Breast-Q sensory outcomes of non-neurotized, autologous, unilateral breast reconstruction with a minimum of 3-year follow-up

INTRODUCTION

Sensory reinnervation of autologous breast tissue after free flap reconstruction is highly variable. There is no long-term follow-up data exploring spontaneous reinnervation and how this affects patients' quality of life nor the nerve-related symptoms they experience. To address this issue, we invited patients with a minimum of 3 years after non-neurotized, free flap breast reconstruction to complete patient-reported outcome measures exploring sensation, quality of life and breast-related symptoms.

METHODS

We performed a retrospective cohort study of patients undergoing unilateral Muscle-Sparing Transverse Rectus Abdominus Muscle (MS-TRAM) or deep inferior epigastric artery perforator (DIEP) flap breast reconstruction between 01-01-2015 and 31-12-2019 in the Department of Plastic and Reconstructive Surgery at Manchester University NHS Foundation Trust. We invited participants to complete the recently developed Breast-Q© Breast Sensation Module.

RESULTS

All patients had undergone unilateral immediate (n = 85) or delayed (n = 82) breast reconstruction after mastectomy using either a free DIEP (n = 150) or TRAM (n = 17) flap reconstruction a minimum of 3 years prior. The median age at operation was 48. Sensation after reconstruction was significantly reduced in the reconstructed breast compared with the contralateral breast (P < 0.0001) with a reduction in reported quality of life (immediate (68.0 [54.0, 89.0]) and delayed (68.0 [62.0, 83.8])). The sensation was significantly better in immediate vs delayed procedures (P = 0.024). Sensory scores after reconstruction increased with age (P = 0.036).

DISCUSSION

Breast sensation after non-neurotized reconstruction with autologous tissue is significantly reduced at long-term follow-up with a reduction in quality of life. A minimum outcome set for quantification of breast sensation is required and future research into the cost-benefit of neurotized, autologous breast reconstruction is needed.

Using consensus methods to prioritize modifiable risk factors for development of manifestations of frailty in hospitalized older adults

AIM

The aim of the study was to reach consensus on modifiable risk factors for a novel system of care to address Manifestations of Frailty in hospitalized older adults.

DESIGN

Consensus study.

METHOD

A modified nominal group technique, incorporating expert group face-to-face interaction, review of existing evidence and pre/post-meeting questionnaire completion was undertaken November 2019-February 2020.

RESULTS

Seventy-one risk factors, within seven risk factor domains (pain, medication, fluid and nutrition intake, mobility, elimination, infection, additional patient factors) were considered. It was agreed that 44 risk factors incorporating patient, organizational and environmental risk factors were modifiable and should be included in a novel system of care.

Evaluation of data imputation strategies in complex, deeply-phenotyped data sets: the case of the EU-AIMS Longitudinal European Autism Project

An increasing number of large-scale multi-modal research initiatives has been conducted in the typically developing population, e.g. Dev. Cogn. Neur. 32:43-54, 2018; PLoS Med. 12(3):e1001779, 2015; Elam and Van Essen, Enc. Comp. Neur., 2013, as well as in psychiatric cohorts, e.g. Trans. Psych. 10(1):100, 2020; Mol. Psych. 19:659–667, 2014; Mol. Aut. 8:24, 2017; Eur. Child and Adol. Psych. 24(3):265–281, 2015. Missing data is a common problem in such datasets due to the difficulty of assessing multiple measures on a large number of participants. The consequences of missing data accumulate when researchers aim to integrate relationships across multiple measures. Here we aim to evaluate different imputation strategies to fill in missing values in clinical data from a large (total N = 764) and deeply phenotyped (i.e. range of clinical and cognitive instruments administered) sample of N = 453 autistic individuals and N = 311 control individuals recruited as part of the EU-AIMS Longitudinal European Autism Project (LEAP) consortium. In particular, we consider a total of 160 clinical measures divided in 15 overlapping subsets of participants. We use two simple but common univariate strategies—mean and median imputation—as well as a Round Robin regression approach involving four independent multivariate regression models including Bayesian Ridge regression, as well as several non-linear models: Decision Trees (Extra Trees., and Nearest Neighbours regression. We evaluate the models using the traditional mean square error towards removed available data, and also consider the Kullback–Leibler divergence between the observed and the imputed distributions. We show that all of the multivariate approaches tested provide a substantial improvement compared to typical univariate approaches. Further, our analyses reveal that across all 15 data-subsets tested, an Extra Trees regression approach provided the best global results. This not only allows the selection of a unique model to impute missing data for the LEAP project and delivers a fixed set of imputed clinical data to be used by researchers working with the LEAP dataset in the future, but provides more general guidelines for data imputation in large scale epidemiological studies.

AB1051 CLINICAL OUTCOMES AND HEALTHCARE RESOURCE UTILIZATION OF UNCONTROLLED GOUT PRIOR TO PEGLOTICASE THERAPY

Background

By definition, uncontrolled gout (UG) cannot be managed with oral urate lowering therapies (ULTs) and is associated with substantial morbidity. UG, also known as refractory gout, results in escalated treatment and management. Recent American College of Rheumatology guidelines recommend treating gout to serum uric acid targets; if targets are not achieved or patients continue to have symptoms, pegloticase is recommended. There is a paucity of data documenting the clinical and economic burden of UG patients.

