Clinical outcome and biomarker assessments of a multi-centre phase II trial assessing niraparib with or without dostarlimab in recurrent endometrial carcinoma

This multi-centre, non-randomized, open-label, phase II trial (NCT03016338), assessed niraparib monotherapy (cohort 1, C1), or niraparib and dostarlimab (cohort 2, C2) in patients with recurrent serous or endometrioid endometrial carcinoma. The primary endpoint was clinical benefit rate (CBR), with ≥5/22 overall considered of interest. Secondary outcomes were safety, objective response rate (ORR), duration of response, progression free survival and overall survival. Translational research was an exploratory outcome. Potential biomarkers were evaluated in archival tissue by immunohistochemistry and next generation sequencing panel. In C1, 25 patients were enrolled, and CBR was 20% (95% CI: 9-39) with median clinical benefit duration of 5.3 months. The ORR was 4% (95% CI: 0-20). In C2, 22 patients were enrolled, and the CBR was 31.8% (95% CI: 16-53) with median clinical benefit duration of 6.8 months. The ORR was 14% (95% CI: 3-35). No new safety signals were detected. No significant association was detected between clinical benefit and IHC markers (PTEN, p53, MMR, PD-L1), or molecular profiling (PTEN, TP53, homologous recombination repair genes). In conclusion, niraparib monotherapy did not meet the efficacy threshold. Niraparib in combination with dostarlimab showed modest activity.

A call for nurse practitioner-led cancer survivorship clinics: The need for development and adoption within Ontario, Canada

The growing prevalence of cancer survivors requiring comprehensive follow-up care after the completion of treatment is placing a significant strain on the Canadian healthcare system (Moura et al., 2022). Given the current landscape and the higher workload demands that are further exacerbated by shortages in healthcare staffing, the oncology specialist-led care, as the standard model for survivorship care is unsustainable and suboptimal in addressing a broad range of physical, psychosocial, supportive, informational, and rehabilitative needs of cancer survivors (Brennan et al., 2010; Canadian Partnership Against Cancer & Canadian Association of Provincial Cancer Agencies, 2010). Nurse-led models of survivorship care provided by oncology nurse practitioners (NPs) have been shown to be safe, effective, feasible, and appropriate for follow-up care (Chan et al., 2018). In the province of Ontario, survivorship care is provided mostly by physicians. Specialized NP-led survivorship clinics or programs are currently lacking based on a recent environmental scan. This paper outlines current barriers and opportunities in NP-led survivorship care. This is a call to action and for advocacy regarding the examination of oncology services and outlines the need for the development and implementation of NP-led survivorship clinics in Ontario, Canada.

Appel à la création de cliniques pour survivants du cancer dirigées par des infirmières praticiennes : un nouveau modèle doit être développé et généralisé en Ontario

La croissance du nombre de survivants du cancer nécessitant des soins de suivi complets après leur traitement exerce une pression considérable sur le système de santé canadien (Moura et al., 2022). Compte tenu du contexte actuel caractérisé par des charges de travail de plus en plus lourdes exacerbées par des pénuries de personnel dans le secteur de la santé, le modèle standard de soins aux survivants sous la direction d’un ou d’une oncologue n’est pas viable ni même optimal pour répondre à tous les besoins physiques, psychosociaux, de soutien, d’information et de réadaptation des survivants du cancer (Brennan et al., 2010; Canadian Partnership Against Cancer/Partenariat canadien contre le cancer et Canadian Association of Provincial Cancer Agencies/Association canadienne des agences provinciales du cancer, 2010). Il a été démontré que les modèles de soins aux survivants dirigés par des infirmières praticiennes (IP) en oncologie sont sûrs, efficaces, réalisables et appropriés pour le suivi des patients (Chan et al., 2018). En Ontario, les soins aux survivants sont principalement dispensés par des médecins. D’après une récente analyse de l’environnement médical, il n’y existe actuellement pas de cliniques ou de programmes spécialisés pour les survivants du cancer dirigés par des IP. Cet article décrit les obstacles et les possibilités qui existent actuellement concernant les soins aux survivants dispensés par des IP. Les auteures lancent un appel au lancement d’un processus d’examen des services d’oncologie et soulignent la nécessité de créer en Ontario des cliniques pour survivants dirigées par des IP.

Outcomes of neonatal congenital diaphragmatic hernia in a non-ECMO center in a middle-income country: a retrospective cohort study

BACKGROUND

Most studies examining survival of neonates with congenital diaphragmatic hernia (CDH) are in high-income countries. We aimed to describe the management, survival to hospital discharge rate, and factors associated with survival of neonates with unilateral CDH in a middle-income country.

METHODS

We retrospectively reviewed the medical notes of neonates with unilateral CDH admitted to a pediatric intensive care unit (PICU) in a tertiary referral center over a 15-year period, from 2003-2017. We described the newborns' respiratory care pathways and then compared baseline demographic, hemodynamic, and respiratory indicators between survivors and non-survivors. The primary outcome measure was survival to hospital discharge.

