A128 GLOBAL TRENDS IN TRAINING AND CREDENTIALING GUIDELINES FOR GASTROINTESTINAL (GI) ENDOSCOPY: A SYSTEMATIC REVIEW

Background

Credentialing in GI endoscopy is not a universally standardized process. National guidelines may provide a framework for local training, however in certain settings, training committees set minimal competency requirements that must be met before a clinician can be accredited to practice independently. There is a paucity of literature assessing the inter-societal and geographic variability in guidelines and training requirements in endoscopy.

Purpose

To systematically review the available credentialing guidelines proposed by different GI endoscopy societies and affiliated training committees internationally.

Method

We conducted a systematic review according to the PRISMA guidelines. A comprehensive literature search was performed for credentialing guidelines for GI endoscopy from inception until January 2022. Two reviewers screened and one reviewer abstracted data using a pre-defined data collection form.

Result(s)

From the 653 records obtained from our search, 20 credentialing guidelines from 12 different GI societies were ultimately included in the review. These guidelines encompassed the following procedures and outlined the following key-performance indicators; a) Colonoscopy: the recommended minimum number of procedures performed ranged from 150-275 with a minimum cecal intubation and adenoma detection rate of 85-90% and 20-30% respectively; b) EGD: the minimum number of procedures prior to credentialing ranged from 130-1000, the minimum duodenal intubation rate ranged from 95-100%, and the range for minimum number of upper GI bleeds managed was 20-45 (in addition to other procedural KPIs); c) ERCP: the recommended minimum number of procedures prior to credentialing ranged from 100-300 cases with a minimum selective duct cannulation rate of 80-90%. Guidelines for flexible sigmoidoscopy, EUS and capsule endoscopy were also obtained.

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Conclusion(s)

There is a general concordance amongst the various international GI societies with regards to minimum procedural volume and performance in key procedural tasks prior to credentialing, however the use of validated education assessment tools was lacking in the majority of guidelines. Additional KPI’s need to be explored for less routinely performed procedures such as EUS and capsule endoscopy.

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None

Disclosure of Interest

None Declared

A119 DEVELOPMENT AND EVALUATION OF LOW-COST GEL POLYPS FOR POLYPECTOMY SKILLS TRAINING IN NOVICE ENDOSCOPISTS

Background

Polypectomy is an essential skill for endoscopists to acquire. As polyps are encountered ad hoc during colonoscopies, exposure to polypectomy in clinical training may vary. There is a need to deliver a curriculum that standardizes exposure to polypectomy while remaining cost-effective for endoscopy programs worldwide.

Purpose

To develop low-cost simulated polyps that can be incorporated into endoscopic training programs, and to evaluate their perceived realism and useability for polypectomy training.

Method

We designed 3D molds based on the Paris classification, a validated rubric for polyp morphology. The polyps are depicted in Figure 1. Using low-cost materials, we created gel-based polyps compatible with physical colonic simulators. Current versions of the polyps were finalized based on visual realism and durability. Expert (performed >1000 procedures) and novice (<25 procedures) endoscopists were invited to perform simulated polypectomies and evaluate the realism of the polyps. Using a 7-point Likert scale (“strongly disagree” to “strongly agree”), we administered a survey adapted from the Direct Observed Polypectomy Skills (DOPyS) checklist to evaluate the polyps on practicality of design and useability for training. Additionally, the simulator’s resemblance to human polypectomy was assessed through a scale with 1 indicating “low resemblance” and 7 indicating “high resemblance”. The ease of identifying morphology was also evaluated, with 1 indicating “difficult” and 7 indicating “easy”.

Result(s)

The survey was completed by 11 expert endoscopists and 10 novices. The median score submitted by experts on the polyps’ useability in training the technique for mobilization of the polyp was 7 (IQR 6-7). Experts rated the simulator’s practicality in teaching cold snare or electrocautery techniques with a median score of 6 (IQR 6-7). Lastly, the ability of the simulator to develop skills in identifying and treating the residual polyp was assessed by expert endoscopists, giving it a median score of 6 (IQR 6-7). The simulators were tested on similarity to human polypectomy, with the median score of expert groups being 5 (IQR 5-6), and novice groups being 6 (IQR 6-6). Both groups were asked to rate if morphology could be identified using the simulator; the median score of expert groups being 6 (IQR 6-7), and 6.5 for novice endoscopists (IQR 5-7).

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Conclusion(s)

The development of simulated polyps with differing morphologies using low-cost and common materials with high realism is feasible. These polyps may potentially be integrated into different endoscopic training programs.

Please acknowledge all funding agencies by checking the applicable boxes below

None

Disclosure of Interest

A. Zhao: None Declared, N. Gimpaya: None Declared, J. Lisondra: None Declared, R. Fujiyoshi: None Declared, Y. Fujiyoshi: None Declared, R. Khan Grant / Research support from: Rishad Khan has received research grants from AbbVie (2018) and Ferring Pharmaceuticals (2019) and research funding from Pendopharm (2019). , D. Tham: None Declared, M. Scaffidi: None Declared, R. Bansal: None Declared, C. Walsh: None Declared, S. Grover Shareholder of: Samir C. Grover has equity in Volo Healthcare., Grant / Research support from: Samir C. Grover has received research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, education grants from Janssen.

A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW

Background

Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.

Purpose

To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework

Method

We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.

Result(s)

From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).

Conclusion(s)

The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG

Disclosure of Interest

None Declared

Outcomes of infective endocarditis in patients with and without pericardial effusion: a National Inpatient Sample study

Introduction

Pericardial effusion (PE) in patients with infective endocarditis (IE) has been shown to be an independent risk factor for severe complications, however no significant association with mortality has been established. Our study aims to study the significance of pericardial effusion in patients with IE.

Methods

We performed a retrospective analysis using the United States National Inpatient Sample (NIS) database to identify all the hospital admissions with IE using ICD 10 codes and divided them into two groups based on the presence of PE. The outcomes of interest were in-hospital mortality, in-hospital complications, need for cardiac surgery, and length of stay (LOS).

Results

A total of 381,300 patients were hospitalized from 2016 to 2019 with IE, of whom 10,370 developed PE. Mean age of patients in the PE group was 51 years and in non-PE group was 61 years with males and Caucasian race being predominant in both groups. PE group had higher rates of in-hospital death (12.7% vs 9%, P≤0.001) and longer in-hospital stay (12 days vs 7 days, P≤0.001) compared to non-PE group. The rates of cardiac surgery were higher in PE group (26.1% vs 8.4%, P≤0.001). The rates of heart failure, heart block, renal failure, cardiogenic shock, and embolic stroke were higher in PE group [Table 1].

Conclusion

Our study shows that presence of PE in patients with IE is a predictor for in-hospital mortality, length of stay, and need for cardiac surgery. Also, these patients are at higher risk for heart failure, heart block, cardiogenic shock and embolic stroke.

Funding Acknowledgement

Type of funding sources: None.

P-381 A novel natural cycle proliferative phase/progesterone replacement(NC/PR) protocol for endometrial preparation for frozen-thawed embryo transfer(FET) Can it improve pregnancy outcomes : a prospective comparative study

Study question

Can a novel protocol for endometrial preparation- NC/PR-FET, lead to better pregnancy outcomes than artificial cycle (AC)-FET, with similar ease of cycle monitoring and scheduling?

Summary answer

NC/PR-FET protocol gave comparable clinical pregnancy rates (CPR), significantly less early miscarriage rates (MR) and significantly more live birth rates (LBR) compared to AC-FET protocol.

What is known already

AC-FET is the most common protocol for endometrial preparation due to flexibility, easy monitoring, and high pregnancy rates albeit with evidence of higher obstetrical risks e.g., miscarriage, pre-eclampsia versus NC-FET. This risk could be due to suboptimal hormonal administration in AC-FET leading to impaired endometrial maturation, predecidualization, and altered endometrial function. Studies indicate, estradiol may have a stronger negative effect(versus progesterone) on the endometrial transcriptome. Hence, we studied a novel protocol with NC-estrogen (but with progesterone similar to AC-FET), for better endometrial maturation, predecidualization along with simple monitoring and flexible ET scheduling. Previously, a proof-of-concept case-series has been reported.

