Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Accuracy of ultrasound signs on two-dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study

OBJECTIVE

Two-dimensional (2D) transvaginal ultrasound (TVS) is an accessible and cost-effective diagnostic tool for the detection of adenomyosis. Different ultrasound features related to adenomyosis have been described, but the predictive value of each ultrasound sign and their combinations requires further investigation. We aimed to analyze the accuracy of 2D-TVS and describe possible combinations of ultrasound signs with a high predictive value in the diagnosis of adenomyosis.

METHODS

This was a prospective multicenter study of patients scheduled for laparoscopic hysterectomy who had been examined using standardized 2D-TVS at nine expert centers specializing in the diagnosis and treatment of endometriosis. 2D-TVS examination included nine typical adenomyosis ultrasound features, comprising heterogeneous myometrium, myometrial linear striations, myometrial cysts, subendometrial microcysts, asymmetrical myometrial thickening, uterine enlargement, the 'question mark sign', thickening of the junctional zone and hyperechoic myometrial spots, in order to predict or exclude the presence of adenomyosis. Ultrasound examination results were compared with histology after hysterectomy. The diagnostic reliability of the nine ultrasound signs and their combinations, and the influence of concurrent fibroids on the accuracy of the results, were analyzed.

RESULTS

A total of 202 patients were enrolled into the study. Histopathological examination revealed adenomyosis in 130 patients (64.4%). The accuracy of prediction of adenomyosis by 2D-TVS examination using all signs was 63.4% (positive predictive value, 71.5%; negative predictive value, 48.6%; sensitivity, 71.5%; specificity, 48.6%). Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy (55.7-62.1%) as individual ultrasound signs for the prediction of adenomyosis. The combination of the most accurate ultrasound signs (subendometrial microcysts, myometrial cysts and heterogeneous myometrium) improved the specificity of prediction (86.1%) when compared with that of these three single markers (35.2-81.7%). Uterine enlargement and asymmetry showed both low sensitivity (60.8% and 52.3%, respectively) and specificity (41.7% and 49.3%, respectively) as individual sonographic signs.

CONCLUSIONS

Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy for the detection of adenomyosis in this study, while uterine enlargement and asymmetry led to high false-positive and false-negative results. A combination of ultrasound features including the most accurate signs increases specificity. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Novel Deep Learning Segmentation Models for Accurate GTV and OAR Segmentation in MR-Guided Adaptive Radiotherapy for Pancreatic Cancer Patients

PURPOSE/OBJECTIVE(S)

MR-guided adaptive radiotherapy (MRgART) improves target coverage and organ-at-risk (OAR) sparing in pancreatic cancer radiation therapy (RT). Inter-fractional changes in patients undergoing RT require time intensive re-delineation of gross tumor volume (GTV) and OARs prior to adaptive optimization. Accurate automatic segmentation has the potential to significantly improve efficiency of the adaptive workflow. We hypothesized that state-of-the-art deep learning (DL) segmentation models could adequately segment GTV and OARs in both planning and daily fractional MR scans.

MATERIALS/METHODS

The study included 21 patients with pancreatic cancer treated with MRgART (10 Gy x 5 fractions). The planning MR as well as all daily MR images and registrations were collected (6 image sets per patient and a total of 126 image sets). The planning MR and fraction 1-4 image sets were used as the training set (N = 105), while the test set (N = 21) comprised images for fraction 5, to simulate the last step of incremental learning from planning to final fraction. Evaluated contours included the GTV, Small Bowel, Large Bowel, Duodenum, Left and Right Kidney, Liver, Spinal Cord, and Stomach. To mimic clinical conditions, contour accuracy was evaluated within the ring structure surrounding the PTV, inside of which daily adaptive re-contouring is applied (2 cm expansion in the cradio-caudal direction, 3 cm expansion otherwise). We evaluated three DL model architectures: SegResNet, SegResNet 2D, and SwinUNETR to autosegment GTV and OARs. The segmentation models were trained on the training set using 5-fold cross-validation (CV) and quantitatively analyzed by comparing against clinically used contours with DICE scores. Qualitative analysis was performed by a radiation oncologist using a scoring scale: 1 = perfect, 2 = minor discrepancy, 3 = moderate discrepancy, and 4 = rejected.

RESULTS

Overall, the DL segmentations were in acceptable agreement with clinical contours. The best performing model was the SwinUNETR model with overall training DICE = 0.88±0.06, test DICE = 0.78±0.11, and qualitative score of 1.6±0.8. The agreement between the DL model and clinical segmentation for the GTV was 0.79±0.08, with a qualitative score of 2.2±0.9. The highest and lowest OAR DICE scores were for the Left Kidney (DICE = 0.93) and Small Bowel (DICE = 0.68), respectively. The highest qualitative OAR scores were for the Kidney, Liver, and Spinal Cord (score = 1.0) and the lowest qualitative score was for the Duodenum (score = 2.3) CONCLUSION: We report here the most comprehensive work on DL segmentation for pancreatic cancer MRgART, including quantitative and clinically-pertinent qualitative evaluations of 126 image sets and 3 DL architectures. Our data show good quantitative agreement between DL and clinical contours, and acceptable clinician evaluations for the majority of GTVs and OARs. The current work has great potential to significantly reduce a major bottleneck in the MRgART workflow for pancreatic cancer patients.

Gamma Secretase Inhibition Sensitizes Pancreatic Adenocarcinoma Tumors to RT In Vivo

PURPOSE/OBJECTIVE(S)

Pancreatic adenocarcinoma (PDAC) is an extremely aggressive cancer that lacks curative treatment options. Almost half of patients present with unresectable disease limiting treatment to non-curative options. Patients treated with neoadjuvant radiation therapy (RT) exhibit increases in fibrosis and epithelial-to-mesenchymal transition (EMT). ADAM10, an extracellular sheddase, can stimulate stromal fibrosis, EMT, and radioresistance. ADAM10 also mediates EMT through Notch signaling by cleaving its extracellular domain. Further cleavage by gamma secretase produces the Notch intracellular domain (NICD), which translocates to the nucleus and activates downstream transcriptional targets. Here, we explore whether inhibition of Notch cleavage by gamma secretase radiosensitizes PDAC tumors.

MATERIALS/METHODS

Bilateral flank subcutaneous PDAC isografts were produced in 40 mice using PK5L1940 KPC cells. Intraperitoneal injections of the gamma secretase inhibitor, DAPT (5 mg/kg), were delivered daily for 7 days, starting 3 days prior to RT. A single dose of 20 Gy was administered to each flank tumor, and volumes were measured twice weekly. Colony formation assays of KPC cells were performed after RT, in the presence or absence of DAPT. Since stromal fibrosis can mediate radio-resistance in the tumor microenvironment (TME), the effect of tumor cells on Notch pathway activation in mouse fibroblasts (3T3 cells) was investigated using a luciferase reporter assay. Thus, 3T3 cells transfected with a Notch pathway luciferase reporter were incubated with PDAC cells for 48 h, followed by measurement of luciferase activity.

