Clinical Experience of Axillary Radiotherapy for Node-positive Breast Cancer

AIMS

Patients with breast cancer who have positive lymph nodes are currently recommended axillary node clearance (ANC) or regional nodal irradiation (RNI). ANC is associated with complications such as lymphoedema, brachial plexopathy and shoulder stiffness. The AMAROS Group showed RNI to be non-inferior to ANC with regards to survival and recurrence, and with a better quality of life. We conducted a large real-world population study to show our centre's experience with the use of RNI and to contribute to the current discussion around the management of node-positive breast cancer.

MATERIALS AND METHODS

We evaluated patients who received RNI as opposed to ANC between 2006 and 2009 (n = 190). Patients had a range of cancer subtypes/grades. All had positive axillary disease, identified by axillary node sampling or sentinel lymph node biopsy. Systemic therapy was given as per standard protocol. Our data were compared with those of patients who had RNI (n = 681) in AMAROS. Patients were followed up retrospectively and overall survival, breast cancer-specific survival, distant metastasis-free survival, locoregional recurrence and toxicity were recorded, including lymphoedema, brachial plexopathy and shoulder stiffness. Survival analysis was performed on R via the Kaplan-Meier method. Univariate and multivariate analyses were also performed. Toxicity data were reported as percentages. Patients meeting POSNOC trial criteria (one to two positive sentinel lymph nodes, macrometastasis, receiving adjuvant chemotherapy) including if oestrogen receptor-positive (stratified POSNOC) were identified for subgroup analysis in the regression model.

RESULTS

Locoregional recurrence was 3.16% versus AMAROS RNI of 1.82%. Overall survival was slightly lower in our population, but cancer-specific survival was higher than AMAROS. Lymphoedema rates were 5.8% versus AMAROS 11% in RNI and 23% in ANC arms, respectively. Brachial plexopathy was 1.6% and arm/shoulder stiffness 7.4%. AMAROS conducted a quality of life survey pertaining to arm/shoulder stiffness, mobility and function, which seemed to affect about 18% in the RNI arm. Univariate analysis revealed POSNOC status, especially if also oestrogen receptor-positive, to be a low risk group with hazard ratio 0.42 (0.20-0.83, P = 0.015). Extracapsular extension of lymph node metastasis was a poor prognostic factor; hazard ratio 4.39 (1.45-14.0, P = 0.009).

CONCLUSION

We support the conclusion of the AMAROS trial with survival and recurrence following RNI being non-inferior to ANC, and with similarly favourable toxicity data. We support the continuing use of RNI as a treatment option for patients with node-positive breast cancer. Further research is required to answer the key questions regarding personalised management for node-positive breast cancer, with regards to de-escalation and also intensification for the patients exhibiting adverse tumour biology.

Attention Mobilization as a Modulator of Listening Effort: Evidence From Pupillometry

Listening to speech in noise can require substantial mental effort, even among younger normal-hearing adults. The task-evoked pupil response (TEPR) has been shown to track the increased effort exerted to recognize words or sentences in increasing noise. However, few studies have examined the trajectory of listening effort across longer, more natural, stretches of speech, or the extent to which expectations about upcoming listening difficulty modulate the TEPR. Seventeen younger normal-hearing adults listened to 60-s-long audiobook passages, repeated three times in a row, at two different signal-to-noise ratios (SNRs) while pupil size was recorded. There was a significant interaction between SNR, repetition, and baseline pupil size on sustained listening effort. At lower baseline pupil sizes, potentially reflecting lower attention mobilization, TEPRs were more sustained in the harder SNR condition, particularly when attention mobilization remained low by the third presentation. At intermediate baseline pupil sizes, differences between conditions were largely absent, suggesting these listeners had optimally mobilized their attention for both SNRs. Lastly, at higher baseline pupil sizes, potentially reflecting overmobilization of attention, the effect of SNR was initially reversed for the second and third presentations: participants initially appeared to disengage in the harder SNR condition, resulting in reduced TEPRs that recovered in the second half of the story. Together, these findings suggest that the unfolding of listening effort over time depends critically on the extent to which individuals have successfully mobilized their attention in anticipation of difficult listening conditions.

Virtual Group Music Therapy for Apathy in Parkinson's Disease: A Pilot Study

OBJECTIVE

To evaluate the effect of virtual group music therapy on apathy in people with Parkinson's disease (PD).

INTRODUCTION

Apathy affects 40% of people with PD, lacks effective therapies, and independently predicts poorer quality of life and greater caregiver burden. Music therapy is the clinical application of music to address a person's physical or emotional needs and is effective in treating apathy in dementia.

