Screening for bacterial vaginosis prior to delivery: a cost-effectiveness study

OBJECTIVE

The objective of this study was to compare the cost and effectiveness of three strategies for screening and/or treating bacterial vaginosis (BV) during pregnancy prior to delivery: (1) the current standard of care, neither test nor treat for BV (Treat None); (2) test all patients for BV at 36 weeks gestation; treat if positive (Test Treat); and (3) treat all patients undergoing cesarean delivery with intravenous metronidazole at time of surgery (Treat All Cesarean). Effectiveness was defined as avoidance of postpartum surgical site infection.

STUDY DESIGN

A decision analytic cost-effectiveness model was designed from a third-party payer perspective using clinical and cost estimates obtained from the literature, American College of Surgeons National Surgical Quality Improvement Program participant use file, National Vital Statistics, Medicare costs, and wholesale drug costs. Cost estimates were inflated to 2020 United States dollars. For this study, effectiveness was defined as postpartum surgical site infections (SSI) avoided.

RESULTS

In the base case analysis, the current standard of care, Treat None, was the most expensive and least effective strategy, with a mean cost of $59.16 and infection rate of 3.71%. Treat All Cesarean was the most effective and least expensive strategy, with a mean cost of $53.50 and an infection rate of 2.75%. Test Treat was also relatively inexpensive and effective, with an infection rate of 2.94% and mean cost of $57.05. Compared to Treat None, we would expect the Treat All Cesarean strategy to reduce the infection rate by 26%.

CONCLUSION

These findings suggest that treating pregnant patients with intravenous metronidazole at time of cesarean delivery could be an effective and cost-saving strategy. Testing and treating for BV could also be considered a reasonable strategy, as it has the added benefit of preserving antibiotic stewardship. In no analysis was the standard of care the preferred strategy.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD)

BACKGROUND

Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized.

METHODS

We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling.

RESULTS

We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services.

CONCLUSIONS

Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Sowing the Seeds of Recovery: A Qualitative Study of Women in Recovery From Addiction and Victimization

The purpose of this study was to understand the lived experiences of women with histories of victimization and addiction who were recently admitted to a sober living home (SLH). From the 17 interviews conducted, five themes (i.e., experiences of violence, challenges leaving an abusive relationship, chaos, using substances to cope, and social support) and one constitutive pattern (i.e., sowing the seeds of recovery) emerged from the data. These results highlight the importance of social support in promoting recovery and that social support may foster positive relationships with safe and trustworthy individuals as well as empower and support others with similar experiences.

The Role of Minority Stress in Psychological Distress and Hazardous Drinking Among Sexual Minority College Student Victims of Intimate Partner Violence

Sexual minority, individuals who are not heterosexual, college students experience high rates of intimate partner violence (IPV), which is linked to a myriad of deleterious outcomes. However, little work has evaluated whether there are differences in IPV outcomes among sexual minority college students as compared to heterosexual college students. Further, the extent to which minority stress at the institutional and individual level relates to IPV outcomes among sexual minority students is understudied. As such, the purpose of the current study was to evaluate IPV outcomes in a large sample of undergraduate students attending 18 medium- to large-sized universities across the contiguous U.S. Results supported that sexual minority victims of IPV had more anxious and depressive symptoms than heterosexual victims of IPV but were not more likely to engage in hazardous drinking. Further, analyses supported that several campus-level (but not individual-level) indicators of minority stress moderated the relation between IPV victimization and negative outcomes among sexual minority students, such that the association between IPV and negative outcomes was stronger among students embedded in campuses with higher levels of minority stressors. Results support the critical importance of interventions addressing campus-level minority stressors to reduce deleterious IPV outcomes among sexual minority college student victims.

Examination of the Multilevel Sexual Stigma Model of Intimate Partner Violence Risk Among LGBQ+ College Students: A Prospective Analysis Across Eighteen Institutions of Higher Education

Sexual stigma operates at multiple levels (institutional, group, individual), which serves to disadvantage sexual minority (LGBQ+) individuals and increases risk for deleterious outcomes. The current study evaluated a novel multilevel sexual stigma model of intimate partner violence (MLSSM-IPV) that incorporates multiple levels of sexual stigma as related to IPV risk via several pathways (e.g. hazardous drinking, affective symptoms). We evaluated this model in a longitudinal study of LGBQ+ undergraduate college students (n = 2,415) attending 18 universities who completed surveys in the Fall and Spring semesters. Group-level sexual stigma on each campus was assessed via surveys with heterosexual students (n = 8,517) and faculty, staff, and administrators (n = 2,865), and institutional-level stigma was evaluated via a campus climate assessment. At the campus level, institutional stigma was related to LGBQ+ students' self-stigma and identity concealment. Moreover, self-stigma prospectively predicted IPV victimization, and hazardous drinking mediated the relations between self-stigma and IPV perpetration and victimization. Results suggest that interventions addressing stigma and hazardous drinking may be efficacious in reducing IPV among LGBQ+ students. Further, comprehensive efforts to improve campus climate for LGBQ+ students are likely to produce a plethora of benefits for these students.

Fear of COVID-19, anxiety, and social support among college students

OBJECTIVE

The present study prospectively examined the association between fear of COVID-19 and anxiety and whether social support moderated this association among college students.

PARTICIPANTS

1,539 students from 11 universities in the United States completed two online surveys, one prior to the COVID-19 pandemic and one during the pandemic.

METHODS

Hierarchical linear regressions assessed the impact of COVID-19 fears and social support on anxiety, after accounting for pre-pandemic anxiety and demographics.

