Oxidative stress mediates associations between preoperative psychosocial phenotype and pain-related outcomes at 6 months following total knee arthroplasty: a longitudinal cohort study

OBJECTIVE

Greater preoperative depression, anxiety, and pain catastrophizing are associated with more severe long-term pain following total knee arthroplasty (TKA). In a secondary analysis of previously reported data, we tested the hypothesis that these associations are mediated by oxidative stress (OS).

DESIGN

A mixed between/within-subjects longitudinal cohort design.

SETTING

A single academic medical center.

SUBJECTS

Osteoarthritis patients (n = 91; 62.6% female) undergoing unilateral TKA.

METHODS

We assessed depression, anxiety, and catastrophizing, as well as markers of central sensitization (widespread pain, temporal summation of pain) preoperatively. Blood samples were then obtained immediately prior to intraoperative tourniquet placement for quantification of in vivo biomarkers of systemic OS, F2-isoprostanes and isofurans. Post-TKA pain intensity (numeric rating scale worst pain [NRS], McGill Pain Questionnaire-2 [MPQ-2]) and function (PROMIS Pain Interference) were assessed at 6 months following TKA.

RESULTS

Greater preoperative depression, catastrophizing, and widespread pain were associated with higher intraoperative combined OS (F2-isoprostanes+isofurans/2), which was in turn associated with higher post-TKA pain intensity and worse function (P < .05). All preoperative phenotype predictors except anxiety were correlated positively with post-TKA pain and/or function (P < .05). Bootstrapped mediation analyses revealed significant (P < .05) indirect (mediated) effects of depression (NRS Worst Pain, MPQ-2, PROMIS Pain Interference), anxiety (MPQ-2, PROMIS Pain Interference), and catastrophizing (PROMIS Pain Interference) on adverse long-term post-TKA outcomes via elevated OS. Central sensitization-related predictors demonstrated only direct effects (P < .05) on post-TKA outcomes that were independent of OS mechanisms.

CONCLUSIONS

Results suggest that the adverse impact of depression, anxiety, and pain catastrophizing on post-TKA pain and functional outcomes are mediated in part by elevated OS.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery

Background

Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications.

Purpose

This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery.

Study Design

Position statement.

Methods

The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated.

Results

A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption.

Conclusion

A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

Sternal stress fracture presenting as acute chest pain

Sternal fractures are rare and are typically caused by major trauma such as motor vehicle collisions. However, sternal insufficiency fractures can occur with minimal to no trauma in patients with exaggerated thoracic kyphosis from multiple thoracic compression fractures, especially in the setting of osteoporosis. We describe a case of a sternal insufficiency fracture that presented as chest pain resembling a myocardial infarction. As sternal insufficiency fractures may vary in clinical presentation, this case demonstrates that radiologists should carefully evaluate the sternum, especially when risk factors are present. Furthermore, awareness and identification of these fractures can prevent unnecessary cardiac workups.

EURADOS ISO/IEC 17025 guidance for IMS: suggestions on how to interpret and implement the requirements including examples from accredited laboratories

Individual monitoring of external radiation is an activity usually regulated by national regulatory bodies in most countries. Regulations generally contain technical requirements to be met by the individual monitoring services (IMS), in order to ensure that the measurements are correct and therefore the dosimetry results are reliable. In some countries, the requirements include or even consist of the accreditation of the service according to the standard ISO/IEC 17025: 'General requirements for the competence of testing and calibration laboratories.' It is a fact that accreditation is a growing trend among European IMS as a way to guarantee confidence in their technical competence. The acceptance of the dosimetry results between countries and their indentation in the respective National Dose Registries is facilitated if laboratories conform to the ISO/IEC 17025 standard. In the framework of the activities of EURADOS (European Radiation Dosimetry Group) working group 2 'Harmonization of Individual Monitoring in Europe' and attending to the concern of many European IMS in the process of accreditation, a guide has been prepared. The purpose was to assist and encourage IMS to apply for accreditation and to share the authors' own experience with the process. The guide intends to be a practical reference for IMS on how to interpret and implement the ISO/IEC 17025 requirements to the specific activity of a personal dosimetry service for external radiation, emphasizing those aspects of special interest. It includes examples from dosimetry laboratories already accredited. The major novelties from a new edition of ISO/IEC 17025: 2017 are also identified in the guide. Finally, the guide aims to assist the auditing process, giving examples of auditor's questions and how to show evidence of compliance. The main findings are presented.

Assessment of the Spatial Bio-Distribution of NBTXR3 for Locally Advanced or Borderline-Resectable Pancreatic Ductal Adenocarcinoma (LAPC or BRPC) Patients Undergoing Radiation Therapy

PURPOSE/OBJECTIVE(S)

NBTXR3 is a novel radioenhancer composed of functionalized hafnium oxide nanoparticles that are injected directly into the tumor. An ongoing phase I trial is assessing the application of NBTXR3 in the treatment of locally-advanced or borderline-resectable pancreatic ductal adenocarcinoma, with the primary goal of determining the recommended NBTXR3 dose for a subsequent phase II trial. Using patients from the ongoing phase I trial, we evaluated the spatial bio-distribution of NBTXR3 in the pancreas as function of time and assessed if there is migration of the compound during radiation therapy.

