Perforated peptic ulcer disease in transferred patients is associated with significant increase in length of stay

BACKGROUND

Perforated peptic ulcer disease (PPUD) has a prevalence of 0.004-0.014% with mortality of 23.5% (Tarasconi et al. in World J Emerg Surg 15(PG-3):3, 2020). In this single center study, we examined the impact associated with patient transfer from outside facilities to our center for definitive surgical intervention (exploratory laparotomy).

METHODS

Using EPIC report workbench, we identified 27 patients between 2018 and 2021 undergoing exploratory laparotomy with a concurrent diagnosis of peptic ulcer disease, nine of which were transferred to our institution for care. We queried this population for markers of disease severity including mortality, length of stay, intensive care unit (ICU) length of stay, and readmission rates. Manual chart reviews were performed to examine these outcomes in more detail and identify patients who had been transferred to our facility for surgery from an outside hospital.

RESULTS

A total of 27 patients were identified undergoing exploratory laparotomy for definitive treatment of PPUD. The majority of patients queried underwent level A operations, the most urgent level of activation. In our institution, a Level A operation needs to go to the operating room within one hour of arrival to the hospital. Average mortality for this patient population was 14.8%. The readmission rate was 40.1%, and average length of ICU stay post-operatively was 16 days, with 83% of non-transfer patients requiring ICU admission and 100% of transfer patients requiring ICU admission, although this was not found to be statistically significant. Average length of hospital stay was 27 days overall. For non-transfer patients and transfer patients, LOS was 20 days and 41 days, respectively, which was statistically significant by one-sided t-test (p = 0.05).

CONCLUSION

Patients transferred for definitive care of PPUD in a population otherwise notable for high mortality and high readmission rates: their average length of stay compared to non-transfer patients was over twice the length, which was statistically significant. Transferred patients also had higher rates of ICU care requirement although this was not statistically significant. Further inquiry to identify modifiable variables to facilitate the care of transferred patients is warranted, especially in the context of improving quality metrics known to enhance patient outcomes, satisfaction, and value.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

GM-CSF is a marker of compartmentalised intrathecal inflammation in multiple sclerosis

BACKGROUND

Granulocyte-macrophage colony stimulating factor (GM-CSF) is a pro-inflammatory cytokine secreted by various immune cells. Several studies have demonstrated an expansion of GM-CSF producing T cells in the blood or CSF of people with MS (pwMS). However, whether this equates to greater concentrations of circulating cytokine remains unknown as quantification is difficult with traditional assays.

OBJECTIVE

To determine whether GM-CSF can be quantified and whether GM-CSF levels are elevated in pwMS.

METHODS

We employed Single Molecule Array (Simoa) to measure GM-CSF in both CSF and blood. We then investigated relationships between GM-CSF levels and measures of blood-CSF-barrier integrity.

RESULTS

GM-CSF was quantifiable in all samples and was significantly higher in the CSF of pwMS compared with controls. No association was found between CSF GM-CSF levels and Q-Albumin - a measure of blood-CSF-barrier integrity. CSF GM-CSF correlated with measures of intrathecal inflammation, and these relationships were greater in primary progressive MS compared with relapsing-remitting MS.

CONCLUSION

GM-CSF levels are elevated specifically in the CSF of pwMS. Our results suggest that elevated cytokine levels may reflect (at least partial) intrathecal production, as opposed to simple diffusion across a dysfunctional blood-CSF-barrier.

Two new mouse models of Gjb1-associated Charcot-Marie-Tooth disease type 1X

BACKGROUND

Charcot-Marie-Tooth disease type 1X is caused by mutations in GJB1, which is the second most common gene associated with inherited peripheral neuropathy. The GJB1 gene encodes connexin 32 (CX32), a gap junction protein expressed in myelinating glial cells. The gene is X-linked, and the mutations cause a loss of function.

AIMS

A large number of disease-associated variants have been identified, and many result in mistrafficking and mislocalization of the protein. An existing knockout mouse lacking Gjb1 expression provides a valid animal model of CMT1X, but the complete lack of protein may not fully recapitulate the disease mechanisms caused by aberrant CX32 proteins. To better represent the spectrum of human CMT1X-associated mutations, we have generated a new Gjb1 knockin mouse model.

METHODS

CRISPR/Cas9 genome editing was used to produce mice carrying the R15Q mutation in Gjb1. In addition, we identified a second allele with an early frame shift mutation in codon 7 (del2). Mice were analyzed using clinically relevant molecular, histological, neurophysiological, and behavioral assays.

RESULTS

Both alleles produce protein detectable by immunofluorescence in Schwann cells, with some protein properly localizing to nodes of Ranvier. However, both alleles also result in peripheral neuropathy with thinly myelinated and demyelinated axons, as well as degenerating and regenerating axons, predominantly in distal motor nerves. Nerve conduction velocities were only mildly reduced at later ages and compound muscle action potential amplitudes were not reduced. Levels of neurofilament light chain in plasma were elevated in both alleles. The del2 mice have an onset at ~3 months of age, whereas the R15Q mice had a later onset at 5-6 months of age, suggesting a milder loss of function. Both alleles performed comparably to wild type littermates in accelerating rotarod and grip strength tests of neuromuscular performance.

INTERPRETATION

We have generated and characterized two new mouse models of CMT1X that will be useful for future mechanistic and preclinical studies.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Detection of companion galaxies around hot dust-obscured hyper-luminous galaxy W0410-0913

The phase transition between galaxies and quasars is often identified with the rare population of hyper-luminous, hot dust-obscured galaxies. Galaxy formation models predict these systems to grow via mergers, that can deliver large amounts of gas toward their centers, induce intense bursts of star formation and feed their supermassive black holes. Here we report the detection of 24 galaxies emitting Lyman-α emission on projected physical scales of about 400 kpc around the hyper-luminous hot dust-obscured galaxy W0410-0913, at redshift z = 3.631, using Very Large Telescope observations. While this indicates that W0410-0913 evolves in a very dense environment, we do not find clear signs of mergers that could sustain its growth. Data suggest that if mergers occurred, as models expect, these would involve less massive satellites, with only a moderate impact on the internal interstellar medium of W0410-0913, which is sustained by a rotationally-supported fast-rotating molecular disk, as Atacama Large Millimeter Array observations suggest.

Lyman-alpha emission is one of the observational probes for the high-redshift universe. Here, the authors show several Lyman-alpha emitting companion galaxies around the hot dust-obscured galaxy W0410-091 suggesting that the galaxy evolves in a very dense environment.

Long-term outcome after biliopancreatic diversion type duodenal switch: A single-center experience with up to 20 years follow-up

Objective

Biliopancreatic diversion type duodenal switch (BPD-DS) is the most effective bariatric procedure in terms of weight loss and remission of comorbidities but carries the risk of severe long-term side effects. The aim of this study was to analyze the long-term effects of BPD-DS on weight loss, comorbidities and reoperation rate.

