings. Strategies should be implemented to improve adherence to asthma treatment guidelines worldwide, with emphasis on access to affordable and quality-assured essential asthma medicines especially in low-income and middle-income countries.

FUNDING

International Union Against Tuberculosis and Lung Disease, Boehringer Ingelheim New Zealand, AstraZeneca, UK National Institute for Health Research, UK Medical Research Council, European Research Council, the Spanish Instituto de Salud Carlos III.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Language barriers for primary care access in Europe: a systematic review

Background

A recent increase in migration both inside Europe and from non-European countries has expanded the language profile of many European countries. As a result, there has been a significant increase in barriers to healthcare access experienced by linguistic minority migrants. This systematic review aims to explore language barriers in primary care, focusing on the experiences of linguistic minority migrants living in Europe.

Methods

PubMed, Embase, Scopus and Global Health were searched to identify studies published in English until May 2021. Qualitative and mixed methods studies on either linguistic minority migrants or healthcare workers working with linguistic minority migrants, exploring the impacts of language barriers in a primary care setting published were eligible. The studies were analysed using a Braun and Clarke's thematic analysis approach. Quality of the studies were assessed using the Mixed Methods Appraisal Tool.

Results

16 studies from 14 different European countries were eligible. Participants in the studies included four groups: linguistic minority migrants (n = 11), healthcare workers (n = 10), interpreters (n = 1) and administrative staff (n = 1). Barriers identified included a lack of interpreters, limited cultural competence of practitioners, a lack of practitioner training and knowledge, a lack of accessible information for migrants, difficulties expressing emotions and building patient-practitioner relationships, and risks to women's bodily autonomy resulting from language barriers.

Conclusions

Linguistic minority migrants living in Europe face a number of barriers when accessing primary care. These barriers can risk patient safety, reduce the likelihood of seeking healthcare services, and impact patient experiences of healthcare services. There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff.

Key messages

• Linguistic minority migrants experience significant barriers to primary healthcare access across Europe.

• There is a need for improved interpreter services, practitioner training, and information accessibility for both migrants and healthcare staff.

Proportionate clinical burden of respiratory diseases in Indian outdoor services and its relationship with seasonal transitions and risk factors: The results of SWORD survey

Background

The Global Burden of Disease data suggest that respiratory diseases contribute to high morbidity in India. However, the factors responsible for high morbidity are not quite clear. Therefore, the Seasonal Waves Of Respiratory Disorders (SWORD) study was planned to estimate the point prevalence due to respiratory diseases in Indian OPD services and its association with risk factors and change in seasons.

Methods

In this point prevalence observational multicenter study conducted during 2017–18, participating physicians recorded information of consecutive patients in response to a questionnaire. The study was conducted on four predetermined days representing transition of Indian seasons i.e., February (winter), May (summer), August (monsoon), and November (autumn).

Results

The eligible number of patients from across 302 sites in India was 25,177. The mean age of study population was 46.1±18.1 years, 14102(56.0%) were males and 11075(44.0%) females. The common diagnoses were: asthma(29.8%), chronic obstructive pulmonary disease (COPD),15.6%, respiratory tract infections (RTIs),11.3%, and tuberculosis(8.7%). All these conditions showed significant seasonal trends (Asthma 31.4% autumn vs. 26.5% summer, COPD 21.1% winter vs. 8.1% summer, RTIs 13.3% winter vs. 4.3% summer, and tuberculosis 12.5% autumn vs. 4.1% summer, p<0.001 for each respectively). After adjustment for risk factors, asthma was significantly associated with exposure to molds (OR:1.12,CI:1.03–1.22), pet animals (OR:1.07,CI:1.01–1.14), recent-travel (OR:1.22,CI:1.13–1.32), and rain-wetting (OR:1.27,CI:1.15–1.40); and RTIs with rain-wetting (OR:1.53,CI:1.34–1.74), and recent-travel (OR:1.17,CI:1.05–1.30).

Conclusions

The SWORD study showed wide seasonal variations in outpatient attendance of patients with common respiratory conditions. Novel risk-factors associated with respiratory diseases were also identified.

