A clinico-radiological review of chronic non-bacterial osteomyelitis in paediatrics, adolescents, and adults: demystifying a forgotten differential

Chronic non-bacterial osteomyelitis (CNO), also known as non-bacterial osteitis, is a chronic autoinflammatory disease of unknown aetiology that primarily occurs in the paediatric population, although rare cases of adult-onset disease also exist. CNO has non-specific clinical and radiological presentations, and the affected population often present with bone pain of insidious onset secondary to sterile bony inflammation that can be associated with swelling, focal tenderness, and warmth at the affected sites. The pattern of bony involvement appears to be dependent on the age of onset, with adults frequently having axial skeletal lesions and children and adolescents often being affected in the appendicular skeletal sites. CNO is a diagnosis of exclusion, and imaging is heavily relied on to identify and characterise the bony lesions in addition to exclude diseases that can mimic CNO. Magnetic resonance imaging is often the reference standard with biochemical and histopathological findings being complementary. Although combining imaging methods can be used to facilitate the diagnosis, a single technique could be adequate depending on the clinical picture. Given the relatively rare incidence of CNO, limited awareness of the disease among care providers, and its similarity in clinical and radiological presentation to various bony diseases, there are often long delays in diagnosis, with adults being unfavourably affected compared to paediatrics and adolescents. This review of CNO will describe the condition, overview its clinical presentation, highlight the radiological features, and emphasise clinical pearls that can aid in diagnosis and ruling out the mimics.

Human Milk Micronutrients and Child Growth and Body Composition in the First 2 years: A Systematic Review

Human milk (HM) provides a plethora of nutritional and non-nutritional compounds that support infant development. For many compounds, concentrations vary substantially among mothers and across lactation, and their impact on infant growth is poorly understood. We systematically searched MEDLINE, Embase, the Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born infants. Outcomes included weight-for-length, length-for-age, weight-for-age, body mass index (in kg/m2)-for-age, and growth velocity. From 9992 abstracts screened, 144 articles were included and categorized based on their reporting of HM micronutrients, macronutrients, or bioactive components. Micronutrients (vitamins and minerals) are reported here, based on 28 articles involving 2526 mother-infant dyads. Studies varied markedly in their designs, sampling times, geographic and socioeconomic settings, reporting practices, and the HM analytes and infant anthropometrics measured. Meta-analysis was not possible because data were sparse for most micronutrients. The most-studied minerals were zinc (15 articles, 1423 dyads) and calcium (7 articles, 714 dyads). HM iodine, manganese, calcium, and zinc concentrations were positively associated with several outcomes (each in ≥2 studies), whereas magnesium (in a single study) was negatively associated with linear growth during early lactation. However, few studies measured HM intake, adjusted for confounders, provided adequate information about complementary and formula feeding, or adequately described HM collection protocols. Only 4 studies (17%) had high overall quality scores. The biological functions of individual HM micronutrients are likely influenced by other HM components; yet, only 1 study analyzed data from multiple micronutrients simultaneously, and few addressed other HM components. Thus, available evidence on this topic is largely inconclusive and fails to address the complex composition of HM. High-quality research employing chronobiology and systems biology approaches is required to understand how HM components work independently and together to influence infant growth and to identify new avenues for future maternal, newborn, or infant nutritional interventions.

Human Milk Macronutrients and Child Growth and Body Composition in the First Two Years: A Systematic Review

Among exclusively breastfed infants, human milk (HM) provides complete nutrition in the first mo of life and remains an important energy source as long as breastfeeding continues. Consisting of digestible carbohydrates, proteins, and amino acids, as well as fats and fatty acids, macronutrients in human milk have been well studied; however, many aspects related to their relationship to growth in early life are still not well understood. We systematically searched Medline, EMBASE, the Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born healthy infants. From 9992 abstracts screened, 57 articles reporting observations from 5979 dyads were included and categorized based on their reporting of HM macronutrients and infant growth. There was substantial heterogeneity in anthropometric outcome measurement, milk collection timelines, and HM sampling strategies; thus, meta-analysis was not possible. In general, digestible carbohydrates were positively associated with infant weight outcomes. Protein was positively associated with infant length, but no associations were reported for infant weight. Finally, HM fat was not consistently associated with any infant growth metrics, though various associations were reported in single studies. Fatty acid intakes were generally positively associated with head circumference, except for docosahexaenoic acid. Our synthesis of the literature was limited by differences in milk collection strategies, heterogeneity in anthropometric outcomes and analytical methodologies, and by insufficient reporting of results. Moving forward, HM researchers should accurately record and account for breastfeeding exclusivity, use consistent sampling protocols that account for the temporal variation in HM macronutrients, and use reliable, sensitive, and accurate techniques for HM macronutrient analysis.

Human Milk Bioactive Components and Child Growth and Body Composition in the First 2 Years: A Systematic Review

Human milk (HM) contains macronutrients, micronutrients, and a multitude of other bioactive factors, which can have a long-term impact on infant growth and development. We systematically searched MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science to synthesize evidence published between 1980 and 2022 on HM components and anthropometry through 2 y of age among term-born infants. From 9992 abstracts screened, 141 articles were included and categorized based on their reporting of HM micronutrients, macronutrients, or bioactive components. Bioactives including hormones, HM oligosaccharides (HMOs), and immunomodulatory components are reported here, based on 75 articles from 69 unique studies reporting observations from 9980 dyads. Research designs, milk collection strategies, sampling times, geographic and socioeconomic settings, reporting practices, and outcomes varied considerably. Meta-analyses were not possible because data collection times and reporting were inconsistent among the studies included. Few measured infant HM intake, adjusted for confounders, precisely captured breastfeeding exclusivity, or adequately described HM collection protocols. Only 5 studies (6%) had high overall quality scores. Hormones were the most extensively examined bioactive with 46 articles (n = 6773 dyads), compared with 13 (n = 2640 dyads) for HMOs and 12 (n = 1422 dyads) for immunomodulatory components. Two studies conducted untargeted metabolomics. Leptin and adiponectin demonstrated inverse associations with infant growth, although several studies found no associations. No consistent associations were found between individual HMOs and infant growth outcomes. Among immunomodulatory components in HM, IL-6 demonstrated inverse relationships with infant growth. Current research on HM bioactives is largely inconclusive and is insufficient to address the complex composition of HM. Future research should ideally capture HM intake, use biologically relevant anthropometrics, and integrate components across categories, embracing a systems biology approach to better understand how HM components work independently and synergistically to influence infant growth.

