Improving Access to Eye Care Through Community Health Screenings Using Artificial Intelligence

PURPOSE

To the best of our knowledge, implementation of artificial intelligence (AI)-based vision screening in community health fair settings has not been previously studied. This prospective cohort study explored the incorporation of AI in a community health fair setting to improve access to eyecare.

METHODS

Vision screening was implemented during a community health fair event using an AI-based non-mydriatic fundus camera. In addition, a questionnaire was provided to survey the various barriers to eyecare and assess eye health literacy.

RESULTS

A total of 53 individuals were screened at this event. Notably, about 88% of participants had follow-up appointments scheduled accordingly with an approximate 62% attendance rate. The most reported barrier to eyecare was lack of health insurance followed by transportation.

CONCLUSION

The addition of AI-based vision screening in community health fairs may ultimately help improve access to eye care.

Semi-Supervised Semantic Role Labeling with Bidirectional Language Models

The recent success of neural networks in NLP applications has provided a strong impetus to develop supervised models for semantic role labeling which forego the requirement for extensive feature engineering. Recent state-of-the-art approaches require high quality annotated datasets that are costly to obtain and almost unavailable for low resource languages. We present a semi-supervised approach that utilizes both labeled and unlabeled data to provide performance improvement over a mere supervised SRL model. We show that our proposed semi-supervised SRL model provides larger improvement over a supervised model in the scenario where labeled training data size is small. Our SRL system leverages unlabeled data under the language modeling paradigm. We demonstrate that the incorporation of self pre-trained bidirectional language model (S-PrLM) to SRL system can help in SRL performance improvement by learning composition functions from the unlabeled data. Previous researches have concluded that syntax information is very useful for high performing SRL system, so we incorporate syntax information by employing an unsupervised approach to leverage dependency path information to connect argument candidates in vector space which helps in distinguishing arguments with similar contexts but different syntactic functions. The basic idea is to connect predicate ( w p ) with argument candidate ( w a ) with the dependency path ( r ) between them in the embedding space. Experiments on CoNLL-2008 and CoNLL-2009 datasets confirm that our full SRL model outperforms previous best models in terms of F 1 score.

How do strategic mineral resources affect clean energy transition? Cross-sectional autoregressive distributed lag (CS-ARDL) approach

In the transition to a low carbon economy, minerals are crucial. The demand for the minerals required to create and install green energy technology, such as solar panels, wind turbines, electric vehicles, and energy storage, is rising along with it. In particular, the countries that hold these mineral reserves should be thought of as thriving economically from the rising demand for essential mineral resources (such as cobalt, lithium, and others). This study uses import demand function analysis to look at how the major mineral importing countries’ mineral import demand changed in response to the clean energy transitions between 2000 and 2021 for selected 14 countries. In the study, the cross-sectional autoregressive distributed lag (CS-ARDL) method was used. Findings show that long-term renewable energy production has a largely favorable impact on mineral import demand. Additionally, CO₂ emissions have a long-term negative impact on mineral import demands, but energy intensity and exchange rate are favorable for mineral imports. The findings have significant ramifications for using the mineral trade to speed up the transition to sustainable energy around the world. Therefore, the study’s key proposed policy is to emphasize the value of mineral resources in clean energy while maximizing their use in the transition to carbon-free energy.

OR28-1 Racial and Ethnic Disparities in Diabetes Technology Use amongst Persons with Type 1 Diabetes

Objective

Despite recent advances in diabetes technology, the distribution of healthcare resources is often unequal among racial and socio-economic groups. A recent multicenter study looking at technology use amongst young adults with T1D demonstrated that socioeconomic status (SES) was not the sole driver of racial/ethnic disparities and that adjustment for income, insurance level, and health literacy did not significantly attenuate disparities. Here we present a retrospective cohort study looking at racial/ethnic disparities in insulin pump and CGM use in adults with T1D at an urban university hospital system.

Methods

We reviewed the charts of all adults aged 18 to 89 with T1D who attended the University of Maryland Center for Diabetes and Endocrinology (UMCDE) between 1/2019 and 12/2019. Age, gender, race/ethnicity, type of insurance, ZIP code, BMI, A1c, method of insulin delivery, and type of glucose monitoring device were obtained from each chart. We utilized the 2019 US Census data to determine the median income for each ZIP code. Patient charts were re-accessed in 2021 to check for changes in diabetes technology use from 1/2020 until 12/2021. Logistic regression modeling was done in PRISM to control for age, gender, race, insurance type, ZIP code, last known provider, BMI, and A1c. Hosmer-Lemeshow test was done to evaluate goodness of fit. Stratified analysis was done for potential confounders such as insurance type and income. The Breslow-Day test and Likelihood Ratio test for nested models were used to evaluate their degree and significance.

Result

A total of 532 adults were included in the study; 277 identified as non-Hispanic (NH) White, 204 identified as NH Black, 7 identified as Hispanic, and 44 identified as other racial/ethnic groups. NH White adults had a significantly higher insulin pump use when compared to NH Black (adjusted ratio 54.0% vs. 18.4%, OR 2.43 after regression, 95%CI [1.41-4.22]). Similarly, NH White adults had significantly higher CGM use when compared to NH Black (66.5% vs. 35.2%, OR 2.00 after regression, 95%CI [1.24-3.22]). Disparities between NH White and NH Black patients did not resolve throughout 2020-2021. Insurance type was a potential effect modifier for CGM prescriptions between NH White and NH Blacks (Crude OR 4.04, Commercial Strata OR 2.68, Medicaid 1.79, Medicare 2.79, Other/Self-pay 25.7, p=0.039 on Breslow-Day test). There was large heterogeneity in the rate of Pump or CGM prescriptions between providers.

Conclusion

NH White adults with T1D were significantly more likely to have been prescribed diabetes-related technologies when compared to other racial/ethnic groups, and this difference did not resolve over 2 years of follow-up. Future directions include a comprehensive survey of our population regarding patient-derived and patient-perceived factors driving disparities beyond socioeconomic status.

Presentation: Tuesday, June 14, 2022 9:45 a.m. - 10:00 a.m.

PSUN36 Subacute Thyroiditis Following mRNA Vaccine for COVID-19 in a 40-Year-Old Male Patient

Background

Subacute thyroiditis typically occurs a few weeks after a viral infection and is the most common cause of painful thyrotoxicosis. Cases of subacute thyroiditis have been reported following both inactivated and live-attenuated vaccines, such as the influenza vaccine. We describe a case of subacute thyroiditis in the setting of the Pfizer-BioNTech mRNA COVID-19 vaccination.

Clinical Case

A 40-year-old man with no significant medical history presented with signs and symptoms of thyrotoxicosis after receiving the Pfizer COVID-19 vaccine. Symptoms began 3 days after receiving the second vaccine dose and included 9 kg unintentional weight loss, arthralgia in both knees, palpitations, fatigue, bilateral thigh weakness, and diffuse neck swelling, pain, and tenderness. Initial treatment with antibiotics for presumed upper respiratory infection did not improve symptoms, and PCR testing for COVID-19 infection was negative. Thyroid ultrasound obtained 15 days after symptoms onset revealed a 4 cm nodule in the left lobe of the thyroid gland. Testing 30 days after onset of symptoms demonstrated TSH<0.005 uIU/mL (ref: 0.45-4.50 uIU/mL), elevated free T4 of 2.53 ng/dL (ref: 0.82-1.77 ng/dL), and elevated erythrocyte sedimentation rate of 42 mm/hr (ref: 0-15 mm/hr). Repeat labs and imaging 9 days later demonstrated improvement with a TSH of 0.071 uIU/mL and free T4 of 1.04 ng/dL as well as decreased nodule size (2.5 cm). At this time, the patient reported resolution of all symptoms and return to baseline weight. Thyroid ultrasound obtained 3 months after symptoms onset demonstrated normal thyroid without detectable nodules or enlargement, and complete normalization of TSH and free T4 levels to 4.250 uIU/mL and 1.22 ng/dL, respectively.

Conclusion

This is the second documented case of subacute thyroiditis following the Pfizer-BioNTech vaccine for COVID-19 in a male patient. A literature review demonstrates 12 other cases of subacute thyroiditis following the Pfizer-BioNTech mRNA COVID-19 vaccine, 3 cases following the Moderna mRNA COVID-19 vaccine, 8 cases following the AstraZeneca recombinant COVID-19 vaccine (one male patient), 4 cases following the CoronaVac inactivated SARS-CoV-2 COVID-19 vaccine, 1 case following the Covaxin inactivated SARS-CoV-2 COVID-19 vaccine, and 3 cases following the Janssen viral vector SARS-CoV-2 COVID-19 vaccine. Albeit uncommon, providers should be aware that transient thyrotoxicosis following COVID-19 vaccination may occur. Similar to subacute thyroiditis due to viral infection, the clinical course is generally self-limited with patients returning to a euthyroid state within a few months. Usual management of subacute thyroiditis with symptomatic management and watchful waiting is appropriate.

