POS0825 DEVELOPMENT OF A NEW AND SIMPLIFIED FORMULA TO PREDICT MORTALITY IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS ADMITTED TO THE INTENSIVE CARE UNIT

Background:

ANCA-associated vasculitis (AAV) can present with a wide range of symptoms, including acute kidney injury (AKI) requiring renal replacement therapy or diffuse alveolar hemorrhage (1). These two manifestations often require admission to an intensive care unit (ICU) and are associated with increased mortality. To predict ICU mortality, the Simplified Acute Physiology Score version 2 (SAPS2) is often used but has not been formally tested in AAV patients (2). In addition, it is cumbersome to assess.

Objectives:

To develop a novel, simplified formula to predict ICU mortality in an AAV ICU population from an academic tertiary care center.

Methods:

We retrospectively recorded clinical and laboratory parameters in patients admitted to our ICU from 2000-2018. We performed risk factor analysis using univariate and multivariate logistic regression. In the multivariate case we applied the least absolute shrinkage and selection operator (lasso) method for variable selection. We considered average marginal effects and partial dependence plots in order to describe the influence of various independent variables on the probability of death more specifically. We evaluated our new score by comparing the corresponding area under the curve (AUC) to the AUC corresponding to the established SAPS2 score.

Results:

We analyzed 58 patients with AAV (39 granulomatosis with polyangiitis, 19 with microscopic polyangiitis) with a mean age of 74±14 (GPA) and 73±12 (MPA). 19/39 (48.7%) of GPA and 9/19 (47.4%) were female. Reasons for admission included disease manifestations or infectious complications from treatment (e. g. pneumonia, urinary tract infection). In total, 13/58 (22.4%) patients died throughout the study (10 GPA, 3 MPA patients). Using a cut-off threshold of 40 for SAPS2, sensitivity and specificity for mortality were 0.92 and 0.60, respectively. Confidence interval for the AUC was [0.68,0.95]. In the fitted multivariate logistic regression model, lasso was applied for variable selection. The identified variables included: disease duration, pH, procalcitonin, hemoglobin, leukocytes on admission, coronary heart disease, and pneumonia on admission. The estimated mortality is given by the formula ƒ(β0 + β1χ1 + …+ β7χ7), where ƒ(u)=1/(1+exp(−u)). Table 1 shows the estimated mortality for various values of the new score.

Table 1.

Example scores predicting mortality using the novel formula.

ScorePredicted mortality-2.20.1-1.10.2500.51.10.752.20.9

Testing if the AUC corresponding to the new model is significantly larger than the one corresponding to the SAPS2 score as independent variable resulted in p-value of 0.037. To identify possible overfitting, a 5-fold cross validation was performed. This resulted in a CI for the AUC of [0.64,0.96], suggesting that the new score allows for simpler prediction of mortality.

Conclusion:

We developed a novel formula corresponding to a score which is able to simpler predict mortality in patients with AAV admitted to the ICU. We will test our formula in the available ICU database MIMIC III, which comprises a large dataset of ICU patients.

References:

[1]Kitching AR, Anders H-J, Basu N, Brouwer E, Gordon J, Jayne DR, et al. ANCA-associated vasculitis. Nature Reviews Disease Primers. 2020 Aug 27;6(1):1–27.

[2]Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993 Dec 22;270(24):2957–63.

Disclosure of Interests:

PETER KORSTEN Speakers bureau: Chugai, Boehringer-Ingelheim, Sanofi Aventis, Abbvie, GSK, Novartis, Consultant of: Lilly, Gilead, Abbvie, Boehringer-Ingelheim, GSK, Novartis, Grant/research support from: GSK, Fabian Kück: None declared, Karaine Tejiozem Donfack: None declared, Radovan Vasko: None declared, Andreas Lena: None declared, Björn Tampe: None declared

A rare clinical entity: stump appendicitis. Case report and complete review of literature

BACKGROUND

Stump appendicitis is a rare delayed complication post-appendectomy and it represents a diagnostic problem as clinicians are often not very familiar with this pathology.