RESULTS

Results supported that adding fear of COVID-19 to the regression model resulted in a significant increase in variance explained over demographics and pre-pandemic anxiety. Social support did not moderate the association between fear of COVID-19 and anxiety.

CONCLUSION

These data underscore the mental health impact of COVID-19 on students and the urgency with which campus-wide initiatives are needed to support students during this unprecedented time.

p21 as a Predictor and Prognostic Indicator of Clinical Outcome in Rectal Cancer Patients

The cell cycle plays a key and complex role in the development of human cancers. p21 is a potent cyclin-dependent kinase inhibitor (CDKI) involved in the promotion of cell cycle arrest and the regulation of cellular senescence. Altered p21 expression in rectal cancer cells may affect tumor cells' behavior and resistance to neoadjuvant and adjuvant therapy. Our study aimed to ascertain the relationship between the differential expression of p21 in rectal cancer and patient survival outcomes. Using tissue microarrays, 266 rectal cancer specimens were immunohistochemically stained for p21. The expression patterns were scored separately in cancer cells retrieved from the center and the periphery of the tumor; compared with clinicopathological data, tumor regression grade (TRG), disease-free, and overall survival. Negative p21 expression in tumor periphery cells was significantly associated with longer overall survival upon the univariate (p = 0.001) and multivariable analysis (p = 0.003, HR = 2.068). Negative p21 expression in tumor periphery cells was also associated with longer disease-free survival in the multivariable analysis (p = 0.040, HR = 1.769). Longer overall survival times also correlated with lower tumor grades (p= 0.011), the absence of vascular and perineural invasion (p = 0.001; p < 0.005), the absence of metastases (p < 0.005), and adjuvant treatment (p = 0.009). p21 expression is a potential predictive and prognostic biomarker for clinical outcomes in rectal cancer patients. Negative p21 expression in tumor periphery cells demonstrated significant association with longer overall survival and disease-free survival. Larger prospective studies are warranted to investigate the ability of p21 to identify rectal cancer patients who will benefit from neoadjuvant and adjuvant therapy.

KRAS and BRAF Mutation Rates and Survival Outcomes in Colorectal Cancer in an Ethnically Diverse Patient Cohort

KRAS and BRAF mutation rates in colorectal cancer (CRC) reported from various mono-ethnic studies vary amongst different ethnic groups. However, these differences in mutation rates may not be statistically significant or may be due to differences in environmental and/or laboratory factors across countries rather than racial genetic differences. Here, we compare the KRAS/BRAF mutation rates and survival outcomes in CRC between ethnic groups at a single institution. We also investigate the contributions of genetic, environmental, and laboratory factors to the variations in KRAS/BRAF mutation rates reported from different countries. Clinicopathological data from 453 ethnically diverse patients with CRC were retrospectively analyzed at Liverpool Hospital, NSW Australia (2014-2016). KRAS/BRAF mutations were detected using real-time PCR (Therascreen kits from Qiagen). Mismatch repair (MMR) status was determined using immunohistochemical staining. Four ethnic groups were analyzed: Caucasian, Middle Eastern, Asian, and South American. Overall survival data were available for 406 patients. There was no significant difference in KRAS mutation rates between Caucasians (41.1%), Middle Easterners (47.9%), Asians (44.8%), and South Americans (25%) (p = 0.34). BRAF mutation rates differed significantly between races (p = 0.025), with Caucasians having the highest rates (13.5%) and Middle Easterners the lowest (0%). A secondary analysis in which Caucasians were divided into three subgroups showed that ethnic grouping correlated significantly with KRAS mutation rate (p = 0.009), with central and eastern Europeans having the highest rates (58.3%). There were no significant differences in overall survival (OS) or disease-free survival (DFS) between the four races. The similarity in KRAS mutation rates across races raises the possibility that the differences in KRAS mutation rates reported from various countries may either not be statistically significant or may be due to environmental and/or laboratory factors rather than underlying racial genetic differences. In contrast, we verified that BRAF mutation rates differ significantly between races, suggesting racial genetic differences may be responsible for the discrepant BRAF mutation rates reported from different countries.

Electron Temperature Measurements Using a Two-Filter Soft X-ray Array in VEST

A multichannel soft X-ray (SXR) array has been developed to measure the electron temperature in the Versatile Experiment Spherical Torus (VEST). To estimate electron temperature using the two-filter method applied to SXR intensity, we designed a pinhole camera that has two photodiode arrays with different metallic filters. We also adopted a filter wheel and tested various filter parameters to find the optimal filter set. Through tests, the combination of aluminum and beryllium was found to be the most suitable for the current experimental conditions in VEST. The filtered SXR signals were acquired with a low-noise preamplifier, exhibiting sufficient signal-to-noise ratios for electron temperature estimation based on the intensity ratio of two signals obtained with different filters. The estimated electron temperature from the developed two-filter SXR array showed reasonably matched levels and consistent trends with Thomson scattering measurements. Error contribution from impurity line emission is also discussed.

Impact of Workflow and Educational Interventions on MR Safety in Radiation Oncology

PURPOSE/OBJECTIVE(S)

Magnetic resonance imaging (MRI) is becoming increasingly integrated into radiation oncology (RO) departments with the use of MRI-Linacs and MRI simulation. Due to the number of implants in patients with cancer, adoption of comprehensive patient screening and MR safety workflows in RO is critical. Identifying MR unsafe implants only at the time of MRI simulation leads to same-day cancellations, potentially delaying treatment, and can risk MR safety events (SEs). This quality improvement study evaluated the impact of workflow and educational interventions on MR safety in RO at a single institution.