Search for Subsolar-Mass Binaries in the First Half of Advanced LIGO's and Advanced Virgo's Third Observing Run

We report on a search for compact binary coalescences where at least one binary component has a mass between 0.2  M_{⊙} and 1.0  M_{⊙} in Advanced LIGO and Advanced Virgo data collected between 1 April 2019 1500 UTC and 1 October 2019 1500 UTC. We extend our previous analyses in two main ways: we include data from the Virgo detector and we allow for more unequal mass systems, with mass ratio q≥0.1. We do not report any gravitational-wave candidates. The most significant trigger has a false alarm rate of 0.14  yr^{-1}. This implies an upper limit on the merger rate of subsolar binaries in the range [220-24200]  Gpc^{-3} yr^{-1}, depending on the chirp mass of the binary. We use this upper limit to derive astrophysical constraints on two phenomenological models that could produce subsolar-mass compact objects. One is an isotropic distribution of equal-mass primordial black holes. Using this model, we find that the fraction of dark matter in primordial black holes in the mass range 0.2  M_{⊙}<m_{PBH}<1.0  M_{⊙} is f_{PBH}≡Ω_{PBH}/Ω_{DM}≲6%. This improves existing constraints on primordial black hole abundance by a factor of ∼3. The other is a dissipative dark matter model, in which fermionic dark matter can collapse and form black holes. The upper limit on the fraction of dark matter black holes depends on the minimum mass of the black holes that can be formed: the most constraining result is obtained at M_{min}=1  M_{⊙}, where f_{DBH}≡Ω_{DBH}/Ω_{DM}≲0.003%. These are the first constraints placed on dissipative dark models by subsolar-mass analyses.

O-292 Comparison of effect of two different trigger regimens; single (hCG) versus dual (hCG + Leuprolide) on outcome of fresh IVF cycles: A randomized controlled trial

Study question

Does adding gonadotropin-releasing hormone agonist (GnRHa) to hCG trigger increases the number of high-grade embryos in GnRH antagonist protocol in fresh non-donor IVF?

Summary answer

Final oocyte maturation triggered by dual trigger increases the number of MII oocytes thus transferring good-quality embryos and cryopreserving surplus embryos compared to hCG trigger.

What is known already

hCG has been conventionally used as a ‘faux’ LH surge to bring about final oocyte maturation due to structural similarity between the two. GnRH agonist, on the other hand, induces a more physiological gonadotropin surge for follicular maturation, but is associated with luteal phase deficiency. Recent studies have shown that combining GnRHa with hCG trigger improves oocyte maturation and embryo quality with the added benefit of a luteal phase support, thereby improving IVF outcomes in terms of both embryological and reproductive outcomes.

Study design, size, duration

A single-center, open labelled, randomized controlled trial including 100 normal responder patients between 21-38 years undergoing IVF using GnRH antagonist protocol between January 2020 to August 2021. The study excluded patients with the presence of other variables of adverse outcomes like diminished ovarian reserve (AFC &lt; 5 or AMH &lt; 1.2 ng/ml), endocrine disorders, thin endometrium (&lt;6mm), previous history of uterine surgeries, and high responders.

Participants/materials, setting, methods

100 patients undergoing fresh IVF cycle using GnRH antagonist protocol were randomized after informed consent to receive either dual trigger (Leuprolide acetate 1 mg + rhCG 250 mcg, n = 50) or single hCG trigger (rhCG 250 mcg, n = 50). Oocyte retrieval was done 35-37 hours after trigger followed by IVF/ICSI, as indicated. Oocyte and embryo grading was done using Istanbul consensus. Analysis was done by ITT. Outcomes were analyzed using Independent t-test and Chi-square test.

Main results and the role of chance

The baseline characteristics were comparable in both arms. the number of MII oocytes retrieved (7.82 versus 5.92, p = 0.003) and the number of day-3 grade-1 embryos (4.24 versus 1.8, p &lt; 0.001) were higher in the dual trigger group, whereas fertilization rates between the two groups (91.82% versus 88.51%, p=NS) were comparable. Consequently, the number of embryos cryopreserved (2.68 versus 0.94, p &lt; 0.001) were significantly higher in the dual trigger group. However, the implantation rate between the two groups (21% versus 19.6%, p = 0.770) was comparable. The serum LH levels 12 hours post trigger were measured in both the arms and as expected, high serum LH values were documented in the dual trigger group (46.23 mIU/ml vs 0.93 mIU/ml, p &lt; 0.0001).