Methods

This is a retrospective single-center study of prospectively collected data of all patients who underwent BPD-DS from 1999 to 2011 at a single institution.

Results

116 patients (83.6% female) underwent BPD-DS with a mean initial body mass index (BMI) of 47 ± 6.5 kg/m2. 68% of the procedures were performed in open technique and 32% laparoscopically. Common channel length was routinely 1  m, mean alimentary limb length (AL) was 1.8 ± 0.6  m and mean bilio-pancreatic limb length (BPL) was 4.9 ± 1.6  m. 76.7% of patients had laparoscopic adjustable gastric banding (LAGB) prior to BPD-DS. Mean follow-up time was 14 ± 4.4 years and follow-up rate at 5, 10 and 14 years was 95.6% (n = 108), 90% (n = 98) and 75.3% (n = 70). Mean excess BMI loss (%EBMIL) at 5, 10 and 14 years was 78% ± 24.1, 76.5% ± 26.7 and 77.8% ± 33.8, respectively. The highest %EBMIL was reached two years postoperatively with 84% ± 23.6. Complete (n = 22) or partial remission (n = 4) of type 2 diabetes mellitus was observed in 92.8% of patients. Reoperation was necessary in 33 patients (28.4%) due to malnutrition or refractory diarrhea (10), excessive weight loss (1), insufficient weight loss or weight rebound (7), reflux or stenosis (7), oxalate nephropathy (2), liver cirrhosis (1) and various/combined indications (5). Mean time to reoperation was 7.7 ± 5 years. The predominant deficiencies were vitamin D (99.1%), zinc (86.9%), iron (83.5%) and calcium (71.3%). The were no procedure-related deaths in the short- or long-term.

Conclusion

BPD-DS leads to sustainable long-term weight loss with an acceptable reoperation rate. Nevertheless, regular follow-up is necessary to detect and treat malnutrition and vitamin deficiencies.

Outcome of revisional procedures up to 14 years after sleeve gastrectomy: A single-center experience

Objective

In the long-term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss, weight regain, development of gastroesophageal reflux disease (GERD) as well as persistence or relapse of comorbidities. The study's objective was to present results regarding weight loss, evolution of comorbidities and reoperation rate of patients who underwent a revisional bariatric procedure after SG.

Methods

Retrospective single-center analysis of a prospective database on patients who had a minimal follow-up of two years after conversion from SG to either a proximal Roux-en-Y gastric bypass (PRYGB), biliopancreatic diversion type duodenal switch (BPD/DS), long bilio-pancreatic limb-Roux-en-Y gastric bypass (LRYGB) or re-sleeve gastrectomy (RSG).

Results

Over a time period of 14 years, 549 SGs were performed. A total of 71 patients (13.0%) underwent a conversion from SG to PRYGB (n = 28, 39.4%), BPD/DS (n = 19, 26.8%), LRYGB (n = 17, 23.9%) and RSG (n = 7, 9.9%). Indications for the revisional procedures were GERD (33.8%), insufficient weight loss/weight regain (32.4%), a combination of both (31.0%) or stenosis/kinking of the sleeve (2.8%). The mean time from SG to revision was 5.2 ± 3.1 years and the mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after revision was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and LRYGB (32.9%) compared to RSG (20.0%; p = 0.04; p = 0.01). Patients with BPD/DS had significantly higher additional %TWL (26.2%) after conversion compared to PRYGB (15.6%, p = 0.04) and RSG (10.9%, p = 0.01). In case of GERD, reoperation led to a resolution of symptoms in 81.6% after RYGB. 19.7% of patients underwent an additional revisional procedure for internal herniation, chronic diarrhea after BDP/DS, common bile duct stones and weight regain.

Conclusion

In the event of insufficient weight loss/weight regain after SG, conversion to BPD/DS provides a significant post-revisional weight loss. RYGB leads to good symptom control in patients suffering from GERD.

A Rapid FRET Real-Time PCR Protocol for Simultaneous Quantitative Detection and Discrimination of Human Plasmodium Parasites

Malaria is the most important parasitic disease worldwide, and accurate diagnosis and treatment without delay are essential for reducing morbidity and mortality, especially in P. falciparum malaria. Real-time PCR is highly sensitive and highly specific, therefore an excellent diagnostic tool for laboratory detection and species-specific diagnosis of malaria, especially in non-endemic regions where experience in microscopic malaria diagnostics is limited. In contrast to many other real-time PCR protocols, our new fluorescence resonance energy transfer-based real-time PCR (FRET-qPCR) allows the quantitative and species-specific detection of all human Plasmodium spp. in one run. Species identification is based on single nucleotide polymorphisms (SNPs) within the MalFL probe, detectable by melting curve analysis. A significant advantage of our FRET-qPCR is the short turn-around time of less than two hours, including DNA extraction, which qualifies it for routine diagnostics. Rapid and reliable species-specific malaria diagnosis is important, because treatment is species-dependent. Apart from first-line diagnosis, the quantitative results of our new FRET-qPCR can be helpful in therapy control, to detect early treatment failure. Graphic abstract.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A42 HETEROGENEITY IN EFFICACY AND SAFETY ENDPOINTS FOR PEDIATRIC CLINICAL TRIALS IN INFLAMMATORY BOWEL DISEASE: A NEED FOR HARMONIZATION

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: None

The integrated stress response contributes to tRNA synthetase-associated peripheral neuropathy

Dominant mutations in ubiquitously expressed transfer RNA (tRNA) synthetase genes cause axonal peripheral neuropathy, accounting for at least six forms of Charcot-Marie-Tooth (CMT) disease. Genetic evidence in mouse and Drosophila models suggests a gain-of-function mechanism. In this study, we used in vivo, cell type–specific transcriptional and translational profiling to show that mutant tRNA synthetases activate the integrated stress response (ISR) through the sensor kinase GCN2 (general control nonderepressible 2). The chronic activation of the ISR contributed to the pathophysiology, and genetic deletion or pharmacological inhibition of Gcn2 alleviated the peripheral neuropathy. The activation of GCN2 suggests that the aberrant activity of the mutant tRNA synthetases is still related to translation and that inhibiting GCN2 or the ISR may represent a therapeutic strategy in CMT.

P–801 Effects of Lonomia obliqua venom components on human endometrial stromal cells: A potential source for new cytoprotective biomolecules against recurrent pregnancy loss

Study question

Could new molecules like Lonomia obliqua lipocalins and hemolins have cytoprotective effects on endometrial stem cells (hESC)?

Summary answer

Lonomia obliqua venom-induced hESC viability, proliferation and migration occurred mainly by protection against oxidative damage and ERK-dependent pathway activation

What is known already

Recurrent pregnancy loss (RPL) is associated with severe physical and psychological morbidity, for which there is no treatment options. The pathophysiology involves deficiency in proliferation and migration capacities of endometrial stromal cells (hESCs) impairing embryo implantation and development. Animal venoms are rich sources of bioactive molecules and despite its known toxic effects, they also have protective components such as pro-proliferative molecules, growth factor-like, anti-apoptotic and anti-oxidant.