MATERIALS/METHODS

In an effort to decrease same-day cancellations and improve safety surrounding use of a 3 Tesla MRI simulator at an academic center, three plan-see-do-act (PDSA) cycles were implemented from 4/18/22 - 1/19/23. MR safety oversight for the simulator was provided by a multidisciplinary team, with input from both radiology and RO. PDSA cycle 1 implemented a two-screen functional workflow, adapted from radiology at the same institution. The first screen is completed by the practice coordinator (PC) at the time of scheduling to triage high-risk patients into a work queue (WQ) for further evaluation by the MR safety team. The second screen is performed by the MR technologist (MRT) at the point of care. PDSA cycle 2 involved education for PCs. PDSA cycle 3 was a second PC educational intervention including a visual aide to assist with WQ use. Efficacy was determined by the number of same-day cancellations, patients in the WQ (a measure of the number of patients identified at the initial screen as having an implant), and SEs in each PDSA cycle.

RESULTS

PDSA cycle 1 spanned 56 workdays during which 91 MR simulations were scheduled with 6 cancellations (6.5%). PDSA cycle 2 spanned 84 days during which 173 MR simulations were scheduled with 18 cancellations (10.4%). PDSA cycle 3 spanned 39 workdays and had 94 MR simulations, with 7 cancellations (7.4%). The cancellation rate during each PDSA cycle was 0.11, 0.21, and 0.17 cancellations/day, respectively. The number of patients in the WQ during each PDSA cycle, representing successfully screened high-risk patients, was 0, 0, and 3, respectively. There were no SEs during the study.

CONCLUSION

In this study, an MR safety workflow from radiology was successfully implemented in RO. There were no SEs during the study, but the number of patients successfully screened as high-risk and placed in the WQ increased after repeat PC education. Further increases in WQ use would decrease the demand for implant assessment at point of care, which could decrease burden on the MRT, same day cancellations, and potentially SEs. This will be especially important if case load increases. Future work could expand educational efforts to additional staff.

Implementation of a validated post-operative opioid nomogram into clinical gynecologic surgery practice: A quality improvement initiative

Objectives

The Gynecologic Oncology Postoperative Opioid use Predictive (GO-POP) calculator is a validated tool to provide evidence-based guidance on post-operative opioid prescribing. The objective of this study was to evaluate the impact of the implementation of GO-POP within an academic Gynecologic Oncology division.

Methods

Two cohorts of patients (pre-implementation and post-implementation) who underwent surgery were compared with reference to GO-POP calculator implementation. All patients were included in the post-implementation group, regardless of GO-POP calculator use. An additional expanded-implementation cohort was used to compare pain control between GO-POP users and non-GO-POP users prospectively. Wilcoxon rank sum tests or ANOVA for continuous variables and Chi-square or Fisher's exact tests were used to categorical variables.

Results

The median number of pills prescribed post-operatively decreased from 15 pills (Q1: 10, Q3: 20) to 10 pills (Q1: 8, Q3: 14.8) after implementation (p < 0.001). In the expanded-implementation cohort (293 patients), 41% patients were prescribed opioids using the GO-POP calculator. An overall median of 10 pills were prescribed with no difference by GO-POP calculator use (p = 0.26). Within the expanded-implementation cohort, refill requests (5% vs 9.2%; p = 0.26), clinician visits (0.8% vs 0.6%, p = 1), ED or urgent care visits (0% vs 2.3%, p = 0.15) and readmissions (0% vs 1.7%, p = 0.27) for pain did not differ between those prescribed opioids with and without the GO-POP calculator.

Conclusions

A 33% reduction in post-operative opioid pills prescribed was seen following implementation of the GO-POP calculator into the Gynecologic Oncology division without increasing post-operative pain metrics or encounters for refill requests.

Gender-neutral bathrooms on campus: a multicampus study of cisgender and transgender and gender diverse college students

Objective: This study examined cisgender and transgender and gender diverse (TGD) college students' perceptions of gender-neutral bathroom availability across eight U.S. campuses, TGD students' fear of harassment related to (lack of) availability of gender-neutral bathrooms, and the relation between fear of harassment and TGD students' psychological distress. Methods: Participants were 4,328 college students (4,195 cisgender, 30 binary transgender, 103 gender diverse) from eight U.S. institutions of higher education. Results: The majority (84.2%) of TGD students and 34.6% of cisgender students perceived there were too few gender-neutral bathrooms on their campus. Further, TGD students' fear of harassment related to a lack of availability of gender-neutral bathrooms on campus was positively associated with psychological distress (i.e., symptoms of depression and anxiety). Conclusion: This study highlights the significance of increasing accessibility of gender-neutral bathrooms on campuses to help mitigate TGD students' fear of harassment and psychological distress.

Rates and Correlates of Intimate Partner Violence Among Indigenous College Students: A Multi-Campus Study

Research suggests that Indigenous girls, women, and LGBTQ+ Two-Spirit people experience disproportionately high rates of intimate partner violence (IPV), but there is a dearth of research on IPV among Indigenous college students. Therefore, the current study sought to explore rates of IPV victimization and perpetration among Indigenous college students, as well as correlates including depressive and anxious symptoms, emotion dysregulation, on-campus social support, and hazardous drinking. Participants were 230 undergraduate students who identified as American Indian/Alaska Native attending 20 medium- and large-sized universities across the contiguous U.S. Results indicated that 28.9% of Indigenous students reported any type of IPV victimization in the past 6 months (psychological: 24.5%; physical: 9.1%; sexual: 9.8%; coercive control: 12.4%). Further, 18.3% of Indigenous students reported any type of IPV perpetration in the past 6 months (psychological: 16.9%; physical: 4.5%; sexual: 2.6%; coercive control: 7.1%). Anxious and depressive symptoms were related to many forms of IPV victimization; emotion dysregulation was related to all forms of IPV victimization and sexual IPV perpetration; and hazardous drinking was related to most forms of IPV victimization and perpetration. These findings underscore the alarmingly high rates of IPV among Indigenous college students as well as the potential deleterious effects of IPV victimization on psychological functioning, as well as the need to concurrently address hazardous alcohol use in IPV prevention and response efforts.