MATERIALS AND METHODS

One case of stump appendicitis has been reported in a 54 year old woman, whose acute phase was conservatively treated in our Department. A review of Medline literature was also carried out, from 1945 to 2015, showing 111 cases of stump appendicitis.

RESULTS

Stump appendicitis has been reported after either open or laparoscopic appendectomy, in a range between days to several years from the first procedure. Nowadays, it is not considered yet as a possible differential diagnosis in patients with pain in the right iliac fossa previously undergone appendectomy. For this reason, the diagnosis can be delayed and complications such as acute abdomen, perforation, sepsis can occur. Completion appendectomy is the treatment of choice for stump appendicitis.

CONCLUSIONS

The aim of this article is to underline the importance of stump appendicitis. Clinicians should be aware of the possibility of SA and they should confirm any clinical suspicion throughout radiologic images, in order to promptly recognize this entity and to avoid the related complications.

Growth and form of a self-constructing tube network

When a small amount of liquid is quickly injected into another liquid with similar density, the fluid jet usually does not propagate very far. However, when the two solutions chemically react to form a flexible membrane at their interface, then structures that are long and branching can form. Here, we describe the tube networks produced when a small amount of AlCl₃ solution is quickly injected into a NaOH solution. Single straight tubes do not occur, but straight tubular "stems" with 2-5 "branches" are observed. The branches emerge relatively symmetrically from the stem at a common branching junction. These structures can have a ratio of propagation distance to stem width as large as 50. The stem and branches grow by the stretching of the membrane sheathing the closed tube system. These tube networks occasionally exhibit the spontaneous creation of new branches at a junction and also the splitting of a branching junction. A model explains why the branches occur, why they are symmetric around the central stem, and why the initial growth speed is insensitive to the flow rate.

P1572Cardiovascular and inflammatory biomarkers in cancer patients and their impact on mortality

Background

Cardiovascular (CV) blood biomarkers are considered prognostic markers of CV dysfunction during anti-cancer treatment. It is largely unknown, whether they are also prognostic markers for mortality.

Purpose

To investigate the prognostic impact of CV and inflammatory biomarker levels in cancer patients without significant CV disease at baseline on all-cause mortality.

Methods

We enrolled 138 unselected cancer patients without significant CV disease from November 2017 until December 2018 (age 63±14yrs, 45%male, body mass index (BMI) 25.5±7.7kg/m2) and 25 healthy controls (age 57±10yrs, 36% male, BMI 25.1±3.4kg/m2). The cancer group consisted of 85 lymphoma (62%), 25 breast cancer (18%), 10 colorectal cancer (7%), 11 non-small cell lung cancer (8%) and 7 other types of cancer (5%) patients. All cancer stages were represented (25% I/II, 76% III/IV). For biomarker analyses, blood samples were taken from an antecubital vein.

Results

N-terminal pro brain natriuretic peptide (NT-proBNP), high-sensitive Troponin T (hsTnT) and C-reactive protein (CRP) were significantly increased in cancer patients vs. healthy controls (90 ng/L [85–94] vs. 40 ng/L [35–45], p<0.0001; 89 ng/L [IQR 85–93] vs. 44 ng/L [39–48], p<0.0001; 84.3 mg/L [78.8–89.7] vs. 27.9 mg/L [22.5–33.4], p<0.0001). 29 cancer patients (21%) died during a mean follow-up time of 172 days (range 1–405) (6-month mortality 23% [95% CI 15–32]). In univariable Cox analyses all biomarkers predicted survival: NT-proBNP (per 100ng/L, HR 1.049 [1.013–1.085], p=0.0082), hsTnT (per 1ng/L, HR 1.017 [95% CI 1.006–1.029], p=0.0017) and CRP (per 1mg/L, HR 1.019 [1.009–1.030], p<0.0001). Including the two CV biomarkers and the inflammatory biomarker, cancer entity, cancer stage and other clinical variables in multivariable Cox analysis, all three biomarkers remained significant prognostic markers of mortality (NT-proBNP per 100ng/L, HR 1.044 [1.007–1.082], p=0.021; hsTnT per 1ng/L, HR 1.017 [1.005–1.030], p=0.0067; CRP per 1ng/L, HR 1.017 [1.005–1.029], p=0.0047). To predict survival, the best cut-offs for the highest product of specificity and sensitivity were 260ng/L for NT-proBNP, 12ng/L for hsTnT and 9mg/L for CRP.