Study design, size, duration

The prospective comparative study was conducted at a tertiary center (Jan2019-Dec2021) with 126 patients (both autologous [AO] and donor oocytes [DO]):79 (AC-FET) and 47 (NC/PR-FET) with similar ICSI, vitrification, ET protocols. 2 or 3 Grade A cleavage stage embryos were transferred. CPR, implantation rates(IR), early MR (≤13 weeks, miscarriages/clinical pregnancies) and LBR (≥28 weeks, LBs/ETs) were compared. Serum progesterone was studied on day 5 post-ET. Antenatal care and most deliveries were at the same institute.

Participants/materials, setting, methods

Patients were non-smokers with normal hysteroscopy. In AC-FET, oral estradiol (6-8mg) was initiated from day 1-2 (for 10-17 days). In both groups, when endometrium ≥7mm and S.progesterone&lt;1ng/ml, intramuscular progesterone was initiated(daily till day 4 post-ET, then every 3rd day till week 8). ET was scheduled on day 4 of intramuscular progesterone, and concurrently, vaginal progesterone was added (till week 10). Chi-square, t-tests, and multiple regression was used for statistical analysis and 2-tailed P &lt;.05 indicated statistical significance.

Main results and the role of chance

Mean age and BMI were comparable in NC/PR-FET and AC-FET groups: 34.48±4.69 years vs. 33.58 ± 5.62 years (P =.35) and 26.27 ± 3.62 kg/m2 vs. 27.34 ± 4.61kg/m2 (P =.18) respectively. Similarly, the source of oocytes (%AO) and % singletons were also comparable in NC/PR-FET and AC-FET groups: 57.4% vs. 46.8% (P = .25), and 78.1% vs. 75% (P= .75) respectively. There were 3 ectopic pregnancies overall. The CPRs and IRs were comparable: 68.09% (NC/PR-FET) vs. 60.76% (AC-FET) (P=.41) and 32.30% (NC/PR-FET) vs. 28.96% (AC-FET) (P=.45) respectively.

The early MR was significantly more in AC-FET vs. NC/PR-FET: 29.17% vs. 6.25% (P =.012). Consequently, LBRs were significantly more in NC/PR-FET vs. AC-FET: 59.57% vs. 39.24% (P =.028). After adjusting for age, BMI, AO/DO, this difference remained significant (AOR 2.66; 95% CI 1.21-5.81; P =.014)

Mean serum progesterone was comparable in all patients in both groups: 38.50 ± 13.6ng/ml (NC/PR-FET) vs. 40.98 ± 28.64 ng/ml (AC-FET) (P =.57). Serum progesterone levels were also comparable in patients who were pregnant in both groups: 38.51 ± 14.79 (NC/PR-FET) vs. 42.25 ± 32.63 (AC-FET) (P =.53).Also, in the AC-FET group serum progesterone was comparable in patients who aborted,44.23 ± 31.60 vs. those who didn’t, 41.48 ± 33.44 (P =.79).

Limitations, reasons for caution

This was a single center study. Due to limited sample size, we could not control for many potential confounders (e.g., multiple pregnancies). For the same reason, we could not compare obstetrical risks as a study outcome.

Wider implications of the findings

This study shows significantly better pregnancy outcomes with a novel NC/PR-FET protocol vs. AC-FET. This needs to be validated in larger studies. Since suboptimal hormone administration in AC-FET could be causal factor for pre-eclampsia, larger studies can test if the NC/PR-FET protocol can lead to better obstetrical outcomes.

Trial registration number

not applicable

A89 PERCEPTIONS OF NON-TECHNICAL SKILLS IN GASTROINTESTINAL ENDOSCOPY: A THEMATIC ANALYSIS OF FOUR FOCUS GROUPS

Background

Nontechnical skills (NTS), which involve an individual’s cognitive, attitudinal, and social skills that supplement task expertise, are an essential component in the practice of gastrointestinal endoscopy. There is a growing body of literature that highlights the association between these skills and patient outcomes. To date, however, these skills have not been adequately defined within the context of gastrointestinal endoscopy.

Aims

To define the domain and corresponding characteristics of NTS in GI endoscopy.

Methods

We conducted a qualitative study at a tertiary-care academic center in Toronto, Ontario. Specifically, we held four focus groups with physician endoscopists, nurses who work in an endoscopy unit, and patients who have had previous endoscopies, in order to ascertain their input on the role of NTS in gastrointestinal endoscopy. The three groups were interviewed independently and there was one focus group of both physicians and nurses that was used for validation of our initial thematic framework. Data from the focus groups was collected using a combination of field notes and discussion transcriptions. Three authors independently generated codes from these data. Using these codes, a thematic network analysis was used to identify emerging themes. The primary outcome of this study was the development of a cohesive thematic network of NTS in endoscopy, including their characteristics and examples.

Results

The four focus groups included a total of 34 participants, including 15 physician endoscopists, 15 nurses, and 4 patients. Using thematic network analysis, we identified six dimensions of NTS using the first three focus groups: communication; professionalism; teamwork; leadership; decision-making; and situational awareness. Additional topics related to the practice and evaluation of NTS were identified. In particular, there is a degree of subjectivity in the appraisal of NTS due to the nuances among individual practice, aside from egregious errors of NTS (e.g. unprofessional behaviours). The use of video recordings was suggested as a way to capture signs of good NTS, such as appropriate levels of calmness during procedures and attention to patient comfort. Finally, patient involvement can be useful for evaluating communication and professionalism based on patient comprehension and the nature of the therapeutic relationship.

Conclusions

Our findings provide the first cohesive framework of NTS in gastrointestinal endoscopy that is anchored in real world experiences with relevant stakeholders – physicians, nurses, and patients. Future research should consolidate these findings into an assessment tool for NTS in order to evaluate and provide feedback to endoscopists who are both in training and in practice.

Funding Agencies

CAG

A25 CRITICAL APPRAISAL OF GI ENDOSCOPY CLINICAL PRACTICE GUIDELINES DURING THE COVID-19 PANDEMIC

Background

Clinical Practice Guidelines (CPGs) are integral during a pandemic, offering guidance to clinicians through uncertainty. Existing literature has established that the need for rapid publication of CPGs during previous infectious disease outbreaks resulted in less rigorous guidelines. CPGs were rapidly developed since the onset of the pandemic in December 2019, providing guidance in gastrointestinal (GI) endoscopy, an area where COVID-19 may pose risk of transmission.

Aims

To evaluate the quality of GI endoscopy guidelines developed during the COVID-19 pandemic and to compare these with (a) endoscopy CPGs developed prior to the pandemic; (b) CPGs for other endoscopic topics unrelated to COVID-19; and, (c) non-endoscopic CPGs published during the pandemic.

Methods

We systematically searched Medline, Embase and Scopus for CPGs published by GI societies from January 1, 2018 to December 31, 2020. A grey literature search was conducted. Two authors screened full-texts. In this interim analysis, CPGs were grouped based on publication year: before 2020, or 2020. Endoscopy CPGs published in 2020 were categorized as COVID or non-COVID related. Two authors independently assessed the CPGs using the AGREE II tool, consisting of six domains for evaluating guidelines. A domain score of 60 was set as a threshold to indicate good quality.

Results

There were 70 endoscopy guidelines and 27 CPGs focused on other GI topics. The mean overall scores were 69% (±12%) for endoscopy CPGs published before 2020 (n=28), and 51% (±23%) for CPGs published in 2020 (n=42). For individual AGREE II domains, mean scores for pre-2020 CPGs ranged from 33.11 (±17.39) in Applicability to 81.55 (±10.37) in Clarity of Presentation. For CPGs published during COVID-19, mean domain scores ranged from 34.18 (±10.52) in Applicability to 75.26 (±13.85) in Clarity of Presentation. 21 of 42 CPGs published in 2020 were related to COVID. Mean overall scores were 35% (±20%) for COVID-related CPGs and 67% (±13%) for non-COVID-19 CPGs. For COVID-19 CPGs, scores ranged from 27.88 (±20.31) in Rigour of Development to 69.58 (±10.81) in Scope and Purpose. For non-COVID CPGs, the scores ranged from 37.30 (±8.93) in Applicability to 84.52 (±5.93) in Clarity of Presentation.

