Prophylactic negative pressure wound therapy to improve wound healing rates following ileostomy closure: a randomized controlled trial

BACKGROUND

Reversal of ileostomy is associated with morbidity including wound infection and prolonged wound healing. Negative pressure wound therapy (NPWT) has been shown to reduce time to wound healing by secondary intention. The aim of this study was to determine whether NPWT improved wound healing rates, compared with simple wound dressings, in patients undergoing reversal of ileostomy where the skin wound is closed with a purse-string suture.

METHODS

This was a dual-centre, open-label, randomized controlled trial with two parallel intervention arms. Patients undergoing elective loop ileostomy reversal were randomized 1:1 to receive NPWT or simple wound dressings. The primary endpoint of the study was assessment of complete wound healing at day 42 post reversal of ileostomy and the secondary endpoints were patient-reported wound cosmesis using a visual analogue scale and rates of surgical site infection (SSI).

RESULTS

The study was conducted from June 2018 to December 2021. The trial was approved by the local ethics committee. We enrolled 40 patients, 20 in each arm. One patient in each arm was lost to follow up. Nine patients (9/19, 47.36%) in the simple dressing group had wound healing vs. 13 patients (13/19, 68.42%) in the NPWT group (P = 0.188). There was no significant difference in patient- reported wound cosmesis or SSI.

CONCLUSION

There was no difference in wound healing rates when comparing NPWT to simple wound dressings at early and late time points post reversal of ileostomy, where the skin wound was closed with a purse-string suture.

A Real-World Precision Medicine Program Including the KidneyIntelX Test Effectively Changes Management Decisions and Outcomes for Patients With Early-Stage Diabetic Kidney Disease

INTRODUCTION/OBJECTIVE

The KidneyIntelX is a multiplex, bioprognostic, immunoassay consisting of 3 plasma biomarkers and clinical variables that uses machine learning to predict a patient's risk for a progressive decline in kidney function over 5 years. We report the 1-year pre- and post-test clinical impact on care management, eGFR slope, and A1C along with engagement of population health clinical pharmacists and patient coordinators to promote a program of sustainable kidney, metabolic, and cardiac health.

METHODS

The KidneyIntelX in vitro prognostic test was previously validated for patients with type 2 diabetes and diabetic kidney disease (DKD) to predict kidney function decline within 5 years was introduced into the RWE study (NCT04802395) across the Health System as part of a population health chronic disease management program from [November 2020 to April 2023]. Pre- and post-test patients with a minimum of 12 months of follow-up post KidneyIntelX were assessed across all aspects of the program.

RESULTS

A total of 5348 patients with DKD had a KidneyIntelX assay. The median age was 68 years old, 52% were female, 27% self-identified as Black, and 89% had hypertension. The median baseline eGFR was 62 ml/min/1.73 m2, urine albumin-creatinine ratio was 54 mg/g, and A1C was 7.3%. The KidneyIntelX risk level was low in 49%, intermediate in 40%, and high in 11% of cases. New prescriptions for SGLT2i, GLP-1 RA, or referral to a specialist were noted in 19%, 33%, and 43% among low-, intermediate-, and high-risk patients, respectively. The median A1C decreased from 8.2% pre-test to 7.5% post-test in the high-risk group (P < .001). UACR levels in the intermediate-risk patients with albuminuria were reduced by 20%, and in a subgroup treated with new scripts for SGLT2i, UACR levels were lowered by approximately 50%. The median eGFR slope improved from -7.08 ml/min/1.73 m2/year to -4.27 ml/min/1.73 m2/year in high-risk patients (P = .0003), -2.65 to -1.04 in intermediate risk, and -3.26 ml/min/1.73 m2/year to +0.45 ml/min/1.73 m2/year in patients with low-risk (P < .001).

CONCLUSIONS

Deployment and risk stratification by KidneyIntelX was associated with an escalation in action taken to optimize cardio-kidney-metabolic health including medications and specialist referrals. Glycemic control and kidney function trajectories improved post-KidneyIntelX testing, with the greatest improvements observed in those scored as high-risk.

Epidemic within a pandemic: Alcohol-associated hepatitis and COVID-19

BACKGROUND

There was an increase in alcoholic beverage sales during the peak of the COVID pandemic in the United States. However, little is known about the impact of SARS-CoV-2 infection among hospitalized alcohol-associated hepatitis (AH) patients.

METHODS

We analyzed the available National Inpatient Data (NIS) data from 2020 to determine mortality and healthcare utilization among hospitalized AH patients with and without COVID-19 in the United States.

RESULTS

We observed a ~15.6% increase in cases of hospitalized AH patients from 136,620 in 2019 to 157,885 in 2020, a significant increase from an average of 5.5% per annum despite an 8.7% decline in US hospital admissions over the same time span. Men younger than 40 were the fastest growing AH group, with a 23% increase in 2020. Approximately 1.8% of hospitalized AH patients had a SARS-CoV-2 infection, which significantly worsened the mortality among patients with AH (11.4% vs. 4.1%, p < 0.0001). This was especially true among older AH patients with concomitant conditions such as clinically apparent cirrhosis, acute renal failure, upper gastrointestinal bleeding, and sepsis. AH patients with COVID-19 also had a longer length of stay (8.6 vs. 6.1 days, p < 0.0001) and higher hospital charges during the stay ($93,670 vs. $66,283, p < 0.0001) than those without COVID-19.

CONCLUSION

Our study highlights the rise in AH cases during the COVID-19 pandemic. Screening and appropriate management of excessive alcohol use and preventive measures such as COVID-19 vaccination should be considered to reduce morbidity and mortality among patients with AH.

Rationale and Design of the SOTA-P-CARDIA Trial (ATRU-V): Sotagliflozin in HFpEF Patients Without Diabetes

Heart failure with preserved ejection fraction (HFpEF) is now the most common form of heart failure (HF). This syndrome is associated with an elevated morbi-mortality, and effective therapies are urgently needed. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are the first pharmacological class that has demonstrated to reduce hospitalization and cardiovascular mortality in large clinical trials in HFpEF. Furthermore, the dual SGLT 1/2 inhibitor sotagliflozin has shown a reduction in cardiovascular outcomes in diabetic HF patients, regardless of ejection fraction Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure (SOLOIST-WHF) Trial, and prevents the development of HF in patients with diabetes and chronic kidney disease Sotagliflozin on Cardiovascular and Renal Events in Patients with Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular Risk (SCORED) trial. The major objective of the Sotagliflozin in Heart Failure With Preserved Ejection Fraction Patients (SOTA-P-CARDIA) trial (NCT05562063) is to investigate whether the observed cardiorenal benefits of sotagliflozin in HF patients with diabetes can be extended to a non-diabetic population. The SOTA-P-CARDIA is a prospective, randomized, double-blinded, placebo-controlled study that will randomize non-diabetic patients with the universal definition of HFpEF (ejection fraction > 50% assessed the day of randomization). Qualifying patients will be randomized, in blocks of 4, to receive either sotagliflozin or placebo for a period of 6 months. The primary outcome is changes in left ventricular mass by cardiac magnetic resonance from randomization to end of the study between the groups. Secondary end points include changes in peak VO₂; myocardial mechanics, interstitial myocardial fibrosis, and volume of epicardial adipose tissue; distance in the 6-min walk test; and quality of life. Finally, the authors expect that this trial will help to clarify the potential benefits of the use of sotagliflozin in non-diabetic HFpEF patients.