MATERIALS/METHODS

Adult patients with LAPC or BRPC were enrolled. Analysis of 8 patients who underwent CT simulation at least 24 hours after receiving the NBTXR3 intratumoral injection in the pancreatic lesion under general anesthesia guided by an endoscopic ultrasound was conducted. Patients were simulated with and without iodinated intravenous contrast under breath hold, with 3mm CT slice thickness and 50-60cm FoV. A contrast-enhanced CT series was chosen for RT planning purposes. All patients were planned for a 15-fraction IMRT course using 6-MV beam energy, with 45Gy and 37.5Gy dose levels (using a simultaneous integrated boost technique) to gross primary tumor and microscopic disease/regional nodes, respectively. Daily image guidance included either cone-beam CT (CBCT, n = 1) or CT-on-Rails (CTOR, n = 7) and were fused to the planning CT images using Velocity, ver. 3.0.1. The NBTXR3 volume was determined by thresholding the images to 165 HU and 300 HU for CTOR and CBCT images, respectively. Bones, stents, and artifacts were manually removed from the NBTXR3 volume. The volumes for the NBTXR3 and the NBTXR3 overlapping with the GTV for each patient were individually fit to a linear model in R, ver. 4.1.3.

RESULTS

One patient from the CTOR cohort was excluded from analysis due to the small volume of NBTXR3 (0.02 cm3) compared to the rest of the cohort (0.716 - 6.917 cm3). The total volume of NBTXR3 in the CBCT images could not be analyzed due the substantial image artifacts, only the volume overlapping the GTV was calculated. There were no statistically significant changes (p > 0.1 Adj-R2 = 0.99) in the raw volume of NBTXR3 for the duration of the treatment in all CTOR patients. For the NBTXR3 volume overlapping with the GTV, five cases did not present with a volume change during the treatment (p > 0.1 Adj-R2 = 0.99), while one CTOR case had a reduction in volume of about 1.5%/day (p = 0.7), and the CBCT case had a reduction of 3%/day (p < 0.001).

CONCLUSION

The raw volume of NBTXR3 injected in the pancreas did not significantly change over the duration of the three weeks of treatment. We also did not observe significant changes in the NBTXR3 volume overlapping the GTV in most cases. The stability of NBTXR3 was demonstrated during RT.

Phase 1 Trial of SPECT-Guided Liver-Directed Ablative Radiotherapy for Patients with Low Functional Liver Volume

PURPOSE/OBJECTIVE(S)

Traditional liver dose constraints specify that a critical volume of 700 cc of non-tumor liver should be spared from receiving a hepatotoxic dose. We evaluated the safety of liver-directed ablative radiotherapy for patients with hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), or liver metastases (LM) with Child-Pugh (CP) A5 liver function at baseline and with low functional liver volume as estimated by Tc-99m sulfur colloid single photon emission computed tomography (SPECT). We hypothesized that functional liver image guidance with SPECT would allow safe delivery of ablative radiotherapy in patients with limited liver volume.

MATERIALS/METHODS

A phase 1 trial with a 3+3 design was conducted to evaluate the safety of comprehensive ablative radiotherapy to the liver disease using escalating functional non-target liver radiation dose constraints. Eligibility criteria included (1) a diagnosis of HCC, iCCA, or LM, (2) prior treatment with irinotecan or oxaliplatin chemotherapy or liver resection, and (3) a minimum functional liver volume of 400 cc as estimated by SPECT using a threshold of 40% maximum intensity. Patients with CP >A5 liver function, prior liver-directed radiotherapy, or prior Yttrium-90 therapy were excluded. The prescription dose was 67.5-75 Gy in 15 fractions or 75-100 Gy in 25 fractions. The volumetric dose constraint for functional non-target liver receiving <24 Gy for 15 fractions or <27 Gy for 25 fractions was determined by the dose level of trial enrollment: level 0 was ≥400 cc and level +1 was ≥300 cc. A level -1 was included if needed. We used standard 15 and 25 fraction dose constraints for other organs at risk. The following dose limiting toxicities (DLTs) were assessed within 6-8 weeks of completing radiotherapy: Grade 3 hypoalbuminemia, increase in INR, increase in bilirubin, or ascites, or Grade 4 hepatic failure or any radiation-related toxicity.

RESULTS

Twelve patients enrolled between February 2016 and June 2022. The median (range) GTV was 36 (2-651) cc. The median CT anatomical non-tumor liver volume was 1584 (764-2699) cc, and the median SPECT functional liver volume was 1117 (570-1928) cc, with a Pearson correlation coefficient of 0.98 (p<0.001). The median non-target SPECT functional liver volume below the volumetric dose constraint was 684 (429-1244) cc. None of the 3 patients treated in dose level 0, and none of the 9 patients treated in dose level +1 experienced any DLTs. The 1-year in-treatment-field control rate was 55%, and 1-year overall survival was 71%.

CONCLUSION

Ablative radiotherapy can be safely delivered using functional SPECT image guidance, which enables sparing lower volumes of functional liver than traditionally accepted in patients with CP A5 liver function. Further evaluation with a phase 2 study is warranted.

Symptoms of dry eye related to the relative humidity of living places

PURPOSE

To investigate the impact of relative humidity (RH) and climate variables of the place of residence on symptoms of dry eye disease (DED) in primary eye care practice.

METHODS

A cross-sectional analysis of the Ocular Surface Disease Index (OSDI) dry eye classification of 1.033 patients [classified as non-DED (OSDI ≤22) and DED (OSDI >22)] was conducted in a multicentre study in Spain. Participants were classified according to the 5-year RH value (data from the Spanish Climate Agency -www.aemet.es) into two groups: those who lived in low RH (<70%) places and those who lived in high RH (≥70%) places. Additionally, differences in daily climate records (EU Copernicus Climate Change Service) were assessed.