Conclusions

The difference in overall scores between COVID-19 endoscopy CPGs and non-COVID endoscopy CPGs may suggest that the urgency to disseminate COVID-19 information decreased CPG quality or completeness of reporting. This interim analysis is limited by the lack of distinction between peer-reviewed CPGs and non-peer reviewed recommendations. Given the importance of CPGs in clinical decision making, it is important to ensure that the rapid development of guidelines does not compromise quality and rigour.

Funding Agencies

None

A99 PHARMACEUTICAL INDUSTRY FUNDING TO GASTROINTESTINAL PATIENT ADVOCACY ORGANIZATIONS

Background

Patient advocacy organizations (PAOs) are not-for-profit organizations that aim to support families and individuals afflicted by illnesses. PAOs play a significant role in guiding health policy, providing education to patients, lobbying, and supporting research. Previous studies have demonstrated that PAOs may receive financial payments from pharmaceutical and medical device manufacturers. This may create a risk of conflict of interest.

Aims

To assess the prevalence and transparency of financial donations from industry to gastrointestinal patient advocacy groups based in the United States (US).

Methods

We conducted a cross-sectional study to determine the prevalence of industry donations to PAOs. Data was extracted from the Kaiser Health News (KHN) Database, a database that tracked payments from pharmaceutical companies to PAOs in 2015. After an initial list of 1215 PAOs was obtained from the database, authors extracted the annual revenues, websites and mission statements for each PAO. Authors individually screened each organization’s mission statement and website to determine whether their primary scope of focus included gastroenterology. A final list of 11 PAOs with annual revenues surpassing $500,000 USD was included for descriptive analysis. From this list, the annual reports and websites of each group were reviewed to determine the extent of transparency of PAOs disclosing financial relationships with industry sponsors. The primary outcome of our study was the total amount of funding that each PAO received from pharmaceutical companies. The secondary outcome was the self-reported amount of funding stated on each PAO’s website and annual report.

Results

From our analysis of 11 PAOs, 9 (81%) organizations received payments from pharmaceutical companies. The median dollar value of donations received was $31,052 USD (IQR=$25 to $302,550). The total dollar value of donations received was $4,059,433 USD. Across the 9 PAOs that received donations, 5 (56%) organizations disclosed a financial relationship with a pharmaceutical company on their website and 2 (22%) disclosed the value of industry donations within a range. No group specified an exact amount of funding received.

Conclusions

Our results demonstrate that a majority of US based gastrointestinal PAOs receive funding from pharmaceutical companies. Furthermore, our results show that many PAOs that receive industry funding do not disclose this amount on their website or annual reports. Given their role in providing patient centered support, it is important for PAOs to disclose financial relationships with industry so as to not produce a conflict of interest.

Funding Agencies

None

Post-mating gene expression of Mexican fruit fly females: disentangling the effects of the male accessory glands

Mating has profound physiological and behavioural consequences for female insects. During copulation, female insects typically receive not only sperm, but a complex ejaculate containing hundreds of proteins and other molecules from male reproductive tissues, primarily the reproductive accessory glands. The post-mating phenotypes affected by male accessory gland (MAG) proteins include egg development, attraction to oviposition hosts, mating, attractiveness, sperm storage, feeding and lifespan. In the Mexican fruit fly, Anastrepha ludens, mating increases egg production and the latency to remating. However, previous studies have not found a clear relationship between injection of MAG products and oviposition or remating inhibition in this species. We used RNA-seq to study gene expression in mated, unmated and MAG-injected females to understand the potential mating- and MAG-regulated genes and pathways in A. ludens. Both mating and MAG-injection regulated transcripts and pathways related to egg development. Other transcripts regulated by mating included those with orthologs predicted to be involved in immune response, musculature and chemosensory perception, whereas those regulated by MAG-injection were predicted to be involved in translational control, sugar regulation, diet detoxification and lifespan determination. These results suggest new phenotypes that may be influenced by seminal fluid molecules in A. ludens. Understanding these influences is critical for developing novel tools to manage A. ludens.

Mek/ERK1/2-MAPK and PI3K/Akt/mTOR signaling plays both independent and cooperative roles in Schwann cell differentiation, myelination and dysmyelination

Multiple signals are involved in the regulation of developmental myelination by Schwann cells and in the maintenance of a normal myelin homeostasis throughout adult life, preserving the integrity of the axons in the PNS. Recent studies suggest that Mek/ERK1/2-MAPK and PI3K/Akt/mTOR intracellular signaling pathways play important, often overlapping roles in the regulation of myelination in the PNS. In addition, hyperactivation of these signaling pathways in Schwann cells leads to a late onset of various pathological changes in the sciatic nerves. However, it remains poorly understood whether these pathways function independently or sequentially or converge using a common mechanism to facilitate Schwann cell differentiation and myelin growth during development and in causing pathological changes in the adult animals. To address these questions, we analyzed multiple genetically modified mice using simultaneous loss- and constitutive gain-of-function approaches. We found that during development, the Mek/ERK1/2-MAPK pathway plays a primary role in Schwann cell differentiation, distinct from mTOR. However, during active myelination, ERK1/2 is dependent on mTOR signaling to drive the growth of the myelin sheath and regulate its thickness. Finally, our data suggest that peripheral nerve pathology during adulthood caused by hyperactivation of Mek/ERK1/2-MAPK or PI3K is likely to be independent or dependent on mTOR-signaling in different contexts. Thus, this study highlights the complexities in the roles played by two major intracellular signaling pathways in Schwann cells that affect their differentiation, myelination, and later PNS pathology and predicts that potential therapeutic modulation of these pathways in PNS neuropathies could be a complex process.

Cardiac sympathetic denervation for catecholaminergic polymorphic ventricular tachycardia

Catecholaminergic polymorphic ventricular tachycardia (CPVT), a rare inheritable fatal arrhythmogenic disorder, is difficult to diagnose and is a challenge to manage. A 21-years-old man presented with recurrent exertional syncope and complex multifocal ventricular ectopy. CPVT was diagnosed based on the clinical criteria, despite the absence of some classical findings. The patient underwent cardiac sympathetic denervation (CSD) after lifestyle modification and pharmacological management were ineffective. CSD proved to be effective. The patient did not have any exertional symptoms or recurrence of syncope at follow-up period of 1 year. The present case report adds to the growing evidence in favour of CSD for CPVT.

A104 PREVALENCE OF GHOST-AUTHORSHIP IN INDUSTRY-SPONSORED CLINICAL TRIALS

Background

Ghost-authorship involves the exclusion of individuals who have made substantial contributions to the article from the author byline. Previous studies have found that ghost-authorship is highly prevalent in industry-sponsored clinical trials. Its prevalence, however, has yet to be investigated in trials of biologics in the management of inflammatory bowel disease (IBD).

Aims

To determine the prevalence of ghost-authorship in IBD biologic industry-sponsored clinical randomized controlled trials (RCTs).

Methods

Biologic medications indicated for ulcerative colitis (UC) or for Crohn’s disease (CD) were identified using the Food and Drug Agency (FDA) database. We identified the clinical trials on clinicaltrials.gov corresponding to the data presented at the time of FDA approval. Specifically, we included the first publication for each trial to report study results for our analysis. Two authors independently identified the presence of ghost-authorship, which we defined as the exclusion on the author byline of the included RCT publication of any individuals who assisted in the writing of the trial manuscript and/or performed the data analyses.

Results

We identified a total of 28 relevant RCTs on biologic medications (10 for UC and 18 for CD), which were matched to 20 publications. We found ghost-authorship in 70% of publications (n=14); 40% (n=8) involved manuscript and protocol writing assistance from sponsor staff; 35% (n=7) involved medical writers from external companies; 15% (n=3) involved both sponsor staff and medical writers assisting in manuscript writing; and 20% (n=4) involved individuals performing data analysis or interpretation.