A real-world assessment of healthcare costs associated with agitation in Alzheimer's dementia

AIMS

To describe and compare clinical characteristics, healthcare costs, and institutionalization/mortality outcomes among patients with and without agitation associated with Alzheimer's dementia (AAD).

METHODS

Data from the Reliant Medical Group database (01/01/2016-03/31/2020) were used, including claims, electronic medical records, and clinical information/physician notes abstracted from medical charts. Patients aged ≥55 years with Alzheimer's dementia (AD) were observed during a randomly selected 12-month study period after AD diagnosis. Using information recorded in medical charts, patients were classified into cohorts based on experiencing (agitation cohort) and not experiencing (no agitation cohort) agitated behaviours during the study period. Entropy balancing was used to create reweighted cohorts with similar characteristics. Study outcomes (patient demographic and clinical characteristics, treatments received, healthcare costs, institutionalization and death events) were compared between cohorts; agitation characteristics were described for the agitation cohort only.

RESULTS

Among 711 patients included in the study, 240 were classified in the agitation cohort and 471 in the no agitation cohort. After reweighting, several comorbidities were more frequently observed in the agitation versus no agitation cohort, including infection, depression, and altered mental status. Use of antidepressants, anticonvulsants, antipsychotics, and antianxiety medications was more common in the agitation versus no agitation cohort. Common agitated behaviours included hitting (20.8%), pacing/aimless wandering (17.5%), and cursing/verbal aggression (15.0%). Total all-cause healthcare costs were $4287 per-patient-per-year higher in the agitation cohort versus no agitation cohort (p = 0.04), driven by higher inpatient costs. Death was more common and time to death and institutionalization were shorter in the agitation versus no agitation cohort.

LIMITATIONS

Results may not be generalizable to the US population with AD.

CONCLUSIONS

Among patients with AD, agitation was associated with shorter time to death/institutionalization and increased comorbidities, medication use, and healthcare costs, highlighting the additional clinical and economic burden that agitation poses to patients and the healthcare system.

Supporting and Incentivizing Peer Leaders for an Internet-Based Private Peer Community for Youths With Type 1 Diabetes: Social Network and Directed Content Analysis

BACKGROUND

Youths with type 1 diabetes (T1D) frequently experience stigma. Internet-based peer communities can mitigate this through social support but require leaders to catalyze exchange. Whether nurturing potential leaders translates into a central role has not been well studied. Another issue understudied in such communities is lurking, the viewing of exchanges without commenting or posting.

OBJECTIVE

We aimed to assess the centrality of the peer leaders we selected, trained, and incentivized within the Canadian Virtual Peer Network (VPN)-T1D. This is a private Facebook (Meta Platforms, Inc) group that we created for persons aged 14 to 24 years with T1D. We specifically sought to (1) compare a quantitative estimate of network centrality between peer leaders and regular members, (2) assess the proportions of network exchanges that were social support oriented, and (3) assess proportions of high engagement (posts, comments, reactions, and votes) and low engagement (lurking) exchanges.

METHODS

We recruited peer leaders and members with T1D from prior study cohorts and clinics. We trained 10 leaders, provided them with a monthly stipend, and encouraged them to post on the private Facebook group we launched on June 21, 2017. We extracted all communications (posts, messages, reactions, polls, votes, and views) that occurred until March 20, 2020. We calculated each member's centrality (80% of higher engagement communications comprising posts, comments, and reactions plus 20% of members with whom they connected). We divided each member's centrality by the highest centrality to compute the relative centrality, and compared the mean values between leaders and members (linear regression). We calculated the proportions of communications that were posts, comments, reactions, and views without reaction. We performed content analysis with a social support framework (informational, emotional, esteem-related, network, and tangible support), applying a maximum of 3 codes per communication.

RESULTS

VPN-T1D gained 212 regular members and 10 peer leaders over 33 months; of these 222 members, 26 (11.7%) exited. Peer leaders had 10-fold higher relative centrality than regular members (mean 0.53, SD 0.26 vs mean 0.04, SD 0.05; 0.49 difference; 95% CI 0.44-0.53). Overall, 91.4% (203/222) of the members connected at least once through posts, comments, or reactions. Among the 75,051 communications, there were 5109 (6.81%) posts, comments, and polls, 6233 (8.31%) reactions, and 63,709 (84.9%) views (lurking). Moreover, 54.9% (3430/6253) of codes applied were social support related, 66.4% (2277/3430) of which were informational (eg, insurance and travel preparation), and 20.4% (699/3430) of which were esteem related (eg, relieving blame).

CONCLUSIONS

Designating, training, and incentivizing peer leaders may stimulate content exchange and creation. Social support was a key VPN-T1D deliverable. Although lurking accounted for a high proportion of the overall activity, even those demonstrating this type of passive participation likely derived benefits, given that the network exit rate was low.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/18714.

Does the Australian influenza season predict the Canadian influenza season? A qualitative comparison of seasons, 2014-2020

A commonly held belief by the Canadian media and public is that the Australian influenza season is a fairly reliable indicator of what the Canadian influenza season that follows might be like. However, this claim is not well substantiated with epidemiological evidence. Therefore, the objective of this work was to qualitatively compare the timing of the onset, peak, and intensity of influenza activity, the dominant circulating influenza strains, and the seasonal vaccine and vaccination policies from 2014 to 2020 between Canada and Australia, using a combination of FluNet data and influenza surveillance reports and publications. Across the epidemiological indicators considered, the epidemics between Canada and Australia often differ. While vaccination policies and coverage are similar between the two countries, vaccine composition and vaccine effectiveness estimates also differ. Ultimately, there are many differences and confounding variables between the Australian and Canadian influenza seasons across numerous indicators that preclude the use of the Australian influenza season as the sole predictor of the Canadian influenza season. However, the availability of global surveillance data and robust national and sub-national surveillance data can provide lead time and inform within-season resource and capacity planning, as well as mitigation measures, for seasonal influenza epidemics.