Has the world survived the population bomb? A 10-year update

Between 1960 and 2011, world population grew from 3 to 7 billion, an unprecedented rate of population growth that will never be seen again. In spite of the addition of 4 billion people in just 51 years, the world experienced some of the biggest improvements in living standards in human history, with declines in poverty and improvements in food production per capita in all major regions. This paper looks at the period since 2011, during which the world added another billion people. Progress has continued in many areas, with food production continuing to grow faster than population and with continued declines in the proportion of the population in poverty in all regions. Not all trends are positive, however. Progress in food production has slowed, with recent declines in food production per capita in Africa. Prices of food and other commodities have recently hit historic highs. Climate change is a challenge to progress in combatting hunger and poverty, especially in Africa. While climate change will make it harder to meet the needs of Africa's continued population growth in this century, the paper shows that the countries with the highest population growth account for a very small share of global CO2 emissions. The record of the last six decades suggests that progress can be made to reduce poverty and hunger, even while world population continues to grow, but continued progress will require solutions to climate change that mainly target high-income and middle-income countries.

Social isolation produces a sex- and brain region-specific alteration of microglia state

Social isolation is a profound form of psychological stress that impacts the mental health of a large proportion of society. Other experimental models of stress have demonstrated a microglia response that serves either a protective or pathological function. However, the effect of adult social isolation on microglia has not been thoroughly investigated. We measured microglia territory, branching, end points and phagocytic-lysosomal activity in group housed C57Bl/6 mice and mice that were socially isolated for 2 weeks. Our results show that the dorsomedial hypothalamus and hippocampal CA2 region of adult male mice undergo increased microglia volume, territory and endpoints following social isolation, whereas females exhibit this increase in the hypothalamus only. Males exhibited decreases in the phagocytic-lysosomal marker CD68 in microglia in these regions, whereas females showed an increase in CD68 in the hypothalamus suggesting sexually dimorphic and brain region-specific change in microglia state in response to social isolation. The prefrontal cortex, central amygdala, nucleus accumbens shell and visual cortex did not exhibit changes in microglia structure in either male or female mice. These data show that microglia in different brain regions undergo a distinct response to social isolation which may account for changes in cognition and behaviour associated with this prevalent form of psychological stress.

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

Barriers to Hepatitis C Virus Care and How Federally Qualified Health Centers Can Improve Patient Access to Treatment

Background

Despite the availability of direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) treatment, disparities in HCV care and treatment persist for underserved populations due to demographic-based and insurance-based barriers. We aim to examine the effect of barriers on HCV treatment access for a federally qualified health center (FQHC) population.

Methods

We retrospectively evaluated medical records of adults diagnosed with chronic HCV at an FQHC clinic from 2016 to 2020 with follow-up through 2021. Univariate and bivariate analyses were used to describe the patient population and significant associations between predictors of linkage to HCV care and treatment access. Adjusted multivariate logistic regression analyses were used to identify predictors of starting HCV treatment.

Results

Of 279 total patients with chronic HCV, 162 patients started treatment (58%), 138 patients (50%) completed treatment, and 99 patients (35%) achieved sustained virological response (SVR). Of the total patients, 145 (52%) were seen by their primary care physician (PCP) for their HCV care and treatment, and 134 (48%) were seen by a provider that specializes in management and treatment of HCV (HCV provider). Patients seen by an HCV provider in addition to their PCP were more likely to have had their prior authorization requests for HCV treatment denied by their insurance providers than patients seen only by their PCP for HCV care (30% vs. 14%, P = 0.001). We believe that this discrepancy stems from two issues. One, prior authorizations are reviewed by insurance providers who are not specially trained in HCV management, so the verbiage used perplexes these reviewers, possibly causing them to issue denials. Two, insurance providers often require HCV genotype testing for DAA medication eligibility, and HCV providers order genotype tests for patients only when HCV treatments have failed to cure patients, so this requirement becomes another barrier to DAA medications. Patients who spoke a non-English language, lived in the USA for less than 10 years, and showed inability to pay for treatment had received treatment despite these characteristics being common barriers to HCV treatment. On multivariate regression, factors independently associated with patients starting treatment included prior denial for DAA medication (odds ratio (OR), 8.88; 95% confidence interval (CI), 3.22 - 24.6; P < 0.001) and being seen by an HCV provider (OR, 24.8; 95% CI, 11.7 - 52.5; P < 0.001). However, the most significant barrier to HCV treatment access for the FQHC population was eligibility restrictions from insurance providers.

Conclusions

Demographic-based barriers (e.g., age, race, and income) often impede HCV care and treatment, but insurance-based barriers are the greatest challenge currently that affects treatment outcomes in our study population. Removing these restrictions would, in our opinion, help to increase treatment levels to underserved populations.

Is There a Male-Breadwinner Norm? The Hazards of Inferring Preferences from Marriage Market Outcomes

This paper argues that distributions of spousal earnings gaps provide no identifying information for the male breadwinner norm, nor such a norm's consequences for gender inequality. First, we show that simple marital matching models-without norm-related assumptions-closely replicate U.S. distributions of wife-husband earnings gaps. Second, we show that the discontinuity in this distribution as wives start to out-earn husbands reflects not breadwinner norms, but rather a point mass of equal-earning couples. We conclude by arguing that the point mass may also threaten other tests of the male breadwinner hypothesis, and proposing several robustness checks that future research should utilize.

LBSUN209 A Novel Algorithm For The Management Of Inpatient Covid-19 Steroid-induced Hyperglycemia

Objective/Background

Hyperglycemia in hospitalized patients with COVID-19 is linked to increased morbidity and mortality. With increasing use of glucocorticoid (GC) therapy for COVID-19 hypoxemia, clinicians are challenged with an increased prevalence of hyperglycemia.

Methods

We developed an insulin protocol to aid front line providers in the management of GC-induced hyperglycemia for hospitalized adults with COVID-19. The protocol was based on expert opinion and was available from March 2021 onward. Glycemic and clinical outcomes were obtained for patients treated with GC and retrospectively compared to historical controls treated with GC admitted up to 6 months prior to protocol implementation. Glycemic parameters for finger stick glucose values (FSG) were defined as hypoglycemia <70 mg/dL, euglycemia 70-180 mg/dL, mild hyperglycemia 180-250 mg/dL and severe hyperglycemia >250 mg/dL. To account for differences in the quantity of total FSG between groups, we adjusted for length of stay and calculated the proportion of FSG per patient.