RESULTS

The prevalence of DED symptoms was 15.5% (95% CI 13.2%-17.6%). Participants who lived in places with <70% RH showed a higher prevalence of DED (17.7%; 95% CI 14.5%-21.1%; P < 0.01 adjusted for age and sex) than those who lived in places with ≥70% RH (13.6%; 95% CI 11.1%-16.7%) and a closer, but not statistically significant, risk for DED (OR = 1.34, 95% CI 0.96 to 1.89; P = 0.09) than previously described DED risk factors [age older than 50 years (OR = 1.51, 95% CI 1.06 to 2.16; P = 0.02) and female sex (OR = 1.99, 95% CI 1.36 to 2.90; P < 0.01)]. Some climate data showed statistically significant differences (P < 0.05) between participants with DED and non-DED (mean wind gusts; atmospheric pressure; mean and minimum relative humidity); these variables did not significantly increase DED risk (OR close to 1.0 and P > 0.05).

CONCLUSION

This study is the first to describe the impact of climate data on dryness symptomatology in Spain, confirming that participants who live in locations with RH <70% have a higher prevalence (corrected for age and sex) of DED. These findings support the use of climate databases in DED research.

Initial progress of the magnetic diagnostics of the MAST-U tokamak

MAST Upgrade has just begun its third physics campaign in April of 2023. The set of magnetic probes used to diagnose the magnetic field and currents on MAST Upgrade are described, and their calibration procedures are outlined including calculation of uncertainties. The median uncertainty in the calibration factors of the flux loops and pickup coils are calculated as 1.7% and 6.3%. The arrays of installed instability diagnostics are described, and the detection and diagnosis of a specimen MHD mode are demonstrated. Plans for the improvement of the magnetics arrays are outlined.

Uncertainties in the adaptation of alpine pastures to climate change based on remote sensing products and modelling

Over the last century, the management of pastoral systems has undergone major changes to meet the livelihood needs of alpine communities. Faced with the changes induced by recent global warming, the ecological status of many pastoral systems has seriously deteriorated in the western alpine region. We assessed changes in pasture dynamics by integrating information from remote-sensing products and two process-based models, i.e. the grassland-specific, biogeochemical growth model PaSim and the generic crop-growth model DayCent. Meteorological observations and satellite-derived Normalised Difference Vegetation Index (NDVI) trajectories of three pasture macro-types (high, medium and low productivity classes) in two study areas - Parc National des Écrins (PNE) in France and Parco Nazionale Gran Paradiso (PNGP) in Italy - were used as a basis for the model calibration work. The performance of the models was satisfactory in reproducing pasture production dynamics (R² = 0.52 to 0.83). Projected changes in alpine pastures due to climate-change impacts and adaptation strategies indicate that: i) the length of the growing season is expected to increase between 15 and 40 days, resulting in changes in the timing and amount of biomass production, ii) summer water stress could limit pasture productivity; iii) earlier onset of grazing could enhance pasture productivity; iv) higher livestock densities could increase the rate of biomass regrowth, but major uncertainties in modelling processes need to be considered; and v) the carbon sequestration potential of pastures could decrease under limited water availability and warming.

From multiallele fish to nonstandard environments, how ZFIN assigns phenotypes, human disease models, and gene expression annotations to genes

Danio rerio is a model organism used to investigate vertebrate development. Manipulation of the zebrafish genome and resultant gene products by mutation or targeted knockdown has made the zebrafish a good system for investigating gene function, providing a resource to investigate genetic contributors to phenotype and human disease. Phenotypic outcomes can be the result of gene mutation, targeted knockdown of gene products, manipulation of experimental conditions, or any combination thereof. Zebrafish have been used in various genetic and chemical screens to identify genetic and environmental contributors to phenotype and disease outcomes. The Zebrafish Information Network (ZFIN, zfin.org) is the central repository for genetic, genomic, and phenotypic data that result from research using D. rerio. Here we describe how ZFIN annotates phenotype, expression, and disease model data across various experimental designs, how we computationally determine wild-type gene expression, the phenotypic gene, and how these results allow us to propagate gene expression, phenotype, and disease model data to the correct gene, or gene related entity.

Perceived health interests of college students

Objective: Investigate how college students perceive positive aspects of health as compared to neutral and/or negative aspects of health. Participants: 20 college students (55% female, 50% Black, M age = 23 years, SD = 4.1 years) completed a card-sorting activity as part of a focus group. Methods: Each participant ranked 57 cards by perceived importance. The cards included positive (n = 19), neutral (n = 19), and negative (n = 19) health topics. Results: Positive and neutral health attributes were significantly more important than negative aspects of health, with student rankings indicating declining importance from positive to neutral to negative aspects of health. Conclusions: Findings suggest that campus health professionals should consider salutogenic approaches to health promotion that enable college students to achieve short-term health gains and health maintenance in addition to disease prevention and harm reduction.

Recognizing Ethyl Chloride Neurotoxicity: Inhalant Abuse Hidden in Plain Sight

Ethyl chloride is a common topical anesthetic. However, when abused as an inhalant, effects can range from headaches and dizziness to debilitating neurotoxicity requiring intubation. While previous case reports describe the short-term reversible neurotoxicity of ethyl chloride, ours show chronic morbidity and mortality outcome. During the initial evaluation, it is essential to consider the rising trend of commercially available inhalants being used as recreational drugs. We present a case of a middle-aged man presenting with subacute neurotoxicity due to repeated abuse of ethyl chloride.