Limitations, reasons for caution

Due to the impact of the Covid-19 pandemic causing an intermittent pause in IVF services at our center, a smaller sample size of 100 patients could be enrolled in the study, and reproductive outcomes in terms of live births and cumulative live births could not be assessed

Wider implications of the findings

This study, though small, has contributed to some evidence of redesigning the dual trigger in all antagonist cycles, with the exception of high responders and PCOS patients. The addition of GnRHa to hCG trigger has led to the possibility of cryopreserving surplus embryos thereby increasing the cumulative live births.

Trial registration number

CTRI/2020/08/027030

P-795 Comparison of intra-ovarian platelet rich plasma versus autologous bone marrow derived stem cell instillation in women with diminished ovarian reserve for ovarian rejuvenation

Study question

To compare role of intra-ovarian platelet rich plasma (PRP) versus marrow derived stem cell (SC) instillation for improvement in ovarian reserve (AFC, AMH and FSH)

Summary answer

Both PRP and SC therapy improves the ovarian reserve however, response to PRP is superior to SC post intervention

What is known already

With increasing incidence of females with diminished ovarian reserve (DOR), posing a serious challenge in terms of limited treatment options for these couples. Clinicians are trying to find effective strategies besides oocyte donation or adoption Of late, novel ovarian rejuvenation approaches has been investigated which are currently available for research purposes only. Multiple studies are evaluating effect of intra-ovarian PRP or autologous SC instillation, the results are encouraging as they are showing improvement in ovarian reserve thus bringing a paradigm shift in treatment options. None of the published studies so far have compared PRP versus SC in DOR population.

Study design, size, duration

A prospective comparative study was conducted at Division of Reproductive Medicine of a tertiary care institute. 72 infertile females (20-39 years) with poor ovarian reserve (AMH &lt;1.2 ng /ml; AFC&lt;5) were enrolled in the study between January 2020 to December 2021. The two comparative groups underwent either intra-ovarian PRP instillation (n = 42) or autologous SC transplantation (n = 30).

Participants/materials, setting, methods

After the two groups were matched (PRP vs SC) for baseline characteristics (Age, AMH, AFC, FSH, Estradiol), 30 subjects in each group were compared for change in serum FSH/AMH/Estradiol levels, AFC, right and left ovarian volume at 1st month and 3rd month post intervention from the baseline. This was also compared between the two groups using Student t-test. The cost and procedural pain measured using Visual analog scale (VAS) were also compared between the groups.

Main results and the role of chance

After matching for baseline characteristics, significant ∼ 1.8/2 and ∼1.5/1.6 fold increase in AFC at 1st/3rd month post intervention (p&lt;0.001) was observed after PRP instillation and SC transplantation respectively. This significant improvement was observed more in PRP group than SC group at 3rd month post intervention (7.07 vs 5.60, p=0.02), while no significant difference existed at 1st month of follow up. However, there was no significant improvement in serum FSH, AMH and Estradiol levels (p0.05) from the baseline at 1st and 3rd month post intervention in both the groups. Similarly, there was no significant difference between the two groups in serum FSH level (7.98 IU/ml vs 9.62 IU/ml, p=0.062; 8.26 IU/ml vs 9.50 IU/ml, p=0.15), AMH level (1.62 ng/ml vs 1.02 ng/ml, p=0.27; 1.35 ng/ml vs 0.95 ng/ml, p=0.24), Estradiol level (49.12 pg/ml vs 56.48 pg/ml p=0.443; 54.7 pg/ml vs 61.12 pg/ml, p=0.44), right ovarian volume (3.13 cm3 vs 2.49 cm3, p=0.06; 3.37 cm3 vs 2.74 cm3,p=0.063) and left ovarian volume (2.98 cm3 vs 2.47 cm3, p=0.102; 2.87 cm3 vs 2.34 cm3,p=0.103) at 1st and 3rd month post intervention respectively. PRP was more cost-effective and associated with less pain (32.5 mm vs 28.13 mm, p=0.02), and better patient compliance.

Limitations, reasons for caution

This was a comparative study and the participants were not randomized but were matched for the baseline characteristics. Also due to impact of Covid-19 causing intermittent pause in nonessential facilities like IVF services, a smaller sample size could be enrolled and also clinical outcomes could not be evaluated

Wider implications of the findings

This study, although comparative, for the first time highlights the beneficial role of PRP over SC, thus can establish superiority of PRP as minimally invasive, economical, patient friendly and a recommended therapy for ovarian rejuvenation and folliculogenesis, providing the DOR females an opportunity to produce their own offspring.

