Digital medicine and minimally invasive surgery in pediatric hepatoblastoma: An update

Hepatoblastoma (HB) is the most common liver malignancy in children, accounting for approximately 60 % of liver tumors in this population. However, the exact cause of HB remains unclear. The combination of surgery and neoadjuvant chemotherapy has significantly improved the overall survival rate of children with HB, increasing it from 40 % in the past to over 70 %. The concept of precise hepatectomy, which aims to achieve the best rehabilitation outcomes with minimal trauma and maximum liver protection, has been widely accepted by hepatobiliary surgeons. This article provides a comprehensive review of the recent advancements in surgical treatment of HB, focusing on digital surgery and minimally invasive techniques.

Accuracy of machine learning in the preoperative identification of ovarian borderline tumors: a meta-analysis

AIM

The objective of this study is to explore the diagnostic value of machine learning (ML) in borderline ovarian tumors through meta-analysis.

METHODS

Pubmed, Embase, Web of Science, and Cochrane Library databases were comprehensively retrieved from database inception untill February 16, 2023. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was adopted to evaluate the risk of bias in the original studies. Sub-group analyses of ML were conducted according to clinical features and radiomics features. We separately discussed the discriminative value of ML for borderline vs benign and borderline vs malignant tumors.

RESULTS

Eighteen studies involving 12,778 subjects were included in our analysis. The modeling variables mainly consisted of radiomics features (n=13) and a small number of clinical features (n=5). When distinguishing between borderline and benign tumors, the ML model based on radiomic features achieved a c-index of 0.782 (95% CI: 0.732-0.831), sensitivity of 0.75 (95% CI: 0.67-0.82), and specificity of 0.75 (95% CI: 0.67-0.81) in the validation set. When distinguishing between borderline and malignant tumors, the ML model based on radiomic features achieved a c-index of 0.916 (95% CI: 0.891-0.940), sensitivity of 0.86 (95% CI: 0.78-0.91), and specificity of 0.88 (95% CI: 0.82-0.92) in the validation set. In addition, we analyzed the discriminatory ability of radiologists and found that their sensitivity was 0.26 (95% CI: 0.12-0.46) and specificity was 0.94 (95% CI: 0.90-0.97).

CONCLUSIONS

ML has tremendous potential in the preoperative diagnosis and differentiation of borderline ovarian tumors and may be more accurate than radiologists in diagnosing and differentiating borderline ovarian tumors.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Body mass index, weight change, and cancer prognosis: a meta-analysis and systematic review of 73 cohort studies

BACKGROUND

Identifying the association between body mass index (BMI) or weight change and cancer prognosis is essential for the development of effective cancer treatments. We aimed to assess the strength and validity of the evidence of the association between BMI or weight change and cancer prognosis by a systematic evaluation and meta-analysis of relevant cohort studies.

METHODS

We systematically searched the PubMed, Web of Science, EconLit, Embase, Food Sciences and Technology Abstracts, PsycINFO, and Cochrane databases for literature published up to July 2023. Inclusion criteria were cohort studies with BMI or weight change as an exposure factor, cancer as a diagnostic outcome, and data type as an unadjusted hazard ratio (HR) or headcount ratio. Random- or fixed-effects models were used to calculate the pooled HR along with the 95% confidence interval (CI).

RESULTS

Seventy-three cohort studies were included in the meta-analysis. Compared with normal weight, overweight or obesity was a risk factor for overall survival (OS) in patients with breast cancer (HR 1.37, 95% CI 1.22-1.53; P < 0.0001), while obesity was a protective factor for OS in patients with gastrointestinal tumors (HR 0.67, 95% CI 0.56-0.80; P < 0.0001) and lung cancer (HR 0.67, 95% CI 0.48-0.92; P = 0.01) compared with patients without obesity. Compared with normal weight, underweight was a risk factor for OS in patients with breast cancer (HR 1.15, 95% CI 0.98-1.35; P = 0.08), gastrointestinal tumors (HR 1.54, 95% CI 1.32-1.80; P < 0.0001), and lung cancer (HR 1.28, 95% CI 1.22-1.35; P < 0.0001). Compared with nonweight change, weight loss was a risk factor for OS in patients with gastrointestinal cancer.

CONCLUSIONS

Based on the results of the meta-analysis, we concluded that BMI, weight change, and tumor prognosis were significantly correlated. These findings may provide a more reliable argument for the development of more effective oncology treatment protocols.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Can Hisense computer-assisted surgery system (Hisense CAS) improve anatomy teaching in pediatric liver surgery?

PURPOSE

This study aimed to investigate the effectiveness of the Hisense computer-assisted surgery system (CAS) in teaching pediatric liver surgical anatomy.

METHODS

The research subjects were residents who underwent standardized training at the Department of Pediatric Surgery at Yijishan Hospital of Wannan Medical College from May 2022 to May 2023.

RESULTS

The study recruited a total of 62 students, with 31 students assigned to the Hisense CAS group (12 males and 19 females) and the remaining 31 students serving as controls (Control group, 15 males and 16 females). There were no significant differences in baseline characteristics observed between the two groups. This study found that the average scores of the Hisense CAS teaching group in the liver surgery evaluations were higher than those of the control group. Specifically, the Hisense CAS group had an average score of 84.25 ± 5.70 points in the liver surgery knowledge test, 77.10 ± 8.12 points in the image reading test, and 70.58 ± 8.79 points in the surgical simulation test, while the traditional teaching group had average scores of 73.45 ± 6.12 points, 69.81 ± 6.05 points, and 66.42 ± 6.61 points, respectively; the differences between the two groups were statistically significant (P < 0.05). Furthermore, this study also found that the Hisense CAS teaching model resulted in significantly better teaching satisfaction on the part of the residents in terms of standardized teaching for physicians in pediatric liver surgical anatomy.

CONCLUSION

In conclusion, this study demonstrated greater satisfaction of the residents with the use of 3D reconstruction added to traditional teaching sessions and better performance during the posttraining evaluation.