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

PSUN192 Therapeutic Benefit of GLP-1 Agonists in Patients with Type 1 Diabetes on Insulin Therapy: an Updated Systematic Review and Meta-analysis

Introduction

Glucagon-like Peptide 1 (GLP-1) agonists are efficacious glycemic control and weight loss agents for obese patients with or without type 2 diabetes mellitus. Use of GLP-1 agonists for patients with type 1 diabetes mellitus (T1DM), on the other hand, is an evolving area of research. Our present meta-analysis aims to critically evaluate existing evidence and provide an estimated average therapeutic effect.

Methods

PubMed, Embase, and Cochrane libraries were searched for randomized controlled trials comparing major efficacy and safety endpoints for 12 weeks or longer administration of GLP-1 agonists compared to placebo in T1DM patients on insulin. Main endpoints for analysis included glycated hemoglobin (A1c) level, body weight, and change in total insulin dose. Study was done in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement.

Results

Of 3736 reports identified on search, 8 studies involving liraglutide 1.8mg daily (total 1415 patients) and 5 studies involving any dosage of exenatide (total 221 patients) were included. Liraglutide 1.8mg overall produced greater decrease in A1c (MD = -0.28%, 95% CI -0.41 to -0.16, I²=42%), body weight (MD = -4.84kg, 95% CI -5.25 to -4.44, I²=0%), and total daily insulin per kilogram body weight (MD = -0.08u/kg, 95% CI -0.10 to -0.06, I²=55%) compared to placebo. Exenatide regimen as a whole also overall produced decreased A1c (MD = -0.17%, 95% CI -0.38 to -0.00, I²=0%), body weight (MD = -4.05kg, 95% CI -14.3 to -3.45, I²=0%), total daily insulin (MD = -0.08u/kg, 95% CI -0.15 to -0.01, I²=0%) compared to placebo. However, 3 out of 5 exenatide trials were open label and studies used multiple doses and formations (short-release and extended release), which limited the interpretation of results in clinical practice.

Conclusion

Our meta-analysis supports the therapeutic benefits of GLP-1 agonists for patients with T1DM. Daily 1.8mg liraglutide injections for at least 12 weeks appear to be a promising adjunct to insulin therapy for T1DM patients, resulting in decreased A1c levels, body weight, and total daily insulin requirements.

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

OR03-3 Impact of Continuous Glucose Monitoring (CGM) on Lifestyle Modifications in Individuals with Prediabetes

Introduction

Adherence to lifestyle modifications can prevent diabetes; however, this poses a challenge for most individuals. CGM is an effective tool for glycemic control and lifestyle modifications in patients with diabetes on insulin therapy. We explored the impact of CGM use in individuals with prediabetes.

Hypothesis

Individuals using CGM in addition to diabetes education will show improved adherence to lifestyle modifications and greater reduction of HbA1c as compared to those receiving diabetes education alone.Design57 individuals with prediabetes were randomized to use CGM for 3 months along with diabetes education (CGM group) or receive diabetes education alone (EDU group). Food frequency (UKDDQ) and physical activity (IPAQ) questionnaires were completed by participants at the beginning and at the end of the study (6 months). Primary outcomes were lifestyle modifications and changes in HbA1c. Secondary outcomes were changes in weight and blood pressure.

Results

Both groups reported an increase in healthy food choices; however, EDU group performed better (EDU: 12.4 vs 9.2, p&lt;0.01, CGM: 10.6 vs 9.5, p 0.08). Unhealthy food choices were reduced in both groups. CGM group reported a greater increase in moderate physical activity levels (CGM: 230 vs 61 minutes/week, p 0.01, EDU: 78.5 vs 48 minutes/week, p 0.22). Vigorous physical activity was reported by more individuals in CGM group than EDU (35% vs 4%). Greater reduction in mean HbA1c was noted in CGM group (5.7 vs 5.9%, p 0.05) compared to EDU (5.8 vs 5.9%, p 0.01). 33% of participants in both groups had normalization of HbA1c at the end of study. CGM group had greater reduction in weight (3.5 vs 0.8 lb, p 0.1) and systolic BP (12 vs 2.4 mmHg, p 0.01) than EDU. Irrespective of group assignment, the study population had improvement in all outcomes despite the beginning of COVID-19 pandemic during 4th month of the study. Smaller number of participants in the CGM group reported negative impact of the pandemic on their lifestyle modifications than EDU (Diet: 68% vs 80%, Physical activity: 48% vs 64%). Majority of CGM group participants were able to maintain lifestyle changes after discontinuing CGM use (Diet: 72%, Physical activity: 84%). On comparing both interventions, 56% of CGM group participants felt CGM to be more helpful than education for lifestyle modifications, while 40% felt both interventions helped equally.

Conclusions

CGM use in addition to diabetes education resulted in improvement in physical activity, food choices, HbA1c, weight, and BP in individuals with prediabetes. The significance of diabetes education was noted by greater improvement in food choices in EDU group. CGM can be an effective tool for diabetes prevention with lifestyle modifications in prediabetes. The long-term impact of CGM use and cost-benefit analysis in high-risk patients needs to be explored further.

Presentation: Saturday, June 11, 2022 12:00 p.m. - 12:15 p.m.

Effects of Electroconvulsive Therapy on Glycemic Control in Type 1 Diabetes

Electroconvulsive therapy (ECT) is a treatment modality for refractory depression and other severe psychiatric diseases. Depression is a common comorbid condition of diabetes. Yet, evidence regarding the effect of ECT on glycemic control in patients with diabetes is limited and conflicting, with reports of both exacerbation and amelioration of hyperglycemia. A 52-year-old Caucasian man with a history of type 1 diabetes mellitus (T1DM) was admitted for ECT therapy in the setting of worsening depression refractory to medical treatment. Pre-admission glycemic control was poor. He had significant glycemic variability during his hospitalization with hyper- and hypoglycemia. He required near-daily adjustment of insulin doses and distinct “ECT day” and “non-ECT day” insulin regimens. By the conclusion of his ECT course, in addition to achieving favorable psychiatric recovery, he had a marked improvement in glycemic control. This suggests that the treatment of depression may have beneficial effects on improving glycemic control in patients with T1DM.

Continuous Glucose Monitoring-Guided Insulin Administration in Hospitalized Patients With Diabetes: A Randomized Clinical Trial

OBJECTIVE

The efficacy and safety of continuous glucose monitoring (CGM) in adjusting inpatient insulin therapy have not been evaluated.

RESEARCH DESIGN AND METHODS

This randomized trial included 185 general medicine and surgery patients with type 1 and type 2 diabetes treated with a basal-bolus insulin regimen. All subjects underwent point-of-care (POC) capillary glucose testing before meals and bedtime. Patients in the standard of care (POC group) wore a blinded Dexcom G6 CGM with insulin dose adjusted based on POC results, while in the CGM group, insulin adjustment was based on daily CGM profile. Primary end points were differences in time in range (TIR; 70-180 mg/dL) and hypoglycemia (<70 mg/dL and <54 mg/dL).

RESULTS

There were no significant differences in TIR (54.51% ± 27.72 vs. 48.64% ± 24.25; P = 0.14), mean daily glucose (183.2 ± 40 vs. 186.8 ± 39 mg/dL; P = 0.36), or percent of patients with CGM values <70 mg/dL (36% vs. 39%; P = 0.68) or <54 mg/dL (14 vs. 24%; P = 0.12) between the CGM-guided and POC groups. Among patients with one or more hypoglycemic events, compared with POC, the CGM group experienced a significant reduction in hypoglycemia reoccurrence (1.80 ± 1.54 vs. 2.94 ± 2.76 events/patient; P = 0.03), lower percentage of time below range <70 mg/dL (1.89% ± 3.27 vs. 5.47% ± 8.49; P = 0.02), and lower incidence rate ratio <70 mg/dL (0.53 [95% CI 0.31-0.92]) and <54 mg/dL (0.37 [95% CI 0.17-0.83]).

CONCLUSIONS

The inpatient use of real-time Dexcom G6 CGM is safe and effective in guiding insulin therapy, resulting in a similar improvement in glycemic control and a significant reduction of recurrent hypoglycemic events compared with POC-guided insulin adjustment.