Results

130 patients with COVID-19 and GC induced hyperglycemia from before (n=65) and after (n=65) protocol implementation were matched 1: 1 based on age, weight, and sex. There were no significant differences in other baseline patient characteristics. Significantly more patients in the protocol group had mean FSG in the euglycemic range (16.9% vs 38.5%, p=0. 006), and there was a decrease in patients with mean glucose in the mild hyperglycemia range that trended toward significance (50.8% vs 35.4%, p=0. 076). The protocol group had a significantly lower proportion of hypoglycemic FSG per patient (0. 003 vs 0. 008, p=0. 044). Patients in the protocol group had more euglycemic FSG per patient, but this did not reach significance (0.413 vs 0.350, p=0.239). Similarly, the proportion of mild hyperglycemic FSG per patient trended lower in the protocol group (0.315 vs 0.272, p=0.291). There were no significant differences in severe hyperglycemia per patient (0.311 vs 0.328, p=0.828). The protocol group had a significantly higher utilization of basal-bolus insulin regimen (n=43 vs n=63, p<0. 0001) with an increase percentage of bolus insulin utilization in peak total daily dose (70.2% vs. 62.4%, p=0. 08). Total peak day insulin dose trended lower in the protocol group (0.25 vs 0.32 U/kg, p=0.36).

Conclusion

A novel insulin protocol for the management of GC-induced hyperglycemia in hospitalized COVID-19 patients is an effective tool to achieve reductions in hypoglycemic events and higher utilization of standard of care basal-bolus insulin regimens without increased hyperglycemia or total daily dose of insulin.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

The prevention of delirium in elderly surgical patients with obstructive sleep apnea (PODESA): a randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) is associated with neurocognitive impairment - a known risk factor for postoperative delirium. However, it is unclear whether OSA increases the risk of postoperative delirium and whether treatment is protective. The objectives of this study were to identify OSA with a home sleep apnea test (HSAT) and to determine whether auto-titrating positive airway pressure (APAP) reduces postoperative delirium in older adults with newly diagnosed OSA undergoing elective hip or knee arthroplasty.

METHODS

We conducted a multi-centre, randomized controlled trial at three academic hospitals in Canada. Research ethics board approval was obtained from the participating sites and informed consent was obtained from participants. Inclusion criteria were patients who were [Formula: see text]0 years and scheduled for elective hip or knee replacement. Patients with a STOP-Bang score of ≥ 3 had a HSAT. Patients were defined as having OSA if the apnea-hypopnea index was ≥ 10/h. These patients were randomized 1:1 to either: 1) APAP for 72 h postoperatively or until discharge, or 2) routine care after surgery. The primary outcome was postoperative delirium, assessed twice daily with the Confusion Assessment Method for 72 h or until discharge or by chart review. The secondary outcome measures included length of stay, and perioperative complications occurring within 30 days after surgery.

RESULTS

Of 549 recruited patients, 474 completed a HSAT. A total of 234 patients with newly diagnosed OSA were randomized. The mean age was 68.2 (6.2) years and 58.6% were male. Analysis was performed on 220 patients. In total, 2.7% (6/220) patients developed delirium after surgery: 4.4% (5/114) patients in the routine care group, and 0.9% (1/106) patients in the treatment group (P = 0.21). The mean length of stay for the APAP vs. the routine care group was 2.9 (2.9) days vs. 3.5 (4.5) days (P = 0.24). On postoperative night 1, 53.5% of patients used APAP for 4 h/night or more, this decreased to 43.5% on night 2, and 24.6% on night 3. There was no difference in intraoperative and postoperative complications between the two groups.

CONCLUSIONS

We had an unexpectedly low rate of postoperative delirium thus we were unable to determine if postoperative delirium was reduced in older adults with newly diagnosed OSA receiving APAP vs. those who did not receive APAP after elective knee or hip arthroplasty.

TRIAL REGISTRATION

This trial was retrospectively registered in clinicaltrials.gov NCT02954224 on 03/11/2016.

All-Printed Ultrahigh-Responsivity MoS2 Nanosheet Photodetectors Enabled by Megasonic Exfoliation

Printed 2D materials, derived from solution-processed inks, offer scalable and cost-effective routes to mechanically flexible optoelectronics. With micrometer-scale control and broad processing latitude, aerosol-jet printing (AJP) is of particular interest for all-printed circuits and systems. Here, AJP is utilized to achieve ultrahigh-responsivity photodetectors consisting of well-aligned, percolating networks of semiconducting MoS₂ nanosheets and graphene electrodes on flexible polyimide substrates. Ultrathin (≈1.2 nm thick) and high-aspect-ratio (≈1 μm lateral size) MoS₂ nanosheets are obtained by electrochemical intercalation followed by megasonic atomization during AJP, which not only aerosolizes the inks but also further exfoliates the nanosheets. The incorporation of the high-boiling-point solvent terpineol into the MoS₂ ink is critical for achieving a highly aligned and flat thin-film morphology following AJP as confirmed by grazing-incidence wide-angle X-ray scattering and atomic force microscopy. Following AJP, curing is achieved with photonic annealing, which yields quasi-ohmic contacts and photoactive channels with responsivities exceeding 10³  A W^-1 that outperform previously reported all-printed visible-light photodetectors by over three orders of magnitude. Megasonic exfoliation coupled with properly designed AJP ink formulations enables the superlative optoelectronic properties of ultrathin MoS₂ nanosheets to be preserved and exploited for the scalable additive manufacturing of mechanically flexible optoelectronics.

Prevalence, co-morbidities, and in-hospital mortality of patients hospitalized with alcohol-associated hepatitis in the United States from 2015 to 2019

BACKGROUND

The goals of our study are to determine the most recent trends in hospitalization, mortality, and healthcare utilization among hospitalized patients with alcohol-associated hepatitis (AH) in the United States.

METHODS

We examined the recent prevalence, co-morbidities, and mortality in hospitalized AH patients in the United States based on the available National Inpatient Sample (NIS) data (2015 to 2019) using appropriate International Classification of Diseases (ICD) codes. We reported our data as national estimates based on the discharge weighting variable (DISCWT). Logistic regression analyses were used to determine factors associated with mortality.

RESULTS

We observed an increase in the total number of hospitalized AH patients from 110,135 in 2015 to 136,620 in 2019, which represented 386 per 100,000 total hospitalizations or 42 per 100,000 US population, which in 2019 was 328 million. Patients were a mean of 48 years old and the majority were White and male. The average length of stay was around 6 days with an overall in-hospital mortality that decreased from 4.19% in 2015 to 3.86% in 2019 (p-value for trend = <0.0001). During the 5-year study period, a total of 24,795 hospitalized AH patients died and 592,885 survived the hospital stay. Those who died were older, had a longer length of stay, and higher hospital charges during the stay. Mortality was significantly greater in patients who presented with complications from portal hypertension, those with acute renal failure, underlying cirrhosis, and sepsis.