Exosomes-mediated drug delivery for the treatment of myocardial injury

Cardiovascular disease has become a major cause of death worldwide. Myocardial injury (MI) caused by myocardial infarction, myocarditis, and drug overdose can lead to impaired cardiac function, culminating in serious consequences such as angina pectoris, arrhythmias, and heart failure. Exosomes exhibit high biocompatibility and target specificity, rendering them an important non-cellular therapy for improving MI. Exosomes are diminutive vesicles that encapsulate nucleic acids and proteins. Exosomes derived from cardiac stem cells themselves have therapeutic effects, and they can also serve as carriers to deliver therapeutic drugs to recipient cells, thereby exerting a therapeutic effect. The molecules within exosomes are encapsulated in a lipid bilayer, allowing them to stably exist in body fluids without being affected by nucleases. Therefore, the utilization of exosomes as drug delivery systems (DDS) for disease treatment has been extensively investigated and is currently undergoing clinical trials. This review summarizes the therapeutic effects of exosomes on MI and provides an overview of current research progress on their use as DDS in MI.

Association between mental health workforce supply and clusters of high and low rates of youth suicide: An Australian study using suicide mortality data from 2016 to 2020

OBJECTIVE

To examine the association between mental health workforce supply and spatial clusters of high versus low incidence of youth suicide.

METHODS

A cross-sectional analysis of spatial suicide clusters in young Australians (aged 10-25) from 2016 to 2020 was conducted using the scan statistic and suicide data from the National Coronial Information System. Mental health workforce was extracted from the 2020 National Health Workforce Dataset by local government areas. The Geographic Index of Relative Supply was used to estimate low and moderate-to-high mental health workforce supply for clusters characterised by a high and low incidence of suicide (termed suicide hotspots and coldspots, respectively). Univariate and multivariate logistic regression was used to determine the association between suicide clusters and a range of sociodemographic characteristics including mental health workforce supply.

RESULTS

Eight suicide hotspots and two suicide coldspots were identified. The multivariate analysis showed low mental health workforce supply was associated with increased odds of being involved in a suicide hotspot (adjusted odds ratio = 8.29; 95% confidence interval = 5.20-13.60), followed by residential remoteness (adjusted odds ratio = 2.85; 95% confidence interval = 1.68-4.89), and illicit drug consumption (adjusted odds ratio = 1.97; 1.24-3.11). Both coldspot clusters occurred in areas with moderate-to-high mental health workforce supply.

CONCLUSION

Findings highlight the potential risk and protective roles that mental health workforce supply may play in the spatial distributions of youth suicide clusters. These findings have important implications for the provision of postvention and the prevention of suicide clusters.

HDAC-Mediated Glial Crosstalk Mediates Radiation Induced Memory Changes from Whole Brain Radiation in a Mouse Model

PURPOSE/OBJECTIVE(S)

Prior work demonstrated radiation sensitivity can be regulated via Class III HDAC-mediated intracellular DNA damage response coordinated with Wnt-beta catenin signaling. We hypothesized that radiation induced functional alterations in HDAC mediated glial crosstalk in the CNS produce intercellular signaling alterations leading to phenotypic changes in cognition following whole brain radiation exposure.

MATERIALS/METHODS

Primary human astrocytes, human astrocytoma (U251), and immortalized human microglia (HMC3) were examined in vitro in response to treatment with conditioned media isolated from irradiated glial cells. Prior to treatment with either single-dose or fractionated radiation schedules, cells were transfected with siRNA expression vector for Sirt2, a class III HDAC, versus scrambled controls. Quantitative PCR and immunoblots for neurotransmitters, metabolism, and inflammatory markers were obtained. Cells exposed to conditioned media were examined by immunofluorescence for cytoskeletal alterations and changes in junctional proteins. The findings were correlated with in vivo qPCR and immunohistochemical changes in brain tissue and functional memory changes in Sirt2 knockout versus wild type mice after whole brain radiation using novel object recognition testing at 2 weeks and 6 month post radiation timepoints. Statistical analysis was performed using paired Students T test between treated and control groups.

RESULTS

Cells treated with conditioned media produced from irradiated U251, astrocytes and microglia produced increased expression of inflammatory cytokines IL-6, IL-8, GM-CSF and VEGF. However, immunofluorescence of cells treated with conditioned media from irradiated Sirt2 knockdown microglia and primary astrocytes demonstrated qualitative disruptions in glutamate neurotransmitter metabolism and actin cytoskeletal alterations with changes in pseudopodia and lamellipodia after staining with phalloidin and neurofilament L, suggesting altered intercellular communication. Connexin 43 in gap junctions was increased >2-fold (p<0.05) after exposure to conditioned media, whereas E-cadherin in adherens junctions was not significantly affected. Novel object recognition testing of Sirt2 knockout mice demonstrated resistance to radiation induced memory decline from whole brain radiation at pre radiation day 5 versus post radiation days 5 and 185 compared to controls (p<0.05).

CONCLUSION

Glial crosstalk can be mediated via elimination of a Class III HDAC and appears to be a key mediator of radiation induced disruptions of intercellular communication in the CNS, connecting radiation to structural changes on the cell surface to synaptic activity and neurotransmitter metabolism, leading to functional disputations in recognition memory similar to what is experienced by patients receiving brain radiotherapy. These data suggest glial cross talk as a new therapeutic avenue to combat radiation induced cognitive dysfunction.

Identifying Common Topics in Patient Portal Messages with Unsupervised Natural Language Processing

PURPOSE/OBJECTIVE(S)

Patient portal messaging is an increasingly important form of communication between patients and medical providers. This has become particularly relevant in oncology, where patients undergo intense longitudinal treatments that require frequent communication regarding symptoms, appointments, and diagnostic results. The rise in the volume of these messages has significantly increased the workload of medical providers and consequent physician burn-out. Natural language processing (NLP), particularly transformer-based models, may offer an automated approach to characterize the content of patient messages and improve message triage and routing. In this study, we employed a state-of-the-art language model (Bidirectional Encoder Representations from Transformers; BERT) to identify data-derived categories of representative topics from real-world data thereby providing basic information to build an appropriate routing system.