RESULTS

In vivo, the combination of DAPT and RT significantly delayed tumor growth, and some tumors were completely eradicated. Mean tumor size for the combination at 21 days was 21 mm3 (range = 0-53, p = 0.005), while tumor size was 577 mm3 (range = 217-955, p = 0.69) for DAPT alone, 435 mm3 for RT alone (range = 51-932, p = 0.79), and 367 mm3 for untreated vehicle (range = 97-1144). Surprisingly, DAPT did not reduce clonogenic survival in vitro. Both ADAM10 knockout and DAPT decreased NICD cleavage and transcription of the downstream target Hes1 in vivo and in vitro. Co-culture with PDAC cells increased Notch luciferase reporter activity in fibroblasts. This effect was not mimicked by PDAC-conditioned media, suggesting a requirement for intercellular contact.

CONCLUSION

Notch pathway inhibition sensitizes PDAC tumors to RT in vivo, but not in vitro, suggesting involvement of the TME. Indeed, co-culture with PDAC cells stimulates notch signaling in fibroblasts, suggesting non-cell autonomous mechanisms mediating fibrosis in the TME driving radioresistance. Future studies will determine if ADAM10 inhibition targeting PDAC cells and/or gamma secretase inhibition targeting the TME enhances radiation sensitivity in vivo by blocking fibroblast Notch signaling.

Early Outcomes of MR-Guided SBRT for Patients with Recurrent Pancreatic Adenocarcinoma

PURPOSE/OBJECTIVE(S)

Local treatment options for patients with locally recurrent pancreatic adenocarcinoma (L-PAC) are limited, with expected median survival time (MST) of 8-11 months (mo) following recurrence. MRI-guided radiation therapy (MRgRT) provides the ability to dose escalate while sparing normal tissue. The literature for MR-guided Stereotactic Body Radiotherapy (MRgSBRT) for L-PAC is sparse. Here we report on the early outcomes of MRgSBRT in patients with L-PAC.

MATERIALS/METHODS

Patients with prior resection of pancreatic adenocarcinoma with post-operative chemotherapy as indicated followed by local recurrence of disease at prior surgical site and treated with MRgSBRT at a single tertiary referral center from 5-2021 to 8-2022 for L-PAC were identified from our prospective database. MRgSBRT was delivered to 40-50 Gy in 4-5 fractions with target and OAR delineation per institutional standards. Descriptive analysis of the patient, disease, and treatment characteristics were performed. Endpoints included local control, defined as absence of tumor progression per RECIST criteria, distant failure, overall survival (OS), and acute and chronic toxicities per Common Terminology Criteria for Adverse Events (CTCAE), version 5.

RESULTS

Eleven patients with L-PAC were identified with median follow-up of 10.7 mo (3.2 - 22.3). Ten of those underwent surgical resection at the treating radiation facility and one patient underwent preoperative radiation for 50.4 Gy in 28 fractions followed by surgical resection at an outside hospital. MRgRT was delivered a median of 18.8 mo (3.5 - 48.0) following resection. There were 5 females and 6 males, with a median age of 72 years (52-83) and median KPS of 80 (60-100). OS rates following initial diagnosis at 12, 18 and 24 mo were 100%, 82%, and 61%, respectively, with an MST of 25.3 mo (12.4-53.1). OS rates following recurrence at 6 and 12 mo were 82% and 52%, respectively, with an MST of 10.7 mo (3.2 - 21.9). One patient experienced local failure at 7.8 mo, and 9 patients experienced distant failure at a median of 3.4 mo (0.3 - 21.9) following MRgSBRT. Five patients experienced distant failure less than 3 mo following radiation. Grade 1 or 2 acute GI toxicity was noted in 45% of patients and chronic GI toxicity, in 18% of patients. No Grade≥3 AEs were noted.

CONCLUSION

MRgSBRT for recurrent pancreatic adenocarcinoma demonstrates good local control with acceptable acute and chronic toxicity as well as reasonable overall survival. Distant failure remains a substantial problem with a significant number of patients demonstrating metastases immediately following radiation, suggesting the presence of micro-metastatic disease prior to local therapy. Adequate patient selection for MRgSBRT, and proper integration of systemic therapy in this patient population remains a topic of discussion that requires further exploration.

Automated monitoring of adherence to evidenced-based clinical guideline recommendations: Design and implementation study

BACKGROUND

Clinical practice guidelines are systematically developed statements intended to optimize patient care. However, a gap-less implementation of guideline recommendations requires health care personnel not only to be aware of the recommendations and to support their content, but also to recognize every situation in which they are applicable. To not miss situations in which guideline recommendations should be applied, computerized clinical decision support could be given through a system that allows an automated monitoring of adherence to clinical guideline recommendation in individual patients.

OBJECTIVE

(1) To collect and analyze the requirements for a system that allows to monitor the adherence to evidence-based clinical guideline recommendations in individual patients, and based on these requirements, (2) to design & implement a software prototype that integrates clinical guideline recommendations with individual patient data and (3) to demonstrate the prototype's utility on a guideline treatment recommendation.

METHODS

We performed a work process analysis with experienced intensive care clinicians to develop a conceptual model of how to support guideline adherence monitoring in clinical routine and identified which steps in the model could be supported electronically. We then identified the core requirements of a software system for supporting recommendation adherence monitoring in a consensus-based requirements analysis within loosely structured focus group work of key stakeholders (clinicians, guideline developers, health data engineers, software developers). Based on these requirements, we designed and implemented a modular system architecture. To demonstrate its utility, we applied the prototype to monitor adherence to a COVID-19 treatment guideline recommendation using clinical data from a large European university hospital.

RESULTS

We have designed a system that integrates guideline recommendations with real-time clinical data to evaluate individual guideline recommendation adherence, and developed a functional prototype. The needs analysis with clinical staff resulted in a flow chart describing the work process of how the adherence to guideline recommendations should be monitored. Four core requirements were identified, including the ability to decide whether a guideline recommendation is applicable and implemented for a specific patient, the ability to integrate clinical data from different data formats and data structures, the ability to display raw patient data, and the use of a FHIR-based format for the representation of clinical practice guideline recommendations to provide an interoperable, standards-based guideline recommendation exchange format.

CONCLUSIONS

Our system holds advantages for individual patient treatment and quality management in hospitals. However, further studies are needed to measure the impact on patient outcomes and evaluate its resource-effectiveness in different clinical settings. We specified a modular software architecture that allows experts from different fields to work independently and focus on their area of expertise. We have released the source code of our system under an open-source license and invite for cooperation and collaborative further development of the system.

POS0087-PARE IMPROVED SELF-MANAGEMENT IN PATIENTS WITH OSTEOPOROSIS AND INFLAMMATORY ARTHRITIS

Background

Self-management care services have received a great deal of attention in Switzerland lately. However, there is still a huge gap in service provision, especially with regard to rheumatic diseases. To fill this gap, the Swiss League against Rheumatism has developed a comprehensive self-management programme for patients with inflammatory arthritis (IA) and osteoporosis. In the course of this programme, eleven medical assistants in outpatient rheumatological and general practitioner clinics were trained to help osteoporosis and IA patients to strengthen their self-management capacity. This programme was implemented within the scope of a three-year pilot project (2019 – 2021) and is continuing as a regular project from 2022 onwards.

Objectives

The ultimate objective was to increase the quality of life and health status of people with osteoporosis and IA by enhancing their capacity for self-management. This included all three components of self-management, i.e. strengthening patients’ knowledge of the disease, motivating them to take action and increasing their ability to manage the disease. Furthermore, the pilot project aimed to close an important gap in the Swiss health care system.