Real-world tolerance and outcomes of oxaliplatin-based adjuvant chemotherapy for stage III colon cancer-Does dose intensity matter?

INTRODUCTION

Fluoropyrimidine and oxaliplatin-based adjuvant chemotherapy delivered as 5-fluorouracil, leucovorin and oxaliplatin (FOLFOX), or capecitabine and oxaliplatin (CAPOX) is the standard of care for resected stage III colon cancer. Without randomized trial data, we compared real-world dose intensity, survival outcomes, and tolerability of these regimens.

METHODS

Records of patients treated with FOLFOX or CAPOX in the adjuvant setting for stage III colon cancer across four institutions in Sydney during 2006-2016 were reviewed. The relative dose intensity (RDI) of fluoropyrimidine and oxaliplatin of each regimen, disease-free survival (DFS), overall survival (OS), and incidence of grade ≥2 toxicities were compared.

RESULTS

Characteristics of patients receiving FOLFOX (n = 195) and CAPOX (n = 62) were evenly matched. FOLFOX patients had a higher mean RDI for both fluoropyrimidine (85% vs. 78%, p < 0.01) and oxaliplatin (72% vs. 66%, p = 0.06). In spite of a lower RDI, CAPOX patients trended toward a better 5-year DFS (84% vs. 78%, HR = 0.53, p = 0.068) and similar OS (89% vs. 89%, HR = 0.53, p = 0.21) compared to the FOLFOX group. This difference was most pronounced in the high-risk (T4 or N2) group where 5-year DFS was 78% versus 67% (HR = 0.41, p = 0.042). Patients receiving CAPOX experienced more grade ≥2 diarrhea (p = 0.017) and hand-foot syndrome (p < 0.001) but not peripheral neuropathy or myelosuppression.

CONCLUSION

In a real-world setting, patients who received CAPOX had similar OS rates when compared to those receiving FOLFOX in the adjuvant setting in spite of lower RDI. In the high-risk population, CAPOX appears to demonstrate a superior 5-year DFS over FOLFOX.

Preoperative physical frailty assessment among octogenarians undergoing cardiac surgery: Upgrading the "eyeball" test

OBJECTIVES

There are many well-described, but as yet unproven, physical ability tools to assess frailty. The objective of this study was to evaluate the effectiveness of 4 preoperative physical tests in predicting mortality, morbidity, and functional outcomes among octogenarians undergoing cardiac surgery.

METHODS

Between 2016 and 2019, 200 patients aged 80 years or more undergoing elective cardiac surgery were prospectively recruited. Four physical tests were performed preoperatively: 5-m walk time, timed up-and-go, 5 time sit-to-stand, and handgrip strength tests. The primary end point was a composite of in-hospital mortality, neurologic, and pulmonary complications. Multivariate analysis was performed.

RESULTS

In-hospital mortality was 1.5%. Slow performance on the 5-m walk test (time ≥6.4 seconds) was the only independent predictor of the composite end point among the tests evaluated (odds ratio, 2.70; 95% confidence interval, 1.34-5.45; P = .006). At follow-up, patients with a slow 5-m walk test had a significantly lower midterm survival compared with patients with a normal test result (1-year survival 91.5% vs 98.7%, log-rank P = .03). Mean Physical and Mental Component Scores of the 12-item short form survey were 47.2 ± 8.3 and 53.6 ± 5.9, respectively, which are comparable to those of a general population aged more than 75 years.

CONCLUSIONS

The 5-m walk time test is an independent predictor of a composite of in-hospital mortality and major morbidity, as well as midterm survival. This test could be used as a simple adjunctive preoperative tool for octogenarians undergoing cardiac surgery.

A36 INVESTIGATING TYPE 1 REGULATORY T CELLS AS A THERAPY FOR INFLAMMATORY BOWEL DISEASE USING A MOUSE MODEL OF ACUTE INTESTINAL EPITHELIAL DAMAGE

Background

Inflammatory bowel disease (IBD) affects an estimated 270,000 people in Canada and is rapidly increasing in prevalence. All patients have relapsing disease, and a subset of individuals do not respond to current treatments. Further, there are no approved treatment options in Canada that reverse IBD-induced intestinal fibrosis. We have previously shown type 1 regulatory cells (Tr1s) are capable of suppressing inflammatory macrophages, promote barrier function of human intestinal epithelial cells, and induce differentiation of mucin-producing goblet cells. We hypothesize that Tr1 cells can prevent inflammatory damage and fibrosis in an mouse model of acute gut damage.

Purpose

We hypothesize that Tr1 cells can prevent inflammatory damage and fibrosis in an mouse model of gut damage. Here we evalute the therapeutic potential of Tr1 cells in an model of acute intestinal epithelial damage.

Method

Tr1 cells were isolated and expanded from CD4⁺ CD44^high FOXP3^- cells. Their phenotype was characterized by flow cytometry and cytokine secretion was measured via ELISA. WT B6 mice were given 2% DSS in H₂O for 7 days, followed by H₂O alone for 7 days. Prior to DSS treatment, mice were sub-lethally irradiated to facilitate engraftment, and given I.P. injections of PBS or 0.5 – 2 x 10⁶ Tr1 cells. Mice weights and health scores were recorded daily. At the endpoint, blood, spleen, and mesenteric lymph nodes were analyzed for Tr1 cell engraftment (or lack thereof) for each mouse. Complete white blood counts were performed for each mouse. Additionally, proximal, medial, and distal portions of the ileum were processed for histologic scoring.

