Large-bore suction thrombectomy for sub-massive pulmonary embolism during second trimester of pregnancy: a case report

Background

Pregnancy-associated pulmonary embolism (PAPE) remains a significant cause of maternal mortality. Anticoagulation remains the mainstay of therapy for most pulmonary embolism (PE)-related pregnancies. However, in patients with haemodynamic compromise or those refractory to anticoagulation, management is challenging. Systemic thrombolysis is associated with a substantial risk of maternal bleeding and fetal loss. In non-pregnant PE patients, large bore catheter-directed suction thrombectomy is a proven and important technique to manage intermediate or high-risk PE, allowing for normalization of pulmonary pressures, avoidance of haemodynamic deterioration, without the need for thrombolytics, major surgery, significant blood loss, or prolonged hospitalization.

Case summary

A primigravid patient in her second trimester of pregnancy, initially diagnosed with a deep vein thrombosis refractory to heparin, presents with near-syncope due to sub-massive pulmonary embolism. The various management options including thrombolysis and surgical embolectomy etc. were discussed in detail by a multi-disciplinary PE team. She underwent large bore suction thrombectomy with complete thrombi removal, normalization of right heart strain, without the need for thrombolytics or surgery, minimal blood loss and was discharged after a short length of stay. She gave birth at term to a healthy infant.

Conclusion

Suction thrombectomy is an important consideration for physicians managing high-risk PAPE and is likely to be associated with much a lower risk of maternal and fetal mortality compared to thrombolysis or surgery.

Acute myocardial infarction and myocarditis following COVID-19 vaccination

Emerging reports raise concerns on the potential association between the COVID-19 vaccines and cardiac manifestations. We sought to evaluate cardiac complications associated with COVID-19 vaccination in a pooled analysis from our institution's cohort study and systematic review. Consecutive patients admitted to a tertiary hospital in Singapore between 1 January 2021 and 31 March 2021, with the onset of cardiac manifestations within 14 days following COVID-19 vaccination, were studied. Furthermore, a systematic review was performed, with PubMed, Embase, Research Square, MedRxiv and LitCovid databases accessed from inception up to 29 June 2021. Relevant manuscripts reporting individual patient data on cardiac complications following COVID-19 vaccination were included. Thirty patients were included in the study cohort, with 29 diagnosed with acute myocardial infarction (AMI) and 1 with myocarditis. Five patients developed heart failure, two had cardiogenic shock, three intubated, and one had cardiovascular-related mortality. In the systematic review, 16 studies were included with 41 myocarditis and 6 AMI cases. In the pooled analysis of the study cohort and the systematic review, 35 patients had AMI and 42 had myocarditis. Majority were men, and myocarditis patients were younger than AMI patients. Myocarditis patients tended to present 72 h postvaccination, while AMI patients were older and typically presented 24 h postvaccination. Majority with AMI or myocarditis developed symptoms after the first and second vaccination dose, respectively. This pooled analysis of patients presenting with cardiac manifestations following COVID-19 vaccination highlights the differences between myocarditis and AMI presentations in temporal association with the vaccination.

A Phase I, First-in-Human Study of PRL3-zumab in Advanced, Refractory Solid Tumors and Hematological Malignancies

BACKGROUND

Phosphatase of regenerating liver-3 (PRL-3) is involved in cellular processes driving metastasis, cell proliferation, invasion, motility and survival. It has been shown to be upregulated and overexpressed in cancer tissue, in contrast to low or no expression in most normal tissue. PRL3-zumab is a first-in-class humanized antibody that specifically binds to PRL-3 oncotarget with high affinity and has been shown to reduce tumor growth and increase survival.

OBJECTIVE

In the study, we aimed to determine the safety and efficacy of PRL3-zumab in patients with advanced solid tumors and hematological malignancies.

METHODS

We conducted a phase I, first-in-human study in advanced solid tumors and hematological malignancies to investigate the safety, tolerability and efficacy of PRL3-zumab. Response rates were evaluated using the Response Evaluation Criteria in Solid Tumors (RECIST) guideline (version 1.1) for solid tumors. For acute myeloid leukemia (AML) patients, bone marrow response criteria based on the European Leukaemia Network (ELN) 2017 guidelines for AML were used. We also explored the pharmacokinetics and pharmacodynamic relationships of PRL3-zumab in patients. This study was registered with ClinicalTrials.gov: NCT03191682.

RESULTS

In the dose-escalation cohort, 11 patients with advanced solid tumors were enrolled into the study. An additional 12 patients with solid tumors and four patients with AML were enrolled in the dose-expansion cohort. Maximum tolerability was not achieved in this study, as there were no dose-limiting toxicities. Potential treatment-emergent adverse events were grade 1 increased stoma output and fatigue and grade 2 vomiting. Best response observed was stable disease in three solid-tumor patients (11.1%). The pharmacokinetics of PRL3-zumab were dose proportional, consistent with an IgG type monoclonal antibody.

CONCLUSIONS

PRL3-zumab, a first-in-class humanized antibody, was safe and tolerable in solid tumors and hematological malignancies.

The global syndemic of metabolic diseases in the young adult population: a consortium from the Global Burden of Disease 2000-2019

Funding Acknowledgements

Type of funding sources: None.

Background

A large proportion of premature deaths are related to metabolic diseases in the young adult population. We examined the global trends and mortality of metabolic diseases using estimates from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019 in individuals aged below 40 years.

Methods

From 2000-2019, global estimates of prevalence, deaths, and disability-adjusted life years (DALYs) were described for metabolic diseases (type 2 diabetes mellitus [T2DM], hypertension, non-alcoholic fatty liver disease [NAFLD]). Global estimates were limited to mortality and DALYs for risk factors (hyperlipidemia and obesity). Subgroup analyses were performed based on sex, geographical regions and Socio-Demographic Index (SDI). Age-standardized prevalence, death, and DALYs were presented per 100,000 population with 95% uncertainty intervals (UI).

Findings

The prevalence for all metabolic diseases increased from 2000-2019, with the most pronounced increase in males and high SDI countries. In 2019, the highest age-standardised death rates were observed in hypertension (133·88 [121·25-155·73]; males, 160·13 [138·91-180·79]; females, 119·66 [102·33-136·86]), followed by obesity (62·59 [39·92-89·13]; males, 66·55 [39·76-97·21]; females, 58·14 [38·53-81·39]), hyperlipidemia (56·51 [41·83-73·62]; males, 67·33 [50·78-86·43]; females, 46·50 [32·70-62·38]), T2DM (18·49 [17·18-19·66]; males, 19·94 [18·50-21·32]; females, 17·30 [15·62-18·70]) and NAFLD (2·09 [1·61-2·60]; males, 2·38 [1·82-3·02]; females, 1·82 [1·41-2·27]). Similarly, obesity (1932·54 [1276·61-2639·74]) had the highest age-standardised DALYs, followed by hypertension (2885·57 [2580·75-3201·05]), hyperlipidemia (1207·15 [975·07-1461·11]), T2DM (801·55 [670·58-954·43]) and NAFLD (53·33 [40·73-68·29]). Mortality rates decreased over time in hyperlipidemia (-60%), hypertension (-47%), NAFLD (-31%) and T2DM (-20%), but not in obesity (107% increase). The highest metabolic-related mortality was observed in the Eastern Mediterranean and low SDI countries.

Conclusion

The growing prevalence of metabolic diseases, increasing obesity-related mortality trends, and the sex-regional-socioeconomic disparities evident in young adulthood, present the concerning global burden of metabolic diseases now and in the years ahead.

Higher risk of adverse cardiovascular outcomes in women with type 2 diabetes mellitus: an umbrella review of systematic reviews

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies have shown that females with type 2 diabetes mellitus (T2DM) may have an excess mortality risk compared to males. Furthermore, other studies have reported sex differences in managing cardiovascular risk factors, such as controlling hypertension and hypercholesterolemia.

Purpose

With the growing evidence from systematic reviews examining the sex differences in cardiovascular outcomes for patients with T2DM, an umbrella review is an essential next step to synthesising and assessing the strength of the available evidence.

Methods

Medline and Embase were searched from inception till 7th August 2022 for systematic reviews and meta-analyses studying the effects of sex on cardiovascular outcomes in T2DM patients. Results from reviews were synthesised with a narrative synthesis, with a tabular presentation of findings and forest plots for reviews that performed a meta-analysis. AMSTAR 2 tool was used to assess the methodological quality of included reviews, while the GRADE assessment was used to assess the quality of evidence for outcomes.