Remission of type 2 diabetes and improved diastolic function by combining structured exercise with meal replacement and food reintroduction among young adults: the RESET for REMISSION randomised controlled trial protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) onset before 40 years of age has a magnified lifetime risk of cardiovascular disease. Diastolic dysfunction is its earliest cardiac manifestation. Low energy diets incorporating meal replacement products can induce diabetes remission, but do not lead to improved diastolic function, unlike supervised exercise interventions. We are examining the impact of a combined low energy diet and supervised exercise intervention on T2DM remission, with peak early diastolic strain rate, a sensitive MRI-based measure, as a key secondary outcome.

METHODS AND ANALYSIS

This prospective, randomised, two-arm, open-label, blinded-endpoint efficacy trial is being conducted in Montreal, Edmonton and Leicester. We are enrolling 100 persons 18-45 years of age within 6 years' T2DM diagnosis, not on insulin therapy, and with obesity. During the intensive phase (12 weeks), active intervention participants adopt an 800-900 kcal/day low energy diet combining meal replacement products with some food, and receive supervised exercise training (aerobic and resistance), three times weekly. The maintenance phase (12 weeks) focuses on sustaining any weight loss and exercise practices achieved during the intensive phase; products and exercise supervision are tapered but reinstituted, as applicable, with weight regain and/or exercise reduction. The control arm receives standard care. The primary outcome is T2DM remission, (haemoglobin A1c of less than 6.5% at 24 weeks, without use of glucose-lowering medications during maintenance). Analysis of remission will be by intention to treat with stratified Fisher's exact test statistics.

ETHICS AND DISSEMINATION

The trial is approved in Leicester (East Midlands - Nottingham Research Ethics Committee (21/EM/0026)), Montreal (McGill University Health Centre Research Ethics Board (RESET for remission/2021-7148)) and Edmonton (University of Alberta Health Research Ethics Board (Pro00101088). Findings will be shared widely (publications, presentations, press releases, social media platforms) and will inform an effectiveness trial.

TRIAL REGISTRATION NUMBER

ISRCTN15487120.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

A systematic review and meta-analysis of the role of doxycycline in chronic rhinosinusitis

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the role of doxycycline in the management of chronic rhinosinusitis.

METHOD

This was a systematic review using Ovid Medline, Cinahl, Scopus and Cochrane and was limited to meta-analyses, systematic reviews and randomised, clinical trials. A combination of the following search terms was used: 'sinusitis', 'nasal polyps', 'doxycycline' and 'tetracycline'. Raw means and standard deviations were extracted from the included studies. The meta-analysis was performed using mean differences of pre- versus post-doxycycline treatment.

RESULTS

A total of 279 studies were screened, of which 5 studies met the criteria (all randomised, controlled trials published between 2010 and 2021). The interventions, endpoints and measured outcomes varied across all studies. Meta-analysis performed on pre- versus post-doxycycline treatment for Sino-Nasal Outcome Test-22, nasal polyp scores and symptom scores did not yield statistically significant results.

CONCLUSION

This review identified a small number of high-quality studies on the use of doxycycline in chronic rhinosinusitis. There does not seem to be convincing evidence for the routine use of doxycycline in patients with chronic rhinosinusitis. Further research may try to identify certain phenotypes of chronic rhinosinusitis that may better respond to doxycycline.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

AB0887 Designing a Phase 3b, Multicenter, Randomized, Double-blind, Placebo-controlled Study to Investigate the Effect of Guselkumab Dosing Interval in Psoriatic Arthritis Patients with Inadequate Response to Tumor Necrosis Factor Inhibition

Background

Tumor necrosis factor inhibitors (TNFi) are frequently chosen as the first biologic therapy for patients (pts) with psoriatic arthritis (PsA), though a sizeable proportion of pts have an inadequate response (IR), and some may also have intolerance. Guselkumab (GUS), a human mAb that targets the IL-23 p19 subunit, provides an alternative mechanism of action to treat PsA. In the Phase 3 (Ph3) DISCOVER-1 study of GUS in active PsA, GUS every 4 weeks (Q4W) and Q8W clinical response rates were generally consistent between TNFi-naïve (263 pts) and TNFi-experienced (118 pts) cohorts. In the TNFi-experienced cohort and the limited number of DISCOVER-1 pts with IR to their prior TNFi (N=44), American College of Rheumatology 50% improvement (ACR50) and ACR70 response rates at W24 were numerically higher in GUS Q4W- than Q8W-treated pts.1

Objectives

To further investigate whether GUS Q4W could provide incremental benefit to some TNFi-IR PsA pts by analyzing the existing DISCOVER-1 dataset to facilitate the design of a new clinical trial.

Methods

Study feasibility assessments included comparison of key efficacy endpoints by treatment group at W24 among TNFi-experienced pts receiving GUS Q8W and Q4W in DISCOVER-1. Results from the DISCOVER-1 study also informed sample size power calculations for a primary endpoint of ACR20 response at W24 in a future study in a TNFi-IR PsA pt population.

Results

Comparison of several efficacy endpoints (ACR70 response, minimal disease activity, Investigator’s Global Assessment [IGA] of psoriasis 0/1 response) across treatment groups in the TNFi-experienced DISCOVER-1 cohort supports a potential dose response, with more frequent GUS administration eliciting numerically higher response rates (Table 1). A similar trend was observed for ACR20/50/70 responses in the smaller TNFi-IR population1, though these findings should be interpreted with caution due to limited sample size. ACR20 response rates at W24 of DISCOVER-1 were employed to estimate sample size requirements for a new study. Assuming comparable rates of GUS treatment effect seen in DISCOVER-1, a sample size of 150 randomized pts per group for PBO, GUS Q8W, and GUS Q4W would provide >90% power to detect a significant difference between each GUS group and PBO for ACR20 response at W24. Based on these findings, a new Ph3b, multicenter, randomized, double-blind, PBO-controlled study, SOLSTICE, was designed to further evaluate the efficacy and safety of GUS in approximately 450 pts with active PsA who had IR to one prior TNFi, and to investigate the effect of GUS dosing interval in this important cohort of pts with PsA (Figure 1).

Table 1.