CONCLUSIONS

Our study documented the increasing prevalence of hospitalized AH patients and their significant associated healthcare costs and utilization. Our results underscore a continuing unmet and urgent need to identify effective therapies for hospitalized AH patients.

Liquid-Phase Exfoliation of Magnetically and Optoelectronically Active Ruthenium Trichloride Nanosheets

α-RuCl₃ is a layered transition metal halide that possesses a range of exotic magnetic, optical, and electronic properties including fractional excitations indicative of a proximate Kitaev quantum spin liquid (QSL). While previous reports have explored these properties on idealized single crystals or mechanically exfoliated samples, the scalable production of α-RuCl₃ nanosheets has not yet been demonstrated. Here, we perform liquid-phase exfoliation (LPE) of α-RuCl₃ through an electrochemically assisted approach, which yields ultrathin, electron-doped α-RuCl₃ nanosheets that are then assembled into electrically conductive large-area thin films. The crystalline integrity of the α-RuCl₃ nanosheets following LPE is confirmed through a wide range of structural and chemical analyses. Moreover, the physical properties of the LPE α-RuCl₃ nanosheets are investigated through electrical, optical, and magnetic characterization methods, which reveal a structural phase transition at 230 K that is consistent with the onset of Kitaev paramagnetism in addition to an antiferromagnetic transition at 2.6 K. Intercalated ions from the electrochemical LPE protocol favorably alter the optical response of the α-RuCl₃ nanosheets, enabling large-area Mott insulator photodetectors that operate at telecommunications-relevant infrared wavelengths near 1.55 μm. These photodetectors show a linear photocurrent response as a function of incident power, which suggests negligible trap-mediated recombination or photothermal effects, ultimately resulting in a photoresponsivity of ≈2 mA/W.

Prognostic implication of the neoadjuvant rectal score and other biomarkers of clinical outcome in Hong Kong Chinese patients with locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy

BACKGROUND

Neoadjuvant chemoradiotherapy is a standard treatment for locally advanced rectal cancer, for which pathological complete response is typically used as a surrogate survival endpoint. Neoadjuvant rectal score is a new biomarker that has been shown to correlate with survival. The main objectives of this study were to investigate factors contributing to pathological complete response, to validate the prognostic significance of neoadjuvant rectal score, and to investigate factors associated with a lower neoadjuvant rectal score in a cohort of Hong Kong Chinese.

METHODS

Data of patients with locally advanced rectal cancer who received neoadjuvant chemoradiotherapy from August 2006 to October 2018 were retrieved from hospital records and retrospectively analysed.

RESULTS

Of 193 patients who had optimal response to neoadjuvant chemoradiotherapy and surgery, tumour down-staging was the only independent prognostic factor that predicted pathological complete response (P<0.0001). Neoadjuvant rectal score was associated with overall survival (hazard ratio [HR]=1.042, 95% confidence interval [CI]=1.021-1.064; P<0.0001), disease-free survival (HR=1.042, 95% CI=1.022-1.062; P<0.0001), locoregional recurrence-free survival (HR=1.070, 95% CI=1.039-1.102; P<0.0001) and distant recurrence-free survival (HR=1.034, 95% CI=1.012-1.056; P=0.002). Patients who had pathological complete response were associated with a lower neoadjuvant rectal score (P<0.0001), but pathological complete response was not associated with survival. For patients with intermediate neoadjuvant rectal scores, late recurrences beyond 72 months from diagnosis were observed.

CONCLUSION

Neoadjuvant rectal score is an independent prognostic marker of survival and disease recurrence in a cohort of Hong Kong Chinese patients who received neoadjuvant chemoradiotherapy for locally advanced rectal cancer.

Morphotaxy of Layered van der Waals Materials

Layered van der Waals (vdW) materials have attracted significant attention due to their materials properties that can enhance diverse applications including next-generation computing, biomedical devices, and energy conversion and storage technologies. This class of materials is typically studied in the two-dimensional (2D) limit by growing them directly on bulk substrates or exfoliating them from parent layered crystals to obtain single or few layers that preserve the original bonding. However, these vdW materials can also function as a platform for obtaining additional phases of matter at the nanoscale. Here, we introduce and review a synthesis paradigm, morphotaxy, where low-dimensional materials are realized by using the shape of an initial nanoscale precursor to template growth or chemical conversion. Using morphotaxy, diverse non-vdW materials such as HfO₂ or InF₃ can be synthesized in ultrathin form by changing the composition but preserving the shape of the original 2D layered material. Morphotaxy can also enable diverse atomically precise heterojunctions and other exotic structures such as Janus materials. Using this morphotaxial approach, the family of low-dimensional materials can be substantially expanded, thus creating vast possibilities for future fundamental studies and applied technologies.

Pudendal Nerve Block for Posthemorrhoidectomy Pain: A Prospective, Single-Blinded Randomized Control Trial

BACKGROUND

Postoperative pain is common in hemorrhoidectomy patients. Local anesthetic given either as an intraoperative pudendal nerve block or as a local wound infiltration may help alleviate postoperative pain.

OBJECTIVES

This study sought to determine whether the addition of an intraoperative pudendal nerve block to a perianal local wound infiltration and standardized analgesia regimen was superior to a perianal local wound infiltration and standardized analgesia regimen alone in reducing early postoperative pain following hemorrhoidectomy. The secondary objective was to measure differences between treatment groups in perceived perianal numbness, oral opioid requirements, and adverse events.

DESIGN

This study was a prospective, single-blinded randomized controlled trial approved by the Eastern Health Human Research and Ethics Committee in Melbourne, Australia (registration number: E09/2014).

SETTINGS

Patients were recruited across 3 Australian hospitals.

PATIENTS

Eighty patients with symptomatic hemorrhoids requiring hemorrhoidectomy in colorectal surgical outpatient clinics were successfully recruited and enrolled in the study, with 1 patient later dropping out.

INTERVENTION

Patients were randomly assigned to either the pudendal nerve block group or a control group. The pudendal nerve block group received 5 mL bupivacaine 0.5% with adrenaline 1:200,000 to both pudendal nerve trunks bilaterally. Both groups received 10 mL of the same local anesthetic injected into the post-hemorrhoidectomy wound bed.

MAIN OUTCOME MEASURES

Visual analogue scales were used to record patient pain scores. Dichotomous (yes/no) answers were recorded for secondary objectives.