Study design, size, duration

This study was an experimental in vitro with endometrial stem cells. Treatment duration was 8–72h. Every assay had control cells exposed to phosphate buffered saline (PBS).

Participants/materials, setting, methods

hESCs were isolated from fresh human endometrial biopsies and characterized according standard protocols. Then the effects of L. obliqua venomous secretions on cell viability, proliferation and migration were determined using MTT, wound-healing assay, sulforhodamine B (SRB) assay and measuring the immunocontent of Ki67. Venom components involved in cell enhancing effects were also identified by classical chromatographic methods and proteomic analysis. Assays were conducted in triplicate.

Main results and the role of chance

The hESCs in culture showed adhesiveness properties, presented a fusiform fibroblastoid morphology and ability to in vitro differentiate into adipocytes, osteocytes and chondrocytes. The expression of cell surface markers was also characterized by flow cytometry. hESCs were positive for mesenchymal markers (CD105, CD90 and CD73) and negative for hematopoietic markers (CD45 and CD11), indicating that isolated cells have potential for multilineage differentiation. L. obliqua bristle extract (LOBE) increased dose-dependently hESCs viability in a concentration range varying from 0.001 to 0.1 µg/mL, independently of the cell isolation bath. For some cell isolates (patient ID 1, 3, 4, 6 and 7) it was observed a slightly reduction in hESC viability at highest LOBE concentrations (10 µg/mL). Treatment increased hESC viability in the presence of low concentrations of fetal bovine serum (1% FBS) and even in its complete absence. This effect was long lasting, being significant up to 72 h of incubation with LOBE in serum deprivation conditions. r to identify the potential molecules involved in the cytoprotective action, a mass spectrometry-based proteomic analysis was performed. It was identified a total number of 430 proteins in LOBE and 312 proteins in L. obliqua hemolymph.

Limitations, reasons for caution

This study was only conducted in vitro.

Wider implications of the findings: In this work we reported the identification of at least six protein classes with cytoprotective properties through proteomic analysis and isolated one fraction enriched in this cytoprotective factors. L. obliqua secretions induced increase in hESCs viability, proliferation and migration mainly by the protection against oxidative damage and ERK-dependent pathway activation.

Trial registration number

Not applicable

Validation of a novel FRET real-time PCR assay for simultaneous quantitative detection and discrimination of human Plasmodium parasites

Increasing numbers of travelers returning from endemic areas, migrants, and refugees have led to a significant rise in the number of imported malaria cases in non-endemic countries. Real- time PCR serves as an excellent diagnostic tool, especially in regions where experience in microscopy is limited. A novel fluorescence resonance energy transfer-based real-time PCR (FRET-qPCR) was developed and evaluated using 56 reference samples of the United Kingdom National External Quality Assessment Service (UK NEQAS) for molecular detection of malaria, including P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. Species identification is based on single nucleotide polymorphisms (SNPs) within the genome where the MalLC640 probe binds, lowering the melting temperature in the melting curve analysis. The novel FRET-qPCR achieved 100% (n = 56) correct results, compared to 96.43% performing nested PCR. The high sensitivity, with a calculated limit of detection of 199.97 parasites/mL blood for P. falciparum, is a significant advantage, especially if low-level parasitemia has to be ruled out. Even mixed infections of P. falciparum with P. vivax or P. ovale, respectively, were detected. In contrast to many other real-time PCR protocols, this novel FRET-qPCR allows the quantitative and species-specific detection of Plasmodium spp. in one single run. Solely, P. knowlesi was detected but could not be differentiated from P. vivax. The turnaround time of this novel FRET-qPCR including DNA extraction is less than two hours, qualifying it for routine clinical applications, including treatment monitoring.

The burden of heat-related mortality attributable to recent human-induced climate change

Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991-2018. Across all study countries, we find that 37.0% (range 20.5-76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): A prospective comparative single center study

Objective

Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).

Methods

All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL) questionnaire.

Results

A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p &lt; 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.

Conclusion

While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

Continuously sutured versus linear-stapled anastomosis in 76 robotic-assisted Ivor Lewis esophagectomies

Objective

We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Two anastomotic techniques have been performed – continuously sutured (COSU) and linear-stapled (LIST). Aim of this study is to evaluate the two anastomotic techniques regarding perioperative outcomes in our experience.

Methods

Retrospective analysis of prospectively collected data between Oct. 2015 and Dec. 2020 including 76 patients. 45 underwent COSU and 31 LIST. Techniques are demonstrated with video material. Minor (Clavien-Dindo &lt; = 3a) and major (Clavien-Dindo &gt; = 3b) morbidity, rate of anastomotic insufficiency, mortality, and duration of hospitalization were compared.

Results

Patient characteristics were as follows: median age of 69 (35-83) years in COSU and 70 (36-83) years in LIST (p = 0.575), male gender in 84.4% of COSU and 83.9% of LIST (p = 1.000), and physical status with American Society of Anesthesiologists score 3 in 62.2% of COSU and 67.7% of LIST (p = 0.771). Concerning tumor characteristics there were 91.1% adenocarcinomas in COSU and 96.8% in LIST (p = 0.642), whereas the others were squamous cell carcinomas and one neuroendocrine tumor in COSU. The tumors were stage II in 22.2% respectively 32.3% and stage III in 57.8% respectively 48.4% of COSU and LIST (p = 0.555). Comparison of minor morbidity occurring in 60.0% of COSU and 54.8% of LIST (p = 0.813), major morbidity in 8.9% respectively 16.1% (p = 0.473), incidence of anastomotic insufficiency in 8.9% of COSU and 6.5% of LIST (p = 1.000), rate of surgical reintervention necessary in 2.2% respectively 9.7% (p = 0.298) as well as mortality of 2.2% in COSU and 3.2% in LIST (p = 1.000) showed no difference. Median duration of hospitalization of 20 (13-49) days in COSU and 20 (14-62) in LIST (p = 0.423) did not differ.

Conclusion

In rob-E COSU and LIST show comparable results and a preferable technique cannot be determined yet. Our results do not support the results of previous reports (Cerfolio et al.) that demonstrated a superiority of LIST. While stapling the backside of the anastomosis in LIST impresses as an elegant way to overcome the surgical demanding part of the anastomosis, other disadvantages such as compromising perfusion of the gastric conduit may prevail and limit the benefits. Further studies with a larger cohort are planned in order to draw more decisive conclusions.

Long-term effects of laparoscopic sleeve gastrectomy: What are the results beyond 10 years?

Objective

Sleeve gastrectomy (SG) has become the most commonly performed bariatric procedure worldwide. Newer studies providing long-term follow-up are showing high incidence of weight regain and high incidence of de novo reflux or worsening of preexisting GERD leading to conversion to different bariatric procedure. The objective of our study was to present 5 to 15-year follow-up results in terms of weight loss, remission of comorbidities and reoperation rate.