Trial registration number

CTRI/2020/01/022726

P-799 To evaluate the effect of Intra-ovarian platelet rich plasma instillation on the clinical outcome of women with diminished ovarian reserve: A prospective interventional study

Study question

Does intra-ovarian instillation of platelet rich plasma (PRP) improves the clinical outcome of IVF cycles in women with Diminished Ovarian reserve (DOR)?

Summary answer

PRP instillation leads to consistent improvement in Antral follicle count (AFC), thus achieving clinical pregnancy rate of 33.3% per cycle in women with DOR.

What is known already

There is rising incidence of females with diminished ovarian reserve (DOR) especially among Asian ethnicity. With the emergence of regenerative medicine, multiple studies have evaluated the role of intra-ovarian PRP, demonstrating a beneficial role in improving ovarian reserve parameters (serum Follicular stimulating hormone (FSH), serum anti-Mullerian hormone (AMH), AFC). Despite its’ favorable effects on biochemical markers and AFC, data regarding improvement in clinical outcome remains elusive and led to inception of this study.

Study design, size, duration

A prospective interventional study was conducted at Division of Reproductive Medicine of a tertiary care institute. 41 infertile females aged 20-39 years with DOR (AMH &lt;1.2 ng /ml; AFC&lt;5) were enrolled in the study during a 6-month period beginning from August 2021.

Participants/materials, setting, methods

After informed consent, patients received fresh autologous PRP, prepared from 30 ml venous blood. 1.5ml of PRP instilled in each ovarian stroma between day 7-10 of menstrual cycle under sedation. Patients were followed up for three-consecutive months to assess ovarian reserve parameters including serum FSH, AMH and AFC. Patients showing significant improvement in parameters were recruited for fresh IVF cycles using Antagonist protocol with 1% transdermal testosterone. Outcomes were analysed using linear mix effect model.

Main results and the role of chance

The average platelet concentration in PRP was ∼10,00,000 platelets/µL. The mean age of enrolled patients was 31.22±4.16 years. Linear improvement in AFC (3.63 vs 6.98 vs 7.97 vs 6.90, p&lt;0.001) was observed from baseline to three consecutive follow-up months with maximal response witnessed in second month in 57.1% of those undergoing IVF cycle. However, there was no significant difference in Serum FSH (p=0.11) and AMH (p=0.16) from the baseline post intervention. Of the 41 patients, 35 (85.3%) responded to the treatment and underwent IVF antagonist cycle. 5 out of 35 IVF cycles were cancelled mid-cycle due to poor ovarian response. The mean dose of gonadotropin requirement was 2667.5±281.1 IU (Follicular stimulating hormone) and 1400±337.3 IU (Human menopausal gonadotropin). The average number of oocytes retrieved was 5.7±2.2 whereas mean number of MII oocytes was 4.63±1.85. The fertilization rate and the cleavage rate were 92.4% and 74.1% respectively. Of the thirty patients, eight patients underwent day 2 transfer due to poor grade of embryos. Mean number of grade 1- day 3 embryos was 1.25±0.55 with surplus embryos available for cryopreservation in 14 patients. The overall clinical pregnancy rate per transfer was 33.33%. No adverse events were reported.

Limitations, reasons for caution

This was a prospective single arm study. A randomized controlled trial comprising a “no-treatment” arm would establish a Level-I evidence. However, “no-treatment” arm in a developing country like ours, imposes financial burden on the couple with no guaranteed clinical success and thus raising ethical concern and need for ovarian rejuvenation.

Wider implications of the findings

With the impetus to provide a biological child to these DOR women, intra-ovarian PRP instillation as a method of ovarian rejuvenation holds promising results. Evidently, PRP is not only effective in improving ovarian reserve but this translates into an improved reproductive outcome in a population, previously limited to oocyte donation.

Trial registration number

REF/2022/01/051033

P-430 Sperm genomic integrity, telomere dynamics and gene expression in recurrent implantation failure

Study question

Does sperm affect the implantation and early embryogenesis?

Summary answer

Deranged sperm genomic integrity, limited repair mechanisms, aberrant gene expression have the potential to be transmitted to developing embryo and affect implantation and embryonic development.