Objectives

Assess clinical outcomes and healthcare resource utilization (HCRU) of UG prior to pegloticase initiation.

Methods

A retrospective observational database analysis was conducted among patients initiating pegloticase between April 1, 2011 and August 31, 2020 using the PharMetrics Plus database. Eligible subjects had ≥1 pegloticase claim (first claim = index date) and continuous enrollment for 24 months prior to index. Relevant clinical and economic (HCRU) outcomes were evaluated over a 24-month pre-index period and compared between two different time intervals prior to index: time interval 1 (Day -720 to Day -361) and time interval 2 (Day -360 to Day -1). Assessment of comorbid disease burden included Charlson Comorbidity Index (CCI) and relevant health conditions. Dependent pairwise comparisons were conducted to compare clinical and economic outcomes between time intervals prior to pegloticase initiation. To assess statistical differences, paired t-tests (continuous variables) or McNemar’s tests (categorical variables) were used.

Results

Of the 408 eligible subjects, most were male (88.5%), with an average age (SD) of 55.2 (11.3) years, 66.9% were between the ages of 45-64 years and 78.2% had a preferred provider organization (PPO) health plan. Most often (34.8% of patients), a rheumatologist was associated with initiation of pegloticase therapy, while primary care physicians accounted for 23.8% of initiations. Mean (SD) CCI score was 2.4 (2.4) with 37.3% of subjects having a CCI score of >3. Prevalence of relevant health conditions over the 24-month pre-index period included tophi (62.5%), urolithiasis (8.6%), chronic kidney disease (34.6%) and chronic pain/fibromyalgia (76.5%), all of which significantly increased from time interval 1 (Day -720 to Day -361) to time interval 2 (Day -360 to Day -1) prior to pegloticase initiation (Table 1). Of patients initiating pegloticase, 57.4% had 1 ULT (excluding probenecid), 11.3% had >2 ULT (excluding probenecid), and 10.3% UG patients had ≥1 probenecid claim over the 24-month pre-index period. Most patients (98.3%) had ≥1 physician office visit, 27.2% had ≥1 hospitalization and 45.3% had ≥1 emergency room (ER) visit over the 24-month pre-index period. HCRU significantly increased from time interval 1 to time interval 2, prior to pegloticase (Figure 1).

Table 1.

Relevant Health Conditions and Disease-specific Health Care Resource Utilization (HCRU)

Overall N= 408Time Interval 1Time Interval 2Tophi62.5%15.4%61.5%***Urolithiasis8.6%4.2%6.9%*Chronic kidney disease34.6%22.5%31.6%***Cardiovascular disease32.6%21.3%28.4%**Type 2 diabetes mellitus31.4%23.3%28.9%**Hypertension76.2%58.1%70.3%***≥1 gout flare87.7%48.5%83.8%***Mean number of gout flare (SD)3.5 (2.4)1.02.1***Gout-related medications ≥1 claim for colchicine56%39.5%63.7%***≥1 claim for opioids71%52.9%60.3%*≥1 claim for oral corticosteroids80%50.2%75.7%***≥1 claim for injectable corticosteroids64%38.5%53.7%***

†Time Interval 1: Day -720 to Day -361 prior to pegloticase initiation; ††Time Interval 2: Day -360 to Day -1 prior to pegloticase initiation

***, p<0.0001; **, p<0.001; *, p<0.05

Conclusion

Overall, these data demonstrate the progressive nature of UG as confirmed by significant increases in gout-related conditions and healthcare resource utilization prior to pegloticase initiation. Further research is needed on healthcare resource utilization among patients with UG post-pegloticase use.

Disclosure of Interests

Robert Morlock Consultant of: Horizon Therapeutics, Victoria Divino Grant/research support from: Horizon Therapeutics, Mitchell DeKoven Grant/research support from: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Atsuko Powers Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Naina Barretto Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Stephanie Taylor Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

Autistic People's Perinatal Experiences II: A Survey of Childbirth and Postnatal Experiences

Qualitative accounts indicate there are sensory and communication related barriers to adequate childbirth and postnatal healthcare for autistic people. However, little quantitative work has explored the topic. This online survey study explored childbirth and postnatal experiences among 384 autistic and 492 non-autistic people. Compared with non-autistic people, autistic people were more likely to find the sensory aspects of birth overwhelming, and experienced lower satisfaction with birth-related and postnatal healthcare. Autistic people were more likely to experience postnatal depression and anxiety. The findings highlight that sensory and communication adjustments should be made to birth and postnatal healthcare for autistic people. The findings indicate the need for greater autism understanding among professionals and greater postnatal mental health support for autistic people.