Results

A total of 28 studies evaluating sex differences in cardiovascular outcomes were included. Females with T2DM had a higher risk of developing coronary heart disease (CHD; RRR 1.52, 95%CI 1.32–1.76, p<0.001), acute coronary syndrome (ACS; RRR 1.38, 95%CI 1.25–1.52, p<0.001), and heart failure (RRR 1.09, 95%CI 1.05–1.13, p<0.001) than males. In terms of mortality outcomes, females had a higher risk of all-cause mortality (RRR 1.13, 95%CI 1.07–1.19, p<0.001), cardiac mortality (RRR 1.49, 95%CI 1.11–2.00, p=0.009) and CHD mortality (RRR 1.44, 95%CI 1.20–1.73, p<0.001) as compared to males. In patients undergoing percutaneous coronary intervention, females reported higher odds of MACE (OR 1.49, 95%CI 1.07–2.07, p=0.020) and all-cause mortality (OR 1.71, 95%CI 1.46–2.00, p<0.001) compared to males. Females in Asia (RRR 1.12, 95%CI 1.03–1.21, p=0.006) and North America (RRR 1.10, 95%CI 1.08–1.12, p<0.001) were at increased risk of all-cause mortality while females in Western countries had an increased risk for cardiac death (RRR 1.84, 95%CI 1.45–2.32, p<0.001) compared to males. Six reviews were rated as high in quality; eight reviews were rated as moderate, and fourteen reviews were rated as low in quality. Regarding the quality of outcomes, all outcomes in non-interventional studies had a moderate quality of evidence, while all outcomes in interventional studies achieved a high quality of evidence.

Conclusions

This umbrella review evaluated the quality of meta-analyses and demonstrated that females with T2DM have a higher risk of cardiovascular outcomes than their male counterparts. Future studies examining the sex differences in outcomes should attempt to address the heterogeneity and epidemiological factors for a better quality of evidence. Policymakers should consider sex-specific differences in implementing effective tailored strategies to tackle T2DM.

Effects of epicardial adipose tissue volume and thickness assessed by computed tomography and echocardiography on cardiovascular and cerebrovascular outcomes: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Epicardial adipose tissue (EAT) has garnered attention as a potential imaging biomarker for the risk stratification of cardiovascular diseases (CVD). However, the prognostic utility of EAT due to inter-ethnic differences and imaging modality (computed tomography (CT) or transthoracic echocardiography (TTE)) remains undetermined.

Purpose

To evaluate the effect of EAT volume and thickness on cardiovascular and cerebrovascular outcomes. We also aim to compare the prognostic utility between CT volumetric and TTE thickness quantification; and provide consolidated data on the heterogeneity in EAT measurements across different ethnic groups.

Methods

Medline and Embase databases were searched from inception till 16 May 2022 for studies that measured EAT volume or thickness of adult patients at baseline and reported follow-up data on outcomes of interest. Outcomes included MACE, all-cause mortality, cardiac death, myocardial infarction (MI), coronary revascularisation, atrial fibrillation (AF), and stroke. Statistical analyses were conducted on Review Manager 5.4.1 to obtain unadjusted and adjusted hazard ratios (HR) and odds ratios (OR) with the results presented on forest plots.

Results

Twenty-nine studies comprising 19709 patients were included in our analysis. Increased EAT thickness and volume were associated with higher risks of MACE (adjusted HR [aHR] 1.46, 95%CI 1.25–1.71, p<0.001), cardiac death (OR 2.53, 95%CI 1.17–5.44, p=0.020), MI (OR 2.63, 95%CI 1.39–4.96, p=0.003), coronary revascularisation (OR 2.99, 95%CI 1.64–5.44, p<0.001), AF (aOR 4.04, 95%CI 3.06–5.32, p<0.001), and stroke (HR 1.02, 95%CI 1.01–1.03, p<0.001). CT-volumetric quantification of EAT conferred a larger MACE risk (aHR 1.79, 95%CI 1.47–2.17, p<0.001) compared to TTE thickness quantification (aHR 1.20, 95%CI 1.09–1.32, p<0.001). Studies originating from North America (HR 1.91, 95%CI 1.26–2.89, p=0.002) and Asia (HR 1.60, 95%CI 1.09–2.36, p=0.020) demonstrated a significantly higher risk of MACE with increased EAT thickness and volume. However, this significance was not seen in European studies (HR 1.48, 95%CI 0.99–2.20, p=0.060). Subgroup differences were also noted across the studies’ countries of origin when analysing the association of EAT and MI (p=0.020). European studies reported a higher magnitude of MI risk associated with higher EAT thickness and volume (OR 5.28, 95%CI 2.34–11.95, p<0.001) as compared to Asian studies (OR 1.75, 95%CI 1.05–2.92, p=0.030). No differences were noted across other outcomes in the subgroup comparisons by geographical region and between CT and TTE quantification of EAT.

Conclusion

The utility of EAT as an imaging biomarker for predicting and prognosticating CVD is promising. Future efforts to harmonise the EAT parameter thresholds, based on the type of imaging modality and the target population’s ethnic characteristics, will be the next important step before including EAT in CVD prediction models.

Global burden of metabolic diseases: data from Global Burden of Disease 2000-2019. A cosortium of metabolic disease

Funding Acknowledgements

Type of funding sources: None.

Background

The growing prevalence of metabolic diseases is a major concern. We sought to examine the global trends and mortality of metabolic diseases using estimates from the Global Burden of Diseases, Injuries and Risk Factors Study (GBD) 2019.

Methods

Global estimates of prevalence, deaths, and disability-adjusted life year (DALYs) from 2000-2019 were examined for metabolic diseases (type 2 diabetes mellitus [T2DM], hypertension, and nonalcoholic fatty liver disease [NAFLD]). For metabolic risk factors (hyperlipidemia and obesity), estimates were limited to mortality and DALYs. Death rates was compared across sex, World Health Organisation regions and Socio-demographic Index (SDI) quintiles. Age-standardised prevalence and death rates were presented per 100,000 population with 95% uncertainty intervals (UI).

Findings

From 2000 to 2019, prevalence rates increased for all metabolic diseases, with the most pronounced increase in high SDI countries. In 2019, the mean (95%UI) age-standardised prevalence per 100,000 population was estimated to be 15,023 (13,493-16,764) for NAFLD, 5,283 (4,864–5,720) for T2DM and 234 (171-313) for hypertension. The highest age-standardised death rates were observed in obesity (62·59 [39·92-89·13]; males, 66·55 [39·76-97·21]; females. 58·14 [38·53-81·39]), followed by hyperlipidemia (56·51 [41·83-73·62]; males, 67·33 [50·78-86·43]; females, 46·50 [32·70-62·38]), T2DM (18·49 [17·18-19·66], males, 67·33 [50·78-86·43]; females, 46·50 [32·70-62·38]), hypertension (15·16 [11·20-16·75]; males, 14·95 [10·32-16·75]; females, 15·05 [11·51-17·09]) and NAFLD (2·09 [1·61-2·60]; males, 2·38 [1·82-3·02]; females, 1·82 [1·41-2·27]). Mortality rates decreased over time in hyperlipidemia (-154%), hypertension (-52%) and NAFLD (-52%), but not in T2DM and obesity. The highest mortality for metabolic diseases was found in Eastern Mediterranean, and low to low-middle SDI countries.

Conclusion

The global prevalence of metabolic diseases has risen over the past two decades regardless of SDI. Attention is needed to address the unchanging mortality rates attributed to metabolic disease and the regional, socioeconomic, and sex disparities in mortality from metabolic disease.

Metabolic associated fatty liver disease increases risk of adverse events after acute coronary syndrome

 

Metabolic Associated Fatty Liver Disease (MAFLD) was recently introduced as an alternative definition for fatty liver, that has been linked to an increased risk of systemic end-organ damage. However, current studies have not examined the impact of MAFLD on patients presenting with acute coronary syndrome (ACS). Here, we present a retrospective analysis on the short and long-term outcomes of ACS patients with MAFLD.

Methods

A retrospective analysis was conducted in a tertiary care centre. Hepatic steatosis and fibrosis was examined with hepatic steatosis index and fibrosis-4 (FIB-4) index. The primary and secondary outcomes of the analysis were long term all-cause mortality, and in-hospital all-cause mortality, stroke, heart failure and cardiogenic shock respectively. Adjusted analysis was conducted for primary and secondary outcomes with covariates including age, sex, race, type of ACS and previous myocardial infarction.