What is known already

The terminally differentiated, transcriptionally quiscent sperm cells are vulnerable to a host of factors which might affect its function. The spermatozoa with truncated repair mechanisms have the potential to fertilize the oocyte, but eventually result in high rates of pre and post implantation losses. Oxidative stress, deranged genomic integrity, aberrant gene expression in the sperm cell has the potential to affect fertilisation potential, implantation and embryonic viability. This has been seen to be correlated with decreased fertilisation, clevage rates and blastocyst development and thus impaired implantation rates.

Study design, size, duration

A case control study of 75 men from infertile couples who had recurrent implantation failure (RIF) in IVF cycles and 75 fertile controls at AIIMS, New Delhi, India. Study duration was 2 years.

Participants/materials, setting, methods

Semen samples from men from couples who had RIF were analyzed as per WHO 2010. Sperm reactive oxygen species (ROS) and DNA fragmentation index (DFI) was assessed by chemiluminiscence and sperm chromatin structure assay (SCSA) respectively. Relative sperm telomere length was evaluated from sperm DNA by q-PCR analysis. The expression of genes pertinent for early embryonic development was done by qPCR. The relative quantification was done after normalizing with GAPDH and β-actin by 2-ΔΔCt method.

Main results and the role of chance

Seminal ROS levels (RLU/sec/million sperm) were seen to be significantly higher [57.75 (10.1-1186.9)] in cases with respect to controls [16.7(1.15-53.9)] (p &lt; 0.001***). The mean DFI of men undergoing ART was significantly higher (37.7 ± 5.7) vs 23.2 ± 4.6%; p &lt; 0.001***) in cases as compared to controls. ROS and DFI levels correlated negatively with sperm concentration and progressive motility (p &lt; 0.001***). We analyzed the expression of FOXG1, SOX3, STAT4, RPS6, RBM9, RPL10A, RPS17, RPL29, WNT5A, HSP90, TOMM7, EIF5A genes. The expression of SOX3, RBM9, WNT5A, HSP90, TOMM7, and EIF5A showed a significant difference from control levels. The relative sperm telomere length was found to be significantly lower in RIF patients as compared to controls (p &lt; 0.001***).

Limitations, reasons for caution

The current study was a case control study and lacked randomization and also is limited by low sample size. There is a lack of stratification in the enrollment of participants due to difference in specific risk of occurrence and varied clinical history.

Wider implications of the findings

The analysis of spermatozoal gene expression is important for understanding the sperm differentiation, fertilization and early embryonic events. Correlation with oxidative stress, genomic integrity and telomere length may help in regulationof gene expression. It may help in establishing sperm gene expression as a potential biomarker.

Trial registration number

Not applicable

P-656 Effect of COVID-19 vaccination on clinical outcome in fully vaccinated infertile women undergoing IVF/ICSI cycles at tertiary care centre: prospective observational study

Study question

Does immune response to COVID-19 vaccination affect the clinical outcome in fully vaccinated infertile women undergoing IVF/ICSI cycles?

Summary answer

COVID-19 IgG antibodies are present in follicular fluid post vaccination and higher immune response increases duration of gonadotrophins required and negatively impacts the IVF outcome.

What is known already

Recent studies assessed the influence of COVID-19 infection and mRNA COVID-19 vaccine on the stimulation cycle characteristics and embryological variables of patients undergoing IVF cycle and found no effect on the IVF outcome in their immediate IVF cycle after recovery, except for a decreased number of top quality embryos. One study reported infection or mRNA vaccine results in rapid formation of anti-COVID IgG which can be detected in follicular fluid. This immune response did not lead to any significant negative effect on ovarian follicular function. There is a possibility that COVID-19 infection might affect numerous fertility-linked proteins.

Study design, size, duration

Prospective observational study, conducted at Division of Reproductive Medicine of tertiary care institute. After taking informed consent, 32 patients who satisfy the inclusion and exclusion criteria with history of receiving two doses of Covishield or Covaxin vaccine with at-least 2 weeks from last dose, were recruited for IVF/ICSI cycles from December 2021 to January 2022, for assessing COVID-19 IgG antibodies in their follicular fluid.