RESULTS

Altogether, 120 neonates were included with 43.3% (52/120) diagnosed antenatally. Stabilization occurred in 38.3% (46/120) with conventional ventilation, 13.3% (16/120) with high-frequency intermittent positive-pressure ventilation, and 22.5% (27/120) with high frequency oscillatory ventilation. Surgical repair was possible in 75.0% (90/120). The overall 30-day survival was 70.8% (85/120) and survival to hospital discharge was 66.7% (80/120). Survival to hospital discharge tended to improve over time (p > 0.05), from 56.0% to 69.5% before and after, respectively, a service reorganization. For those neonates who could be stabilized and operated on, 90.9% (80/88) survived to hospital discharge. The commonest post-operative complication was infection, occurring in 43.3%. The median survivor length of stay was 32.5 (interquartile range 18.8-58.0) days. Multiple logistic regression modelling showed vaginal delivery (odds ratio [OR] = 4.8; 95% confidence interval [CI] [1.1-21.67]; p = 0.041), Apgar score [Formula: see text] 7 at 5 min (OR = 6.7; 95% CI [1.2-36.3]; p = 0.028), and fraction of inspired oxygen (FiO₂) < 50% at 24 h (OR = 89.6; 95% CI [10.6-758.6]; p < 0.001) were significantly associated with improved survival to hospital discharge.

CONCLUSIONS

We report a survival to hospital discharge rate of 66.7%. Survival tended to improve over time, reflecting a greater critical volume of cases and multi-disciplinary care with early involvement of the respiratory team resulting in improved transitioning from PICU. Vaginal delivery, Apgar score [Formula: see text] 7 at 5 min, and FiO₂ < 50% at 24 h increased the likelihood of survival to hospital discharge.

Discriminatory accuracy of the SOFA score for determining clinical decompensation in patients presenting with COVID-19

Introduction

While the global dissemination of vaccines targeting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a decline in the incidence of infections, the case fatality rates have remained relative stable. A major objective of managing hospitalized patients with documented or suspected COVID-19 infection is the rapid identification of features associated with severe illness using readily available laboratory tests and clinical tools. The sequential organ failure assessment (SOFA) score is a validated tool to facilitate the identification of patients at risk of dying from sepsis.

Purpose

The aim of this study was to assess the discriminatory accuracy of the SOFA score in predicting clinical decompensation in patients hospitalized with COVID-19 infection.

Methods

We conducted a retrospective analysis at a three-hospital health system, comprised of one tertiary and two community hospitals, located in the Chicago metropolitan area. All patients had positive SARS-CoV-2 testing and were hospitalized for COVID-19 infection. The primary outcome was clinical decompensation, defined as the composite endpoint of death, ICU admission, or need for intubation. We utilized the most abnormal laboratory values observed during the admission to calculate the SOFA score. Receiver Operating Curves (ROC) were then constructed to determine the sensitivity and specificity of SOFA scores.

Results

Between March 1st and May 31st 2020, 1029 patients were included in our analysis with 367 patients meeting the study endpoint. The median SOFA score was 2.0 IQR (Q1, Q3 1,4) for the entire cohort. Patients who had in-hospital mortality had a median SOFA score of 4.0 (Q1,Q3 3,7). In patients that met the primary composite endpoint, the median SOFA score was 3.0, IQR (Q1, Q3 2,6). The ROC was 0.776 (95% CI 0.746–0.806, p<0.01).

Conclusion

The SOFA score demonstrates strong discriminatory accuracy for prediction of clinical decompensation in patients presenting with COVID-19 at our urban hospital system.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Loyola University Medical Center

Predictors of clinical decompensation in patients presenting with COVID-19 in an urban hospital health system

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in a pandemic which has infected more than 128 million people and led to over 2.8 million deaths worldwide. Although the introduction of efficacious vaccines has led to overall declines in the incidence of SARS-CoV-2 infection, there has been a recent increase in infections once more due to the appearance of mutant strains with higher virulence. It therefore remains vital to identify predictors of poor outcomes in this patient population.

Purpose

The objective of our study was to identify predictors of prolonged hospitalization, intensive care unit (ICU) admission, intubation, and death in patients infected with SARS-CoV-2.

Methods

We conducted a retrospective analysis of all patients hospitalized with SARS-CoV-2 at our health system that includes one tertiary care center and two community hospitals located in the Chicago metropolitan area. The main outcome was a composite endpoint of hospitalization >28 days, ICU admission, intubation, and death.

Explanatory variables associated with the primary outcome in the bivariate analysis (p<0.05) were included in the multivariable logistic regression model. Statistical analysis was performed using IBM SPSS 25.0.

Results

Between March 1, 2020 and May 31, 2020, 1029 patients hospitalized with SARS-CoV-2 were included in our analysis. Of these patients, 379 met the composite endpoint. Baseline demographics are described in Table 1. Of note, our cohort consisted of a predominantly minority patient population including 47% Hispanic, 17% African American, 16% Caucasian, and 16% other.

In bivariate analysis, age, hypertension, tobacco and alcohol abuse, obesity, coronary artery disease, arrhythmias, valvular heart disease, dyslipidemia, hypertension, stroke, diabetes, documented thrombosis, troponin, CRP, ESR, ferritin, LDH, BNP, D-dimer >5x the upper limit of normal, lactate, and right ventricular outflow tract velocity time integral <9.5 were significant.