Transformational leadership and project success: The mediating role of trust and job satisfaction

Transformational leadership (TFL) impacts on project and organizational success are well established. However, many underlying factors that make TFL effective are still missing. Therefore, we formulated hypotheses and tested the mediating role of trust (TS) and job satisfaction (JS) in linking TFL to project success (PS). A time-lagged methodology was used to collect quantitative data using a structured questionnaire from 326 project manager-team member dyads working in Pakistan’s public sector. Our results showed that TS, JS, and TFL significantly impacted project success. Moreover, we found that TS and JS mediate the relationship between TFL and PS. These findings highlight the importance of trust and job satisfaction as mechanisms that translate TFL into the success of projects for organizations.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Incorporating CNN Features for Optimizing Performance of Ensemble Classifier for Cardiovascular Disease Prediction

Cardiovascular diseases (CVDs) have been regarded as the leading cause of death with 32% of the total deaths around the world. Owing to the large number of symptoms related to age, gender, demographics, and ethnicity, diagnosing CVDs is a challenging and complex task. Furthermore, the lack of experienced staff and medical experts, and the non-availability of appropriate testing equipment put the lives of millions of people at risk, especially in under-developed and developing countries. Electronic health records (EHRs) have been utilized for diagnosing several diseases recently and show the potential for CVDs diagnosis as well. However, the accuracy and efficacy of EHRs-based CVD diagnosis are limited by the lack of an appropriate feature set. Often, the feature set is very small and unable to provide enough features for machine learning models to obtain a good fit. This study solves this problem by proposing the novel use of feature extraction from a convolutional neural network (CNN). An ensemble model is designed where a CNN model is used to enlarge the feature set to train linear models including stochastic gradient descent classifier, logistic regression, and support vector machine that comprise the soft-voting based ensemble model. Extensive experiments are performed to analyze the performance of different ratios of feature sets to the training dataset. Performance analysis is carried out using four different datasets and results are compared with recent approaches used for CVDs. Results show the superior performance of the proposed model with 0.93 accuracy, and 0.92 scores each for precision, recall, and F1 score. Results indicate both the superiority of the proposed approach, as well as the generalization of the ensemble model using multiple datasets.

Use of continuous glucose monitor as a motivational device for lifestyle modifications to improve glycaemic control in patients with type 2 diabetes treated with non-insulin therapies

The efficacy of continuous glucose monitors (CGM) to improve glycaemic control in individuals on intensive insulin therapy (basal and prandial) has been well established in several studies; however, there is limited evidence on its usage and efficacy in patients with type 2 diabetes (T2D) who are on non-insulin therapies. Lifestyle modifications and glucose monitoring are essential components of the management of T2D. We report a case that demonstrates the impact of CGM use as an effective tool for patient education and motivation to implement and adhere to lifestyle modifications in improving glycaemic control in a patient with long-standing poorly controlled T2D who was on oral glucose-lowering medications. CGM use is associated with high level of patient satisfaction which can improve quality of life and has the potential to reduce long-term complications related to poor glycaemic control. These observations emphasise the need to broaden the use of CGM in this patient population.

Emotional and behavioral problems of 7-11 year old children in war-torn Nagorno–Karabakh region in Azerbaijan

Introduction

The emotional, behavioral and psychosocial effects of chaotic environments following wars and armed conflicts in terms of exposure to trauma and displacement is well recognized. School-age children who are directly exposed to or witnessed negative effects of armed conflicts show an array of emotional and behavioral problems.

Objectives

Our study aimed to examine the mental health conditions of children living in war and conflict zones and attending primary schools in Agdam.

Methods

The study sample comprised of 617 children (mean age 8.9, SD 1.24; 50.7% female), residing in the conflict areas in the southwestern of Azerbaijan. The children were evaluated with the previously validated Azerbaijani version of the Strengths and Difficulties Questionnaire (SDQ) Teacher Form.

Results

About a third of children (32.7%) had abnormal total scores, and a fifth (21.4%) were in borderline range. The SDQ subscale scores included emotional problems (19.4%); conduct problems (20.3%), hyperactivity/inattention (12.2%), peer relationship problems (31.1%), and pro-social behavior difficulties (13.1%). As a result, externalizing problem scores were higher in males (p<.001) and internalizing problems in females (p<.05). Due to correlation analysis, age is negatively and significantly related with externalising (p<.05), internalising (p<.01), and total difficulty (p<.05) scores.

Conclusions

The findings of the study show that more than half of the children living in the war zone in Azerbaijan suffer from mental health problems and highlight the need for child mental health services and family supports in the region.

Disclosure

No significant relationships.

Memorizing All for Implicit Discourse Relation Recognition

Implicit discourse relation recognition is a challenging task due to the absence of the necessary informative clues from explicit connectives. An implicit discourse relation recognizer has to carefully tackle the semantic similarity of sentence pairs and the severe data sparsity issue. In this article, we learn token embeddings to encode the structure of a sentence from a dependency point of view in their representations and use them to initialize a baseline model to make it really strong. Then, we propose a novel memory component to tackle the data sparsity issue by allowing the model to master the entire training set, which helps in achieving further performance improvement. The memory mechanism adequately memorizes information by pairing representations and discourse relations of all training instances, thus filling the slot of the data-hungry issue in the current implicit discourse relation recognizer. The proposed memory component, if attached with any suitable baseline, can help in performance enhancement. The experiments show that our full model with memorizing the entire training data provides excellent results on PDTB and CDTB datasets, outperforming the baselines by a fair margin.

Analyses of Public Attention and Sentiments towards Different COVID-19 Vaccines Using Data Mining Techniques

COVID-19 is a widely spread disease, and in order to overcome its spread, vaccination is necessary. Different vaccines are available in the market and people have different sentiments about different vaccines. This study aims to identify variations and explore temporal trends in the sentiments of tweets related to different COVID-19 vaccines (Covaxin, Moderna, Pfizer, and Sinopharm). We used the Valence Aware Dictionary and Sentiment Reasoner (VADER) tool to analyze the public sentiments related to each vaccine separately and identify whether the sentiments are positive (compound ≥ 0.05), negative (compound ≤ −0.05), or neutral (−0.05 < compound < 0.05). Then, we analyzed tweets related to each vaccine further to find the time trends and geographical distribution of sentiments in different regions. According to our data, overall sentiments about each vaccine are neutral. Covaxin is associated with 28% positive sentiments and Moderna with 37% positive sentiments. In the temporal analysis, we found that tweets related to each vaccine increased in different time frames. Pfizer- and Sinopharm-related tweets increased in August 2021, whereas tweets related to Covaxin increased in July 2021. Geographically, the highest sentiment score (0.9682) is for Covaxin from India, while Moderna has the highest sentiment score (0.9638) from the USA. Overall, this study shows that public sentiments about COVID-19 vaccines have changed over time and geographically. The sentiment analysis can give insights into time trends that can help policymakers to develop their policies according to the requirements and enhance vaccination programs.

A model-based simulation of glycaemic control and body weight when switching from semaglutide to 3.0- and 4.5-mg doses of once-weekly dulaglutide

AIM

To evaluate HbA1c and body weight changes when semaglutide 0.5- or 1.0-mg once-weekly (QW) is switched to dulaglutide 3.0- or 4.5-mg QW via exposure-response modelling.

METHODS

HbA1c and body weight time-course models were developed and validated with data from the SUSTAIN 1 to 10 trials for semaglutide and the AWARD-11 trial for dulaglutide. Simulations were conducted for HbA1c and body weight over 52 weeks. In the initial 26 weeks, semaglutide was initiated at 0.25-mg and titrated to 0.5- or 1.0-mg QW via 4-weekly stepwise titration, followed by 26 weeks of dulaglutide initiated at 0.75- or 1.5-mg QW and escalated to 3.0- or 4.5-mg QW via 4-weekly stepwise titration.

RESULTS

At 26 weeks, model-predicted mean changes from baseline in HbA1c and weight for semaglutide 0.5 mg were up to -1.55% and -3.44 kg, respectively. After switching to dulaglutide 3.0 mg, further reductions were 0.19% and 1.40 kg, respectively, at 52 weeks. Predicted mean HbA1c and weight changes for semaglutide 1.0 mg at 26 weeks were -1.84% and -4.96 kg, respectively; after switching to dulaglutide 4.5 mg, HbA1c was maintained with additional weight reduction of up to 0.57 kg at 52 weeks. Glycaemic control was preserved when switching from semaglutide 1.0 mg to dulaglutide 3.0 mg.

CONCLUSION

Switching from semaglutide 0.5 mg to dulaglutide 3.0 or 4.5 mg with dose escalation potentially yields additional HbA1c and weight reductions; switching from semaglutide 1.0 mg to dulaglutide 4.5 mg may enhance weight loss.

Neural Unsupervised Semantic Role Labeling

The task of semantic role labeling ( SRL ) is dedicated to finding the predicate-argument structure. Previous works on SRL are mostly supervised and do not consider the difficulty in labeling each example which can be very expensive and time-consuming. In this article, we present the first neural unsupervised model for SRL. To decompose the task as two argument related subtasks, identification and clustering, we propose a pipeline that correspondingly consists of two neural modules. First, we train a neural model on two syntax-aware statistically developed rules. The neural model gets the relevance signal for each token in a sentence, to feed into a BiLSTM, and then an adversarial layer for noise-adding and classifying simultaneously, thus enabling the model to learn the semantic structure of a sentence. Then we propose another neural model for argument role clustering, which is done through clustering the learned argument embeddings biased toward their dependency relations. Experiments on the CoNLL-2009 English dataset demonstrate that our model outperforms the previous state-of-the-art baseline in terms of non-neural models for argument identification and classification.