Participants/materials, setting, methods

Women of 21-40 years with normal ovarian reserve and normal uterine cavity were included, those with history of COVID infection were excluded. All patients underwent GnRH antagonist protocol. Follicular fluid was collected at time of oocyte retrieval. After collecting oocytes, 400 microlitre of follicular fluid was stored at -80 and later thawed and analysed for SARS-CoV-2 IgG antibodies (ADVIA Centaur COV2G assay, Germany) which are expressed in index value and reported as reactive (≥1 index).

Main results and the role of chance

Out of 32, 21 (65.6%) of the participants had received COVISHIELD (V1)and 11 (34.3%) received COVAXIN (V2). The mean gap between vaccine and the IVF cycle was 84.94 ± 52.65 days. The mean COVID IgG antibody titres (Index) were significantly higher in V1, 28.77±33.50 (0.34 -100), than V2 2.28±3.74(0.05-13.23), p<0.001. Patients with higher antibody titres, required longer duration of ovarian stimulation, rho=0.42, p = 0.017. Patients with higher COVID IgG antibodies were negatively correlated with clinical pregnancy rate (20.9 0± 29.68 vs 4.60 ± 6.28, p = 0.153). The time gap from the last dose of vaccine to IVF cycle had moderate negative correlation with percentage of grade-I embryos out of the total embryos fertilised (%), rho= -0.33, p = 0.068. Furthermore, higher gonadotropins doses were required in patients with high antibody titres, rho=0.25, p = 0.160, and amongst V1 vs V2, total dose of gonadotropins required was 3802.38±742.92 vs 3422.73±564.52, respectively, p=0.115. COVID IgG antibody titres had weak negative correlation with number of grade-I embryos, rho= -0.16, p = 0.396. The time gap from the last dose of vaccine to IVF cycle had a weak negative correlation with number of grade-I embryos, rho=-0.28, p = 0.124.

Limitations, reasons for caution

The main limitation of this study is small sample size. However, the study is currently ongoing, and these are the interim results of the same. As prospective studies with larger sample size would be required to assess the effect of different COVID-19 vaccines in different populations on the IVF outcomes.

Wider implications of the findings

The present study confirms the presence of COVID IgG antibodies in follicular fluid in vaccinated women, and proves that COVISHIELD vaccinated patients had higher antibody titres. Higher antibody titres require longer duration of stimulation and result in poorer outcomes so a longer interval from vaccine to IVF should be recommended.

Trial registration number

NA

P-394 Peripheral and uterine natural killer cell cut-off levels and their correlation in fertile controls and women with unexplained recurrent implantation failure (RIF)

Study question

What is cut-off value for peripheral and uterine natural killer (pNK, uNK) cells and any correlation between them in fertile and RIF women?

Summary answer

Cut-off values were 7% for uNK and 11.6% for pNK in fertile controls. No significant correlation observed among fertile and infertile women with RIF.

What is known already

Association of uNK and pNK cells with infertility is debatable. It is not clear whether measuring NK cell levels in RIF has a role. pNk cell levels however has been used in various studies to guide the need of immunotherapy in RIF women. Definition of normal range of uNK cell numbers has also not been stated clearly because of lack of standardised protocol. Literature reveals the cut off values for pNk cells to be 12% or 18% and for uNK cells between 5-12.9%. Correlation between uNK and pNK cells in fertile or RIF women has not been studied earlier.

Study design, size, duration

A prospective study was conducted at ART Centre, Department of Obstetrics and Gynecology at tertiary care institute during a period from January 2019 to January 2021. Thirty women with RIF and fifty fertile controls with age &lt;35 years having regular menstrual cycles and no hormonal treatment in last 3 months were enrolled in the study for uNK and pNK cell testing. The permission was obtained from the Institute Ethics Committee.

Participants/materials, setting, methods

Subjects included women with RIF with age 20-35 years, tubal and unexplained factors, normal ovarian reserve, normal karyotype and normal uterine cavity. In both subjects and controls, midluteal endometrial biopsy sample was taken for Immunohistochemistry staining of CD 56+ cells to determine uNK cells. Peripheral venous blood was also obtained at the time of biopsy for flow cytometry in peripheral blood mononuclear cells to determine pNK cells. Cut off values were derived from fertile controls.