Results

A total of 5770 patients were included in the analysis, and 21% of ACS patients had concomitant MAFLD. MAFLD resulted in a 23% increase in long-term all-cause mortality compared to non-MAFLD (HR: 1.230, CI: 1.065 to 1.420, p=0.005). MAFLD increased the risk of in-hospital mortality, stroke, heart failure and cardiogenic shock compared to non-MAFLD. A sensitivity analysis conducted based on MAFLD with advance fibrosis, chronic kidney disease and diabetes also demonstrated significantly increased effect size magnitude of all-cause mortality, compared to non-MAFLD.

Conclusion

MAFLD represents an encapsulation of metabolism dysregulation and has been associated with increased risk of systematic disease. The present study shows that MAFLD is associated with significantly increased adverse prognostic outcomes after ACS compared to non-MAFLD. An increase in awareness of MAFLD is required beyond the field of hepatology for improvements in multidisciplinary care and management.

Funding Acknowledgement

Type of funding sources: None.

Reconstructed meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting for left main disease

Background

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results.

Objectives

We performed a systematic review from inception to 23 May 2021 and one-stage reconstructed individual-patient data meta-analysis (IPDMA) that included 10-year mortality outcomes.

Methods

The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke and unplanned revascularization at 5 years. We did IPDMA using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups.

Results

Of 583 articles retrieved, 5 RCTs were included. A total of 4595 patients from these 5 RCTs were randomly assigned to PCI (N=2297) or CABG (N=2298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6% respectively (HR 1.093, 95% CI: 0.925–1.292; p=0.296). PCI conferred similar time-to-MI (RMST ratio 1.006, 95% CI: 0.992–1.021, p=0.391) and stroke (RMST ratio 1.005, 95% CI: 0.998–1.013, p=0.133) at 5 years. Unplanned revascularization was more frequent following PCI compared with CABG (HR 1.807, 95% CI: 1.524–2.144, p<0.001) at 5 years.

Conclusion

This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data

Background and aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p<0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p<0.001; HR: 1.856, 1.380–2.497, p<0.001 respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Funding Acknowledgement

Type of funding sources: None.

Prognostically distinct phenotypes of metabolic health beyond obesity in aortic stenosis

Background

Whilst current evidence are in favour of metabolic health and non-obesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) based on the presence of metabolic health and obesity.

Methods

This retrospective cohort on consecutive patients presenting with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups based on obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy non-obese (MHNO), metabolically unhealthy obese (MUO) and metabolically unhealthy non-obese (MUNO). Metabolic health was defined in accordance to Program Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, sex, chronic kidney disease and AVR as a time-dependent covariate.

Results

Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%) and MHO (6.9%) groups (p=0.001). Compared to MHNO, MHO (HR 0.159, 95% CI 0.038–0.668, p=0.012) and MUO (HR 0.614, 95% CI 0.403–0.937, p=0.024) were independently associated with lower all-cause mortality rates, after adjusting for confounders. In obese patients, metabolic health had favourable survival compared to metabolically unhealthy (p=0.015), but this protective impact of metabolic health was not observed in overweight or normal weight individuals. Obesity had favourable survival compared to overweight and normal weight, in both metabolically health (p=0.002) and unhealthy (p=0.007) patients,

Conclusion

MHO patients with AS have the most favourable prognosis whilst the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift towards prioritising metabolic health rather than weight reduction in patients with significant AS.

Funding Acknowledgement

Type of funding sources: None.

The prognostic outcomes of acute myocardial infarction stratified according to metabolic health and obesity status

Background

There has been emerging evidence on the favourable cardiovascular disease incidence in non-obese subjects with healthy metabolism. However, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease is established. This study examines the prognosis of patients with acute myocardial infarction (AMI) stratified according to metabolic health and obesity status.

Methods

A retrospective study conducted in a tertiary hospital between 2014–2021. Consecutive patients with AMI were allocated into 4 groups based on metabolic and obesity profile: metabolically healthy obesity (MHO), metabolically healthy non-obesity (MHNO), metabolically unhealthy obesity (MUO) and metabolically unhealthy non-obesity (MUNO). The primary outcome was all-cause mortality. Cox regression examined the independent association between mortality and metabolic phenotypes, adjusting for age, sex, AMI type and ejection fraction.

Results

A total of 9958 patients were studied with majority (68.5%) in the MUNO group, followed by MUO (25.1%), MHNO (5.6%), and MHO (0.8%). MHO patients had lowest mortality (7.4%), followed by MHNO (9.7%), MUO (19.2%) and MUNO (22.6%, p<0.001). Relative to MHNO, MUO (HR 1.610, 95% CI 1.198–2.163, p=0.002) and MUNO (HR 1.383, 95% CI 1.043–1.835, p=0.024) had significantly higher mortality risk, but not MHO (HR 1.514, 95% CI 0.649–3.534, p=0.337), after adjusting for confounders. Kaplan-Meier curves showed favourable survival in metabolically healthy groups with clear divergence from metabolically unhealthy groups (p<0.001). There were stepwise increments in mortality with increasing number of metabolic risk factors regardless of obesity status (p<0.001). Favourable survival was observed in overweight and obese versus normal weight patients regardless of metabolic health.

Conclusion

Metabolically healthy AMI patients had favourable prognosis compared to metabolically unhealthy patients. The obesity paradox was observed in the AMI cohort, but the beneficial effects of obesity appeared not as pronounced in magnitude as in metabolically healthy groups.

Funding Acknowledgement

Type of funding sources: None.

Factors associated with transmission of COVID-19 in long-term care facility outbreaks

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a disproportionate impact on residents in long-term care facilities (LTCFs).

Aim

To identify risk factors associated with outbreak severity to inform current outbreak management and future pandemic preparedness planning efforts.

Methods

A retrospective cohort study design was used to evaluate the association between non-modifiable factors (facility building, organization level, and resident population characteristics), modifiable factors (measured through an assessment tool for infection prevention and control (IPC) and pandemic preparedness), and severity of COVID-19 outbreaks (attack rate) in LTCFs.

Findings

From March 1^st, 2020 to January 10^th, 2021, a total of 145 exposures to at least one confirmed case of COVID-19 in 82 LTCFs occurred. Risk factors associated with increased outbreak severity were older facility age, a resident (vs staff) index case, and poorer assessment tool performance. Specifically, for every item not met in the assessment tool, a 22% increase in the adjusted rate ratio was observed (1.2; 95% confidence interval: 1.1–1.4) after controlling for other risk factors.

Conclusion

Scores from an assessment tool, older building age, and the index case being a resident were associated with severity of COVID-19 outbreaks in our jurisdiction. The findings reinforce the importance of regularly assessing IPC measures and outbreak preparedness in preventing large outbreaks. Regular, systematic assessments incorporating IPC and outbreak preparedness measures may help mitigate impacts of future outbreaks and inform future pandemic preparedness planning.

Cost-Effectiveness of Serum Galactomannan Surveillance during Mould-Active Antifungal Prophylaxis

Serial galactomannan (GM) monitoring can aid the diagnosis of invasive aspergillosis (IA) and optimise treatment decisions. However, widespread adoption of mould-active prophylaxis has reduced the incidence of IA and challenged its use. We evaluated the cost-effectiveness of prophylaxis-biomarker strategies. A Markov model simulating high-risk patients undergoing routine GM surveillance with mould-active versus non-mould-active prophylaxis was constructed. The incremental cost for each additional quality-adjusted life-year (QALY) gained over a lifetime horizon was calculated. In 40- and 60-year-old patients receiving mould-active prophylaxis coupled with routine GM surveillance, the total cost accrued was the lowest at SGD 11,227 (USD 8255) and SGD 9234 (USD 6790), respectively, along with higher QALYs gained (5.3272 and 1.1693). This strategy, being less costly and more effective, dominated mould-active prophylaxis with no GM monitoring or GM surveillance during non-mould-active prophylaxis. The prescription of empiric antifungal treatment was influential in the cost-effectiveness. When the GM test sensitivity was reduced from 80% to 30%, as might be anticipated with the use of mould-active prophylactic agents, the conclusion remained unchanged. The likelihood of GM surveillance with concurrent mould-active prophylaxis being cost-effective was 77%. Routine GM surveillance remained cost-effective during mould-active prophylaxis despite lower IA breakthroughs. Cost-saving from reduced empirical antifungal treatment was an important contributing factor.