Predictors of Severe COVID-19 in Patients With Diabetes: A Multicenter Review

OBJECTIVE

Diabetes is an independent risk factor for severe SARS-CoV-2 infections. This study aims to elucidate the risk factors predictive of more severe outcomes in patients with diabetes by comparing the clinical characteristics of those requiring inpatient admissions with those who remain outpatient.

METHODS

A retrospective review identified 832 patients-631 inpatients and 201 outpatients-with diabetes and a positive SARS-CoV-2 test result between March 1 and June 15, 2020. Comparisons between the outpatient and inpatient cohorts were conducted to identify risk factors associated with severity of disease determined by admission rate and mortality. Previous dipeptidyl peptidase 4 inhibitor use and disease outcomes were analyzed.

RESULTS

Risk factors for increased admission included older age (odds ratio [OR], 1.04 [95% CI, 1.01-1.06]; P = .003), the presence of chronic kidney disease (OR, 2.32 [1.26-4.28]; P = .007), and a higher hemoglobin A1c at the time of admission (OR, 1.25 [1.12-1.39]; P < .001). Lower admission rates were seen in those with commercial insurance. Increased mortality was seen in individuals with older age (OR, 1.09 [1.07-1.11]; P < .001), higher body mass index number (OR, 1.04 [1.01-1.07]; P = .003), and higher hemoglobin A1c value at the time of diagnosis of COVID-19 (OR, 1.12 [1.01-1.24]; P = .028) and patients requiring hospitalization. Lower mortality was seen in those with hyperlipidemia. Dipeptidyl peptidase 4 inhibitor use prior to COVID-19 infection was not associated with a decreased hospitalization rate.

CONCLUSION

This retrospective review offers the first analysis of outpatient predictors for admission rate and mortality of COVID-19 in patients with diabetes.

Accuracy of Dexcom G6 Continuous Glucose Monitoring in Non-Critically Ill Hospitalized Patients With Diabetes

OBJECTIVE

Advances in continuous glucose monitoring (CGM) have transformed ambulatory diabetes management. Until recently, inpatient use of CGM has remained investigational, with limited data on its accuracy in the hospital setting.

RESEARCH DESIGN AND METHODS

To analyze the accuracy of Dexcom G6, we compared retrospective matched-pair CGM and capillary point-of-care (POC) glucose data from three inpatient CGM studies (two interventional and one observational) in general medicine and surgery patients with diabetes treated with insulin. Analysis of accuracy metrics included mean absolute relative difference (MARD), median absolute relative difference (ARD), and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of POC reference values for blood glucose >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses.

RESULTS

A total of 218 patients were included (96% with type 2 diabetes) with a mean age of 60.6 ± 12 years. The overall MARD (n = 4,067 matched glucose pairs) was 12.8%, and median ARD was 10.1% (interquartile range 4.6, 17.6]. The proportions of readings meeting % 15/15, % 20/20, and % 30/30 criteria were 68.7, 81.7, and 93.8%, respectively. CEG analysis showed 98.7% of all values in zones A and B. MARD and median ARD were higher in the case of hypoglycemia (<70 mg/dL) and severe anemia (hemoglobin <7 g/dL).

CONCLUSIONS

Our results indicate that CGM technology is a reliable tool for hospital use and may help improve glucose monitoring in non-critically ill hospitalized patients with diabetes.

Malignancy Risk in 18F-FDG-Avid Thyroid Incidentalomas: Controversies and Limitations

Introduction: The prevalence of malignancy in thyroid incidentalomas (TI) discovered on ¹⁸F-FDG-PET or PET/CT varies between 0% and 63.6%. The pooled malignancy rate according to three systematic reviews is 33-35%. The 2015 American Thyroid Association (ATA) guidelines recommend that such nodules, when one centimeter or larger in size, should undergo further investigation with thyroid ultrasound (US) and fine-needle aspiration (FNA) cytology. Objectives: The objective of our study was to determine the rate of malignancy amongst TI discovered incidentally on ¹⁸F-FDG-PET or PET/CT, examine their clinicopathologic characteristics, and assess the usefulness of maximum standardized uptake values (SUV_max) in differentiating benign and malignant lesions. Methods: We performed an electronic medical record search looking at all ¹⁸F-FDG-PET or PET/CT reports during the study period of 12/01/2015 to 05/31/2019 that included the keyword ‘thyroid’ in the impression. Exclusion criteria included a history of thyroid disease or malignancy, known lesion(s) detected on previous clinical or radiological examinations and diffuse radiotracer uptake. Of the 476 reports reviewed, 136 cases were included in the study. Results: Common indications included initial staging or restaging of lymphoma (diffuse large B-cell, mantle-cell, T-cell types) (27.9%), lung adenocarcinoma (18.4%), head and neck cancer (16.9%) and breast cancer (11%). Fifty-eight (42.6%) patients had metabolically inactive lesions; five (8.6%) underwent further investigation with thyroid US and 3 subsequently with FNA (5%). All 3 had benign cytology. Seventy-seven (56.6%) patients had metabolically active lesions and 25 (32.5%) underwent imaging with thyroid US. Twelve (15.6%) had FNA; eight (66.7%) had benign cytology, two (16.7%) revealed atypia of undetermined significance and two (16.7%) were malignant. Biopsy for the two patients with malignant cytology showed follicular cell neoplasm of oncocytic hurtle cell type, and invasive follicular carcinoma with focal insular and papillary features and extensive capsular and vascular invasion. The mean SUV_max in malignant vs benign lesions was 9.05 and 6.41 respectively. Conclusion: The malignancy rate was 2.6% amongst all patients with ¹⁸F-FDG-avid TI and 8% amongst patients with metabolically active lesions who were investigated with thyroid US+/- FNA. This is significantly lower than malignancy rates previously reported in the literature. The evident inhomogeneity in the literature is likely multifactorial and may be explained in part by a dissimilarity among studies, and an informed decision by some to avoid invasive testing in the context of poor prognosis from underlying non-thyroidal cancer. Research is needed to determine the cohort of patients who could potentially benefit from further evaluation and treatment.

Emotional and behavioral problems of 7-11 year old children in war-torn nagorno – karabakh region in azerbaijan

Introduction

The present aimed to examine the mental health conditions of children, ages 7-11 years, living in conditions of war and conflict conditions in two districts of a Nagorno-Karabakh, Azerbaijan.

Objectives

The study surveyed teachers of 617 primary school children (mean age 8.9, SD 1.24; 50.7% female) across nine schools in Agdam and Karabakh districts.

Methods

The children were evaluated with the previously validated Azerbaijani version of the Strengths and Difficulties Questionnaire (SDQ) Teacher Form. The total difficulty and five subscale scores (emotional problems, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior) were assessed.

Results

About a third of children (32.7%) had abnormal total scores, and a fifth (21.4%) were in borderline range. The SDQ subscale scores included emotional problems (19.4%); conduct problems (20.3%), hyperactivity/inattention (12.2%), peer relationship problems (31.1%), and pro-social behavior difficulties (13.1%). Boys had higher level of difficulties than females (p<.01) with a negative correlation of children’s school performance with maternal education.

Conclusions

The findings of the study show that more than half of the children living in the war zone in Azerbaijan have significant mental health problems. The psychological effects of the war environments have a profund effect on child development and education and need to be revisited under the United Nations Sustainable Development Goals. These include the provision of implicit supports in terms of their emotional, behavioral, psychosocial development and education of children and protection of children from wars, conflicts, and persecution.

Disclosure

No significant relationships.

Knowledge of Hemoglobin A1c and Glycemic Control in an Urban Population

AIM

Our study aims to assess the knowledge of hemoglobin A1c (HbA1c) and glycemic control in patients with diabetes mellitus (DM) at an urban academic institution.

METHODS

This was a retrospective cross-sectional study that included a survey of 100 adult patients with DM. Our patient cohort was divided into those with recent HbA1c < 8.0% and those with HbA1c ≥ 8.0% for subgroup analysis.

RESULTS

The majority (71%) of patients correctly defined HbA1c and half were aware of their HbA1c target, but they were unable to correlate the correct average blood glucose for an HbA1c level of 7%. Worse control, defined as an HbA1c level of ≥ 8%, was associated with co-morbid disease, but was not associated with understanding HbA1c definition, target or socioeconomic disparities. Perceived glycemic control was congruent with the actual control in 46% of our patients. Ninety percent of those with HbA1c ≥ 8% perceived their control to be better than it actually was, and 97% of those with HbA1c < 8% perceived their control worse than it actually was (P < 0.00001).

CONCLUSION

Although most patients knew the definition of HbA1c, they were unable to correlate HbA1c with average blood sugar. There remain opportunities to increase education for this vulnerable population with co-morbid disease on the use of the HbA1c disease marker as an education tool.