Brain charts for the human lifespan

Over the past few decades, neuroimaging has become a ubiquitous tool in basic research and clinical studies of the human brain. However, no reference standards currently exist to quantify individual differences in neuroimaging metrics over time, in contrast to growth charts for anthropometric traits such as height and weight1. Here we assemble an interactive open resource to benchmark brain morphology derived from any current or future sample of MRI data ( http://www.brainchart.io/ ). With the goal of basing these reference charts on the largest and most inclusive dataset available, acknowledging limitations due to known biases of MRI studies relative to the diversity of the global population, we aggregated 123,984 MRI scans, across more than 100 primary studies, from 101,457 human participants between 115 days post-conception to 100 years of age. MRI metrics were quantified by centile scores, relative to non-linear trajectories2 of brain structural changes, and rates of change, over the lifespan. Brain charts identified previously unreported neurodevelopmental milestones3, showed high stability of individuals across longitudinal assessments, and demonstrated robustness to technical and methodological differences between primary studies. Centile scores showed increased heritability compared with non-centiled MRI phenotypes, and provided a standardized measure of atypical brain structure that revealed patterns of neuroanatomical variation across neurological and psychiatric disorders. In summary, brain charts are an essential step towards robust quantification of individual variation benchmarked to normative trajectories in multiple, commonly used neuroimaging phenotypes.

Maternal steroid levels and the autistic traits of the mother and infant

BACKGROUND

Prenatal sex steroids have been associated with autism in several clinical and epidemiological studies. It is unclear how this relates to the autistic traits of the mother and how early this can be detected during pregnancy and postnatal development.

METHODS

Maternal serum was collected from pregnant women (n = 122) before or during their first ultrasound appointment [mean = 12.7 (SD = 0.7) weeks]. Concentrations of the following were measured via immunoassays: testosterone, estradiol, dehydroepiandrosterone sulphate, progesterone; and sex hormone-binding globulin which was used to compute the free fractions of estradiol (FEI) and testosterone (FTI). Standardised human choriogonadotropin (hCG) and pregnancy-associated plasma protein A (PAPP-A) values were obtained from clinical records corresponding to the same serum samples. Mothers completed the Autism Spectrum Quotient (AQ) and for their infants, the Quantitative Checklist for Autism in Toddlers (Q-CHAT) when the infants were between 18 and 20 months old.

RESULTS

FEI was positively associated with maternal autistic traits in univariate (n = 108, Pearson's r = 0.22, p = 0.019) and multiple regression models (semipartial r = 0.19, p = 0.048) controlling for maternal age and a diagnosis of PCOS. Maternal estradiol levels significantly interacted with fetal sex in predicting infant Q-CHAT scores, with a positive relationship in males but not females (n = 100, interaction term: semipartial r = 0.23, p = 0.036) after controlling for maternal AQ and other covariates. The opposite was found for standardised hCG values and Q-CHAT scores, with a positive association in females but not in males (n = 151, interaction term: r = -0.25, p = 0.005).

LIMITATIONS

Sample size of this cohort was small, with potential ascertainment bias given elective recruitment. Clinical covariates were controlled in multiple regression models, but additional research is needed to confirm the statistically significant findings in larger cohorts.

CONCLUSION

Maternal steroid factors during pregnancy are associated with autistic traits in mothers and their infants.

45 Quality Improvement Project on Delirium Care in Older Patients at Mid Yorkshire Hospitals NHS Trust (MYHT)

Background

To improve delirium care in older patients admitted to a large district general NHS Trust in the UK, a quality improvement project was conducted.

Introduction

The national NICE guidelines (CG103) and recent SIGN guidelines recommend delirium is diagnosed by a clinical assessment based on DSM criteria (e.g. CAM or 4AT) and managed by identifying and treating the causes alongside multicomponent interventions.

The results of MYHT’s 2018 delirium audit showed the use of CAM or 4AT was 32.5% and delirium care plan was 20%. A quality improvement project was developed and implemented for 6 weeks on a frailty admission unit.

Method

The quality improvement project introduced a delirium care checklist sticker for medical notes in cases of suspected delirium, brief education sessions for ward doctors regarding delirium care and use of the sticker and reminder emails, all implemented by the elderly medicine registrar. The target measures were completion of stickers, 4AT and delirium care plan. Data was collected by the registrar once a week for 6 weeks and entered into a run chart. Feedback was collected from staff on barriers to use.

Results

31 patients with suspected delirium has their notes reviewed. The sticker use gradually reduced from 57% of cases in week 1, to 0% in week 6. The 4ATwas completed in 57%, 50% and 100% of cases in the first 3 weeks, but dropped to 40%, 4.2% and 1.3% in the last 3 weeks. A delirium care plan was initiated in 42% and 37% of cases in the first two weeks but ended at 0% by week 6.

Barriers included a lack of education sessions from week 2 onwards due to registrar on call shifts. Also junior doctor changeover in week 3. Feedback indicated barriers were time taken to complete, and confusion over ownership of completing 4AT and care plan between medical and nursing teams.

Conclusion

Although a delirium care checklist sticker and brief education sessions can improve delirium care, sustained improvement requires ongoing education and addressing barriers to completion.

References

1. National Institute for Health and Care Excellence (2019) Delirium: prevention, diagnosis and management (NICE Guideline CG103). Available at: https://www.nice.org.uk/guidance/cg103 Accessed 21/09/2019].

