Evaluating the impact of sickle cell disease on COVID-19 susceptibility and severity: a retrospective cohort study based on electronic health record

Background

Sickle cell trait/disease (SCT/SCD) are enriched among Black people and associated with various comorbidities. The overrepresentation of these characteristics prevents traditional regression approach obtaining convincing evidence for the independent effect of SCT/SCD on other health outcomes. This study aims to investigate the association between SCT/SCD and COVID-19-related outcomes using causal inference approaches that balance the covariate.

Methods

We leveraged electronic health record (EHR) data from the University of Chicago Medicine between March 2020 and December 2021. Demographic characteristics were retrieved. Medical conditions were identified using ICD-10 codes. Five approaches, including two traditional regression approaches (unadjusted and adjusted) and three causal inference approaches [covariate balancing propensity score (CBPS) matching, CBPS weighting, and CBPS adjustment], were employed.

Results

A total of 112,334 patients were included in the study, among which 504 had SCT and 388 SCD. Patients with SCT/SCD were more likely to be non-Hispanic Black people, younger, female, non-smokers, and had a diagnosis of diabetes, heart failure, asthma, and cerebral infarction. Causal inference approaches achieved a balanced distribution of these covariates while traditional approaches failed. Across these approaches, SCD was consistently associated with COVID-19-related pneumonia (odds ratios (OR) estimates, 3.23 (95% CI: 2.13-4.89) to 2.57 (95% CI: 1.10-6.00)) and pain (OR estimates, 6.51 (95% CI: 4.68-9.06) to 2.47 (95% CI: 1.35-4.49)). While CBPS matching suggested an association between SCD and COVID-19-related acute respiratory distress syndrome (OR = 2.01, 95% CI: 0.97-4.17), this association was significant in other approaches (OR estimates, 2.96 (95% CI: 1.69-5.18) to 2.50 (95% CI: 1.43-4.37)). No association was observed between SCT and COVID-19-related outcomes in causal inference approaches.

Conclusion

Using causal inference approaches, we provide comprehensive evidence for the link between SCT/SCD and COVID-19-related outcomes.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

Amoebic crab disease (ACD) in edible crab Cancer pagurus from the English Channel, UK

The genera Paramoeba and Neoparamoeba (Amoebozoa, Dactylopodida, Paramoebidae) include well-known opportunistic pathogens associated with fish (N. peruans; amoebic gill disease), lobsters, molluscs and sea urchins, but only rarely with crabs (grey crab disease of blue crabs). Following reports of elevated post-capture mortality in edible crabs Cancer pagurus captured from a site within the English Channel fishery in the UK, a novel disease (amoebic crab disease, ACD) was detected in significant proportions of the catch. We present histopathological, transmission electron microscopy and molecular phylogenetic data, showing that this disease is defined by colonization of haemolymph, connective tissues and fixed phagocytes by amoeboid cells, leading to tissue destruction and presumably death in severely diseased hosts. The pathology was strongly associated with a novel amoeba with a phylogenetic position on 18S rRNA gene trees robustly sister to Janickina pigmentifera (which groups within the current circumscription of Paramoeba/Neoparamoeba), herein described as Janickina feisti n. sp. We provide evidence that J. feisti is associated with ACD in 50% of C. pagurus sampled from the mortality event. A diversity of other paramoebid sequence types, clustering with known radiations of N. pemaquidensis and N. aestuarina and a novel N. aestuarina sequence type, was detected by PCR in most of the crabs investigated, but their detection was much less strongly associated with clinical signs of disease. The discovery of ACD in edible crabs from the UK is discussed relative to published historical health surveys for this species.

POS1060 CHANGES IN DISEASE ACTIVITY AND PATIENT-REPORTED OUTCOMES IN PSORIATIC ARTHRITIS PATIENTS TREATED WITH IXEKIZUMAB IN A REAL-WORLD US COHORT

Background

Ixekizumab (IXE), an IL-17A inhibitor, has demonstrated efficacy in clinical trials1-3 but real-world effectiveness (RWE) data are limited.4

Objectives

To describe changes in disease activity and patient-reported outcomes (PROs) at 6 and 12 months follow-up among psoriatic arthritis (PsA) patients initiating IXE in a routine clinical setting.