MATERIALS/METHODS

Patient-generated portal messages sent to a messaging pool for a single institution radiation oncology department from 2014 to 2023 were extracted. BERTopic, an NLP-based topic modeling technique based on BERT was optimized for topic modeling of patient messages. Uniform Manifold Approximation and Projection (UMAP) was used to reduce dimensionality and visualize topic relationships across messages. The BERTopic-identified topic categories were subsequently labeled manually by one of the physician investigators. Differences of number of messages over time were assessed using t-tests.

RESULTS

A total of 47,492 messages were retrieved. The average number of messages per month from a single patient ranged from 1 to 18 (median 1.67, interquartile range 1.0-2.4). The total volume of patient messages showed a ten-fold increase over the study period, with 101 messages per month sent in 2014 and 999 messages per month in 2022 (p<0.001). BERTopic initially identified 35 topics whose relationships and degrees of overlap were visualized by UMAP. Due to physician-identified similarities, these topics were reduced into 13 categories. The most frequent topic category was messages about laboratory tests or imaging studies: 24.3%, followed by messages expressing appreciation: 18.9%, scheduling discussions: 15.6%, symptom-related messages: 11%, and treatment-related messages: 10.7%.

CONCLUSION

Patient portal messages sent to a single institution radiation oncology department have increased dramatically in volume since implementation, corresponding to a broader national trend. NLP successfully identified common subject themes across patient messages, many of which are related to scheduling. This presents potential opportunities to apply NLP to automate message routing in the future.

Whole blood transfusion among allied partnerships: unified and interoperable blood banking for optimised care

Whole blood transfusion is being increasingly used for trauma resuscitation, particularly in military settings. Low-titre group O whole blood simplifies the logistical challenges and maximises the benefits of blood transfusion when compared with component therapy in austere battlefield conditions. Screening protocols and blood testing requirements for prescreened donors in walking blood banks (WBBs), which are used for emergency transfusions, are established by both the USA and most partner nations, though they are not necessarily uniform across these combined forces. Interoperability and standardisation of blood bank resources and protocols across allied forces in multinational military operations, including uniformity in screening processes, collection methods and storage is essential to the provision of safe and effective blood product transfusions in this austere setting. Predeployment screening, multinational training exercises and universal WBB sets with instructions in multiple languages can help enhance the interoperability of combined multinational operations and create a more efficient WBB system. Standardisation of blood collection, nomenclature, equipment and screening practices will allow for the most optimal utilisation of whole blood resources across a multinational battlefield.

The role of OIP5 in the carcinogenesis and progression of ovarian cancer

BACKGROUND

Opa interacting protein 5 (OIP5), which is a cancer/testis-specific gene, plays a cancer-promoting role in various types of human cancer. However, the role of OIP5 in the carcinogenesis and progression of ovarian cancer remains unknown.

METHODS

We first analyzed the expression of OIP5 in ovarian cancer and various human tumors with the Sangerbox online analysis tool. GSE12470, GSE14407 and GSE54388 were downloaded from the Gene Expression Omnibus (GEO) database, and GEO2R was used to screen differentially expressed genes in ovarian cancer tissues. Gene Ontology (GO) enrichment analysis was used to explore the related biological processes. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive ability of OIP5 for ovarian cancer. Next, RT-PCR, immunohistochemistry and Western blotting were utilized to evaluate the expression of OIP5 in ovarian cancer. CCK8, EdU proliferation assays and colony formation assays were used to measure cell proliferation, cell cycle progression was examined by PI staining and flow cytometry, and cell apoptosis was examined by Caspase3/7 activity assays. The effect of OIP5 on the migration and invasion of ovarian cancer cells was analyzed with Transwell assays.

RESULTS

We found that OIP5 is highly expressed in ovarian cancer through bioinformatics analysis, and importantly, OIP5 may be an important biomarker for the prognosis and diagnosis of ovarian cancer. RT-PCR assays, immunohistochemistry and Western blotting were also used to confirm the high expression of OIP5 in ovarian cancer. Subsequently, we demonstrated that the proliferation and migration of the ovarian cancer cell line A2780 were significantly inhibited after OIP5 gene silencing, apoptosis was increased and cell cycle progression was arrested at the G1 phase.

CONCLUSION

This study indicated that OIP5 was highly expressed in ovarian cancer and that downregulation of OIP5 inhibited the proliferation, migration and invasion of ovarian cancer cells, induced cell cycle arrest and promoted cell apoptosis. Therefore, OIP5 may be an important biomarker for the early diagnosis and potential target for treatment of ovarian cancer.

Effects of lactic acid bacteria-fermented formula milk supplementation on colonic microbiota and mucosal transcriptome profile of weaned piglets

Supplemental probiotic fermented milk as a gut modulator can improve growth performance for weaned piglets by promoting the development of the small intestine in digestion and immune function. The effect on colon health might also play a considerable part in the favourable role of probiotic fermented milk in the growth performance improvement of weaned piglets; however, it has yet to be reported. This study aimed to investigate the effects of supplementation with lactic acid bacteria-fermented formula milk (LFM) on colonic morphology, microbiota composition, and mucosal transcriptome profile in weaned piglets. A total of 24 male weaned piglets were randomly divided into two groups: a control (CON) treatment or the LFM-supplemented treatment. Each group consisted of six replicates (cages) with two piglets per cage, and each piglet in the LFM group was supplemented with 80 mL LFM three times a day for 21 d, while the CON group was treated with the same amount of drinking water. Results showed that supplementation of LFM reduced the colonic histological damage scores and significantly increased the number of goblet cells per crypt. Furthermore, LFM consumption decreased the levels of pro-inflammation cytokines in the colonic mucosa. LFM downregulated the expression of inflammatory genes (CXCL9 and CXCL10) involving Toll-like receptor signalling pathway, immune response, and response to bacterium, and up-regulated two active genes (S100A8 and S100A9) involving the IL-17 signalling pathway and Toll-like receptor 4 binding. In addition, LFM could increase the potential probiotic genera containing Lachnospira and Anaerorhabdus furcosa group, which were positively related to short-chain fatty acid (SCFA) production. Correspondingly, LFM-fed piglets had higher total bacterial load and total SCFA concentration in the colonic digesta compared with the CON group. These novel findings support the benefits of LFM in enhancing intestinal homoeostasis and ameliorating weaning stress for weaned piglets, which is associated with the modulation of gut microbiota composition and immune-related genes.