METHODS

People with idiopathic PD and apathy (Movement Disorders Society-Unified Parkinson's Disease Rating Scale, apathy item ≥ 2) and their caregivers participated in twelve, weekly virtual group music therapy sessions, with session attendance signifying adherence. Participants completed pre- and post-intervention assessments of apathy (Apathy Scale (AS)), quality of life (Parkinson's Disease Questionnaire-short form), functional ability (Schwab & England Activities of Daily Living Scale), depression (Beck Depression Inventory (BDI-II)), and cognition (Montreal Cognitive Assessment-Blind). Among secondary outcomes, we assessed caregiver burden (Zarit Burden Interview-short form) and strain (Multidimensional Caregiver Strain Index).

RESULTS

Sixteen PD participants (93.8% men, mean age 68.3 ± 8.4 years, median 6 years PD duration) and their caregivers (93.8% women, mean age 62.6 ± 11 years) completed the study. All PD participants and 88% of caregivers were >70% adherent to the intervention. Apathy (AS, effect size = 0.767, P = 0.002) and depression (BDI-II, effect size = 0.542, P = 0.03) improved, with no change in caregiver measures.

CONCLUSION

Group music therapy is an effective treatment for apathy in PD and may improve mood. The virtual format is a feasible alternative to in-person sessions with high adherence and satisfaction.

Mindfulness training is associated with improved quality of life in female collegiate athletes

OBJECTIVE

To examine the effects of a mindfulness intervention on health-related quality of life in female Division I collegiate athletes.

PARTICIPANTS

135 female collegiate athletes, ages 18 - 23 years.

METHODS

Health related quality of life (HRQoL) was reported twice/year in approximately January and July from January 2017 to 2020 with the 12-question Veterans Rand survey (VR-12). Twenty-three of the participants received a 6-week, in-person, group mindfulness training in spring 2019, while 112 did not.

RESULTS

A significant interaction between time and mindfulness was identified with respect to the mental component score of the VR-12 of the VR-12 (MCS; β = 3.86 ± 1 .56, p = 0.012) but no significant relationships were identified with respect to time (pre-mindfulness: β = -2.36 ± 1.38, p = 0.074), mindfulness (yes: β = -2.26 ± 1.54, p = 0.14) or season (winter: β = -0.84 ± 0.57, p = 0.14). With respect to the physical component score (PCS), no significant relationships were identified with respect to time (pre-mindfulness: β = -1.09 ± 1.21, p = 0.37), mindfulness (yes: β = 1.30 ± 1.31, p = 0.32), season (winter: β = 0.50 ± 0.50, p = 0.32), or the interaction between time and mindfulness (β = 0.35 ± 1 .36, p = 0.80).

CONCLUSIONS

Among female collegiate athletes, mindfulness training is associated with significant improvements in mental HRQoL, but not physical HRQoL.

Online prediction tools for melanoma survival: A comparison

BACKGROUND

Breslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.

OBJECTIVE

To compare online melanoma survival prediction tools that request user input on clinical and pathological features.

METHODS

Search engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.

RESULTS

Three tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumours as higher risk than intermediate tumours. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration and tumour thickness. The LifeMath.net tool was found to appropriately consider tumour thickness, ulceration, age, sex, site and tumour subtype in predicting survival.

LIMITATIONS

The authors did not have access to the base data used to compile various prediction tools.

CONCLUSION

The LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.

Exploring views of members of the public and policymakers on the acceptability of population level dietary and active-travel policies: a qualitative study

BACKGROUND

There is limited evidence on what shapes the acceptability of population level dietary and active-travel policies in England. This information would be useful in the decision-making process about which policies should be implemented and how to increase their effectiveness and sustainability. To fill this gap, we explored public and policymakers' views about factors that influence public acceptability of dietary and active-travel policies and how to increase public acceptability for these policies.

METHODS

We conducted online, semi-structured interviews with 20 members of the public and 20 policymakers in England. A purposive sampling frame was used to recruit members of the public via a recruitment agency, based on age, sex, socioeconomic status and ethnicity. Policymakers were recruited from existing contacts within our research collaborations and via snowball sampling. We explored different dietary and active-travel policies that varied in their scope and focus. Interviews were transcribed verbatim and analysed using thematic reflexive analysis with both inductive and deductive coding.

RESULTS

We identified four themes that informed public acceptability of dietary and active-travel policies: (1) perceived policy effectiveness, i.e., policies that included believable mechanisms of action, addressed valued co-benefits and barriers to engage in the behaviour; (2) perceived policy fairness, i.e., policies that provided everyone with an opportunity to benefit (mentioned only by the public), equally considered the needs of various population subgroups and rewarded 'healthy' behaviours rather than only penalising 'unhealthy' behaviours; (3) communication of policies, i.e., policies that were visible and had consistent and positive messages from the media (mentioned only by policymakers) and (4) how to improve policy support, with the main suggestion being an integrated strategy addressing multiple aspects of these behaviours, inclusive policies that consider everyone's needs and use of appropriate channels and messages in policy communication.