2. Scottish Intercollegiate Guidelines Network (2019) risk reduction and management of delirium (SIGN Guideline 157). Available at https://www.sign.ac.uk/assets/sign157.pdf. Accessed 21/09/2019.

OP0173 IMMUNOMODULATION CO-THERAPY WITH PEGLOTICASE: DATABASE TRENDS 2014-2019

Background:

Pegloticase is a PEGylated biologic therapy for patients with uncontrolled gout who have not improved on or could not tolerate conventional urate-lowering therapies.1All biologics have the ability to engender anti-drug antibodies (ADAs) and it is known that some patients given pegloticase develop ADAs that cause them to stop treatment prior to recieving a complete course of therapy.2-3In other rheumatic autoimmune diseases, DMARDs such as methotrexate or azathioprine are used as standard of care to prevent the development of ADAs to biologics. These DMARDs often allow patients to remain on biologic therapies longer and recieve the full therapeutic benefits while minimizing adverse events.4While pegloticase has been used traditionally as monotherapy, recent case series have demonstrated the therapeutic benefit of immunomodulator co-administration, allowing more patients to receive a full course of pegloticase therapy.5-6Little has been published on how widespread this practice is and whether it has changed over time.

Objectives:

To examine medical claims database from 2014-2019 for trends in immunomodulating therapies being co-prescribed with pegloticase.

Methods:

An IQVIA claims database (November 2014 to October 2019) representing 1.3 billion claims, covering 30 million patients diagnosed with gout or CKD, was utilized to search for patients who had received pegloticase. Patients who had recieved pegloticase were classified as having been on an immunomodulating co-therapy if they were prescribed methotrexate or azathioprine within 60 days before or after initiation of their first pegloticase infusion.

Results:

We found relatively steady low rates of immunomodulation co-therapy with pegloticase from 2014 through 2018 ranging from 1% in 2016 to 4% in 2018 (Figure 1). In 2019 however, the proportion of pegloticase patients that were co-treated with methotrexate or azathioprine therapy increased to 15%. Most patients were started on immunomodulating therapy 20 days before to 10 days after initiation of pegloticase. Methotrexate was the more frequently used immunomodulaton co-therapy as compared to azathioprine.

Conclusion:

We found evidence of a relatively dramatic increasing initiation of immunomodulation therapy with pegloticase beginning soon after a November 2018 presentation of a case series which demonstrated improved response rates of pegloticase when co-administered with methotrexate. These data indicate that clinicians began to more frequently employ a strategy of DMARD co-treatment with pegloticase in 2019 to improve response rates to this important gout medicine.

References:

[1]Sundy JS, et al.JAMA2011;306:711-20.

[2]Abeles AM.Arthritis Research & Therapy2014, 16:112

[3]Strand V, et al.BioDrugs2017; 31:299–316.

[4]Krieckaert CL, et al.Arthritis Res Ther2010;12:217.

[5]Botson J and Peterson J.Ann Rheum Dis.2019; 78: A1289.

[6]Bessen SY, et al.Semin Arthritis Rheum.2019;49:56-61.

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Karl Svensson Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

AB1043 AWARENESS OF THYROID EYE DISEASE, AN AUTOIMMUNE CONDITION, AMONG RHEUMATOLOGISTS

Background:

Autoimmune inflammatory conditions of the eye may be associated with rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus, and granulomatosis with polyangiitis. This is also observed with thyroid eye disease (TED). Loss of immune tolerance to the thyroid stimulating hormone receptor has thyroidal consequences and nearly 40% of patients with Graves’ disease also have clinically evident Graves’ orbitopathy or TED.1TED results from tissue inflammation that causes retro orbital fat expansion2and extraocular muscle enlargement2and stiffening.3Because the orbital cavity is bony and of limited volume, proptosis and, in severe cases, optic nerve compression, can result. In many patients, muscle changes also cause ocular motility issues and double-vision. Because TED can have a similar presentation to other inflammatory orbital diseases (e.g., granulomatosis with polyangiitis) and Graves’ disease patients frequently have other autoimmune conditions (10% of Graves’s patients also have rheumatoid arthritis),4rheumatologists are likely to care for, or even diagnose, patients with TED.

Objectives:

This analysis sought to understand rheumatologists’ knowledge, and degree of participation in the treatment, of TED including referral patterns from ophthalmologists and endocrinologists for infusion therapies.

Methods:

Rheumatologists practicing in the United States attended an educational session and agreed to complete a 12-item survey regarding TED awareness, referral patterns, and management.

Results:

Of the 47 rheumatologists surveyed, 45 (96%) were familiar with TED. Ten (21%) physicians reported managing patients with TED, but the majority of physicians (62%) reported that they co-managed other autoimmune diseases in patients who also had TED. Additionally, 98% and 64% of polled rheumatologists had received referrals from ophthalmologists and endocrinologists, respectively, for autoimmune disease management or infusion therapy. Ophthalmology referrals for intravenous (IV) medication administration were most frequently for biologics (82%), but some referrals were also made for corticosteroids (2%) or other medication (13%) infusions. Only 23% of rheumatologists had administered a biologic specifically for TED (rituximab: 17%, tocilizumab: 2%, other: 4%), but 89% expressed an interest in administering a TED-specific monoclonal antibody therapy, awaiting FDA approval.