46 The Hidden Truth About Gender Bias in Surgery. A Systematic Review

Introduction

Gender discrimination remains pervasive in surgery, significantly impacting current and future surgeons and population health. This study analyses the gender barriers and critical retention factors for female surgeons and trainees in surgery.

Method

Five electronic databases were searched till May 2020. Titles and abstracts were sieved, followed by a full text review. Data synthesis and inductive thematic analysis were conducted using the Thomas and Harden methodology.

Result

14 articles were included, involving 528 participants. Four themes were generated–unfavourable working environment, male-dominated culture, societal pressures and progress towards gender equality. Females in surgery often faced harassment, disrespect and perceptions of incompetence, resulting in hostile work conditions, which were aggravated by the inadequate support and mentorship. The persistence of male-dominated cultures was observed, with females facing prejudice and exclusion from professional and social circles. Differential treatment and higher expectations of female surgeons also arose from entrenched societal pressures. Despite these, increased acceptance of motherhood and greater recognition of contributions by female surgeons were reported, indicating some progress in gendered culture.

Conclusions

There is a need to increase female surgical leadership and allocate resources to address the deep-rooted causes of biased surgical culture and ingrained perceptions, to achieve greater gender equality in surgery.

19 Colectomy Rate for Moderate to Severe Ulcerative Colitis with Biologics

Introduction

Biologics are recommended by both the ACG and ECCO community for the treatment of ulcerative colitis. Yet, current literature has yet to estimate the rate of colectomies after biologic therapy, and thus a pooled meta-analysis was conducted the rate of colectomies in 1month, 6 months, 1 year, 2years and five years after biologics.

Method

Medline and Embase were searched for articles examining biologics use in moderate to severe UC or acute severe UC (ASUC) from inception to 21st May 2020. Analysis of proportions were undertaken after a freeman-tukey double arcsine transformation.

Results

The pooled overall colectomy rates of ASUC and moderate to severe UC were 9% (CI: 4% - 14%) at one month, 18% (CI: 13% - 25%) at six months, 21% (CI:16% - 27%) at one year, 29% (CI:24% - 34%) at two years and 38% (CI:30% - 45%) at five years. Additionally, colectomy rates were consistently lower comparing between articles before and after 2010. At one-year, overall colectomy rate following infliximab use was at 25%, golimumab at 15%, vedolizumab at 14%, and adalimumab at 3%.

Conclusions

Colectomy rates in the era of biologics ranged from 8% to 38% and lower post-2010 showing significant improvement in management and supporting the utility of biologics in Ulcerative colitis management.

10 Complete Mesocolic Excision Produces Favorable Survival Outcomes Compared to Conventional Colectomy

Introduction

Conventional colectomy, and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) D2 Lymphadenectomy (LND2), are the standards of care for the surgical management of colon cancer. Colectomy with complete mesocolic excision (CME) and JSCCR D3 Lymphadenectomy (LND3) are alternative, and more radical procedures, that provide greater lymph nodal clearance. However, controversy exists over the long-term survival benefits of CME/LND3 over non-CME colectomies (NCME)/LND2.

Method

In this study, we performed a meta-analysis to compare the survival outcomes of CME/LND3 with NCME/LND2. Medline and Embase databases were searched for articles reporting survival outcomes of both CME/LND3 and NCME/LND2, with comparisons presented using odds ratios (OR).

Results

Ten studies were included in this analysis. Overall and disease-free survival favored CME/LND3 (3-year OS: OR = 1.56; CI 1.22-2.00; p = 0.0004, 5-year OS: OR = 1.29; CI 1.02-1.64, p = 0.03, 3-year DFS: OR = 1.45; CI 1.12-1.88; p = 0.005, 5-year DFS: OR = 1.61; CI 1.14-2.28; p = 0.007). Overall and disease-free survival rates at five years were 79.8% and 85.9%, and 74.6% and 78.0%, in the CME/LND3 and NCME/LND2 groups respectively.

Conclusions

This is the first meta-analysis to demonstrate that CME/LND3 has superior long-term survival outcomes compared to NCME/LND2, hence a strong case can be made for incorporating CME/LND3 into standard care practice.

131 Concerns of The Unheard: A Qualitative Systematic Review on The Preoperative Concerns of General Surgery Patients

Aim

Method

CINAHL, Medline, PsycINFO, and Web of Science were searched, and articles related to patients’ preoperative concerns were included. Key quotes were extracted, coded, and thematically analyzed according to Thomas and Harden’s methodology.

Results

Three themes were generated from the 27 included articles; lead-up to surgery, the postoperative recovery process, and HCP care provision. Patients were uncertain and concerned about the impact the surgery or disease may have on them while they waited for their surgery to occur. Additionally, perceived inadequate provision of care by patients led to them doubting their HCPs’ ability, heightening their preoperative anxiety. Lastly, postoperative recovery processes were often unclear, leading to increased distress as patients wonder if they could recover from the disease and/or surgery.

Conclusions

Unresolved preoperative concerns increase patients’ anxiety and uncertainty, negatively affecting their postoperative recovery. A combination of individualized preoperative education and complementary therapy can be implemented by HCPs to alleviate these concerns, leading to better postoperative outcomes.

368 Perioperative Outcomes in Open versus Laparoscopic Surgery in Elderly Patients Undergoing Right Hemicolectomy

Introduction

With the global aging population, elderly patients are increasingly undergoing colorectal surgery. This study aims to evaluate postoperative outcomes in open (OS) and laparoscopic surgery (LS) for right hemicolectomy in elderly patients.

Method

We retrospectively reviewed patients aged 70 and above undergoing right hemicolectomy for malignancies at our institution. Additionally, Embase and Medline databases were reviewed, and comparative meta-analysis was conducted.

Results

84 patients were included in our cohort (OS = 34; LS = 50). No significant difference in anastomotic leak (AL) (OS = 4; LS = 2; p = 0.176), surgical site infection (SSI) (OS = 4; LS = 2; p = 0.216), and ileus (OS = 10; LS = 16; p = 0.801) was observed. LS was associated with decreased postoperative stay (p = 0.001). Additionally, LS had faster return of bowel function (ROBF) (p = 0.068) and resumption of diet (p = 0.147), albeit without significance. Overall survival (p = 0.062), and disease-free survival (p = 0.067) did not significantly differ between LS and OS.

Pooled analysis of 463 patients yielded no significant difference in AL (OR:1.15; 95%CI: 0.17-8.01; p = 0.89), SSI (OR:0.88; 95%CI: 0.44-1.76; p = 0.71), and ileus (OR:1.42; 95%CI: 0.69 – 2.92; p = 0.35). Postoperative stay (WMD:1.90 days; 95%CI: -1.81–5.61 days; p = 0.31), and ROBF (WMD:14.49 hours; 95%CI: -4.07–33.05 hours; p = 0.13) were shortened in LS, although without significance.

Conclusions

LS is associated with improved functional outcomes without an increased risk of postoperative morbidity or mortality.

20 Post-Operative Biologics and the Rate of Recurrence in Crohn’s Disease

Introduction

Post-operative recurrence after Crohn’s surgery poses a significant challenge to clinicians with an estimated of 70-90% recurrence rate. However, with the advent of biologics, reduction of recurrence after surgery has been observed in various landmark trials. Hence, we aim to quantify the rate of recurrence with post-operative biologics.

Method

Searches were done on Embase and Medline database for articles using biologics for post-operative management. A single arm meta-analysis with generalized linear mixed model and Clopper-Pearson method confidence interval was applied in the synthesis of the data on six months, one year, two year and five year.

Results

A total of 1,864 abstracts were identified, with a final total of 24 articles and 1042 patients were included in the meta-analysis. The one-year rate of recurrence for surgical, endoscopic and clinical was 3.08% (CI: 0.74% - 11.95%), 19.93% (15.81% - 24.81%) and 13.06% (CI: 8.18% - 18.92%) respectively. Correspondingly, the five-year recurrence 16.90% (CI: 9.57% - 28.11%), 84.21% (CI: 72.35% - 91.57%), 5.60% (CI: 9.92% -23.66%) respectively.

Conclusions

An observed reduction in surgical rates was reduced at five years with post-operative Crohn’s disease with biologics. Biologics therapy thus can be considered as a suitable alternative for reducing post-operative recurrence in individuals with higher risk.