CONCLUSIONS

Our findings highlight that members' of the public and policymakers' support for dietary and active-travel policies can be shaped by the perceived effectiveness, fairness and communication of policies and provide suggestions on how to improve policy support. This information can inform the design of acceptable policies but can also be used to help communicate existing and future policies to maximise their adoption and sustainability.

Arginase 1 Deficiency: using genetic databases as a tool to establish global prevalence

BACKGROUND/OBJECTIVE

Arginase 1 Deficiency (ARG1-D) is a rare inherited metabolic disease with progressive, devastating neurological manifestations with early mortality and high unmet need. Information on prevalence is scarce and highly variable due to limited newborn screening (NBS) availability, variability of arginine levels in the first days of life, and high rates of misdiagnosis. US birth prevalence was recently estimated via indirect methods at 1.1 cases per million live births. Due to the autosomal recessive nature of ARG1-D we hypothesize that the global prevalence may be more accurately estimated using genetic population databases.

METHODS

MEDLINE and EMBASE were systematically searched for previously reported disease variants. Disease variants in ARG1-D were annotated wherever possible with allele frequencies from gnomAD. Ethnicity-specific prevalence was calculated using the Hardy-Weinberg equation and applied to generate country-specific carrier frequencies for 38 countries. Finally, documented consanguinity rates were applied to establish a birth prevalence for each country.

RESULTS

133 of 228 (58%) known causative alleles were annotated with ethnic-specific frequencies. Global birth prevalence for ARG1-D was estimated at 2.8 cases per million live births (country-specific estimates ranged from 0.92 to 17.5) and population prevalence to be 1.4 cases per million people (approximately 1/726,000 people). Birth prevalence estimates were dependent on population demographics and consanguinity rate.

CONCLUSION

Birth prevalence of ARG1-D based on genetic database analysis was estimated to be more frequent than previous NBS studies have indicated. There was a higher degree of confidence in North American and European countries due to availability of genetic databases and mutational analysis versus other regions. These findings suggest the need for greater disease education around signs and manifestations of ARG1-D, as well as more widespread testing and standardization of screening for this severe disease in order to appropriately identify patients prior to disease progression.

Parkinson Disease and Subthalamic Nucleus Deep Brain Stimulation: Cognitive Effects in GBA Mutation Carriers

OBJECTIVE

This study was undertaken to compare the rate of change in cognition between glucocerebrosidase (GBA) mutation carriers and noncarriers with and without subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson disease.

METHODS

Clinical and genetic data from 12 datasets were examined. Global cognition was assessed using the Mattis Dementia Rating Scale (MDRS). Subjects were examined for mutations in GBA and categorized as GBA carriers with or without DBS (GBA+DBS+, GBA+DBS-), and noncarriers with or without DBS (GBA-DBS+, GBA-DBS-). GBA mutation carriers were subcategorized according to mutation severity (risk variant, mild, severe). Linear mixed modeling was used to compare rate of change in MDRS scores over time among the groups according to GBA and DBS status and then according to GBA severity and DBS status.

RESULTS

Data were available for 366 subjects (58 GBA+DBS+, 82 GBA+DBS-, 98 GBA-DBS+, and 128 GBA-DBS- subjects), who were longitudinally followed (range = 36-60 months after surgery). Using the MDRS, GBA+DBS+ subjects declined on average 2.02 points/yr more than GBA-DBS- subjects (95% confidence interval [CI] = -2.35 to -1.69), 1.71 points/yr more than GBA+DBS- subjects (95% CI = -2.14 to -1.28), and 1.49 points/yr more than GBA-DBS+ subjects (95% CI = -1.80 to -1.18).

INTERPRETATION

Although not randomized, this composite analysis suggests that the combined effects of GBA mutations and STN-DBS negatively impact cognition. We advise that DBS candidates be screened for GBA mutations as part of the presurgical decision-making process. We advise that GBA mutation carriers be counseled regarding potential risks associated with STN-DBS so that alternative options may be considered. ANN NEUROL 2022;91:424-435.

Visual estimate of coronary artery calcium predicts prevalent coronary artery disease in patients with respiratory disease

Background

Coronary artery calcification (CAC) measured using ECG-triggered coronary computed tomography correlates strongly with overt cardiovascular disease risk. Evidence is emerging to suggest CAC measured on non-gated thoracic CT scans may also correlate with cardiovascular disease. Herein, we sought to ascertain the utility of Weston scoring (visual score for CAC) in predicting prevalent coronary artery disease (CAD) and incident cardiovascular disease (CVD) for patients undergoing lung cancer screening or follow-up for interstitial lung disease with a non-triggered high-resolution CT (HRCT) thorax.