After multivariable adjustment, explanatory variables associated with the composite endpoint included troponin (OR 2.36; 95% CI 1.08–5.17, p 0.03), D-dimer (OR 1.5; 95% CI 1.23–1.98, p<0.01, lactate (OR 1.58; 95% CI 1.28–1.95, p<0.01), and documented thrombosis (OR 3.56; 95% CI 1.30–8.70, p<.05). Race was not a predictor of poor outcomes in the bivariate or multivariate analysis (Table 2).

Conclusions

In a large urban cohort with a predominantly minority population, we identified several clinical predictors of poor outcomes. Of note, race was not a predictor of the primary endpoint in this study. While recent literature has demonstrated worse outcomes among racial minorities infected with SARS-CoV-2, our data suggests these variations are related to social determinants of health rather than biologic causes.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Loyola University Medical Center

Estimating premorbid intelligence in persons with traumatic brain injury: an examination of the Test of Premorbid Functioning

Knowledge of intelligence is essential for interpreting cognitive performance following traumatic brain injury (TBI). The Test of Premorbid Functioning (ToPF), a word reading test co-normed with the Wechsler Adult Intelligence Scale 4th Edition (WAIS-IV), was examined as a tool for estimating premorbid intelligence in persons with a history of TBI. Fifty-two participants with mild, moderate, or severe TBI were administered the ToPF and WAIS-IV between two weeks and 19 months post-injury. The independent ability of the ToPF/demographic score and the Verbal Comprehension Index (VCI) to predict WAIS-IV Full Scale IQ (FSIQ) was examined, as were discrepancies between ToPF and WAIS-IV scores within and between participants. The ToPF/demographic predicted FSIQ accounted for a significant proportion of variability in actual FSIQ, above and beyond that accounted for by education or time since injury. ToPF and WAIS-IV scores did not differ by injury severity. In our sample, the ToPF/demographic predicted FSIQ underestimated intelligence in a substantial portion of our participants (31%), particularly in those with high average to superior intelligence. Finally, VCI scores were more predictive of actual FSIQ than the ToPF/demographic predicted FSIQ. The ToPF frequently underestimated post-injury intelligence and is therefore not accurately measuring premorbid intelligence in our sample, particularly in those with above average to superior intelligence. Clinicians are encouraged to administer the entire WAIS-IV, or at minimum the VCI subtests, for a more accurate measure of intelligence in those with above average intelligence and history of TBI.

P-296 Examining the link between environmental toxin exposure and uterine leiomyoma: a systematic review

Study question

Is there an association between exposure to certain environmental toxins and the prevalence of uterine leiomyoma in women?

Summary answer

Some evidence was obtained to suggest an association between phthalate esters, bisphenol A, heavy metals, persistent organic pollutants and the prevalence of uterine fibroids.

What is known already

Environmental toxins are naturally occurring, or human made chemicals that can act as endocrine disrupting chemicals (EDCs) by binding and activating estrogen receptors in the body. Uterine fibroids, often called leiomyoma are non-cancerous growths occurring in the uterus. Though often asymptomatic, they can cause pain, infertility, pregnancy complications and are a leading cause for hysterectomy. The aetiology of leiomyoma is not fully understood but both estrogen and progesterone have been implicated in their growth. We aimed to investigate the epidemiological evidence for the association between EDCs and the prevalence of fibroids. 

Study design, size, duration

We undertook a systematic review and in keeping with PRISMA guidelines, a structured search of Medline, Embase, Scopus, and Web of Science was conducted (to October 2020). Case-control, cross-sectional, cohort and experimental studies were included. 

Participants/materials, setting, methods

The included studies analyzed the association between one or more toxins and the occurrence, or growth of leiomyoma in humans, including human cell lines. The types of toxins, patient characteristics, association and outcome, body concentration of toxin and confounding variables were extracted and analyzed. Quality assessment was performed using the Newcastle-Ottawa Scale.

Main results and the role of chance

In total, 34 studies were included. The majority (76%) of studies revealed a significant association between the exposure studied and the prevalence of uterine leiomyoma. In examining body burden in cases vs controls, phthalate esters showed an association with increased odds of uterine leiomyoma, except in one case where a negative association was observed. In vitro experimental studies examining the effect of alkyl-phenols such as bisphenol A (BPA), octylphenol (OP) and nonylphenol (NP) demonstrated that these environmental estrogens can act to promote the proliferation of leiomyoma cells through a number of mechanisms, typically including the estrogen receptor alpha (ERa) signalling pathway. There were conflicting results for the association between alkyl-phenols and fibroids in case-control studies. A positive association between cadmium was demonstrated in only two studies. There were conflicting results for the association between lead, mercury, arsenic and uterine fibroids. Several metabolites of organophosphate esters, alternative plasticizers, and persistent organic pollutants were associated with an increased risk of uterine fibroids. 

Limitations, reasons for caution

Separating these exposures from the multiple other factors that could affect the outcome of leiomyoma is challenging, but an important issue for future research. 

Wider implications of the findings

The link between some environmental toxins and uterine fibroids discussed is in agreement with previous literature. However, our review provides a more in depth analysis on specific dosage effects, odds ratios, and potential gene mechanisms of the exposures. This information could contribute to more accurate preventative measures.