Methods

This is a retrospective analysis of prospectively collected data. The minimal follow-up time was 5 years. Patients who underwent SG between August 2004 and December 2014 were included. In case of reoperation patients were converted to Roux-en-Y gastric bypass or biliopancreatic diversion type duodenal-switch with or without hiatal hernia repair.

Results

A total of 307 patients underwent SG either as primary bariatric procedure (n = 262) or as redo operation after failed laparoscopic gastric banding (n = 45). Mean body mass index at time of primary SG was 46.4 ± 8.0 kg/m2. Mean age at operation was 43.7 ± 12.4 years with 68% females. Follow-up was 84% and 70% at 5 and 10 years respectively. The mean EBMIL for primary SG was 62.8 ± 23.1% after 5 years, 53.6 ± 24.6% after 10 years and 51.2 ± 20.3% after 13 years. Reoperation after SG was necessary in almost every fifth SG patient: 24 patients (7.8%) were reoperated due to insufficient weight loss, 12 patients (3.9 %) due to reflux, while 23 patients (7.5%) needed conversion due to both, insufficient weight loss and reflux. Comorbidities improved considerably while the incidence of new onset reflux was 29.7%.

Conclusion

SG provides a long-term EBMIL from 51 to 54% beyond 10 years and a significant improvement of comorbidities. On the other hand, a high incidence of both weight loss failure and de novo reflux was observed leading to conversion.

Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Objective

Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB.

Methods

Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, 493 without jejunal mesenteric defect closure, 292 with closure by non-absorbable suture with a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel, as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored.

Results

By primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5% to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery could reduce the rate of IH from 5.3% to 2.4%. Higher weight loss seemed to increase the risk of developing an IH.

Conclusion

The closure of the jejunal mesenteric defect by non-absorbable suture can reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, especially in patients with excellent weight loss. Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

Roux-en-Y gastric bypass with a long compared to a short biliopancreatic limb leads to better weight loss and glycemic control in obese mice

Objective

Roux-en-Y gastric bypass (RYGB) shows durable long-term weight loss and control of comorbidities in randomized controlled trials. However, the impact of the proportions of the biliopancreatic limb (BPL) and the total alimentary limb (TALL) on weight loss or glucose metabolism is still unclear.

Methods

Six weeks old C57BL/6J mice were fed high fat diet (HFD) to induce obesity and glucose intolerance. Mice underwent RYGB surgery with a very-long BPL (35% of total bowel length [TBL]), long BPL (25% of TBL), short BPL (15 % of TBL), or sham surgery. The alimentary limb (AL) was adjusted in dependency on the BPL to achieve a fixed CC length. Glycemia was assessment by intraperitoneal glucose tolerance tests.

Results

Mice undergoing RYGB with a very-long BPL showed excessive weight loss and mortality and were therefore excluded for further analyses. Total weight loss (TWL%) was significantly higher in the long BPL- compared to short BPL-group. Mice with a long BPL showed significantly improved glucose tolerance 14 days postoperatively, while 35 days postoperatively, the improvement in glucose tolerance with a long BPL was much less distinctive.

Conclusion

RYGB with a longer BPL leads to improved results including weight loss and glucose tolerance. However, the metabolic improvements seem to decrease over time. These findings could potentially be translated to humans by adjusting the BPL according to body weight and comorbidities. To avoid possible negative effects of a longer BPL total bowel length measurement is mandatory.

Superiority of continuous over intermittent intraoperative nerve monitoring in preventing vocal cord palsy

BACKGROUND

Continuous intraoperative nerve stimulation (IONM) with uninterrupted monitoring is likely better than intermittent IONM in preventing vocal cord palsy after thyroid surgery.

METHODS

This was a comparative study of intermittent versus continuous IONM in patients with benign and malignant thyroid disease treated at a tertiary centre over 10 years. Early postoperative and permanent vocal cord palsy rates were estimated. Multivariable logistic regression analysis was used to quantify the contributions of clinical and histopathological variables to early postoperative and permanent vocal cord palsy.

RESULTS

A total of 6029 patients were included, of whom 3139 underwent continuous and 2890 intermittent IONM. Based on nerves at risk (5208 versus 5024 nerves), continuous IONM had a 1·7-fold lower early postoperative vocal cord palsy rate than intermittent monitoring (1·5 versus 2·5 per cent). This translated into a 30-fold lower permanent vocal cord palsy rate (0·02 versus 0·6 per cent). In multivariable logistic regression analysis, continuous IONM independently reduced early postoperative vocal cord palsy 1·8-fold (odds ratio (OR) 0·56) and permanent vocal cord palsy 29·4-fold (OR 0·034) compared with intermittent IONM. One permanent vocal cord palsy per 75·0 early vocal cord palsies was observed with continuous IONM, compared with one per 4·2 after intermittent IONM. Early postoperative vocal cord palsies were 17·9-fold less likely to become permanent with continuous than intermittent IONM.

CONCLUSION

Continuous IONM is superior to intermittent IONM in preventing vocal cord palsy.

Combining the production of L-lactic acid with the production of feed protein concentrates from alfalfa

The production of L-lactic acid was investigated in combination with the production of protein concentrates in the frame of a green biorefinery for efficient utilization of grasses and legume crops. Alfalfa green juice was the sole substrate utilized for initial lactic acid fermentation with Lactobacillus salivarius, Lactobacillus paracasei or Bacillus coagulans in order to drop the pH and precipitate the plant proteins present in the juice. Afterwards, proteins were separated by microfiltration with 40-42% of protein recovery into protein concentrates, suited for feeding monogastric animals. The (residual) brown juice was investigated as source of nutrients for producing L-lactic acid from glucose or xylose with B. coagulans A107 or B. coagulans A166, respectively. Fermentation of glucose (30, 60, 100 g L^-1) resulted in productivities of 2.8-4.0 g L^-1 h^-1 and yields of 0.85-0.91 g LA per g consumed glucose. Fermentation of xylose (30, 60 g L^-1) resulted productivities of 1.1-2.3 g L^-1 h^-1 and yields of 0.83-0.88 g LA per g consumed xylose. Comparing different brown juices, initial green juice fermentation with B. coagulans is recommended if the brown juice is to be used for producing L-lactic acid. Based on our results, it is possible to combine protein recovery with lactic acid production, and the brown juice proved to be a good nutrient source for L-lactic acid production with high optical purities.