Conclusion

In cancer patients without significant CV disease, plasma levels of the CV biomarkers NT-proBNP, hsTnT and the inflammatory biomarker CRP are elevated compared to healthy controls. All three blood biomarkers are independent prognostic markers of short-term mortality.

Concentrated adipose tissue infusion for the treatment of knee osteoarthritis: clinical and histological observations

PURPOSE

Osteoarthritis (OA) is characterized by articular cartilage degeneration and subchondral bone sclerosis. OA can benefit of non-surgical treatments with collagenase-isolated stromal vascular fraction (SVF) or cultured-expanded mesenchymal stem cells (ASCs). To avoid high manipulation of the lipoaspirate needed to obtain ASCs and SVF, we investigated whether articular infusions of autologous concentrated adipose tissue are an effective treatment for knee OA patients.

METHODS

The knee of 20 OA patients was intra-articularly injected with autologous concentrated adipose tissue, obtained after centrifugation of lipoaspirate. Patients' articular functionality and pain were evaluated by VAS and WOMAC scores at three, six and 18 months from infusion. The osteogenic and chondrogenic ability of ASCs contained in the injected adipose tissue was studied in in vitro primary osteoblast and chondrocyte cell cultures, also plated on 3D-bone scaffold. Knee articular biopsies of patients previously treated with adipose tissue were analyzed. Immunohistochemistry (IHC) and scanning electron microscopy (SEM) were performed to detect cell differentiation and tissue regeneration.

RESULTS

The treatment resulted safe, and all patients reported an improvement in terms of pain reduction and increase of function. According to the osteogenic or chondrogenic stimulation, ASCs expressed alkaline phosphatase or aggrecan, respectively. The presence of a layer of newly formed tissue was visualized by IHC staining and SEM. The biopsy of previously treated knee joints showed new tissue formation, starting from the bone side of the osteochondral lesion.

CONCLUSIONS

Overall our data indicate that adipose tissue infusion stimulates tissue regeneration and might be considered a safe treatment for knee OA.

Health and social problems of the elderly: a cross-sectional study in udupi taluk, karnataka

BACKGROUND

Change in socio-economic status and various health problems adversely affect an individual's way of life during old age.

OBJECTIVES

To study the health and social problems of the elderly and their attitude towards life.

MATERIALS AND METHODS

Descriptive study carried out in the Field practice area of the Department of Community Medicine in South India. A total of 213 elderly patients (60 years old and above) who attended the outreach clinics were interviewed using a pre-tested schedule. Findings were described in terms of proportions and percentages to study the socio-economic status of the samples and its correlation to social problems.

RESULTS

Around 73% of the patients belonged to the age group of 60-69 years old. Nearly half of the respondents were illiterate. Around 48% felt they were not happy in life. A majority of them had health problems such as hypertension followed by arthritis, diabetes, asthma, cataract, and anemia. About 68% of the patients said that the attitude of people towards the elderly was that of neglect.

CONCLUSIONS

The results of the study showed that there is a need for geriatric counseling centers that can take care of their physical and psychological needs. The stringent rules for eligibility to social security schemes should be made more flexible to cover a larger population.

Effectiveness of reproductive health education among rural adolescent girls: a school based intervention study in Udupi Taluk, Karnataka

BACKGROUND

Adolescence is the most important and sensitive period of one's life [1] . According to the World Health Organization (WHO) Expert Committee, adolescence is defined as the period between 10 and 19 years, the second decade of life.