Methods

This retrospective cohort study included patients from the OM1 PsA Registry (OM1, Boston, MA), a linked electronic medical record and administrative claims dataset with over 50,000 patients. Eligible patients had ≥1 prescription for IXE (first = index), were ≥18 years old at index, had ≥1 diagnosis code for PsA in the 12 months before or on index, and had ≥12 months of baseline and ≥6 months of follow-up data as of June 2021. For patients with baseline and follow-up measures available, changes in Clinical Disease Activity Index (CDAI), PROs, and other clinical outcomes from baseline to 6 and 12 months were described. For patients on IXE monotherapy, change in CDAI score from baseline to 6 and 12 months was assessed using mixed effects linear models adjusted for age, sex, and baseline CDAI score.

Results

The study population included 1,812 patients with a mean age of 53.7 years (Table 1). Psoriasis was present in 82% and enthesitis in 28%. Over 60% of patients were obese, and the mean Charlson Comorbidity Index was 1.3. Most patients (84%) had prior treatment with a biologic disease-modifying antirheumatic drug (bDMARD) and 40% with a targeted synthetic DMARD (tsDMARD). The mean number of bDMARDs and tsDMARDs used during all available prior history was 2.3 and 1.1, respectively. The most common prior bDMARDs were secukinumab (n=428, 24%) and adalimumab (n=245, 14%).

Table 1.

Demographic and Clinical Characteristics by Therapy Status

All Patients(N=1,812)Monotherapy(N=1,485)Combination Therapy(N=327)Age (years)Mean (s.d.)53.7 (12.2)53.9 (12.3)52.9 (11.7)Median (Q1-Q3)55 (46-62)55 (46-62)54 (45-61)SexFemale1,108 (61.1%)909 (61.2%)199 (60.9%)Male704 (38.9%)576 (38.8%)128 (39.1%)Charlson Comorbidity IndexMean (s.d.)1.3 (1.6)1.3 (1.6)1.5 (1.7)Median (Q1-Q3)1 (0-2)1 (0-2)1 (0-2)BMIUnderweight: <18.510 (0.6%)10 (0.7%)0 (0.0%)Normal weight: 18.5-24.9210 (12.2%)172 (12.2%)38 (12.1%)Overweight: 25-29.9455 (26.5%)379 (27.0%)76 (24.2%)Obese: >= 301,045 (60.8%)845 (60.1%)200 (63.7%)Missing927913Domains of PsA: PsoriasisYes1,490 (82.2%)1,222 (82.3%)268 (82.0%)No322 (17.8%)263 (17.7%)59 (18.0%)Domains of PsA: EnthesitisYes510 (28.1%)409 (27.5%)101 (30.9%)No1,302 (71.9%)1,076 (72.5%)226 (69.1%)

Of patients with a baseline CDAI score, 61% had moderate or severe disease activity. For all patients, CDAI scores improved (decreased) by an average of 3.4 and 3.7 points at 6 and 12 months, respectively, from a baseline mean of 15.4. All disease activity measures and PROs improved from baseline to 6 and 12 months (Figure 1). In patients persistent with IXE, 35.3% and 33.7% were in CDAI remission or low disease activity at 6 and 12 months after initiation, respectively. For IXE monotherapy users (82% of patients), at baseline, patients had a mean CDAI of 14.3 (n=131) and 15.1 (n=105) for the 6 and 12 month analyses, respectively. Adjusted mean changes in CDAI from baseline to 6 months (-3.6 points, p < 0.0001) and 12 months (-4.9 points, p < 0.0001) were statistically significant.

Conclusion

In this cohort of PsA patients with multiple prior b/tsDMARD failures, improvements in disease activity and PROs were observed at 6 and 12 months after initiating treatment with IXE. Improvements were observed in patients overall and in the monotherapy subgroup. More real-world research on IXE and other bDMARDs are important to understand the effect of treatment choices on clinical and PROs in both bDMARD-naive and experienced PsA patients.

