Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial

Importance

The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown.

Objective

To determine the association of age with outcomes of CT and ICA in patients with stable chest pain.

Design, Setting, and Participants

The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023.

Interventions

Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy.

Main Outcomes and Measures

MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years.

Results

Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients.

Conclusions and Relevance

Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02400229.

Combination of computed tomography angiography with coronary artery calcium score for improved diagnosis of coronary artery disease: a collaborative meta-analysis of stable chest pain patients referred for invasive coronary angiography

OBJECTIVES

Coronary computed tomography angiography (CCTA) has higher diagnostic accuracy than coronary artery calcium (CAC) score for detecting obstructive coronary artery disease (CAD) in patients with stable chest pain, while the added diagnostic value of combining CCTA with CAC is unknown. We investigated whether combining coronary CCTA with CAC score can improve the diagnosis of obstructive CAD compared with CCTA alone.

METHODS

A total of 2315 patients (858 women, 37%) aged 61.1 ± 10.2 from 29 original studies were included to build two CAD prediction models based on either CCTA alone or CCTA combined with the CAC score. CAD was defined as at least 50% coronary diameter stenosis on invasive coronary angiography. Models were built by using generalized linear mixed-effects models with a random intercept set for the original study. The two CAD prediction models were compared by the likelihood ratio test, while their diagnostic performance was compared using the area under the receiver-operating-characteristic curve (AUC). Net benefit (benefit of true positive versus harm of false positive) was assessed by decision curve analysis.

RESULTS

CAD prevalence was 43.5% (1007/2315). Combining CCTA with CAC improved CAD diagnosis compared with CCTA alone (AUC: 87% [95% CI: 86 to 89%] vs. 80% [95% CI: 78 to 82%]; p < 0.001), likelihood ratio test 236.3, df: 1, p < 0.001, showing a higher net benefit across almost all threshold probabilities.

CONCLUSION

Adding the CAC score to CCTA findings in patients with stable chest pain improves the diagnostic performance in detecting CAD and the net benefit compared with CCTA alone.

CLINICAL RELEVANCE STATEMENT

CAC scoring CT performed before coronary CTA and included in the diagnostic model can improve obstructive CAD diagnosis, especially when CCTA is non-diagnostic.

KEY POINTS

• The combination of coronary artery calcium with coronary computed tomography angiography showed significantly higher AUC (87%, 95% confidence interval [CI]: 86 to 89%) for diagnosis of coronary artery disease compared to coronary computed tomography angiography alone (80%, 95% CI: 78 to 82%, p < 0.001). • Diagnostic improvement was mostly seen in patients with non-diagnostic C. • The improvement in diagnostic performance and the net benefit was consistent across age groups, chest pain types, and genders.

Deceased-Donor Kidney Transplant Outcome Prediction Using Artificial Intelligence to Aid Decision-Making in Kidney Allocation

In kidney transplantation, pairing recipients with the highest longevity with low-risk allografts to optimize graft-donor survival is a complex challenge. Current risk prediction models exhibit limited discriminative and calibration capabilities and have not been compared to modern decision-assisting tools. We aimed to develop a highly accurate risk-stratification index using artificial intelligence (AI) techniques. Using data from the UNOS database (156,749 deceased kidney transplants, 2007-2021), we randomly divided transplants into training (80%) and validation (20%) sets. The primary measure was death-censored graft survival. Four machine learning models were assessed for calibration (integrated Brier score [IBS]) and discrimination (time-dependent concordance [CTD] index), compared with existing models. We conducted decision curve analysis and external validation using UK Transplant data. The Deep Cox mixture model showed the best discriminative performance (area under the curve [AUC] = 0.66, 0.67, and 0.68 at 6, 9, and 12 years post-transplant), with CTD at 0.66. Calibration was adequate (IBS = 0.12), while the kidney donor profile index (KDPI) model had lower CTD (0.59) and AUC (0.60). AI-based D-TOP outperformed the KDPI in evaluating transplant pairs based on graft survival, potentially enhancing deceased donor selection. Advanced computing is poised to influence kidney allocation schemes.

Coronary Artery Calcium Score Predicts Major Adverse Cardiovascular Events in Stable Chest Pain

Background Coronary artery calcium (CAC) has prognostic value for major adverse cardiovascular events (MACE) in asymptomatic individuals, whereas its role in symptomatic patients is less clear. Purpose To assess the prognostic value of CAC scoring for MACE in participants with stable chest pain initially referred for invasive coronary angiography (ICA). Materials and Methods This prespecified subgroup analysis from the Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial, conducted between October 2015 and April 2019 across 26 centers in 16 countries, focused on adult patients with stable chest pain referred for ICA. Participants were randomly assigned to undergo either ICA or coronary CT. CAC scores from noncontrast CT scans were categorized into low, intermediate, and high groups based on scores of 0, 1-399, and 400 or higher, respectively. The end point of the study was the occurrence of MACE (myocardial infarction, stroke, and cardiovascular death) over a median 3.5-year follow-up, analyzed using Cox proportional hazard regression tests. Results The study involved 1749 participants (mean age, 60 years ± 10 [SD]; 992 female). The prevalence of obstructive coronary artery disease (CAD) at CT angiography rose from 4.1% (95% CI: 2.8, 5.8) in the CAC score 0 group to 76.1% (95% CI: 70.3, 81.2) in the CAC score 400 or higher group. Revascularization rates increased from 1.7% to 46.2% across the same groups (P < .001). The CAC score 0 group had a lower MACE risk (0.5%; HR, 0.08 [95% CI: 0.02, 0.30]; P < .001), as did the 1-399 CAC score group (1.9%; HR, 0.27 [95% CI: 0.13, 0.59]; P = .001), compared with the 400 or higher CAC score group (6.8%). No significant difference in MACE between sexes was observed (P = .68). Conclusion In participants with stable chest pain initially referred for ICA, a CAC score of 0 showed very low risk of MACE, and higher CAC scores showed increasing risk of obstructive CAD, revascularization, and MACE at follow-up. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Hanneman and Gulsin in this issue.