Trial registration number

not applicable

P–296 Examining the link between environmental toxin exposure and uterine leiomyoma: a systematic review

Study question

Is there an association between exposure to certain environmental toxins and the prevalence of uterine leiomyoma in women?

Summary answer

Some evidence was obtained to suggest an association between phthalate esters, bisphenol A, heavy metals, persistent organic pollutants and the prevalence of uterine fibroids.

What is known already

Environmental toxins are naturally occurring, or human made chemicals that can act as endocrine disrupting chemicals (EDCs) by binding and activating estrogen receptors in the body. Uterine fibroids, often called leiomyoma are non-cancerous growths occurring in the uterus. Though often asymptomatic, they can cause pain, infertility, pregnancy complications and are a leading cause for hysterectomy. The aetiology of leiomyoma is not fully understood but both estrogen and progesterone have been implicated in their growth. We aimed to investigate the epidemiological evidence for the association between EDCs and the prevalence of fibroids.

Study design, size, duration

We undertook a systematic review and in keeping with PRISMA guidelines, a structured search of Medline, Embase, Scopus, and Web of Science was conducted (to October 2020). Case-control, cross-sectional, cohort and experimental studies were included.

Participants/materials, setting, methods

The included studies analyzed the association between one or more toxins and the occurrence, or growth of leiomyoma in humans, including human cell lines. The types of toxins, patient characteristics, association and outcome, body concentration of toxin and confounding variables were extracted and analyzed. Quality assessment was performed using the Newcastle-Ottawa Scale.

Main results and the role of chance

In total, 34 studies were included. The majority (76%) of studies revealed a significant association between the exposure studied and the prevalence of uterine leiomyoma. In examining body burden in cases vs controls, phthalate esters showed an association with increased odds of uterine leiomyoma, except in one case where a negative association was observed. In vitro experimental studies examining the effect of alkyl-phenols such as bisphenol A (BPA), octylphenol (OP) and nonylphenol (NP) demonstrated that these environmental estrogens can act to promote the proliferation of leiomyoma cells through a number of mechanisms, typically including the estrogen receptor alpha (ERa) signalling pathway. There were conflicting results for the association between alkyl-phenols and fibroids in case-control studies. A positive association between cadmium was demonstrated in only two studies. There were conflicting results for the association between lead, mercury, arsenic and uterine fibroids. Several metabolites of organophosphate esters, alternative plasticizers, and persistent organic pollutants were associated with an increased risk of uterine fibroids.

Limitations, reasons for caution

Separating these exposures from the multiple other factors that could affect the outcome of leiomyoma is challenging, but an important issue for future research.

Wider implications of the findings: The link between some environmental toxins and uterine fibroids discussed is in agreement with previous literature. However, our review provides a more in depth analysis on specific dosage effects, odds ratios, and potential gene mechanisms of the exposures. This information could contribute to more accurate preventative measures.

Trial registration number

Not applicable

Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications: a prospective, randomised, double-blind trial in high-risk older patients

BACKGROUND

Residual neuromuscular block is associated with an increased risk of postoperative pulmonary complications in retrospective studies. The aim of our study was to investigate prospectively the incidence of postoperative pulmonary complications after reversal with either sugammadex (SUG) or neostigmine (NEO) in high-risk older patients.

METHODS

We randomly allocated 180 older patients with significant morbidity (ASA physical status 3) ≥75 yr old to reversal of rocuronium with either SUG or NEO. Adverse events in the recovery room and pulmonary complications (defined by a 5-point [0-4; 0=best to 4=worst] outcome score) on postoperative Days 1, 3, and 7 were compared between groups.

RESULTS

Data from 168 patients aged 80 (4) yr were analysed; SUG vs NEO resulted in a reduced probability (0.052 vs 0.122) of increased pulmonary outcome score (impaired outcome) on postoperative Day 7, but not on Days 1 and 3. More patients in the NEO group were diagnosed with radiographically confirmed pneumonia (9.6% vs 2.4%; P=0.046). The NEO group showed a non-significant trend towards longer hospital length of stay across all individual centres (combined 9 vs 7.5 days), with a significant difference in Malaysia (6 vs 4 days; P=0.011).

CONCLUSIONS

Reversal of rocuronium neuromuscular block with SUG resulted in a small, but possibly clinically relevant improvement in pulmonary outcome in a select cohort of high-risk older patients.

CLINICAL TRIAL REGISTRATION

ACTRN12614000108617.

Phase II trial assessing niraparib with or without dostarlimab (anti-PD-1) in recurrent endometrial carcinoma