Hypernatremia in Diabetic Ketoacidosis: A Rare Metabolic Derangement Requiring a Cautionary Approach in Fluid Resuscitation

Diabetic ketoacidosis (DKA) with hypernatremia is an atypical metabolic derangement that warrants additional consideration in choosing IV fluids. Our patient, a middle-aged male with a history of insulin-dependent diabetes mellitus type 2 and hypertension, presented with DKA and hypernatremia in the setting of poor intake, community-acquired pneumonia (CAP), and COVID-19. DKA and hypernatremia led to a meticulous approach to fluid resuscitation, where a crystalloid solution was the choice in treating and preventing exacerbation of either condition. Successful treatment of these conditions requires understanding the unique pathophysiology, which demands further research on management.

Patient Satisfaction with Upper and Lower Complete Dentures: A Service Evaluation Report

PURPOSE

The purpose of this questionnaire-based service evaluation was to assess patient satisfaction with complete dentures provided in a dental teaching hospital.

METHODS

Patients completed the self-administered questionnaire before, immediately after, and 2-months following provision of new complete dentures. The questionnaire consisted of the following sections: Patient characteristics, current denture history and satisfaction with the fit of upper/lower complete dentures, chewing ability, speech, and aesthetics. Descriptive analysis, chi-square test, student t-test, and 2-way-ANOVA were performed on satisfaction levels pre-and post-treatment to assess denture fit, chewing ability, speech, and appearance. Age and gender-wise satisfaction levels along with correlations and associations between patient satisfaction levels and various factors were assessed.

RESULTS

147 participants, including 91 males (61.9%) and 56 females (38.1%) completed the study. A statistically significant improvement in satisfaction scores was seen post-treatment in all domains (p⟨0.05), with most respondents showing great satisfaction. Overall, satisfaction levels were: Upper complete denture fit (82%), appearance (87%), speech (67%), chewing ability and lower complete denture fit (39%). A strong positive correlation was observed between the number of previous dentures used and patient satisfaction with upper denture fit (R=1).

CONCLUSION

Denture replacement positively impacts the satisfaction of patients and improves complete denture acceptance.

A multicenter retrospective study evaluating the impact of desmopressin on hematoma expansion in patients with antiplatelet-associated intracranial hemorrhage

INTRODUCTION

Antiplatelet medications interfere with hemostasis which can contribute to increased risk of hematoma expansion and potentially worse outcomes in patients presenting with intracranial hemorrhages (ICH). Current Neurocritical Care Society guidelines recommend desmopressin (DDAVP) in patients with antiplatelet-associated ICH with evidence limited by small cohorts.

MATERIALS AND METHODS

Patients were included in our multi-center, retrospective study if they had computed tomographic (CT) scan confirmed ICH and were taking antiplatelet medications. Patients were excluded if hospital length of stay was <24 h, administered DDAVP dose was <0.3 μg/kg, no follow-up head CT scan was performed within the first 24 h after baseline, major neurosurgical intervention was performed in between CT scans, or the injury was an acute on chronic ICH. The primary outcome was incidence of hematoma expansion (defined as >20 % increase from baseline). Secondary outcomes were incidence of thrombotic complications within 7 days, largest absolute decrease in serum sodium within the first 24 h, and patient disposition.

RESULTS

Among the 209 patients included in the study, 118 patients received DDAVP while 91 did not. The frequency of hematoma expansion was similar between patients who received DDAVP and those who did not (16.1 % vs 17.6 %; P = 0.78). No difference in secondary outcomes was observed between the two groups.

CONCLUSIONS

These findings in conjunction with recently published literature may suggest minimal benefit or harm with DDAVP treatment. However, further study could elucidate any potential impact on long-term function outcomes.

Identification of Demographic and Clinical Prognostic Factors in Traumatic Intraventricular Hemorrhage

BACKGROUND

The presence of traumatic intraventricular hemorrhage (tIVH) following traumatic brain injury (TBI) is associated with worse neurological outcome. The mechanisms by which patients with tIVH have worse outcome are not fully understood and research is ongoing, but foundational studies that explore prognostic factors within tIVH populations are also lacking. This study aimed to further identify and characterize demographic and clinical variables within a subset of patients with TBI and tIVH that may be implicated in tIVH outcome.

METHODS

In this observational study, we reviewed a large prospective TBI database to determine variables present on admission that predicted neurological outcome 6 months after injury. A review of 7,129 patients revealed 211 patients with tIVH on admission and 6-month outcome data. Hypothesized risk factors were tested in univariate analyses with significant variables (p < 0.05) included in logistic and linear regression models. Following the addition of either the Rotterdam computed tomography or Glasgow Coma Scale (GCS) score, we employed a backward selection process to determine significant variables in each multivariate model.

RESULTS

Our study found that that hypotension (odds ratio [OR] = 0.35, 95% confidence interval [CI] = 0.13-0.94, p = 0.04) and the hemoglobin level (OR = 1.33, 95% CI = 1.09-1.63, p = 0.006) were significant predictors in the Rotterdam model, whereas only the hemoglobin level (OR = 1.29, 95% CI = 1.06-1.56, p = 0.01) was a significant predictor in the GCS model.

CONCLUSIONS

This study represents one of the largest investigations into prognostic factors for patients with tIVH and demonstrates that admission hemoglobin level and hypotension are associated with outcomes in this patient population. These findings add value to established prognostic scales, could inform future predictive modeling studies, and may provide potential direction in early medical management of patients with tIVH.