Clinical efficacy at W24 among DISCOVER-1 TNFi-experienced pts

PlaceboGUS Q8WGUS Q4WACR2017.9% (7/39)56.1% (23/41)57.9% (22/38)ACR505.1% (2/39)26.8% (11/41)34.2% (13/38)ACR702.6% (1/39)2.4% (1/41)21.1% (8/38)MDA2.6% (1/39)17.1% (7/41)26.3% (10/38)IGA 0/1a7.7% (2/26)48.3% (14/29)67.9% (19/28)

aIGA score of 0 (clear) or 1 (almost clear) among pts with ≥3% body surface area of psoriatic involvement and an IGA score ≥2 (mild-to-severe psoriasis) at baseline.

ACR20/50/70, American College of Rheumatology 20%/50%/70% improvement; GUS, guselkumab; IGA, Investigator’s Global Assessment; MDA, minimal disease activity; Q4W, every 4 weeks; Q8W, every 8 weeks; TNFi, tumor necrosis factor inhibitor; W, week

Conclusion

PsA pts with TNFi-IR are typically difficult to treat. Overall data from the pivotal DISCOVER-1 study of GUS in pts with active PsA showed consistent clinical response between doses and between TNFi-naïve and TNFi-experienced pts. Analyses based on limited numbers of TNFi-experienced pts from DISCOVER-1 demonstrated potential incremental benefit for achievement of higher response criteria with more frequent dosing in some TNFi-IR pts. SOLSTICE, a Ph3b, randomized, placebo-controlled study, will test this hypothesis.

References

[1]Deodhar A, et al. Lancet. 2020;395:1115-1125.

Figure 1.

Disclosure of Interests

Alexis Ogdie Shareholder of: Her husband has received royalties from Novartis, Consultant of: AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Global Health Living Foundation, Janssen, Eli Lilly, Novartis, Pfizer, and UCB Pharma, Grant/research support from: Abbvie, Pfizer and Novartis/Amgen to the University of Pennsylvania, Joseph F. Merola Paid instructor for: AbbVie, Arena, Biogen, Bristol Myers Squibb, Dermavant, Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Arena, Biogen, Bristol Myers Squibb, Dermavant, Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Christopher T. Ritchlin Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, and Janssen, Grant/research support from: UCB Pharma, AbbVie, and Amgen, Jose U. Scher Consultant of: Janssen, Novartis, Pfizer, Abbvie, Sanofi, Kaleido and UCB Pharma, Grant/research support from: Novartis, Pfizer and Janssen (for investigator-initiated studies), Daphne Chan Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Soumya D Chakravarty Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Wayne Langholff Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, Olivia Choi Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Yevgeniy Krol Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Katelyn Rowland Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Alice B Gottlieb Consultant of: AnaptsysBio, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, Bristol-Myers Squibb Co., Incyte, GSK, Janssen, LEO Pharma, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical Industries, Inc., UCB Pharma, Dermavant, and Xbiotech, Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB Pharma, Xbiotech, and Sun Pharma

AB0893 An Analysis of Fatigue in Patients With Psoriatic Disease Utilizing SF-36 Vitality Scores: Results Through Week 24 in Phase 3 Trials of Guselkumab in Patients With Psoriasis and Psoriatic Arthritis

Background

Patients with chronic inflammatory diseases can experience significant fatigue, negatively impacting health-related quality-of-life.1,2

Objectives

This post-hoc analysis evaluated baseline fatigue severity among patients with psoriasis and/or psoriatic arthritis (PsA) and the effect of guselkumab treatment on patient-reported fatigue.

Methods

VOYAGE-2 evaluated guselkumab every 8 weeks (Q8W) versus placebo (W16→guselkumab) and adalimumab in treating moderate-to-severe psoriasis.3 DISCOVER-14 and DISCOVER-25 evaluated guselkumab Q4W and Q8W versus placebo in treating active PsA. Fatigue was assessed using 36-item Short Form (SF-36) vitality scale score (includes 4 questions on fatigue/energy level); the US population norm=50±10; 5-10-point decrements are typically observed in conditions known to cause fatigue2; scores ≤35 indicate clinically important fatigue1; increases ≥5 indicate clinically meaningful improvement.2

Results

Across randomized groups at baseline, mean SF-36 vitality scores were 47.7-48.5 in psoriasis and 42.2-44.0 in PsA patients; 11%-15% of psoriasis and 20%-28% of PsA patients had scores <35. In psoriasis patients, mean increases in SF-36 vitality score at W16 were: placebo, 1.1; adalimumab, 3.9 (p<0.001 versus placebo); guselkumab, 5.6 (p<0.001 versus placebo); at W24: placebo→guselkumab, 4.6; adalimumab, 3.9; guselkumab, 5.8 (p=0.0148 versus adalimumab). In PsA patients, mean increases at W24 were: placebo, 2.3-4.0; guselkumab, 5.5-7.5 (p≤0.001 versus placebo). Through the placebo-controlled periods, significantly greater proportions of guselkumab-treated patients achieved clinically meaningful improvement in fatigue versus placebo (W16 psoriasis: guselkumab, 48%; placebo, 32%; p<0.001; W24 PsA: guselkumab, 53%-55%; placebo, 34%-44%; p<0.05).

Conclusion

At baseline, patients with psoriatic disease experienced clinically important fatigue, more so with PsA (20%-28%) than psoriasis (11%-15%). In guselkumab-treated psoriasis and PsA patients, clinically meaningful improvements in fatigue were achieved at W16 and W24, respectively.

References

[1]Skoie IM et al. Br J Dermatol. 2017;177:505-12

[2]Bjorner JB et al. Curr Med Res Opin. 2007;23:731-9

[3]Reich K et al. J Am Acad Dermatol. 2017;76:418-31

[4]Deodhar A et al. Lancet. 2020;395:1115-25

[5]Mease PJ et al. Lancet. 2020;395:1126-36

Disclosure of Interests

Joseph F. Merola Consultant of: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Dermavant, Eli Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Yi-Hsuan Liu Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson, Ya-Wen Yang Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Megan Miller Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, May Shawi Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Daphne Chan Employee of: Janssen Scientific Affairs, LLC and may own stock or stock options in Johnson & Johnson, Saakshi Khattri Speakers bureau: Abbvie, Eli Lilly, UCB, Janssen, Paid instructor for: Abbvie, Eli Lilly, UCB, Janssen, Consultant of: Abbvie, Eli Lilly, UCB, Janssen, Grant/research support from: Pfizer, Abbvie, Leo, BMS, Eli Lilly, Laura Savage Speakers bureau: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Consultant of: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Grant/research support from: Janssen and Pfizer, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Consultant of: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Chenglong Han Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson

AB1473 EFFICACY RESPONSES ACROSS DISEASE SEVERITY AND TREATMENT HISTORY SUBGROUPS OF PATIENTS WITH MODERATE TO SEVERE PLAQUE PSORIASIS TREATED WITH GUSELKUMAB: POOLED RESULTS FROM VOYAGE-1 AND VOYAGE-2 THROUGH 5 YEARS

Background

The VOYAGE-1 and VOYAGE-2 phase 3 studies evaluated efficacy and safety of guselkumab (GUS) in patients with moderate-to-severe plaque psoriasis.