295 Radiotherapy for Curative-intent Metastatic Rectal Cancer: A Systematic Review and Meta-Analysis

Introduction

The role and optimal regimen of radiotherapy in curative-intent treatment of metastatic rectal cancer is unclear and hence a single arm meta-analysis was performed.

Method

Medline, Embase and Cochrane Library databases were searched up to 16 May 2020. A Meta-analysis of binomial data was performed using a Freeman-Tukey double arcsine transformation, and pooled estimates were used to construct risk ratios and confidence intervals via the Katz-logarithmic method. Additionally, comparative meta-analysis was performed with the Mantel Haenszel model.

Results

18 studies were included. Rectal pathological complete response (pCR) was observed in 14% of tumours treated with radiotherapy (n = 57/388, CI 0.07 to 0.23). Comparative meta-analysis of cohort studies showed that treatment regimens including radiotherapy were associated with higher pT1 tumour and better oncological outcomes compared to regimens without radiotherapy. Katz-logarithmic method showed that neoadjuvant radiotherapy had a higher proportion of pN0 staging (RR = 1.81, 95% CI 1.06 to 3.09, p = 0.029) and better oncological outcomes compared to adjuvant radiotherapy, and that short course radiotherapy (SCRT) had a lower proportion of pT3 tumours (RR = 0.778, 95% CI 0.609 to 0.994, p = 0.044) and similar oncological outcomes compared to long course radiotherapy (LCRT).

Conclusions

This study supports the evidence that radiotherapy should be used in curative intent metastatic rectal cancer.

189 Preliminary Results from an Innovative Surgical Research Group for Medical Students

Introduction

Learning research in medical school can be daunting and difficult with many lacking appropriate guidance. Particularly, research in surgery can be difficult with most clinicians tied to long hours from clinical duties, leaving medical students lost to learn the ropes for medical research.

Method

We started a surgical research group in January of 2020 under a shepherd sheep model. Shepards were senior medical students who had previous experience in research and were provided resources from consultants on statistics and research designs. Thereafter, each Shepard were paired with junior medical students (sheep) and a resident to provide clinical background. Research was then carried out small teams with minimal guidance from consultants.

Results

To date, the group has published 11 articles (median impact factor: 2.41, range: 1.89 - 3.42), 3 articles in revision and 9 articles in review.

Conclusions

We provide preliminary evidence of a successful model for building medical student research in surgery. While current analysis was limited to meta-analysis and systematic review due to the availability of data, current expansion is currently underway to expand to observational studies.

NanoVar: accurate characterization of patients' genomic structural variants using low-depth nanopore sequencing

The recent advent of third-generation sequencing technologies brings promise for better characterization of genomic structural variants by virtue of having longer reads. However, long-read applications are still constrained by their high sequencing error rates and low sequencing throughput. Here, we present NanoVar, an optimized structural variant caller utilizing low-depth (8X) whole-genome sequencing data generated by Oxford Nanopore Technologies. NanoVar exhibits higher structural variant calling accuracy when benchmarked against current tools using low-depth simulated datasets. In patient samples, we successfully validate structural variants characterized by NanoVar and uncover normal alternative sequences or alleles which are present in healthy individuals.

Prevalence and associated risk factors of insomnia among pregnant women in China

BACKGROUND

Insomnia is common during pregnancy but the prevalence and risk factors of insomnia in Chinese women during pregnancy is not well studied. This study aimed to examine the prevalence of insomnia and its risk factors in Chinese women during pregnancy.

METHODS

In this cross sectional study, 436 Chinese pregnant women with Insomnia Severity Index (ISI) ≥ 8 were clinically assessed using the insomnia criteria based on the combination of DSM-IV (Diagnostic and Statistical Manual-4th Edition) and ICD-10 (International Classification of Dieases, 10th Edition). Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Pregnancy Pressure Scale (PPS), Perceived physical discomfort level and number, Epworth Sleepiness Scale (ESS), and a general socio-demographic questionnaire were administered.

RESULTS

The results showed that about 20% of the pregnant women met the strict diagnosis criteria of insomnia. Independent-samples t-test revealed that several risk factors were correlated with the group with insomnia (N = 84) compared to the group without insomnia (N = 352). Binary Logistic regression analysis found that more significant bed partner influence (OR = 1.92, 95% CI: 1.03-3.60), depressive symptoms (OR = 1.07, 95% CI: 1.00-1.14), daytime sleepiness (OR = 1.07, 95% CI: 1.01-1.14), subjective somatic discomfort (OR = 2.27, 95% CI: 1.11-4.65), kinds of somatic discomfort (OR = 1.14, 95% CI: 1.03-1.27) and later gestation (OR = 1.05, 95% CI: 1.01-1.09) were significantly associated with insomnia.

CONCLUSION

In this cohort of Chinese pregnant women, about a fifth of women suffered from clinically significant insomnia. Measures to prevent the adverse effects of insomnia should be provided to pregnant women with depressive symptoms, Sleep disturbance of the bed partner, excessive daytime sleepiness and somatic discomfort, especially late in gestation.

Prevalence of comorbid major depressive disorder in Type 2 diabetes: a meta-analysis of comparative and epidemiological studies

AIMS

To examine the average point prevalence of major depressive disorder in people with Type 2 diabetes and its associated factors in a comprehensive meta-analysis.

METHODS

Two researchers independently conducted a systematic literature search of PubMed, EMBASE, PsycINFO and Cochrane databases. Studies reporting the prevalence of major depressive disorder in people with Type 2 diabetes were identified and analysed using a random-effects model.

RESULTS

A total of 26 studies meeting the inclusion criteria were included in the study. The point prevalence of major depressive disorder was 14.5% (95% CI 7.9-25.3; I²=99.65). People with Type 2 diabetes were more likely to have major depressive disorder compared with the general population (odds ratio 1.73, 95% CI 1.38-2.16). Subgroup and meta-regression analyses showed that study site, study type, diagnostic criteria and age significantly moderated the prevalence of major depressive disorder.

CONCLUSIONS

In this meta-analysis, the average point prevalence of major depressive disorder in people with Type 2 diabetes was high. Routine screening and more effective interventions should be implemented for this population.

PRL3-zumab as an immunotherapy to inhibit tumors expressing PRL3 oncoprotein

Tumor-specific antibody drugs can serve as cancer therapy with minimal side effects. A humanized antibody, PRL3-zumab, specifically binds to an intracellular oncogenic phosphatase PRL3, which is frequently expressed in several cancers. Here we show that PRL3-zumab specifically inhibits PRL3⁺ cancer cells in vivo, but not in vitro. PRL3 antigens are detected on the cell surface and outer exosomal membranes, implying an 'inside-out' externalization of PRL3. PRL3-zumab binds to surface PRL3 in a manner consistent with that in classical antibody-dependent cell-mediated cytotoxicity or antibody-dependent cellular phagocytosis tumor elimination pathways, as PRL3-zumab requires an intact Fc region and host FcγII/III receptor engagement to recruit B cells, NK cells and macrophages to PRL3⁺ tumor microenvironments. PRL3 is overexpressed in 80.6% of 151 fresh-frozen tumor samples across 11 common cancers examined, but not in patient-matched normal tissues, thereby implicating PRL3 as a tumor-associated antigen. Targeting externalized PRL3 antigens with PRL3-zumab may represent a feasible approach for anti-tumor immunotherapy.

Definition of treatment-resistant depression - Asia Pacific perspectives

BACKGROUND

The lack of uniformity in the definition of treatment resistant depression (TRD) within the Asia-Pacific (APAC) region may have implications for patient management. We aimed to characterize the most commonly used TRD definition in selected APAC countries.

METHODS

A systematic literature review of TRD definitions in APAC countries was conducted in Medline and Embase (2010-2016) and conference proceedings (2014 and 2016). TRD guidelines (APAC, Europe regional, US, or international) were also searched. An expert-panel explored APAC nuances in TRD definitions to achieve consensus for a regional-level definition.

RESULTS

Ten guidelines and 89 studies qualified for study inclusion. Among the studies, variations were observed in definitions regarding: number of antidepressants failed (range: ≥1 to ≥3), classes of antidepressants (same or different; 59% did not specify class), duration of previous treatments (range: 4-12 weeks), dosage adequacy, and consideration of adherence (yes/no; 88% of studies did not consider adherence). No TRD-specific guidelines were identified. The emerging consensus from the literature review and panel discussion was that TRD is most commonly defined as failure to ≥2 antidepressant therapies given at adequate doses, for 6-8 weeks during a major depressive episode.