References

[1]Mease PJ. Ann. Rheum. Dis. 2017;76(1):79-87

[2]Nash P. Lancet. 2017;389(10086):2317-2327

[3]Mease PJ. Ann. Rheum. Dis. 2020;79(1):123-131

[4]Berman J. Biologics. 2021 Nov 18;15:463-470

Disclosure of Interests

Julie Birt Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis,, Pfizer, UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, UCB, Cristi Cavanaugh: None declared, Yoojin Jung: None declared, Aisha Vadhariya Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Sarah Ross Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Jess Paulus: None declared, Aubrey Trevelin Sprabery Shareholder of: Shareholder of Eli Lilly and Company, Employee of: Employee of Eli Lilly and Company, Ennio Lubrano: None declared

Impact of homeometric autoregulation using a stepwise change in heart rate on dP/dtmax and time to peak dP/dt with resynchronization therapy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East heath Authorities

Background

We investigated the homeometric autoregulation utilizing a stepwise change in heart rate on dP/dtmax and time to peak dP/dt (Td) with biventricular pacing (BIVP) and the LV lead positioned in the apical, anterior and lateral positions. Pacing at low HR (LHR) and high heart rates (HHR) changes contractility through homeometric autoregulation (Bowditch effect) without changing the resynchronization itself.

Purpose

To determine the effect of a change in contractility through homeometric autoregulation on two different effect measures of resynchronization therapy.

Methods

Twenty-nine patients in heart failure with LBBB underwent CRT implantation with continuous LV pressure registration. The LV lead was first placed in either apical or anterior position followed by a permanent placement in a lateral position. Sequential BIVP pacing was performed for one minute, at a rate 10% above intrinsic heart rate (LHR = 75 ± 9bpm), before dP/dtmax measurements were recorded, and the sequence was repeated with pacing rate increased by 30% (HHR = 98 ± 11bpm). Td was defined as the time from pacemaker stimuli to peak dP/dt. Mixed linear models were used for statistics, numbers are estimated marginal means ± SEM. Significance was set at p &lt; 0.05.

Results

DP/dtmax was higher with HHR in lateral position (1036 ± 41mmHg/s) than with LHR (933mmHg/s). The same was observed for all other lead positions. However, there was no difference between lateral position with LHR and apical position with HHR (930 ± 44mmHg/s). There were no differences in Td between LHR and HHR, but Td was shorter with BIVP in lateral position at pacing LHR (158 ± 4ms) and HHR (155 ± 4ms) than in all other positions. Overall dP/dtmax increased by 10% from LHR to HHR (888 ± 41mmHg/s vs. 980 ± 41 mmHg/s), while overall Td decreased by 2.4% from 168 ± 4ms to 164 ± 4ms. We found a linear relationship between Td and dP/dtmax (R = 0.7) with β=-0.07 that would indicate a 6ms reduction in Td going from LHR to HHR. The overall change in Td from LHR to HHR could therefore be attributed to the change in dP/dtmax.

Conclusion

Homeometric regulation does not influence Td, but Td is sensitive to changes in resynchronization and pacing lead position. Td is shorter with BIVP in lateral position at both high and low HR as would be expected from a biomarker of resynchronization. HR influences dP/dtmax so distinction between optimal and non-optimal positions using dP/dtmax may be difficult without knowledge of homeometric state.

The missing link- time to maximal rate of left ventricular pressure rise reflects resynchronization with biventricular pacing in patients with heart failure and left bundle branch block

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities

Introduction

Resynchronization therapy effectively restores myocardial function. No measures exist that specifically quantifies resynchronization. A parameter that quantifies resynchronization should be able to detect effective resynchronization and should not respond to changes in contractility caused by heterometric regulation.  Left ventricular pacing (LVP) is associated with dyssynchronous contraction patterns, while biventricular pacing (BIVP) promotes resynchronization dependent on the pacing position of the LV electrode.

Purpose

We compared the acute differences between BIVP and LVP with regards to the preload dependent maximum rate of the LV pressure rise (dP/dtmax), and time to peak dP/dt (Td) to determine which better reflect dyssynchrony and resynchronization.