Result(s)

Tr1 cells isolated from CD4⁺ CD44^high FOXP3^- cells produce high levels of IL-10 following stimulation (>35,000 pg/ml/1 x 10⁵ cells). Additionally, these cells express high levels of Tr1 markers CD49b and Lag-3. Optimization experiments indicated no significant differences between mice irradiated and given DSS and mice only given DSS (no irradiation). Our results suggest no significant differences in inflammatory cell infiltrate scores between control and Tr1 treated mice. However, gut architecture scores appeared to improve with increasing Tr1 doses. Further, weight change improved with Tr1 treatment, as compared to PBS controls. Interestingly, Tr1 treatment appeared to decrease total eosinophil and neutrophil counts from peripheral blood.

Conclusion(s)

Our initial findings indicate Tr1 adoptive transfer prior to acute damage via DSS improves gut damage and weight loss.

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CIHR

Disclosure of Interest

None Declared

BEAM: a combinatorial recombinase toolbox for binary gene expression and mosaic analysis

Genetic mosaic analysis, in which mutant cells reside intermingled with wild-type cells, is a powerful experimental approach, but has not been widely used in mice because existing genome-based strategies require complicated and protracted breeding schemes. We have developed an alternative approach termed BEAM (for Binary Expression Aleatory Mosaic) that relies on sparse recombinase activation to generate two genetically distinct, non-overlapping populations of cells for comparative analysis. Following delivery of DNA constructs by transfection or viral transduction, combinatorial recombinase activity generates two distinct populations of cells labeled with either green or red fluorescent protein. Any gene of interest can be mis-expressed or deleted in one population for comparison with intermingled control cells. We have extensively optimized and characterized this system both in vitro and in vivo , and demonstrate its power for investigating cell autonomy, identifying temporally or spatially aberrant phenotypes, revealing changes in cell proliferation or death, and controlling for procedural variability.

1323 VOLUNTEER-LED ONLINE GROUP EXERCISE FOR OLDER ADULTS: A FEASIBILITY AND ACCEPTABILITY STUDY

Introduction

The health benefits of physical activity for older people are well recognised and include reduction in falls, improvement in frailty status and physical function. Nonetheless, physical inactivity remains a significant problem among older adults. This study aimed to determine the feasibility and acceptability of implementing online volunteer-led group exercise for community-dwelling older adults.

Methods

This pre-post mixed methods study was conducted among older adults attending community social clubs. Eligible participants were aged ≥ 65 years, able to walk independently, and able to provide written consent. The intervention consisted of a once weekly volunteer-led online group chair-based exercise. The primary outcomes were the feasibility and acceptability of the intervention. Secondary outcomes included physical activity levels measured using the Community Health Model Activities Program for Seniors (CHAMPS) questionnaire, functional status (Barthel Index), and health-related quality of life (EQ-5D-5L). Outcomes were measured at baseline and at 6 months. Trials registration: NCT04672200.

Results

Nineteen volunteers were recruited, 15 completed training and 9 were retained (mean age 68 years, 7 female). Thirty participants (mean age 77 years, 27 female) received the intervention and attended 54% (IQR 37-67) of exercise sessions. One minor adverse event was reported. Participants had no significant changes in secondary outcome measures, with a trend towards improvement in physical activity levels. The intervention was acceptable to volunteers, participants, and staff. The seated exercises were perceived as safe, manageable and enjoyable. Volunteers were relatable role models providing positive vicarious experiences that improved participants confidence to exercise within a friendly, non-judgmental environment. Technological issues, or reluctance to learn how to use technology were barriers to the intervention. The social interactions and sense of belonging motivated participation.

Conclusions

Trained volunteers can safely deliver online group exercise for community-dwelling older adults and the intervention was feasible and acceptable to older adults, volunteers and club staff.

Levels of physical activity and sitting time in women with infants, toddlers and preschoolers: a population-based cross-sectional study

OBJECTIVES

Insufficient physical activity (PA) and prolonged sitting time (ST) increase the risk of chronic disease and mortality. Caring for young children can potentially impact maternal PA and sedentary behaviours. The aims of this study were to explore the levels of PA and ST in women with young children (infants, toddlers and preschoolers) and sociodemographic and behavioural factors associated with these.

STUDY DESIGN

This was a population-based cross-sectional study.

METHODS

Survey 5 data collected in 2009 (n = 4290) of the 1973-1978 birth cohort of the Australian Longitudinal Study on Women's Health were used. Multiple linear and logistic regression models were used to examine associations.

RESULTS

In adjusted models, compared with women with preschoolers, women whose youngest child was an infant aged 0-6 months, aged >6-12 months or toddler had lower PA (-321.3 MET.min/week [95% confidence interval (CI) -416.2, -226.4], -147.9 MET.min/week [95% CI -237.6, -58.1] and -106.4 MET.min/week [95% CI -172.3, -40.5]). ST was higher in women whose youngest child was an infant aged 0-6 months (0.48 h/day; 95% CI 0.19, 0.77) but lower with infants aged >6-12 months (-0.33 h/day; 95% CI -0.60, -0.05) and toddlers (-0.40 h/day; 95% CI -0.60, -0.20) than in those with preschoolers. The findings were similar in the logistic model. Sociodemographic and behavioural factors such as occupation and marital status also influenced PA and ST.