In vitro selection of aptamers and their applications

The introduction of the in-vitro evolution method known as SELEX (Systematic Evolution of Ligands by Exponential enrichment) more than 30 years ago led to the conception of versatile synthetic receptors known as aptamers. Offering many benefits such as low cost, high stability and flexibility, aptamers have sparked innovation in molecular diagnostics, enabled advances in synthetic biology and have facilitated new therapeutic approaches. The SELEX method itself is inherently adaptable and offers near limitless possibilities in yielding functional nucleic acid ligands. This Primer serves to provide guidance on experimental design and highlight new growth areas for this impactful technology.

Single-incision laparoscopic appendectomy versus traditional three-hole laparoscopic appendectomy for acute appendicitis in children by senior pediatric surgeons: a multicenter study from China

Objective

The aim of this study was to evaluate the clinical efficacy of single-incision laparoscopy appendectomy (SILA) and traditional three-hole laparoscopy appendectomy (THLA) for the treatment of acute appendicitis in children.

Methods

The clinical data of children (<14 years old) who underwent laparoscopic appendectomy at Yijishan Hospital of Wannan Medical College, Hubei Provincial Maternal Health Hospital and Qingdao Women and Children's Medical Center from January 2019 to June 2022 were retrospectively analyzed. According to the operation method, the patients were assigned to the SILA group or the THLA group. The clinical data, including the efficacy, and the surgical details, including the complications, of the two surgical methods were compared. The personal information of the children and the time of disease onset were recorded.

Results

In this study, the data of 588 patients, including 385 patients in the THLA group and 203 patients in the SILA group were collected. The baseline characteristics between the two groups of patients before surgery were comparable. There was no significant difference in the average operation time between the THLA group and the SILA group (56.31 ± 1.83 min vs. 57.48 ± 1.15 min, P > 0.05). There was also no significant difference in the average length of hospital stay between the THLA group and the SILA group (6.91 ± 0.24 days vs. 7.16 ± 0.36 days, P > 0.05). However, the FLACC scores of the SILA group (3.71 ± 0.78) were significantly lower than those of the THLA group (3.99 ± 0.56) on the second postoperative day, and the difference was significant (P < 0.05). The score of the questionnaire evaluating cosmetic appearance of the postoperative abdomen was significantly higher in the SILA group (15.81 ± 0.36) than in the THLA group (13.10 ± 0.24) (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05).

Conclusion

SILA is more advantageous in terms of postoperative FLACC scores and cosmetic appearance in children than THLA. There was no significant difference in the incidence of complications or other aspects between the two surgical methods.

β-hydroxybutyrate is a metabolic regulator of proteostasis in the aged and Alzheimer disease brain

Loss of proteostasis is a hallmark of aging and Alzheimer disease (AD). Here, we identify β-hydroxybutyrate (βHB), a ketone body, as a regulator of protein solubility in the aging brain. βHB is a small molecule metabolite which primarily provides an oxidative substrate for ATP during hypoglycemic conditions, and also regulates other cellular processes through covalent and noncovalent protein interactions. We demonstrate βHB-induced protein insolubility across in vitro, ex vivo, and in vivo mouse systems. This activity is shared by select structurally similar metabolites, is not dependent on covalent protein modification, pH, or solute load, and is observable in mouse brain in vivo after delivery of a ketone ester. Furthermore, this phenotype is selective for pathological proteins such as amyloid-β, and exogenous βHB ameliorates pathology in nematode models of amyloid-β aggregation toxicity. We have generated a comprehensive atlas of the βHB-induced protein insolublome ex vivo and in vivo using mass spectrometry proteomics, and have identified common protein domains within βHB target sequences. Finally, we show enrichment of neurodegeneration-related proteins among βHB targets and the clearance of these targets from mouse brain, likely via βHB-induced autophagy. Overall, these data indicate a new metabolically regulated mechanism of proteostasis relevant to aging and AD.

Medical operations in the 21st century: application of TAK among wartime medical assets

Advances in technology have improved the ability for real-time communication and enhanced awareness of medically related information on the battlefield. A government off-the-shelf platform, Team Awareness Kit (TAK), may enhance the ability for battlefield healthcare delivery, evacuation, telecommunication, and medical command and control. Integration of TAK into existing medical infrastructure provides a global view of resources, patient movement and direct communication, significantly reducing the 'fog of war' as it relates to battlefield injury and evacuation. Rapid integration and adoption are technically feasible with minimal resource investment. This technology can be rapidly scaled for the increasingly interconnected world of healthcare delivery.

Quantitative fingerprint and antioxidative properties of Artemisia argyi leaves combined with chemometrics

Quantitative fingerprint and differences of Artemisia argyi from different varieties, picking time, aging year, and origins were analyzed combing with chemometrics. The antioxidant activity was determined and antioxidant markers of Artemisia argyi were screened. Variety WA3 was significantly different from that of the other varieties. Fingerprint peak response and antioxidant activity of A. argyi picked in December were lower than samples collected in May and August. Fresh A. argyi leaves were significantly superior to withered leaves and stems. Artemisia argyi aging 1-5 years presented a classification trend. Antioxidant activity of A. argyi produced in Nanyang was generally superior to others origins. Peak 9, isochlorogenic acid A, and 6-methoxyluteolin contributed greatly for classification of A. argyi from different variety, picking time, aging year, and origin. Isochlorogenic acid A, isochlorogenic acid C, 6-methoxyluteolin, and chlorogenic acid were selected as antioxidant marker of A. argyi. The method based on quantitative fingerprint, antioxidant activity evaluation, and chemometrics was reliable to analyze the differences of A. argyi samples from different sources.