Conclusions

We found that ghost-authorship in industry-sponsored IBD biologic clinical trials has a moderately high prevalence, with the most common being manuscript or protocol writing assistance. A lack of transparency regarding sponsor-affiliated and/or external contributors may negatively affect the trust placed in medical research. One limitation is that data was only extracted from publications. Further evidence on ghost-authorship may be found in study protocols and registrations, which will be investigated in the future.

Funding Agencies

None

A160 PREVALENCE OF OUTCOME SWITCHING AMONG PUBLISHED PHASE 3 INTERVENTIONAL TRIALS FOR INFLAMMATORY BOWEL DISEASE THERAPEUTICS

Background

Outcome switching is a well-described form of inconsistent reporting in randomized clinical trials (RCTs), wherein pre-specified primary and/or secondary outcomes are changed between trial registration and the publication of results without explanation. This is of particular concern, as the selective publication of results that are favorable will insert bias into the trial’s results and may cast doubt on the veracity of its findings. While it has been investigated in other disciplines, the prevalence of outcome switching has yet to be described among RCTs for inflammatory bowel disease (IBD).

Aims

To determine the prevalence of correctly reported pre-specified primary and secondary outcomes in published phase 3 interventional RCTs for IBD.

Methods

We identified all phase 3 interventional trials for IBD with published results using clinicaltrials.gov. We included all results with an associated publication that detailed the results of the trial. We excluded registrations if: only an abstract of the results was available; trial results were only published as a pooled analysis; multiple trial segments were reported collectively; or a publication of the results could not be identified through clinicaltrials.gov or a custom search.

Two reviewers extracted all pre-specified primary and secondary outcomes for each trial using the clinical trial registration page that was dated before the commencement of the trial. These outcomes were compared to the outcomes reported in the corresponding journal articles. Any discrepancies were noted, and additional outcomes were extracted.

Results

We identified a total of 88 phase 3 interventional RCTs for IBD, of which 57 were matched to independent publications of their results. All trials pre-specified a primary outcome, and 50 (87.7%) pre-specified secondary outcomes. 10 (17.5%) of trials did not report some or all primary outcomes, and 19 (33.3%) trials had a change or alteration to the primary outcome. Of the trials that pre-specified secondary outcomes, 16 (28.1%) did not report all pre-specified secondary outcomes. 49 (86.0%) trials added 6 (IQR: 2–8) unspecified secondary outcomes on average.

Conclusions

Many phase 3 interventional RCTs in IBD either did not report some or all primary outcomes, or altered the primary outcome. Trials routinely reported additional outcomes that were not pre-specified and failed to note that they were added post hoc. Based on these results, we recommend improvements in the reporting of pre-specified outcomes and higher fidelity in order to maintain confidence in trial results.

Funding Agencies

None

A70 PREVALENCE OF SELF-PUBLICATION AMONG EDITORIAL BOARD MEMBERS OF GASTROENTEROLOGY JOURNALS

Background

Editorial self-publication refers to the practice wherein editors publish research in journals to which they serve as editorial board members. The International Committee of Medical Journal Editors (ICMJE) has detailed recommendations against the practice of self-publication. There is evidence to suggest that editorial board membership may influence the decision to publish academic papers, which may contribute to publication bias. Despite this, there have been few attempts to characterize this practice in gastroenterology journals.

Aims

To determine the prevalence of original gastroenterology research articles published by editorial board members in their own journal.

Methods

We conducted a cross-sectional study to determine the prevalence of editorial board members publishing within their own journals. A list of the top 25 highest impact factor gastroenterology journals was created through InCites Journal reports. Journals were screened to determine eligibility based on whether their primary focus included gastroenterology research and whether archives with the names and affiliations of editorial board members were available. 10 journals were selected based on these criteria. For each journal, we extracted all original research articles published in 2019 using Web of Science (Clarivate Analytics ©). Articles classified as editorial material, meeting abstracts, reviews, and clinical practice guidelines were excluded. We cross-referenced the affiliations of all authors found in each publication with affiliations of editors disclosed on the journal website. For each editorial board member, we determined the number of publications within their own journal.

Results

We identified 844 editorial board members in the 10 journals included. Overall, 337 (39.9%) of the editors had a publication in their own journal, of which, 152 (18.0%) had more than one publication. Across all journals, the median number of editors with self-publication is 27 (IQR=20.3–49.8). The median number of editors with more than one self-publication is 16 (IQR=10.0–25.3). In total, 507 (60.1%) of all editors had no publications within their respective journals.

Conclusions

Despite recommendations against this practice, our results show a high number of research publications authored by editorial board members. These results demonstrate a potential risk for publication bias. However, this study was limited by the inability to investigate beyond the prevalence of self-publication. Furthermore, the explicit implications of our results remain unclear. Further research is required to evaluate factors such as disclosures and the review process associated with increased rates of self-publication as well as its impact on publication bias.

Funding Agencies

None

A89 CHARACTERISTICS AND CONFLICTS OF INTEREST AT FOOD AND DRUG ADMINISTRATION GASTROINTESTINAL DRUG ADVISORY COMMITTEE MEETINGS

Background

The United States Food and Drug Administration (FDA) Gastrointestinal Drug Advisory Committee (GIDAC) is involved in gastrointestinal drug application reviews. Characteristics and conflicts of interest (COI) in GIDAC meetings are not well described.

Aims

To analyze FDA GIDAC meetings and characteristics that predict recommendations.

Methods

This was a cross-sectional study of all publicly available GIDAC meetings where proposed medications were voted on from 1998–2018. Data were collected on individual meetings and individual voting members at meetings. Predefined predictor variables included type of medication, medication sponsor, primary efficacy studies, and voting member characteristics (e.g. committee membership, COI). Univariate analyses were conducted at per-meeting and per-vote levels to assess for predictors of committee recommendation and individual votes respectively.

Results

Thirty-four meetings with 476 individual votes from 1998–2018 were included. Twenty-three (68%) proposals were recommended for approval and 25 (74%) received FDA approval. Most proposals involved &gt;1 primary study (n=27, 79%). At least one voting member had a COI in 24 (71%) of 34 meetings. Twelve (35%) meetings had at least one sponsor COI. Among 476 individual votes, 74 (15.5%) involved a COI, with 33 (6.9%) sponsor COI. COI decreased significantly over time, with more COI in 1996–2000 and 2001–2005 compared to 2006–2010, 2011–2015, and 2016–2020 (p&lt;0.01). There were no significant associations between pre-defined predictors, including COI, and committee level recommendations or individual votes (p&gt;0.05 for all univariate analyses).

Conclusions

The GIDAC reviewed 34 proposals from 1998–2018. The majority were recommended for approval and later approved by the FDA, highlighting the GIDAC’s prominence in the regulatory process. COI are present among GIDAC panelists but decreasing over time and not associated with recommendations.

Funding Agencies

None

A77 A REUSABLE POLYCARBONATE BOX TO DECREASE DROPLET CONTAMINATION DURING UPPER ENDOSCOPY: A SIMULATION-BASED STUDY FOR THE COVID-19 PANDEMIC

Background

Upper gastrointestinal (GI) endoscopic procedures are aerosol-generating, increasing the risk of healthcare workers (HCW) contracting Coronavirus disease 2019 (COVID-19).

Aims

To present a polycarbonate box (EndoBox) designed for use in upper GI endoscopy and evaluate its impact on the contamination of endoscopy staff during simulated procedures.

Methods

Simulated gastroscopies were performed using an upper body simulator placed in left lateral decubitus (LLD) and supine positions. The endoscopist and assistant wore personal protective equipment. Droplet exposure was measured using fluorescent abiotic surrogate particles. Two blinded observers independently viewed images from each scenario to qualitatively evaluate contamination levels. The primary outcome was the level of HCW contamination by droplets generated from a simulated cough with and without the EndoBox on the upper body simulator. The endoscopist’s ergonomic behaviour was also assessed using the Rapid Upper Limb Assessment (RULA) tool.