Effect of Body Mass Index on Effectiveness of CT versus Invasive Coronary Angiography in Stable Chest Pain: The DISCHARGE Trial

Background Recent trials support the role of cardiac CT in the evaluation of symptomatic patients suspected of having coronary artery disease (CAD); however, body mass index (BMI) has been reported to negatively impact CT image quality. Purpose To compare initial use of CT versus invasive coronary angiography (ICA) on clinical outcomes in patients with stable chest pain stratified by BMI category. Materials and Methods This prospective study represents a prespecified BMI subgroup analysis of the multicenter Diagnostic Imaging Strategies for Patients with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial conducted between October 2015 and April 2019. Adult patients with stable chest pain and a CAD pretest probability of 10%-60% were randomly assigned to undergo initial CT or ICA. The primary end point was major adverse cardiovascular events (MACE), including cardiovascular death, nonfatal myocardial infarction, or stroke. The secondary end point was an expanded MACE composite, including transient ischemic attack, and major procedure-related complications. Competing risk analyses were performed using the Fine and Gray subdistribution Cox proportional hazard model to assess the impact of the relationship between BMI and initial management with CT or ICA on the study outcomes, whereas noncardiovascular death and unknown causes of death were considered competing risk events. Results Among the 3457 participants included, 831 (24.0%), 1358 (39.3%), and 1268 (36.7%) had a BMI of less than 25, between 25 and 30, and greater than 30 kg/m2, respectively. No interaction was found between CT or ICA and BMI for MACE (P = .29), the expanded MACE composite (P = .38), or major procedure-related complications (P = .49). Across all BMI subgroups, expanded MACE composite events (CT, 10 of 409 [2.4%] to 23 of 697 [3.3%]; ICA, 26 of 661 [3.9%] to 21 of 422 [5.1%]) and major procedure-related complications during initial management (CT, one of 638 [0.2%] to five of 697 [0.7%]; ICA, nine of 630 [1.4%] to 12 of 422 [2.9%]) were less frequent in the CT versus ICA group. Participants with a BMI exceeding 30 kg/m² exhibited a higher nondiagnostic CT rate (7.1%, P = .044) compared to participants with lower BMI. Conclusion There was no evidence of a difference in outcomes between CT and ICA across the three BMI subgroups. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article.

Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial

OBJECTIVES

To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status.

MATERIALS AND METHODS

This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications).

RESULTS

Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy.

CONCLUSION

For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers.

CLINICAL RELEVANCE STATEMENT

This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02400229.

KEY POINTS

• No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.

Computed Tomography Versus Invasive Coronary Angiography in Patients With Diabetes and Suspected Coronary Artery Disease

OBJECTIVE

To compare cardiac computed tomography (CT) with invasive coronary angiography (ICA) as the initial strategy in patients with diabetes and stable chest pain.

RESEARCH DESIGN AND METHODS

This prespecified analysis of the multicenter DISCHARGE trial in 16 European countries was performed in patients with stable chest pain and intermediate pretest probability of coronary artery disease. The primary end point was a major adverse cardiac event (MACE) (cardiovascular death, nonfatal myocardial infarction, or stroke), and the secondary end point was expanded MACE (including transient ischemic attacks and major procedure-related complications).

RESULTS

Follow-up at a median of 3.5 years was available in 3,541 patients of whom 557 (CT group n = 263 vs. ICA group n = 294) had diabetes and 2,984 (CT group n = 1,536 vs. ICA group n = 1,448) did not. No statistically significant diabetes interaction was found for MACE (P = 0.45), expanded MACE (P = 0.35), or major procedure-related complications (P = 0.49). In both patients with and without diabetes, the rate of MACE did not differ between CT and ICA groups. In patients with diabetes, the expanded MACE end point occurred less frequently in the CT group than in the ICA group (3.8% [10 of 263] vs. 8.2% [24 of 294], hazard ratio [HR] 0.45 [95% CI 0.22-0.95]), as did the major procedure-related complication rate (0.4% [1 of 263] vs. 2.7% [8 of 294], HR 0.30 [95% CI 0.13 - 0.63]).

CONCLUSIONS

In patients with diabetes referred for ICA for the investigation of stable chest pain, a CT-first strategy compared with an ICA-first strategy showed no difference in MACE and may potentially be associated with a lower rate of expanded MACE and major procedure-related complications.

Presence of SARS-CoV-2-like coronaviruses in bats from east coast Malaysia

Most of the public health importance coronaviruses, such as Severe acute respiratory syndrome coronavirus (SARS-CoV), Middle East respiratory syndrome coronavirus (MERS-CoV) and SARS-CoV-2 are likely originated from bats and spread to humans through intermediate hosts; civet cats, dromedary camel and Malayan pangolin, respectively. SARS-CoV-2-like coronaviruses were detected in Thailand, which is neighbouring with Kelantan in East Coast Malaysia. To date, there is no report on the presence of public health concerns (SARS-CoV, SARS-CoV-2 and MERS-CoV) coronaviruses in bats from Malaysia. This study was aimed to elucidate the presence of these coronaviruses in bat samples from East Coast, Malaysia. A total of hundred seventy oropharyngeal swab samples were collected from three states of East Coast Malaysia. Reverse Transcription-Polymerase Chain Reaction (RT-PCR) was conducted based on partial 3' Untranslated region (3'UTR) or ORF10 gene and the products were sequenced. The sequences were compared with all coronavirus sequences from the National Center for Biotechnology Information-GenBank (NCBI-GenBank) using NCBI-Basic Local Alignment Search Tool (NCBI-BLAST) software. A phylogenetic tree was constructed to determine the genetic relationship among the detected coronaviruses with the reference coronaviruses from the NCBI-GenBank. Our results showed that SARSCoV-2-like viruses were present in 3% (5/170) of the bats from East Coast Malaysia that have 98-99% sequence identities and are genetically related to SARS-CoV-2 from humans. This finding indicates the presence of SARS-CoV-2-like viruses in bats from East Coast Malaysia that may become a public health concern in the future.

A81 OPTIMIZING THE INDICATIONS FOR BILIARY STENT PLACEMENT IN PATIENTS WITH CBD STONES: A QUALITY IMPROVEMENT INITIATIVE TO ENHANCE PATIENT CARE AND REDUCE HEALTHCARE RESOURCE UTILIZATION

Background

A retrospective chart audit was performed to review biliary stent utilization from January 2020 to 2021 at the University of Alberta Hospital (UAH). Inappropriate stent usage was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this clinical practice, a quality improvement (QI) initiative was developed and completed.

Purpose

To reduce the number of inappropriately inserted biliary stents in patients with CBD stones.