Conclusion:

Nearly all surveyed rheumatologists were aware of the signs and symptoms of TED, although most did not actively manage or administer medication for TED. Given the high level of interest in infusing novel, TED-specific biologics, rheumatologists may become an integral part of TED patient management with the approval of a new biologic, teprotumumab, for thyroid eye disease.

References:

[1]Bartley GB, et al.Am J Ophthalmol1996;121:284-90.

[2]Forbes G, et al.AJNR Am J Neuroradiol1986;7:651-656.

[3]Simonsz HJ, et al.Strabismus1994;2:197-218.

[4]Cardenas Roldan J, et al.Arthritis2012 2012;864907.

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, James Rosenbaum Consultant of: AbbVie, Corvus, Eyevensys, Gilead, Novartis, Janssen, Roche, UCB Pharma; royalties from UpToDate

OP0169 AMPUTATION PROCEDURES IN PATIENTS WITH GOUT COMPARED TO PATIENTS WITH DIABETES

Background:

Gout is the most common inflammatory arthritis in the United States (U.S.) and is associated with specific comorbidities, including hypertension, renal disease, cardiovascular disease, hyperlipidemia, and metabolic syndrome (1). This set of comorbidities is known for carrying an increased risk of macrovascular complications (e.g., myocardial infarction, stroke) and peripheral limb problems (e.g., skin ulcers, amputations). Diabetics are known to have an elevated risk of undergoing ulcer and amputation procedures, which have been shown to increase morbidity and mortality in this population (2,3). It is currently not known if patients with gout have an elevated independent risk for limb amputations or whether gout potentiates amputation rates in patients with diabetes.

Objectives:

To assess and compare the rate of amputation procedures conducted in patients with gout, diabetes, both gout and diabetes, and neither gout nor diabetes.

Methods:

In September 2019, a large U.S. claims database (includes data from 190 million patients over 7 years, TriNetX “Diamond” network) was used to determine amputation rates in patients with gout and diabetes. TriNetX only provides aggregate data and statistical summaries of de-identified patient information. Initial cohorts were developed to understand the amputation rate in patients with gout, regardless of diabetes comorbidity (n=4,467,721), and the amputation rate in patients with diabetes, regardless of gout comorbidity (n= 25,972,726). Subsequently, the following four cohorts were constructed to isolate these two diseases: 1) presence of gout without diabetes (n=2,471,430), 2) presence of diabetes without gout (n=23,976,435), 3) presence of both gout and diabetes (n=1,996,291), and 4) absence of both gout and diabetes (control cohort, n=144,705,645). Demographic features of these groups were tabulated and amputation (foot, toes, hand, fingers) rates were calculated using procedural codes reported in each group.

Results:

The overall rate of amputations in patients with gout (0.434%) was similar to the amputation rate in patients with diabetes (0.484%). However, when separating these patients into distinct, non-overlapping cohorts, the amputation rate in patients with gout but not diabetes (0.162%) differed from the rate in patients with diabetes but not gout (0.461%). The control population (no gout or diabetes) had an amputation rate of 0.035%. Unexpectedly, patients with both gout and diabetes had an amputation rate of 0.770%, the highest of all groups examined.

Conclusion:

Gout is increasingly being linked to unfavorable cardiovascular, renal, and metabolic complications. Our analysis showed that having gout also increased the likelihood of undergoing an amputation procedure. Patients with gout but not diabetes suffered an approximately 3-fold increase in amputations compared to patients without either disease. Additionally, patients with both gout and diabetes had a notably increased risk of amputation compared to patients with only diabetes (no gout). Because amputations are an unfavorable outcome associated with procedural complication risk and long-term sequelae, this apparent increased risk of amputation in patients with gout warrants further exploration.

References:

[1]Dalbeth N, et al.Nature Reviews Disease Primers, 2019;5(69):1-17

[2]Geiss LS, et al.Diabetes Care, 2019;42:50-54

[3]Moulik PK, et al.Diabetes Care, 2003;26:491-494

Disclosure of Interests:

Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Megan Francis-Sedlak Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Robert Holt Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

New variant and expression studies provide further insight into the genotype-phenotype correlation in YAP1-related developmental eye disorders

YAP1, which encodes the Yes-associated protein 1, is part of the Hippo pathway involved in development, growth, repair and homeostasis. Nonsense YAP1 mutations have been shown to co-segregate with autosomal dominantly inherited coloboma. Therefore, we screened YAP1 for variants in a cohort of 258 undiagnosed UK patients with developmental eye disorders, including anophthalmia, microphthalmia and coloboma. We identified a novel 1 bp deletion in YAP1 in a boy with bilateral microphthalmia and bilateral chorioretinal coloboma. This variant is located in the coding region of all nine YAP1 spliceforms, and results in a frameshift and subsequent premature termination codon in each. The variant is predicted to result in the loss of part of the transactivation domain of YAP1, and sequencing of cDNA from the patient shows it does not result in nonsense mediated decay. To investigate the role of YAP1 in human eye development, we performed in situ hybridisation utilising human embryonic tissue, and observed expression in the developing eye, neural tube, brain and kidney. These findings help confirm the role of YAP1 and the Hippo developmental pathway in human eye development and its associated anomalies and demonstrate its expression during development in affected organ systems.