Posterior fossa ischemic infarction: single-center retrospective review of non-surgical and surgical cases

Cerebellar ischemic stroke (CIS) is a morbid neurological event, with potentially fatal consequences. There is currently no objective standard of care regarding when surgical procedures are required for this entity. We retrospectively reviewed 763 patients with CIS, 247 patients of which had a stroke larger than 1 cm in greatest dimension on cranial imaging. In this subgroup, 11% of patients received ventriculostomy, 12% suboccipital craniectomy, and 9% mechanical endovascular thrombectomy. Various clinical and radiographic variables were examined for relationship to surgical procedures, 30-day mortality rate, and modified Rankin scores. The smallest volume of stroke requiring a surgical procedure was 15.5 mL3 (BrainLab Software). Patients receiving surgical procedures had a higher incidence of multi-territory infarctions, hydrocephalus, cistern compression, 4th ventricular compression, as well as younger age, lower admission GCS, higher admission NIHSS, and higher 30-day mortality/disability. Patients deemed to require surgical procedures for CIS have a higher expected morbidity and mortality than those not requiring surgery. Various clinical and radiographic variables, including stroke volume, can be used to guide selection of patients requiring surgery.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Recruitment and organising 3rd year pharmacy undergraduates into summer placements in primary care in Southwest England

Introduction

Primary care is facing a workforce shortage, especially in Southwest England (SW).1 Funding for clinical pharmacist roles in GP has an impact on community pharmacy with pharmacists leaving to take up PCN positions.2 SW has higher rate of vacancies in than nationally.3 Oriel data showed that fill rate for split foundation training placements in GP is high, however, in SW is significantly low.

Aim

To increase recruitment of future pharmacists in SW by offering pharmacy undergraduates paid 5-week summer placements in GP or GP/community pharmacy partnership, gaining primary care experience, showcasing benefits of cross-sector working and encouraging development of partnerships for increased cross-sector training placements.

Objectives

Students enjoy SW area placement, Students recommend placement to other students, Students preference GP foundation placement, Supervisors express interest in a summer placement for 2022, Supervisors express interest in the GP split trainee pharmacist programme.

Methods

Expressions of interest (EOIs) sought from primary care placements in SW and 16 sites selected. Applicants shortlisted and interviewed online. 16 offered placements based on preference of location. Funding by HEE South reimbursed for student’s wages. Planning booklets provided to GPs, workbooks to students and online induction attended. During the placement, students completed an audit and case-based discussion, shadowed healthcare professionals, assisted administration and pharmacy tasks and practised basic procedural skills. Students attended end-of-placement event to share learning and sent questionnaire focusing on enjoyment of the placement and likelihood of returning to the Southwest and primary care for future employment. Supervisors sent questionnaire separately focusing on likelihood to partake in future. Questionnaires were sent, completed and analysed via Jisc. Ethics approval was not required.

Results

10 students and 11 supervisors completed the survey. 60% students enjoyed SW. 90% students would recommend placement to other students and 90% would like to see them in other areas. 70% students very likely to or definitely would apply for GP foundation placement. 63% supervisors benefitted from having a student and 81% would recommend having summer placement student. 55% supervisors would definitely EOI in future summer placement programme and 55% would definitely EOI in GP split foundation programme. 25% students chose GP/Community placements in SW, 18% other placements in SW, 12% GP placements in other regions. Oriel fill rates in SW increased from 36.67% in 2020 to 39.30% in 2021, GP/Community placements remained the same in 2021 at 28.2% and community placements increased in from 18.14% in 2020 to 18.75% in 2021.

Discussion/Conclusion

The students enjoyed their placements and would recommend to other students. Supervisors found having students useful and would have a student in the future. Although some students were successful in securing a placement in SW for foundation training, due to nature of Oriel it’s not possible to determine how many preferenced SW and GP split programme, this is a limitation to the evaluation. Oriel fill rates didn’t increase for SW community/GP placements as desired, however this was a very small cohort. This pilot will be repeated summer 2022 so fill rates can be evaluated in 2023.

References

1. NHS. The NHS Long Term Plan. Long Term Plan. [Online] 2019. Available from: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf.

2. BMA. Investment and Evolution: A five year gramework for GP contract reform to implement the NHS long term plan. England NHS. [Online] 2019. Available from: https://www.england.nhs.uk/wp-content/uploads/2019/01/gp-contract-2019.pdf.

3. Community Pharmacy Workforce Development Group. A Review of the Community Pharmacy Workforce. Community Pharmacy Workforce. [Online] 2021. Available from: https://communitypharmacyworkforce.files.wordpress.com/2021/06/cpwdg-report-a-review-of-the-community-pharmacy-workforce-final.pdf.

204 DEDICATED NURSING HOME SERVICE IN A TERTIARY HOSPITAL: EFFECT ON ADMISSION NUMBERS AND LENGTH OF STAY

Background

In 2019 a dedicated Nursing Home (NH) in-patient service was established in a tertiary hospital, comprising a Consultant Geriatrician, clinical nurse specialist, NCHD and administrative support. All NH residents over 65 with medical diagnoses were admitted by the NH team who also provide a consult service for NH residents under other specialties.

Methods

Data were sourced from the Hospital Inpatient Enquiry system on length of stay of patients identified as admitted from a nursing home compared to those admitted under the NH team and their average lengths of stay over 2019-2021.

Results

In 2019, 749 NH residents were admitted to hospital with an average length of stay (ALOS) of 7.93 days, the NH inpatient service was established in July 2019 and showed a reduction of ALOS from 9.25 to 6.6 days in the 6 months following its establishment (29% difference.) In 2020, 707 NH residents were admitted with 352 admitted under the NH team. The ALOS of NH residents admitted under the NH team was 5.66 days in 2020 compared to 8.65 overall (35% difference.) In 2021, 765 NH residents were admitted with 402 under the NH team. ALOS of NH residents admitted under the NH team was 5.33 days in 2021 compared to 8.28 overall (36% difference.)