Methods

A questionnaire was designed to measure the change in self-management abilities and the health status of patients. The questionnaire was given to patients at three points in time (t1=enrolment of patient, t2=last session of the self-management programme and t3= two months after the last session) and contained several validated scales such as the heiQ, Self-Efficacy for Managing Chronic Disease 6-Item Scale, RADAI-5 and EQ-5D-5L. Descriptive statistics were applied to analyse the data by comparing the mean values of all relevant indicators at three points in time.

Results

In total 52 patients were enrolled in the pilot project. 48 patients completed the programme and 35 took part in the follow-up questionnaire. Overall, the results show a positive trend in self-management abilities and an improvement in the patients’ current health status. The slight increase in knowledge remained until the follow-up. Significant changes are seen in Skill and Technique Acquisition as well as in Self-Monitoring and Insight of the disease, which are two important components of self-management. Other components such as the knowledge and constructive attitudes and approaches also underwent a small but positive change that lasts up to two months after the last session of the self-management programme. Self-efficacy improved as well, but with a slight decrease during the follow-up. The disease activity also declined slightly over time. The results also indicate a small and steady improvement of the current health status. Using a visual analogue scale as part of the EQ-ED-EL, participants evaluated their current health status as 69 (t=1), 73 (t=2) and 74 (t=3). The quality of life has improved too, but the change doesn’t seem to be relevant. Furthermore, the use of health services indicates a slight decline after taking part in the self-management programme.

Conclusion

The comprehensive self-management programme designed by the Swiss League against Rheumatism embedded in outpatient rheumatological and general practitioner clinics proved to be successful. The three components of self-management in particular, i.e. knowledge, motivation to take action and skills to manage the disease improved significantly. The results also show a positive trend in the patients’ current health status, their quality of live and a decline in disease activity. However, based on the study design, it cannot be concluded that there is a correlation between the improved health status/quality of life and the self-management programme. For this purpose, a control group would be necessary to evaluate the programme’s effect on the health status and quality of life of people with rheumatic disease. Nevertheless, this pilot project represents an important foundation on which further services and programmes to strengthen self-management in rheumatology can be developed.

Disclosure of Interests

None declared

Colchicine for the treatment of COVID-19

BACKGROUND

The development of severe coronavirus disease 2019 (COVID-19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti-inflammatory medicine and is thought to improve disease outcomes in COVID-19 through a wide range of anti-inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID-19 and a thorough understanding of the current body of evidence.

OBJECTIVES

To assess the effectiveness and safety of Colchicine as a treatment option for COVID-19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021.

SELECTION CRITERIA

We included randomised controlled trials evaluating colchicine for the treatment of people with COVID-19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection but at high risk of SARS-CoV-2 exposure.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID-19: all-cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all-cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events.

MAIN RESULTS

We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non-hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non-hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID-19 All-cause mortality: colchicine plus standard care probably results in little to no difference in all-cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate-certainty evidence). Worsening of clinical status: colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate-certainty evidence). Improvement of clinical status: colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate-certainty evidence). Quality of life, including fatigue and neurological status: we identified no studies reporting this outcome. Adverse events: the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low-certainty evidence). Serious adverse events: the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low-certainty evidence). Treatment of non-hospitalised people with asymptomatic SARS-CoV-2 infection or mild COVID-19 All-cause mortality: the evidence is uncertain about the effect of colchicine on all-cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low-certainty evidence). Admission to hospital or death within 28 days: colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate-certainty evidence). Symptom resolution: we identified no studies reporting this outcome. Quality of life, including fatigue and neurological status: we identified no studies reporting this outcome. Adverse events: the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment-related events only in 4412 participants (low-certainty evidence). Serious adverse events: colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate-certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti-viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this.

AUTHORS' CONCLUSIONS

Based on the current evidence, in people hospitalised with moderate to severe COVID-19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all-cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes.

Systemic corticosteroids for the treatment of COVID-19

BACKGROUND

Systemic corticosteroids are used to treat people with COVID-19 because they counter hyper-inflammation. Existing evidence syntheses suggest a slight benefit on mortality. So far, systemic corticosteroids are one of the few treatment options for COVID-19. Nonetheless, size of effect, certainty of the evidence, optimal therapy regimen, and selection of patients who are likely to benefit most are factors that remain to be evaluated.

OBJECTIVES

To assess whether systemic corticosteroids are effective and safe in the treatment of people with COVID-19, and to keep up to date with the evolving evidence base using a living systematic review approach.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register (which includes PubMed, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies to 16 April 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated systemic corticosteroids for people with COVID-19, irrespective of disease severity, participant age, gender or ethnicity.  We included any type or dose of systemic corticosteroids. We included the following comparisons: systemic corticosteroids plus standard care versus standard care (plus/minus placebo), dose comparisons, timing comparisons (early versus late), different types of corticosteroids and systemic corticosteroids versus other active substances.  We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome or Middle East respiratory syndrome), corticosteroids in combination with other active substances versus standard care, topical or inhaled corticosteroids, and corticosteroids for long-COVID treatment.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess the risk of bias in included studies, we used the Cochrane 'Risk of bias' 2 tool for RCTs. We rated the certainty of evidence using the GRADE approach for the following outcomes: all-cause mortality, ventilator-free days, new need for invasive mechanical ventilation, quality of life, serious adverse events, adverse events, and hospital-acquired infections.

MAIN RESULTS

We included 11 RCTs in 8075 participants, of whom 7041 (87%) originated from high-income countries. A total of 3072 participants were randomised to corticosteroid arms and the majority received dexamethasone (n = 2322). We also identified 42 ongoing studies and 16 studies reported as being completed or terminated in a study registry, but without results yet.  Hospitalised individuals with a confirmed or suspected diagnosis of symptomatic COVID-19 Systemic corticosteroids plus standard care versus standard care plus/minus placebo  We included 10 RCTs (7989 participants), one of which did not report any of our pre-specified outcomes and thus our analysis included outcome data from nine studies.  All-cause mortality (at longest follow-up available): systemic corticosteroids plus standard care probably reduce all-cause mortality slightly in people with COVID-19 compared to standard care alone (median 28 days: risk difference of 30 in 1000 participants fewer than the control group rate of 275 in 1000 participants; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.80 to 1.00; 9 RCTs, 7930 participants; moderate-certainty evidence).  Ventilator-free days: corticosteroids may increase ventilator-free days (MD 2.6 days more than control group rate of 4 days, 95% CI 0.67 to 4.53; 1 RCT, 299 participants; low-certainty evidence). Ventilator-free days have inherent limitations as a composite endpoint and should be interpreted with caution.  New need for invasive ventilation: the evidence is of very low certainty. Because of high risk of bias arising from deaths that occurred before ventilation we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics.  Quality of life/neurological outcome: no data were available. Serious adverse events: we included data on two RCTs (678 participants) that evaluated systemic corticosteroids compared to standard care (plus/minus placebo); for adverse events and hospital-acquired infections, we included data on five RCTs (660 participants). Because of high risk of bias, heterogeneous definitions, and underreporting we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics (very low-certainty evidence).    Different types, dosages or timing of systemic corticosteroids  We identified one study that compared methylprednisolone with dexamethasone. The evidence for mortality and new need for invasive mechanical ventilation is very low certainty due to the small number of participants (n = 86). No data were available for the other outcomes. We did not identify comparisons of different dosages or timing. Outpatients with asymptomatic or mild disease Currently, there are no studies published in populations with asymptomatic infection or mild disease.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that systemic corticosteroids probably slightly reduce all-cause mortality in people hospitalised because of symptomatic COVID-19. Low-certainty evidence suggests that there may also be a reduction in ventilator-free days. Since we are unable to  adjust for the impact of early death on subsequent endpoints, the findings for ventilation outcomes and harms have limited applicability to inform treatment decisions. Currently, there is no evidence for asymptomatic or mild disease (non-hospitalised participants).  There is an urgent need for good-quality evidence for specific subgroups of disease severity, for which we propose level of respiratory support at randomisation. This applies to the comparison or subgroups of different types and doses of corticosteroids, too. Outcomes apart from mortality should be measured and analysed appropriately taking into account confounding through death if applicable.  We identified 42 ongoing and 16 completed but not published RCTs in trials registries suggesting possible changes of effect estimates and certainty of the evidence in the future. Most ongoing studies target people who need respiratory support at baseline. With the living approach of this review, we will continue to update our search and include eligible trials and published data.