Identification and functional characterisation of genetic variants in OLFM2 in children with developmental eye disorders

Anophthalmia, microphthalmia, and coloboma are a genetically heterogeneous spectrum of developmental eye disorders and affect around 30 per 100,000 live births. OLFM2 encodes a secreted glycoprotein belonging to the noelin family of olfactomedin domain-containing proteins that modulate the timing of neuronal differentiation during development. OLFM2 SNPs have been associated with open angle glaucoma in a case-control study, and knockdown of Olfm2 in zebrafish results in reduced eye size. From a cohort of 258 individuals with developmental eye anomalies, we identified two with heterozygous variants in OLFM2: an individual with bilateral microphthalmia carrying a de novo 19p13.2 microdeletion involving OLFM2 and a second individual with unilateral microphthalmia and contralateral coloboma who had a novel single base change in the 5' untranslated region. Dual luciferase assays demonstrated that the latter variant causes a significant decrease in expression of OLFM2. Furthermore, RNA in situ hybridisation experiments using human developmental tissue revealed expression in relevant structures, including the lens vesicle and optic cup. Our study indicates that OLFM2 is likely to be important in mammalian eye development and disease and should be considered as a gene for human ocular anomalies.

PICO™ incision closure in oncoplastic breast surgery: a case series

Single-use negative pressure wound therapy (PICO™) has been used on high-risk surgically incised wounds with encouraging results, but there is no evidence for its use in oncoplastic breast surgery. This article reports a case series with closed incisions in oncoplastic breast procedures following the introduction of PICO™.

Morning stiffness response with delayed-release prednisone after ineffective course of immediate-release prednisone

Objective: To assess morning stiffness in rheumatoid arthritis (RA) patients switched from immediate-release (IR) to delayed-release (DR) prednisone.

Method: Circadian Administration of Prednisone in Rheumatoid Arthritis-1 (CAPRA-1) is a 12-week, randomized, multicentre, active-controlled study of morning stiffness that consisted of a double-blind phase and a 9-month open-label extension. Patients receiving IR prednisone with no significant improvement after the double-blind study were switched to DR prednisone. Morning stiffness duration and median absolute and relative changes in pain and global assessment were evaluated (3, 6, and 9 months).

Results: In patients switched from IR to DR prednisone (n = 110), statistically significant reductions in morning stiffness occurred over 3 months and were sustained for 9 months. Absolute reduction of morning stiffness was ~50 min with > 40% relative reduction at each visit. Interleukin (IL)-6 levels were reduced by the same amount. Statistically significant and clinically meaningful mean reductions in morning stiffness were maintained at > 67 min at each visit along with significant improvements in pain and patient global assessment. There was no evidence of tachyphylaxis seen over the 9-month study.

Conclusions: Patients receiving disease-modifying anti-rheumatic drugs (DMARDs) and IR prednisone who had not had significant reductions in morning stiffness demonstrated statistically significant and clinically meaningful improvements when switched to DR prednisone.

Developmental white matter microstructure in autism phenotype and corresponding endophenotype during adolescence

During adolescence, white matter microstructure undergoes an important stage of development. It is hypothesized that the alterations of brain connectivity that have a key role in autism spectrum conditions (ASCs) may interact with the development of white matter microstructure. This interaction may be present beyond the phenotype of autism in siblings of individuals with ASC, who are 10 to 20 times more likely to develop certain forms of ASC. We use diffusion tensor imaging to examine how white matter microstructure measurements correlate with age in typically developing individuals, and how this correlation differs in n=43 adolescents with ASC and their n=38 siblings. Correlations observed in n=40 typically developing individuals match developmental changes noted in previous longitudinal studies. In comparison, individuals with ASC display weaker negative correlation between age and mean diffusivity in a broad area centred in the right superior longitudinal fasciculus. These differences may be caused either by increased heterogeneity in ASC or by temporal alterations in the group's developmental pattern. Siblings of individuals with ASC also show diminished negative correlation between age and one component of mean diffusivity-second diffusion eigenvalue-in the right superior longitudinal fasciculus. As the observed differences match for location and correlation directionality in our comparison of typically developing individuals to those with ASC and their siblings, we propose that these alterations constitute a part of the endophenotype of autism.

A prospective observational study to investigate the association between abnormal hand movements and delirium in hospitalised older people

OBJECTIVE

to examine the relationship between carphology (aimlessly picking at bedclothes), floccillation (plucking at the air) and delirium in older patients admitted to specialist elderly care wards.

DESIGN

daily observation for behaviours of carphology and floccillation embedded within a 'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted to hospital as emergencies.

METHODS

patients recruited into a delirium prevention study were observed daily for delirium using the confusion assessment method (CAM). Occurrences of carphology and/or floccillation were also recorded. Sensitivity, specificity and positive and negative predictive values for carphology/floccillation for the diagnosis of delirium were calculated. Inpatient mortality rates were compared for patients who did, and did not exhibit features of carphology and/or floccillation.