Method

The results of the chart audit (pre-intervention) were shared with the ERCP group. The QI intervention was to align biliary stent insertion in accordance with published guidelines. A chart audit (post-intervention) was then performed on all ERCPs from July, 2021 to June, 2022. The indication for biliary stent insertion was assessed independently by two blinded reviewers.

Result(s)

A total of 661 patients (337 F) with mean age of 59±19 years (range 12-98 years) underwent 885 ERCPs during this post-intervention period. Of the 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared to the pre-intervention year (223/598, 37%, p=ns). However, only 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the pre-intervention year (p<0.0001). This accounts for a 75% reduction in overall unnecessary stent placement. This reduction was mainly seen in the CBD stone subgroup, where there was an 88% reduction in inappropriate biliary stent placement compared to the pre-intervention year (8/384, 2% vs. 61/376, 16%, p<0.0001).

Image

Conclusion(s)

Education to align practice in accordance with published guidelines has demonstrated a significant improvement in biliary stent insertion during ERCP in patients with CBD stones. This has resulted in significantly fewer inappropriate stent placements, a reduction in unnecessary follow-up ERCPs, and an overall saving of healthcare resources.

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Disclosure of Interest

None Declared

A78 BILIARY STENT USE IN ERCP: A QUALITY ASSURANCE STUDY ASSESSING ADHERENCE TO CLINICAL GUIDELINES AND COST OUTCOMES

Background

A perceived increase in the use of biliary stents during endoscopic retrograde cholangiopancreatography (ERCP) was observed by our nursing team leader and brought to the attention of the Director of Endoscopy.

Purpose

To assess a) biliary stent utilization during ERCP, b) the adherence for stent placement based on published guidelines, and c) the associated cost.

Method

A chart review of all consecutive patients that underwent ERCP for one year (January 2020 to 2021) at the University of Alberta Hospital (UAH) was performed. The need for biliary stent placement was assessed independently by two blinded reviewers and compared with published guidelines. Costs were calculated using Alberta Health Services fee codes.

Result(s)

A total of 598 patients (316 F) with mean age of 60±19 years (range 3-99 years) underwent 842 ERCPs. Clinical indications for the initial ERCP were common bile duct (CBD) stones (376, 63%), malignant stricture (84, 14%), benign stricture (49, 8%), bile leak (27, 5%), stent removal (15, 3%), and others (47, 8%). Of the 244 patients that had a follow-up ERCP, the most common indications were stent removal (126, 52%), stent replacement (61, 25%), stent placement (28, 11%), and stone extraction (8, 3%). A total of 296 biliary stents were inserted, of which 223 stents (114 plastic, 109 metal) were inserted during the first ERCP (223/598, 37%) and 73 stents (43 plastic, 30 metal) during follow-up ERCP (73/244, 30%).

Of the 296 stents, 79 (27%) were inserted for indications not in accordance with published guidelines (63/223 initial ERCP, and 16/73 follow-up ERCP, kappa=0.62). Most of these were placed in CBD stone cases (61/63 initial ERCP, 6/16 follow-up ERCP). In the subgroup of 376 patients with CBD stones, 61 (16%) underwent stent placement not in accordance with published guidelines. The added cost of such stent insertions and follow-up ERCPs for stent removal was $130,000.

Conclusion(s)

Stent insertion not in accordance with published guidelines was identified in some patients with CBD stones presenting for ERCP. To reduce unnecessary follow-up procedures and healthcare resource utilization, ERCP stent insertion education based on published guidelines, as well as regular practice audit and feedback are required.

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Disclosure of Interest

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A290 PHENOTYPE AND OUTCOME OF PATIENTS HOSPITALIZED FOR ACUTE PANCREATITIS IN A TERTIARY PEDIATRIC CENTER

Background

A recent meta-analysis of 48 studies, showed an equal prevalence of AP (16%) among the following etiologies; systemic disease, alcohol, medication, genetics, gallstones and infection in North American hospitalized and ambulatory pediatric patients. However, data on the epidemiology of severe pediatric acute pancreatitis (AP) in Canada are lacking.

Purpose

We aim to evaluate the clinical presentation, etiologies, comorbidities and outcome of pediatric patients with AP admitted to a tertiary hospital in Quebec, Canada.

Method

A retrospective observational cohort study (January 2014-December 2021) was performed at the CHU Sainte-Justine. Descriptive analyses were performed with SAS statistical softwar

Result(s)

Among the 214 patients included (110 (51%) males), 58 (27.1%) were already hospitalized at time of AP diagnosis (AP as secondary diagnosis) while 156 (72.9%) were admitted from the emergency room mainly with a presentation of abdominal pain (AP as primary diagnosis). Thirty-two patients (15.0%) were transferred to the ICU due to hemodynamic instability or respiratory failure. Comorbidities included cancer (38 patients (17.7%)), obesity (17 (7.9%)) and inflammatory bowel disease (15 (7.0%)). The three most commonly identified etiologies were medication (19.6%), biliary disease (16.3%) and infection (14,9%). Despite extensive investigations, 26.2% of cases were idiopathic. The main complications were, ascites (48 patients (22.4%)), necrotic pancreatitis (10 (4.6%)) and pancreatic pseudocyst (10 (4.6%)). The median duration of hospitalization for AP as a primary diagnosis was 4 days (interquartile range (IQR) 2-7) as compared to 22 (11-37) for AP as a secondary diagnosis.

Conclusion(s)

Approximately one third of hospitalized patients had an underlying condition requiring treatments that could cause AP, which explains the high prevalence of drug-induced AP in this report. The longest hospitalizations were associated with AP as secondary diagnosis. Ongoing work will identify factors associated with disease severity and outcome in particular in primary AP.

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Disclosure of Interest

None Declared

A127 TIMING OF CHOLECYSTECTOMY AFTER ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN A TERTIARY CENTRE: EVALUATION OF OUTCOMES

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for patients with choledocholithiasis. Early cholecystectomy (within 24 to 72 hours) is recommended after the initial ERCP to reduce the risk of subsequent biliary events.

Purpose

To investigate the timing of cholecystectomy after ERCP in patients with choledocholithiasis and its associated outcomes in a single tertiary care centre.

Method

This is a retrospective analysis of adult patients who underwent cholecystectomy after ERCP from August 2021 to April 2022 at the University of Alberta Hospital. Outcomes data were stratified according to the length of time between ERCP and cholecystectomy, within 72 hours (early) or after 72 hours (delayed).