Metformin and Androgen Receptor-Axis-Targeted (ARAT) Agents Induce Two PARP-1-Dependent Cell Death Pathways in Androgen-Sensitive Human Prostate Cancer Cells

We explored whether the anti-prostate cancer (PC) activity of the androgen receptor-axis-targeted agents (ARATs) abiraterone and enzalutamide is enhanced by metformin. Using complementary biological and molecular approaches, we determined the associated underlying mechanisms in pre-clinical androgen-sensitive PC models. ARATs increased androgren receptors (ARs) in LNCaP and AR/ARv7 (AR variant) in VCaP cells, inhibited cell proliferation in both, and induced poly(ADP-ribose) polymerase-1 (PARP-1) cleavage and death in VCaP but not LNCaP cells. Metformin decreased AR and ARv7 expression and induced cleaved PARP-1-associated death in both cell lines. Metformin with abiraterone or enzalutamide decreased AR and ARv7 expression showed greater inhibition of cell proliferation and greater induction of cell death than single agent treatments. Combination treatments led to increased cleaved PARP-1 and enhanced PARP-1 activity manifested by increases in poly(ADP-ribose) (PAR) and nuclear accumulation of apoptosis inducing factor (AIF). Enhanced annexin V staining occurred in LNCaP cells only with metformin/ARAT combinations, but no caspase 3 recruitment occurred in either cell line. Finally, metformin and metformin/ARAT combinations increased lysosomal permeability resulting in cathepsin G-mediated PARP-1 cleavage and cell death. In conclusion, metformin enhances the efficacy of abiraterone and enzalutamide via two PARP-1-dependent, caspase 3-independent pathways, providing a rationale to evaluate these combinations in castration-sensitive PC.

Cardiovascular outcomes trials with glucagon-like peptide-1 receptor agonists: A comparison of study designs, populations and results

Despite treatment advances leading to improved outcomes over the past 2 decades, cardiovascular (CV) disease (CVD) remains the leading cause of morbidity and mortality in people with diabetes. People with type 2 diabetes (T2D) have a 2- to 4-fold increased risk of CVD and CV death. Individuals with T2D have not seen the same improvements in CV morbidity and mortality as those without T2D. Given this, it is important to understand the CV impact of drugs used to treat T2D. In patients with T2D, glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have shown a reduction in HbA1c and body weight regardless of their differences in chemical structure and pharmacokinetic variables. Glycaemic efficacy, accompanied by the potential for weight reduction and a low risk of hypoglycaemia, has moved GLP-1 RAs to the first treatment of choice following metformin monotherapy in the latest American Diabetes Association treatment guidelines. Additionally, all GLP-1 RAs have shown CV safety and several have proven CV benefit. GLP-1 RAs have been evaluated in cardiovascular outcomes trials (CVOTs) of varying sizes, designs and patient populations with differing reported effects on CV outcomes. The purpose of this article is to review the completed GLP-1 RA CVOTs with special attention to how their design, size, patient populations and conduct may influence the interpretation of results.

Avascular Necrosis of Both Hips From Iatrogenic Cushing 's Syndrome due to Coadministration of Fluticasone and Ritonavir in an HIV-Infected Patient

We report a case of avascular necrosis (AVN), hypercalcemia, and iatrogenic Cushing’s syndrome in an HIV-positive patient taking inhaled (ICS) and nasal corticosteroids fluticasone and ritonavir.

A 45-year-old HIV-infected African-American woman was seen for initial evaluation for multinodular goiter in December 2015. Relevant medications were ritonavir, raltegravir, darunavir, fluticasone propionate HFA, and nasal fluticasone propionate. Physical examination revealed classical cushingoid appearance but laboratory testing showed abnormal adrenocorticotropic hormone (ACTH) stimulation test. A diagnosis of iatrogenic Cushing’s syndrome due to inhibition of fluticasone metabolism from protease inhibitor (PI) therapy with secondary adrenal suppression was made. Fluticasone nasal spray and HFA were discontinued and hydrocortisone replacement dose was initiated. The patient’s Cushing’s related symptoms improved over several months. Follow-up evaluation showed non-parathyroid hormone-mediated hypercalcemia. A detailed laboratory evaluation looking for the etiology for hypercalcemia was unremarkable except for an elevated urine N-telopeptide/creatinine ratio. Meanwhile, the patient developed a new symptom of hip pain. MRI of both hips showed bilateral AVN. Sickle cell screen was negative and a right hip replacement was completed in May 2017.

Since this is the fourth case report of AVN from iatrogenic Cushing’s syndrome in an HIV-infected patient taking a PI and ICS concomitantly, there is more likely a causal relationship and not simply a coincidental finding. Extreme caution should be used when considering any ICS therapy in combination with PIs in HIV-infected patients.

Asymmetric impact of energy consumption on environmental degradation: evidence from Australia, China, and USA

The goal of this study is to examine the asymmetric impact of disaggregate energy consumption, i.e., oil, gas, coal, and electricity consumption on environmental degradation in Australia, China, and USA. The study uses annual time series data of three courtiers, i.e., Australia, China, and USA from 1975 to 2018 and applies nonlinear ARDL (NARDL) model to examine the long run and short run relationship. Results show that an increase in oil and coal consumption in Australia; oil, gas, and electricity consumption in China; and oil, coal, and gas consumption in USA leads to increase in the carbon dioxide emissions in the long run. However, a decrease in oil, gas, and electricity consumption in Australia; oil and electricity consumption in China; and coal, gas, and electricity consumption in USA reduces carbon dioxide emissions in the long run. Research and development centers are required to control pollution through new technologies, while to reduce emissions use renewable energy resources as a source of energy.

Efficacy of Dulaglutide as a First Injectable Option for Patients with Type 2 Diabetes: A Post-Hoc Pooled Analysis

INTRODUCTION

The ADA-EASD consensus report recommends using glucagon-like peptide-1 receptor agonists (GLP-1RAs) as the first injectable therapy prior to basal insulin in most patients with type 2 diabetes (T2D) not at glycemic goals after oral anti-hyperglycemia medications (OH). The objective of this analysis was to assess the glycemic efficacy of once-weekly dulaglutide 1.5 mg in patients with T2D when added on a background of commonly used OH regimens.

METHODS

Patients from seven phase 3 AWARD [Assessment of Weekly AdministRation of LY2189265 (Dulaglutide) in Diabetes] trials, where once-weekly dulaglutide 1.5 mg was added to OHs, were pooled into the following categories based on OH regimens: metformin (MET), sulfonylurea (SU), MET + SU, MET + pioglitazone, and MET + SGLT2i. Change from baseline in glycated hemoglobin A1c (HbA1c), fasting serum glucose and body weight, proportion of patients reaching target HbA1c < 7%, and safety parameters were assessed.

RESULTS

A total of 1784 patients treated with once-weekly dulaglutide 1.5 mg were included in this analysis. Baseline characteristics of the overall population were (mean ± standard deviation): age, 55.4 ± 9.8 years, HbA1c: 8.2 ± 1.0%, body mass index: 31.4 ± 5.4 kg/m2, duration of diabetes: 8.0 ± 5.6 years, and 878 (49.2%) were female. At 6 months, the addition of once-weekly dulaglutide 1.5 mg to various OH regimens significantly reduced HbA1c (- 1.3 to - 1.6%) and fasting blood glucose (- 29 to - 45 mg/dl) from baseline in all groups (p < 0.001), with 39-61% and 52-76% of these patients achieving HbA1c targets of ≤ 6.5% and < 7%, respectively. Significant reductions in body weight (- 0.8 to - 2.9 kg) were also observed in all groups (p < 0.001). Nausea, vomiting, and diarrhea were reported by 10-35%, 4-19%, and 6-28% of patients, respectively. Severe hypoglycemia occurred in one patient (MET + SU).

CONCLUSION

The addition of a once-weekly GLP-1RA, dulaglutide, demonstrated clinically meaningful HbA1c reduction in patients with T2D on different background OH regimens, making it an effective first injectable option.

FUNDING

Eli Lilly and Company.

Energy consumption and environmental quality in South Asia: evidence from panel non-linear ARDL

The objective of this study is to estimate the non-linear effect of energy consumption i.e. oil, gas, electricity, and coal consumption on CO₂ emission in South Asian countries. The study uses annual panel data of three South Asian countries i.e. Bangladesh, India, and Pakistan from 1985 to 2017 and applies panel non-linear ARDL methodology to examine the long-run and short-run relationship. Results show that an increase in gas, electricity, coal, and electricity consumption leads to an increase in the carbon dioxide emission, whereas decrease in electricity and coal consumption reduces the carbon dioxide emissions in the long run. Non-linear relationship exists between electricity consumption and CO₂ emissions as well as between coal consumption and CO₂ emissions in South Asian countries in the long run. Results of short run dynamics of individual countries show that non-linear relationship exists between oil consumption and CO₂ emissions, electricity consumption and CO₂ emissions, and coal consumption and CO₂ emissions in Bangladesh and Pakistan. Research and development centers are required to control pollution through new technologies, while discourage to use higher electricity and coal consumption as a source of energy for a healthier environment.