LIMITATIONS

Few studies provided definitions of TRD used in daily clinical practice, and a limited number of countries were represented in the included studies and expert panel.

CONCLUSION

Attaining consensus on TRD definition may promote accurate, and possibly early detection of patients with TRD to enable appropriate intervention that may impact patient outcomes and quality of life.

Low-level expression of SAMHD1 in acute myeloid leukemia (AML) blasts correlates with improved outcome upon consolidation chemotherapy with high-dose cytarabine-based regimens

Sterile alpha motif and histidine/aspartic acid domain containing protein 1 (SAMHD1) limits the efficacy of cytarabine (ara-C) used in AML by hydrolyzing its active metabolite ara-CTP and thus represents a promising therapeutic target. SAMHD1 has also been implicated in DNA damage repair that may impact DNA damage-inducing therapies such as anthracyclines, during induction therapy. To determine whether SAMHD1 limits ara-C efficacy during induction or consolidation therapy, SAMHD1 protein levels were assessed in two patient cohorts of de novo AML from The University of Texas MD Anderson Cancer Center (USA) and the National University Hospital (Singapore), respectively, using immunohistochemistry and tissue microarrays. SAMHD1 was expressed at a variable level by AML blasts but not in a broad range of normal hematopoietic cells in reactive bone marrows. A sizeable patient subset with low SAMHD1 expression (<25% of positive blasts) was identified, which was significantly associated with longer event-free (EFS) and overall (OS) survival in patients receiving high-dose cytarabine (HDAC) during consolidation. Therefore, evaluation of SAMHD1 expression level in AML blasts at diagnosis, may stratify patient groups for future clinical trials combining HDAC with novel SAMHD1 inhibitors as consolidation therapy.

N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the efficacy and safety of adjunctive N-acetylcysteine (NAC), an antioxidant drug, in treating major depressive disorder (MDD), bipolar disorder, and schizophrenia.

METHODS

The PubMed, Cochrane Library, PsycINFO, CNKI, CBM, and WanFang databases were independently searched and screened by two researchers. Standardized mean differences (SMDs), risk ratios, and their 95% confidence intervals (CIs) were computed.

RESULTS

Six RCTs (n = 701) of NAC for schizophrenia (three RCTs, n = 307), bipolar disorder (two RCTs, n = 125), and MDD (one RCT, n = 269) were identified and analyzed as separate groups. Adjunctive NAC significantly improved total psychopathology (SMD = -0.74, 95% CI: -1.43, -0.06; I² = 84%, P = 0.03) in schizophrenia, but it had no significant effect on depressive and manic symptoms as assessed by the Young Mania Rating Scale in bipolar disorder and only a small effect on major depressive symptoms. Adverse drug reactions to NAC and discontinuation rates between the NAC and control groups were similar across the three disorders.

CONCLUSIONS

Adjunctive NAC appears to be a safe treatment that has efficacy for schizophrenia, but not for bipolar disorder or MDD. Further higher quality RCTs are warranted to determine the role of adjunctive NAC in the treatment of major psychiatric disorders.

A case of blackwater fever with persistent Plasmodium falciparum parasitaemia detected by PCR after artemether-lumefantrine treatment

Background

Blackwater fever is a complication of malaria infection consisting of a syndrome of febrile intra-vascular haemolysis with severe anaemia and intermittent passage of dark-red to black colour urine. Despite numerous reports and studies of this condition, its pathogenesis remains incompletely understood.

Case presentation

This report describes a case of classic blackwater fever in a returning traveller, without prior history of malaria infection nor usage of anti-malarial prophylaxis, treated with two courses of oral artemether–lumefantrine combination therapy. Unusual persistence of submicroscopic Plasmodium falciparum parasitaemia was detected by PCR for 18 days after initiation of treatment.

Conclusion

To the authors’ knowledge this is the first reported occurrence of a case of blackwater fever associated with prolonged submicroscopic parasitaemia. This unusual case challenges the current knowledge of the pathogenesis of this condition and opens questions that may have important diagnostic and treatment implications.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2180-1) contains supplementary material, which is available to authorized users.

Adjunctive memantine for schizophrenia: a meta-analysis of randomized, double-blind, placebo-controlled trials

BACKGROUND

Dysfunction of N-methyl-D-aspartate receptor (NMDAR) is involved in the pathophysiology of schizophrenia. A meta-analysis of randomized controlled trials (RCTs) was conducted to examine the efficacy and safety of memantine, a non-competitive NMDAR antagonist, in the treatment of schizophrenia.

METHODS

Standardized/weighted mean differences (SMDs/WMDs), risk ratio (RR), and their 95% confidence intervals (CIs) were calculated and analyzed.

RESULTS

Included in the meta-analysis were eight RCTs (n = 452) of 11.5 ± 2.6 weeks duration, with 229 patients on memantine (20 mg/day) and 223 patients on placebo. Adjunctive memantine outperformed placebo in the measures of Positive and Negative Syndrome Scale and Brief Psychiatric Rating Scale negative symptoms [SMD: -0.63 (95% CI -1.10 to -0.16), p = 0.009, I 2 = 77%], but not in the total, positive and general symptoms [SMD: -0.46 to -0.08 (95% CI -0.93 to 0.22), p = 0.06-0.60, I 2 = 0-74%] or the Clinical Global Impression Severity Scale [WMD: 0.04 (95% CI -0.24 to 0.32), p = 0.78]. The negative symptoms remained significant after excluding one outlying RCT [SMD: -0.41 (95% CI -0.72 to -0.11), p = 0.008, I 2 = 47%]. Compared with the placebo group, adjunctive memantine was associated with significant improvement in neurocognitive function using the Mini-Mental State Examination (MMSE) [WMD: 3.09, (95% CI 1.77-4.42), p < 0.00001, I 2 = 22%]. There was no significant difference in the discontinuation rate [RR: 1.34 (95% CI 0.76-2.37), p = 0.31, I 2 = 0%] and adverse drug reactions between the two groups.

CONCLUSIONS

This meta-analysis showed that adjunctive memantine appears to be an efficacious and safe treatment for improving negative symptoms and neurocognitive performance in schizophrenia. Higher quality RCTs with larger samples are warranted to confirm these findings.

Identifying large indels in targeted next generation sequencing assays for myeloid neoplasms: a cautionary tale of the ZRSR1 pseudogene

Targeted next generation sequencing platforms have been increasingly utilised for identification of novel mutations in myeloid neoplasms, such as acute myeloid leukaemia (AML), and hold great promise for use in routine clinical diagnostics. In this study, we evaluated the utility of an open source variant caller in detecting large indels in a targeted sequencing of AML samples. While we found that this bioinformatics pipeline has the potential to accurately capture large indels (>20 bp) in patient samples, we highlighted the pitfall of a confounding ZRSR1 pseudogene that led to an erroneous ZRSR2 variant call. We further discuss possible clinical implications of the ZRSR1 pseudogene in myeloid neoplasms based on its molecular features. Knowledge of the confounding ZRSR1 pseudogene in ZRSR2 sequencing assays could be particularly important in AML diagnostics because the detection of ZRSR2 in AML patients is highly specific for an s-AML diagnosis.

Single-cell genomic profiling of acute myeloid leukemia for clinical use: A pilot study

Although bulk high-throughput genomic profiling studies have led to a significant increase in the understanding of cancer biology, there is increasing awareness that bulk profiling approaches do not completely elucidate tumor heterogeneity. Single-cell genomic profiling enables the distinction of tumor heterogeneity, and may improve clinical diagnosis through the identification and characterization of putative subclonal populations. In the present study, the challenges associated with a single-cell genomics profiling workflow for clinical diagnostics were investigated. Single-cell RNA-sequencing (RNA-seq) was performed on 20 cells from an acute myeloid leukemia bone marrow sample. Putative blasts were identified based on their gene expression profiles and principal component analysis was performed to identify outlier cells. Variant calling was performed on the single-cell RNA-seq data. The present pilot study demonstrates a proof of concept for clinical single-cell genomic profiling. The recognized limitations include significant stochastic RNA loss and the relatively low throughput of the current proposed platform. Although the results of the present study are promising, further technological advances and protocol optimization are necessary for single-cell genomic profiling to be clinically viable.