Results

Without the EndoBox, there was a higher level of contamination on the endoscopist when the upper body simulator is in the LLD position. A higher level of contamination was observed on the assistant when the simulator is in supine position. With the EndoBox, the contamination levels on the endoscopy staff were lower in both LLD and supine scenarios. The endoscopist’s ergonomics were rated 2 to 3 on the RULA tool when using the EndoBox.

Conclusions

The EndoBox reduces macroscopic droplet contamination during simulated gastroscopy. The endoscopist’s risk of musculoskeletal injury remained in the low risk categories as assessed by the RULA tool. Another advantage of the EndoBox design is the arch extending from the bottom that allows for removal of the box without withdrawing the endoscope. This enables rapid access to the patient’s airway if they experience respiratory distress. This study was limited by an inability to assess microscopic contamination and contamination at the level of the port or buttons when suction is applied. Within these limitations, the EndoBox may be a useful adjunct to traditional personal protective equipment.

Funding Agencies

SMHA AFP COVID-Related Innovation Funds

A161 PREVALENCE OF FINANCIAL CONFLICTS OF INTEREST (FCOI) AMONG PROPENSITY-SCORE MATCHED RETROSPECTIVE STUDIES EVALUATING BIOLOGIC THERAPEUTICS FOR IBD

Background

Inflammatory Bowel Disease (IBD) studies have commonly relied on real-world evidence to evaluate different therapies. An emerging idea has been the use of propensity score matching as a statistical method to account for baseline characteristics in IBD patients. In retrospective studies, propensity score matching of patients helps reduce treatment assignment bias and mimic the effects of randomization. Recently, propensity-score matching has become an important tool in IBD studies comparing biologic therapeutics. Biologic medications are among the highest-grossing drugs worldwide, and their pharmaceutical producers make considerable payments to physicians to market them. In spite of this, there is a lack of evidence examining the role of undue industry influence among propensity-score matched comparative studies evaluating biologic therapeutics for IBD.

Aims

Given the documented association between IBD biologics and FCOI, we hypothesize a high burden of FCOI in propensity-score matched studies. The aim of this study was to evaluate the prevalence of disclosed & undisclosed financial conflicts of Interest (FCOI) in propensity-score matched comparison studies evaluating biologics for IBD.

Methods

We developed & ran a librarian-reviewed systematic search on EMBASE, MEDLINE, and Cochrane Library databases for all propensity-score matched retrospective studies comparing biologics for the treatment of IBD. Full-text retrieval & screening was performed on all studies in duplicate. 16 articles were identified. Industry payments to authors were only considered FCOI if they were made by a company producing a biologic that was included in the comparison study. Disclosed FCOI were identified by authors’ interests disclosures in full-texts. Any undisclosed FCOI among US authors were identified using the Centre for Medicare and Medicaid Services (CMS) Open Payments Database, which collects industry payments to physicians.

Results

Based on a preliminary analysis of 16 studies, there was at least one author with a relevant FCOI in 14 (88%) of the 16 studies. 14 studies (88%) had at least one disclosed FCOI, while 6 studies (37.5%) had at least one undisclosed FCOI. Among studies with disclosed FCOI, a mean of 40.2% (SD = 23.4%) of authors/study reported FCOI. Among studies with undisclosed FCOI, a mean of 18.8% (SD = 7.0%) of authors/study reported FCOI. The total dollar value of FCOIs was $1,974,328.3. The median conflict dollar value was $5,576.6 (IQR: $321.6 to $36,394.9).

Conclusions

We found a high burden of undisclosed FCOI (37.5%) among authors of propensity-score matched studies evaluating IBD biologics. Given the potential for undue industry influence stemming from such payments, authors should ensure better transparency with industry relationships.

Funding Agencies

None

A71 RECOMMENDATION REVERSALS IN GASTROENTEROLOGY CLINICAL PRACTICE GUIDELINES

Background

Clinical practice guidelines are evidence-based resources designed to inform clinical decision making. Often, superior evidence will support the inclusion of novel procedures and practices to replace older recommendations. Recommendation reversals occur when (a) superior quality evidence emerges to suggest the harm or non-beneficence of prior recommendations, and (b) that recommendation is not supplanted by a newer one.

Aims

The primary objective of this study was to describe the content, frequency and rationale for recommendation reversals in CPGs published by gastroenterological societies.

Methods

For this meta-epidemiologic study, we considered two criteria to define a recommendation reversal: (a) the more recent CPG makes a recommendation that contradicts a previously accepted practice; and (b) the prior recommendation is not replaced by any novel intervention. We searched CPGs published by 20 major GI societies from 1991- 2019. Guidelines were included if had at least two iterations with the same title and used a valid evidence rating system (such as GRADE). Explicit recommendations which reported definite levels of evidence and strength of recommendation were extracted.

Results

We identified 1022 clinical guidelines from GI societies over 28 years. 292 CPGs were included for data synthesis. 5985 explicit statements were extracted. 12 reversals were confirmed and are summarized in the Table. Six reversals (50.0%) occurred due to studies reporting non-beneficence and 3 (25.0%) occrred due to studies reporting harm. Three recommendations (25.0%) were reversed due to new clinical trials; 3 (25.0%) due to systematic reviews or meta-analyses; and 2 to conform with CPGs of other societies (16.7%).

Conclusions

We describe recommendation reversals made in gastroenterology CPGs, and the reasons thereof. Investigation of recommendation reversals allows for the identification of low-value medical practices. This reinforces the need for GI CPG committees to (1) iteratively review guidelines to re-evaluate recommendations made on low-quality evidence and; (2) refrain from making recommendations when evidence for the same is weak.

Funding Agencies

None

Is the right ventricular function affected by permanent pacemaker?

Funding Acknowledgements

Type of funding sources: None.

Background

The effect of right ventricular (RV) pacing on left ventricular (LV) function has been extensively evaluated, and so has the effect of the RV pacing lead on tricuspid valve function. However, the effects on RV function per se have not been evaluated systematically.

Purpose

We aimed to assess the RV dimensions and RV function six months after dual chamber pacemaker implantation

performed for atrioventricular (AV) block by detailed echocardiography, including three-dimensional (3D) echocardiography.

Method

All adult patients undergoing dual chamber pacemaker from January 2018 to March 2019 for symptomatic AV block with a structurally normal heart were included in the study. They underwent pre-procedure detailed echocardiography specifically directed at measuring RV dimensions and function [including 3D RV ejection fraction (EF)] and a repeat detailed echocardiogram at six-month follow-up, by the same echocardiographer. The echocardiographic parameters at baseline and after six-month follow-up were compared.

Results

All patients had more than 75% ventricular pacing in these six months. At six-month follow-up, there was no significant change in LVEF, while there was a mild decrease in RVEF as outlined in the Table 1. While there was some overlap between RVEF range of values at baseline and after six months, 23 (38.3%) patients showed a drop in RVEF by &gt;5%.

Conclusion

Our study shows a change in several RV function parameters in a majority of patients six months after

pacemaker implantation for AV block.

RV Function at six month follow-up Parameters Pre-procedure Six-Month Follow-up p value (Paired t-test) PASP (mm Hg) 20.2 ± 1.3 26.1 ± 12.2 &lt;0.001 FAC (%) 42.6 ± 3.4 39.4 ± 6 &lt;0.001 TAPSE (mm) 18.4 ±3.8 15.6 ± 4.7 &lt;0.001 RIMP 0.66 ± 0.09 0.61 ± 0.11 0.003 RV E/E’ 9.4 ± 2.1 7.7 ± 2.1 &lt;0.001 RV S’ 13.6 ± 2.4 10.7 ± 2.4 &lt;0.001 RVEF % [By 3D Echocardiography] 47.7± 5.1 44.9 ± 7.4 &lt;0.001 TR Jet Area (cm2) 0.03 ± 0.26 0.55 ± 0.96 &lt;0.001 RV= Right Ventricle; RA= Right Atrium; RVOT = Right Ventricular Outflow Tract; PASP = Pulmonary Artery Systolic Pressure; FAC= Fractional Area Change; TAPSE= Tricuspid Annular Plane Systolic Excursion; RIMP = Right Ventricular Index of Myocardial Performance; TR = Tricuspid Regurgitation S’ = Peak Systolic Annular Velocity; RVEF = Right Ventricular Ejection Fraction; 3D = Three Dimensional Abstract Figure. Change in RVEF in 6 months

Coronary artery bypass grafting versus percutaneous coronary intervention for left main disease in chronic kidney disease patients: a meta-analysis

Background

Limited data exist on the optimal revascularization strategy for patients with left main coronary artery disease (LMCAD) and chronic kidney disease (CKD). We conducted a meta-analysis to compare the outcomes of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this population.