RESULTS

There were no significant differences in postoperative pain between groups at 4 hours, 8 hours, 12 hours, or 24 hours. Additionally, there were no significant differences between groups with respect to perceived perianal numbness, oral opioid usage or adverse events.

LIMITATIONS

The authors recognize that without a nerve stimulator, an argument can be made that the pudendal nerve block was not actually achieved.

CONCLUSION

Pudendal nerve block does not appear to demonstrate additional benefit in post-hemorrhoidectomy pain reduction beyond local anesthetic to the wound. See Video Abstract at http://links.lww.com/DCR/B780.

BLOQUEO DEL NERVIO PUDENDO PARA EL DOLOR POSHEMORROIDECTOMA ESTUDIO PROSPECTIVO, ALEATORIO, CONTROLADO, CIEGO

ANTECEDENTES:El dolor posoperatorio es común en pacientes luego de una hemorroidectomía. La administración de anestésico local como bloqueo del nervio pudendo intraoperatorio o infiltración local de la herida puede ayudar a aliviar el dolor posoperatorio.OBJETIVOS:Determinar si agregar un bloqueo intraoperatorio del nervio pudendo a una infiltración local perianal de la herida y un régimen de analgesia estandarizado fue superior a una infiltración local perianal de la herida más un régimen de analgesia estandarizado para reducir el dolor posoperatorio precoz después de una hemorroidectomía. Los objetivos secundarios incluyeron sensación de adormecimiento perianal, requerimientos de opioides orales y eventos adversos informados.DISEÑO:Este estudio fue un ensayo controlado aleatorio, prospectivo, ciego, aprobado por el Comité de Ética e Investigación en Humanos de Eastern Health en Melbourne, Australia (número de registro: E09 / 2014).ESCENARIO:Los pacientes fueron reclutados en tres hospitales australianos.PACIENTES:Ochenta pacientes se inscribieron con éxito en el estudio, y más tarde un paciente abandonó.INTERVENCIÓN:Los pacientes fueron asignados al azar al grupo de bloqueo del nervio pudendo o al grupo control. El grupo de bloqueo del nervio pudendo recibió 5 ml de bupivacaína al 0,5% con adrenalina 1: 200.000 en ambos troncos del nervio pudendo bilateralmente. Ambos grupos recibieron 10 ml del mismo anestésico local inyectado en el lecho de la herida posterior a la hemorroidectomía.PRINCIPALES VARIABLES ANALIZADAS:Se utilizaron escalas analógicas visuales para registrar las puntuaciones de dolor del paciente. Se registraron respuestas dicotómicas (sí / no) para los objetivos secundarios.RESULTADOS:No hubo diferencias significativas en el dolor posoperatorio entre los grupos a las 4, 8, 12 o 24 horas. Además, no hubo diferencias significativas entre los grupos con respecto al adromecimiento perianal percibido, el uso de opioides orales o los eventos adversos.LIMITACIONES:Sin el uso de un estimulador nervioso, se puede argumentar que el bloqueo del nervio pudendo no se logró realmente.CONCLUSIÓNES:El bloqueo del nervio pudendo no parece demostrar un beneficio adicional en la reducción del dolor posterior a la hemorroidectomía más allá del anestésico local en la herida. Consulte Video Resumen en http://links.lww.com/DCR/B780.

Clinical Utility of KidneyIntelX in Early Stages of Diabetic Kidney Disease in the CANVAS Trial

INTRODUCTION

KidneyIntelX is a composite risk score, incorporating biomarkers and clinical variables for predicting progression of diabetic kidney disease (DKD). The utility of this score in the context of sodium glucose co-transporter 2 inhibitors and how changes in the risk score associate with future kidney outcomes are unknown.

METHODS

We measured soluble tumor necrosis factor receptor (TNFR)-1, soluble TNFR-2, and kidney injury molecule 1 on banked samples from CANagliflozin cardioVascular Assessment Study (CANVAS) trial participants with baseline DKD (estimated glomerular filtration rate [eGFR] 30-59 mL/min/1.73 m2 or urine albumin-to-creatinine ratio [UACR] ≥30 mg/g) and generated KidneyIntelX risk scores at baseline and years 1, 3, and 6. We assessed the association of baseline and changes in KidneyIntelX with subsequent DKD progression (composite outcome of an eGFR decline of ≥5 mL/min/year [using the 6-week eGFR as the baseline in the canagliflozin group], ≥40% sustained decline in the eGFR, or kidney failure).

RESULTS

We included 1,325 CANVAS participants with concurrent DKD and available baseline plasma samples (mean eGFR 65 mL/min/1.73 m2 and median UACR 56 mg/g). During a mean follow-up of 5.6 years, 131 participants (9.9%) experienced the composite kidney outcome. Using risk cutoffs from prior validation studies, KidneyIntelX stratified patients to low- (42%), intermediate- (44%), and high-risk (15%) strata with cumulative incidence for the outcome of 3%, 11%, and 26% (risk ratio 8.4; 95% confidence interval [CI]: 5.0, 14.2) for the high-risk versus low-risk groups. The differences in eGFR slopes for canagliflozin versus placebo were 0.66, 1.52, and 2.16 mL/min/1.73 m2 in low, intermediate, and high KidneyIntelX risk strata, respectively. KidneyIntelX risk scores declined by 5.4% (95% CI: -6.9, -3.9) in the canagliflozin arm at year 1 versus an increase of 6.3% (95% CI: 3.8, 8.7) in the placebo arm (p < 0.001). Changes in the KidneyIntelX score at year 1 were associated with future risk of the composite outcome (odds ratio per 10 unit decrease 0.80; 95% CI: 0.77, 0.83; p < 0.001) after accounting for the treatment arm, without evidence of effect modification by the baseline KidneyIntelX risk stratum or by the treatment arm.

CONCLUSIONS

KidneyIntelX successfully risk-stratified a large multinational external cohort for progression of DKD, and greater numerical differences in the eGFR slope for canagliflozin versus placebo were observed in those with higher baseline KidneyIntelX scores. Canagliflozin treatment reduced KidneyIntelX risk scores over time and changes in the KidneyIntelX score from baseline to 1 year associated with future risk of DKD progression, independent of the baseline risk score and treatment arm.

In Situ, Atomic-Resolution Observation of Lithiation and Sodiation of WS2 Nanoflakes: Implications for Lithium-Ion and Sodium-Ion Batteries

WS₂ nanoflakes have great potential as electrode materials of lithium-ion batteries (LIBs) and sodium-ion batteries (SIBs) because of their unique 2D structure, which facilitates the reversible intercalation and extraction of alkali metal ions. However, a fundamental understanding of the electrochemical lithiation/sodiation dynamics of WS₂ nanoflakes especially at the nanoscale level, remains elusive. Here, by combining battery electrochemical measurements, density functional theory calculations, and in situ transmission electron microscopy, the electrochemical-reaction kinetics and mechanism for both lithiation and sodiation of WS₂ nanoflakes are investigated at the atomic scale. It is found that compared to LIBs, SIBs exhibit a higher reversible sodium (Na) storage capacity and superior cyclability. For sodiation, the volume change due to ion intercalation is smaller than that in lithiation. Also, sodiated WS₂ maintains its layered structure after the intercalation process, and the reduced metal nanoparticles after conversion in sodiation are well-dispersed and aligned forming a pattern similar to the layered structure. Overall, this work shows a direct interconnection between the reaction dynamics of lithiated/sodiated WS₂ nanoflakes and their electrochemical performance, which sheds light on the rational optimization and development of advanced WS₂ -based electrodes.