Development of TaqMan-based real-time PCR assay based on the E1 genefor the quantitative detection of the Getah virus

To develop a sensitive, specific, and rapid approach for the detection Getah virus (GETV), a set of primers targeting the conserved region of the E1 gene was created. The TaqMan-based real-time PCR method for GETV detection was developed by optimizing the reaction conditions. The method demonstrated excellent specificity, and amplification did not occur with the causative agents of all prevalent swine viral infections (CSFV, PRRSV, PRV, PEDV, PTV, and JEV), except GETV. Additionally, upon assessing the sensitivity of the method, the minimum detection limit for GETV was found to be 5.94 copies/μL, which is 10 times higher than that of the traditional PCR approach. Further, the intra- and inter-assay variation coefficients were less than 1%, demonstrating good repeatability. Moreover, GETV was found in 10 of the 20 field serum samples using real-time PCR but only in three of the samples using traditional PCR. Consequently, the first GETV TaqMan-based real-time PCR approach based on the E1 gene was developed for GETV pathogenic diagnoses, and this exhibited high specificity, sensitivity, and repeatability. This assay is practical for the pathogenic diagnosis and epidemiology of GETV.

Impact of omitting post-transplant minidose-methotrexate doses in allogeneic hematopoietic cell transplantation

Given prophylactic methotrexate (MTX) is often held in the setting of toxicity we investigated the impact of omitting minidose-MTX dose(s). Outcomes were compared between patients who had 1-3 doses omitted and those who received all four planned doses of minidose-MTX. Of 370 consecutive patients, 50 had MTX dose(s) omitted. When MTX was omitted, initial management was mycophenolate mofetil (MMF; 36/50 patients) with or without corticosteroids (14/50 patients). Rates of grade 3-4 acute GVHD were similar between groups. Omission of minidose-MTX resulted in an increased risk of chronic GVHD (cGVHD; HR 2.27; p = .024) and decreased overall survival (HR 1.61; p = .024). However, other transplant-related outcomes were comparable. In summary, omission of minidose-MTX doses was not associated with an increased risk of acute GVHD when an alternative was added (e.g. MMF ± corticosteroids). This did not abrogate the increased risk of cGVHD or decreased overall survival.

Prevention of Exposure Keratopathy in the Intensive Care Unit: Evaluation of an EMR-Based Lubrication Order Protocol for Ventilated Patients

Purpose In this pilot study, we aimed to investigate the efficacy of an electronic medical record (EMR) order set for lubricating ointment (four times daily) in the prevention of exposure keratopathy in ventilated patients in the intensive care unit (ICU) at the University of Utah. We attempted to capture the magnitude of morbidity, cost, and care burden in ventilated patients, as well as the utility of a systematic EMR-based preventative lubrication protocol in the ICU setting.

Methods After implementation of the order set, a retrospective chart review was performed to capture all ventilated ICU patients pre- and postintervention. Three separate study periods were used: (1) Six months prior to coronavirus disease 2019 (COVID-19) and prior to the ocular lubrication intervention; (2) the subsequent 6-month period including COVID-19 patients but prior to any intervention; and (3) the subsequent 6-month period postintervention, including COVID-19 patients. The primary endpoint of ointment use per day was analyzed with a Poisson regression model. Secondary endpoints including rates of ophthalmologic consultation and exposure keratopathy were compared with Fisher's exact test. A poststudy survey of ICU nurses was included.

Results A total of 974 ventilated patients were included in the analysis. Ointment use per day increased by 155% (95% confidence interval [CI] 132–183%, p < 0.001) following the intervention. Rates also increased 80% (95% CI 63–99%, p < 0.001) during the COVID-19 study period but prior to intervention. The percentage of ventilated patients requiring a dilated eye exam for any indication was 3.2, 4, and 3.7% in each of the study periods, respectively. There was an overall down trend in the rate of exposure keratopathy which was diagnosed in 33.3, 20, and 8.3% of those receiving ophthalmologic consultation, though these rates were not statistically significant.

Conclusion These preliminary data show a statistically significant increase in the rates of lubrication in mechanically ventilated patients using an EMR-based order set in the ICU setting. There was no statistically significant decrease in the rates of exposure keratopathy. Our preventative protocol with lubrication ointment was of minimal cost burden to the ICU. Further longitudinal and multicenter studies are needed to better assess the efficacy of such a protocol.

Mesenchymal stem cells-derived exosomes prevent sepsis-induced myocardial injury by a CircRTN4/miR-497-5p/MG53 pathway

Sepsis is a life-threatening organ function dysfunction featured by stimulated oxidative stress and inflammatory responses, in which about 40%-60% of sepsis patients are accompanied with cardiac dysfunction. Mesenchymal stem cells (MSCs)-derived exosomes exert critical roles in the treatment of multiple diseases through transferring non-coding RNAs. Circular RNA (circRNA) is a novel form of functional RNAs that involves in the progression of multiple cardiac pathological condition. Nevertheless, the function of MSCs-derived exosomal circRTN4 in sepsis-induced myocardial injury is still obscure. Significantly, FISH assay demonstrated the location of circRTN4 in cytoplasm of cardiomyocytes. The expression of circRTN4 was reduced in the cardiac tissues from caecal ligation and puncture (CLP) rats and LPS-treated cardiomyocytes. CircRTN4 could be delivered to cardiomyocytes cells via MSCs-derived exosomes. The cardiac injury and apoptosis were induced in the CLP rats and the treatment of MSCs-derived exosomal circRTN4 relieved the phenotypes. MSCs-derived exosomal circRTN4 notably suppressed the upregulated ROS level in the CLP rats. The activity of SOD and GSH was repressed in CLP rats, in which MSCs-derived exosomal circRTN4 rescued the activity in the rats. The upregulated IL-1β, IL-6, and TNF-α levels in CLP rats were reduced by the treatment of MSCs-derived exosomal circRTN4. MSCs-derived exosomal circRTN4 improved cell survival and suppressed apoptosis of LPS-treated cardiomyocytes. CircRTN4 direct interact with miR-497-5p to upregulate MG53 expression in cardiomyocytes. MSCs-derived exosomal circRTN4 relieves LPS-stimulated cardiomyocyte damage via targeting miR-497-5p/MG53 axis. Therefore, we determine that MSCs-derived exosomes prevent sepsis-induced myocardial injury by a circRTN4/miR-497-5p/MG53 pathway. Our data provides novel insight into the regulatory mechanism by which MSCs-derived exosomal circRTN4 regulates sepsis-induced myocardial injury. MSCs-derived exosomal circRTN4 may be applied as a promising therapeutic approach for sepsis-induced myocardial injury.