Objectives

To assess the five-year efficacy of GUS by baseline disease characteristics and treatment history.

Methods

This study evaluated 1829 patients randomized to GUS, placebo (PBO)→GUS, and adalimumab (ADA) →GUS from the VOYAGE-1 and VOYAGE-2 trials. All patients received open-label GUS 100 mg every 8 weeks (Q8W) during Week (W) 52 to W252 in VOYAGE-1 and during W76 to W252 in VOYAGE-2. The proportions of combined GUS patients (including PBO→GUS and ADA→GUS) achieving Investigator’s Global Assessment of cleared or minimal (IGA-0/1) and Psoriasis Area and Severity Index (PASI) 90 response were evaluated from W100 to W252 by baseline PASI (<20/≥20) and IGA (<4/=4) scores, body surface area (BSA; <20%/≥20%), and prior psoriasis treatments. Analysis was performed using observed data after applying treatment failure rules.

Results

At W252, proportions of combined GUS patients achieving IGA 0/1 or PASI 90, respectively, were comparable or numerically greater for patients with baseline PASI < 20 (85.4%; 81.1%) vs PASI ≥ 20 (81.4%; 83.8%); IGA < 4 (85.1%; 82.7%) vs IGA = 4 (78.9%; 81.1%); BSA < 20% (85.1%; 82.7%) vs BSA ≥ 20% (82.6%; 82.0%); no prior phototherapy (83.3%; 84.0%) vs prior phototherapy (83.8%; 81.1%); no prior non-biologic systemic therapy (84.5%; 83.0%) vs prior non-biologic systemic therapy (83.2%; 82.0%); and no prior biologics (85.3%; 83.8%) vs prior biologics (76.7%; 76.3%). This trend was consistent at each timepoint evaluated from W100 to W252.

Conclusion

This analysis demonstrated that the high degree of efficacy of GUS treatment is durable through 5 years among broad subpopulations of patients with varying disease severity characteristics and previous psoriasis treatments.

References

None

Disclosure of Interests

Kenneth Gordon Grant/research support from: AbbVie, Almirall, Amgen, BMS, Celgene, Dermira, Dermavant, Eli Lilly, Janssen, LEO Pharma, Novartis, Ortho Dermatologics, Pfizer, Sun Pharma, and UCB Pharma, Joseph F. Merola Consultant of: AbbVie, Arena, Avotres, Biogen, Bristol-Myers Squibb, Celgene, Dermavant, Eli Lilly, EMD Sorono, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB pharma, Peter Foley Speakers bureau: AbbVie, Celgene, Eli Lilly, Galderma, GSK, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, and Valeant, Consultant of: AbbVie, Amgen, Arcutis, Aslan, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Celtaxsys, CSL, Cutanea, Dermira, Eli Lilly, Galderma, Genentech, GSK, Hexima, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals Inc, Reistone, Roche, Sanofi, Sun Pharma, UCB Pharma, and Valeant, Grant/research support from: grant/research support from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Sanofi, and Sun Pharma; and travel grants from AbbVie, Eli Lilly, Galderma, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, Sanofi, and Sun Pharma, Olivia Choi Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Daphne Chan Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Megan Miller Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yin You Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yaung-Kaung Shen Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Ya-Wen Yang Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, Andrew Blauvelt Speakers bureau: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

A74 SURVEILLANCE IMAGING FOLLOWING COMPLETELY RESECTED GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS: A SINGLE CENTER AUDIT OF LOCAL PRACTICE PATTERNS

Background

Neuroendocrine tumours (NET) are a heterogenous group of neoplasms that secrete peptides and neuroamines. For patients with potentially malignant gastroenteropancreatic (GEP) NET, surgical resection represents the only curative option. GEP NETs are characterized by long periods of disease-free survival and time-to-recurrence following surgical resection. Clinical guidelines recommend surveillance with cross sectional imaging, either CT or MRI, for at least 10 years.

Aims

The purpose of this study was to characterize local practice patterns of imaging surveillance (modality, frequency, and duration of follow-up) and how this compares to guideline recommendations.

Methods

We retrospectively reviewed clinical and imaging records from patients diagnosed with well-differentiated GEP NET at our center from January 2005 to July 2020 inclusive. Eligible cases were identified by a data analyst from the Alberta Cancer Board with each case being manually screened for eligibility. Exclusion criteria included patients with metastatic disease at presentation, G1 appendiceal NET &lt; 1 cm, R0 G1 T1 rectal NET, and insulinoma. Location of primary NET, modality of surveillance imaging, date of test and duration of follow-up collected. The mean number of surveillance scans per person and per person-year follow-up based on the location of the primary NET were calculated.

Results

A total of 387 cases were initially retrieved with 62 eligible cases identified. The mean length of follow-up was 71 months (range 8 to 147). The mean number of surveillance scans was 7 (range 2 to 14) and the mean number of surveillance scans per person year was 1.1. Frequency of surveillance scans per year of follow-up did not differ based on the location of the primary tumor (p=0.966). Imaging modalities included cross sectional imaging (MRI and contrast enhanced CT) and nuclear medicine imaging (octreotide, MIBG, F-18 FDG-PET, and Gallium-68 DOTATATE PET CT). Most commonly, cross-sectional imaging was performed with CT or MRI representing 38% (n=166) and 39% (n=170) of all surveillance respectively. Nuclear medicine imaging was used in 15% (n=61) of surveillance scans and 3% used combined cross-sectional and nuclear medicine. Amongst cases with resection date &gt;10 years (n=8) mean length of follow-up was 119 months (9.9 years).