POS1174 HYPERINFLAMMATION AND CLINICAL OUTCOMES FOR PATIENTS WITH SYSTEMIC RHEUMATIC DISEASES HOSPITALIZED FOR COVID-19: A COMPARATIVE COHORT STUDY

Background:

COVID-19 can induce a hyperinflammatory state resulting in cytokine storm, which can lead to poor outcomes. Patients with systemic rheumatic diseases may be at increased risk for respiratory failure with COVID-19. Therefore, we investigated the relationship between rheumatic disease, hyperinflammation, and clinical outcomes among hospitalized COVID-19 patients.

Objectives:

To compare laboratory values, hyperinflammation, and clinical outcomes of hospitalized COVID-19 rheumatic patients and matched comparators.

Methods:

We performed a comparative cohort study of patients with polymerase chain reaction (PCR)-confirmed COVID-19 requiring hospitalization between 3/1/20-7/7/20 at a large health care system. We compared each systemic rheumatic disease case to up to 5 matched (by age, sex, and date of +SARS-CoV-2 PCR) comparators without systemic rheumatic disease. We extracted laboratory values from their hospitalization to compare peaks/troughs of individual laboratory results by case status and derived the COVID-19-associated hyperinflammation score (cHIS), a composite of 6 laboratory domains (0-6, ≥2 indicating hyperinflammation), as previously developed1. We used multivariable logistic regression to estimate ORs for COVID-19 outcomes by hyperinflammation and case status.

Results:

We identified 57 hospitalized rheumatic disease cases (mean age 67 years, 67% female) and 232 matched comparators hospitalized with PCR-confirmed COVID-19. Among cases, 26 (46%) had rheumatoid arthritis and 14 (25%) had systemic lupus erythematosus. Most cases (34, 60%) had active rheumatic disease. At baseline, 15 (27%) of cases were treated with biologic DMARDs, and 32 (56%) were using glucocorticoids. We analyzed 39,900 total laboratory results (median 85 per patient). Cases had higher peak neutrophil-to-lymphocyte ratio (9.6 vs 7.8, p=0.02), LDH (421 vs 345 U/L, p=0.04), creatinine (1.2 vs 1.0 mg/dL, p=0.01), and BUN (31 vs 23 mg/dL, p=0.03) than comparators but similar peak CRP (149 vs 116 mg/L, p=0.11, Figure 1). Cases had higher peak median cHIS (3 vs 2, p=0.01). Peak cHIS ≥2 had higher odds of intensive care unit (ICU) admission (OR 3.45, 95%CI 1.98-5.99), mechanical ventilation (OR 66.0, 95%CI 9.0-487.8), and mortality (OR 16.4, 95%CI 4.8-56.4) compared to cHIS <2 (Table 1). Cases had increased risk of ICU admission (OR 2.0, 95%CI 1.1-3.7) and mechanical ventilation (OR 2.7, 95%CI 1.4-5.2) than comparators.

Table 1.

Associations of peak cHIS and systemic rheumatic disease with COVID-19 hospitalization outcomes

Intensive care unit admissionMechanical ventilationDeath%Adjusted OR (95%CI)%Adjusted OR (95%CI)%Adjusted OR (95%CI)Hospitalization outcomes by hyperinflammation on cHIS1cHIS <2 (n=112)21%1.0 (Ref)1%1.0 (Ref)3%1.0 (Ref)cHIS ≥2 (n=177)48%3.5 (2.0-6.0)37%66.2 (9.0-487.8)27%16.4 (4.8-56.4)Hospitalization outcomes by rheumatic disease statusComparators (n=232)30%1.0 (Ref)19%1.0 (Ref)16%1.0 (Ref)Rheumatic cases (n=57)51%1.87 (1.03-3.40)39%2.46 (1.30-4.67)21%1.32 (0.61-2.88)

Matching factors: age, sex, and date of +PCR.

1Adjusted for age, sex, and case status.

2Adjusted for race, smoking, comorbidities, and body mass index.

cHIS, COVID-19-associated hyperinflammation score; CI, confidence interval; OR, odds ratio; PCR, polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

Conclusion:

Patients with systemic rheumatic disease hospitalized for COVID-19 had higher risk for hyperinflammation, kidney injury, and mechanical ventilation than non-rheumatic comparators. We validated the cHIS in our cohort, which was strongly associated with poor COVID-19 outcomes. These findings highlight that hospitalized patients with rheumatic diseases may be vulnerable to poor COVID-19 outcomes.

References:

[1]Webb BJ et al. Clinical criteria for COVID-19-associated hyperinflammatory syndrome. Lancet Rheumatol. 2020 Dec;2(12):e754-e763.

Disclosure of Interests:

Tiffany Hsu: None declared, Kristin D’Silva: None declared, Naomi Serling-Boyd: None declared, Jiaqi Wang: None declared, Alisa Mueller: None declared, Xiaoqing Fu: None declared, Lauren Prisco: None declared, Lily Martin: None declared, Kathleen Vanni: None declared, Alessandra Zaccardelli: None declared, Claire Cook: None declared, Hyon Choi Consultant of: Dr. Choi reports consultancy fees from Takeda, Selecta, GlaxoSmithKline, and Horizon, Grant/research support from: Dr. Choi reports research support from AstraZeneca., Yuqing Zhang: None declared, Ellen Gravallese: None declared, Zachary Wallace Consultant of: Dr. Wallace reports consulting fees from Viela Bio and MedPace., Grant/research support from: Dr. Wallace reports research support from Bristol-Myers Squibb and Principia., Jeffrey Sparks Consultant of: Dr. Sparks reports consultancy fees from Bristol-Myers Squibb, Gilead, Inova, Janssen, Optum, and Pfizer., Grant/research support from: Dr. Sparks reports research support from Amgen and Bristol-Myers Squibb.