Cadmium uptake by onions, lettuce and spinach in New Zealand: Implications for management to meet regulatory limits

Paired soil and plant samples collected from the main commercial growing areas for onions (Allium cepa), lettuce (Lactuca sativa) and spinach (Spinacia olearacea) in New Zealand were used to assess the influence of plant and soil factors on cadmium (Cd) uptake in these crops. Differences in Cd concentration between eight lettuce sub-types were not consistent across sites, nor were differences in Cd concentrations in three crisphead cultivars assessed at two sites. Similarly, differences in Cd concentrations between four onion cultivars were inconsistent across sites. Mean lettuce Cd concentrations in eight lettuce varieties (range 0.005-0.034 mg∙kg-1 (fresh weight, FW) were markedly lower than those in baby leaf and bunching spinach, (range 0.005-0.19 mg∙kg-1 FW). Significant regional variation was observed in Cd concentrations in one onion cultivar (mean range 0.007-0.05 mg∙kg-1 FW). Soil Cd concentration, pH and region were statistically significant predictors of onion Cd concentration, explaining low (38% for soil Cd and pH) to moderate (50% for all three parameters) percentage of the variation. Soil Cd concentration and exchangeable magnesium or total carbon were statistically significant predictors of Cd concentration in baby leaf and bunching spinach, respectively, explaining a moderate percentage (49% and 42%) of the variation in Cd concentration. Increasing pH and soil carbon may assist in minimising Cd uptake in onion and bunching spinach, respectively. The low to moderate proportion of explained variation is partly attributable to the narrow range in some measured soil properties and indicates factors other than those assessed are influencing plant uptake. This highlights a challenge in using these relationships to develop risk-based soil guideline values to support compliance with food standards. Similarly, the inconsistency in Cd concentrations in different cultivars across sites highlights the need for multi-site assessments to confirm the low Cd accumulation status of different cultivars.

MON-622 Can Calcitonin Replacement Improve Quality of Life in Hypothyroid Patients?

Background: Hypothyroidism is one of the most common endocrine hormone deficiencies and is associated with symptoms of cold intolerance, fatigue and weight gain. Many patients with a history of hypothyroidism continue to report persistent symptoms despite treatment with hormone replacement and normalization of Thyroid Stimulating Hormone (TSH) levels. Saravanan et al., reported that approximately 15% of the population studied reported fatigue or psychological symptoms on L-thyroxine even with normal TSH levels. This can prove challenging for physicians as there are few available options for adjunctive therapy for patients reporting significant symptoms that negatively impact their quality of life. Primary hypothyroidism is a common cause of hypothyroidism and is characterized by thyroid gland dysfunction due to radioactive ablation, surgical removal, or autoimmune Hashimoto’s thyroiditis. This dysfunction also impacts calcitonin production in the parafollicular C cells. Calcitonin treatment for persistent symptoms of hypothyroidism despite euthyroidism on replacement hormone has not been studied. However, the use of calcitonin has shown improvements in QoL in patients with osteoporosis and osteoarthritis (Shohrati et al, 2015; Esenyel et al, 2013). We proposed a pilot study in treating subjects with ongoing psychologic or metabolic symptoms and euthyroidism on thyroid hormone replacement with calcitonin. Methods: Subjects with symptomatic hypothyroidism were recruited for the study. Any patient between the age of 18-89, on levothyroxine treatment with normal TSH levels in the past 3 months qualified. Those who were considering pregnancy or had a history of PPI use, smoking, hypocalcemia, glucocorticoid use, congenital hypothyroidism, pituitary disease or thyroid cancer were excluded. Study participants filled out a Modified City of Hope Quality of Life (QoL) questionnaire that included questions about social concerns, physical health and physical well-being rated on a 10 point scale. Preliminary laboratory evaluation included calcitonin, Parathyroid Hormone panel, Phosphorus, TSH, Free T4 and Total T3. Participants were then instructed to use calcitonin nasal spray 200 International Units (IU) daily for 6 weeks. At the conclusion of the study, subjects were asked to fill out the same questionnaire to assess change in QoL. Results: We have undertaken a study to evaluate the effects of calcitonin treatment on subjects with hypothyroidism and suboptimal QoL despite thyroid hormone replacement and normal TSH.

Polyherbal dietary supplementation for prediabetic adults: study protocol for a randomized controlled trial

Background

Prediabetes describes a state of hyperglycemia outside of normal limits that does not meet the criteria for diabetes diagnosis, is generally symptomless, and affects an estimated 38% of adults in the United States. Prediabetes typically precedes the diagnosis of type 2 diabetes, which accounts for increased morbidity and mortality. Although the use of dietary and herbal supplements is popular worldwide, and a variety of single herbal medicines have been examined for glycemic management, the potential of increasingly common polyherbal formulations to return glycemic parameters to normal ranges among adults with prediabetes remains largely unexplored. The purpose of this study is to evaluate the efficacy of a commercially available, polyherbal dietary supplement on glycemic and lipid parameters in prediabetic individuals.

Methods

In this multi-site, double-blinded, randomized controlled clinical trial, 40 participants with prediabetes will be randomized to either a daily oral polyherbal dietary supplement (GlucoSupreme™ Herbal; Designs for Health®, Suffield, CT, USA; containing cinnamon bark (Cinnamomum cassia), banaba leaf (Lagerstroemia speciosa standardized to 1% corosolic acid), kudzu root (Pueraria lobata standardized to 40% isoflavones), fenugreek seed (Trigonella foenum-graceum standardized to 60% saponins), gymnema leaf (Gymnema sylvestre standardized to 25% gymnemic acid), American ginseng root (Panax quinquefolius standardized to 5% ginsenosides), and berberine HCl derived from bark (Berberis aristata)) or placebo for 12 weeks. Short-, medium-, and comparatively long-term markers of glycemic control (blood glucose and fasting insulin, fructosamine, and glycated hemoglobin/A1c, respectively), and other glycemic parameters (GlycoMark, β-cell function, and insulin sensitivity/resistance) will be obtained. Lipid profile (total cholesterol, LDL, HDL, and triglycerides), inflammation (hs-CRP), progression to type 2 diabetes mellitus, as well as safety indices (ALT, AST) will be obtained. An intention-to-treat analysis will be used to assess changes in study outcomes.

Discussion

Treatment options for adults with prediabetes are currently limited. This study aims to evaluate the safety and efficacy of a commercially available dietary supplement in the popular, but as yet insufficiently studied, category of polyherbal formulas for the management of glycemic parameters and other biomarkers associated with prediabetes.

Trial registration

ClinicalTrials.gov, ID: NCT03388762. Retrospectively registered on 4 January 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3032-6) contains supplementary material, which is available to authorized users.

Challenging behaviours at early adulthood in autism spectrum disorders: topography, risk factors and evolution

BACKGROUND

Challenging behaviours are highly prevalent in children and adolescents with autism spectrum disorders (ASD), but little is known about the prevalence and course of these behaviours during adulthood. The aims of this study were to describe the topography of challenging behaviours in a cohort of 106 young adults with ASD and to identify the risk factors for challenging behaviours. Our secondary objective was to study the changes in challenging behaviours from adolescence to early adult years.

METHOD

The present study uses data from the EpiTED prospective follow-up study in France. The presence of challenging behaviours was assessed by the Aberrant Behaviour Checklist (ABC) completed by parent informants. Several dimensions of behaviour were studied: irritability, stereotypy, lethargy, hyperactivity and self-injury. Clinical variables were collected on ASD symptom severity, cognitive and language levels, adaptive behaviours and comorbid medical disorders.

RESULTS

The presence of challenging behaviours at early adulthood was related to the young adult's cognitive and language level, ASD symptom severity and comorbid gastrointestinal and sleep disorders. The main risk factor for challenging behaviours was ASD symptom severity. The level of language impairment was a significant predictor of self-injury. Gastrointestinal disorders were a significant predictor of stereotypy. The change in behaviour topography from adolescence to early adult years corresponded with decreased parent report of hyperactivity, but no significant decrease in parent reports of irritability, stereotypy, lethargy and self-injurious behaviours.

CONCLUSIONS

The challenging behaviours in individuals with ASD persist in early adulthood and are related to core symptom severity, levels of cognitive and language impairments and medical comorbidity. The results emphasise the importance of early interventions for children with ASD to target cognitive and language abilities and to alleviate the severity of ASD symptoms. They also underscore the need to enhance opportunities for individuals with ASD to better communicate discomforts and pain in the context of medical illness.

[Anxiety in women undergoing surgical treatment of breast cancer]

AIM

To assess anxiety level and factors contributing to its development in patients undergoing surgical treatment for breast cancer.