The lymph node ratio does not provide additional prognostic information compared with the N1/N2 classification in Stage III colon cancer

AIM

The ratio of positive nodes to total nodes, the lymph node ratio (LNR), is a proposed alternative to the current N1/N2 classification of nodal disease. The true clinical benefit of adopting the LNR, however, has not been definitively demonstrated. This study compared the LNR with the current N1/N2 classification of Stage III colon cancer.

METHOD

Patients with Stage III colon cancer were identified from a prospectively maintained database (1996-2012). The specificity and sensitivity of the N1/N2 classification in the prediction of overall survival were determined using R. A cut-off point for the LNR was determined by setting the specificity the same as for the N1/N2 classification. The sensitivity of the two methods was then compared, and bootstrapping 1000-fold was performed. This was then repeated for disease-specific survival.

RESULTS

The specificity and sensitivity of the N1/N2 classification in predicting 3-year overall survival in this cohort (n = 402) was 62.2% and 52.1%, respectively. The cut-off point for the LNR was determined to be 0.27 for these data. On comparing LNR with the N1/N2 classification showed that for a given specificity, the LNR did not provide a statistically significant improvement in sensitivity (52.8% vs 52.1%, P = 0.31). For disease-specific death at 3 years, the specificity and sensitivity were 60.8% and 54.6%, respectively. The LNR did not provide a statistically significant improvement (55.4% vs 54.6%, P = 0.44).

CONCLUSION

Both the N1/N2 system and the LNR predict survival in colon cancer, but both have low specificity and sensitivity. The LNR does not provide additional prognostic value to current staging for overall or disease-specific survival for a given cut-off point.

LIN28B Activation by PRL-3 Promotes Leukemogenesis and a Stem Cell-like Transcriptional Program in AML

PRL-3 (PTP4A3), a metastasis-associated phosphatase, is also upregulated in patients with acute myeloid leukemia (AML) and is associated with poor prognosis, but the underlying molecular mechanism is unknown. Here, constitutive expression of PRL-3 in human AML cells sustains leukemogenesis in vitro and in vivo Furthermore, PRL-3 phosphatase activity dependently upregulates LIN28B, a stem cell reprogramming factor, which in turn represses the let-7 mRNA family, inducing a stem cell-like transcriptional program. Notably, elevated levels of LIN28B protein independently associate with worse survival in AML patients. Thus, these results establish a novel signaling axis involving PRL-3/LIN28B/let-7, which confers stem cell-like properties to leukemia cells that is important for leukemogenesis.Implications: The current study offers a rationale for targeting PRL-3 as a therapeutic approach for a subset of AML patients with poor prognosis. Mol Cancer Res; 15(3); 294-303. ©2016 AACR.

A Prospective Study of Serotonin and Norepinephrine Transporter Genes and the Response to Desvenlafaxine Over 8 Weeks in Major Depressive Disorder

No studies to date have evaluated SLC6A2 and SLC6A4 genetic polymorphisms influencing antidepressant response to desvenlafaxine. We conducted an 8-week, open-label, prospective pilot study in 35 patients with major depressive disorder to assess the effects of genetic variations in SLC6A2 and SLC6A4 on both efficacy and side effect profile of desvenlafaxine. Results revealed that homozygotes for the SLC6A4 HTTLPR S allele showed a 33% HDRS reduction compared to a 58% reduction for L allele carriers (p=0.037). No results survived adjustments for covariates or multiple comparisons. While these results need to be interpreted cautiously, they provide preliminary support for the SLC6A4 HTTLPR polymorphism as potential modifier of desvenlafaxine efficacy.

Extract of Ginkgo biloba for Tardive Dyskinesia: Meta-analysis of Randomized Controlled Trials

OBJECTIVE

Free radicals may be involved in the pathogenesis of tardive dyskinesia (TD). We conducted this meta-analysis to systematically examine the efficacy of extract of Ginkgo biloba (EGb), a potent antioxidant possessing free radical-scavenging properties, as a treatment for TD in schizophrenia using randomized controlled trial (RCT) data.

METHOD

Drawn from English and Chinese databases, 3 RCTs of EGb augmentation of antipsychotics (APs) vs. AP plus placebo or AP monotherapy were identified. 2 evaluators extracted data. The primary outcome measure was the severity of TD symptoms assessed by the Abnormal Involuntary Movement Scale (AIMS). Weighted mean difference (WMD) and risk ratio (RR) ±95% confidence intervals (CI) were calculated. Statistical analyses were performed using Review Manager (version 5.1.7.0) and STATA (version 12.0).

RESULTS

The 3 RCTs (n=299) from China, of 12 weeks duration, involved schizophrenia patients with TD of 55.9±13.4 years old. EGb (240 mg/day) outperformed the control group in reducing the severity of TD and clinical symptoms as measured by the AIMS (trials=3, n=299, WMD: -2.30 (95%CI: - 3.04, -1.55), P<0.00001) and the adverse drug reactions as assessed by the Treatment Emergent Symptom Scale (TESS) (trials=2, n=142, WMD: -2.38 (95%CI: -4.01, -0.74), P=0.004). Both the Positive and Negative Syndrome Scale (PANSS) total score (trials=2, n=239, P=0.87) and all-cause discontinuation (trials=3, n=299, P=0.21) were similar between the EGb and control group.

CONCLUSION

This meta-analysis suggests that adjunctive EGb appeared to be an effective and safe option for improving TD in the treatment of schizophrenia patients. However, better RCTs are needed to demonstrate its efficacy and safety especially on cognitive function in TD.

TRIAL REGISTRATION

PROSPERO

CRD42015024930.

Coverage analysis in a targeted amplicon-based next-generation sequencing panel for myeloid neoplasms

AIMS

PCR amplicon-based next-generation sequencing (NGS) panels are increasingly used for clinical diagnostic assays. Amplification bias is a well-known limitation of PCR amplicon-based approaches. We sought to characterise lower-performance amplicons in an off-the-shelf NGS panel (TruSight Myeloid Sequencing Panel) for myeloid neoplasms and attempted to patch the low read depth for one of the affected genes, CEBPA.

METHODS

We performed targeted NGS of 158 acute myeloid leukaemia samples and analysed the amplicon read depths across 568 amplicons to identify lower-performance amplicons. We also correlated the amplicon read depths with the template GC content. Finally, we attempted to patch the low read depth for CEBPA using a parallel library preparation (Nextera XT) workflow.

RESULTS

We identified 16 lower-performance amplicons affecting nine genes, including CEBPA. There was a slight negative correlation between the amplicon read depths and template GC content. Addition of the separate CEBPA library generated a minimum read depth per base across the CEBPA gene ranging from 268x to 758x across eight samples.

CONCLUSIONS

The identification of lower-performance amplicons will be informative to laboratories intending to use this panel. We have also demonstrated proof-of-concept that different libraries (TruSight Myeloid and Nextera XT) can be combined and sequenced on the same flow cell to generate additional reads for CEBPA.

Clozapine prescription and quality of life in Chinese patients with schizophrenia treated in primary care

OBJECTIVE

Clozapine is frequently used to treat schizophrenia in China. Maintenance treatment for clinically stable patients with schizophrenia is usually provided by Chinese primary care physicians, but no study has investigated the frequency of its use prescribed by primary care physicians. This study described the frequency, demographic and clinical characteristics of clozapine treatment and its impact on insight and quality of life (QOL) of patients with schizophrenia treated in primary care in China.

METHOD

A total of 623 patients with schizophrenia treated in 22 primary care services in Guangzhou, China in 2013 formed the study sample. Patients' socio-demographic and clinical characteristics including psychopathology, medication side effects and QOL were recorded using a standardized protocol and data collection.

RESULTS

The frequency of clozapine prescription was 35.6% with a mean daily dose of 127.7±88.2 mg. There were no significant differences between the patients with and without clozapine in either of the QOL domains after controlling the confounding factors. Multiple logistic regression analyses revealed that patients on clozapine had younger age of onset, more hospitalizations, more severe extrapyramidal side effects, but better insight and fewer prescriptions of first generation antipsychotics.

CONCLUSIONS

Clozapine use was found to be common and associated with better insight in patients with schizophrenia treated in primary care in China. Further examination of the rationale and appropriateness of clozapine in primary care in China is warranted.