Conclusions

Frequency and modality of imaging at our center is generally in accordance with current clinical guidelines, though the role of nuclear medicine imaging in this setting has not been established. CT and MRI were utilized equally during surveillance. The burden of these modalities in terms of radiation exposure and cost warrants further evaluation.

Funding Agencies

None

Application of an organotypic ocular perfusion model to assess intravitreal drug distribution in human and animal eyes

Intravitreal (ITV) drug delivery is a new cornerstone for retinal therapeutics. Yet, predicting the disposition of formulations in the human eye remains a major translational hurdle. A prominent, but poorly understood, issue in pre-clinical ITV toxicity studies is unintended particle movements to the anterior chamber (AC). These particles can accumulate in the AC to dangerously raise intraocular pressure. Yet, anatomical differences, and the inability to obtain equivalent human data, make investigating this issue extremely challenging. We have developed an organotypic perfusion strategy to re-establish intraocular fluid flow, while maintaining homeostatic pressure and pH. Here, we used this approach with suitably sized microbeads to profile anterior and posterior ITV particle movements in live versus perfused porcine eyes, and in human donor eyes. Small-molecule suspensions were then tested with the system after exhibiting differing behaviours in vivo. Aggregate particle size is supported as an important determinant of particle movements in the human eye, and we note these data are consistent with a poroelastic model of bidirectional vitreous transport. Together, this approach uses ocular fluid dynamics to permit, to our knowledge, the first direct comparisons between particle behaviours from human ITV injections and animal models, with potential to speed pre-clinical development of retinal therapeutics.

Detecting impaired language processing in patients with mild cognitive impairment using around-the-ear cEEgrid electrodes

Mild cognitive impairment (MCI) is the term used to identify those individuals with subjective and objective cognitive decline but with preserved activities of daily living and an absence of dementia. Although MCI can impact functioning in different cognitive domains, most notably episodic memory, relatively little is known about the comprehension of language in MCI. In this study, we used around-the-ear electrodes (cEEGrids) to identify impairments during language comprehension in patients with MCI. In a group of 23 patients with MCI and 23 age-matched controls, language comprehension was tested in a two-word phrase paradigm. We examined the oscillatory changes following word onset as a function of lexico-semantic single-word retrieval (e.g., swrfeq vs. swift) and multiword binding processes (e.g., horse preceded by swift vs. preceded by swrfeq). Electrophysiological signatures (as measured by the cEEGrids) were significantly different between patients with MCI and controls. In controls, lexical retrieval was associated with a rebound in the alpha/beta range, and binding was associated with a post-word alpha/beta suppression. In contrast, both the single-word retrieval and multiword binding signatures were absent in the MCI group. The signatures observed using cEEGrids in controls were comparable with those signatures obtained with a full-cap EEG setup. Importantly, our findings suggest that patients with MCI have impaired electrophysiological signatures for comprehending single words and multiword phrases. Moreover, cEEGrid setups provide a noninvasive and sensitive clinical tool for detecting early impairments in language comprehension in MCI.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Induction of specific brain oscillations may restore neural circuits and be used for the treatment of Alzheimer's disease

Brain oscillations underlie the function of our brains, dictating how we both think and react to the world around us. The synchronous activity of neurons generates these rhythms, which allow different parts of the brain to communicate and orchestrate responses to internal and external stimuli. Perturbations of cognitive rhythms and the underlying oscillator neurons that synchronize different parts of the brain contribute to the pathophysiology of diseases including Alzheimer's disease, (AD), Parkinson's disease (PD), epilepsy and other diseases of rhythm that have been studied extensively by Gyorgy Buzsaki. In this review, we discuss how neurologists manipulate brain oscillations with neuromodulation to treat diseases and how this can be leveraged to improve cognition and pathology underlying AD. While multiple modalities of neuromodulation are currently clinically indicated for some disorders, nothing is yet approved for improving memory in AD. Recent investigations into novel methods of neuromodulation show potential for improving cognition in memory disorders. Here, we demonstrate that neuronal stimulation using audiovisual sensory stimulation that generated 40-HZ gamma waves reduced AD-specific pathology and improved performance in behavioural tests in mouse models of AD, making this new mode of neuromodulation a promising new avenue for developing a new therapeutic intervention for the treatment of dementia.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

POS0124 QUALITY OF LIFE FOR PATIENTS WITH KNEE OSTEOARTHRITIS WITH OR WITHOUT PAIN SENSITIZATION

Background:

Patients with central sensitization (CS) may have poorer quality of life (QOL).

Objectives:

We aim to evaluate whether different ways of classifying CS have an impact on a patient’s QOL among patients with knee osteoarthritis (KOA).

Methods:

We use the baseline pre-operative data from a cohort of consecutive KOA patients enlisted for knee replacement surgery (1). We collected demographics, number and position of painful sites of body. Quality of life was assessed by the Medical Outcome Survey Short-Form 36 (SF-36). Pain pressure threshold was measured at volar side of right forearm. We classify CS using three sets of criteria: 1). widespread pain (pain involving both upper/ lower trunk, and both side of body), 2). lowest 10th percentile of pressure pain threshold (PPT) measured at the forearm and 3) the painDETECT questionnaire >=13/38.

Results:

Of 233 patients (79.8% women) with complete data set for analysis, mean (standard deviation, SD) age was 66.0 (8.3) years. 15.5%, 25.8%, and 4.7% of patients were classified as having CS by widespread pain, low PPT and painDETECT criteria. KOA patients with CS have poorer QoL compared with those without. Low PPT identified patients with poorer general health, while widespread pain and PainDETECT criteria identified patients with poorer QoL in more domains including vitality mental health (Table 1).

Table 1.