[Intraoperative measurement of parathyroid hormone in hyperparathyroidism]

Intraoperative parathyroid hormone (IOPTH) determination is based on the short half-life of parathyroid hormone (PTH) and the rapid analytical technology. The IOPTH provides functional information regarding correction of the overproductive state in hyperparathyroidism (HPT) and is superior to macroscopic evaluation of the parathyroid gland (PG) as well as any (intraoperative frozen section) form of histology (so-called biochemical frozen section). In this article the relevance and evaluation of IOPTH is defined for the most important forms of HPT, for primary HPT, renal secondary and tertiary HPT, multiple endocrine neoplasia type 1 (MEN1) and parathyroid carcinoma and clinical scenarios based on the currently available data. It becomes apparent that the additional benefits of IOPTH depend on diverse prerequisites of the specific type of HPT, the diagnostics as well as individual patient factors and strategic considerations for resection. Overall, the costs for IOPTH are comparably low and seem to be justified with respect to the gain in quality. In the hands of specialized endocrine surgeons IOPTH is an essential tool for intraoperative decision-making and quality assurance.

A 6-month randomized, double-blind, placebo-controlled trial of weekly exenatide in adolescents with obesity

BACKGROUND

Pharmacological treatment options for adolescents with obesity are very limited. Glucagon-like-peptide-1 (GLP-1) receptor agonist could be a treatment option for adolescent obesity.

OBJECTIVE

To investigate the effect of exenatide extended release on body mass index (BMI)-SDS as primary outcome, and glucose metabolism, cardiometabolic risk factors, liver steatosis, and other BMI metrics as secondary outcomes, and its safety and tolerability in adolescents with obesity.

METHODS

Six-month, randomized, double-blinded, parallel, placebo-controlled clinical trial in patients (n = 44, 10-18 years, females n = 22) with BMI-SDS > 2.0 or age-adapted-BMI > 30 kg/m² according to WHO were included. Patients received lifestyle intervention and were randomized to exenatide extended release 2 mg (n = 22) or placebo (n = 22) subcutaneous injections given once weekly. Oral glucose tolerance tests (OGTT) were conducted at the beginning and end of the intervention.

RESULTS

Exenatide reduced (P < .05) BMI-SDS (-0.09; -0.18, 0.00), % BMI 95th percentile (-2.9%; -5.4, -0.3), weight (-3 kg; -5.8, -0.1), waist circumference (-3.2 cm; -5.8, -0.7), subcutaneous adipose tissue (-552 cm³ ; -989, -114), 2-hour-glucose during OGTT (-15.3 mg/dL; -27.5, -3.1), total cholesterol (11.6 mg/dL; -21.7, -1.5), and BMI (-0.83 kg/m² ; -1.68, 0.01) without significant change in liver fat content (-1.36; -3.12, 0.4; P = .06) in comparison to placebo. Safety and tolerability profiles were comparable to placebo with the exception of mild adverse events being more frequent in exenatide-treated patients.

CONCLUSIONS

Treatment of adolescents with severe obesity with extended-release exenatide is generally well tolerated and leads to a modest reduction in BMI metrics and improvement in glucose tolerance and cholesterol. The study indicates that the treatment provides additional beneficial effects beyond BMI reduction for the patient group.

Assessing resilience of healthcare infrastructure exposed to COVID-19: emerging risks, resilience indicators, interdependencies and international standards

In the moment of preparation of this paper, the world is still globally in grip of the Corona (COVID-19) crisis, and the need to understand the broader overall framework of the crisis increases. As in similar cases in the past, also with this one, the main interest is on the “first response”. Fully appreciating the efforts of those risking their lives facing pandemics, this paper tries to identify the main elements of the larger, possibly global, framework, supported by international standards, needed to deal with new (emerging) risks resulting from threats like Corona and assess the resilience of systems affected. The paper proposes that future solutions should include a number of new elements, related to both risk and resilience. That should include broadening the scope of attention, currently focused onto preparation and response phases, to the phases of “understanding risks”, including emerging risks, and transformation and adaptation. The paper suggests to use resilience indicators in this process. The proposed approach has been applied in different cases involving critical infrastructures in Europe (energy supply, water supply, transportation, etc., exposed to various threats), including the health system in Austria. The detailed, indicator-based, resilience analysis included mapping resilience, resilience stress-testing, visualization, etc., showing, already before the COVID-19, the resilience (stress-testing) limits of the infrastructures. A simpler (57 indicator based) analysis has, then been done for 11 countries (including Austria). The paper links these results with the options available in the area of policies, standards, guidelines and tools (such as the RiskRadar), with focus on interdependencies and global standards—especially the new ISO 31,050, linking emerging risks and resilience.

OP0290 EMAPALUMAB (ANTI-INTERFERON-GAMMA MONOCLONAL ANTIBODY) IN PATIENTS WITH MACROPHAGE ACTIVATION SYNDROME (MAS) COMPLICATING SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (SJIA)

Background:

MAS is a severe complication of rheumatic diseases and occurs most frequently in patients with sJIA. Data from animal models and from observational studies in patients suggest that interferon gamma (IFNy) is a driver of the hyperinflammation and hypercytokinemia observed in MAS.

Objectives:

To assess the pharmacokinetics, efficacy, and safety of intravenous (IV) infusions of emapalumab, a fully human anti-IFNγ monoclonal antibody, in patients with MAS in the context of sJIA.

Methods:

This ongoing, pilot, open-label, single-arm study (NCT03311854) includes patients with MAS (2016 ACR/EULAR criteria) on a background of confirmed, or high presumption of, sJIA, and with inadequate response to high-dose IV glucocorticoids. Emapalumab is initiated at 6 mg/kg (1 dose) and continued at 3 mg/kg twice weekly for a total of 4 weeks, or less upon achievement of complete response (CR). CR is defined as an absence of MAS clinical signs plus white blood cell and platelet counts above the lower limit of normal, LDH, AST and ALT <1.5 x upper limit of normal, fibrinogen >100 mg/dL, and ferritin decreased by ≥80% or to <2,000 ng/mL.

Results:

We report preliminary data from the first 9 patients (median age [range] 11.6 [2.1-25.3] years) enrolled (7 in Europe and 2 in the USA). All patients had failed high-dose methylprednisolone, of which there were prior treatment failures from cyclosporin A (n=4) and from anakinra (n=4). Treatment with emapalumab resulted in rapid IFNγ neutralization, as demonstrated by the decrease in CXCL9 levels (Figure 1), and subsequent deactivation of T cells, as indicated by the decrease in sIL-2R levels. CR was achieved in all patients after a median of 23 (12-56) days. A progressive improvement in all clinical and laboratory parameters of MAS was observed (Table 1 and Figure 2). Glucocorticoids were tapered in all patients (median % tapering -92%; range -45% to -98% at Week 8). Emapalumab infusions were well tolerated by all patients, with no discontinuation. CMV reactivation was reported in 1 patient as a serious event possibly related to emapalumab and resolved with antiviral treatment.

Table 1.

Time to response for key clinical and laboratory parameters.