Metacarpal shaft fixation: a biomechanical comparison of dorsal plating, lag screws, and headless compression screws

Background

Metacarpal shaft fractures are common and can be treated nonoperatively. Shortening, angulation, and rotational deformity are indications for surgical treatment. Various forms of treatment with advantages and disadvantages have been documented. The purpose of the study was to determine the stability of fracture fixation with intramedullary headless compression screws in two types of metacarpal shaft fractures and compare them to other common forms of rigid fixation: dorsal plating and lag screw fixation. It was hypothesized that headless compression screws would demonstrate a biomechanical stronger construct.

Methods

Five matched paired hands (age 60.9 ± 4.6 years), utilizing non-thumb metacarpals, were used for comparative fixation in two fracture types created by an osteotomy. In transverse diaphyseal fractures, fixation by headless compression screws (n = 7) and plating (n = 8) were compared. In long oblique diaphyseal fractures, headless compression screws (n = 8) were compared with plating (n = 8) and lag screws (n = 7). Testing was performed using an MTS frame producing an apex dorsal, three point bending force. Peak load to failure and stiffness were calculated from the load-displacement curve generated.

Results

For transverse fractures, headless compression screws had a significantly higher stiffness and peak load to failure, means 249.4 N/mm and 584.8 N, than plates, means 129.02 N/mm and 303.9 N (both p < 0.001). For long oblique fractures, stiffness and peak load to failure for headless compression screws were means 209 N/mm and 758.4 N, for plates 258.7 N/mm and 518.5 N, and for lag screws 172.18 N/mm and 234.11 N. There was significance in peak load to failure for headless compression screws vs plates (p = 0.023), headless compression screws vs lag screws (p < 0.001), and plates vs lag screws (p = 0.009). There was no significant difference in stiffness between groups.

Conclusion

Intramedullary fixation of diaphyseal metacarpal fractures with a headless compression screw provides excellent biomechanical stability. Coupled with lower risks for adverse effects, headless compression screws may be a preferable option for those requiring rapid return to sport or work.

Level of evidence

Basic Science Study, Biomechanics.

Pain Control in Dermatologic Conditions

PURPOSE OF REVIEW

Pain management in dermatologic conditions can be complicated by the primary disease burden and associated decreased quality of life, disability, and psychosocial issues. This review focuses on pain management strategies in some of the more painful dermatologic conditions.

RECENT FINDINGS

Pain management in painful dermatologic conditions such as pyoderma gangrenosum, postherpetic neuralgia, lower limb ulcers, and hidradenitis suppurativa revolves around treatment of the underlying disease process. Topical agents such as topical steroids and systemic immunosuppressants with over-the-counter analgesics usually suffice in mild to moderate pain. Severe pain may need neuropathic agents and referral to interventional pain physicians for consideration of advanced techniques such as epidural steroid injections and sympathetic nerve blocks. Part of the treatment process is for dermatologists to establish patient expectations and to treat pain within their scope of practice. More research is needed towards pain control in painful dermatologic conditions with elucidation of treatment algorithms unique to each condition.

Changes to gastrointestinal function after surgery for colorectal cancer

Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.

Ultrasound-Guided Neuraxial Anesthesia

PURPOSE OF REVIEW

There has been a recent surge of interest in clinical applications of ultrasound, which has revolutionized acute pain management. This review is to summarize the current status of ultrasound utilization in neuraxial anesthesia, the most common type of regional anesthesia.

RECENT FINDINGS

Ultrasound-assisted and ultrasound-guided neuraxial anesthesia has improved clinical accuracy and patient safety through landmark identification including proper vertebral level and midline, as well as via measurements on neuraxial space. Direct needle or catheter visualization during the entire procedure has not yet been achieved consistently. The recent introduction of ultrasound into neural anesthesia has clinical performance benefits and patient safety implications, with documented improvement on overall efficacy with higher first attempt success rate as well as less needle pass. More controlled studies are needed for the overall impact of ultrasonography in neuraxial anesthesia in obstetric and non-obstetric patients.

Clinical utilization of magnetic resonance enterography in small bowel Crohn's disease management: a retrospective tertiary centre experience

BACKGROUND

Magnetic resonance enterography (MRE) is the mainstay imaging modality in the evaluation of small bowel Crohn's disease (CD) activity and its associated complications. Few studies have assessed the indications for ordering it and its association with management changes. The objective was to identify the current clinical utilization of MRE and associated management changes in patients with established small bowel CD.

METHODS

A retrospective audit was conducted on all patients with established CD who underwent MRE at a tertiary centre from November 2014 to December 2017. Clinical indications, radiological findings and management changes were obtained from patient records.

RESULTS

A total of 220 patients underwent a total of 287 MRE examinations. The most common indications for ordering MREs were based on patient symptoms (n = 204, 71.1%) and routine disease surveillance (n = 57, 19.9%). The most common radiological findings were inflammation (n = 156, 54.4%) and strictures (n = 98, 34.1%). Management changes post MRE occurred in 152 of 287 (53%) cases. Of the 152 patients, 87 (57.2%) had changes in medical management, 40 (26.3%) had surgical or endoscopic intervention and 25 (16.4%) had both medical and surgical management changes. Management changes following MRE in patients with new or concerning symptoms were significantly higher than in surveillance patients (OR 4.1, P = 0.000003).

CONCLUSION

This study provides a foundation for understanding the current utilization of MRE in small bowel CD at a tertiary centre. However, its role in altering management particularly within surveillance patients is yet to be defined. Future prospective trials are required to better delineate its role and develop an algorithm for small bowel CD management.

Endometriosis Pain Management: a Review

PURPOSE OF REVIEW

The purpose of this review is to summarize the up-to-date pain management options and recommendations for the challenging disease, endometriosis.

RECENT FINDINGS

The mainstays of endometriosis advances of both surgical and medical management continue to evolve. Experimental pharmaceuticals include Gestirone, and aromatase inhibitors have shown promise but are still under scrutiny. Surgical techniques include laparoscopic uterosacral nerve ablation/resection and presacral neurectomy. No studies have directly compared medical versus surgical management, and as such, no one treatment modality can be recommend as superior to the other. Patients may initially be given a medical diagnosis and treated with nonsteroidal anti-inflammatory drugs, neurolepitcs, OCP, GNRH agonists/antagonists, and Danazol. Assessing the success of these regimens has proved difficult. Surgical management relies on various methods including excision/ablation of the lesions, nerve ablation, neurectomy, hysterectomy, and oophorectomy.