OBJECTIVE

To determine the effectiveness of an educational intervention program on knowledge of reproductive health among adolescent girls.

SETTINGS AND DESIGN

This educational intervention study was carried out over a period of one year. A total of 791 rural girls in the age group 16-19 years were randomly selected from coastal villages in Udupi District, Karnataka.

MATERIALS AND METHODS

Adolescent girls were educated regarding reproductive health and their awareness levels were evaluated immediately following intervention.

STATISTICAL ANALYSIS

Data was tabulated and analyzed using SPSS version 11.0 for Windows. Findings were described in terms of proportions and percentages. Chi square test was used to test the effect of the intervention.

RESULTS

A significant increase in overall knowledge after the intervention (from 14.4 to 68%, P < 0.01) was observed regarding contraception. Knowledge regarding ovulation, first sign of pregnancy and fertilization improved by 37.2% (95% CI = (35.2, 39.2), P < 0.001). Knowledge regarding the importance of diet during pregnancy improved from 66 to 95% following the intervention.

CONCLUSION

This study clearly showed that an educational intervention program can bring about a desirable change in knowledge among adolescent girls regarding reproductive health.

Endometrial lymphoepitheliomalike carcinoma: absence of Epstein–Barr virus genomes

The aim of this study was to report a case of primary lymphoepitheliomalike endometrial carcinoma (FIGO stage IB). A 57-year-old woman presented with an endometrial tumor showing the classic clinical and hysteroscopic aspects of endometrial carcinoma. Morphologically, the neoplasm was similar to undifferentiated nasopharyngeal carcinoma (lymphoepithelioma). Immunohistochemistry showed that the tumor cells were cyokeratins and epithelial membrane antigen positive. Leucocyte common antigen, estrogen and progesterone receptors, neuron specific enolase, cromogranin, synaptophysin, and p53 were negative. We did not find evidence of Epstein–Barr virus (EBV) infection using immunohistochemistry and polymerase chain reaction (PCR). We report the third case of an endometrial lymphoepitheliomalike carcinoma (LELC). The patient did not receive chemotherapy and is alive and free of disease 24 month after diagnosis. LELC can occur in the endometrium and in this location may not be associated with EBV infection

Management of benign adnexal masses by vaginal route

Until recently, surgical treatment of a benign adnexal mass implied a laparotomy. In recent years, the development of laparoscopic surgery, as well as ultrasound-guided aspiration techniques, have significantly modified the treatment options for these patients. These procedures have shown considerable advantages. They have reduced surgical trauma and have shortened the hospital stay. We present the results of our experience on the feasibility of a trans-vaginal surgical approach for the removal of benign adnexal masses. This technique, using traditional and cheap surgical instruments, allows the surgeon to excise benign adnexal masses, by entering the peritoneum through the posterior vaginal fornix and thus avoids the trauma of laparotomy. Fifty-four patients were operated on by this technique at our Department. The mean age was 39 years (range 21-66). In all cases, the operation was completed by the trans-vaginal approach. The median operative time was 30 minutes (range 20-45), and no blood transfusion was needed. The pathological diagnoses were as follows: functional ovarian cyst; 19, endometriotic cyst; 18, dermoid cyst; 11, parovarian cyst; 4 and peduncolated fibroid of the uterine fundus; 2 cases. The diameter of the adnexal masses ranged from 3 to 10 cm (median of 6 cm). In 30 cases, a conservative surgery was done (including 2 myomectomies), whereas in 24 cases, the adnexectomy was needed. Median post-operative stay in hospital was 4 days (range 1-14). This study shows the feasibility of trans-vaginal surgical approach for benign adnexal masses. The advantages and limitations of this technique, as well as of the traditional and laparoscopic surgery are considered and discussed. We believe that the transvaginal approach could be useful and cost-effective for the treatment of selected cases of adnexal masses.