ParametersMedian baseline value (range)Median days of treatment (range)D-dimers to <1000 mg/L12,480 (550-89,552)15 (1-49)sIL-2R to <2000 ng/L4596 (1664-20,954)21 (6-37)Ferritin <500 mg/L29,240 (716-192,584)21 (9-42)Physician visual analog scale of MAS activity ≤19.0 (2-10)19 (9-56)All MAS laboratory parameters within range of CRNA21 (15-55)All MAS parameters within range of CRNA23 (12-56)Glucocorticoid tapering at ≤1 mg/kg prednisolone equivalent*NA42 (16-50)

*Data incomplete for 1 patient

Figure 1.

Rapid neutralization of IFNy. Each line represents an individual patient (n=9).

Figure 2.

Ferritin levels and platelet counts over time.

Conclusion:

Emapalumab administration led to rapid neutralization of IFNy and was efficacious in controlling MAS with a favorable safety profile. These results support the pathogenic role of IFNγ in MAS/sJIA and the therapeutic value of IFNγ neutralization in MAS patients who have failed standard of care.

Disclosure of Interests:

Fabrizio De Benedetti Grant/research support from: AbbVie, Pfizer, Novartis, Novimmune, Sobi, Sanofi, Roche, Speakers bureau: AbbVie, Novartis, Roche, Sobi, Paul Brogan Grant/research support from: Sobi, Novartis, Roche, Chemocentryx, Consultant of: Roche, Sobi, Speakers bureau: Sobi, Roche, Novartis, UCB, Claudia Bracaglia: None declared, Manuela Pardeo: None declared, Giulia Marucci: None declared, Emanuela Sacco: None declared, Despina Eleftheriou Speakers bureau: Sobi, Charalampia Papadopoulou: None declared, Alexei Grom Grant/research support from: Novartis, AB2Bio, Consultant of: Novartis, Pierre Quartier Consultant of: AbbVie, Chugai-Roche, Lilly, Novartis, Sanofi, Sobi, Speakers bureau: AbbVie, BMS, Chugai-Roche, Novartis, Pfizer, Sobi, Rayfel Schneider Grant/research support from: Roche, Novartis, Sobi, Pfizer, Consultant of: Sobi, Novartis, Novimmune, Philippe Jacqmin Consultant of: Sobi, Rikke Frederiksen Employee of: Sobi, Maria Ballabio Employee of: Sobi, Cristina De Min Employee of: Sobi

AB1059 A RANDOMIZED, PLACEBO-CONTROLLED STUDY OF ANAKINRA IN PATIENTS WITH STILL´S DISEASE

Background:

Adult-onset Still’s disease (AOSD) and systemic juvenile idiopathic arthritis (SJIA) are rare autoinflammatory disorders associated with an activated IL-1 pathway, characterized by spiking fever, rash, arthritis, lymphadenopathy, hepatosplenomegaly and serositis. There is a growing understanding that SJIA and AOSD are one disease with different ages of onset, i.e. Still’s disease. The anaSTILLs study (anakinra inStill´sdisease) was designed to further evaluate efficacy and safety of anakinra in patients with Still´s disease across all age groups.

Objectives:

The primary objective was to demonstrate efficacy of anakinra versus placebo as assessed by ACR30 response with absence of fever at Week 2. Secondary objectives included: early onset of efficacy, sustained efficacy, time to study drug discontinuation, safety, pharmacokinetics, clinical signs and biomarkers.

Methods:

‘anaSTILLs’ was a randomized, double-blind, placebo-controlled, 12-week study including patients with active and newly diagnosed (6 months) Still´s disease according to adapted ILAR criteria if <16, or Yamaguchi criteria, if ≥16 years of age at disease onset. Patients were randomized to anakinra 2 mg/kg (max 100 mg/day), 4 mg/kg (max 200 mg/day) or placebo.

Results:

12 patients were randomized and received study drug: 6 anakinra (2 mg/kg n=2, 4 mg/kg n=4) and 6 placebo, the study was terminated early due to slow recruitment. 1 patient on placebo had lymphoma, not Still’s disease, and was excluded; thus in total 11 patients were analyzed for efficacy, 8 were children [median (range) age=4.0 (1-11) years] and 3 were adults [median (range) age=32.0 (25-51) years]. 55% were male and the mean symptom duration was 74.2 days. All patients on anakinra but none on placebo achieved ACR30 response with absence of fever at Week 2 (p-value=0.0022). The efficacy of anakinra was further demonstrated by superiority to placebo in ACR50/70/90 responses with absence of fever at Week 2. All placebo patients discontinued the study within 6 weeks, 2 due to progressive disease, 2 due to lack of efficacy and 1 due to withdrawal by patient. There was a numerically higher proportion with early onset of efficacy (Week 1) in the anakinra group compared to placebo. The ACR30/50/70/90 responses in the anakinra group were sustained throughout the study period. Patients in the anakinra group had a prompt and persistent decrease in CRP and ferritin levels at Week 1, which was not observed in the placebo group. There were no unexpected safety findings. All anakinra patients developed anti-drug antibodies (ADAs) at some timepoint during the study. ADAs were persistent throughout the treatment period, except in one patient. Titers were low to moderate. One placebo patient had low ADA titers at one occasion. No neutralizing antibodies were observed and the ADAs did not appear to impact clinical efficacy or safety.

Conclusion:

Anakinra is superior to placebo in the treatment of Still’s disease. ADAs occur frequently but do not appear to adversely impact efficacy or safety. These results confirm the benefits of anakinra treatment in patients with active, newly diagnosed Still´s disease across ages.

Disclosure of Interests:

Laura Schanberg Grant/research support from: Sobi, BMS, Consultant of: Aurinia, UCB, Sanofi, Peter Nigrovic Grant/research support from: Novartis, BMS, Pfizer, Consultant of: Novartis, BMS, Pfizer, Sobi, Miach Orthopedics, Simcere, XBiotech, Quench Bio, Ashley Cooper: None declared, Winn Chatham Grant/research support from: Sobi, Consultant of: Sobi, Shoghik Akoghlanian: None declared, Namrata Singh: None declared, Egla Rabinovich Grant/research support from: AbbVie, UCB Pharma, Janssen Research & Development, Akaluck Thatayatikom: None declared, Alysha Taxter: None declared, Jonathan Hausmann Consultant of: Novartis, Milan Zdravkovic Shareholder of: Sobi, Employee of: Sobi, Sven Ohlman Shareholder of: Sobi, Employee of: Former employee of Sobi, Henrik Andersson Employee of: Sobi, Susanna Cederholm Shareholder of: Sobi, Employee of: Sobi, Margareta Wikén Shareholder of: Sobi, Employee of: Former employee of Sobi, Rayfel Schneider Grant/research support from: Roche, Novartis, Sobi, Pfizer, Consultant of: Sobi, Novartis, Novimmune, Fabrizio De Benedetti Grant/research support from: AbbVie, Pfizer, Novartis, Novimmune, Sobi, Sanofi, Roche, Speakers bureau: AbbVie, Novartis, Roche, Sobi

A novel 5-Plex qPCR-HRM assay detecting human diarrheal parasites

Background

Intestinal parasitic diseases occur worldwide, and their diagnosis poses considerable challenges. Cryptosporidium spp., Entamoeba histolytica, Giardia intestinalis, (and, arguably, Dientamoeba fragilis and Blastocystis spp.) are among the most important and common parasitic protozoans causing diarrhea. Several multiplex real-time PCR assays have been developed for the synchronous detection of these parasites. However, most assays include the use of hydrolysis probes, increasing the cost of stool examination. In this study, we designed and evaluated a real-time PCR protocol, based on high-resolution melting (HRM) curve analysis, to simultaneously detect and differentiate five gastrointestinal parasites.