5574

Background: Treatment options in recurrent endometrial carcinoma (EC) are limited. Endometrioid EC shows alterations in PTEN, a possible biomarker of response to PARP inhibitors (PARPi). Similarly, homologous recombination deficiency (HRd), a biomarker of response to PARPi in ovarian cancer, is associated with serous EC harbouring TP53 mutations. Preclinical EC models have shown synergy between combining a PARPi and immune checkpoint inhibitor (ICI). Methods: A pilot multi-centre, non-randomized, phase II trial enrolled patients (pts) with recurrent serous or endometrioid EC in two consecutive cohorts (NCT03016338). In the first cohort (C1) pts received niraparib 200 or 300 mg qd, based on baseline body weight and platelet count, in 4 week (w) cycles. In the second cohort (C2) niraparib was given with dostarlimab 500 mg q 3 w for 4 cycles, followed by 1000 mg q 6 w thereafter. There was no limit on prior lines of therapy. Prior ICI was not allowed in C2. Primary endpoint was clinical benefit rate (CBR; complete, partial response or stable disease ≥16w). Secondary endpoints included toxicity assessment and ORR. CT scans were performed q 8 w. Potential biomarkers were assessed in archival tissue by IHC (PTEN, p53, MMR, PDL-1 [threshold 1%]) and a NGS panel (including TP53, PTEN, POLE and other HRd genes). Tumour mutational burden-high (TMBh) was defined as top 20% mutation load. Results: In C1, 25 pts were enrolled (23 evaluable for response). Median age was 69 years old, 64% had serous EC, 72% were platinum resistant (PlatR) and median prior therapies was 2 (range 1-4). Median number of cycles was 3. The CBR was 20% (95% CI: 9-39) and median clinical benefit (CB) duration was 5.3 (1.8-7.2) months. The ORR was 1/23 (4%; 0-20). Related grade (g) ≥3 AEs ≥10% were anemia (24%), fatigue (16%) and thrombocytopenia (16%). In C2, 22 pts were enrolled (all evaluable) and two continue on-treatment. Median age was 64 years old, 46% had serous EC, 68% were PlatR and median prior therapies was 2 (1-6). Three pts had MMR deficient (MMRd) tumors (14%) and one pt a POLE mutation (5%). Median number of cycles was 3. The CBR was 31.8% (16-53) and median CB duration was 6.8 months (3.7-9.5). The ORR was 3/22 (14%; 3-35), out of the three responders one had MMRd and one a POLE mutation. Related g≥3 AEs ≥10% were anemia (27%) and neutropenia (14%). No significant correlation was detected between CB and IHC markers (PTEN, p53, MMR, PDL-1), or NGS ( PTEN, TP53, HRd TMBh) in C1 and C2. Conclusions: Niraparib as single agent for treatment in a PlatR enriched recurrent EC population showed modest activity with clinical benefit rate at 16w of 20%. The combination of niraparib and dostarlimab showed a clinical benefit rate at 16w of 31.8% in a predominantly PlatR recurrent EC. PTEN loss by IHC or NGS, and alterations in HRd genes did not correlate with clinical benefit. Clinical trial information: NCT03016338.

Dynamic CTA-Derived Perfusion Maps Predict Final Infarct Volume: The Simple Perfusion Reconstruction Algorithm

BACKGROUND AND PURPOSE

Infarct core volume measurement using CTP (CT perfusion) is a mainstay paradigm for stroke treatment decision-making. Yet, there are several downfalls with cine CTP technology that can be overcome by adopting the simple perfusion reconstruction algorithm (SPIRAL) derived from multiphase CTA. We compare SPIRAL with CTP parameters for the prediction of 24-hour infarction.

MATERIALS AND METHODS

Seventy-two patients had admission NCCT, multiphase CTA, CTP, and 24-hour DWI. All patients had successful/quality reperfusion. Patient-level and cohort-level receiver operator characteristic curves were generated to determine accuracy. A 10-fold cross-validation was performed on the cohort-level data. Infarct core volume was compared for SPIRAL, CTP-time-to-maximum, and final DWI by Bland-Altman analysis.

RESULTS

When we compared the accuracy in patients with early and late reperfusion for cortical GM and WM, there was no significant difference at the patient level (0.83 versus 0.84, respectively), cohort level (0.82 versus 0.81, respectively), or the cross-validation (0.77 versus 0.74, respectively). In the patient-level receiver operating characteristic analysis, the SPIRAL map had a slightly higher, though nonsignificant (P < .05), average receiver operating characteristic area under the curve (cortical GM/WM, r = 0.82; basal ganglia  = 0.79, respectively) than both the CTP-time-to-maximum (cortical GM/WM = 0.82; basal ganglia = 0.78, respectively) and CTP-CBF (cortical GM/WM = 0.74; basal ganglia = 0.78, respectively) parameter maps. The same relationship was observed at the cohort level. The Bland-Altman plot limits of agreement for SPIRAL and time-to-maximum infarct volume were similar compared with 24-hour DWI.

CONCLUSIONS

We have shown that perfusion maps generated from a temporally sampled helical CTA are an accurate surrogate for infarct core.

Analysis of complications following multidisciplinary functional intervention in paediatric craniomaxillofacial deformities

Paediatric craniomaxillofacial (CMF) surgery requires a multidisciplinary team approach to ensure the optimal and holistic management of children with craniofacial deformities. The aim of this retrospective study was to analyse the complications following functional interventions among 34 CMF deformity patients in a single multidisciplinary craniofacial centre. Electronic data including patient demographic characteristics and clinical entry were analysed. Inclusion criteria were all paediatric patients with CMF deformities who underwent various functional interventions. A total of 64 interventions (48 intermediate and 16 definitive) were conducted. Based on the Sharma classification of complications, 20.3% were type I, 4.7% were type II, 1.6% were type III, and 4.7% were type IV . Most complications were type I, which included local infection (3.1%) and premature opening of tarsorrhaphy (3.1%). More serious complications (types III and IV) included temporary visual loss (1.6%) and intraoperative haemorrhage (1.6%). Although a low complication rate was observed in intermediate interventions, a higher complication rate was observed in more complex definitive interventions such as monobloc distraction osteogenesis. Although most complications were manageable, effective prevention remains mandatory, as serious complications may lead to permanent damage and mortality. This analysis highlights the importance of a multidisciplinary team approach to optimize the outcomes in CMF patient management.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