OP0012 INTERFERON-α MEDIATED THERAPEUTIC RESISTANCE IN EARLY RA IMPLICATES EPIGENETIC REPROGRAMMING

Background

An interferon gene signature (IGS) is present in approximately 50% of early, treatment naive rheumatoid arthritis (eRA) patients. We previously demonstrated it negatively impacts on initial disease outcomes.

Objectives

To 1) reproduce previous findings demonstrating the harmful effects of the IGS on early RA clinical outcomes, 2) identify which IFN class is responsible for the IGS and 3) seek evidence that IFN-α exposure contributes to harmful epigenetic footprint at disease onset.

Methods

In a large multicentre inception cohort (n=190) of eRA patients (RA-MAP TACERA) whole blood transcriptome, IGS (MxA, IFI44L, OAS1, ISG15, IFI6) and circulating interferons (IFN)-α, -β, -γ and -λ was examined at baseline and 6 months in conjunction with disease activity and clinical characteristics. A separate eRA cohort of paired methylome and transcriptome from CD4 T and CD19 B cells (n=41 for each) was used to explore any epigenetic influence of the IGS.

Results

The baseline IGS reproducibly and significantly negatively impacts on 6-month clinical outcomes. In the high IGS cohort there was increased DAS-28 (p=0.025) and reduced probability of achieving a good EULAR response (p=0.034) at 6-months. In addition, the IGS in eRA is shown for the first time to predominantly reflect raised circulating IFN-α protein, not other classes of IFN and examination of whole blood upstream nucleic acid sensors expression suggest a RNA trigger. Both the IGS and IFN-α significantly fell in parallel at 6 months (p<0.0001), whereas other classes of IFN remained statistically static. There was a significant association with IFN-α and RF titre but not ACPA. Comparison of CD4 T and CD19 B cells between IGS high and low eRA patients demonstrated differentially methylated CPG sites and altered transcript expression of disease relevant genes e.g. PARP9, STAT1, EPTSI1 which was similarly, and persistently, altered 6 months in the separate TACERA cohort. Differentially methylated CPGs implicated altered transcription factor binding in B cells (GATA3, ETSI, NFATC2, EZH2) and T cells (p300, HIF1α) which cumulatively suggested IFN-α induced epigenetic changes promoting increased, and sustained, lymphocyte activation, proliferation and loss of anergy in the IGS high cohort.

Conclusion

We validate that the IGS is a robust prognostic biomarker in eRA predicting poor therapeutic response. Its persistent harmful effects may be driven via epigenetic modifications. These data have relevance for other IFN-α states, such as COVID-19, but also provide a rationale for the initial therapeutic targeting of IFN-α signalling, such as with JAKi, at disease onset in stratified eRA subsets.

References

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Acknowledgements

JDI is a National Institute for Health Research (NIHR) Senior Investigator. The authors acknowledge the support of TACERA Principal Investigators from all contributing NHS sites and the members of the TACERA Study Steering and Data Monitoring Committee. Additional acknowledgements include patient volunteers and administrative support from Ben Hargreaves. Newcastle researchers received infrastructural support via the Versus Arthritis Research into Inflammatory Arthritis Centre (Ref 22072), funding from The Medical Research Council; Academy of Medical Sciences; British Society of Rheumatology; The Wellcome Trust; JGW Patterson Foundation; Immune-Mediated Inflammatory Disease Biobank in the UK (IMID-Bio-UK), ANR and RTCure. This work was supported by the NIHR Newcastle Biomedical Research Centre at Newcastle Hospitals Foundation Trust and Newcastle University; views expressed are the authors’ and not necessarily those of the National Health Service, the National Institute of Health Research or the Department of Health.

Disclosure of Interests

Faye Cooles Speakers bureau: Astrazeneca: December 2021, Jessica Tarn: None declared, Dennis Lendrem: None declared, Najib Naamane: None declared, Alice Lin: None declared, Ben Millar: None declared, Nicola Maney: None declared, Nishanthi Thalayasingam: None declared, Vincent Bondet: None declared, Darragh Duffy: None declared, Michael Barnes: None declared, Graham Smith: None declared, Sandra Ng: None declared, David Watson: None declared, Rafael Henkin: None declared, Andrew Cope: None declared, Louise Reynard: None declared, Arthur Pratt: None declared, RA-MAP Consortium: None declared, John Isaacs Speakers bureau: speaker/consulting fees from AbbVie, Gilead, Roche and UCB., Grant/research support from: JDI discloses research grants from Pfizer, Janssen and GSK.

Has improved treatment contributed to the declining rate of transition to psychosis in ultra-high-risk cohorts?

BACKGROUND

The factors contributing to declining psychotic disorder transition rates in ultra-high-risk populations remain unclear. We examined the contribution of longitudinal changes in standard clinical treatment ('treatment as usual') to this decline.

METHOD

An audit was conducted on 105 clinical files of patients who received standard care at a specialised ultra-high-risk service. The session notes of these files were quantified, allowing examination of treatment quantity, targets, psychotherapy, and medication. Differences in these aspects across patients' year of clinic entry were assessed. Variables with significant differences across years were examined using cox regression to assess their contribution to psychosis transition rates.

RESULTS

Findings were that, as a function of patients' year of clinic entry, there were increases in: patients' number of sessions, cognitive behavioural therapy (CBT), problem and solving therapy. There was a relationship between baseline year cohort and psychosis transition rate, with lower rates observed in more recent cohorts. When changes in treatment between cohorts were adjusted for, the relationship between baseline year cohort and transition rate disappeared. The relationship between baseline year and transition rate was attenuated most by increases in CBT.