Methods

Twenty nine patients in heart failure with LBBB underwent CRT implantation with continuous LV pressure registration. The LV lead was first placed in either apical or anterior position followed by a permanent placement in a lateral position. Sequential LVP and BIVP pacing were performed for one minute, at a rate 10% above intrinsic heart rate, before dP/dtmax measurements were recorded. For LVP, BIVP and RVP a patient specific AV delay was used to avoid fusion with intrinsic conduction. Td was defined as the time from pacemaker stimuli to peak dP/dt. Mixed linear models were used for statistics, numbers are estimated marginal means ± SEM and are only reported when with significance set at p &lt; 0.05.

Results

We found no differences in dP/dtmax between BIVP (899 ± 37mmHg/s) and LVP (910 ± 37mmHg/s), while RVP (799 ± 37mmHg/s) was lower. Td was lower with BIVP (165 ± 4ms) than LVP (178 ± 4ms) and RVP (184 ± 4ms).  We found no differences in dP/dtmax between lateral (890 ± 35mmHg/s) and anterior (874 ± 38mmHg/s) while apical (824 ± 38mmHg/s) was lower. Td was lower in lateral (171 ± 4ms) than in anterior (179 ± 4ms) and apical (182 ± 4ms) positions. BIVP in lateral position (158 ± 4ms) was lower than any other pacingmode*position, with BIVP*anterior at 173 ± 4ms) and LVP*lateral at 170 ± 2ms. No difference was seen in dP/dtmax between  (BIVP + LVP)*(lateral + anterior) that was higher than all other pacingmode*positions.

Conclusion

Td shortens with BIVP and lateral position, and even more so with BIVP in lateral position and thus reflects resynchronization compared to all other combinations tested. DP/dtmax did not reflect resynchronization as BIVP/LVP and lateral/anterior performs equally good. There are no differences between dP/dtmax with any combination of pacing mode (BIVP + LVP) with position (anterior + lateral). This suggests that Td reflects resynchronization while dP/dtmax does not. Resynchronization with biventricular pacing in lateral position translates into a shorter Td and hence links electrical and mechanical events. Td could be the missing link between electrical and mechanical dyssynchrony and may serve as a biomarker for cardiac resynchronization therapy.

Time delay to peak left ventricular pressure rise identifies the substrate for dyssynchronous heart failure and detects disease modification with resynchronization- an observational clinical study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian South East Health Authorities

Introduction

Identification of disease modification prior to implantation of Cardiac Resynchronization Therapy may help select the right patients, increase responder-rates and promote the utilization of CRT. We tested the hypothesis that shortening of time-to-peak left ventricular pressure rise (Td) with CRT is useful to predict long-term volumetric response (End-systolic volume (ESV) decrease &gt;15%) to CRT.

Methods

Forty-five heart failure patients admitted for CRT implantation with a class I/IIa indication according to current ESC/AHA guidelines were included in the study. Td was measured from onset QRS at baseline and from onset of pacing with CRT.

Results

Baseline characteristics were mean age 63 ± 10 years , 71% males, NYHA class 2.5, 87% LBBB, QRS duration 173 ± 15ms, EF biplane 31 ± 1%, ESV 144 ± 12mL and end-diastolic volume 2044 ± 14mL. At 6-months follow-up six patients increased ESV by 5 ± 8%, while 37 responders (85%) had a mean ESV decrease of 40 ± 2%.  Responders presented with a higher Td at baseline compared to non-responders (163 ± 4ms vs 119 ± 9ms, p &lt; 0.01). Td decreased to 156 ± 4ms (p = 0.02) with CRT in responders, while in non-responders Td increased to 147 ± 10ms (p &lt; 0.01) with CRT. A decrease in Td of less than +3.5ms from baseline accurately identified responders to therapy (AUC 0.98, p &lt; 0.01, sensitivity 97%, specificity 100%). AUC was 0.92 for baseline Td and a cut-off at 120ms yielded a sensitivity of 100% and specificity of 80% to identify volumetric responders. A linear relationship between the change in Td from baseline and ESV decrease on long term was found (β=-61, R = 0.58, P &lt; 0.01).

Conclusions

Td at baseline and the shortening of Td with CRT accurately identifies responders to CRT, with incremental value on top of current guidelines, in a population with already high response rates. Td carries the potential to become the marker for prediction of long-term volumetric response in CRT candidates. Abstract Figure.