Is S-Adenosyl Methionine (SAMe) for Depression Only Effective in Males? A Re-Analysis of Data from a Randomized Clinical Trial

OBJECTIVE

The aim of this study was to examine whether gender differences may have affected treatment response to S-adenosyl methionine (SAMe) in a recent failed randomized clinical trial (RCT) for adults with major depressive disorder.

METHODS

Data from a 2-site, 12-week, double-blind RCT (n=189) assessing the efficacy of SAMe vs. placebo and a comparator selective serotonin reuptake inhibitor (escitalopram) were subjected to post-hoc analyses to evaluate effects of patient gender on treatment response.

RESULTS

When assessing the efficacy outcomes within each gender separately, SAMe was superior to placebo among males (n=51), but not among females (n=62). Males showed a significant reduction of depression severity from baseline to study endpoint on the 17-item Hamilton Depression Rating Scale (4.3 point difference; p=0.034; d=0.95), while females did not show significant change. This finding emerged despite equivalence on baseline measures of depression severity between the gender groups.

CONCLUSION

RESULTS of this secondary data analysis suggest that gender might impact the antidepressant efficacy of SAMe, with greater therapeutic effect found in males. The underlying mechanism is still relatively unknown. Further work is needed to replicate this observation in independent samples.Clinicaltrials.gov identifier: NCT00101452.

Abstract P6-06-11: The Will Rogers phenomenon in breast cancer - How does the change from AJCC 5th edition to AJCC 6th edition affect cancer survival?

Introduction: Staging of cancers are important to select appropriate treatment and to estimate prognosis. The most extensive and significant revisions that have ever been made in the breast cancer staging system occurred when the 5th Edition (AJCC5) was updated to the 6th Edition (AJCC6) in Jan 2003. The principal changes were related to the size, number, and location of metastases to the lymph nodes. AJCC6 takes into account the number of lymph nodes involved, and if 4 or more lymph nodes are involved, a Stage 2 breast cancer under AJCC5 is upstaged to Stage 3 under AJCC6. The presence of a supraclavicular lymph node in the absence of other metastases was considered a Stage 4 under AJCC5, but under AJCC6, patients with a supraclavicular lymph node is downstaged to Stage 3. The Will Rogers phenomenon to describe the effect of the “stage migration” has been described as one of the most important biases limiting the use of historical cohorts when comparing survival or treatment. In breast cancer, when we move the “poor prognosis” Stage 2’s, with 4 or more nodes involved, to Stage 3, the Stage 2's remaining will be a “better prognosis” Stage 2, and hence survival should improve. These “poor prognosis” Stage 2's will then be the “better prognosis” Stage 3's and hence the survival of Stage 3 should improve. The aim of this study is to investigate how the change from AJCC5 to AJCC6 affected stage-specific survival in a group of Asian breast cancer patients.

Patients and Methods: 3127 new cases of breast cancer cases presenting to the University Malaya Medical Centre between Jan 1993 and Dec 2007 were prospectively registered into the UMMC Breast Cancer Database. Non-epithelial cancers and ductal carcinoma in situ were excluded. All patients were restaged into AJCC5 and AJCC6

Results:

Comparison of Staging by AJCC5 and AJCC6StageAJCC5AJCC61706 (22.6%)706 (22.6%)21553 (49.7%)1230 (39.3%)3511 (16.3%)854 (27.3%)4357 (11.4%)337 (10.8%)Total31273127

Discussion: It is important to compare stage-specific survival in different time periods to determine whether survival has improved, usually due to timely and optimal treatment. Out of 1553 women classified into Stage 2 breast cancer, 323 or 20.8%, were moved to Stage 3 under AJCC6. The shift from Stage 4 to 3 is less significant because only 20 out of 357 women (5.6%) had supraclavicular lymph node metastases only. The survival of AJCC 5 Stage 2 breast cancer had a 5 year survival rate of 82.9% compared to a 86.1% with AJCC6 Stage 2. Similarly, the 5 year survival of AJCC5 Stage 3 was 50.6% compared to 59% with AJCC6 Stage 3.

Conclusion: Similar to other studies, the stage specific survival in women with Stage 2 and 3 breast cancer improves significantly when AJCC6 is used for staging in the same cohort of patients, again underlying the importance of standardizing the stage when comparing survival from two time periods.

Comparison of 5-year relative survival by AJCC5 and AJCC6StageAJCC5AJCC6196.996.9282.986.1350.659414.412.6

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-11.

ABCB1 polymorphism predicts escitalopram dose needed for remission in major depression

The ATP-binding cassette family of transporter proteins, subfamily B (MDR/TAP), member 1 (ABCB1) (P-glycoprotein) transporter is a key component of the blood-brain barrier. Many antidepressants are subject to ABCB1 efflux. Functional polymorphisms of ABCB1 may influence central nervous system bioavailability of antidepressants subject to efflux. Single-nucleotide polymorphisms (SNPs) at rs1045642 (C3435T) of ABCB1 have been associated with efflux pump efficiency. This may explain part of the interindividual variation in antidepressant dose needed to remit. Individuals (N=113) with DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) major depressive disorder (MDD) were treated with escitalopram (ESC) or venlafaxine (VEN) over 8 weeks. The17-item Hamilton Depression Rating Scale was assessed serially, blind to genotype. SNP rs1045642 of ABCB1 along with two SNPs previously reported to be in linkage disequilibrium with it (rs2032582 and rs1128503) were genotyped. Demographic features, clinical features, P450 metabolizer status and 5-HTTLPR (serotonin-transporter-linked promoter region) genotype were controlled for. Carriers of rs1045642 TT needed on average 11 mg of ESC to remit, whereas TC and CC carriers required 24 and 19 mg, respectively (P=0.0001). This equates to a 2.0- (95% confidence interval=1.5-3.4; P<0.001) fold greater ESC dose needed to remit for C carriers compared with TT carriers at rs1045642. Of VEN-treated subjects carrying TT genotype at rs1045642, 73.3% remitted compared with 12.5% for CC genotype (odds ratio=6.69; 95% confidence interval=1.72-25.9, P=0.006). These data suggest that antidepressant dose needed to remit can be predicted by an ABCB1 SNP. This has the potential clinical translation implications for dose selection and remission from MDD.

Relative contribution of individual oxidized components in ox-LDL to inhibition on endothelium-dependent relaxation in rat aorta

BACKGROUND AND AIM

Oxidized low-density lipoprotein (ox-LDL) causes atherosclerosis and endothelial dysfunction. No study up to the present date has examined the relative contribution of all the oxidized components in ox-LDL to inhibition on vascular function. Our aim was to investigate the effects of individual oxidized components at concentrations similar to those in ox-LDL on the impairment of endothelium-dependent relaxation in rat aorta.

METHODS AND RESULTS

Rat thoracic aorta was pre-treated with lysophosphatidylcholine (LPC), cholesterol oxidized products (COPs), oxidized linoleic acid (ox-18:2) and oxidized linolenic acid (ox-18:3) at concentrations similar to those in human ox-LDL. Ox-LDL as a whole caused 61% inhibition while LPC, COPs and ox-18:2 at concentrations similar to those in ox-LDL caused 12%, 24% and 19% inhibition, respectively, on endothelium-dependent relaxation, suggesting that COPs produced the most adverse effect followed by ox-18:2 and LPC in an additional way. Three COPs including 7-ketocholesterol, 7α-hydroxycholesterol and 7β-hydroxycholesterol showed inhibition on endothelium-dependent relaxation with E(max) being reduced to 79-87% compared with the control E(max) (95%). At Western blot analysis phosphorylation of eNOS at Ser1177 site and total eNOS were not altered by ox-LDL treatment, indicating that ox-LDL did not affect nitric oxide (NO) synthesis capacity. Ox-LDL might react directly with NO and lower NO bioavailability.

CONCLUSION

The present study demonstrated the relative contribution of individual oxidized components in ox-LDL in the inhibition of endothelium-dependent relaxation in rat aorta. This inhibitory effect could be caused by the reduction of NO bioactivity.

Relapse of amoebic infection 10 years after the infection

A 52-year-old man with schizophrenia, who had a history of amoebic liver abscess treated with combination antimicrobial agents, presented 10 years later with severe rectal bleeding. Diagnosis of amoebic colitis was confirmed by histological examination of endoscopic biopsy. Doctors treating patients with amoebic infection should be aware of the risk of eradication failure. Post-treatment stool testing, preferably by antigen testing or polymerase chain reaction, should be performed after antimicrobial treatment.