1118 Examining the Role of Serum and Exosomal Biomarkers in Symptoms of Fatigue and Daytime Sleepiness Following Traumatic Brain Injury

Introduction

Fatigue and daytime sleepiness are two of the most common chronic symptoms reported after traumatic brain injury (TBI). However, there is limited understanding of the pathophysiological mechanisms following TBI that result in these symptoms. Previous research has observed elevations in peripheral blood levels of proteins in TBI patients versus controls, including neurofilament light chain (NFL)—predominantly expressed in long myelinated subcortical axons—and glial fibrillary acidic protein (GFAP)—predominantly expressed in reactive astrocytes responding to central nervous system injuries. This study examines the relationship between serum and exosomal NFL and GFAP, and symptoms of fatigue and daytime sleepiness in TBI patients 1-year after injury.

Methods

Sixty-seven patients with TBIs ranging from mild to severe were included in this study. Blood samples were collected from all participants 1-year post TBI, with concentrations of GFAP and NFL measured in serum and exosomes using Single Molecule Array technology (Simoa), an ultrasensitive assay. Participants reported fatigue using the Fatigue Severity Scale (FSS), and daytime sleepiness using the Epworth Sleepiness Scale (ESS).

Results

A linear regression model of fatigue symptoms and exosomal NFL controlling for age revealed that fatigue was negatively associated with exosomal NFL concentrations (β = -.317, p = .041, ηp2 = -.343) and accounted for 20.2% of the change in NFL. Serum NFL concentrations were not associated with fatigue, nor were GFAP serum or exosomes. No significant associations were found between NFL, GFAP, and daytime sleepiness.

Conclusion

Our findings suggest that exosomal NFL may be related to mechanisms underlying TBI-related fatigue and the potential of NFL as a biomarker of fatigue. To our knowledge, this study is the first to examine the relationship between post-TBI NFL levels and fatigue symptoms. Further investigation into serum and exosome biomarkers of TBI-related fatigue and daytime sleepiness is warranted.

Support

National Institutes of Health and Center for Neuroscience and Regenerative Medicine

Cardiopulmonary exercise test indices of respiratory buffering before and after aerobic exercise training in women with pulmonary hypertension: Differentiation by magnitudes of change in six-minute walk test performance

While aerobic exercise training (AET) has generally been shown to improve 6-min walk test (6MWT) distance (6MWD) in patients with pulmonary hypertension (PH), a substantial number of patients appear to adapt differently, with minimal or even negative changes in 6MWT distance being reported.

PURPOSE

To compare post-aerobic exercise training adaptations in cardiorespiratory functional capacity across three groups of patients with PH: those with high (HI), low (LI) and negative (NEG) post-training increases in 6MWD.

METHODS

Participants were 25 females (age 54 ± 11 years; BMI 31 ± 7 kg/m²) who completed a vigorous, 10-week, thrice weekly, supervised treadmill walking exercise program. Cardiopulmonary exercise tests (CPET) and 6MWT were completed before and after training. Ten of the 25 participants were classified as HI (range = 47-143 m), 11 were classified as LI (range = 4-37 m) and 4 were classified as NEG (range = -17 to -53 m).

RESULTS

Peak CPET duration, WR and time to anaerobic threshold (AT) were significantly higher (p < 0.05) after training in both the LI and HI groups but not in the NEG group. There was a significant improvement in VE/VCO₂ (p = 0.042), PETCO₂ (p = 0.011) and TV (p = 0.050) in the HI group after training, but not in the NEG or LI group.

CONCLUSION

These findings suggest that sustained ventilatory inefficiency and restricted respiratory buffering may mediate exercise intolerance and impede the ability to adapt to exercise training in some patients with PH.

Bispectral Index during Modified Rapid Sequence Induction Using Thiopentone or Propofol and Rocuronium

This randomized controlled trial compared Bispectral Index (BIS) values in 40 patients after a modified rapid sequence induction using thiopentone 4 mg/kg or propofol 2 mg/kg with rocuronium 0.6 mg/kg as muscle relaxant. Endotracheal intubation was performed at 60 seconds from induction of anaesthesia and BIS values were recorded for three minutes after induction. At the 120, 150 and 180 second measurements there was a significantly greater proportion of subjects with BIS values ≤ 60 (“anaesthetized”) in the propofol group compared with the thiopentone group (P values <0.02, <0.01 and <0.01 respectively).

All intubations were completed within two minutes. No explicit recall of intubation was detected clinically with either induction agent. The BIS scores we have measured suggest that thiopentone 4 mg/kg is more likely to be associated with lighter planes of anaesthesia and consequent risk of awareness than propofol 2 mg/kg, if intubation is delayed or prolonged.