Result(s)

During the study period, 55 subjects were examined. Indications for ERCP included gallstone pancreatitis (24/55, 44%), choledocholithiasis (19/55, 34%), and acute cholangitis (12/55, 21%).

In total, 30 (55%) subjects received cholecystectomy within 72 hours, while 25 (45%) subjects received cholecystectomy after 72 hours. The two groups were comparable in age, sex ratios, and comorbidities. Out of the patients who received cholecystectomy after 72 hours, 8 (32%) subjects received their cholecystectomy on a subsequent admission. Of these, 2 subjects developed recurrent biliary events before their cholecystectomy, and 1 subject required a conversion to open cholecystectomy. There were no recurrent biliary events amongst the individuals with early cholecystectomy.

Subjects who received early cholecystectomy had a shorter total hospital stay compared to those with delayed cholecystectomy (4.5 days vs 7.3 days, p=0.0002). There was no significant difference between early and late cholecystectomy in conversion rate (3% vs 8%, p=0.58), average operating time (86min vs 83min, p=0.79), intraoperative complications including adhesions (13% vs 12%, p>0.05) and empyema (27% vs 28%, p>0.05), as well as histological rate of chronic cholecystitis (88% vs 92%, p=0.68).

Reasons associated with significantly delayed (>7 days) cholecystectomy after ERCP (n=12) include requiring coordination/consultation with other services prior to operation (3 subjects), prolonged course of gallstone pancreatitis (3 subjects), poor candidate for operation due to comorbidities (2 subjects), surgical cancellation/delays (2 subjects), post-ERCP pancreatitis (1 subject), and patient preference (1 subject).

Image

Conclusion(s)

Early cholecystectomy is associated with a shorter length of hospital stay and absence of recurrent biliary events. Other post-cholecystectomy outcomes were comparable. Early laparoscopic cholecystectomy should continue to be encouraged through an interdisciplinary approach.

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Disclosure of Interest

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Vanillin-Based Indolin-2-one Derivative Bearing a Pyridyl Moiety as a Promising Anti-Breast Cancer Agent via Anti-Estrogenic Activity

The structure-based design introduced indoles as an essential motif in designing new selective estrogen receptor modulators employed for treating breast cancer. Therefore, here, a series of synthesized vanillin-substituted indolin-2-ones were screened against the NCI-60 cancer cell panel followed by in vivo, in vitro, and in silico studies. Physicochemical parameters were evaluated with HPLC and SwissADME tools. The compounds demonstrated promising anti-cancer activity for the MCF-7 breast cancer cell line (GI = 6-63%). The compound with the highest activity (6j) was selective for the MCF-7 breast cancer cell line (IC₅₀ = 17.01 μM) with no effect on the MCF-12A normal breast cell line supported by real-time cell analysis. A morphological examination of the used cell lines confirmed a cytostatic effect of compound 6j. It inhibited both in vivo and in vitro estrogenic activity, triggering a 38% reduction in uterine weight induced by estrogen in an immature rat model and hindering 62% of ER-α receptors in in vitro settings. In silico molecular docking and molecular dynamics simulation studies supported the stability of the ER-α and compound 6j protein-ligand complex. Herein, we report that indolin-2-one derivative 6j is a promising lead compound for further pharmaceutical formulations as a potential anti-breast cancer drug.

Detection of pathogenic Vibrio species and antibiogram activity in Asian Seabass (Lates calcarifer) in Tumpat, Kelantan

Some of Vibrio species is well known as pathogenic bacteria in aquaculture and the marine industry. Its infection is able to generate a massive outbreak and affect the fish population, especially for net caged fish such as seabass. This study was conducted to investigate the prevalence of Vibrio spp. isolated from seabass (Lates calcarifer) in Sri Tujuh Lagoon, Tumpat, Kelantan. Then, to determine the antibiotic resistance in Vibrio isolates. Polymerase chain reaction (PCR) was used to detect Vibrio species using specific primer VR169 and VR744 with estimation base pair size band, 597 bp and further identified by sequencing. On the other hand, antibiotic susceptibility tests were continued by using 13 types of antibiotics; kanamycin (K30), chloramphenicol (C30), neomycin (N10), ampicillin (AMP10), nitrofurantoin (F300), tetracycline (TE30), streptomycin (S10), norfloxacin (NOR10), ciprofloxacin (CIP5), nalidixic acid (NA30), gentamicin (CN10), doxycycline (DO30) and sulfamethoxazole (SXT100). As a result, 14 Vibrio isolates were identified, including Vibrio fluvialis (n=6), Vibrio parahaemolyticus (n=3), Vibrio harveyi (n=2) and each isolate for Vibrio vulnificus, Vibrio alginolyticus and Vibrio spp. The results showed that all isolates were sensitive to most antibiotics except ampicillin, neomycin and streptomycin. The MAR index value was ranging from 0 to 0.31. This study demonstrates the prevalence of Vibrio spp. in seabass and the report on multidrug resistance strains that could be of concern to the fish farmers. In addition, data from this study can be further used in fish disease management plans.

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality

Background

The COVID-19 pandemic had a significant impact on the quality of healthcare provision across all specialities and disciplines. However, there are limited data on the scale of its disruption to cardiac procedure activity from a national perspective and whether procedural outcomes different before and during the COVID-19 pandemic.

Methods

Major cardiac procedures (n=374,899) performed between 1st January and 31st May for the years 2018, 2019 and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression modelling was undertaken to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period (vs. pre-COVID).

Results

There was a deficit of 45,501 procedures during the COVID period compared to the monthly averages (March-May) in 2018–2019. Cardiac catheterisation and cardiac electronic device implantations were the most affected in terms of numbers (n=19,637 and n=10,453) while surgical procedures including mitral valve replacement, other valve replacement/repair, atrial and ventricular septal defect repair, and CABG were the most affected as a relative percentage difference (D) to previous years' averages. TAVR was the least affected (D-10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterisation (OR 1.25 95% confidence interval (CI) 1.07–1.47, p=0.006) and cardiac device implantation (OR 1.35 95% CI 1.15–1.58, p&lt;0.001).

Conclusion

There was a significant decline in national cardiac procedural activity in England during the COVID-19 pandemic, with a deficit in excess of 45000 procedures over the study period. However, there was no increase in risk of mortality for most cardiac procedures performed during the pandemic. While health service pressures are gradually easing given the increased roll out of vaccination and decline in infection rates, there is a need for major restructuring of cardiac services deal with this significant backlog of procedures, which would inevitably impact longer-term morbidity and mortality.