The effect of peri-operative dexmedetomidine on the incidence of postoperative delirium in cardiac and non-cardiac surgical patients: a randomised, double-blind placebo-controlled trial

Delirium occurs commonly following major non-cardiac and cardiac surgery and is associated with: postoperative mortality; postoperative neurocognitive dysfunction; increased length of hospital stay; and major postoperative complications and morbidity. The aim of this study was to investigate the effect of peri-operative administration of dexmedetomidine on the incidence of postoperative delirium in non-cardiac and cardiac surgical patients. In this randomised, double-blind placebo-controlled trial we included 63 patients aged ≥ 60 years undergoing major open abdominal surgery or coronary artery bypass graft surgery with cardiopulmonary bypass. The primary outcome was the incidence of postoperative delirium, as screened for with the Confusion Assessment Method. Delirium assessment was performed twice daily until postoperative day 5, at the time of discharge from hospital or until postoperative day 14. We found that dexmedetomidine was associated with a reduced incidence of postoperative delirium within the first 5 postoperative days, 43.8% vs. 17.9%, p = 0.038. Severity of delirium, screened with the Intensive Care Delirium Screening Checklist, was comparable in both groups, with a mean maximum score of 1.54 vs. 1.68, p = 0.767. No patients in the dexmedetomidine group died while five (15.6%) patients in the placebo group died, p = 0.029. For patients aged ≥ 60 years undergoing major cardiac or non-cardiac surgery, we conclude that the peri-operative administration of dexmedetomidine is associated with a lower incidence of postoperative delirium.

People with type 1 diabetes and impaired awareness of hypoglycaemia have a delayed reaction to performing a glucose scan during hypoglycaemia: a prospective observational study

AIMS

Considering that people with type 1 diabetes and impaired awareness of hypoglycaemia (IAH) have a delayed perception of hypoglycaemia, the question arises whether they perform scans later in case of hypoglycaemia than people without IAH. We assessed whether time to performing a scan after reaching hypoglycaemia while using a flash glucose monitoring (flash GM) system is different in people with IAH compared with people without IAH.

METHODS

Ninety-two people with type 1 diabetes [mean (± sd) age 42 ± 14 years, HbA1c 57 ± 9 mmol/mol] using a flash GM system for 3 months were included. Flash GM data were assessed for time until scan after reaching hypoglycaemia level 1 (< 3.9 mmol/l) and level 2 (< 3.0 mmol/l) and compared for type 1 diabetes with vs. without IAH via unpaired t-test/Mann-Whitney U test (P < 0.05).

RESULTS

Significant differences were found only for the delay between reaching hypoglycaemia and scan between people with and without IAH for Gold score [hypoglycaemia level 1: IAH 78 (51-105) min vs. without IAH 63 (42-89) min, P = 0.03; night-time hypoglycaemia level 2: IAH 140 (107-227) min vs. without IAH 96 (41-155) min, P = 0.004] and Pedersen-Bjergaard score [hypoglycaemia level 1: IAH 76 (52-97) min vs. without IAH 54 (38-71) min, P = 0.011; night-time hypoglycaemia level 1: IAH 132 (79-209) min vs. without IAH 89 (59-143) min, P = 0.011; night-time hypoglycaemia level 2: IAH 134 (66-212) min vs. without IAH 80 (37-131) min, P = 0.002). Data are shown as median (i.q.r.).

CONCLUSIONS

Time until scan after reaching hypoglycaemia might be an objective assessment tool for IAH, but needs to be investigated comprehensively in future studies.

Elution from intact and broken vaginal contraceptive rings: an in vitro study

OBJECTIVE

The in vitro elution of the active substances etonogestrel (ETO) and ethinylestradiol (EE) of Ornibel® (a vaginal delivery system) was determined after a deliberate breakage of the vaginal contraceptive ring and compared to the standard elution and hormone release of intact rings under the same experimental conditions.

MATERIALS AND METHODS

Ornibel® intact and broken vaginal rings were placed in a dissolution buffer and subject to a repetitive sampling of ETO and EE following a standardized in vitro elution (IVE) procedure for 21 days. The hormone dissolution profile was determined by HPLC using a fully validated analytical method. In a second study, rings were broken after day seven, and their elution profiles were compared to that of intact rings. For all utilized batches, the stability conditions established were 24 months at 5°C. Furthermore, no special storage conditions are needed.

RESULTS

The instantaneous elution on day 1 of ETO and EE for intact rings were 119±8 µg/day and 15±1 µg/day, respectively (mean ± SD), which was non-significantly different to the immediate release of ETO and EE for broken rings (118±4 µg/day and 14±1 µg/day). The average elution profile for days 2-20 were 132±5 µg/day and 18±1 µg/day (ETO/EE, intact rings) and 132±4 µg/day and 19±1 µg/day (ETO/EE, broken rings) respectively. On day 21, the elution of ETO and EE was numerically similar 111±5 (±4) µg/day and 18±1 µg/day) for both intact and broken rings. The IVE results from intact rings and vaginal rings deliberately cut on day seven similarly did not differ in their release of ETO and EE.

CONCLUSIONS

Our study concludes that the hormonal release of ETO and EE from Ornibel® are similar for intact and broken vaginal rings under standardized in vitro conditions.

PARE0032 STRENGTHENING SELF-MANAGEMENT TO IMPROVE THE QUALITY OF LIFE AND HEALTH STATUS OF PATIENTS WITH INFLAMMATORY ARTHRITIS AND OSTEOPOROSIS IN SWITZERLAND

Background:

Previous UK studies suggest that people with arthritis taking part in self-management programmes feel more confident in their ability to manage and control their symptoms. These patients may also visit the doctor less frequently and have shown improved physical and clinical outcomes (1, 2). Based on this evidence, self-management has become an essential component of care for patients with arthritis, or generally with chronic diseases. However, there is still a huge gap regarding such self-management services and support programmes in rheumatology in Switzerland.

In the Swiss National Strategy “Musculoskeletal Diseases” 2017–2022, strengthening patients’ empowerment is one of the main strategic pillars. Considering that approximately 500,000 people are suffering in Switzerland from inflammatory arthritis (IA) and osteoporosis (OP) alone, there is huge potential to strengthen patients’ self-management capacity and thus improve their quality of life (3).

Therefore, the SLR has developed a self-management programme for IA and OP patients. In this programme medical assistants in outpatient rheumatology clinics are trained to consult patients in self-management. This programme is part of a two-year pilot project (2019–2020) that is supported by a consortium of important stakeholders in rheumatology in Switzerland.

Objectives:

The ultimate objective is to increase the quality of life and the health status of people with IA and OP in Switzerland by enhancing their capacity for self-management. Furthermore, this pilot project aims at closing an important gap in the Swiss healthcare system by creating an innovative model that can potentially be replicated for other chronic diseases.

Methods:

To measure the quality of life, the health status as well as the change in behaviour in patients, the study design includes both qualitative and quantitative methods. Patients enrolled in the programme are asked to answer a questionnaire at three points in time; at enrolment, after the last session and two months after completing the programme. It is expected that at least 45 patients will be enrolled. For a qualitative assessment, in-depth interviews will be conducted with rheumatologists and their medical assistants as well as some of the programme participants.

The training material for the medical assistants was developed by the SLR and will be evaluated by the programme participants. All patients will also evaluate the quality of the consulting provided by the medical assistant, answering a questionnaire after the last session.

Results:

Within the first year of implementation, ten outpatient clinics, with twenty-four rheumatologists and twelve medical assistants, were enrolled in the pilot project. Four medical assistants were trained in 2019 and eight are in the process of receiving training in spring 2020. Only after the completion of training will patients be enrolled in the self-management programme. Therefore, outcome-related results cannot be expected until the beginning of 2021.