Methods

The Computerised Radiology Information Service (CRIS) database was manually searched to determine all HRCT scans performed in a single UK trust from 01/05/2016 to 01/05/2017 for the aforementioned indications. Radiology reports and images of selected studies were reviewed. For patients with evidence of CAC, we calculated the calcium score using the Agatston and Weston methods. Clinical events were determined from the electronic medical record without knowledge of patients' CAC findings. At baseline, significant CAC was defined as Agatston >400 and Weston >7.

Results

2152 scans were analysed. Data at follow up was available for 100% of patients, with a median duration of follow up of 3.6 years. A history of CAD was reported by 8% (172) of subjects at baseline, who were subsequently excluded from analysis. Significant CAC was found in 450 (22.5%) and 650 (32.5%) by Weston and Agatston scores respectively, with a significant correlation between the two scores (r-0.71, p<0.01). During follow up 7.4% (160) of patients developed incident CVD. Patients with low Weston scores of ≤7 and Agatston scores of ≤400 had a lower incidence of CVD compared to those with Weston >7 and Agatston >400 (31 [19.3%] vs 129 [80.6%]; P=0.003 for Weston scores; 37 [23.1%] vs 123 [76.9%] for Agatston scores; P<0.001).

Conclusion

In this retrospective study of patients with respiratory disease attending for HRCT scanning, the Weston visual score for CAC performs well in predicting prevalent CAD and future CVD events. With previous data demonstrating excellent inter- and intra- observer agreement, our study demonstrates Weston scoring is a valid tool in reporting non-gated CT scans, removing the need for dedicated software analysis as required with the Agatston score, and has a high overall positive and negative predictive value for future CVD. Further multi-centre prospective studies of this strategy, should be conducted to clarify the utility of Weston CAC scoring in non-gated CTs as a prediction tool which may be used to modify cardiac risk and reduce the risk of incident cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

An evaluation of patient outcomes following transcatheter pulmonary valve implantation: a meta-analysis

Background

Transcatheter pulmonary valve implantation has emerged as an effective alternative to surgery in patients with congenital Right Ventricular Outflow Tract Dysfunction (RVOT). There is demonstrable evidence that Percutaneous Pulmonary Valve Implantation (PPVI) effectively restores conduit graft viability with a consequent improvement in right ventricular pressures.

Aim

The objective of this study was to perform a meta-analysis of all previously published studies examining the outcome of PPVI and the associated early and late peri-procedural factors in patients with RVOT dysfunction. Data from procedures performed within our own centre have also been included.

Methodology

We performed a meta-analysis of all observational studies investigating early and late outcomes following PPVI. Risk ratios and risk differences were pooled in a random-effects model. The I2 statistic was used to quantify heterogeneity between studies. We searched EMBASE, MEDLINE, CINAHL, PsychInfo and Cochrane databases from their inception until 2021. Studies were included if they reported any comparative data regarding study endpoints. Primary endpoint was mean RVOT gradient. Secondary end points include pulmonary regurgitation fraction, left and right ventricular end-diastolic and systolic volume indexes, and left ventricular ejection fraction. Complication rates were considered a safety endpoint.

Results

A total of 23 studies with 1501 participants enrolled were included in the final meta-analysis. The RVOT gradient decreased significantly [weighted mean difference (WMD) = −20.32 mmHg; 95% confidence interval (CI): −22.15, −19.11; p<0.001]. Mean right ventricular (RV) systolic pressures fell significantly [(WMD)= −18.4 mmHg; 95% CI: −16.4, −20.2; p<0.001) and RV diastolic pressures decreased significantly [(WMD) = −6.3 mmHg, 95% CI: −4.3, −8.9; p<0.001). Pulmonary regurgitation fraction (PRF) also decreased notably (WMD = −24.38%, 95% CI: −28.27, −17.32; p<0.001).The incidence of infective endocarditis was 1.8% (95% CI: 0.7–3.8).

Conclusion

PPVI is an effective and safe strategy in relieving right ventricular remodelling and improving haemodynamic and clinical outcomes in patients with RVOT dysfunction. Multi-centre collaborations are essential to further determine the long-term effects of PPVI on cardiac function, exercise tolerance and quality of life in RVOT dysfunction.

Funding Acknowledgement

Type of funding sources: None.

Parkinson's Disease in African Americans: A Review of the Current Literature

Parkinson’s disease (PD) is the second most common neurodegenerative disease, though evidence suggests that this disorder does not affect all racial groups similarly. Research in African Americans, in particular, has been conflicting. Some studies have found similar prevalence rates in African Americans and whites whereas other studies have found much lower prevalence and incidence rates in African Americans. A few studies identify potential factors underlying these discrepancies, including biologic differences as well as disparities in healthcare access. However, African Americans remain underrepresented in research studies, which make understanding the underlying reasons for these differences difficult. The purpose of this paper is to summarize existing research in African Americans with PD, highlight some of the reasons why differences exist in diagnostic rates of PD in this population, and briefly discuss interventions that may need to be made in order to ensure adequate care is provided to these patients.