Funding Acknowledgement

Type of funding sources: None.

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.

MO700: Outcomes of Remote Patient Monitoring among Peritoneal Dialysis Population in the Covid-19 ERA

BACKGROUND AND AIMS

Automated peritoneal dialysis (APD) is a growing PD modality but as with other home dialysis methods, the lack of monitoring of patients' adherence to prescriptions is a limitation with potential negative impact on clinical outcome parameters. Remote patient monitoring (RPM-PD) allowing the clinical team to have access to dialysis data and adjust the treatment may overcome this limitation. As a result of the coronavirus disease 2019 (COVID-19) pandemic, the importance of RPM programs has raised to allow the physicians ensure optimal care of PD patients. In addition, to avoid the increased risk of complications or technique failure, the present study sought to determine clinical outcomes associated with RPM use in patients on APD therapy.

METHOD

We performed a systematic review in PubMed, MEDLINE, Embase and Cochrane databases to select studies that met the inclusion criteria. The search terms used were: peritoneal dialysis, remote monitoring, sharesource, outcomes, peritonitis, hospitalization, technique failure and adherence. These search terms were individually used and then combined in different databases. References within the chosen studies were reviewed. We followed the recommendations of Cochrane collaboration and the Quality of Reporting of Meta-analyses guidelines. STATA package-15 was used. We combined all study-specific estimates using inverse-variant weighted averages of logarithmic relative risk in random effects model. Confidence interval including the value of 1 was used evident for statistically significant estimate. Heterogeneity was evaluated using the Higgins I² statistic. Heterogeneity was estimated when the level of P-value was &lt; 0.1. Results of the random effects model were spread out on the forest plot graph.

RESULTS

Twenty-two studies were included in our meta-analysis. In qualitative analysis: five studies showed that RPM in APD patients had lower hospitalization rates compared to traditional PD. Five studies showed better adherence in the RPM-PD group. Five studies showed better outcomes among RPM-APD patients in terms of symptom control, management of fluid balance, blood pressure control, dialysis prescription and electrolyte management. Five studies showed that RPM-APD had better outcomes in terms of patient independence, quality of life, patient and caregiver satisfaction. Five studies showed better cost-effectiveness in RPM-PD compared to traditional PD. Four studies showed better cost-effectiveness in RMP-PD. Three studies showed lower technique failure rates in RPM-PD compared to traditional PD. Three studies showed lower mortality rates in RPM-PD compared to traditional PD. Three studies showed better quality of life and patient satisfaction in RPM-PD. In quantitative analysis, RPM-PD patients had lower rates of technique failure (log relative risk = −0.32, 95% CI: −0.59 to −0.04), lower hospitalization rates (SMD = −0.84, 95% CI: −1.24 to −0.45), lower mortality rates (log RR = −0.26, 95% CI: −0.44 to −0.08) in comparison to traditional PD.

CONCLUSION

RPM-PD has better outcomes in terms of cost-effectiveness, patient adherence, hospital admissions, rate of peritonitis, technique failure, mortality rates, symptom control, quality of life, patient and caregiver satisfaction.

MO994: Impact of Hla-A, B DR and DQ on renal transplant outcomes in the Tacrolimus/Mmf Era: An Artificial Intelligence Approach

BACKGROUND AND AIMS

One of the biological barriers that can increase risk of acute rejection in kidney transplantation is HLA mismatch. Several immunotherapy protocols have been implemented to reduce the effect of HLA-mismatch and improve outcomes. The aim of our study is to assess the effect of HLA mismatches on acute rejection rates in the Tacrolimus era.

METHOD

All kidney transplant patients registered in UNOS database between 1 January 2005 and 1 December 2019 were retrospectively reviewed. Inclusion criteria: deceased donor transplants that were discharged on Tacrolimus/Mycophenolate Mofetil. Exclusion criteria: multiple organ transplants, previous kidney transplants, recipient age &lt;18 years old, living donor transplants, patients not discharged on Tacrolimus/Mycophenolate Mofetil immunotherapy, missing HLA mismatch or ABO incompatible transplant. We used double-selection lasso (‘least absolute shrinkage and selection operator) logistic regression model to assess for the effect of HLA-A, B, DR and DQ on acute rejection rates at one-year post-transplant. We used square-root lassos for the variables of interest. Variables of interest were HLA-A, B, DR and DQ mismatch. Variables Lasso selected from were: recipient characteristics (age, sex, BMI, ethnicity, diabetes, recipient/donor CMV status, time on dialysis), donor characteristics (KDPI score) and transplant characteristics (type of induction therapy, steroid therapy at time of discharge, cold ischemia time, delayed graft function, PRA). For survival analysis, we fit a penalized Cox model to the entire set of data and obtained the estimated set of alphas. The variables included in the penalized cox model donor, recipient and transplant factors in addition to the HLA mismatches. Then we determined the set of alpha for evaluation using optimized cross-validated grid-search. Moreover, we visualized how the coefficients changed for varying α using ridge regression model.

RESULTS

About 73 910 were included in our study. Worse acute rejection rates at one-year post-transplant were noted with incremental increase in HLA-DQ (Two HLA-DQ: OR = 1.56, P = 0.005, 95%CI: 1.04–1.27; One HLA DQ: OR = 1.15, P = 0.01, 95%CI: 1.03–1.24), HLA-DR mismatches (two HLA-DR: HR = 1.46, P &lt; 0.01, 95%CI: 1.31–1.62; One HLA-DR: OR = 1.29, P &lt; 0.01, 95%CI: 1.16–1.43), and Two HLA-A (OR = 1.12, P = 0.049, 95%CI: 1.0006–1.26). However, the effect of different HLA-mismatches on death-censored graft survival were minimal (HLA-DQ coefficient: 0.003, HLA-DR coefficient: 0.05, HLA-A coefficient: 0.008 and HLA-B coefficient: 0.007). Mean follow-up time was 3.79 years. Figure 1 shows the visualisation of coefficients among different alphas for the ridge penalised cox regression model.

CONCLUSION

HLA-DQ, DR and A mismatches still play a vital role in the occurrence of acute rejection in the Tacrolimus/MMF era. However, the effect of HLA mismatches on the graft survival is minimal.