Conclusion:

This pilot project provides an innovative approach to closing an important gap in the Swiss healthcare system and to providing a missing component of care for patients with IA and OP. However, it has been challenging to enrol enough clinics in the pilot project. The way the programme is embedded in the current healthcare system, it demands a cultural change within outpatient clinics, allowing medical assistants to step into a new role as consultant.

References:

[1]Barlow JH, Turner, Wright (2000). ‘A randomised controlled study of the arthritis self-management programme in the UK’. Health Ed Res 15(6): 665–80.

[2]De Silva, D. (2011). Evidence: Helping people help themselves. A review of the evidence considering whether it is worthwhile to support self-management. The Health Foundation. London.

[3]Swiss League against Rheumatism (2017). Swiss National Strategy ‘Musculoskeletal Diseases’ 2017–2022. Zurich: 10–13.

Disclosure of Interests:

None declared

Critical care guidelines on pain, agitation and delirium management: Which one to use? A systematic literature search and quality appraisal with AGREE II

BACKGROUND

Clinical practice guidelines (CPGs) facilitate the provision of standardized, high-quality intensive care medicine. For the management of pain, agitation and delirium, several coexisting CPGs have been published. This study aims at the appraisal of CPGs on pain, agitation and delirium management in the intensive care unit to (a) identify high quality guidelines appropriate for clinical use and (b) identify potential areas for future improvement.

METHODS

We performed a systematic literature search of Medline, three guideline registers and two grey-literature databases. The scope covered guidelines from 2007 to 2020 available in English or German. Identified CPGs were appraised by three independent reviewers using the appraisal of Guidelines Research and Evaluation (AGREE II) instrument.

RESULTS

Eight CPGs were included in the final analysis. Three of the included guidelines exceeded the quality threshold of 60% in all six domains. The highest median [IQR] scores were achieved in the domain "Scope and Purpose" (84.3% [78.7-88.9]), whereas "Applicability" (45.8% [19.4-79.9]) received the lowest median score.

CONCLUSION

Three of the eight reviewed guidelines exceeded the quality threshold in all domains, while the overall guideline quality was also very high. Focusing on guideline applicability and identifying strategies to facilitate implementation can improve future CPGs.

Postoperative anaemia might be a risk factor for postoperative delirium and prolonged hospital stay: A secondary analysis of a prospective cohort study

BACKGROUND

Postoperative anaemia is a frequent surgical complication and in contrast to preoperative anaemia has not been validated in relation to mortality, morbidity and its associated health economic effect. Postoperative anaemia can predispose postoperative delirium through impairment of cerebral oxygenation. The aim of this secondary analysis is to investigate the association of postoperative anaemia in accordance with the sex specific World Health Organization definition of anaemia to postoperative delirium and its impact on the duration of hospital stay.

METHODS

A secondary analysis of the prospective multicentric observational CESARO-study was conducted. 800 adult patients undergoing elective surgery were enrolled from various operative disciplines across seven hospitals ranging from university hospitals, district general hospitals to specialist clinics of minimally invasive surgery in Germany. Patients were classified as anaemic according to the World Health Organization parameters, setting the haemoglobin level cut off below 12g/dl for females and below 13g/dl for males. Focus of the investigation were patients with acute anaemia. Patients with present preoperative anaemia or missing haemoglobin measurement were excluded from the sample set. Delirium screening was established postoperatively for at least 24 hours and up to three days, applying the validated Nursing Delirium Screening Scale.

RESULTS

The initial sample set contained 800 patients of which 183 were suitable for analysis in the study. Ninety out of 183 (49.2%) suffered from postoperative anaemia. Ten out of 93 (10.9%) patients without postoperative anaemia developed a postoperative delirium. In the group with postoperative anaemia, 28 (38.4%) out of 90 patients suffered from postoperative delirium (odds ratio 3.949, 95% confidence interval, (1.358-11.480)) after adjustment for NYHA-stadium, severity of surgery, cutting/suture time, duration of anaesthesia, transfusion of packed red cells and sedation status with Richmond Agitation Scale after surgery. Additionally, patients who suffered from postoperative anaemia showed a significantly longer duration of hospitalisation (7.75 vs. 12.42 days, odds ratio = 1.186, 95% confidence interval, 1.083-1.299, after adjustments).

CONCLUSION

The study results reveal that postoperative anaemia is not only a frequent postsurgical complication with an incidence probability of almost 50%, but could also be associated with a postoperative delirium and a prolonged hospitalisation.

P5489Old ladies paradox: trends in the inpatient care of coronary heart disease 2005–2016 in Germany

Objectives

Coronary heart disease (CHD) and subsequent illnesses are the most common cause of death in industrialized countries and they continue to lead the cause of death statistics.

In Germany, 2015 from all registered deaths 7.1% (n=65,686) are due to chronic CHD and 5.3% (n=49,210) due to acute myocardial infarction (AMI), but the proportion has fallen: Compared to 2003, when 10.9% (n=92,637) of the deceased of CHD and 7.5% of AMI (n=64,229).

It is established that there are sex-differences in prevalence and in the age of the persons concerned. E.g. 2015 AMI infarction is cause of death in 57% (n=27,835) men and 43% (n=21,375) women from 49% men (n=36,049) and 51% women (n=37,127) in 2003.

Aim of the study was, whether these differences in prevalence and diagnostic and interventional measurements in the hospital sector have shifted in recent years with the various entities of the acute coronary disease.

Methods

G-DRG Report-Browser 2005–2016 of the German DRG-Institute (InEK) and Federal Statistical Office data were used.

Analysis was carried out with Microsoft Excel and Access (version 2016).

Results

Inpatient cases of main diagnosis AMI increased from 2005 from 206,104 cases to 219,156 cases in 2016 (+6.3%).

Share of male increased from 62.5% to 66.6%.

The NSTEMI share increased from 39.7% in 2005 to 66.2% in 2016; a total 145.202 cases (+77.2% to 2005). The increase was smaller in older women: 60–70y: +33.7%; 70–80y: +44.5%; 80–90y: +61.9%The NSTEMI increase in men was slightly higher than in women; proportion of men 2005: 64.2%, 2016; 65.1%. The STEMIs number shrank from 104,082 in 2005 to 70,521 (−34.0%) in 2016. The relative reduction was very high in older women:

60–70y: −45.2%; 70–80y: −55.3%; 80–90y: −54.1%. Share of men 2005: 60.1%, 2015; 70.0%.

In 2008: 220,595 diagnostic-only coronarographies were conducted from a total of 690,745 coronarography measurements.

These numbers increased to 485.496 (+120.1%) and 869.002 (+25.8%) in 2016.

Share of the male decreased from 73.0% in 2008 to 65.6% in 2015.

The increase for all coronarographies was highest in older women: 50–60y: +60.7% 60–70y: +39.4%; 70–80y: +72.5%; 80–90y: +168,4%

The total number of percutaneous transluminal vascular interventions (PCI) increased from 2008 with 488,542 to 661,693 in 2016 (+35.4%). The relative increase in PCI was high in older women:

60–70y: +18.6%; 70–80y: +42.7%; 80–90y: +126.1%; >90y: +314.1%

Conclusions

The number of cases of ACS is declining since 2005. There is a significant shift from STEMI to NSTEMI events over the observation period.

In all forms of the ACS, the proportion of men in is increasing.