[The selection of patients who are candidates for lung transplantation]

From January 1991 to September 1993 we evaluated 49 patients (27 males and 22 females--mean age 42 years) with chronic respiratory failure as possible candidates for lung transplantation. 27 patients had idiopathic pulmonary fibrosis, 9 emphysema, 4 bronchiectasis, 3 cystic fibrosis, 3 primary pulmonary hypertension and 1 respectively lymphangiomatosis, thromboembolism and vanishing lung. 16 patients were considered suitable for single or double lung transplantation. 4 patients died waiting, 4 underwent single lung transplantation and 8 are still on the waiting list. The mean survival of patients in the waiting list was 145 days (52 for patients with idiopathic pulmonary fibrosis), ranging between 35 and 398 days.

[Video-assisted thoracoscopy in the treatment of recurrent pneumothorax]

Between April 1992 and May 1994, 45 patients with recurrent spontaneous pneumothorax underwent videoassisted thoracoscopy (group I). The mean chest tube duration, the length of hospital stay, the use of parenteral narcotics, the complications and the follow-up were analyzed and compared to the same data of a group of 21 patients previously treated by open approach between January 1991 and March 1993 (group II). Average age, sex and surgical indications distribution were comparable (group I: 36 males, 9 females, mean age 31.7 years; group II: 17 males, 4 females, mean age 31.5 years). Mean chest tube duration was lower in group I (group I 4.3 days vs group II 7.2 days), as was mean hospital stay (group I 4.6 days vs group II 10.3 days) and the necessity of parenteral narcotics for pain relief (group I 11% vs group II 66% of patients). No episodes of relapsing pneumothorax occurred in either group of patients after a mean follow-up of 12.4 months (range from 1-24 months) for group I and 30 months (range from 24-36 months) for group II. The incidence of minor complications was less in group I (4.4%) than group II (23.8%). Our early results in the treatment of recurrent spontaneous pneumothorax by videoassisted thoracoscopy have been encouraging and the merits of this approach make it preferable to thoracotomy.

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax

OBJECTIVE

To present our experience of video-assisted thoracoscopy in the treatment of recurrent spontaneous pneumothorax, and to compare the results with those of a historical control group treated by lateral thoracotomy.

DESIGN

Prospective evaluation with historical controls.

SETTING

Teaching hospital, Italy.

SUBJECTS

41 Patients with recurrent spontaneous pneumothorax, 20 of whom were treated by video-assisted thoracoscopy and 21 of whom underwent lateral thoracotomy (historical control group).

MAIN OUTCOME MEASURES

Duration of chest drainage, length of hospital stay, amount of narcotic analgesia required, postoperative complications, and recurrence during follow up.

RESULTS

The mean (range) duration of chest drainage in the group who underwent video-assisted thoracoscopy was 5 days (4-7) compared with 7 days (4-13) in the control group; the corresponding figures for length of hospital stay were 6 days (4-8) compared with 10 days (5-16). 3 Patients (15%) in the thoracoscopy group required parenteral narcotic analgesia compared with 14 (66%) in the control group, and 2 (10%) developed minor complications compared with 5 (24%). The mean length of follow up was 9 months (range 1-18) compared with 26 months (19-34), and no patient in either group developed a recurrence.

CONCLUSION

Our early results of treating recurrent spontaneous pneumothorax with video-assisted thoracoscopy have been encouraging, and we have adopted it in preference to lateral thoracotomy.

Utility of arm circumference as a screening instrument to identify women at nutritional risk

Anthropometric measurements of 567 healthy nonpregnant women aged 20-40 years were studied to assess the utility of mid-upper-arm-circumference as a screening test to detect malnutrition. The prevalence of malnutrition in the study sample was 38.4%. A cut-off point of 24 cm was found to be most appropriate in the study setting as at that level the sensitivity, specificity and positive predictive values were 71.1%, 69.6% and 59.4%, respectively.