Main results and the role of chance

The mean age and BMI were comparable between fertile control and study group(29.45±3.3 vs 31.17±3.3 years, 22.97±1.89 vs 23.21±2.2 kg/m2; p-value &gt;0.05). The control group had median value of 7% for uNK cell levels and 11.6% for pNK cell levels. In RIF subjects, the median value for uNK cells was 13.5% and even though higher compared to controls it was not statistically significant(p-value &gt;0.05) . The median pNK values were comparable among controls and RIF group (11.6% vs. 12%). All RIF subjects did not have elevated NK cell levels. 18 (60%) subjects had elevated uNK cell levels (more than 7%) whereas 40% had below the reference value. pNK cells were also elevated in only 53.3% of subject population. There was positive correlation found between uNK and pNK cell levels in RIF subjects, however it was not statistically significant (r 0.312, p-value 0.09). In fertile controls, there was insignificant negative correlation between uNK and pNK cell levels (r -0.231, p-value 0.33).

Limitations, reasons for caution

The small sample size is the foremost limitation of study.

Wider implications of the findings

uNK cell testing may be worthwhile in women with unexplained RIF so as to guide immunotherapy to improve pregnancy outcomes. As no significant correlation has been found between pNK and uNK cells in fertile and RIF women, pNK cell testing in RIF women may be done with caution.

Trial registration number

Not Applicable

POS0656 FRAILTY AND RISK OF ADVERSE OUTCOMES IN BIOLOGIC OR TARGETED-SYNTHETIC DMARD TREATED PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Recently, it has been recognized that frailty and pre-frailty are common in patients with rheumatoid arthritis (RA) [1]. Whether frailty status portends an increased risk of adverse outcomes in patients with RA on biologic or targeted synthetic disease modifying anti-rheumatic drugs (b- or tsDMARDs) remains unknown.

Objectives

To evaluate the association between frailty and adverse outcomes in patients with RA exposed to b- or tsDMARDs.

Methods

Using the IBM/Watson MarketScan Commercial Claims and Encounters Databases, we identified all patients with RA who filled new prescriptions (or received infusions) for TNFα antagonists (TNFi), non-TNFi biologics (rituximab, abatacept, tocilizumab) or Janus Kinase inhibitors (JAKi) between 2008-2019. We used a 1-year lookback period without the use of these drugs to identify new users. The date of the first prescription within these three drug categories was the index date. Patients’ frailty risk score was calculated using the Claims-Based Frailty Index (CFI) [2], which estimates a deficit-accumulation frailty index using International Classification of Diseases codes, Current Procedural Terminology codes, and Healthcare Common Procedure Coding System codes in administrative claims data in the 1-year baseline period. The index ranges from 0 (not at all frail) to 1 (severely frail). The primary outcome was time to serious infections (those requiring hospitalization); secondary outcomes: any infection (outpatient or inpatient encounters) and all-cause hospitalizations.

Patients were followed until 1) outcome occurrence; 2) disenrollment; 3) >90 days elapsed (or >180 days for rituximab) without further fills of the first drug categories; 4) they filled/received infusions of b-/tsDMARDs from a different drug category; or 5) 2 years after index. Cox proportional hazards adjusting for demographics, calendar year, serious and/or opportunistic infections in the 12-months prior to index were used to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CIs) for each outcome. In separate model, we additionally adjusted for comorbidity burden, and health care utilization (HCU).

Results

A total of 62,246 patients with RA met our inclusion criteria of whom 50,910 (82%) started TNFi as their first biologic, 9525 (15%) non-TNFi biologics, and 1811 (3%) JAKi. Among these, 3928 (6%) were considered frail. In multivariable analyses, frail patients had higher risk of serious infections compared to non-frail patients (aHR 2.37, 95% CI 2.05-2.74) which decreased to aHR 1.34, 95% CI 1.13-1.58 (Table 1) after adjusting for comorbidity burden and the HCU. Similarly, frailty was associated with increased risk of any infection (aHR 1.18, 95% CI 1.11-1.25), and all-cause hospitalizations (aHR 1.34, 95% CI 1.21-1.49) relative to non-frail individuals.

Table 1.

Multivariable models evaluating the association between frailty status and inpatient infections as the outcome

Variable#Hazard Ratio (95% Confidence Interval)@Hazard Ratio (95% Confidence Interval)Frail2.37 (2.05, 2.74)1.34 (1.13, 1.58)

#Model adjusts for age, sex, major infection requiring inpatient admission in 12 months prior, concomitant baseline drugs such as csDMARDs, glucocorticoids, NSAIDs and opioids

@Model additionally adjusts for Chalrson comorbidy score and healthcare utilization

Conclusion

Frailty is an important predictor for the risk of adverse outcomes among patients with RA treated with b- or tsDMARDs. Our findings underscore the need for considering this parameter in patient evaluations (even among younger patients) in the clinic.