RESULTS

four hundred and thirty-seven patients were recruited into the study. One hundred and ten participants experienced an episode of delirium, 21 exhibited behaviours of carphology and/or floccillation. The sensitivity and specificity of carphology and/or floccillation for the diagnosis of delirium were 14 and 98%, respectively; positive likelihood ratio 6.8. Carphology and floccillation were associated with both hyper- and hypo-active delirium subtypes, and occurred early during incident delirium (67% within 2 days of delirium onset). The inpatient mortality rate in patients with carphology/floccillation was double the rate in patients without the behaviours (23.8 versus 11.2%, Fisher's exact test P = 0.16).

CONCLUSIONS

carphology and floccillation are uncommon physical signs, but their presence is highly suggestive of delirium. The behaviours are unrelated to delirium subtype making their presence particularly useful in the diagnosis of hypo-active delirium.

Pilot trial of Stop Delirium! (PiTStop)--a complex intervention to prevent delirium in care homes for older people: study protocol for a cluster randomised controlled trial

Background

Delirium (or acute confusion) is a serious illness common in older people, in which a person’s thinking and perceptions may be affected. Reducing delirium is important because of the considerable distress it causes, and the poor outcomes associated with it, such as increased admissions to hospital, falls, mortality and costs to the National Health Service (NHS). Preventing delirium is possible using multicomponent interventions; successful interventions in hospitals have reduced it by one-third. However, there is little research to guide practice in care homes, where it is common because of the clustering of known risk factors (older age, frailty, and dementia). In previous work we developed a multicomponent intervention to prevent delirium in care homes, called Stop Delirium! The intervention was based upon evidence from the research literature relating to the prevention of delirium and on strategies to change professional practice. Before starting a large costly trial of Stop Delirium!, this pilot study will test and help improve the design and feasibility of the trial protocol.

Methods/Design

We plan to conduct a cluster randomised pilot trial in 14 care homes (independent residential and nursing). Following recruitment of residents (over 60 years, consenting or with consultee agreement, able to communicate in English, and not in palliative care) participating homes will be randomised, stratified by size of home and proportion of residents with dementia. Stop Delirium! will be delivered to intervention homes over 16 months, with controls receiving usual care. The primary outcome measure will be the presence of delirium on any day during a one-month post-intervention period.

We will collect data to determine 1) recruitment and attrition rates, 2) feasibility of various outcomes measurements, and 3) feasibility of capturing health resource use (resident diaries and by examining health records). We will estimate the between-cluster variation for the primary outcome, delirium occurrence.

Discussion

This pilot study will refine methods for the definitive trial. The lessons learnt will also contribute to implementing National Institute for Health and Clinical Excellence (NICE) delirium guidelines, which recommend multicomponent interventions for delirium prevention.

Trial registration

ISRCTN27972532.

History of a suspected delirium is more common in dementia with Lewy bodies than Alzheimer's disease: a retrospective study

BACKGROUND

Delirium is common and is associated with an increased risk of dementia. However, it is not clear whether delirium confers increased risk of any particular type of dementia. We performed a retrospective study of Alzheimer's disease (AD) and Dementia with Lewy bodies (DLB) to ascertain whether a suspected episode of preceding delirium was more common prior to diagnosis in either type of dementia.

METHODS

The study was carried out in a tertiary referral unit for the diagnosis of dementia. Clinic letters from the first presentation to the unit of 85 cases with DLB and 95 cases of AD were reviewed for documentation of any previous episodes of suspected delirium.

RESULTS

In this study, 25% of DLB cases had at least one reported episode of suspected delirium as compared to 7% of AD cases (p = 0.001). For the DLB cases who had a prior suspected delirium, 23% had more than one episode compared with 14% of the AD group. The median time between most recent suspected episode of delirium and diagnosis of dementia in both groups was less than a year

CONCLUSIONS

A greater proportion of those presenting and diagnosed with DLB had a documentation of a suspected delirium than those diagnosed with AD. Delirium may lead to a higher risk of DLB as opposed to other forms of dementia, or delirium may, at least in some cases, represent the early stages of DLB. These data suggest that a diagnosis of DLB should be specifically considered in those presenting with a delirium.

Interventions for preventing delirium in older people in institutional long-term care

BACKGROUND

Delirium is a common and distressing complication of a range of stressor events including infection, new medications and environment change that is often experienced by older people with frailty and dementia. Older people living in institutional long-term care (LTC)are at high risk of delirium, which increases the risk of admission to hospital, development of or worsening of dementia, and mortality.Delirium is also associated with substantial healthcare costs. Although it is possible to prevent delirium in the hospital setting by providing multicomponent delirium prevention interventions it is currently unclear whether interventions to prevent delirium in LTCare effective.