Quality of life comparing patients with or without CS

Widespread painlowest 10th percentile of forearm PPTPainDETECT >=13/38No (n = 197)Yes (n= 36)No (n= 206)Yes (n= 27)No (n= 222)Yes(n= 11)SF-Physical functioning39.0 (21.8)32.6 (19.0)38.7 (21.8)32.8 (17.8)38.8 (21.3)22.3 (19.2)*SF-Role physical21.6 (33.3)8.3 (22.4)*20.3 (32.2)13.9 (32.0)19.7 (32.6)15.9 (23.1)SF-Bodily pain36.3 (19.5)28.1 (14.0)*35.1 (19.5)34.0 (14.7)35.5 (19.1)24.2 (13.3)SF-General health68.9 (21.1)64.6 (20.3)69.4 (20.6)59.3 (22.4)*68.7 (20.7)58.4 (25.7)SF-Vitality score69.7 (22.4)59.3 (20.4)**68.8 (22.5)63.1 (21.1)69.0 (21.8)51.8 (29.2)*SF-Social functioning57.7 (37.2)48.3 (39.2)57.3 (38.0)48.1 (33.7)56.7 (37.7)47.7 (42.1)SF-Role emotion86.1 (34.4)86.1 (33.2)86.7 (33.5)79.0 (38.3)86.9 (32.9)63.6 (50.5)SF-Mental health82.4 (16.2)77.4 (19.2)82.2 (16.8)77.8 (15.8)82.2 (16.3)70.2 (22.2)*Physical component score32.5 (10.1)30.3 (8.0)32.4 (9.8)30.6 (9.7)32.4 (9.9)28.8 (8.7)Mental component score53.0 (10.5)48.3 (10.0)*52.7 (10.6)48.5 (9.2)52.6 (10.2)44.2 (13.7)**

* p<0.05; **p<0.01

Conclusion:

KOA patients who have CS have poorer QoL compared to those without. Different criteria defined patients with different pattern of QoL impacts. In general, KOA patients who have CS have poorer QoL compared to those without. This highlight the importance of additional impact of CS to QoL

References:

[1]Leung YY, Lim Z, Fan Q, et al. Pre-operative pressure pain thresholds do not meaningfully explain satisfaction or improvement in pain after knee replacement: a cohort study. Osteoarthritis and cartilage 2019;27(1):49-58.

Disclosure of Interests:

None declared

Cardiovascular and behavioural risk factors in families with elevated lipoprotein(a)[Lp(a)]

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Elevated lipoprotein(a)[Lp(a)] is an inherited and independent risk factor for atherosclerotic cardiovascular diseases (ASCVD). However, it is an under detected condition with no specific therapy available at present for lowering Lp(a). Hence, identifying the distribution of modifiable cardiovascular and behavioural risk factors is important for implementing an effective intervention programme to mitigate the overall risk of ASCVD in high-risk individuals with elevated Lp(a).

Purpose

The primary aim was to describe and compare the distribution of modifiable cardiovascular and behavioural risk factors in both index cases and their relatives with elevated Lp(a) identified through cascade testing at the Lipid Disorders Clinic, Royal Perth Hospital.

Methods

We studied 51 index cases and 71 relatives cascade tested with elevated Lp(a) (≥0.5 g/L).  Questionnaires were completed concerning aspects of cardiovascular health (cholesterol level, blood pressure and blood glucose level) and behavioural health metrics (diet, smoking, physical activity, body-mass-index [BMI]). Lp(a) was measured by an immunoassay having minimal dependence on apolipoprotein(a) isoform size. The health metrics were described as proportions and statistical analyses performed using Student’s t-test or Chi-square where appropriate.

Results

Compared with the index cases, a higher proportion of their affected relatives were female (62% vs 43%, p = 0.039), younger (43 years vs 53 years, p &lt; 0.001) and had lower Lp(a) levels (1.03 g/L vs 1.12 g/L, p = 0.003). A lower proportion of the affected relatives were treated for dyslipidaemia (31% vs 96%, p &lt; 0.001). The affected relatives also had a lower incidence of ASCVD events (3% vs 37%, p &lt; 0.001), hypertension (21% vs 43%, p = 0.003), and lower HbA1c levels (5.3% vs 5.9%, p = 0.031) compared with index cases. Additionally, a larger proportion of the affected relatives had ideal cardiovascular health (35% vs 14%, p = 0.008) compared with their index cases. However, more than half of the index cases and their relatives did not maintain a healthy diet (59% and 69%, respectively) and an ideal BMI (68% and 59%, respectively).

Conclusion(s)

Although the younger affected relatives with elevated Lp(a) have a lower cardiovascular risk compared with the index cases, a focus on modifiable behavioural changes, such as a healthy diet and an ideal body weight, is still required to mitigate the overall risk of ASCVD.

The international Perinatal Outcomes in the Pandemic (iPOP) study: protocol

Preterm birth is the leading cause of infant death worldwide, but the causes of preterm birth are largely unknown. During the early COVID-19 lockdowns, dramatic reductions in preterm birth were reported; however, these trends may be offset by increases in stillbirth rates. It is important to study these trends globally as the pandemic continues, and to understand the underlying cause(s). Lockdowns have dramatically impacted maternal workload, access to healthcare, hygiene practices, and air pollution - all of which could impact perinatal outcomes and might affect pregnant women differently in different regions of the world.

In the international Perinatal Outcomes in the Pandemic (iPOP) Study, we will seize the unique opportunity offered by the COVID-19 pandemic to answer urgent questions about perinatal health. In the first two study phases, we will use population-based aggregate data and standardized outcome definitions to: 1) Determine rates of preterm birth, low birth weight, and stillbirth and describe changes during lockdowns; and assess if these changes are consistent globally, or differ by region and income setting, 2) Determine if the magnitude of changes in adverse perinatal outcomes during lockdown are modified by regional differences in COVID-19 infection rates, lockdown stringency, adherence to lockdown measures, air quality, or other social and economic markers, obtained from publicly available datasets. We will undertake an interrupted time series analysis covering births from January 2015 through July 2020.

The iPOP Study will involve at least 121 researchers in 37 countries, including obstetricians, neonatologists, epidemiologists, public health researchers, environmental scientists, and policymakers. We will leverage the most disruptive and widespread “natural experiment” of our lifetime to make rapid discoveries about preterm birth. Whether the COVID-19 pandemic is worsening or unexpectedly improving perinatal outcomes, our research will provide critical new information to shape prenatal care strategies throughout (and well beyond) the pandemic.

Type 1 Diabetes Mellitus Virtual Patient Network as a Peer Support Community: Protocol for Social Network Analysis and Content Analysis

Background

Type 1 Diabetes Mellitus Virtual Patient Network (T1DM-VPN) is a private Facebook group for youths with type 1 diabetes mellitus (T1DM) in Canada intended to facilitate peer-to-peer support. It was built on the finding that stigma is prevalent among youth with T1DM and impedes self-management.