Gene alteration in zebrafish exposed to a mixture of substances of abuse

A recent surge in the use and abuse of diverse prescribed psychotic and illicit drugs necessitates the surveillance of drug residues in source water and the associated ecological impacts of chronic exposure to the aquatic organism. Thirty-six psychotic and illicit drug residues were determined in discharged wastewater from two centralized municipal wastewater treatment facilities and two wastewater receiving creeks for seven consecutive days in Kentucky. Zebrafish (Danio rerio) larvae were exposed to the environmental relevant mixtures of all drug residues, all illicit drugs, and all prescribed psychotic drugs. The extracted RNA from fish homogenates was sequenced, and differentially expressed sequences were analyzed for known or predicted nervous system expression, and screened annotated protein-coding genes to the true environmental cocktail mixture. Illicit stimulant (cocaine and one metabolite), opioids (methadone, methadone metabolite, and oxycodone), hallucinogen (MDA), benzodiazepine (oxazepam and temazepam), carbamazepine, and all target selective serotonin reuptake inhibitors including sertraline, fluoxetine, venlafaxine, and citalopram were quantified in 100% of collected samples from both creeks. The high dose cocktail mixture exposure group revealed the largest group of differentially expressed genes: 100 upregulated and 77 downregulated (p ≤ 0.05; q ≤ 0.05). The top 20 differentially expressed sequences in each exposure group comprise 82 unique transcripts corresponding to 74% annotated genes, 7% non-coding sequences, and 19% uncharacterized sequences. Among 61 differentially expressed sequences that corresponded to annotated protein-coding genes, 23 (38%) genes or their homologs are known to be expressed in the nervous system of fish or other organisms. Several of the differentially expressed sequences are associated primarily with the immune system, including several major histocompatibility complex class I and interferon-induced proteins. Interleukin-1 beta (downregulated in this study) abnormalities are considered a risk factor for psychosis. This is the first study to assess the contributions of multiple classes of psychotic and illicit drugs in combination with developmental gene expression.

Pet health insurance reduces the likelihood of pre-surgical euthanasia of dogs with gastric dilatation-volvulus in the emergency room of an Australian referral hospital

AIMS

To determine the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with gastric dilatation-volvulus (GDV).

METHODS

Insurance status at the time of GDV diagnosis was sought for a cohort of 147 non-referred, confirmed cases of GDV that presented to the emergency department of a university-based veterinary hospital in Australia between 2008 and 2017. Insurance status was obtained from the medical record (n=18) or after contacting the owners by phone using a standardised questionnaire (n=129). Animal, clinical and outcome data was retrospectively compiled in a research database. The primary outcome measure was whether or not the dog was euthanised before surgery. The Mantel-Haenszel procedure was used to quantify the association between the presence of pet health insurance and the risk of euthanasia at the time of diagnosis for dogs with GDV, adjusting for the confounding effect of age at the time of presentation using Bayesian methods.

RESULTS

Of the 69 dogs for which insurance information could be obtained, 10 (14%) cases were insured at the time of the GDV event and 59 (86%) cases were not. The majority of non-insured dogs (37/59; 63 (95% CI=50-74)%) were euthanised before surgery, while none (0 (95% CI=0-28)%) of the insured dogs were euthanised at that time (p<0.001). Of the 32 insured and non-insured dogs that underwent surgery, four dogs (13 (95% CI=5-28)%) did not survive to hospital discharge. Three dogs (9%) were euthanised during or after surgery and one dog (3%) experienced cardiopulmonary arrest during treatment. The majority of dogs for which insurance status was known did not survive to hospital discharge (41/69; 59%), and 90 (95% CI=7-96)% of deaths were caused by euthanasia prior to surgery. Uninsured dogs were 5.0 (95% credible interval=1.8-26) times more likely to undergo presurgical euthanasia compared with insured dogs.

CONCLUSIONS

Euthanasia prior to treatment was most common cause of death in non-referred dogs with GDV; such euthanasia was entirely absent in the cohort of dogs that were insured.

CLINICAL RELEVANCE

Financial considerations significantly contribute to mortality of dogs with GDV presented to an emergency room. Financial instruments to reduce the out-of-pocket expense for pet owners confronted with unexpected veterinary expenses have potential to reduce pet mortality.

Penile cancer in Ireland - A national review

OBJECTIVE

Penile cancer is a rare malignancy, with a reported incidence of 1.5/100,000 males in the Republic of Ireland in 2015. The aim of this study was to perform the first national review and to evaluate clinicopathological factors affecting survival.

SUBJECTS AND METHODS

All cases of penile cancer in Ireland between 1995 and 2010 were identified through the National Cancer Registry Ireland (NCRI) and analysed to identify factors affecting survival.