OBJECTIVES

To assess the effectiveness of interventions for preventing delirium in older people in long term care.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois) - the Cochrane Dementia and Cognitive Improvement Group's Specialised Register- on 23 April 2013. The search was as sensitive as possible to identify all studies on ALOIS relating to delirium. We ran additional separate searches in major healthcare databases, trial registers, the Cochrane Central Register of Controlled Trials (CENTRAL) and grey literature sources, to ensure that the search was as comprehensive as possible.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials (cluster-RCTs) of single- and multi componentn on-pharmacological and pharmacological interventions for preventing delirium in older people (aged 65 years and over) in permanent LTC residence.

DATA COLLECTION AND ANALYSIS

Two independent review authors examined the titles and abstracts of citations identified by the search for eligibility and extracted data, with any disagreements settled by consensus. Primary outcomes were prevalence, incidence and severity of delirium. Secondary outcomes included new diagnosis of dementia, activities of daily living, quality of life and adverse outcomes. We used risk ratios (RRs)as measures of treatment effect for dichotomous outcomes and hazard ratios (HR) for time to event data.Main results We included two trials that recruited 3636 participants.Both were complex single-component non-pharmacological delirium prevention interventions. Risk of bias for many items was unclear due to inadequate reporting. Notably, there was no evidence of blinding of trial participants or assessors in either trial. One small cluster-RCT (n = 98) of a hydration-based intervention reported no reduction in delirium incidence in the intervention group compared to control (RR 0.85, 95% confidence interval (CI) 0.18 to 4.00, analysis not adjusted for clustering, very low quality evidence). Results were imprecise and there were serious limitations evident in trial design.One large cluster-RCT (n = 3538) of a computerised system to identify medications that may contribute to delirium risk and trigger a pharmacist-led medication review reported a large reduction in delirium incidence (12-month HR 0.42, CI 0.34 to 0.51, moderat equality evidence) but no clear evidence of reduction in hospital admissions (HR 0.89, CI 0.72 to 1.10, moderate quality evidence), in mortality (HR 0.88, CI 0.66 to 1.17, moderate quality evidence) or in falls risk (HR 1.03, CI 0.92 to 1.15, moderate quality evidence).Authors' conclusions Our review identified very limited evidence on interventions for preventing deliriumin older people in LTC. Introduction of a software based intervention to identify medications that could contribute to delirium risk so that a pharmacist-led medication review and monitoring plan can be initiated may reduce incidence of delirium for older people in institutional LTC. This is based on one large RCT in the United States and may not be practical in other countries which do not have comparable information technology services available in care homes. Our review identified only one ongoing pilot trial of a multicomponent delirium prevention intervention and no trials of pharmacological agents. Future trials of computerised medication management systems and multicomponent non-pharmacological and pharmacological delirium prevention interventions for older people in LTC are needed to help inform the provision of evidence based care for this vulnerable group.

Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards

OBJECTIVE

to examine the effect of a multi-component, delirium prevention intervention on rates of incident delirium for patients admitted to specialist elderly care wards.

DESIGN

'before' and 'after' study.

SETTING

three specialist elderly care wards in a general hospital.

SUBJECTS

older people admitted as emergencies.

METHODS

a multi-component delirium prevention intervention that targeted delirium risk factors was implemented by clinical staff. Demographic information and assessments for delirium risk factors were recorded by research staff within 24 h of admission to the ward. New onset (incident) delirium was diagnosed by daily research staff assessments using the Confusion Assessment Method and Delirium Rating Scale-Revised-98.

RESULTS

a total of 436 patients were recruited (249 in the 'before' and 187 in the 'after' group). Incident delirium was significantly reduced ('before' = 13.3%; 'after' = 4.6%; P = 0.006). Delirium severity and duration were significantly reduced in the 'after' group. Mortality, length of stay, activities of daily living score at discharge and new discharge to residential or nursing home rates were similar for both groups.

CONCLUSIONS

a multi-component, delirium prevention intervention directed at delirium risk factors and implemented by local clinical staff can reduce incident delirium on specialist elderly care wards.

How well are we managing diabetes in long-term care?

The care received by nursing home residents with diabetes does not meet ADA standards for ambulatory adults, this study finds. Nor should it. The frail elderly need new standards that address their particular needs.

Stop Delirium! A complex intervention to prevent delirium in care homes: a mixed-methods feasibility study

BACKGROUND

delirium is likely to be particularly common in care homes, given the clustering of known risk factors in these settings. Preventing delirium should result in significant benefits, including better quality of care and improved outcomes for residents.

OBJECTIVE

to test the feasibility of 'Stop Delirium!', an intervention to prevent delirium in care homes for older people, and to optimise parameters to inform the design of a future trial evaluation.

METHOD

we delivered Stop Delirium! to six care homes over 10 months, in a mixed methods before and after study.

RESULTS

Stop Delirium! was successfully implemented in the study homes. We found evidence supporting positive changes in staff attitudes and practice after the intervention. Although qualitative data suggested it was too early to expect changes in resident outcomes, we also found preliminary evidence suggesting potential improvements in a range of outcomes, including a reduction in the number of falls and prescribed medications.

CONCLUSION

a complex intervention for delirium prevention in care homes is feasible and has the potential to improve staff practice and outcomes for residents. This work provides the basis for the next phase of the evaluation to establish its effectiveness and cost-effectiveness.