CONCLUSIONS

Women with infants and toddlers have lower PA than women with preschoolers. Women are more likely to sit more in the first 6 months after childbirth. These findings can inform resources and intervention development to improve activity levels in women with young children through consideration of the age of the youngest child, sociodemographic and behavioural factors.

Comparison of the clinical effectiveness of treatments for aromatase inhibitor-induced arthralgia in breast cancer patients: A systematic review with network meta-analysis

Aromatase inhibitor-induced arthralgia (AIA) contributes to poor adherence of aromatase inhibitor therapies in patients with breast cancer. A systematic review using network meta-analysis (NMA) was conducted to examine the clinical effectiveness of multiple therapies and rank probabilities for the management of AIA. Randomized controlled trials (RCTs) assessing treatments for AIA in postmenopausal women with stage 0-III hormone receptor-positive breast cancer were searched from inception to October 2021. The main NMA involved 1516 participants from 17 RCTs. Acupuncture was the highest ranked intervention to improve pain intensity followed by sham acupuncture, multicomponent herbal medicine, exercise, duloxetine, vitamin D, omega-3 fatty acids, physical therapy, testosterone, and inactive controls. Single natural products were inferior to controls. The current review provides new insights into the management of AIA in breast cancer survivors for increased survival and can be utilized to make evidence-based decisions regarding treatment.

The long-term cardiac events after coronary bifurcation stenting with second-generation drug-eluting stents in elderly patients are comparable to those of younger patients

Background

Elderly patients undergoing percutaneous coronary intervention (PCI) generally have a high risk of adverse clinical outcomes. We investigated the long-term clinical impact of PCI on coronary bifurcation disease in elderly patients in Korea and Italy.

Methods

From the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) data, we evaluated 5,537 patients who underwent PCI for coronary bifurcation disease. The primary outcome was major adverse cardiac events (MACEs), defined as the composite of target vessel myocardial infarction, target lesion revascularisation, and stent thrombosis. Kaplan–Meier estimates and Cox proportional hazard models were used to compare elderly patients (aged ≥75 years) and younger patients (aged &lt;75 years).

Results

A total of 1,415 patients (26%) were aged ≥75 years. Elderly patients were more frequently female, had higher rates of hypertension and chronic kidney disease (CKD), and presented more frequently with left main (LM) disease. After a median follow-up of 2.1 years, MACEs were comparable between elderly and younger patients. In multivariable analysis, old age was not an independent predictor of MACEs (p=0.977). In elderly patients, CKD and LM disease were independent predictors of MACEs, whereas in younger patients, hypertension, diabetes, CKD, reduced left ventricular ejection fraction, LM disease, and two-stent strategy usage were independent predictors.

Conclusions

Elderly patients who underwent coronary bifurcation PCI with second-generation drug-eluting stents demonstrated similar clinical outcomes to those of younger patients. Both CKD and LM disease were independent predictors of MACEs, regardless of age after coronary bifurcation PCI.

Funding Acknowledgement

Type of funding sources: None.

The differential effects of antihypertensive drugs on central blood pressure: nebivolol versus telmisartan (ATD-CBP)

Background

Central blood pressure and central pulse pressure have a better correlation with the risk of cardiovascular disease compared to those of peripheral measurement. In a previous study, a second-generation beta-blocker showed poor CBP-lowering effects. However, the effect on CBP by third-generation beta-blockers is not fully elucidated. Thus, this randomised study investigated whether nebivolol-based hypertension treatment may confer advantages over telmisartan, an angiotensin II receptor-blocker, in reducing CBP.

Methods

This was a prospective, randomised, multicentre, open-label, controlled trial that evaluated 98 hypertensive patients. Patients received either nebivolol- (N=49) or telmisartan-based (N=49) treatment for hypertension for 12 weeks with a target BP of ≤140/80. The primary outcome was the difference in change from baseline central systolic BP (cSBP) after 12 weeks.

Results

There were no significant differences between the two groups in baseline central and peripheral SBP. The mean change in cSBP from baseline (ΔcSBP) was −17.2±3 mmHg for nebivolol group (P&lt;0.001) and −29.9±3 mmHg for telmisartan group (P&lt;0.001). The difference in ΔcSBP between the two groups was significant (12.7mmHg, 95% confidence interval [CI], 4.13 to 21.2; P=0.004). Peripheral SBP (pSBP) decreased less in nebivolol group compared to telmisartan group (−18.0±3 in nebivolol group vs. −26.3±3 in telmisartan group, P=0.032). After adjusting for reduction in pSBP, reduction in cSBP was higher in telmisartan group compared to nebivolol group, as shown by the ratio of changes in cSBP and pSBP (ΔcSBP/ΔpSBP; 0.67 for nebivolol group vs. 1.11 for telmisartan group, P=0.080), albeit without statistical significance.

Conclusions

Nebivolol-based hypertension treatment may have less potent CBP-lowering effects compared to telmisartan. However, larger-scale studies are warranted to further elaborate our findings.

Funding Acknowledgement

Type of funding sources: None.

Effect of an early invasive strategy based on time of symptom onset in patients with non-ST elevation myocardial infarction

Background

A limitation of the current guidelines of the timing of invasive coronary angiography (ICA) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is based on randomization time. So far, no study has reported the clinical outcomes of invasive strategy timing based on the time of symptom onset. Herein, we aimed to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with NSTE myocardial infarction (MI).