RESULTS

360 cases of penile cancer were identified, with a mean age at diagnosis of 65.5 years and 88% (n = 315) of cases occurred in those over 50. 91% (n = 328) of cases were squamous cell carcinomas (SCC). The majority of patients were treated surgically (n = 289), with 57% (n = 206) and 24% (n = 87) undergoing partial penectomy and total penectomy respectively. Only 18% (n = 65) received radiotherapy, and 8% (n = 27) received chemotherapy. Mean overall survival (OS) was 113 months, and five year disease specific survival (DSS) was 70% (95%CI: 59.1-77.8%). Age at diagnosis, nodal status and presence of metastatic disease were independent prognostic markers on multivariate analysis.

CONCLUSION

This study represents the first national review of penile cancer in Ireland. The annual incidence and survival rates are comparable to European figures, though superior DSS has previously been reported from our institution, highlighting the role for centralisation of care in Ireland.

LEVEL OF EVIDENCE

2b.

Comorbidities of alopecia areata: a population-based cohort study

BACKGROUND

Previous studies have associated alopecia areata (AA) with a number of comorbidities. However, the timing between AA and the development of such comorbidities remains poorly understood.

AIM

To examine the temporal relationship between AA diagnosis and comorbidity development in Denmark.

METHODS

A Danish nationwide register-based cohort study was performed on all individuals diagnosed with AA between 2007 and 2016 (n = 1843), and each patient was matched for age and sex with 10 healthy controls (HCs). Time between AA and comorbidity development was assessed, and incidence rate ratios (IRRs) were calculated to assess risk of comorbidity following initial AA diagnosis.

RESULTS

Use of antidepressant and anxiolytic drugs were mostly started prior to AA diagnosis, and these drugs were used more frequently before than after diagnosis with AA. Additional frequent comorbidities included thyroid disease, hyperlipidaemia, type 2 diabetes and asthma. Most comorbidities occurred prior to AA diagnosis; however, among those that occurred after AA diagnosis, antidepressants (IRR = 1.26, 95% CI 1.01-1.56), anxiolytics (IRR = 1.55, 95% CI 1.17-2.05), atopic dermatitis (AD; IRR = 9.41, 95% CI 4.00-22.16), asthma (IRR = 2.17, 95% CI 1.46-3.21), vitiligo (IRR = 30.35, 95% CI 6.13-150.39), Crohn disease (CD; IRR = 3.04; 95% CI 1.22-7.56) and thyroid disease (IRR = 2.38; 95% CI 1.72-3.29) occurred more frequently among patients with AA compared with controls.

CONCLUSION

A diagnosis of AA was significantly associated with risk of several comorbidities, most notably vitiligo, AD and CD. Nonetheless, the majority of patients appeared to have developed these comorbidities prior to AA diagnosis, suggesting that a thorough medical history screening by dermatologists at the initial visit may be appropriate.

A systematic review and meta-analysis of laparotomy compared with laparoscopic management of interstitial pregnancy

BACKGROUND

Interstitial pregnancy is a rare but life-threatening condition accounting for 1-4% of all types of tubal ectopic pregnancies. It can be managed by open and minimally invasive surgical techniques. Our goal was to compare laparoscopic and open surgery for managing interstitial pregnancy.

SEARCH STRATEGY

We searched PubMed, Scopus, Web of Science, and Cochrane up to May 2020.

SELECTION CRITERIA

1) Women with interstitial pregnancy, 2) Intervention: laparoscopic surgery, 3) Comparator: open surgery, 4) Outcomes: Hospital stay, operation time, pain scale, blood loss. Secondary outcomes: any other reported 5) Study designs: interventional and observational.

DATA COLLECTION AND ANALYSIS

Data was extracted from the relevant articles and was pooled as mean difference (MD) or relative risk (RR) with a 95% confidence interval (CI).

MAIN RESULTS

We included six studies, three of which provided eligible data. The duration of hospital stay was lower in the laparoscopic surgery group (MD = -1.42, 95% CI [-1.72, -0.76], P < 0.0001). There was no significant difference in operative time (MD = 5.90, 95% CI [-11.30, 23.09], P = 0.50, blood loss (MD = -9.43, 95% CI [-214.18, 195.32], P = 0.93), complications (RR = 1.54, 95% CI [0.20, 11.85], P = 0.68), or blood transfusions (RR = 0.77, 95% CI [0.50, 1.25], P = 0.30).

CONCLUSION

Laparoscopic surgery is associated with shorter hospital stay, with no difference in terms of blood loss, post-, and intraoperative complications, and need for blood transfusion compared with laparotomy.

Novel Outreach Program and Practical Strategies for Patients with Parkinsonism in the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has upended daily life and neurologic care for most patients, including those with Parkinson's disease and parkinsonism. Disruptions to routine care, high volumes of patient and caregiver calls, and our patients' risk of infection and complications inspired a proactive COVID-19 outreach program. This program targets patients with advanced Parkinson's disease and related disorders, specifically those who are homebound, receiving or eligible for palliative care, and/or lacking support networks. We describe the program and practical strategies providers can implement to support wellbeing and successful telehealth uptake during this time of social isolation and gradual reopening.