The rate of coronary diagnostic and coronary intervention in men is disproportionately high in relation to disease rate. Paradoxically the share of examinations older women without further action increases strongly, despite their share in the disease was small and is still decreasing.

Minocycline Prevents the Development of Mechanical Allodynia in Mouse Models of Vincristine-Induced Peripheral Neuropathy

Vincristine is an antineoplastic substance that is part of many chemotherapy regimens, used especially for the treatment of a variety of pediatric cancers including leukemias and brain tumors. Unfortunately, many vincristine-treated patients develop peripheral neuropathy, a side effect characterized by sensory, motoric, and autonomic symptoms. The sensory symptoms include pain, in particular hypersensitivity to light touch, as well as loss of sensory discrimination to detect vibration and touch. The symptoms of vincristine-induced neuropathy are only poorly controlled by currently available analgesics and therefore often necessitate dose reductions or even cessation of treatment. The aim of this study was to identify new therapeutic targets for the treatment of vincristine-induced peripheral neuropathy (VIPN) by combining behavioral experiments, histology, and pharmacology after vincristine treatment. Local intraplantar injection of vincristine into the hind paw caused dose- and time-dependent mechanical hypersensitivity that developed into mechanical hyposensitivity at high doses, and lead to a pronounced, dose-dependent infiltration of immune cells at the site of injection. Importantly, administration of minocycline effectively prevented the development of mechanical hypersensitivity and infiltration of immune cells in mouse models of vincristine induce peripheral neuropathy (VIPN) based on intraperitoneal or intraplantar administration of vincristine. Similarly, Toll-like receptor 4 knockout mice showed diminished vincristine-induced mechanical hypersensitivity and immune cell infiltration, while treatment with the anti-inflammatory meloxicam had no effect. These results provide evidence for the involvement of Toll-like receptor 4 in the development of VIPN and suggest that minocycline and/or direct Toll-like receptor 4 antagonists may be an effective preventative treatment for patients receiving vincristine.

Impact of physical exercise on sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system in people with Type 1 diabetes: a randomized crossover trial

AIMS

To evaluate the sensor performance of the FreeStyle Libre intermittently viewed continuous glucose monitoring system using reference blood glucose levels during moderate-intensity exercise while on either full or reduced basal insulin dose in people with Type 1 diabetes.

METHODS

Ten participants with Type 1 diabetes [four women, mean ± sd age 31.4 ± 9.0 years, BMI 25.5±3.8 kg/m² , HbA_1c 55±7 mmol/mol (7.2±0.6%)] exercised on a cycle ergometer for 55 min at a moderate intensity for 5 consecutive days at the clinical research facility, while receiving either their usual or a 75% basal insulin dose. After a 4-week washout period, participants performed the second exercise period having switched to the alternative basal insulin dose. During exercise, reference capillary blood glucose values were analysed using the fully enzymatic-amperometric method and compared with the interstitial glucose values obtained. Intermittently viewed continuous glucose monitoring accuracy was analysed according to median (interquartile range) absolute relative difference, and Clarke error grid and Bland-Altman analysis for overall glucose levels during exercise, stratified by glycaemic range and basal insulin dosing scheme (P<0.05).

RESULTS

A total of 845 glucose values were available during exercise to evaluate intermittently viewed continuous glucose monitoring sensor performance. The median (interquartile range) absolute relative difference between the reference values and those obtained by the sensor across the glycaemic range overall was 22 (13.9-29.7)%, and was 36.3 (24.2-45.2)% during hypoglycaemia, 22.8 (14.6-30.6)% during euglycaemia and 15.4 (9-21)% during hyperglycaemia. Usual basal insulin dose was associated with a worse sensor performance during exercise compared with the reduced (75%) basal insulin dose [median (interquartile range) absolute relative difference: 23.7 (17.2-30.7)% vs 20.5 (12-28.1)%; P<0.001).

CONCLUSIONS

The intermittently viewed continuous glucose monitoring sensor showed diminished accuracy during exercise. Absolute glucose readings derived from the sensor should be used cautiously and need confirmation by additional finger-prick blood glucose measurements.

Import of community-associated, methicillin-resistant Staphylococcus aureus to Europe through skin and soft-tissue infection in intercontinental travellers, 2011-2016

OBJECTIVES

Recently, following import by travel and migration, epidemic community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused nosocomial outbreaks in Europe, sometimes with a fatal outcome. We describe clinico-epidemiological characteristics of CA-MRSA detected by the European Network for the Surveillance of imported S. aureus (www.staphtrav.eu) from May 2011 to November 2016.

METHODS

Sentinel surveillance at 13 travel clinics enrolling patients with travel-associated skin and soft-tissue infection (SSTI) and analysing lesion and nose swabs at one central laboratory.

RESULTS

A total of 564 independent case-patients with SSTI were enrolled and had 374 (67%) S. aureus-positive lesions, of which 14% (51/374) were MRSA. The majority of CA-MRSA isolates from SSTI were Panton-Valentine leucocidin (PVL) -positive (43/51, 84%). The risk of methicillin-resistance in imported S. aureus varied by travel region (p <0.001) and was highest in Latin America (16/57, 28%, 95% CI 17.0-41.5) and lowest in Sub-Saharan Africa (4/121, 3%, 95% CI 0.9-8.3). Major epidemic clones (USA300 / USA300 Latin-American Variant, Bengal Bay, South Pacific) accounted for more than one-third (19/51, 37%) of CA-MRSA imports. CA-MRSA SSTI in returnees was complicated (31/51 multiple lesions, 61%; 22/50 recurrences, 44%), led to health-care contact (22/51 surgical drainage, 43%; 7/50 hospitalization, 14%), was transmissible (13/47 reported similar SSTI in non-travelling contacts, 28%), and associated with S. aureus nasal colonization (28 of 51 CA-MRSA cases, 55%; 24 of 28 colonized with identical spa-type in nose and lesion, 85%).

CONCLUSIONS

Travel-associated CA-MRSA SSTI is a transmissible condition that leads to medical consultations and colonization of the infected host.

Neurofeedback Tunes Scale-Free Dynamics in Spontaneous Brain Activity

Brain oscillations exhibit long-range temporal correlations (LRTCs), which reflect the regularity of their fluctuations: low values representing more random (decorrelated) while high values more persistent (correlated) dynamics. LRTCs constitute supporting evidence that the brain operates near criticality, a state where neuronal activities are balanced between order and randomness. Here, healthy adults used closed-loop brain training (neurofeedback, NFB) to reduce the amplitude of alpha oscillations, producing a significant increase in spontaneous LRTCs post-training. This effect was reproduced in patients with post-traumatic stress disorder, where abnormally random dynamics were reversed by NFB, correlating with significant improvements in hyperarousal. Notably, regions manifesting abnormally low LRTCs (i.e., excessive randomness) normalized toward healthy population levels, consistent with theoretical predictions about self-organized criticality. Hence, when exposed to appropriate training, spontaneous cortical activity reveals a residual capacity for "self-tuning" its own temporal complexity, despite manifesting the abnormal dynamics seen in individuals with psychiatric disorder. Lastly, we observed an inverse-U relationship between strength of LRTC and oscillation amplitude, suggesting a breakdown of long-range dependence at high/low synchronization extremes, in line with recent computational models. Together, our findings offer a broader mechanistic framework for motivating research and clinical applications of NFB, encompassing disorders with perturbed LRTCs.