Methods

Multiple electronic databases were queried for studies comparing CABG and PCI in CKD patients undergoing LMCAD (&gt;50% diameter stenosis) revascularization. CKD was defined as estimated glomerular filtration rate of &lt;60 ml/min/1.73 m2. The primary outcome was long-term major adverse cardiac and cerebrovascular events (MACCE), which was a composite of cardiovascular death, myocardial infarction (MI), stroke and repeat revascularization. Secondary outcomes included all-cause mortality, MI, stroke and repeat revascularization. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The analysis was performed using the DerSimonian and Laird random effect model.

Results

Six studies (4 observational, 2 randomized controlled trials) met inclusion criteria with a total of 2051 patients (CABG: 977, PCI: 1074). Patients undergoing CABG had a higher incidence of multi-vessel disease (74.7% vs 65.7%, p=0.01). At a mean follow-up of 3.4±1.1 years, MACCE was significantly lower in the CABG group (OR = 0.70, 95% CI 0.57–0.87; p=0.001) (Figure 1). The odds of MI or repeat revascularization were lower with CABG, whereas the odds of stroke were higher; no statistically-significant difference was seen in all-cause mortality.

Conclusion

This meta-analysis shows that CABG is associated with lower rates of MACCE and MI but with a higher rate of stroke compared to PCI in LMCAD patients with CKD.

Funding Acknowledgement

Type of funding source: None

Case report: Xanthogranulomatous pyelonephritis masquerading as cystic renal cell carcinoma

Background: Xanthogranulomatous pyelonephritis (XGP) is a rare chronic bacterial inflammation of the renal parenchyma and is often a diagnostic dilemma.Case Presentation: We present a challenging case of a patient with XGP. Initially thought to have had renal cell cancer she was treated accordingly with a partial nephrectomy. However, on the final pathology, she was found to have XGP and required further antibiotic therapy and referral to the infectious disease service.Discussion: Management of XGP and diagnostic pitfalls are discussed.Conclusion: XGP is a diagnostic and therapeutic dilemma. Partial Nephrectomy may be appropriate in management of XGP in select cases.

Developmental stage-specific role of Frs adapters as mediators of FGF receptor signaling in the oligodendrocyte lineage cells

FGF signaling is important for numerous cellular processes and produces diverse cellular responses. Our recent studies using mice conditionally lacking FGF-Receptor-1 (Fgfr1) or Fgfr2 during different stages of myelinogenesis revealed that Fgfr signaling is first required embryonically for the specification of oligodendrocyte progenitors (OPCs) and then later postnatally for the growth of the myelin sheath during active myelination but not for OPC proliferation, differentiation, or ensheathment of axons. What intracellular signal transduction pathways are recruited immediately downstream of Fgfrs and mediate these distinct developmentally regulated stage-specific responses remain unclear. The adapter protein Fibroblast-Growth-Factor-Receptor-Substrate-2 (Frs2) is considered a key immediate downstream target of Fgfrs. Therefore, here, we investigated the in vivo role of Frs adapters in the oligodendrocyte lineage cells, using a novel genetic approach where mice were engineered to disrupt binding of Frs2 to Fgfr1 or Fgfr2, thus specifically uncoupling Frs2 and Fgfr signaling. In addition, we used conditional mutants with complete ablation of Frs2 and Frs3. We found that Frs2 is required for specification of OPCs in the embryonic telencephalon downstream of Fgfr1. In contrast, Frs2 is largely dispensable for transducing Fgfr2-mediated signals for the growth of the myelin sheath during postnatal myelination, implying the potential involvement of other adapters downstream of Fgfr2 for this function. Together, our data demonstrate a developmental stage-specific function of Frs2 in the oligodendrocyte lineage cells. This contextual requirement of adapter proteins, downstream of Fgfrs, could partly explain the distinct responses elicited by the activation of Fgfrs during different stages of myelinogenesis.

28Impact of non-invasive rapid cardiac magnetic resonance for the assessment of cardiomyopathies in developing countries

Background

Cardiovascular mortality is higher in developing countries. Part of that is suboptimal testing. Cardiac magnetic resonance (CMR) is the gold standard for measuring structure, function of the heart and adds incremental value by imaging scarring and to assess iron level. Despite the existence of MRI units, CMR is identified as a complex test, with poor training and availability in developing countries.

Purpose

To assess the potential impact of a faster CMR protocol at a multicentre level in developing countries; implementing it with an education program, for the assessment cardiomyopathies.

Methods

An international partnership. A rapid CMR protocol for the evaluation of cardiac volumes, function and tissue characterization (Cardiac Iron T2* and LGE for scar) Figure 1a. We deployed the protocol as a multicentre study: Argentina, Peru, India and South Africa accompanied by a program of education. Pre-scan clinical information, scanning data: complications, image quality and post-scan follow-up of participants for the assessment on impact, between 3 to 24 months.

Results

510 scans (4 countries, 6 cities, 12 centres) were performed with the rapid CMR protocol. Contrast studies in 378 (74%). There were no scan-related complications. Quality of the studies was maintained in a high level as an average of 89%. 97% of studies responded referral's question. All patients with contrast CMR scan have had at least one 2D echocardiogram before CMR. Average scan duration was 21±6 mins for contrast studies and 12±3 for non-contrast T2* protocol. The most common underlying diagnoses were non-ischaemic cardiomyopathy in 73% of participants (including cardiac iron level assessment in 26%, HCM in 17%, DCM in 15%), 27% for ischaemic cardiomyopathy and 15% for other pathologies. 4 of the 12 participant centres started to incorporate CMR for the first time. Findings impacted management in 60% of patients, including new diagnosis in 21% of participants. See table 1, figure 1b. For just cardiac iron assessment: 1/3 of participants had iron deposited in the heart with 14% of patients in severe levels.

Conclusions

CMR can be delivered faster and easier. When this abbreviated protocol is enabled with education, it can be implemented in developing countries with existing technology. This protocol shows high quality exam, with an important impact on patient's management.

Characteristics and impact on management Contrast studies Non-contrast studies All patients (%) 378 (74) 132 (36) Age, mean (range) years 54 (16–93) 24 (13–41) Male (%) 151 (39) 64 (48) Pre-echocardiography exam (%) 370 (98) 42 (32) Scanning duration mean (SD) 21 (6) 12 (3) Good quality exam (%) 329 (87) 120 (91) Impact on management Total All patients (%) 510 (100) Completely new diagnosis (%) 105 (21) Change/Addition of Medication (%) 128 (25) Intervention/ Surgery (%) 31 (6) Invasive angiography/biopsy (%) 25 (5) Hospital discharge/admission (%) 15 (3) TOTAL 306 (60%) SD: Standard Deviation.

Acknowledgement/Funding

Global Engagement UCL, UK Foreign & Commonwealth Office and The Peruvian Scientific, Technological Development and Technological Innovation (FONDECYT)

Morphological measurements of anatomical landmarks in human maxillary first molar pulp chambers and evaluation of number of pulp canal orifices using spiral computed tomography: An in vitro study

Context:

Comprehensive understanding of the anatomic position of pulp canal orifices and the measurements of the molar pulp space may maintain the pulp health during conservative tooth preparation and minimize the possibility of mishaps during endodontic therapy.

Aims:

The idea of the present study was to analyze the morphological measurements of anatomical landmarks in human maxillary first molar pulp chambers and evaluation of number of pulp canal orifices using three-dimensional spiral computed tomography (SCT).