Results

Using a blinded panel of 143 clinical samples with laboratory diagnostic data to evaluate the method, we obtained a 95.8% concordance with conventional methods. Moreover, 4.2% of the samples were positive for D. fragilis and 2.8% additional Cryptosporidium infections were found with our multiplex assay. Our method is sensitive and specific for the selected parasites with the additional possibility of being run in single-plex as a backup control for mixed infections.

Conclusions

The assay is a convenient and cost-effective method that could contribute to a quicker and accurate diagnosis as well as to more targeted therapies of parasite-derived diarrhea. Finally, this new multiplex PCR assay could also be instrumental in epidemiology studies on these parasites.

Anomalous pressure dependence of the electronic transport and anisotropy in SrIrO3 films

Iridate oxides display exotic physical properties that arise from the interplay between a large spin-orbit coupling and electron correlations. Here, we present a comprehensive study of the effects of hydrostatic pressure on the electronic transport properties of SrIrO3 (SIO), a system that has recently attracted a lot of attention as potential correlated Dirac semimetal. Our investigations on untwinned thin films of SIO reveal that the electrical resistivity of this material is intrinsically anisotropic and controlled by the orthorhombic distortion of the perovskite unit cell. These effects provide another evidence for the strong coupling between the electronic and lattice degrees of freedom in this class of compounds. Upon increasing pressure, a systematic increase of the transport anisotropies is observed. The anomalous pressure-induced changes of the resistivity cannot be accounted for by the pressure dependence of the density of the electron charge carriers, as inferred from Hall effect measurements. Moreover, pressure-induced rotations of the IrO6 octahedra likely occur within the distorted perovskite unit cell and affect electron mobility of this system.

Procalcitonin in hemodialysis patients presenting with fever or chills to the emergency department

We sought to assess the role of procalcitonin in discriminating severe bacterial infections requiring antibiotic treatment from non-bacterial causes of fever or chills in chronic dialysis patients. Chronic hemodialysis patients who were admitted to the emergency room due to fever and/or chills were recruited to the study. The presence or absence of bacterial infection was defined after recruitment conclusion by an infectious disease specialist who was blinded to procalcitonin results. Procalcitonin levels were compared between infected and non-infected patients. Out of 54 patients recruited, 22 (41%) patients eventually diagnosed with infection. Mean (± SD) procalcitonin values were 4.3 (± 5.5) ng/ml among cases, 1.0 (± 2.0) ng/ml among controls with no infection (p = 0.02). A cutoff PCT value of 1 ng/ml or higher had 77% sensitivity and 59% specificity for the diagnosis of severe infection. Procalcitonin cannot usefully identify hemodialysis patient with bacterial infection.

A57 VALPROATE INDUCED DRESS SYNDROME CAUSING MIXED LIVER INJURY

Background

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome occurs with 1 in every 1,000 to 10,000 drug exposures and has a mortality rate of up to 10%. It is one mechanism by which medications can induce liver injury with elevated liver enzymes seen in the majority of cases. In children, aromatic anticonvulsants are the drugs most commonly associated with DRESS syndrome. Valproate, a non-aromatic anti-epileptic, is not known to have a heightened risk of hypersensitivity syndromes and is often the anti-epileptic of choice in patients who develop hypersensitivity syndromes from other anti-epileptics. Valproate hepatotoxicity is normally caused by its inhibition of fatty acid transport and mitochondrial β-oxidation; vanishing bile duct syndrome is also reported.

Aims

We present a case, to the best of our knowledge the first in paediatrics, in which valproate causes DRESS syndrome and a secondary, predominantly cholestatic, liver injury.

Methods

Literature review and case report.

Results

A previously healthy 14-year-old girl was diagnosed with new-onset seizures and started on valproate. Three weeks later, she developed a pruritic exanthem. Despite discontinuing her valproate, the rash persisted and she developed fever and jaundice. She was admitted to the ICU at the Hospital for Sick Children with a diagnosis of DRESS syndrome (RegiSCAR DRESS score 7) for treatment with IV steroids. At admission, she had a skin eruption, fever, leukocytosis (22.86 x109/L), eosinophilia (1.03x109/L), atypical lymphocytes (1.62 x109/L), lymphadenopathy, and internal organ involvement (BiliC 138, GGT 501, INR 1.3, ALT 543, AST 370, Crt 109). Of note, her EBV PCR was positive. By discharge, her rash improved and kidney function normalized. Her cholestasis persisted, despite improvement in her transaminases and eosinophilia (BiliC 163, INR 1.0, GGT 338, ALT 506, AST 220, Eos 0.98x109/L). She was discharged home on an oral steroid wean, ursodeoxycholic acid, levocarnitine, and levetiracetam. Upon reaching a daily dose of 20mg of prednisone, her rash and pruritus worsened, she had lost 7kg, and she was readmitted for IV steroids. Her rash improved within 4 days and she was discharged on a slower steroid taper, with the addition of cholestyramine and insulin for steroid induced diabetes. At present (2 ½ months after diagnosis), she continues her oral steroids and has persistent liver injury and pruritus.

Conclusions

We report the first paediatric case of valproate induced DRESS syndrome causing a significant cholestatic presentation with otherwise preserved liver synthetic function. The prolonged cholestasis and pruritus may be a result of the natural course of DRESS syndrome, EBV reactivation/infection, or polypharmacy. Early recognition of DRESS syndrome as a mechanism of valproate induced liver injury in children is essential for earlier diagnosis and initiation of targeted therapy.