Fluorescent Labeling and 2-Photon Imaging of Mouse Tooth Pulp Nociceptors

Retrograde fluorescent labeling of dental primary afferent neurons (DPANs) has been described in rats through crystalline fluorescent DiI, while in the mouse, this technique was achieved with only Fluoro-Gold, a neurotoxic fluorescent dye with membrane penetration characteristics superior to the carbocyanine dyes. We reevaluated this technique in the rat with the aim to transfer it to the mouse because comprehensive physiologic studies require access to the mouse as a model organism. Using conventional immunohistochemistry, we assessed in rats and mice the speed of axonal dye transport from the application site to the trigeminal ganglion, the numbers of stained DPANs, and the fluorescence intensity via 1) conventional crystalline DiI and 2) a novel DiI formulation with improved penetration properties and staining efficiency. A 3-dimensional reconstruction of an entire trigeminal ganglion with 2-photon laser scanning fluorescence microscopy permitted visualization of DPANs in all 3 divisions of the trigeminal nerve. We quantified DPANs in mice expressing the farnesylated enhanced green fluorescent protein (EGFPf) from the transient receptor potential cation channel subfamily M member 8 (TRPM8^EGFPf/+) locus in the 3 branches. We also evaluated the viability of the labeled DPANs in dissociated trigeminal ganglion cultures using calcium microfluorometry, and we assessed the sensitivity to capsaicin, an agonist of the TRPV1 receptor. Reproducible DiI labeling of DPANs in the mouse is an important tool 1) to investigate the molecular and functional specialization of DPANs within the trigeminal nociceptive system and 2) to recognize exclusive molecular characteristics that differentiate nociception in the trigeminal system from that in the somatic system. A versatile tool to enhance our understanding of the molecular composition and characteristics of DPANs will be essential for the development of mechanism-based therapeutic approaches for dentine hypersensitivity and inflammatory tooth pain.

Gender-specific impairment of in vitro sinoatrial node chronotropic responses and of myocardial ischemia tolerance in rats exposed prenatally to betamethasone

Excessive fetal glucocorticoid exposure has been linked to increased susceptibility to hypertension and cardiac diseases in the adult life, a process called fetal programming. The cardiac contribution to the hypertensive phenotype of glucocorticoid-programmed progeny is less known, therefore, we investigated in vitro cardiac functional parameters from rats exposed in utero to betamethasone. Pregnant Wistar rats received vehicle (VEH) or betamethasone (BET, 0.1mg/kg, i.m.) at gestational days 12, 13, 18 and 19. Male and female offspring were killed at post-natal day 30 and the right atrium (RA) was isolated to in vitro evaluation of drug-induced chronotropic responses. Additionally, whole hearts were retrograde-perfused in a Langendorff apparatus and infarct size in response to in vitro ischemia/reperfusion (I/R) protocol was evaluated. Male and female progeny from BET-exposed pregnant rats had reduced birth weight, a hallmark of fetal programming. Male BET-progeny had increased basal RA rate, impaired chronotropic responses to noradrenaline and adenosine, and increased myocardial damage to I/R. Though a 12-fold reduction in the negative chronotropic responses to adenosine, the effects of non-metabolisable adenosine receptor agonists 5'-(N-ethylcarboxamido)adenosine or 2-Chloro-adenosine were not different between VEH- and BET-exposed male rats. BET-exposed female offspring presented no cardiac dysfunction. Prenatal BET exposure engenders male-specific impairment of sinoatrial node function and on myocardial ischemia tolerance resulting, at least in part, from an increased adenosine metabolism in the heart. In light of the importance of adenosine in the cardiac physiology our results suggest a link between reduced adenosinergic signaling and the cardiac dysfunctions observed in glucocorticoid-induced fetal programming.

Inpatient treatment of patients with acute idiopathic peripheral facial palsy: A population-based healthcare research study

OBJECTIVES

To determine the inpatient management for patients with acute idiopathic facial palsy (IFP) in Thuringia, Germany.

DESIGN

Population-based study.

SETTING

All inpatients with IFP in all hospitals with departments of otolaryngology and neurology in 2012, in the German federal state, Thuringia.

MAIN OUTCOME MEASURES

Patients' characteristics and treatment were compared between departments, and the probability of recovery was tested.

RESULTS

A total of 291 patients were mainly treated in departments of otolaryngology (55%) and neurology (36%). Corticosteroid treatment was the predominant therapy (84.5%). The probability to receive a facial nerve grading (odds ratio [OR=12.939; 95% confidence interval [CI]=3.599 to 46.516), gustatory testing (OR=6.878; CI=1.064 to 44.474) and audiometry (OR=32.505; CI=1.485 to 711.257) was significantly higher in otolaryngology departments, but lower for cranial CT (OR=0.192; CI=0.061 to 0.602), cerebrospinal fluid examination (OR=0.024; CI=0.006 to 0.102). A total of 131 patients (45%) showed a recovery to House-Brackmann grade≤II. A pathological stapedial reflex test (Hazard ratio [HR]=0.416; CI=0.180 to 0.959) was the only independent diagnostic predictor of worse outcome. Prednisolone dose >500 mg (HR=0.579; CI 0.400 to 0.838) and no adjuvant physiotherapy (HR=0.568; CI=0.407 to 0.794) were treatment-related predictors of worse outcome.

CONCLUSIONS

Inpatient treatment of IFP seems to be highly variable in daily practice, partly depending on the treating discipline and despite the availability of evidence-based guidelines. The population-based recovery rate was worse than reported in clinical trials.

Preclinical and clinical evaluation of carbohydrate immunopharmaceuticals in the prevention of sepsis and septic sequelae

Sepsis and sepsis syndrome are significant causes of morbidity and mortality in critically ill patients. Despite technological and therapeutic advances in critical care, sepsis continues to be a pivotal factor in 20-50 % of deaths in surgical intensive care units. It is clear that alternative approaches to the prevention and/or treatment of sepsis must be found. Preclinical data indicate that macrophage activation with (1→3)-β-D-glucans will ameliorate sequelae associated with Gram-negative septicemia. Recent clinical data indicate that macrophage activation with (1→3)-β-D-glucans will significantly reduce septic morbidity and mortality in trauma and/or high-risk surgical patients. This work reviews the preclinical and clinical evaluation of (1→3)-β-D-glucans in the prevention of sepsis and septic sequelae.

Biomonitoring of prenatal analgesic intake and correlation with infantile anti-aeroallergens IgE

An association between prenatal acetaminophen or ibuprofen intake and an increased risk of asthma and increased IgE level in children is discussed in various epidemiological studies. Although the molecular mechanistic link is still unknown, the question whether or not acetaminophen and/or ibuprofen are safe pain medications during pregnancy arose. In this study, we associate maternal acetaminophen and ibuprofen intake during pregnancy and breastfeeding to infantile asthma phenotypes and elevated IgE level. Therefore, we analysed questionnaires from a local mother-child cohort and monitored drug intake by LC-MS biomonitoring in urine. No association was found between drug intake and any analysed health outcome using questionnaire data. For the information obtained from biomonitoring, no association was found for ibuprofen and acetaminophen intakes during breastfeeding. However, an association between prenatal acetaminophen intake and increased infantile IgEs related to aeroallergens was statistically detected, but not for asthma phenotypes.