Abstract A29: Association of support group attendance with quality-of-life metrics in head and neck cancer patients

Quality of life has emerged as an increasingly prominent metric of interest for those with head and neck cancer during the course of their recovery. Although many factors have been shown to affect quality of life, the effect of support group attendance has been limited and mixed in the head and neck cancer literature. There is still controversy with regard to the efficacy of support groups. This study aims to add to the literature by reporting the association of support group attendance on quality-of-life measures in head and neck cancer patients. Our findings will help with recommendations for implementing support groups into head and neck cancer care. This is a cross-sectional, survey-based study employing the University of Washington head and neck cancer quality-of-life questionnaire. This survey has been previously validated in the literature as an objective quality of life measurement tool for head and neck cancer patients. All study participants are head and neck cancer patients who have received treatment. Study participants were separated into two separate groups: 1) patients who have never attended support group in the past; 2) patients who have utilized support group. Survey scores are compared between the two groups via unpaired Mann-Whitney U test. Patients who attended support group (N=32) compared to those who have not (N=52) showed significantly greater quality-of-life median scores on appearance (support group median score = 75 vs. no support group median score = 50, U=513, p=0.02), activity (75 vs. 50, U=463, p=0.004), recreation (75 vs. 50, U=404, p&lt;0.001), mood (75 vs. 50, U=310, p&lt;0.001), anxiety (100 vs. 30, U=164, p&lt;0.001), and overall sense of quality of life (80 vs. 60, U=365, p&lt;0.001). There were no statistically significant differences between the two groups for scores in pain, swallowing, chewing, speech, shoulder mobility, taste, or recent changes in subjective sense of quality of life. Our data suggest that support group attendance is associated with a higher quality of life specifically related to mental health and social well-being. There was no observable benefit in physical functional recovery with support group attendance. There appear to be psychosocial benefits from incorporating support groups into head and neck cancer rehabilitation.

Citation Format: Kyohei Itamura, David Lam, Brian Cameron, Tamara Chambers, Niels Kokot, Dennis Maceri, Uttam Sinha, Mark Swanson, Brenda Villegas. Association of support group attendance with quality-of-life metrics in head and neck cancer patients [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr A29.

Development of the Hong Kong Sign Language Sentence Repetition Test

This paper presents the design and development of the Hong Kong Sign Language-Sentence Repetition Test (HKSL-SRT). It will be argued that the test offers evidence of discriminability, reliability, as well as practicality and can serve as an effective global measurement of individuals' proficiency in HKSL. The full version of the test consists of 40 signed sentences of increasing length and complexity. Specifically, we will evaluate the manual and non-manual components of these sentences to find out whether and to what extent they can differentiate three groups of deaf signers, namely, native signers, early learners and late learners. Statistical analyses show that the test scores based on a correct repetition of the manual signs of each sentence bear a significant negative correlation with signers' age of acquisition. Including the correct repetition of non-manuals in the scoring scheme can result in higher reliability and separation index of the test in the Rasch model. This paper will also discuss how psychometric measures of Rasch analysis, including the concept of fit and the rankings of items/persons in the Wright map, have been applied to the original list of the 40 sentence items for the development of a shortened test.

MON-632 The Effects of a High Intensity Glycemic Program on Weight and BMI

Background:

Multiple studies have shown that intensive glycemic control leads to improved HbA1c and delays the onset of complications in diabetes.1 However, improvement in glycemic control has also been associated with weight gain.1 The High A1C (HAC) program uses a multidisciplinary team to provide intensive therapy to patients with HbA1C ≥ 10% over 3 months to improve glycemic control. The aim of this retrospective study is to examine if the HAC program is associated with a significant change in weight and BMI.

Methods:

Patients enrolled in the HAC program were scheduled for frequent visits over the course of 3 months with an Endocrinologist, nurse practitioner, or diabetes educator. Data from patients with type 2 diabetes enrolled from March 2018 to June 2019 who attended at least 2 appointments was collected. Pre-enrollment HbA1c, weight, BMI, and total daily dose (TDD) of insulin (units/kg/day) were compared to post-enrollment using t-test analysis. Use of weight-lowering anti-hyperglycemic agents such as Metformin, GLP-1 agonists (GLP1A) and SGLT-2 inhibitors (SGLT2i) was collected.

Results:

44 patients were enrolled with 39/44 (88.6%) attending at least 2 visits and 5/44 (11.3%) who were lost to follow-up. The median HbA1c improved from 11.5% (9.7-14%) to 8.4% (5.9-14%), p&lt;0.001.There was no significant change in mean weight (195lbs (110-360) vs 192lbs (114-358), p=0.14) or BMI (31 (20-49) vs 31 (21-49) kg/m2, p=0.86). Pre-enrollment, 33/39 (84.6%) patients were on Metformin, 10/39 (25.6%) were on a GLP1A, and 3/39 (7.7%) were on a SGLT2i. At the end of the program, there were 34/39 (87%) patients on Metformin, 26/39 (66.6%) on a GLP1A, and 17/39 (43.5%) on a SGLT2i. There was no difference in the mean TDD of insulin at the start of the program of 0.63 units/kg/day (0-3.52 units/kg/day) compared to 0.60 units/kg/day (0-4.07 units/kg/day) at the end of the program (p=0.97).

Conclusions:

Patients enrolled in a high intensity glycemic control program had significant improvements in HbA1c without change in weight or BMI. Additional adjunctive non-insulin therapies and lifestyle management may be contributing factors for weight neutrality in our population. The significant improvement in HbA1c was not linked with increases in TDD of insulin.

Citation:

1.“U.K. Prospective Diabetes Study Group: Intensive blood glucose control with sulfonylureas or insulin compared with convention treatment and risk of complications in patients with Type 2 Diabetes.” Lancet, vol.353, 1998, pp.837-53.

Does depression explain poor effort on Symptom Validity Tests (SVT)?

Background and aims

Valid assessments require sufficient effort from the part of the testee. Motivation may be compromised, particularly in psychiatric conditions. We examined associations between response bias on free recall and self-reported symptoms in depressed and PTSD patients.

Participants and methods

This is a cross-sectional study. Patients had depression (n = 48), or PTSD or other anxiety disorders (n = 37). A control group (n = 47%) had chronic pain disorder, fibromyalgia or chronic fatigue. The Green Word Memory Test (GWMT) was administered to all subjects. The Structured Inventory of Malingered. Symptomatology (SIMS), and the Beck Depression Inventory (BDI-II) were administered in subsamples. Study outcome was self-reported depressive symptoms in Symptom Validity Test (SVT) negative cases.