CONCLUSION

Changes in standard treatment, particularly increases in CBT, may have contributed to the decline in psychosis risk observed in recent ultra-high-risk cohorts, although these variables do not fully explain this trend. Implications for clinical practice, prediction and intervention research are discussed. Future ultra-high-risk research should investigate the impact of other treatment factors, such as therapeutic alliance.

Dental Caries Postradiotherapy in Head and Neck Cancer

BACKGROUND

Treatment for head and neck cancer (HNC) such as radiotherapy (RT) can lead to numerous acute and chronic head and neck sequelae, including dental caries. The goal of the present study was to measure 2-y changes in dental caries after radiotherapy in patients with HNC and test risk factors for caries increment.

METHODS

Cancer and dental disease characteristics, demographics, and oral health practices were documented before and 6, 12, 18, and 24 mo after the start of RT for 572 adult patients with HNC. Patients were eligible if they were age 18 y or older, diagnosed with HNC, and planned to receive RT for treatment of HNC. Caries prevalence was measured as decayed, missing, and filled surfaces (DMFS). The association between change in DMFS and risk factors was evaluated using linear mixed models.

RESULTS

On average, DMFS increased from baseline to each follow-up visit: 6 mo, +1.11; 12 mo, +2.47; 18 mo, +3.43; and 24 mo, +4.29 (P < 0.0001). The increase in DMFS during follow-up was significantly smaller for the following patient characteristics: compliant with daily fluoride use (P = 0.0004) and daily oral hygiene (brushing twice daily and flossing daily; P = 0.015), dental insurance (P = 0.004), and greater than high school education (P = 0.001). DMFS change was not significantly associated with average or maximum RT dose to the parotids (P > 0.6) or salivary flow (P > 0.1). In the subset of patients who had salivary hypofunction at baseline (n = 164), lower salivary flow at follow-up visits was associated with increased DMFS.

CONCLUSION

Increased caries is a complication soon after RT in HNC. Fluoride, oral hygiene, dental insurance, and education level had the strongest association with caries increment after radiotherapy to the head and neck region. Thus, intensive oral hygiene measures, including fluoride and greater accessibility of dental care, may contribute to reducing the caries burden after RT in HNC.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians when deciding how to minimize oral complications related to cancer therapy for patients with head and neck cancer. Identification of modifiable factors (e.g., oral hygiene and prescription fluoride compliance) associated with increased caries risk can minimize radiation caries burden.

Vascular inflammation in patients with obstructive sleep apnoea and coronary artery disease shown on coronary computed tomography angiography attenuation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obstructive sleep apnoea (OSA) is associated with increased plaque burden in coronary artery disease (CAD), but the role of vascular inflammation in this relationship is unclear. Coronary computed tomography angiography (CTA) enables surrogate assessment of systemic inflammation via subcutaneous adipose tissue attenuation (ScAT-a), and of coronary inflammation via epicardial adipose tissue volume and attenuation (EAT-v and EAT-a) and pericoronary adipose tissue attenuation (PCAT-a).

Purpose

To investigate whether vascular inflammation is increased in patients with severe OSA and high plaque burden.

Methods

Patients with clinically indicated polysomnography and coronary CTA were included. Severe OSA was classified as apnoea/hypopnoea index (AHI) &gt;30. High plaque burden was defined as a CT-Leaman score (CT-LeSc) &gt;8.3. Patients with both severe OSA and high plaque burden were defined as ‘Group 1’, all other patients were classified as ‘Group 2’. ScAT-a, EAT-a, EAT-v and PCAT-a were assessed on semi-automated software.

Results

A total of 91 patients were studied (59.3 ± 11.1 years). Severe OSA was associated with high plaque burden (p = 0.02). AHI correlated with CT-LeSc (r = 0.24, p = 0.023). Group 1 had lower EAT-a and PCAT-a compared to Group 2 (EAT-a: -87.6 vs. -84.0 HU, p = 0.01; PCAT-a: -90.4 vs. -83.4 HU, p &lt; 0.01). However, among patients without high plaque burden, EAT-a was increased in patients with severe OSA versus mild-moderate OSA (-80.3 vs. -84.0 HU, p = 0.020). On multivariable analysis, EAT-a independently associated with severe OSA and high plaque burden (p &lt; 0.02), and PCAT-a associated with severe OSA and high plaque burden, and hypertension (all p &lt; 0.01).

Conclusions

EAT attenuation is decreased in patients with severe OSA and high plaque burden but increased in patients with severe OSA and low plaque burden. These divergent results suggest coronary inflammation may be increased in OSA independent of CAD, but larger studies are required to validate these findings.

Salvianolic acid B inhibits the progression of liver fibrosis in rats via modulation of the Hedgehog signaling pathway

Salvianolic acid B (Sal B) has previously reported anti-hepatic fibrosis effects, though it is not clear if it can inhibit hepatic fibrosis by regulating the hedgehog (Hh) signaling pathway. The aim of the present study was to explore the roles and mechanism of Sal B in preventing and treating liver fibrosis in rats. The study also aimed to determine the role of the Hh signaling pathway in this process. A rat model of liver fibrosis was induced through the subcutaneous injection of 50% carbon tetrachloride, followed by treatment with Sal B. After gavage, blood was collected to detect serum markers of liver injury. The degree of liver fibrosis and tissue damage was assessed using histopathological analysis. Western blotting and reverse transcription-quantitative PCR were used to detect the expression levels of TGF-β1 and Hh signaling pathway-related genes, including Sonic hedgehog (Shh) protein, membrane protein receptor protein patched homolog 1 (Ptch1), membrane protein receptor Smoothened (Smo) and transcription factor glioma-associated oncogene homolog 1 (Gli1). Serum alanine aminotransferase, aspartate aminotransferase and total bilirubin levels were decreased, whilst levels of albumin were increased in rats with liver fibrosis that were treated with Sal B (P<0.05). Additionally, significant increases in TGF-β1, Shh, Ptch1, Smo, Gli1 and α-smooth muscle actin expression levels were observed in the liver tissues of rats with hepatic fibrosis (P<0.05). However, Sal B treatment significantly reduced the expression levels of these proteins (P<0.05). In conclusion, the results of the present study suggested that the Hh signaling pathway may be activated during the process of rat liver fibrosis. Thus, Sal B may exert its anti-hepatic fibrosis effects, at least in part, by inhibiting the activation of the Hh signaling pathway.