Subjects and Methods:

One hundred and thirty extracted intact human adult maxillary first molars were chosen from the North Indian population and were analyzed using SCT in axial and coronal sections.

Statistical Analysis Used:

Standard deviation, mean, and coefficient of variance were calculated. Interobserver reliability was evaluated using kappa value to avoid any bias.

Results:

The results from our study showed that 69.23% of the sample teeth had four canal orifices, the mesial and distal pulp horns were present at an average distance of 0.80 ± 0.36 mm and 0.41 ± 0.34 mm, respectively, above the cementoenamel junction (CEJ), and the mean distance from the central groove of central fossa to furcation and the central groove of central fossa to the pulp chamber's roof was 8.37 ± 0.33 mm and 3.87 ± 0.29 mm, respectively. The average distance of the pulp chamber's floor from the furcation was found to be 2.47 ± 0.11 mm. The highest degree of variance was observed in case of relation of CEJ to pulp horns, i.e., 44.85% and 82.60%.

Conclusions:

The dimensions observed in this study and its resemblance to the various studies reported in literature shift the fundamental anatomic approach to a more systemic quantifiable approach to the endodontic maxillary first molar access preparation.

Papilloedema: diffusion-weighted imaging of optic nerve head

AIM

To establish the correlation between clinical grading of papilloedema and diffusion abnormalities of optic nerve head (ONH) on diffusion-weighted imaging (DWI).

MATERIALS AND METHODS

Brain magnetic resonance imaging (MRI), including readout segmented echo planar imaging-based DWI, was performed in 32 patients with papilloedema and the same number of age- and sex-matched controls. Clinical grading of papilloedema was done according to the modified Frisén scale. Two neuroradiologists independently evaluated the MRI for ONH hyperintensity and apparent diffusion coefficient (ADC) value of ONH. The comparison between papilloedema clinical grade and qualitative grade of ONH hyperintensity and its presence between cases and control groups were done using the Chi-square test and Fisher's exact test, respectively. The comparison between mean ADC value of ONH among different grades and between cases and controls were done using analysis of variance (ANOVA)-F-test and Student's t-test, respectively. Receiver operating characteristic (ROC) analysis was done to calculate a cut-off ADC value between the case and control groups.

RESULTS

Significant correlation between ONH hyperintensity and mean ADC value of ONH with clinical grades of papilloedema and between cases and control groups were found. ONH hyperintensity was found to be a highly sensitive (87.5% for both) and specific (specificity 97.1% and 98.6% for two observers) sign of papilloedema. A mean cut-off ONH ADC value was found to have high sensitivity (96.83%) and specificity (95.31%) to distinguish between the cases and controls.

CONCLUSIONS

Diffusion parameters of ONH have significant correlation with clinical grading of papilloedema and can serve as a surrogate marker for intracranial pressure.

Neuregulin 1 type III improves peripheral nerve myelination in a mouse model of congenital hypomyelinating neuropathy

Myelin sheath thickness is precisely regulated and essential for rapid propagation of action potentials along myelinated axons. In the peripheral nervous system, extrinsic signals from the axonal protein neuregulin 1 (NRG1) type III regulate Schwann cell fate and myelination. Here we ask if modulating NRG1 type III levels in neurons would restore myelination in a model of congenital hypomyelinating neuropathy (CHN). Using a mouse model of CHN, we improved the myelination defects by early overexpression of NRG1 type III. Surprisingly, the improvement was independent from the upregulation of Egr2 or essential myelin genes. Rather, we observed the activation of MAPK/ERK and other myelin genes such as peripheral myelin protein 2 and oligodendrocyte myelin glycoprotein. We also confirmed that the permanent activation of MAPK/ERK in Schwann cells has detrimental effects on myelination. Our findings demonstrate that the modulation of axon-to-glial NRG1 type III signaling has beneficial effects and improves myelination defects during development in a model of CHN.

Reattachment of complex fractures; a reality by advances in self-etch bonding systems

An 18-year-old female patient reported to the Department of Conservative and Endodontics with the chief complaint of fractured tooth with respect to 21 and increased pain and mobility tooth with respect to 22. Intraoral periapical radiograph of 21 revealed coronal loss of tooth structure involving enamel, dentin, and pulp, suggestive of split tooth with respect to 21. Intraoral examination revealed a fracture of coronal structure of 22 and increased mobility in the coronal aspect, suggestive of horizontal crown-root fracture. For management of 21, after endodontic phase, placement of fiberpost, and coronal buildup, intentional reimplantation was done to expose and reattach the vertically fractured root fragment. For management of 22, after endodontic phase, crown lengthening was done, and the fractured fragment was reattached by making it a Natural Richmond's Crown. Radiographs revealed a complete sealing of the fractured fragment and proper positioning of the tooth.

Independent and cooperative roles of the Mek/ERK1/2-MAPK and PI3K/Akt/mTOR pathways during developmental myelination and in adulthood

Multiple extracellular and intracellular signals regulate the functions of oligodendrocytes as they progress through the complex process of developmental myelination and then maintain a functionally intact myelin sheath throughout adult life, preserving the integrity of the axons. Recent studies suggest that Mek/ERK1/2-MAPK and PI3K/Akt/mTOR intracellular signaling pathways play important, often overlapping roles in the regulation of myelination. However, it remains poorly understood whether they function independently, sequentially, or converge using a common mechanism to facilitate oligodendrocyte differentiation, myelin growth, and maintenance. To address these questions, we analyzed multiple genetically modified mice and asked whether the deficits due to the conditional loss-of-function of ERK1/2 or mTOR could be abrogated by simultaneous constitutive activation of PI3K/Akt or Mek, respectively. From these studies, we concluded that while PI3K/Akt, not Mek/ERK1/2, plays a key role in promoting oligodendrocyte differentiation and timely initiation of myelination through mTORC1 signaling, Mek/ERK1/2-MAPK functions largely independently of mTORC1 to preserve the integrity of the myelinated axons during adulthood. However, to promote the efficient growth of the myelin sheath, these two pathways cooperate with each other converging at the level of mTORC1, both in the context of normal developmental myelination or following forced reactivation of the myelination program during adulthood. Thus, Mek/ERK1/2-MAPK and the PI3K/Akt/mTOR signaling pathways work both independently and cooperatively to maintain a finely tuned, temporally regulated balance as oligodendrocytes progress through different phases of developmental myelination into adulthood. Therapeutic strategies aimed at targeting remyelination in demyelinating diseases are expected to benefit from these findings.

Racial predilection of C-shaped canal configuration in the mandibular second molar

Aim:

The purpose of this article is to determine the racial predilection of C-shaped canal configuration in a mandibular second molar.

Background:

Unusual root canal anatomy always poses a diagnostic and treatment challenge. Identification of such variation is important for the success of root canal treatment outcome. C-shaped canal configuration is such an aberrant morphology of molar teeth that vary in different population and is commonly seen in a mandibular second molar. Thus, knowledge of racial predilection of C-shaped canal configuration in different population for early diagnosis is obligatory.

Materials and Methods:

An exhaustive search was undertaken to identify published research articles related to C-shaped canal configuration in mandibular second molars. Forty-three research articles were analyzed which included 12,481 mandibular second molars. Chi-square test using value of P < 0.05 was performed to assess the statistical significance of this anomalous anatomic variation among the different population.

Results:

Statistical test revealed a significant variation between the Asian and nonAsian population. The highest incidence of racial predilection was observed in China (Asia) with 93.1%, and the minimum was observed in America with 2.7%.

Conclusion:

This research reported that racial predilection of C-shaped canal configuration in mandibular second molar varies significantly.

Morphology and prevalence of middle canals in the mandibular molars: A systematic review

Objectives:

The purpose of this paper is to systematically review the various studies and case reports on the morphology and prevalence of middle canals in the mandibular molars.