MO993: Incidence of Ptld and Its Relationship with Cmv-Serostatus Positivity Among Childhood and Adulthood Population: A Registry Data Study

BACKGROUND AND AIMS

It is unknown how the epidemiology of post-transplant lymphoproliferative disease (PTLD) and its relationship with CMV infection differ between adult and pediatric kidney transplant recipients. In addition, with current advancements in immunosuppressive therapy, the incidence of PTLD has changed dramatically. The aim of our study is to elucidate the relationship between PTLD and CMV infection. Moerover, to assess the incidence of PTLD among Adult and pediatric renal transplant patients in the current era.

METHOD

All renal transplant patients registered in the Organ Procurement and Transplantation Network between 2005 and 2019 were retrospectively reviewed. Patient were followed up till December 2020. Patients who had multiple organ transplant or those with previous renal transplants were excluded from the study. Data about recipient factors (age, sex ethnicity, diabetes, CMV serostatus, and EBV serostatus), donor factors (living or deceased), transplant factors (PRA, Cold ischemia time, HLA mismatches, induction and immunosuppressive therapy) were reviewed. Incidence rate of PTLD at one year and five years post-transplant were calculated among the Adult and Pediatric population. Univariate and Multivariate cox-hazard regression models were performed to assess the relationship between CMV serostatus and occurrence of PTLD.

RESULTS

About 10 947 pediatric renal transplant patients were included. About 315 pediatric patients developed PTLD during the follow-up time (2.88%). About 50.55% of PTLD occurred within the first-year post-transplant. 60% occurred within two-year post-transplant, while 80.63% of them occurred within five years post-transplant. CMV recipient infection was not associated with PTLD occurrence in the pediatric population (HR = 0.88, Pvalue = 0.81, 95% confidence interval ranged between 0.66 and 1.18). Proportional hazard assumption was not violated with P = 0.55. Among the adult population, 1990/277 955 developed PTLD (0.77%). About 25.77% of PTLD among the adult population occurred within the first-year post-transplant. About 39.39% of PTLD in the adult occurred within two-year post-transplant. About 66.55% of PTLD in the adult occurred within five-years post-transplant. CMV recipient positive serostatus was associated with a protective effect against occurrence of PTLD (HR = 0.82, Pvalue &lt;0.01, 95% confidence interval ranged between 0.73 and 0.94). The most common type of PTLD among the pediatric and adult population was monomorphic PTLD ( 40% and 34%, respectively).

CONCLUSION

PTLD is a rare complication of renal transplantation in the current era. The risk of development of PTLD is highest during the first-year post-transplant. CMV recipient positive serostatus has a protective effect against development of PTLD.

MO992: Is It Safe to Receive Kidneys from Deceased Kidney Donors Who Tested Positive for Covid-19 Infection?

BACKGROUND AND AIMS

Our modern world is facing extraordinary circumstances while passing through a serious pandemic caused by the novel coronavirus (COVID-19) which may lead to multi-organ system failure and death. COVID-19 deaths may provide a potential source for kidneys available for transplantation. In our study, we are discussing the safety of receiving kidneys from donors who tested positive for the novel coronavirus.

METHOD

All renal transplant recipients registered in UNOS database who had their transplants between 1 March 2020 and 1 June 2021 were retrospectively reviewed. Patients who received kidney transplants from a deceased donor with positive PCR of COVID-19 test were included in our study. Patients were followed up till 1 July 2021. Data about recipient factors (age, sex, ethnicity, diabetes and date of renal transplant), transplant factors (type of induction therapy, maintenance immunosuppressive therapy, delayed graft functions, early post-operative rejection episodes, HLA mismatch, PRA level and cold ischemia time) and donor factors (age, sex, ethnicity, diabetes, hypertension, date of COVID-19 test and type of COVID-19 test) were collected. Outcome measured were post-transplant hospitalisation, acute rejection, delayed graft function, patient, and graft survival till the end of the follow-up.

RESULTS

Eighty-six transplant patients received kidneys from deceased donors who tested positive for COVID-19 infection using PCR test. Sixty patients received kidneys from deceased patients who tested positive for COVID-19 within 30 days pre-transplant. Twenty-six patients received kidneys from deceased patients who tested positive for COVID-19 between 30 and 90 days pre-transplant. Number of post-transplant hospitalisation and acute rejection episodes were nil. 19.76% of the patients had delayed graft functions. Graft loss occurred in one patient due to graft vein thrombosis. Patient survival was 100%.

CONCLUSION

Receiving kidneys from deceased donors who tested positive for COVID-19 infection seems safe and does not affect hospitalisation, acute rejection rates, graft or patient survival. Longer follow-up is needed to confirm our results.

Dating Ultrasounds are Fundamental to Modern Obstetric Care

Aims Dating ultrasounds for all women remains a goal of the National Maternity Strategy. We sought to examine the utility of guideline based first trimester scanning when performed in a tertiary maternity unit. Methods A retrospective review of all public dating ultrasound scans was preformed over a one year period. Results 6,077 scans were reviewed. Viability was confirmed in 97.9% (n=5953), 1.5% (n=94) were deemed non-viable, and 0.48% (n=29) required follow up for uncertain viability. There were 97.9% (n=5,951) singleton pregnancies, 1.8% (n=112) multiple pregnancies, and 0.2% (n=14) with an absent fetal pole. Of those attending for a first dating ultrasound, 81.7% (n=4,966) were between 10 and 13+6 weeks. 16% (n=977) of women relied on dating scans rather than last menstrual period (LMP) to estimate gestational age. Overall, the mean difference between ultrasound scan and recalled menstrual dates was 3.9 gestational days. Other findings of significance included 0.4% (n=25) pregnancies with fetal anomalies diagnosed and 1.2% (n=78) of women were reported as having uterine anomalies. Conclusion Dating ultrasound confirms viability, pregnancy number and due date. These factors are the basis of antenatal care. This study reinforces the need for routine scanning of all pregnancies in the first trimester.

Ventilation support in SARS-CoV-2 pneumonia. Strategy and indications

The SARS-CoV2 pandemic has generated a need for knowledge, new concepts in pathophysiology and an increase of the use of respiratory support in highly complex patients. This fact has provoked the need to evolve to the concept of personalized ventilatory support according to the patient’s response to treatment.