Assessing the impact of organ-specific lesion dynamics on survival in patients with recurrent urothelial carcinoma treated with atezolizumab or chemotherapy

Background

Tumor dynamics typically rely on the sum of the longest diameters (SLD) of target lesions, and ignore heterogeneity in individual lesion dynamics located in different organs.

Patients and methods

Here we evaluated the benefit of analyzing lesion dynamics in different organs to predict survival in 900 patients with metastatic urothelial carcinoma treated with atezolizumab or chemotherapy (IMvigor211 trial).

Results

Lesion dynamics varied largely across organs, with lymph nodes and lung lesions showing on average a better response to both treatments than those located in the liver and locoregionally. A benefit of atezolizumab was observed on lung and liver lesion dynamics that was attributed to a longer duration of treatment effect as compared to chemotherapy (P value = 0.043 and 0.001, respectively). The impact of lesion dynamics on survival, assessed by a joint model, varied greatly across organs, irrespective of treatment. Liver and locoregional lesion dynamics had a large impact on survival, with an increase of 10 mm of the lesion size increasing the instantaneous risk of death by 12% and 10%, respectively. In comparison, lymph nodes and lung lesions had a lower impact, with a 10-mm increase in the lesion size increasing the instantaneous risk of death by 7% and 5%, respectively. Using our model, we could anticipate the benefit of atezolizumab over chemotherapy as early as 6 months before the end of the study, which is 3 months earlier than a similar model only relying on SLD.

Conclusion

We showed the interest of organ-level tumor follow-up to better understand and anticipate the treatment effect on survival.

•

Nine hundred metastatic urothelial carcinoma patients from the IMvigor211 phase III trial were treated with atezolizumab versus chemotherapy.

•

A total of 4489 organ-specific measurements were made: 1544 measurements in the lymph, 999 in the lung, 691 in the liver, and 559 locoregionally.

•

Longer treatment effect was observed in the lung (P value = 0.043) and liver (P = 0.001) lesions under atezolizumab compared to chemotherapy.

•

Those with a 10-mm growth of liver lesion had their instantaneous risk of death increased by 12%, compared to 5% in the lung.

•

Treatment effect on overall survival could be predicted based on early organ-specific tumor data 6 months after last patient inclusion.

Enhanced recovery after surgery protocol and postoperative opioid prescribing for cesarean delivery: an interrupted time series analysis

INTRODUCTION

Enhanced recovery after surgery (ERAS) pathways have emerged as a promising strategy to reduce postoperative opioid use and decrease the risk of developing new persistent opioid use in surgical patients. However, the association between ERAS implementation and discharge opioid prescribing practices is unclear.

STUDY DESIGN

We conducted a retrospective observational quasi-experimental study of opioid-naïve patients aged 18+ undergoing cesarean delivery between February 2015 and December 2019 at a large academic center. An interrupted time series analysis (ITSA) was used to model the changes in pain medication prescribing associated with the implementation of ERAS to account for pre-existing temporal trends.

RESULTS

Among the 1473 patients (out of 2249 total) who underwent cesarean delivery after ERAS implementation, 80.72% received a discharge opioid prescription vs. 95.36% at baseline. Pre-ERAS daily oral morphine equivalents (OME) on the discharge prescription decreased by 0.48 OME each month (p<0.01). There was a level shift of 35 more OME prescribed (p<0.01), followed by a monthly decrease of 1.4 OMEs per month after ERAS implementation (p<0.01). Among those who received a prescription, 61.35% received a total daily dose greater than 90 OME compared to 11.35% pre-implementation (p<0.01), while prescriptions with a total daily dose less than 50 OME decreased from 79.86 to 25.85% after ERAS implementation(p<0.01).

CONCLUSION

Although ERAS implementation reduced the overall proportion of patients receiving a discharge opioid prescription after cesarean delivery, for the subset of patients receiving an opioid prescription, ERAS implementation may have inadvertently increased the prescribing of daily doses greater than 90 OME. This finding highlights the importance of early and continued evaluation after new policies are implemented.

Heterotopia in Individuals with 22q11.2 Deletion Syndrome

BACKGROUND AND PURPOSE

MR imaging studies and neuropathologic findings in individuals with 22q11.2 deletion syndrome show anomalous early brain development. We aimed to retrospectively evaluate cerebral abnormalities, focusing on gray matter heterotopia, and to correlate these with subjects' neuropsychiatric impairments.

MATERIALS AND METHODS

Three raters assessed gray matter heterotopia and other morphologic brain abnormalities on 3D T1WI and T2*WI in 75 individuals with 22q11.2 deletion syndrome (27 females, 15.5 [SD, 7.4] years of age) and 53 controls (24 females, 12.6 [SD, 4.7] years of age). We examined the association among the groups' most frequent morphologic findings, general cognitive performance, and comorbid neuropsychiatric conditions.

RESULTS

Heterotopia in the white matter were the most frequent finding in individuals with 22q11.2 deletion syndrome (n = 29; controls, n = 0; between-group difference, P < .001), followed by cavum septi pellucidi and/or vergae (n = 20; controls, n = 0; P < .001), periventricular cysts (n = 10; controls, n = 0; P = .007), periventricular nodular heterotopia (n = 10; controls, n = 0; P = .007), and polymicrogyria (n = 3; controls, n = 0; P = .3). However, individuals with these morphologic brain abnormalities did not differ significantly from those without them in terms of general cognitive functioning and psychiatric comorbidities.

CONCLUSIONS

Taken together, our findings, periventricular nodular heterotopia or heterotopia in the white matter (possibly related to interrupted Arc cells migration), persistent cavum septi pellucidi and/or vergae, and formation of periventricular cysts, give clues to the brain development disorder induced by the 22q11.2 deletion syndrome. There was no evidence that these morphologic findings were associated with differences in psychiatric or cognitive presentation of the 22q11.2 deletion syndrome.