Evaluation of the quality of acute pain management in a pediatric surgical setting: Validation of a parent proxy modified version of the revised American Pain Society Patient Outcome Questionnaire

BACKGROUND

Effective pain management involves a cycle of continual pain assessment, good pain control strategies, and assessment of a standard quality improvement measures. A validated questionnaire that focuses on the quality of postoperative pain management in pediatric surgical patients and parental satisfaction on pain treatment is lacking. We, therefore, modified the revised American Pain Society Patient Outcome Questionnaire to evaluate the quality of postoperative pain management in a pediatric surgical setting. The primary aim of this study was to validate the modified version of revised American Pain Society Patient Outcome Questionnaire.

METHODS

Parents whose children aged below 12 years and were scheduled for elective surgery in a teaching hospital, were approached to participate in this survey. The reliability of the modified version of revised American Pain Society Patient Outcome Questionnaire was evaluated using Cronbach's alpha test, while the construct validity was assessed with a principal component analysis using a varimax rotation. The parental satisfaction with pain treatment received was measured.

RESULTS

A total of 108 parents completed the questionnaire. The internal consistency of the questionnaire shows a Cronbach's alpha of 0.798. Principal component analysis revealed a four-factor structure of the 12 items which explained 69.7% of the total variance. The factors are "Interference of sleep and activity," "Pain severity and drowsiness," "Perception of care," and "Adverse effects," respectively. Our study showed that this questionnaire is a valid and reliable measure for "Interference of sleep and activity" and "Pain severity and drowsiness" factors, but not for "Perception of care" and "Adverse effects." The results for "Perception of care" and "Adverse effects," therefore, should be reported as individual items instead of total score. The parental satisfaction with pain treatment given was good (median 8.0; IQR 3.0).

CONCLUSION

The modified version of revised American Pain Society Patient Outcome Questionnaire is a feasible and easy instrument to administer. The questionnaire can be used to obtain feedback from parents about the outcomes and experiences of pain management and is helpful in continuous quality evaluation and improvement in the postoperative care in a pediatric setting.

Randomized comparison of the Baska FESS mask and the LMA Supreme in different head and neck positions

BACKGROUND

The Baska functional endoscopic sinus surgery (FESS) mask is a new supraglottic airway designed for head and neck procedures. This prospective, randomized controlled trial compared the oropharyngeal leak pressure (OLP) of the Baska FESS mask with the laryngeal mask airway (LMA) Supreme in different head and neck positions.

METHODS

One hundred patients undergoing elective surgery were recruited. OLP was compared in supine position, 45° lateral rotation, 45° neck extension, and 30° neck flexion. Glottic view, insertion time, ease of insertion, number of attempts, ease and time of insertion of gastric tube, and complications were also compared.

RESULTS

The OLP of the Baska FESS was higher than the LMA Supreme in all head and neck positions studied (p < 0.001). Glottic views were better in the Baska FESS in supine and lateral rotation. LMA Supreme was easier (p = 0.046) and faster (p < 0.001) to insert. First attempt insertion success rates were 91.8% for Baska FESS and 98% for LMA Supreme. Gastric drain was easier and faster to insert (p < 0.001) in the LMA Supreme.

CONCLUSIONS

The Baska FESS provides a superior airway seal with higher mean OLP than the LMA Supreme in all head and neck positions studied. However, LMA Supreme was superior in terms of ease and speed of insertion.

Sensitivity of various body indices and visceral adiposity index in predicting metabolic syndrome among Chinese patients with adult growth hormone deficiency

AIM

Adult growth hormone deficiency (AGHD) refers to decreased secretion of growth hormones in the adults, which is associated with increased clustering of conventional cardiovascular risk factors such as central obesity, insulin resistance and dyslipidemia. Metabolic syndrome (MetS), a recognized risk factor of cardiovascluar diseases, shares some clinical features. Given that the prevalence of MetS is on the rise in patients with AGHD, and that cardiovascular disease (CVD) is an important cause of morbidity and mortality in that population, the alternative, simple, non-invasive methods of assessing MetS among this population are needed. This study aims to determine the sensitivity of five anthropometric indices [Body mass index (BMI), Waist circumference (WC), Waist-to-hip ratio (WHR), Waist-to-height ratio (WHtR) and Visceral adiposity index (VAI)] in predicting metabolic syndrome in Chinese population-based patients with adult growth hormone deficiency.

MATERIALS AND METHODS

A total of 96 Chinese patients with adult growth hormone deficiency were included in this study. They were compared with equal number of apparently healthy persons with similar characteristics (matched with age and gender) to the previous group. Anthropometric measurements including weight, height, serum lipids indices, blood pressure (BP), fasting plasma glucose (FPG), WC were measured. BMI, WHR, WHtR, and VAI were calculated.

RESULTS AND DISCUSSION

AGHD patients with MetS had higher WC (91.00 ± 8.28 vs 78.01 ± 7.12), BMI (24.95 ± 2.91 VS 23.30 ± 2.80), WHR (0.92 ± 0.06 VS 0.87 ± 0.07), WHtR (0.53 ± 0.06 VS 0.47 ± 0.05), VAI [(5.59 (4.02, 7.55) VS 1.69 (0.87, 3.05)] levels in comparison to those without MetS. Meantime WC, BMI, WHR, WHtR, VAI was positively correlated to MetS components. ROC curve for participants with AGHD showed that VAI had the highest SS of 92% (BMI 0.812; WHR 0.706; WHtR 0.902; VAI 0.920, respectively) for prediction of MetS in AGHD. The optimal cutoff values for different adiposity markers in predicting MetS were as follows: WC (79.65), BMI (23.46); WHR (0.89); WHtR (0.54); VAI (2.29).