Evidence of Three-Dimensional Asymmetries Seeded by High-Density Carbon-Ablator Nonuniformity in Experiments at the National Ignition Facility

Inertial confinement fusion implosions must achieve high in-flight shell velocity, sufficient energy coupling between the hot spot and imploding shell, and high areal density (ρR=∫ρdr) at stagnation. Asymmetries in ρR degrade the coupling of shell kinetic energy to the hot spot and reduce the confinement of that energy. We present the first evidence that nonuniformity in the ablator shell thickness (∼0.5% of the total thickness) in high-density carbon experiments is a significant cause for observed 3D ρR asymmetries at the National Ignition Facility. These shell-thickness nonuniformities have significantly impacted some recent experiments leading to ρR asymmetries on the order of ∼25% of the average ρR and hot spot velocities of ∼100  km/s. This work reveals the origin of a significant implosion performance degradation in ignition experiments and places stringent new requirements on capsule thickness metrology and symmetry.

Object Permanence, Reaching, and Locomotion in Infants who are Blind

This article reviews research and other work that suggests that congenital total blindness during infancy retards motor functions, most notably reaching for sound-making stimuli. Since there is a correlation between when infants who are blind begin to reach for rattles, bells, and the like and when sighted infants search for hidden toys in Piagetian experiments, it has been argued that for sound cues alone to elicit reaching, infants must first develop an object concept. Problems with this formulation are highlighted, and an alternative explanation is proposed that suggests possible interventions to redress the effects of congenital blindness on development.

Screening Nitrate in Forages with a Test Strip: Collaborative Study

A collaborative study was conducted for screening nitrate in forages with a commercially available test strip. The method involves extracting a finely ground sample with deionized water. The test strip is dipped in the sample extract. The color of the reaction zone on the test strip changes from white to pink or purple depending on the nitrate concentration in sample extract. The nitrate present in the extract is determined by comparing the color of the test strip to the color scale on the test strip container. Six blind quintuplicates of forage samples were analyzed by 20 collaborators. Nitrate concentrations in forage samples tested ranged from &lt;1000 ppm nitrate to &gt;10 000 ppm nitrate on dry matter basis. Each collaborator was asked to assign each sample to one of the 4 following nitrate concentration ranges: (1) &lt;1000 ppm, (2) 1000 to 5000 ppm, (3)&gt;5000 ppm to 10 000 ppm, and (4) &gt;10 000 ppm. Nineteen of 20 collaborators reported results. Results from 2 laboratories were rejected as outliers by inspection and χ2 test. Sensitivity rates (p+) ranged from 0.965 to 0.998, with standard errors of 0.006 to 0.16. Specificity rates (p−) ranged from 0.991 to 0.997 for the 4 ranges, with standard errors of 0.003 to 0.006. False-positive rates (pf+) ranged from 0.006 to 0.046, with standard errors of 0.006 to 0.025. False-negative rates (pf−) ranged from 0.003 to 0.007, with standard errors of 0.003 to 0.006. Screening nitrate in forages with a test strip has been adopted first action by AOAC INTERNATIONAL.

B-50 Frequency of Sports-Related Concussion in Athletes with Neurodevelopmental Conditions

Objective

Research demonstrates that athletes with neurodevelopmental diagnoses may have a higher frequency of lifetime concussions (Iverson et al., 2016; Alosco, Fedor & Gunstad, 2014) possibly due to underlying attention, processing speed, or reaction time difficulties. The present study investigates concussion history and sports-related concussions between athletes with and without a history of neurodevelopmental disorders in a longitudinal, state-wide sample.

Method

Participants included 39,586 high school athletes (Mage = 15.18; 56.2% males) who were assessed pre and post-concussion with ImPACT between 2008 and 2016. There were 36,880 athletes (55.1% males) who did not report neurodevelopmental disorders and served as the control group and 2,706 athletes (71.4% males) in the clinical group who self-reported diagnosis of ADHD (55.6%), Learning Disability (LD;13.6%), Autism (3.2%), ADHD+LD (4.5%), and athletes in special education but no reported diagnosis (SpEd; 22%). Concussion frequency in each group was analyzed using chi-square analysis.