385 Improving Neurosurgical Handover: A Quality Improvement Project

Aim

Efficient, succinct, and salient handover of current issues of surgical inpatients between doctors is an essential process which, if done ineffectively can contribute to patient harm. It was recognised that existing junior neurosurgical handover could be improved and using the Royal College of Surgeons’ and NICE guidelines for clinical handover we aimed to improve the existing handover system, improving doctor’s satisfaction with handover and patient safety.

Method

19 junior doctors on the SHO rota were surveyed to establish their perspective on the existing handover process. Based on this feedback, we redesigned handover combining national bodies’ guidance and local ideas. We resurveyed following these changes to measure improvement.

Results

Initial results showed only 36 % of junior doctors were satisfied with the existing handover procedure and only 50.5% felt the existing handover was safe. After these changes there was a 44% improvement in satisfaction with handover and a 24% improvement in the perceived safety of the handover process.

Conclusions

Handovers should be optimised to improve patient care and doctors working environment. We have improved our existing handover procedure increasing the perceived safety and doctor’s satisfaction of the handover process.

Needs assessment for health service design for people with back pain in a hospital setting: A qualitative study

BACKGROUND

There is a need for effective health service solutions to provide greater structure and support for implementing evidence-based practice in back pain care. Patient involvement in developing these solutions is crucial to increase relevance, acceptability and uptake.

OBJECTIVES

To determine patients' perceived needs and barriers to best-practice back pain care, and potential solutions to better address care needs. The study is the third in a series of needs assessment studies feeding into the 'idea generation' for service design in a large teaching hospital in a culturally and linguistically diverse community in metropolitan Sydney, Australia.

DESIGN

We conducted a combination of focus groups and in-depth interviews using an interpretive description approach. We used inductive thematic analysis to identify the main themes.

SETTING AND PARTICIPANTS

We purposively sampled patients with diverse characteristics from the neurosurgery and physiotherapy outpatient clinics, in particular those whose primary language was English, Arabic, Persian or Mandarin. Non-English audio recordings were translated and transcribed by bilingual researchers.

RESULTS

There were 24 participants (focus groups = 9; individual interviews = 15) when data saturation was reached. The analysis identified three key themes with several subthemes around what service designers needed to understand in helping people with back pain in this setting: (1) This is who I am; (2) It's not working for me; and (3) What I think I need.

DISCUSSION AND CONCLUSION

This study highlights that perceived unmet needs of patients are underpinned by unhelpful beliefs about the causes of and solutions for back pain, misaligned care expectations, unclear expectations of the hospital role and fragmentations in the health system. To design and implement a service that can deliver better back pain care, several solutions need to be integrated around: developing new resources that challenge unhelpful beliefs and set realistic expectations; improving access to education and self-management resources; focusing on individualized care; using a collaborative multidisciplinary approach within the hospital; and better connecting with and directing primary health care services.

PATIENT OR PUBLIC CONTRIBUTION

A consumer representative of the Western Sydney Local Health District provided input during study conceptualisation and is duly recognized in the Acknowledgements section.

Prognosticating outcome using magnetic resonance imaging in patients with moderate to severe traumatic brain injury: a machine learning approach

INTRODUCTION

Over the last decade advancements in computer processing have enabled the application of machine learning (ML) to complex medical problems. Convolutional neural networks (CNN), a type of ML, have been used to interrogate medical images for variety of purposes. In this study, we aimed to investigate the potential application of CNN in prognosticating patients with traumatic brain injury (TBI).

METHODS

Patients with moderate to severe TBI and evidence of diffuse axonal injury (DAI) were selected retrospectively. A CNN model was developed using a training subgroup and a holdout subgroup was used as a testing dataset. We reported the model characteristics including area under the receiver operating characteristic curve (AUC).

RESULTS

We included a total of 38 patient, of which we generated 725 MRI sections. We developed a CNN model based on a modified AlexNet architecture that interpreted the brain stem injury to generate outcome predictions. The model was able to predict GOS outcomes with a specificity of 0.43 and a sensitivity of 0.997. It showed an AUC of 0.917.

CONCLUSION

The utilization of machine learning MRI analysis for prognosticating patients with TBI is a valued method that require further investigation. This will require multicentre collaboration to generate large datasets.

Remission of T2DM by digital twin technology with reduction of cardiovascular risk: interim results of randomised controlled clinical trial

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): TWIN HEALTH INC

Background

 Twin Precision Treatment (TPT) is a novel intervention designed to improve glycemia and reverse T2D using a Whole-Body Digital Twin (WBDT) platform powered by Artificial Intelligence and the Internet of Things. Technology enabled precision nutrition, a combination of macro, micro and biota nutrients, along with Continuous Glucose Monitoring (CGM) have been demonstrated to be a key for reversal of diabetes. WBDT platform captures 174 health markers and 3000 daily data points through a panel of blood tests and connected devices that measure weight, physical activity, sleep and BP. CGM is used initially and then the algorithm predicts personalized glucose responses from multiple inputs. Nutritional, physical activity and sleep counseling is through an app or phone to provide individualized meal plans that balance 87 macro, micro and probiotic nutrients to reduce glucotoxicity and lipotoxicity. Program physicians titrate medications and monitor metabolic outcomes. 

Purpose

 To assess the initial change, in glycemic, extra glycemic, cardiovascular parameters for patients who completed 3 months longitudinal follow up.

Methods

 We performed an interim analysis [n = 173, 139 TWIN Intervention arm (T), 34 Control group (C)] of ongoing randomized controlled trial of TPT across India

Results

 The mean age (years) in the T was 43.04 (±8.6, 95% CI 41.57 to 44.52) which was significantly less as compared to the C 51.4 (±9.6, 95% CI 48.3 to 54.5); p &lt; 0.0001. The mean duration of diabetes (years) in the T was 3.5 (±2.6) which was comparable to the C 4.3 (±2.6); p = 0.12 ns. In the T there were 113 male (84.3%) and 21 female (15.6%) as compared to C, 15 male (38.4%) and 24 female (61.5%); p &lt; 0.0001. The difference of change for HbA1c (%), small dense LDL-C sdLDL (mg/dL), TG/HDL Ratio, HOMA 2IR (%), Visceral Adiposity Index (VAI), Systolic BP (mmHg), BMI (kg/m2), Framingham Risk Score (%), in T when compared to C, were significant. The mean reduction HbA1c, sdLDL, HOMA 2IR, VAI, SBP, BMI, FRS in T was -3.2 % (8.8 to 5.6), -14.1 mg/dL, (52.6 to 38.5), -0.9 % (1.9 to 1), -2.3 (4.6 to 2.3), -10.3mmHg (128.4 to 118.1), -2.9 kg/m2 (27.1 to 24.2), -7.9% (16 to 8.1), respectively. (figure) At baseline in T, mean daily intake of medication was 1.7 which reduced significantly (p &lt; 0.0001) to 0.05. 96 patients in T were able to stop anti-diabetic medications