Determinants of placebo effects

Determinants of placebo effects and placebo response can be considered from multiple intrinsic and extrinsic perspectives. Intrinsic factors may influence the patient and the clinician/researcher. Patient expectations and previous experiences are considered two of the major intrinsic determinants of placebo response. Other patient determinants include the neural systems under treatment/study, situational factors and reactions to the environment, and personality traits. Clinician/researcher determinants of placebo response include personality factors such as empathy, perceived expertise, the clinical relationship with the patient, and the clinician's belief in the efficacy of the treatment. Extrinsic determinants include the type of study design, influence of advertising or branding, and forces expressed by the cultural milieu. These determinants do not act in isolation, but rather form a complex interaction that ultimately impacts the promotion or deterrence of the placebo effect in clinical and research settings.

0426 Time Restricted Feeding Consolidates Sleep in the BACHD Mouse Model of Huntington’s Disease

Introduction

Disturbances in the daily sleep-wake cycle are common in individuals with neurodegenerative disorders. Huntington’s disease (HD) is a genetic neurodegenerative disorder in which patients exhibit a variety of impairments that include, poor motor function, disrupted circadian rhythms, and sleep abnormalities such as difficulty initiating sleep at bedtime and more frequent nighttime arousals. In the BACHD mouse model time restricted feeding (TRF) has been successful at improving motor functions and circadian rhythms. The BACHD mouse model has a bacterial artificial chromosome that expresses the full-length human mutant huntingtin gene.

Methods

In order to determine the effects of TRF on sleep-wake architecture, EEG/EMG polysomnographic records were examined in mice between 3-4 months old bearing the BAC knock-in of a human genetic mutation of HD and WT litter mates, first during ad libitum (ad lib) feeding then during an 18 hour fasting protocol. TRF protocol consisted of 6 hours of food access limited between ZT15-ZT21 and 18 hours of fasting.

Results

A two-way ANOVA revealed that TRF significantly decreased the amount of total sleep (p=0.04) and NREM sleep (p=0.04) in the dark phase in both WT and BACHD mice. TRF did not significantly affect sleep in the light phase, however trends suggest that BACHD mice have more sleep in the light phase under TRF than ad lib.

Conclusion

This data suggests that TRF improves sleep by consolidating sleep to the light phase and wake to the dark phase. In conclusion, TRF may be a promising tool that can improve the negative effects of neurodegenerative diseases on sleep-wake processes.

Support

These experiments were supported by R01-NS078410 and UCLA start-up funds.

Determination of Crude Protein in Animal Feed, Forage, Grain, and Oilseeds by Using Block Digestion with a Copper Catalyst and Steam Distillation into Boric Acid: Collaborative Study

A collaborative study was conducted to evaluate the repeatability and reproducibility of an extension of AOAC Official Method 991.20, Nitrogen (Crude) in Milk, to animal feed, forage (plant tissue), grain, and oilseed materials. Test portions are digested in an aluminum block at 420°C in sulfuric acid with potassium sulfate and a copper catalyst. Digests are cooled and diluted, and concentrated sodium hydroxide is added to neutralize the acid and make the digest basic; the liberated ammonia is distilled by using steam distillation. The liberated ammonia is trapped in a weak boric acid solution and titrated with a stronger standardized acid, hydrochloric acid; colorimetric endpoint detection is used. Fourteen blind samples were sent to 13 collaborators in the United States, Denmark, Sweden, Germany, and the United Kingdom. Recoveries of nitrogen from lysine, tryptophan, and acetanilide were 86.8, 98.8, and 100.1%, respectively. The within-laboratory relative standard deviation (RSDr, repeatability) ranged from 0.40 to 2.38% for crude protein. The among-laboratories (including within-) relative standard deviation (RSDR, reproducibility) ranged from 0.44 to 2.38%. It is recommended that the method be adopted First Action by AOAC INTERNATIONAL. A lower concentration (1% H3BO3) of trapping solution was compared with the concentration specified in the original protocol (4% H3BO3) and was found comparable for use in an automatic titration system in which titration begins automatically as soon as distillation starts. The Study Directors recommend that 1% H3BO3 as an optional alternative to 4% boric acid trapping solution be allowed for automatic titrators that titrate throughout the distillation.

Steps forward for the SCIROCCO tool and its evaluation as part of SCIROCCO Exchange

The ambition of the SCIROCCO Exchange project is to maximise the value and impact of the B3-Maturity Model and the SCIROCCO tool. To this aim, SCIROCCO Exchange will develop an enhanced tool including a Knowledge Management Hub. The first objective of this presentation will be describing the progress and plans towards this enhanced tool.