Results

Athletes were more likely to report prior concussions if they had a self-reported neurodevelopmental diagnosis (17%) compared to the control group (9%, χ2(1) = 112.11, p < .001). Odds ratios indicated that athletes with neurodevelopmental conditions were 1.43 times more likely to have a sports-related concussion.

Conclusions

Consistent with past research, results indicate that neurodevelopmental conditions are associated with greater lifetime risk of concussion, including sport-related concussions. Future studies may expand this research by examining underlaying causes of this increased risk in order to develop specific interventions to help reduce rates of concussion for this population.

B-55 Performance of ImPACT Validity Indices for Athletes with Neurodevelopmental Disorders

Objective

Research demonstrates neurodevelopmental diagnoses may increase likelihood of failing scores on ImPACT embedded validity indicators that flag questionable effort. New criteria have been proposed to enhance sensitivity of these indicators although their utility in athletes with neurodevelopmental diagnosis have not been thoroughly examined. This study investigates the effect of neurodevelopmental history on frequency of invalid performance on the standard and three proposed validity indicators.

Methods

Participants included 41,214 high school athletes (Mage = 15.1; 44.2% female; Meducation = 9.1) who completed baseline ImPACT testing. Athletes included these groups: ADHD (3.7%), Learning Disability (LD; 1.5%), Autism (0.2%), ADHD+LD (0.6%), Autism+ADHD/LD (0.1%), athletes with special education history but no diagnosis reported (SpEd; 2.8%), and healthy athletes (91.1%). Odds ratios were calculated to determine differences in invalid performance by both standard and proposed cutoffs.

Results

Neurodevelopmental disorder was associated with increased invalid performance using standard and proposed cutoffs with odds ratios ranging from 1.32 to 3.25. Invalid performance differed significantly across groups for both standard and two sets of proposed criteria (chi square p < .00001). For standard cutoffs, athletes with ADHD, LD, and ADHD/LD were significantly more likely than healthy athletes to have invalid performance. This pattern remained similar across the two sets of proposed criteria.

Conclusions

Results indicate increased incidence of invalid ImPACT performance based on standard and proposed validity indicators in athletes who self-report neurodevelopmental disorders. Findings indicate current and proposed cutoffs may not accurately capture low effort for neurodevelopmental populations. Future research should examine utility of separate cutoff criteria and expanded norms for athletes with neurodevelopmental history.

P81 Intraoperative MEP recordings from a urethral sphincter electrode for spinal conus tumour surgery and its importance

Objectives

To emphasise the importance of motor evoked potential (MEP) recordings from a simple urethral sphincter electrode along with routine use of bulbocavernosus reflex recordings, anal sphincter and other lower limb muscle free running and stimulated EMG and MEP’s, and SEP techniques for sphincter preservation.

Design

Case report.

Subjects

Patients with conus or other spinal lesions at risk of postoperative sphincter disturbance.

Methods

Transcranial ‘train of 5’ stimulation (5 pulses, interstimulus interval 4msec, 200 µsec pulse width) was applied, with recordings from the urethral sphincter (small electrode taped to Foley catheter to lie just inside the urethra, referred to nearby needle anteriorly in mons pubis) and anal sphincter (paired needle electrodes in both left and right sides of external sphincter).

Results

Intraoperative stimuli of structures during dissection at one point gave a motor response confined to the urethral sphincter suggesting that these fibres may have been considered non-functional and cut had these not been assessed separately. Urethral sphincter MEP’s during the dissection confirmed that these motor fibres remained in continuity throughout.. The patient was intact after tumour removal.

Conclusions

This is an avant-garde technique by which we managed to save the nerve supply to the urethral sphincter and eventually urinary continence which would have been compromised if separate urethral monitoring was not attempted along with usual intraoperative nerve monitoring. We believe its first in the UK.

Note on Color Preference and Color Vision Test Performance

The incidence of color deficient vision was investigated using the Pseudo-Isochromatic Plates on a relatively large and representative group. in the sample of 112 adults aged 20 to 80 yr. and comprised of 53% women and 12% minorities, 8% of men and 3% of women were color deficient. Over-all performance indicated no effects for sex or race. Nearly half of the plates were nondiscriminating among sex, minority/majority, and ”normal” and ”defective” color vision groups. Named color preferences within the ”normal” group strongly favored blues and reflected no sex differences.