Discussion

 The initial results are an early indicator for the translation of the scientific rationale for the technological intervention, through digital twin technology, powered by Internet of Things and Artificial Intelligence, as a modality to enable reversal of diabetes. TPT appears to have potential to mitigate the cardiovascular risk as assessed by Framingham Risk Score and modulate the non glycemic parameters, including BMI and SBP. However, larger, long-term studies would yield precise insights for the durability of the significant change that has been observed in this study Abstract Figure. Comparison for the Change in the Glycemi

Diabetes Mellitus and COVID-19: Review Article

BACKGROUND AND AIMS

We aim to cover most of the current evidence on the mutual effect of diabetes & COVID-19 infection on each other and the management of the COVID-19 patients with diabetes.

METHODS

We utilized databases to review the current evidence related to diabetes mellitus and COVID-19.

RESULTS

We discussed the most recent evidence of diabetes milieus and COVID-19 regarding risk factors, management, complications, and telemedicine.

CONCLUSION

Diabetes mellitus is associated with a significant risk of complications, extended hospital stays, and mortality in COVID-19 infected patients.

Coronavirus disease 2019 and renal transplantation

Ever since the severe acute respiratory syndrome virus causing coronavirus disease 2019 (COVID-19) struck the world, global health strategies have changed significantly. According to the Centers for Disease Control and Prevention, kidney transplant recipients are stratified as being high risk of developing fatal illness from COVID-19 infection. Kidney transplant is the gold-standard treatment for end-stage kidney disease subjects. During the pandemic, significant concerns have emerged regarding continuation of kidney transplant surgeries and management of kidney transplant recipients post-transplant. The added risk of immunosuppression in this cohort was and remains a theoretical concern, posing a potential risk of transplantation rather than benefit. This comprehensive review aims to cover most of the faced challenges in kidney transplantation in different stages of the pandemic. In addition, it will elucidate the epidemiology, nature, course of the disease, surgical consideration in donors and recipients as well as role of immunosuppression and management of COVID-19 infected kidney transplant recipients during these extraordinary circumstances.

ABO incompatibility in renal transplantation

ABO blood group incompatibility (ABO-I) was historically considered an absolute contraindication to kidney transplantation due to the significant risk of acute antibody-mediated rejection and early graft loss. Nevertheless, the urge to minimize the gap between the candidates’ number on the waitlist for kidney transplants and the available kidney donors encourage investigation into finding ways to use organs from ABO-I kidney donors, especially in the era of using more potent immunosuppression therapies. This review aims to discuss a general overview of ABO-I kidney transplantation and the different protocols adopted by some transplant centers to meaningfully overcome this barrier.

New-onset Type 1 Diabetes Mellitus with Diabetic Ketoacidosis and Pancreatitis in a Patient with COVID-19

Coronavirus Disease 2019 (COVID-19) had struck the world with health and economic catastrophes and recently with unusual autoimmune presentations, including new-onset Type 1 Diabetes.

Herein we present a 17-year-old male patient who presented to the outptient clinic with fever, palpitation, and cough of four-week duration; he was referred to the emergency room and was found to have DKA. CT of the chest showed ground-glass opacities suggestive of COVID-19 pneumonia, and abdominal cuts showed dilated intrahepatic biliary radicles with pancreatic loculations suggestive of pancreatitis. The patient was admitted to the ICU, started on intravenous fluids and insulin infusion then COVID-19 PCR returned positive. We hypothesize that SARS-CoV-2 has a vital role in eliciting an autoimmune response triggering type 1 diabetes, and further studies are needed to confirm this hypothesis. SARS-CoV-2 may cause pancreatitis, and the first presentation could be high blood sugar or DKA.

Current systematic reviews and meta-analyses of COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) has left a significant impact on the world's health, economic and political systems; as of November 20, 2020, more than 57 million people have been infected worldwide, with over 1.3 million deaths. While the global spotlight is currently focused on combating this pandemic through means ranging from finding a treatment among existing therapeutic agents to inventing a vaccine that can aid in halting the further loss of life.

AIM

To collect all systematic reviews and meta-analyses published related to COVID-19 to better identify available evidence, highlight gaps in knowledge, and elucidate further meta-analyses and umbrella reviews that are yet to be performed.

METHODS

We explored studies based on systematic reviews and meta-analyses with the key-terms, including severe acute respiratory syndrome (SARS), SARS virus, coronavirus disease, COVID-19, and SARS coronavirus-2. The included studies were extracted from Embase, Medline, and Cochrane databases. The publication timeframe of included studies ranged between January 01, 2020, to October 30, 2020. Studies that were published in languages other than English were not considered for this systematic review. The finalized full-text articles are freely accessible in the public domain.

RESULTS

Searching Embase, Medline, and Cochrane databases resulted in 1906, 669, and 19 results, respectively, that comprised 2594 studies. 515 duplicates were subsequently removed, leaving 2079 studies. The inclusion criteria were systematic reviews or meta-analyses. 860 results were excluded for being a review article, scope review, rapid review, panel review, or guideline that produced a total of 1219 studies. After screening articles were categorized, the included articles were put into main groups of clinical presentation, epidemiology, screening and diagnosis, severity assessment, special populations, and treatment. Subsequently, there was a second subclassification into the following groups: gastrointestinal, cardiovascular, neurological, stroke, thrombosis, anosmia and dysgeusia, ocular manifestations, nephrology, cutaneous manifestations, D-dimer, lymphocyte, anticoagulation, antivirals, convalescent plasma, immunosuppressants, corticosteroids, hydroxychloroquine, renin-angiotensin-aldosterone system, technology, diabetes mellitus, obesity, pregnancy, children, mental health_, smoking, cancer, and transplant.

CONCLUSION

Among the included articles, it is clear that further research is needed regarding treatment options and vaccines. With more studies, data will be less heterogeneous, and statistical analysis can be better applied to provide more robust clinical evidence. This study was not designed to give recommendations regarding the management of COVID-19.