Objective

We aim to determine if T1DM-VPN provides support as intended and to ascertain what type of members provide support. Specifically, we will (1) identify text consistent with any one of 5 social support categories, (2) describe the network by visualizing its structure and reporting basic engagement statistics, and (3) determine whether being a designated peer leader is related to a member’s centrality (ie, importance in the network) and how frequently they offer social support.

Methods

We will manually extract interaction data from the Facebook group (posts, comments, likes/reactions, seen) generated from June 21, 2017 (addition of first member), to March 1, 2020. Two researchers will independently code posts and comments according to an existing framework of 5 social support categories—informational, emotional, esteem, network, and tangible—with an additional framework for nonsocial support categories. We will calculate how frequently each code is used. We will also report basic engagement statistics (eg, number of posts made per person-month) and generate a visualization of the network. We will identify stable time intervals in the history of T1DM-VPN by modeling monthly membership growth as a Poisson process. Within each interval, each member’s centrality will be calculated and standardized to that of the most central member. We will use a centrality formula that considers both breadth and depth of connections (centrality = 0.8 × total No. of connections + 0.2 × total No. of interactions). Finally, we will construct multivariate linear regression models to assess whether peer leader status predicts member centrality and the frequency of offering social support. Other variables considered for inclusion in the models are gender and age at diagnosis.

Results

T1DM-VPN was launched in June 2017. As of March 1, 2020, it has 196 patient-members. This research protocol received ethics approval from the McGill University Health Centre Research Ethics Board on May 20, 2020. Baseline information about each group member was collected upon addition into the group, and collection of interaction data is ongoing as of May 2020.

Conclusions

This content analysis and social network analysis study of a virtual patient network applies epidemiological methods to account for dynamic growth and activity. The results will allow for an understanding of the topics of importance to youth with T1DM and how a virtual patient network evolves over time. This work is intended to serve as a foundation for future action to help youth improve their experience of living with diabetes.

International Registered Report Identifier (IRRID)

PRR1-10.2196/18714

Developmental genome-wide DNA methylation asymmetry between mouse placenta and embryo

In early embryos, DNA methylation is remodelled to initiate the developmental program but for mostly unknown reasons, methylation marks are acquired unequally between embryonic and placental cells. To better understand this, we generated high-resolution DNA methylation maps of mouse mid-gestation (E10.5) embryo and placenta. We uncovered specific subtypes of differentially methylated regions (DMRs) that contribute directly to the developmental asymmetry existing between mid-gestation embryonic and placental DNA methylation patterns. We show that the asymmetry occurs rapidly during the acquisition of marks in the post-implanted conceptus (E3.5-E6.5), and that these patterns are long-lasting across subtypes of DMRs throughout prenatal development and in somatic tissues. We reveal that at the peri-implantation stages, the de novo methyltransferase activity of DNMT3B is the main driver of methylation marks on asymmetric DMRs, and that DNMT3B can largely compensate for lack of DNMT3A in the epiblast and extraembryonic ectoderm, whereas DNMT3A can only partially compensate in the absence of DNMT3B. However, as development progresses and as DNMT3A becomes the principal de novo methyltransferase, the compensatory DNA methylation mechanism of DNMT3B on DMRs becomes less effective.

Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

A trajectory analysis of daily step counts during a physician-delivered intervention

OBJECTIVES

Higher steps are associated with lower mortality and cardiovascular event rates. We previously demonstrated that tailored physician-delivered step count prescriptions successfully increased steps/day in adults with type 2 diabetes mellitus (T2DM) and/or hypertension. In the present analysis, we examined patterns of step count change and the factors that influence different responses.

DESIGN

Longitudinal observational study METHODS: Active arm participants (n=118) recorded steps/day. They received a step count prescription from their physician every 3-4 months. We computed mean steps/day and changes from baseline for sequential 30-day periods. Group-based trajectory modeling was applied.

RESULTS

Four distinct trajectories of mean steps/day emerged, distinguishable by differences in baseline steps/day: sedentary (19%), low active (40%), somewhat active (30%) and active (11%). All four demonstrated similar upward slopes. Three patterns emerged for the change in steps from baseline: gradual decrease (30%), gradual increase with late decline (56%), and rapid increase with midpoint decline (14%); thus 70% had an increase from baseline. T2DM (odd ratios [OR]: 3.7, 95% CI 1.7, 7.7) and age (OR per 10-year increment: 2, 95% CI 1.3, 2.8) were both associated with starting at a lower baseline but participants from these groups were no less likely than others to increase steps/day.

CONCLUSIONS

T2DM and older age were associated with lower baseline values but were not indicators of likelihood of step count increases. A physician-delivered step count prescription and monitoring strategy has strong potential to be effective in increasing steps irrespective of baseline counts and other clinical and demographic characteristics.

Preventing diabetes after pregnancy with gestational diabetes in a Cree community: an inductive thematic analysis

INTRODUCTION

Historical and political factors underpin the disproportional burden of type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) in women, a harbinger of future T2DM, in Indigenous populations. There is a need for T2DM prevention strategies driven by the voices of Indigenous women. In this study, we aimed to understand the perspectives of Cree women with prior GDM living in northern Quebec, where over a quarter of pregnancies are complicated by GDM.

RESEARCH DESIGN AND METHODS

A local healthcare worker invited women with GDM in the prior 5 years to participate in semistructured interviews. A Cree-origin research partner and a researcher jointly conducted interviews in-person or by teleconference. Open-ended questions addressed GDM experience, maintaining a healthy lifestyle, and needs/preferences pertinent to designing a T2DM prevention program aimed at women affected by GDM. We adopted an inductive thematic analysis framework to categorize experiences and opinions.

RESULTS

Among the 13 mothers interviewed, some success with health behavior changes during pregnancy was reported but there were difficulties postpartum resulting from time constraints, costs of healthy foods, discomfort at the gym related to not being perceived as athletic, and safety concerns. They acknowledged the existence of programs addressing T2DM prevention in their community but did not participate. They endorsed preferences for group sessions, with family collaboration and childcare, that addressed healthy cooking and physical activity and incorporated traditional elements.

CONCLUSION

Cree mothers with a history of GDM highlighted several barriers to diabetes prevention. We are working to address these barriers through the creation of a Cree-facilitator-led community-based intervention.