Methods and results

Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we evaluated 5,856 patients with NSTEMI. The patients were categorized according to symptom-to-catheter (StC) time (&lt;48 h and ≥48 h). The primary outcome was 3-year all-cause mortality, and the secondary outcome was a 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. Overall, 3,919 (66.9%) patients were classified into the StC time &lt;48 h group. This group had lower all-cause mortality than the StC time ≥48 h group (7.3% vs. 13.4%, p&lt;0.001). The continuous association of StC time and risk of primary and secondary endpoints showed shorter StC time (reference: 48 h), and lower adjusted hazard ratio reduction was observed. In multivariable analysis, independent predictors of delayed ICA were older age, non-specific symptoms, no use of emergency medical services, no ST-segment deviation, chronic kidney disease, and Global Registry of Acute Coronary Events score &gt;140.

Conclusion

Early invasive strategy based on the StC time improves all-cause mortality in patients with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Effect of social instability stress in adolescence or adulthood on sensitivity to sucrose concentration in a social context in male and female Long-Evans rats

Although there is evidence of sex differences in responding to social stress, and that age when stressed matters, females are understudied and adult-stress comparisons are few. Here, we investigated stress effects on reward sensitivity by examining rats' choice of social versus sucrose reward in a continuous spatial allocation design. We predicted social instability stress (SS) in adolescence would result in greater social discounting (spend less time near a novel peer when provided access to sucrose) relative to nonstressed controls (CTLs) and relative to SS in adulthood. All increased sucrose intake as the concentration increased, with no evidence of social discounting. SS males tested soon after the stress had a decrease in intake, whereas those tested long after had an increase in both time near the peer and in intake. CTL and SS females did not differ in intake, although their dose-response curves differed when tested soon after the SS. We also tested whether SS changed the stimulus value of the rat as a social peer; when tested in triads, CTL rats spent similar time in interaction with SS versus CTL rats. In sum, effects of SS on reward sensitivity were greater for males irrespective of administered in adolescence versus adulthood.

Predicting neoadjuvant chemoradiotherapy response with functional imaging and liquid biomarkers in locally advanced rectal cancer

INTRODUCTION

Non-invasive predictive quantitative biomarkers are required to guide treatment individualization in patients with locally advanced rectal cancer (LARC) in order to maximise therapeutic outcomes and minimise treatment toxicity. Magnetic resonance imaging (MRI), positron emission tomography (PET) and blood biomarkers have the potential to predict chemoradiotherapy (CRT) response in LARC.

AREAS COVERED

This review examines the value of functional imaging (MRI and PET) and liquid biomarkers (circulating tumor cells (CTCs) and circulating tumor nucleic acid (ctNA)) in the prediction of CRT response in LARC. Selected imaging and liquid biomarker studies are presented and the current status of the most promising imaging (apparent diffusion co-efficient (ADC), K^trans, SUV_max, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) and liquid biomarkers (circulating tumor cells (CTCs), circulating tumor nucleic acid (ctNA)) is discussed. The potential applications of imaging and liquid biomarkers for treatment stratification and a pathway to clinical translation are presented.

EXPERT OPINION

Functional imaging and liquid biomarkers provide novel ways of predicting CRT response. The clinical and technical validation of the most promising imaging and liquid biopsy biomarkers in multi-centre studies with harmonised acquisition techniques is required. This will enable clinical trials to investigate treatment escalation or de-escalation pathways in rectal cancer.

Examining the effect of COVID-19 pandemic on exercise behavior and perceived academic stress among U.S. college students

Objective: The aim of this study was to capture the impact of COVID-19 on exercise behavior in U.S. college students. Exercise behaviors and perceived academic stress were examined from pre-COVID-19 (January-March 2020) and early-COVID-19 (April-July 2020) to continued-COVID-19 times (August-October 2020). Participants: One hundred and thirty-two participants completed the online questionnaires retrospectively. Methods: Two-way analyses of variance were used to examine exercise behaviors and academic stress perception over time between genders. Results: Participants spent much time in sedentary behavior and an increase in academic stress was evident in learning during the early-COVID-19 period. The time spent in sedentary behavior was reduced, but the stress involving coursework remained during the continued-COVID period. The impact of the COVID pandemic was observed to be universal across sex groups. Conclusions: Universities should consider how to support physical and mental health during lockdown and extended closure due to a pandemic.

Group B Streptococcus (GBS) colonisation is dynamic over time, whilst GBS capsular polysaccharides-specific antibody remains stable

Group B Streptococcus (GBS) is a leading cause of adverse pregnancy outcomes due to invasive infection. This study investigated longitudinal variation in GBS rectovaginal colonization, serum and vaginal GBS capsular polysaccharide (CPS)-specific antibody levels. Non-pregnant women were recruited in the UK and were sampled every 2 weeks over a 12-week period. GBS isolates were taken from recto-vaginal swabs and serotyped by polymerase chain reaction. Serum and vaginal immunoglobulin G (IgG) and nasal immunoglobulin A (IgA) specific to CPS were measured by Luminex, and total IgG/A by ELISA. Seventy women were enrolled, of median age 26. Out of the 66 participants who completed at least three visits: 14/47 (29.8%) women that were GBS negative at screening became positive in follow-up visits and 16/19 (84.2%) women who were GBS positive at screening became negative. There was 50% probability of becoming negative 36 days after the first positive swab. The rate of detectable GBS carriage fluctuated over time, although serum, vaginal, and nasal CPS-specific antibody levels remained constant. Levels of CPS-specific antibodies were higher in the serum of individuals colonized with GBS than in non-colonized, but similar in the vaginal and nasal mucosa. We found correlations between antibody levels in serum and the vaginal and nasal mucosa. Our study demonstrates the feasibility of elution methods to retrieve vaginal and nasal antibodies, and the optimization of immunoassays to measure GBS-CPS-specific antibodies. The difference between the dynamics of colonization and antibody response is interesting and further investigation is required for vaccine development.