References

[1]Salaffi F et al: Prevalence of frailty and its associated factors in patients with rheumatoid arthritis: a cross-sectional analysis. Clin Rheumatol 2019

[2]Kim DH et al. Validation of a Claims-Based Frailty Index Against Physical Performance and Adverse Health Outcomes in the Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2019

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS1422 USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS AND RISK OF MULTIPLE MYELOMA IN PERSONS WITH RHEUMATOID ARTHRITIS

Background

Biologic therapies used in the management of rheumatoid arthritis (RA) target several cytokines that have been implicated in the pathogenesis of multiple myeloma (MM). Yet little is known about the association between use of biologic or targeted synthetic disease modifying anti-rheumatic drugs (b or tsDMARDs) in RA and the incidence of MM.

Objectives

Our objective was to estimate the association between b/tsDMARD use and the risk of MM among persons with RA using Veterans Health Administration (VHA) data. We hypothesized that b-/tsDMARD use is associated with a lower incidence of MM compared with conventional synthetic DMARDs (csDMARDs).

Methods

In this retrospective cohort study, we identified patients >18 years of age diagnosed with RA in any United States VHA facility from 1/1/2002 and 12/31/2018. All patients met the following inclusion criteria: 1) two or more International Classification of Diseases Version 9 or 10 (ICD9 or ICD10) codes for RA at least 7 days apart but no more than 365 days apart 2) a prescription for a csDMARD within 90 days of the first RA diagnosis 3) one inpatient or outpatient visit 30 days to 2 years preceding first RA diagnosis (indicating a regular user of VHA). Medication data was derived from the outpatient prescription fills, bar coded medication administration (BCMA), and intravenous (IV) data domains. The csDMARDs included in these analyses were: methotrexate, sulfasalazine, leflunomide, and hydroxychloroquine. The bDMARDs included were tumor necrosis factor inhibitors (TNFi) and non-TNFi biologics such as tocilizumab, rituximab, abatacept, and biosimilars; tsDMARD was tofacitinib. Patients with MM before the diagnosis of RA were excluded. Incident MM was determined by 1 or more ICD9/10 code or ICD-oncology codes. Multivariable Cox proportional hazards model were performed to estimate the hazard ratio for developing MM among those during and following the use of a b-/tsDMARD relative to b-/tsDMARD-naïve persons adjusting for age, gender, race, and ethnicity.

Results

27,540 veterans with RA met study eligibility criteria, of whom 8,322 (30%) had taken a b-/tsDMARD. Over the study period there were 77 incident MM over a total of 192,000 person years. There were 55 events in users of csDMARDs, an incidence rate (IR) of 0.40 (95% CI 0.30-0.52) per 1000 person-years and 22 in persons currently or formerly using b-/tsDMARDs (IR 0.41, 0.25-0.61 per 1000 person years). The unadjusted hazard ratio for MM following bDMARD use relative to csDMARD only use was 1.04 (0.63, 1.73), which increased to 1.28 (0.76, 2.16) after adjusting for demographic characteristics (Table 1).

Table 1.

Multivariable Cox proportional hazards model for association between use of disease modifying anti-rheumatic drugs and incident multiple myeloma.

Clinical characteristicHazards ratio (95% CI)csDMARDReferenceb-/tsDMARD use1.28 (0.76-2.16)Age*1.04 (1.02-1.07)Female0.58 (0.20-1.62)RaceReferenceWhite2.11 (1.15-3.86)Black0.70 (0.10-5.08)OtherHispanic Ethnicity0.71 (0.17-2.92)

Abbreviations: b-/tsDMARD- biologic or targeted synthetic disease modifying anti-rheumatic drug; CI: confidence interval

*Hazards ratio reflects risk per every 1-year increase in age

Model adjusted for age, gender, race, and ethnicity

Conclusion

In this nationwide VA study, we did not observe an association between bDMARD use and the incidence of MM. Of note, the median interval from initiation of a bDMARD to the end of follow-up was approximately 5.8 years, which does not allow for an examination of a possible longer term influence.

Disclosure of Interests

None declared