Funding Agencies

None

Determination of Sucralose in Soft Drinks by High-Performance Thin-Layer Chromatography: Interlaboratory Study

An interlaboratory comparison was carried out to evaluate the effectiveness of a method based on HPTLC in which reagent-free derivatization is followed by UV/fluorescence detection. The method was tested for the determination of sucralose (C12H19Cl3O8; (2R,3R,4R,5S,6R)-2- [(2R,3S,4S,5S)-2,5-bis(chloromethyl)-3,4-dihydroxyoxolan- 2-yl]oxy-5-chloro-6-hydroxymethyl)oxane-3, 4-diol; CAS Registry No. 56038-13-2) in carbonated and still beverages at the proposed European regulatory limits. For still beverages, a portion of the sample was diluted with methanolwater. For carbonated beverages, a portion of the sample was degassed in an ultrasonic bath before dilution. Turbid beverages were filtered after dilution through an HPLC syringe filter. The separation of sucralose was performed by direct application on amino-bonded (NH2) silica gel HPTLC plates (no cleanup needed) with the mobile phase acetonitrilewater. Sucralose was determined after reagent-free derivatization at 190C; it was quantified by measurements of both UV absorption and fluorescence. The samples, both spiked and containing sucralose, were sent to 14 laboratories in five different countries. Test portions of a sample found to contain no sucralose were spiked at levels of 30.5, 100.7, and 299 mg/L. Recoveries ranged from 104.3 to 124.6 and averaged 112 for determination by UV detection; recoveries ranged from 98.4 to 101.3 and averaged 99.9 for determination by fluorescence detection. On the basis of the results for spiked samples (blind duplicates at three levels), as well as sucralosecontaining samples (blind duplicates at three levels and one split level), the values for the RSDr ranged from 10.3 to 31.4 for determinations by UV detection and from 8.9 to 15.9 for determinations by fluorescence detection. The values for the RSDR values ranged from 13.5 to 31.4 for determinations by UV detection and from 8.9 to 20.7 for determinations by fluorescence detection.

Early Multidisciplinary Intensive-care Therapy can Improve Outcome of Severe Anti-NMDA-receptor Encephalitis Presenting with Extreme Delta Brush

Anti-N-methyl-D-aspartate receptor encephalitis (Anti-NMDARE) is a synaptic autoimmune encephalitis syndrome mainly affecting young females. An underlying tumor, most commonly ovarian teratomas in young females, may indicate a paraneoplastic syndrome. Prognostic factors of the clinical course of disease and outcome play a central role in view of early administration of second-line immunotherapy and intensive-care therapy. We report a case of severe Anti-NMDARE associated with unfavorable predictors including an extreme delta brush (EDB) electroencephalographic-pattern and high anti-NMDAR-antibody titers in the cerebral spinal fluid (CSF), which necessitated the admission to an intensive care unit. In spite of the poor prognosis, the patient completely recovered; we attribute this to an early escalation to second-line immunotherapy with rituximab and multidisciplinary intensive-care therapy. The present case underlines the relevance of multidisciplinary management for individuals with Anti-NMDARE.

[Surgical treatment options for cervical paragangliomas]

The therapies available for the rare tumor entity of cervical paraganglioma (PG) are currently undergoing a paradigm shift. The treatment of choice for small carotid body tumors, malignant and active endocrine tumors is surgical resection; however, for locally advanced carotid body tumors and vagal PG, surgical therapy should be critically evaluated. Due to the immediate proximity of these hypervascularized tumors to the caudal cranial nerves, there is a risk of severe nerve damage with a significant impairment of quality of life after resection, particularly for locally advanced cervical PG, emphasizing further the importance of a restrictive surgical strategy. External radiotherapy can provide an equivalent primary therapeutic option with respect to the rate of recurrence and is accompanied by a lower morbidity. The slow rate of tumor progression and the multifocality of the familial variant of cervical PG or significant comorbidities in older, asymptomatic patients warrant a less aggressive treatment strategy for these tumors. When a wait and scan approach is implemented, a closely monitored radiological and clinical re-evaluation is of upmost importance. In a multidisciplinary approach the following critical points require consideration before a therapy is implemented,: size and location of the tumor, progression rate, genetic background, patient age and general condition, relevant comorbidities, the presence of synchronous PG and/or vasoactive catecholamine-producing tumors. Although best practice algorithms for the treatment of cervical PG have already been devised, recent innovative developments have led to more patient-tailored, individualized treatment approaches.

Preliminary Evidence for the Absence of Cystic Echinococcosis in Gabon: A Cross-Sectional Pilot Survey in Humans and Definitive Hosts

Cystic echinococcosis (CE) is a globally endemic zoonosis caused by the larval stage of the Echinococcus granulosus sensu lato (s.l.) complex. Although the disease is known to be highly prevalent in certain parts of North and East Africa, data on CE, both in humans and definitive hosts, are extremely scarce for Central Africa. The present study assessed the epidemiology of CE in humans and dogs in rural Gabon. An ultrasound and serologic survey was conducted in volunteers from rural villages in Gabon. A two-step approach was used for serological testing with an indirect hemagglutination assay as a screening test and Western Blot as a confirmatory test. Fecal dog samples were analyzed microscopically, and polymerase chain reaction (PCR) amplification of nad1 and cox1 genes was performed when taeniid eggs were visible. Regional hospitals and the national reference center for parasitology in Gabon were contacted for information about previous cases of CE. Randomly selected communities were invited to participate. Three hundred and forty-eight human volunteers from these communities were screened. No suspected cases of CE were detected. Definitive host screening was performed from 128 fecal samples from representative subregions, but no eggs from E. granulosus s.l. were found. No documented cases of echinococcosis were reported from the local health-care institutions and the national diagnostic reference center in Gabon. Cystic echinococcosis seems to be very rare or absent in Gabon. The reason for this lack of evidence for echinococcosis is unknown, but the absence of livestock may play a major role.

Twenty-year experience of paediatric thyroid surgery using intraoperative nerve monitoring

BACKGROUND

There are few data on intermittent and continuous intraoperative nerve monitoring (IONM) during thyroidectomy in children.

METHODS

All children aged 18 years or younger who had standard thyroid operations using intermittent or continuous IONM between January 1998 and December 2016 were included in the study. The impact of age and type of IONM on basal amplitude, latency and complications after thyroidectomy were assessed.

RESULTS

A total of 504 children were included in the study. With continuous IONM, median basal amplitude and latency increased significantly with age, more on the left side (from 199 to 870 μV, and from 3·88 to 5·75 ms) than on the right (from 340 to 778 μV, and from 2·63 to 3·50 ms). Compared with intermittent IONM with needle electrode, continuous IONM with tube electrode resulted in an increase in median basal amplitude in children aged 13-18 years on both sides (from 675 to 778 μV on the right and from 450 to 870 μV on the left), and a decrease in median latency in all children older than 3 years: in children aged 4-6 years, from 4·20 to 3·00 ms on the right and from 6·10 to 4·63 ms on the left; in children aged 7-12 years, from 4·60 to 3·50 ms and from 6·00 to 5·25 ms respectively; and in children aged 13-18 years, from 4·60 to 3·50 ms and from 6·40 to 5·75 ms. Overall, wound infection, but not bleeding/haematoma or vocal fold palsy, affected younger children more: 3 per cent of children aged 3 years or less; 2 per cent of children aged 4-6 years; and 0 per cent of children aged over 6 years (P = 0·031). With continuous IONM, no wound infection, bleeding/haematoma or permanent vocal fold palsy was noted in any age group.

CONCLUSION

Continuous IONM measures nerve electrophysiology more accurately than intermittent IONM during thyroidectomy in children.