957 THE USE OF IPADS AS PART OF PERSON CENTERED CARE IN A TEACHING HOSPITAL IN SINGAPORE

The elderly patients are currently the main occupants of acute hospital beds and this trend will likely increase as the world ages. The elderly patients with cognitive issues frequently have behavioural symptoms which may be challenging for the care staff to manage, especially the staff who have not been formally trained in Gerontology. The use of restraints for this group of vulnerable patients should be discouraged as restraints can cause harmful effects.

The use of iPads as a non pharmacological strategy for managing the behavioural symptoms among the elderly in-patients with cognitive issues was effective in reducing agitation, with an improvement in mood and sundown symptoms. The patients were actively and meaningfully engaged with their iPads during therapy.

The nursing staff too, benefited from iPads as a novel therapy for their elderly in-patients with cognitive issues in providing cognitive and social stimulations, which they had no time to provide for. While the patients showed improvement in their behavioural symptoms, the nurses’ stress levels reduced with improved self-reported job satisfaction.

COVID-Specific Coercive Control among Emerging Adults Attending College: A Brief Note

The COVID-19 pandemic represents a "perfect storm" with regards to risk for intimate partner violence (IPV). Abusive partners may engage in novel forms of coercive control, such as pressuring their partner to engage in activities associated with COVID-19 infection risk (e.g., attend a large gathering). However, no empirical research has focused on COVID-specific coercive control. The current study sought to evaluate the prevalence of COVID-specific coercive control in a large sample of U.S. college students, as well as its association with other forms of IPV and depression and anxiety. A total of 2,289 undergraduate students attending eight U.S. universities who were currently in a sexual/dating/romantic relationship completed an online survey in Fall 2020 about COVID-specific coercive control, other forms of IPV (psychological, physical, sexual, coercive control) and depression and anxiety symptoms. Overall, 15.5% (n = 355) of students reported experiencing COVID-specific coercive control. Individuals who experienced COVID-specific coercive control were more likely to have experienced all other forms of IPV than those who did not experience COVID-specific coercive control. Further, individuals who experienced COVID-specific coercive control had significantly greater anxiety than individuals who did not experience any form of IPV. Individuals who experienced both COVID-specific coercive control and other forms of IPV had the highest levels of depression and anxiety. COVID-specific coercive control may serve to increase depression and anxiety, particularly if it co-occurs with other forms of IPV. Future work should evaluate the prevalence and long-term impact of coercive control during the COVID-19 pandemic.

Neuraxial labor analgesia: Maintenance techniques

Since the advent of neuraxial analgesia for labor, approaches to maintaining intrapartum pain relief have seen significant advancement. Through pharmacologic innovations and improved drug delivery mechanisms, current neuraxial labor analgesia maintenance techniques have been shaped by efforts to maximize patient comfort during the birthing process, while minimizing undesirable side effects and promoting the unimpeded progress of labor. To these ends, a modern anesthesiologist may avail themselves of several techniques, including programmed intermittent epidural bolus (PIEB), patient controlled epidural analgesia (PCEA) and dilute concentration local anesthetic + opioid epidural solutions. We explore the historical development and the evidential underpinnings of these techniques, in addition to several contemporary neuraxial labor analgesia practices. We also summarize current understanding of the effects these interventions have on maternal/fetal health and the labor course, as well as several important aspects of analgesic safety and monitoring.

Impact of changes in tricuspid regurgitation on clinical outcomes following mitral valve teer compared to guideline-directed medical therapy: a sub-analysis of the COAPT trial

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT)

Background

Prior studies suggest tricuspid regurgitation (TR) diminishes/resolves following mitral valve surgery and thus do not require treatment and may not influence outcomes.

Purpose

  We sought to evaluate the change in TR (ΔTR) and its association with outcomes after transcatheter edge-to-edge repair (TEER) compared with guideline-directed medical therapy (GDMT) in the COAPT trial.

Methods

Patients from the COAPT trial with echo core lab TR assessment at baseline and 30-day follow-up (n = 504) were included and divided into 2 groups: those whose TR worsened (ΔTR-INC) and those with no change or improvement in TR (ΔTR-SAME/DEC).  Two-year composite endpoints of death or heart failure hospitalization (HFH) and the individual components were analyzed, after excluding events occurring within the first 30 days.

Results

ΔTR-SAME/DEC occurred in 430 pts (228 TEER, 202 GDMT) while ΔTR-INC was noted in 74 pts (38 TEER, 36 GDMT) (Figure 1A). From 30 days to 2 years, ΔTR-INC pts had a higher rate of the composite outcome of death or HFH compared with ΔTR-SAME/DEC (p = 0.006, Figure 1B). Both 2-year death (HR 1.52, 95% CI 1.01-2.27; p = 0.04) and HFH (HR 1.52, 95% CI 1.04-2.22; p = 0.03) were associated with ΔTR-INC. Assessed by treatment group (Figure 1C and 1D), the relationship between ΔTR-INC and composite death or HFH was significant in GDMT alone pts (HR 1.86, 95% CI 1.21-2.86) but not in TEER pts (HR 1.33, 95% CI 0.79-2.23), although interaction testing demonstrated consistency between the two treatments  (Pint = 0.31). 

Conclusions

Worsening TR at 30 days occurred in ∼15% of pts in the COAPT trial whether they were treated with TEER or GDMT alone. DTRINC was associated with increased death and HFH during 2-year follow-up. Abstract Figure 1