Conclusion

Within six months of its commencement the dedicated NH service had decreased length of stay by 29%. The average length of stay across all services has decreased year on year from 6.6 to 5.3 days from 2019 to 2021. The ALOS in the total cohort (including residents admitted surgically and those under 65) was 29-36% higher. Though difficult to accurately compare these cohorts due to different presenting diagnoses and medical backgrounds in those admitted surgically or those under 65, the overall reduction in length of stay over the three years does highlight the benefit from this dedicated service.

203 TRANSITIONS TO LONG-TERM CARE: EXPERIENCE OF A COHORT OF COMMUNITY-DWELLING OLDER ADULTS RECEIVING INTEGRATED CARE

Background

Data from the Nursing Home support scheme 2018 (NHSS) shows the majority of applications to the NHSS come from acute hospitals (44%) followed by referrals from the community (38%). We examined this transition in a cohort of community dwelling older adults to assess how many transition from home to nursing home and, when admission to nursing home from hospital occurred, the indications for same.

Methods

Retrospective examination of Integrated Care Team (ICT) and Acute Hospital data from 2019 in respect of a cohort of older adults. Transitions in care to nursing home including residence at time of admission, last acute hospital presentation prior to nursing home admission and commencement of NHSS application recorded.

Results

319 patients referred to the integrated care service in 2019, average age 81 and 58% female, predominantly from outpatient clinics in the Medicine for the Older Person’s service. 47 patients had moved to nursing home; within this cohort 14 (29.7%) transitioned from home, 28 (59.6%) transitioning after acute hospital admission. Main reasons for presentation to hospital were: Intercurrent acute illness (n=11); Falls (n=6); progression of dementia (n=4). Fair Deal application commenced in community by ICT in 20 of the 47 (42.5%) patients including 8 of 28 patients (28.5%) admitted to hospital prior to moving to nursing home.

Conclusion

This preliminary evaluation highlights the importance of advance care planning in this population when acute hospital admissions can be difficult to predict. Involvement of the ICT can help this transition and lead to shorter hospital stays.

160 A CLOSED-LOOP AUDIT EXAMINING THE USE OF PROPHYLACTIC ANTI-COAGULATION IN OLDER ADULTS ADMITTED TO A SPECIALIST GERIATRIC SERVICE

Background

Guidelines recommend prescription of Prophylactic Anticoagulation (PA) to all hospitalized older adults unless a contraindication exits. In many cases this does not happen at the time of admission increasing the risk of thromboembolic events. We aimed to assess the use of PA across the medicine for the geriatric service of a level 3 hospital (average daily census of service 120) then use quality improvement to achieve our goal of 95% prescription of prophylactic anticoagulation when appropriate.

Methods

Medication kardexes and clinical notes were reviewed to collect variables including age, length of stay, creatinine clearance, weight, mobility status, use and dose of antithrombotic medications and documentation of reason if not prescribed. Following initial data collection, cause and effect analysis was performed to identify reasons for under-prescription and small tests of change were conducted across 4 PDSA cycles before data collection was repeated.

Results

Initial data collection revealed that only 80% of older adults admitted to the service were receiving prophylactic anticoagulation. Cause and effect analysis identified many reasons for failure to prescribe PA including inadequate history taking, lack of clinician education and training, poor documentation, lack of handover between clinicians, failure to complete medication reconciliation on admission and lack of pharmacy support on some wards. Each of these contributory factors were addressed in turn. After a month of QI activities prescription of PA improved to 83% and by 3 months 98.1% (104/106) of patients were receiving PA with only 2 patients for whom PA was not prescribed without clear documentation of the reason.

Conclusion

Sustained quality improvement resulted in a culture change across our service improving rates of appropriate prescription of PA and raising the quality of care delivered to older adults. This model of quality improvement is now being replicated across our department to address other gaps in service delivery.

Multiomic atlas with functional stratification and developmental dynamics of zebrafish cis-regulatory elements

Zebrafish, a popular organism for studying embryonic development and for modeling human diseases, has so far lacked a systematic functional annotation program akin to those in other animal models. To address this, we formed the international DANIO-CODE consortium and created a central repository to store and process zebrafish developmental functional genomic data. Our data coordination center ( https://danio-code.zfin.org ) combines a total of 1,802 sets of unpublished and re-analyzed published genomic data, which we used to improve existing annotations and show its utility in experimental design. We identified over 140,000 cis-regulatory elements throughout development, including classes with distinct features dependent on their activity in time and space. We delineated the distinct distance topology and chromatin features between regulatory elements active during zygotic genome activation and those active during organogenesis. Finally, we matched regulatory elements and epigenomic landscapes between zebrafish and mouse and predicted functional relationships between them beyond sequence similarity, thus extending the utility of zebrafish developmental genomics to mammals.

OP0221 EFFICACY OF SECUKINUMAB IN ENTHESITIS-RELATED ARTHRITIS: RESULTS FROM A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, TREATMENT WITHDRAWAL, PHASE 3 STUDY (JUNIPERA)

Background

Enthesitis-related Arthritis (ERA) is a category of juvenile idiopathic arthritis (JIA) characterised by heterogeneous and insidious manifestations comprising axial and/or peripheral arthritis, and enthesitis.1 Secukinumab (SEC) demonstrated efficacy and safety in both ERA and juvenile psoriatic arthritis (JPsA) in the JUNIPERA trial.2

Objectives

To evaluate the rate of flare risk reduction and efficacy of SEC on axial and peripheral manifestations in patients (pts) with active ERA.