Methodology:

Electronic databases such as MEDLINE, PubMed, EBSCOhost, ScienceDirect and various journals were screened to identify published literature till March 2017 and earlier for articles related to middle canals in the human permanent mandibular molars. Obtained articles were categorized as original researches, case reports and review articles. Well-defined review questions were developed using the patient population, intervention, comparison and outcome framework to summarize the objectives: “Does middle canal vary in morphology and anatomic location? What is the prevalence of middle canals in mandibular molars? Does ethnicity affect the prevalence of middle canals in mandibular molars?” Morphology was studied and prevalence rates were determined from the evaluation of data extracted from the articles.

Results:

The search strategy resulted in 87 articles, of which 36 were original research papers and 51 were case reports. The prevalence of middle canals in the various populations ranged from 0.26% to 53.8%. Middle canals were reported in Europeans, Asians, Africans and South and North American populations. The prevalence of middle mesial canal and middle distal canal in various races was reported as up to 53.8% and 10%, respectively. The orifice of middle canal exists below a dentinal projection in the groove between the two main canals. They were observed in fin, confluent and independent configuration. Out of these, confluent configuration was more prevalent.

Conclusion:

Middle canal varies in morphology and anatomic location. Ethnicity affects the prevalence of middle canals in the mandibular molars.

Maternal and neonatal complications during pregnancy in women with epilepsy

Epilepsy is the commonest serious neurological problem faced by obstetricians and gynaecologists. Epidemiological studies estimate epilepsy to complicate 0.3–0.7% of all pregnancies.1 2 The importance of epilepsy in pregnancy lies in the fact that many women with epilepsy (WWE) have to go through their pregnancy while taking antiepileptic (AED) drugs. Both the seizures and AEDs can have harmful effects on the mother as well the foetus. Thus, during pregnancy, the clinician faces dual challenge of controlling seizures as well as preventing teratogenicity of AEDs.1 In this review we discuss the possible impact of seizures as well as AEDs on mother as well as the child. We try to answer some of the commonest questions which are relevant to successful management of pregnancy and ensuring birth of a healthy baby.

Diastereoselectivity in the Aza-Michael Reaction of Chiral α-Methylbenzylamines with α,β-Unsaturated Carbonyl Compounds

The aza-Michael reaction of (S)-(–)- and (R)-(+)-α-methylbenzylamines with trans-cinnamaldehyde and other α,β-unsaturated carbonyl compounds occurs with 52–98% diastereoselectivity (de); however, in the reaction with crotonaldehyde, the de is lower (20–38%). In the products obtained from the reaction with α,β-unsaturated aldehydes, the de could be determined on the basis of the relative intensities of the aldehydic protons of the two diastereomers. Theoretical investigations of the reaction of (S)-(–)-α-methylbenzylamine with trans-cinnamaldehyde at the DFT (B3LYP/6-31+G*) level reveal that the diastereomer formed from the attack of the amine on the Re face is thermodynamically more stable. The calculations also show that the aldehydic proton of this diastereomer is expected to be more deshielded, which on the basis of the 1H NMR spectrum is the major product.

Comparison of canal transportation and centering ability of Twisted Files, HyFlex controlled memory, and Wave One using computed tomography scan: An in vitro study

Aim:

The aim of the present study was to compare the canal transportation and centering ability of three rotary nickel-titanium (NiTi) systems (Twisted Files [TF], HyFlex controlled memory [CM], and Wave One [WO]) in curved root canals using computed tomography (CT).

Materials and Methods:

Sixty freshly extracted single-rooted teeth having curved root canals with at least 25–35 degrees of curvature were selected. The teeth were randomly divided into three experimental groups of twenty each. After preparation with TF, HyFlex CM, and WO, all teeth were scanned using CT to determine the root canal shape. Pre- and post-instrumentation images were obtained at three levels, 3 mm apical, 9 mm middle, and 15 mm coronal above the apical foramen were compared using CT software. Amount of transportation and centering ability were assessed. The three groups were statistically compared with analysis of variance and post hoc Tukey's honestly significant difference test.

Results:

Least apical transportation and higher centering ability were seen in HyFlex CM file system in all the three sections followed by TF. WO file system showed maximum transportation.

Conclusions:

The canal preparation with HyFlex CM file system showed lesser transportation and better centering ability than TF, WO file system.

MTBDRplus for the rapid diagnosis of ocular tuberculosis and screening of drug resistance

PurposeTimely diagnosis of intraocular tuberculosis (IOTB) along with detection of drug resistance can save many eyes from visual impairment. With the growing incidence of IOTB and rising drug resistance, a reliable diagnostic platform for simultaneous detection of the agent and mutated gene is urgently needed. The MTBDRplus assay was evaluated directly on vitreous fluid samples for the same.Patients and methodsIn a prospective study, The MTBDRplus assay was performed on 127 vitreous fluid samples (77 'study group' comprising cases of presumed ocular tuberculosis and 50 'control group' cases of disease controls (n=25) and non-uveitic controls (n=25)). All samples positive by MTBDRplus assay were subjected to gene sequencing to confirm the mutations for rifampicin and isoniazid resistance.ResultsThe MTBDRplus assay produced a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 36.36%, 100%, 100%, and 50.50%, respectively, for the detection of IOTB. Among the 28 cases from study group that were positive by MTBDRplus assay, rifampicin resistance was reported in six and isoniazid resistance in two cases. On sequencing of rpoB and katG gene, one case of false rifampicin-resistant by MTBDRplus was found. The other resistant isolates showed concordant mutations between MTBDRplus assay and sequencing.ConclusionThe MTBDRplus assay is an effective tool for the rapid diagnosis of IOTB along with detection of drug resistance, thereby improving the outcome in IOTB.

Effect of Different Composite Restorations on the Cuspal Deflection of Premolars Restored with Different Insertion Techniques- An In vitro Study

INTRODUCTION

This study was conducted to assess the effect of different composite materials on the cuspal deflection of premolars restored with bulk placement of resin composite in comparison to horizontal incremental placement and modified tangential incremental placement.

AIM

The aim of this study was to evaluate the cuspal deflection caused by different composite materials when different insertion techniques were used.

MATERIALS AND METHODS

Two different composite materials were used that is Tetric N Ceram (Ivoclar Vivadent marketing, India) and SonicFill^TM (Kerr Sybron Dental). Forty standardized Mesio-Occluso-Distal (MOD) preparations were prepared on maxillary first premolars. Each group was divided according to composite insertion technique (n=10), as follows: Group I - bulk insertion using Tetric N Ceram, Group II - Horizontal incremental insertion technique using Tetric N Ceram, Group III- Modified tangential incremental technique using Tetric N Ceram, and Group IV- bulk insertion using SonicFill^TM. Preparations were acid-etched, and bonded with adhesive resin to provide micro mechanical attachment before restoration using a uniform etching and bonding protocol in all the groups. All groups received the same total photo-polymerization time. Cuspal deflection was measured during the restorative procedure using customized digital micrometer assembly. One-way ANOVA test was applied for the analysis of significant difference between the groups, p-value less than 0.05 was considered statistically significant.

RESULTS

The average cuspal deflections for the different groups were as follows: Group I 0.045±0.018, Group II 0.029±0.009, Group III 0.018±0.005 and Group IV 0.017±0.004. The intergroup comparison revealed statistically significant difference.

CONCLUSION

A measurable amount of cuspal deflection was present in all the four studied groups. In general, bulkfill restoration technique with conventional composite showed significantly highest cusp deflection. There were no significant differences in cuspal deflection among sonicFill^TM and modified tangential incremental insertion techniques.

A conservative management of iatrogenically damaged distal root of the mandibular second molar

Trauma to the adjacent hard and soft tissue is the most common iatrogenic injury during extraction of the mandibular third molar. As every functional component of the dental arch is of prime importance in contemporary dental practice, the major concern must be in conserving the tooth and its structure as much as possible. The present case discusses the application of this conservative approach for management of iatrogenically damaged distal root of the mandibular second molar during extraction of impacted third molar, in which excessive guttering of alveolar bone and fractured apical third of distal root of 37 was observed radiographically. A conservative and noninvasive approach was successfully achieved to restore the damaged root by the bioactive material. Sealing of the remaining root with mineral trioxide aggregate allowed regeneration of soft and hard tissue around it.