Results

Average age of the participants was 45.1 years (SD 9.5), 48.5% were female. GWMT was positive in 52.3% of all cases, GWMT and SIMS were positive in 33.8%, and GWMT and SIMS were negative in 37.7%. No significant group effects on GWMT were found. Average BDI-II scores were 32.8 (SD 13.9) for depressed patients, 28.3 (15.5) for those with anxiety disorders, and 27.6 (14.1) for controls (P = 0.43). Seventy-eight percent of depressed GWMT negative cases reported at least moderate depressive symptoms (BDI-II > 18), and 44.4% severe symptoms (BDI-II > 29). Approximately half of the GWMT negative cases with anxiety disorders and controls scored BDI-II > 18.

Conclusions

Non credible test performance is prevalent in disability claimants with affective, mood disorders. However, depressive symptoms per se do not explain poor effort on cognitive tasks.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Novel Regional Anesthesia for Outpatient Surgery

PURPOSE OF REVIEW

Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge.

RECENT FINDINGS

Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events. Some of these novel blocks are particularly suitable for ambulatory procedures, including but not limited to motor-sparing lower extremity nerve blocks and phrenic-sparing nerve blocks for shoulder surgeries. The adoption of peripheral nerve block into outpatient surgery is a multidisciplinary effort that encompasses appropriate patient choice, careful selection of nerve blocks that minimize potential adverse events after discharge, and proper patient follow-up until block effects resolve.

SAT-LB029 Patient Participation Is Determined by Referral Source in an Intensive Diabetes Management Program

The HAC program was created for patients with high HbA1C values and consists of frequent visits, intensive pharmacologic management, and patient education. In this retrospective study, our primary objective was to determine if there are patient characteristics associated with participation in the program. We hypothesized that younger patients with shorter disease duration and lower HbA1C values would have higher rates of participation. The patients we evaluated were scheduled to begin the program between March and November 2018. Data regarding age, ethnicity, patient reported disease duration, HbA1C, and referral source were collected. We compared patients who participated in the program (Participants) and those who missed their first appointment or only attended one appointment (Non-participants). All Participants attended at least 2 appointments. A total of 30 patients were included, 19 patients in the Participant group and 11 patients in the Non-participant group. The Participant group had an average pre-enrollment HbA1C of 11.8% (8.7%-15.5%), average patient reported disease duration of 16.9 years (0.5-55 years), and average age of 55 years (32-78 years). 10/19 of patients in the Participant group were referred from an outpatient endocrinology clinic, 5/19 were referred from an inpatient endocrine service, and 4/19 were referred from a primary care setting. The Non-participant group had an average pre-enrollment HbA1C of 12.5% (10.2%-14.6%); average patient reported disease duration of 13.5 years (5-35 years), and average age of 53 years (32-65 years). 5/11 of patients in the Non-participant group were referred from an outpatient endocrinology clinic, 1/11 were referred from an inpatient medicine service, and 5/11 were referred from a primary care setting. There were 10 patients in the Participant group and 7 patients in the Non-participant group who had an HbA1C drawn 3 months after their initial enrollment. The Participant group’s HbA1C had a significant reduction to 8.6% (7.2%-10.5%) (p=0.0017). The average HbA1C in the Non-participant group did not change after 3 months and was 12.1% (9.3%-14.0%) Our program of intensive diabetes management, similar to what has been demonstrated in other studies, improved the glycemic outcomes in enrolled patients. In our HAC program, age, disease duration, and baseline HbA1C were not determinants of participation or improvement in glycemic control. More Participants were referred by an outpatient or inpatient endocrinology service. Patients’ motivation to participate may have been influenced by expectations set by the provider, acute illness, or the patient-provider relationship. Further studies to understand the impact of provider-patient relationships may help to optimize patient engagement in intensive diabetes management programs. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

The International Diabetes Closed-Loop Study: Testing Artificial Pancreas Component Interoperability

BACKGROUND

Use of artificial pancreas (AP) requires seamless interaction of device components, such as continuous glucose monitor (CGM), insulin pump, and control algorithm. Mobile AP configurations also include a smartphone as computational hub and gateway to cloud applications (e.g., remote monitoring and data review and analysis). This International Diabetes Closed-Loop study was designed to demonstrate and evaluate the operation of the inControl AP using different CGMs and pump modalities without changes to the user interface, user experience, and underlying controller.

METHODS

Forty-three patients with type 1 diabetes (T1D) were enrolled at 10 clinical centers (7 United States, 3 Europe) and 41 were included in the analyses (39% female, >95% non-Hispanic white, median T1D duration 16 years, median HbA1c 7.4%). Two CGMs and two insulin pumps were tested by different study participants/sites using the same system hub (a smartphone) during 2 weeks of in-home use.

RESULTS

The major difference between the system components was the stability of their wireless connections with the smartphone. The two sensors achieved similar rates of connectivity as measured by percentage time in closed loop (75% and 75%); however, the two pumps had markedly different closed-loop adherence (66% vs. 87%). When connected, all system configurations achieved similar glycemic outcomes on AP control (73% [mean] time in range: 70-180 mg/dL, and 1.7% [median] time <70 mg/dL).

CONCLUSIONS

CGMs and insulin pumps can be interchangeable in the same Mobile AP system, as long as these devices achieve certain levels of reliability and wireless connection stability.

Randomized controlled trial of probiotic use for post-colonoscopy symptoms

BACKGROUND

Symptoms of bloating, discomfort and altered bowel function persist post-colonoscopy in up to 20% of patients. A previous randomized controlled trial of probiotics for post-colonoscopy symptoms has demonstrated a reduction in duration of pain with the use of probiotics. This was performed with air insufflation and the question was asked whether the effect would persist with the use of carbon dioxide to insufflate the colon.

METHODS

Eligible patients were recruited and randomized to receive either probiotic or placebo capsules post colonoscopy. A questionnaire was completed documenting the presence of pre-procedural and post-procedural symptoms for the following 2 weeks. The results were entered into a database and processed by an independent statistician. The primary outcome was mean pain score and incidence of bloating over the first 7 days and at 14 days post procedure. The secondary outcome was the time to return of normal bowel function.

RESULTS

Two hundred and forty participants were recruited and randomized (120 probiotic and 120 placebo). Data were available for 75 patients in the probiotic and 75 in the placebo group. There was no significant difference between groups in post-procedural discomfort, bloating nor time to return of normal bowel function. Subgroup analysis of the patients with preexisting symptoms showed a reduction in incidence of bloating with the use of probiotics.

CONCLUSION

There may be a role for the use of probiotics in the subgroup of patients with preexisting symptoms; however, routine use of probiotics to ameliorate post-procedural symptoms of carbon dioxide insufflation colonoscopy cannot be advocated.