Methods

ERA pts (2 to <18 years of age) with active disease (both ≥3 active joints and ≥1 active enthesitis site) were included. In the open-label (OL) treatment-period (TP)1, s.c. SEC (75/150 mg in pts <50/ ≥50 kg) was administered at baseline (BL), and at Week (Wk) 1–4, 8 and 12. Pts who achieved at least JIA-ACR30 response at Wk 12 were randomised into the double-blinded TP2 to continue SEC or placebo (PBO) every 4 wk until a disease flare, or up to Wk 100. The primary endpoint was time to flare in ERA and JPsA pts. The juvenile spondyloarthritis disease activity Index (JSpADA) is a disease activity assessment tool that contains 8 items to measure axial and peripheral disease activity.3 Evaluation of axial and peripheral manifestations at the end of TP1 and TP2 in pts who experienced these symptoms at BL included modified Schober test (lumbar flexion), inflammatory back pain, FABER (Flexion, ABduction, External Rotation) test, JIA-ACR responses, Juvenile Arthritis Disease Activity Score (JADAS)-27, and resolution of enthesitis and dactylitis for peripheral disease. These outcomes were also used to assess JIA disease course at the end of TP2.

Results

A total of 52/86 (60.5%) pts with ERA were enrolled in the OL period TP1 (mean age, 13.7 years; male, 78.8%). In total, 51/52 (98.1%) pts completed TP1 and 41/44 (93.2%) completed TP2. At BL, mean JADAS-27 was 14.8, mean JSpADA index was 3.9, mean enthesitis and dactylitis counts were 2.7 and 0.4, respectively, mean number of active joints was 6.2 and of mean joints with limited range of motion 4.9. The relative risk reduction of experiencing a disease flare in TP2 was 55% (HR 0.45, 95% CI: 0.16–1.28, p=0.075) in ERA pts (Figure 1). The overall axial and peripheral disease symptoms improved over time and are presented in the Table 1. At the end of TP1, 84.6% (44/52) of pts achieved JIA-ACR 30 and 65.4% (34/52) achieved JIA-ACR 70. Clinically relevant reduction of functional ability as assessed by Childhood Health Assessment Questionnaire (CHAQ) also occurred (see Table 1).

Table 1.

Resolution of axial and peripheral disease symptoms and JIA ACR responses at the end of TP1 and 2

Clinical response, mean (SD) change from BL (unless otherwise stated)TP1-Wk 12End of TP2*SEC (N=52)SEC (N=22)PBO (N=22)JSpADA index−2.4 (1.7)−2.7 (1.7)−2.3 (2.1)JSpADA Schöber, %58.3100.0100.0Inflammatory back pain, %77.8100.050.0FABER test, %52.6100.083.3Clinical sacroiliitis, %53.3100.050.0Enthesitis−2.2 (1.9)−2.5 (2.1)−1.3 (1.8)Dactylitis−0.2 (0.8)−0.2 (1)−0.1 (0.4)JIA ACR30, %84.690.968.2JIA ACR50, %78.881.868.2JIA ACR70, %65.468.254.5JIA ACR90, %32.745.550.0JIA ACR100, %26.936.445.5Inactive disease, %38.550.050.0CHAQ−0.5 (0.5)−0.6 (0.7)−0.4 (0.5)CRP, median (SD) change from BL−1.8 (38.7)−5.8 (38.3)0 (35.9)JADAS-27−9.6 (7.5)−11.0 (8.9)−7.6 (8.9)Resolution of enthesitis#, %72.378.683.3Resolution of dactylitis#, %5066.70

*End of TP2 is based on individual pts’ last visit at TP2. #At BL, in TP1, enthesitis (n= 46); dactylitis (n=5). In TP2, no. of pts who had presence at BL and showed complete resolution at the end of TP2: enthesitis, SEC 14, PBO 18; dactylitis, SEC 3, PBO, 0. CRP, C-reactive protein

Conclusion

In pts with ERA, SEC demonstrated longer time to disease flare vs PBO and exhibited rapid and sustained improvement of axial and peripheral manifestations up to Wk 104.

References

[1]Pagnini I, et al. Front Med 2021;8:6673052.

[2]Brunner H, et al. Arthritis Rheumatol 2021;73 (suppl 10).

[3]Weiss PF, et al. Arthritis Care Res 2014;66:1775-82.