The SCIROCCO enhanced tool will support measures for scaling up integrated care, and an important part of it will involve building cross system community to facilitate transfer and scaling. Through its Knowledge Management Hub, the enhanced tool will include the capacity to integrate knowledge from highly relevant sources of information on integrated care practice and advice. To support and augment twinning and coaching activities, it will allow the searching for, combination of this knowledge and its adjustment to the maturity levels of health systems and the maturity requirements of good practices. The enhanced tool will also support the tracking of the evolution of the maturity of the health systems and the maturity requirements of good practices, which will allow the development of further functionality for improvement planning and monitoring.

The second objective of this presentation will be outlining progress and plans towards the evaluation of the enhanced SCIROCCO tool. This evaluation will focus on the assessment of the enhanced tool’s personalised knowledge transfer and capacity-building support. It will provide feedback on the processes of knowledge transfer and capacity-building support, and help conclude on the key mechanisms supporting these processes. Moreover, this evaluation will feed into the development of Improvement Plans in the 9 SCIROCCO Exchange regions. The ultimate goal of this evaluation is to optimise the potential of the enhanced SCIROCCO tool as a key facilitator and integrator of knowledge transfer and capacity-building support for integrated care.

Maturity of integrated care in Scotland - What can we learn?

Issue/Problem

Multiple chronic conditions and the complexity of needs arising from them demands a rethinking of delivery systems, innovation, and resourcing. Tools and methodologies that help understand these complex transformational processes and orchestrate discussions of all stakeholders involved are core to this process. As a result, Scotland was keen to apply SCIROCCO tool to assess their readiness for integrated care.

Results

The application of SCIROCCO self-assessment tool showed a range of strengths and weaknesses of Flanders region to adopt and implement integrated care. More than 15 stakeholders were involved in this process which proved the importance and added value to the assessment process. In addition, the outcomes of this process help to identify the potential focus of the capacity-building support.

Lessons

SCIROCCO tool is a very useful participatory tool which can help to drive the transformational change towards integrated care.

Modulation of the Wnt pathway through inhibition of CLK2 and DYRK1A by lorecivivint as a novel, potentially disease-modifying approach for knee osteoarthritis treatment

OBJECTIVES

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteoblast differentiation, increased catabolic enzymes, and inflammation. The small-molecule Wnt pathway inhibitor, lorecivivint (SM04690), which previously demonstrated chondrogenesis and cartilage protection in an animal OA model, was evaluated to elucidate its mechanism of action.

DESIGN

Biochemical assays measured kinase activity. Western blots measured protein phosphorylation in human mesenchymal stem cells (hMSCs), chondrocytes, and synovial fibroblasts. siRNA knockdown effects in hMSCs and BEAS-2B cells on Wnt pathway, chondrogenic genes, and LPS-induced inflammatory cytokines was measured by qPCR. In vivo anti-inflammation, pain, and function were evaluated following single intra-articular (IA) lorecivivint or vehicle injection in the monosodium iodoacetate (MIA)-induced rat OA model.

RESULTS

Lorecivivint inhibited intranuclear kinases CDC-like kinase 2 (CLK2) and dual-specificity tyrosine phosphorylation-regulated kinase 1A (DYRK1A). Lorecivivint inhibited CLK2-mediated phosphorylation of serine/arginine-rich (SR) splicing factors and DYRK1A-mediated phosphorylation of SIRT1 and FOXO1. siRNA knockdowns identified a role for CLK2 and DYRK1A in Wnt pathway modulation without affecting β-catenin with CLK2 inhibition inducing early chondrogenesis and DYRK1A inhibition enhancing mature chondrocyte function. NF-κB and STAT3 inhibition by lorecivivint reduced inflammation. DYRK1A knockdown was sufficient for anti-inflammatory effects, while combined DYRK1A/CLK2 knockdown enhanced this effect. In the MIA model, lorecivivint inhibited production of inflammatory cytokines and cartilage degradative enzymes, resulting in increased joint cartilage, decreased pain, and improved weight-bearing function.

CONCLUSIONS

Lorecivivint inhibition of CLK2 and DYRK1A suggested a novel mechanism for Wnt pathway inhibition, enhancing chondrogenesis, chondrocyte function, and anti-inflammation. Lorecivivint shows potential to modify structure and improve symptoms of knee OA.

Successful placement of an epidural catheter through a split skin graft after degloving injury of the lower back

Degloving soft tissue injuries of the back are uncommon in women of child-bearing age. Treatment of such injuries may include split skin grafting of the affected area. We present the case of a 30-year-old primigravid woman who suffered degloving of the skin over the lumbar area that had been treated by split skin grafting three years prior to her pregnancy. She was seen in the antenatal anaesthetic clinic where she expressed a desire to have early epidural analgesia for her labour and delivery. An epidural catheter was placed successfully through the skin graft. The considerations for performing an invasive procedure through a skin graft and the available evidence are discussed.