MATERIAL AND METHODS

The subjects of the study were 72 women, aged 20-80 years, with the diagnosis of primary breast cancer. The Basic Psycho-Oncological Documentation Scale (PO-BADO), the European Organization for Research, and the Treatment of Cancer Quality of Life Questionnaire and its Breast Cancer Module (EORTC QLQ-C30; BR-23), the Hospital Anxiety and Depression Scale (HADS) were used.

RESULTS AND CONCLUSION

The anxiety score showed negative correlation with EORTC QLQ-C30 'physical functioning', 'cognitive functioning', 'emotional functioning', 'global health status/quality of life' subscales (p≤0,002). Anxiety is a highly prevalent in women with breast cancer and has a marked negative impact, in particular on younger patients.

Abstract P1-10-08: Factors affecting the administration of post-mastectomy radiation therapy (PMRT) in Michigan

Background: Evidence-based guidelines for locoregional therapy of invasive breast cancer treated with mastectomy include adjuvant PMRT for: ≥4 positive axillary lymph nodes (LN); T3 or above; or a positive surgical margin. We assessed PMRT uptake using data from the Michigan Breast Oncology Quality Initiative (MiBOQI), a Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored collaborative quality initiative, and identified factors influencing its use in Michigan.

Methods: We prospectively collected clinical data on all patients with stage I-III breast cancer in 25 health systems belonging to MiBOQI and identified patients who underwent mastectomy from 2008 to 2013. Patients with previous cancer, bilateral disease, or treated with neoadjuvant chemotherapy were excluded. Univariate and multivariate analyses were performed to identify independent factors associated with the use of PMRT in patients with 0, 1-3, and 4+ positive LNs. Covariates included age, hormone receptor status, HER2 status, surgical margin, T category, Charlson comorbidity index, and immediate reconstruction. Two-tailed p-values &lt;0.05 were considered significant. Analyses were carried out using SAS software, version 9.4 (SAS Institute, Cary, NC).

Results: We identified 6,596 patients with stage I-III invasive breast cancer. Of these, 4,455 had no positive axillary LNs; 1,481, 1-3 positive LNs; and 660, ≥4 positive LNs. There was wide variation in PMRT use across MiBOQI sites, from 13% to 63.% in patients with 1-3 positive LNs (overall 42%) and from 35% to 91% in patients with 4+ positive LNs (overall 69%). In multivariate analyses stratified by nodal status (0, 1-3, 4+), age ≥ 70 yrs was negatively associated with PMRT. We also noted lower PMRT use in women aged 51-69 with 0 and 1-3 positive LNs (Table 1).

Table 1. Multivariate analysis: PMRT and age (+)LNs = 0(+)LNs = 1-3(+)LNs ≥ 4AgeOdds ratiop-valueOdds ratiop-valueOdds ratiop-value≤50 y (reference)1.0 1.0 1.0 51-69 y0.70 (0.49 - 0.98)0.030.69 (0.54 - 0.88)&lt;0.00011.03 (0.63 - 1.65)&lt;0.0001≥70 y0.60 (0.37 - 0.96) 0.26 (0.18 - 0.37) 0.31 (0.18 - 0.54) 

In the 0 and 1-3 positive node groups, PMRT use was strongly associated with T category and close or positive margin status (Table 2).

Table 2: Surgical characteristics and PMRT uptake (+)LNs = 0(+)LNs = 1-3(+)LNs ≥4VARIABLEOdds ratiop-valueOdds ratiop-valueOdds ratiop-valueMargin status      Negative (reference)1.0 1.0 1.0 Positive16.7 (10.5 - 26.7)&lt;0.00012.27 (1.32 - 3.90)0.0010.69 (0.32 - 1.47)0.90Close (&lt;1 mm)4.63 (3.03 - 7.10) 1.90 (1.29 - 2.80) 0.97 (0.55 - 1.69)        T category      T0 to T2 (reference)1.0 1.0 1.0 T3 to T426.2 (16.4 - 41.8)&lt;0.00013.24 (2.19 - 4.78)&lt;0.00010.86 (0.57 - 1.28)0.45

Finally, there was no association between PMRT use and hormone receptor status, HER2 status, Charlson comorbidity index, or reconstructive surgery at the time of mastectomy.

Conclusions: PMRT use across Michigan was lower than the American College of Surgeons Commission on Cancer target of 90% in patients with 4 or more positive LNs. Contrary to common belief, immediate reconstructive surgery was not independently associated with decreased PMRT uptake. Understanding reasons for nonuse of PMRT may lead to interventions to increase its use by MiBOQI member institutions in patients for whom it is indicated.

Citation Format: Gorski DH, Braun T, Munir K, Griggs JJ, Breslin TM, Henry NL. Factors affecting the administration of post-mastectomy radiation therapy (PMRT) in Michigan [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-10-08.

Abstract P5-08-07: Appropriate use of the 21-gene recurrence score (RS) assay across Michigan

Background: The 21-gene RS assay is used to assess prognosis and to predict response to adjuvant chemotherapy in patients with early stage hormone receptor positive, Her2 negative invasive breast cancer. The National Comprehensive Cancer Network (NCCN) first recommended consideration of testing of appropriate patients with the RS assay in 2008. We examined trends in the use of testing with the RS assay in hospitals across Michigan from 2006 through 2013 using data from the Michigan Breast Oncology Quality Initiative (MiBOQI), a Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored quality initiative.

Methods: Demographic, pathologic, and treatment data for women with breast cancer treated at all 25 hospitals participating in MiBOQI were abstracted from the medical record. Patients were excluded if they had stage 0 or IV disease at diagnosis, received neoadjuvant therapy, had bilateral breast cancer, or had a prior history of breast cancer. The primary outcome was the percentage of patients eligible for testing according to NCCN criteria (version 2010) who underwent testing with the RS assay. Analyses were performed using the statistical software R, Version 3.0.1.

Results: Of the 18,046 patients in the MiBOQI Registry from 2006-2013 who met inclusion and exclusion criteria, 7133 (39.5%) met the NCCN criteria for testing (eligible). The rate of testing increased from 2006 to 2013 in both the eligible and ineligible cohorts, and varied by site.

21-Gene Recurrence Score (RS) Testing in MiBOQI, 2006-2013FactorEligible (n=7133)Ineligible (n=10913)Tested with RS assay3920 (55.5%)1424 (13.0%)Testing rate in 200643.8%7.3%Testing rate in 201362.3%19.6%Testing by site, 2006-2013 (range)35.8% - 73.3%6.8% - 26.2%

Testing of the eligible cohort was statistically significantly associated with younger age, lower tumor grade, and lack of nodal involvement. Overall, 73.4% of patients whose tumors were tested with the RS assay met the NCCN criteria for testing and were deemed appropriately tested. This rate of appropriate testing ranged from 60.8% to 85.4% across sites. Of all patients who underwent testing, 498 (9.3%) had 1 or more positive lymph nodes (&gt;0.2 cm). Receipt of chemotherapy was lower in eligible patients who were tested compared to those not tested (25.5% vs 29.9%, p&lt;0.001). Of the 2387 eligible patients with RS &lt; 18, 117 (5.5%) received chemotherapy, which ranged from 0% - 13.6% across the 25 sites. Of the 341 patients with RS &gt; 30, 56 (9.8%) did not receive treatment with chemotherapy, which ranged from 0% - 50% across the sites. Of the 1192 patients with RS 18-30, 502 (45.7%) received chemotherapy, ranging from 14.5% for RS 18 to 72.5% for RS 30.

Conclusions: In sites across Michigan the majority of patients whose tumors were tested with the RS assay were in accordance with the NCCN guidelines, although there was considerable variability across sites. The rate of testing for patients who do not meet the NCCN criteria is increasing. There is very low inappropriate use of the recurrence score for making chemotherapy treatment decisions.

Citation Format: Ali HY, Munir K, Braun T, Griggs JJ, Silver SM, Gorski DH, Breslin TM, Henry NL. Appropriate use of the 21-gene recurrence score (RS) assay across Michigan. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-07.

Vascular and metabolic actions of the green tea polyphenol epigallocatechin gallate

Epidemiological studies demonstrate robust correlations between green tea consumption and reduced risk of type 2 diabetes and its cardiovascular complications. However, underlying molecular, cellular, and physiological mechanisms remain incompletely understood. Health promoting actions of green tea are often attributed to epigallocatechin gallate (EGCG), the most abundant polyphenol in green tea. Insulin resistance and endothelial dysfunction play key roles in the pathogenesis of type 2 diabetes and its cardiovascular complications. Metabolic insulin resistance results from impaired insulin-mediated glucose disposal in skeletal muscle and adipose tissue, and blunted insulin-mediated suppression of hepatic glucose output that is often associated with endothelial/vascular dysfunction. This endothelial dysfunction is itself caused, in part, by impaired insulin signaling in vascular endothelium resulting in reduced insulin-stimulated production of NO in arteries, and arterioles that regulate nutritive capillaries. In this review, we discuss the considerable body of literature supporting insulin-mimetic actions of EGCG that oppose endothelial dysfunction and ameliorate metabolic insulin resistance in skeletal muscle and liver. We conclude that EGCG is a promising therapeutic to combat cardiovascular complications associated with the metabolic diseases characterized by reciprocal relationships between insulin resistance and endothelial dysfunction that include obesity, metabolic syndrome and type 2 diabetes. There is a strong rationale for well-powered randomized placebo controlled intervention trials to be carried out in insulin resistant and diabetic populations.