Urinary stress incontinence and other maternal outcomes 2 years after caesarean or vaginal birth for twin pregnancy: a multicentre randomised trial

OBJECTIVE

Does planned caesarean compared with planned vaginal birth lower the risk of problematic urinary stress, faecal, or flatal incontinence?

DESIGN

Women between 32^0/7 and 38^6/7 weeks of gestation with a twin pregnancy were randomised to planned caesarean or planned vaginal birth.

SETTING

The trial took place at 106 centres in 25 countries.

POPULATION

A total of 2305 of the 2804 women enrolled in the study completed questionnaires at 2 years (82.2% follow-up): 1155 in the planned caesarean group and 1150 in the planned vaginal birth group.

METHODS

A structured self-administered questionnaire completed at 2 years postpartum.

MAIN OUTCOME MEASURES

The primary maternal outcome of the Twin Birth Study was problematic urinary stress, or fecal, or flatal incontinence at 2 years RESULTS: Women in the planned caesarean group had lower problematic urinary stress incontinence rates compared with women in the planned vaginal birth group [93/1147 (8.11%) versus 140/1143 (12.25%); odds ratio, 0.63; 95% confidence interval, 0.47-0.83; P = 0.001]. Among those with problematic urinary stress incontinence, quality of life (measured using the Incontinence Impact Questionnaire, IIQ-7) was not different for planned caesarean versus planned vaginal birth groups [mean (SD): 18.4 (21.0) versus 19.1 (21.5); P = 0.82]. There were no differences in problematic faecal or flatal incontinence, or in other maternal outcomes.

CONCLUSIONS

Among women with a twin pregnancy and no prior history of urinary stress incontinence, a management strategy of planned caesarean compared with planned vaginal birth reduces the risk of problematic urinary stress incontinence at 2 years postpartum. Our findings show that the prevalence but not the severity of urinary stress incontinence was associated with mode of birth.

FUNDING

Canadian Institutes of Health Research (CIHR) (grant no. MCT-63164).

TWEETABLE ABSTRACT

For women with twins, planned caesarean compared with planned vaginal birth is associated with decreased prevalence but not severity of urinary stress incontinence at 2 years.

Surgical treatment of stress urinary incontinence-trans-obturator tape compared with tension-free vaginal tape-5-year follow up: an economic evaluation

OBJECTIVE

To conduct an economic evaluation of the use of trans-obturator tape (TOT) compared with tension-free vaginal tape (TVT) in the surgical treatment of stress urinary incontinence in women.

DESIGN

Cost-utility and cost-effectiveness analyses from a public-payer perspective, conducted alongside a randomised clinical trial.

SETTING

Health services provided in Alberta, Canada.

SAMPLE

A total of 195 women participated in the randomised clinical trial, followed to 5 years postsurgery.

METHODS

Comparisons were undertaken between study groups for cost and two health-outcome measures. Multiple imputation was used to estimate the 14% of missing data. Bootstrapping was used to account for sampling uncertainty. Sensitivity analyses were based on complete case analyses and the removal of a TVT patient with extreme health service cost.

MAIN OUTCOME MEASURES

The 15D instrument was used to calculate quality-adjusted life-years (QALYs) for the primary analysis. Absence of serious adverse events was also analysed. Costs were based on inpatient and outpatient hospital use data and practitioner fee-for-service claims data.

RESULTS

The TOT group had a nonsignificant average saving of $2368 (95% CI -$7166 to $2548) and incremental gain of 0.04 QALYs (95% CI -0.06 to 0.14) compared with TVT. TOT was dominant in over 71% of bootstrap replications and cost-effective over a wide range of willingness-to-pay. Cost-effectiveness analysis using the absence of an serious adverse events provided similar results.

CONCLUSION

The results suggest that TOT is cost-effective compared with TVT in the treatment of stress urinary incontinence.

TWEETABLE ABSTRACT

The results of a 5-year cost-effectiveness analysis suggest that trans-obturator tape is cost-effective compared with tension-free vaginal tape in the treatment of stress urinary incontinence.