CONCLUSION

In conclusion, our study showed all adiposity measures of interest present themselves as easy and practical tools for use in population studies and clinical practice for evaluating MetS in AGDH and VAI was identified as the best in Chinese AGHD patients among them.

In vitro and in vivo Evaluation of New Topical Anaesthetic Cream Formulated with Palm Oil Base

BACKGROUND

Topical local anaesthetic cream was reported to be useful for pain relief for cutaneous procedures such as minor surgery and venipuncture.

OBJECTIVE

The aim of this study was to evaluate the effectiveness of new formulation of lidocaine topical anaesthetic using palm oil base, HAMIN® and to determine how fast this new formulation produces adequate numbness compared to the currently used EMLA cream, in the University of Malaya Medical Centre (UMMC) set-up.

METHOD

The skin permeation test was conducted by using Franz type diffusion cell and pain assessment was carried out in healthy subject by using Verbal Rating Score (VRS) and Visual Analogue Score (VAS) evaluation.

RESULT

Result of permeation test demonstrated that the cumulative amount of lidocaine released from HAMIN® cream was increased with time and slightly higher than EMLA cream. The clinical study showed that HAMIN® single lidocaine cream can produces numbness through venepuncture procedure and comparable with EMLA cream which is a combination therapy for local anaesthetic (lidocaine and prilocaine).

CONCLUSION

It can be concluded that HAMIN® Lidocaine cream is suitable for cream preparation especially for topical application and it can be regarded as an achievement in palm oil and medical industries.

Gene Expression in Biopsies of Acute Rejection and Interstitial Fibrosis/Tubular Atrophy Reveals Highly Shared Mechanisms That Correlate With Worse Long-Term Outcomes

Interstitial fibrosis and tubular atrophy (IFTA) is found in approximately 25% of 1-year biopsies posttransplant. It is known that IFTA correlates with decreased graft survival when histological evidence of inflammation is present. Identifying the mechanistic etiology of IFTA is important to understanding why long-term graft survival has not changed as expected despite improved immunosuppression and dramatically reduced rates of clinical acute rejection (AR) (Services UDoHaH. http://www.ustransplant.org/annual_reports/current/509a_ki.htm). Gene expression profiles of 234 graft biopsy samples were obtained with matching clinical and outcome data. Eighty-one IFTA biopsies were divided into subphenotypes by degree of histological inflammation: IFTA with AR, IFTA with inflammation, and IFTA without inflammation. Samples with AR (n = 54) and normally functioning transplants (TX; n = 99) were used in comparisons. A novel analysis using gene coexpression networks revealed that all IFTA phenotypes were strongly enriched for dysregulated gene pathways and these were shared with the biopsy profiles of AR, including IFTA samples without histological evidence of inflammation. Thus, by molecular profiling we demonstrate that most IFTA samples have ongoing immune-mediated injury or chronic rejection that is more sensitively detected by gene expression profiling. These molecular biopsy profiles correlated with future graft loss in IFTA samples without inflammation.

Comparing the efficacy and safety between propofol and dexmedetomidine for sedation in claustrophobic adults undergoing magnetic resonance imaging (PADAM trial)

STUDY OBJECTIVE

To determine the efficacy of sedation with dexmedetomidine compared to propofol for claustrophobic adults undergoing magnetic resonance imaging (MRI) in our institution.

DESIGN

Randomized, prospective, double-blinded study.

SETTING

University-based tertiary referral center.

PATIENTS

Thirty claustrophobic adults with American Society of Anesthesiologists physical status I and II who were planned for MRI.

INTERVENTIONS

Patients were randomly assigned to target-controlled infusion propofol or dexmedetomidine loading followed by maintenance dose for procedural sedation.

MEASUREMENTS AND MAIN RESULTS

The primary end point was adequate reduction in patient anxiety levels to allow successful completion of the MRI sequence. Both methods of sedation adequately reduced anxiety levels in visual analog scale scores and Spielberger Strait Test Anxiety Inventory (P<.001). Dexmedetomidine required a longer time to achieve anxiolysis, 7.36minutes (SD, 2.59), and required increasing maintenance dose to induce sleep compared to 10.71minutes (SD, 4.63) for propofol. In terms of image quality, 2 patients (16.67%) in the dexmedetomidine group were satisfactory, whereas all with propofol were graded as good to excellent. Adverse effects were seen in patients sedated with dexmedetomidine with number needed to harm 8 for hypotension and 15 for bradycardia compared to none recorded in the propofol arm. There was no significant difference in patient satisfaction scores or home readiness after the MRI.

CONCLUSIONS

Both dexmedetomidine and propofol can effectively reduce anxiety levels of claustrophobic adults undergoing MRI, but dexmedetomidine takes longer to achieve adequate anxiolysis and sleep and may have an effect on image quality. Hypotension and bradycardia are common adverse effects observed with dexmedetomidine.