Effects of polyether ionophores on the protective immune responses of broiler chickens against Angara disease and Newcastle disease viruses

Immunization against Angara disease virus (ADV), a serotype 4 avian adenovirus, and Newcastle disease virus (NDV), an avian paramyxovirus serotype 1, is the mainstay of a broiler vaccination programme, while polyether ionophores usually form an essential component of a broiler medication programme in most parts of India and Pakistan. The role of polyether ionophores in the protective immune responses of broiler chickens vaccinated and challenged with ADV and NDV was investigated. A total of 1600 birds were divided into eight groups of 200 birds each. First four groups were vaccinated against NDV and ADV, while the remaining four served as unvaccinated controls. The first 3 groups of birds were administered salinomycin, monensin and cyclophosphamide (CYP), respectively. The last group served as an untreated control. The same treatment schedule was also followed for the next four unvaccinated groups. The post-vaccination and post-challenge serological responses to NDV and ADV, body and lymphoid organ weight gains, post-challenge survival rate and detection of NDV and ADV in the tissues of infected birds were evaluated. Birds administered salinomycin showed a significant stimulation of protective immune responses against both NDV and ADV as compared to the untreated and CYP-treated birds. Monensin also enhanced the protective immune responses against both viruses but the effect was not statistically significant. Thus, it is concluded that monensin and salinomycin augment the anti-NDV and anti-ADV immune responses in broiler chickens, which supports their use in poultry flocks.

Two cases of thyroid storm-associated cholestatic jaundice

OBJECTIVE

To describe the association of the rare and serious complication of jaundice with severe thyrotoxicosis, a potentially lethal endocrine disorder.

METHODS

We report the clinical, laboratory, and pathologic findings of 2 cases of severe jaundice (total bilirubin levels: 35.2 mg/dL in case 1 and 42 mg/dL in case 2) associated with thyroid storm in the absence of a history of liver disease, thionamide exposure, or congestive heart failure. We also present other relevant reports available in the literature.

RESULTS

Case 1 was a 38-year-old woman who presented with nausea, vomiting, fatigue, pruritus, and frequent nonbloody diarrhea. She was transferred to our institution because of worsening hyperbilirubinemia. Case 2 was a 35-year-old woman admitted to a community hospital with thyroid storm and jaundice. Upon transfer to our institution, the patient was unconscious, mechanically ventilated, and in atrial fibrillation. In case 2, liver biopsy results revealed diffuse hepatocellular ballooning with intrahepatic cholestasis with mild portal lymphocytic infiltration. Both patients presented with severe cholestatic jaundice in the absence of congestive heart failure; underlying liver disease (infectious or autoimmune); or previous exposure to thionamides, other hepatotoxic agents, or complementary and alternative medications. In both cases, jaundice responded to therapy with antithyroid medications. Both patients eventually underwent thyroidectomy with complete resolution of the jaundice.

CONCLUSION

The data strongly suggest that in these patients, the hepatic dysfunction was primarily due to hyperthyroidism. These cases indicate that the mere presence of hyperbilirubinemia during severe thyrotoxicosis should not per se delay the use of potentially life-saving thionamides once a thorough evaluation for other causes of liver disease has been completed.

Transjugular intrahepatic cavoportal shunt for Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is characterized by obstruction of the hepatic venous outflow tract. Therapeutic options for BCS are limited. We report a case of a 21-year-old woman with protein S and C deficiency with gross ascites. Treatment with transjugular intrahepatic portosystemic shunt (TIPS) was attempted, which revealed occluded hepatic veins, so transcaval TIPS was performed. No serious procedure-related complication occurred. After successful shunt creation, the patient's symptoms subsided and she was discharged and followed up for 6 months.

Lack of clopidogrel-CYP3A4 statin interaction in patients with acute coronary syndrome

OBJECTIVE

To assess a clinically significant interaction between cytochrome P450 3A4 (CYP3A4) metabolised statin and clopidogrel.

DESIGN

Prospective single centre cohort study.

SETTING

Academic teaching hospital in the USA.

PATIENTS

1651 patients presenting with acute coronary syndromes between January 1999 and February 2003 were studied. Data on baseline demographics, co-morbidities, and in-hospital management were collected.

MAIN OUTCOME MEASURE

Association of CYP3A4 metabolised statin and clopidogrel use with in-hospital and six month mortality. The impact of the combined use of a CYP3A4 statin and clopidogrel on six month mortality and major adverse cardiac events was analysed by a risk adjusted logistic regression model.

RESULTS

The odds ratios for six month mortality were: for CYP3A4 statin, 0.43 (95% confidence interval (CI) 0.27 to 0.71, p = 0.0009); for CYP3A4 statin plus clopidogrel, 0.36 (95% CI 0.23 to 0.60, p < 0.001); for non-CYP3A4 statin, 0.22 (95% CI 0.08 to 0.59, p = 0.002); and for non-CYP3A4 statin plus clopidogrel, 0.22 (95% CI 0.06 to 0.75, p = 0.016).

CONCLUSIONS

Use of a combination of a CYP3A4 statin plus clopidogrel was associated with lower six month mortality and morbidity in patients with acute coronary syndromes. There was no significant difference in clinical benefit between a CYP3A4 statin and a non-CYP3A4 statin when used in conjunction with clopidogrel. This suggests that the proposed interaction is probably an ex vivo phenomenon and may not be clinically relevant.

The evaluation of hepatocellular carcinoma with biphasic contrast enhanced helical CT scan

OBJECTIVE

To evaluate the role of biphasic contrast-enhanced helical CT including Hepatic Arterial Phase (HAP) imaging with Portal Venous Phase (PVP) imaging, in the detection and characterization of hepatocellular carcinomas.

METHODS

The study included 40 patients (M = 26, F = 14) with histopathologically proven HCC. Age range was between 30-85 years (mean = 55) by following consecutive patients with cirrhosis in whom Hepatocellular carcinoma was diagnosed or suspected either by raised serum a (alpha)-fetoprotein level or Ultrasound.

RESULTS

Biphasic contrast-enhanced examination revealed a total of 85 lesions in these 40 patients, out of which 13 were unifocal, 12 showed a dominant mass with satellite lesions, 2 showed cluster of contiguous nodules and 13 were multifocal HCCs. Mean diameter was 3.1 cm, ranging from 0.8 to 14 cm. On HAP imaging 85% were detected. (hyperattenuating = 69, hypoattenuating = 3) while on PVP imaging detectibility was only 48% (hyperattenuating = 2, hypoattenuating = 39). Hence detectibility was significantly (p = 0.008) superior in HAP as compared to PVP imaging. In 7 patients (17%) tumor was visible only on HAP images. Venous invasion was present in 12 patients (30%) while arterio-portal shunting was seen in 5 patients (13%).

CONCLUSION

Biphasic contrast enhanced helical CT is a useful method in detection and characterization of HCC.

The role of magnetic resonance cholangiopancreatography (MRCP) in obstructive jaundice

OBJECTIVE

To evaluate the diagnostic value of MRCP in studying the sites and cause of obstructive jaundice in comparison with other imaging modalities at the Department of Radiology, Aga Khan University Hospital, from January 1999 to May 2001.

METHODS

Forty nine consecutive patients included 19 men and 30 women, suspected of obstructive jaundice. Patients underwent ultrasound (n = 49), CT (n = 11), ERCP (n = 25) and biliary surgery (n = 17). Final diagnosis was established by surgical exploration, endoscopic sphincterectomy, cytology and clinical follow up.

RESULTS

Of the 49 patients 17 had choledocholithiasis. Twenty five patients had malignant strictures, out of which 11 had non-specific malignant strictures, 7 had pancreatic carcinoma, 3 had Klatskin tumors, 3 had periampullary carcinoma and 1 had gallbladder carcinoma. Six patients had benign strictures and 1 patient had choledochal cyst. Overall, MRCP was sensitive (88%) and specific (96.8%) in detecting choledocholithiasis. MRCP sensitivity and specificity in detecting benign main bile duct stricture was equal to 83.3% and 97.6% respectively, and 92% and 100% for malignant stricture.

CONCLUSION

Our prospective study confirms that MRCP, a noninvasive and well tolerated imaging technique is of value in the diagnosis of obstructive jaundice.