Disclosure of Interests

Nicolino Ruperto Speakers bureau: Eli Lilly, GlaxoSmith and Kline, Pfizer, SOBI and UCB, Paid instructor for: Eli Lilly and Pfizer, Consultant of: Ablynx, Amgen, Astrazeneca-Medimmune, Aurinia, Bayer, Bristol Myers and Squibb, Cambridge Healthcare Research (CHR), Celegene, Domain therapeutic, Eli Lilly, EMD Serono, GlaxoSmith and Kline, Idorsia, Janssen, Novartis, Pfizer, SOBI and UCB, Grant/research support from: Bristol Myers and Squibb, Eli Lilly, F Hoffmann-La Roche, Novartis, Pfizer and SOBI, Elena Chertok: None declared, Joke Dehoorne Speakers bureau: Abbvie, Roche, Consultant of: Abbvie, Roche, Pfizer, Grant/research support from: Abbvie, Roche, Gerd Horneff Speakers bureau: Novartis, Pfizer, Janssen, Grant/research support from: Pfizer, Novartis, Roche, MSD, Tilmann Kallinich Speakers bureau: Roche, Ingrid Louw Speakers bureau: Pfizer, Abbvie, BMS, Consultant of: Pfizer, Abbvie, Janssen, Amgen and Cipla, Sandrine Compeyrot-Lacassagne: None declared, Bernard Lauwerys Employee of: UCB Pharma, Neil Martin: None declared, Katherine Marzan Grant/research support from: Novartis, Sanofi, William Knibbe Speakers bureau: Novartis, Amgen, UCB, Abbvie, Ruvie Martin Shareholder of: Novartis, Employee of: Novartis, Xuan Zhu Shareholder of: Novartis, Employee of: Novartis, sarah whelan Shareholder of: Novartis, Employee of: Novartis, Luminita Pricop Shareholder of: Novartis, Employee of: Novartis, Alberto Martini Speakers bureau: Aurinia, Bristol Myers and Squibb, Eli Lilly, EMD, Janssen, Pfizer, Roche and Serono, Consultant of: Aurinia, Bristol Myers and Squibb, Eli Lilly and EMD, Daniel J Lovell Consultant of: Astra Zeneca, Boehringer Ingelheim, GSK, Hoffman LaRoche, Novartis, UBC, Grant/research support from: Astra Zeneca, Boehringer Ingelheim, GSK, Hoffman LaRoche, Novartis, UBC, Hermine Brunner Consultant of: Novartis, Grant/research support from: Novartis

Harmonizing model organism data in the Alliance of Genome Resources

The Alliance of Genome Resources (the Alliance) is a combined effort of 7 knowledgebase projects: Saccharomyces Genome Database, WormBase, FlyBase, Mouse Genome Database, the Zebrafish Information Network, Rat Genome Database, and the Gene Ontology Resource. The Alliance seeks to provide several benefits: better service to the various communities served by these projects; a harmonized view of data for all biomedical researchers, bioinformaticians, clinicians, and students; and a more sustainable infrastructure. The Alliance has harmonized cross-organism data to provide useful comparative views of gene function, gene expression, and human disease relevance. The basis of the comparative views is shared calls of orthology relationships and the use of common ontologies. The key types of data are alleles and variants, gene function based on gene ontology annotations, phenotypes, association to human disease, gene expression, protein-protein and genetic interactions, and participation in pathways. The information is presented on uniform gene pages that allow facile summarization of information about each gene in each of the 7 organisms covered (budding yeast, roundworm Caenorhabditis elegans, fruit fly, house mouse, zebrafish, brown rat, and human). The harmonized knowledge is freely available on the alliancegenome.org portal, as downloadable files, and by APIs. We expect other existing and emerging knowledge bases to join in the effort to provide the union of useful data and features that each knowledge base currently provides.

Zebrafish Information Network, the knowledgebase for Danio rerio research

The Zebrafish Information Network (zfin.org) is the central repository for Danio rerio genetic and genomic data. The Zebrafish Information Network has served the zebrafish research community since 1994, expertly curating, integrating, and displaying zebrafish data. Key data types available at the Zebrafish Information Network include, but are not limited to, genes, alleles, human disease models, gene expression, phenotype, and gene function. The Zebrafish Information Network makes zebrafish research data Findable, Accessible, Interoperable, and Reusable through nomenclature, curatorial and annotation activities, web interfaces, and data downloads. Recently, the Zebrafish Information Network and 6 other model organism knowledgebases have collaborated to form the Alliance of Genome Resources, aiming to develop sustainable genome information resources that enable the use of model organisms to understand the genetic and genomic basis of human biology and disease. Here, we provide an overview of the data available at the Zebrafish Information Network including recent updates to the gene page to provide access to single-cell RNA sequencing data, links to Alliance web pages, ribbon diagrams to summarize the biological systems and Gene Ontology terms that have annotations, and data integration with the Alliance of Genome Resources.

Static postural differences between male and female equestrian riders on a riding simulator

This study aimed to compare static posture of male and female riders on a riding simulator. Ten female and five male riders underwent a 5 min standardised exercise programme on the simulator, they were then videoed for 10 s from each the left, right, and rear views whilst stationary on the simulator. Two-dimensional kinematic analysis of the videos showed that male riders had a more neutrally positioned pelvis in the sagittal plane (median left: 6.47°, right: 5.24°) with females demonstrating a posterior pelvic tilt (L: 14.04°, R: 13.55°). Females showed significantly greater pelvic obliquity (median female: 1.99°, male: 0.73°), trunk lean (F: 1.60°, M: 0.43°), and shoulder tilt (F: 1.79°, M: 0.57°) in the frontal plane, demonstrating an overall greater postural asymmetry. Previous studies of elite riders have shown a more anteriorly rotated pelvis to be more desirable. Symmetry of riding position is favourable as it allows movements to be performed with ease and ensures even force distribution through the saddle to the horse. Male riders may therefore have a biomechanical advantage over females when it comes to maintaining a desirable riding position. This research should now be extended to study riders on the horse in motion.

Global Burden of Disease from Major Air Pollution Sources (GBD MAPS): A Global Approach

Ambient fine particulate matter (particles <2.5 μm in aerodynamic diameter [PM2.5]) is the world's leading environmental health risk factor. Reducing the PM2.5 disease burden requires specific strategies that target dominant sources across multiple spatial scales. The Global Burden of Disease from Major Air Pollution Sources (GBD MAPS) project provides a contemporary and comprehensive evaluation of contributions to the ambient PM2.5 disease burden from source sectors and fuels across 21 regions, 204 countries, and 200 subnational areas. We first derived quantitative contributions from 24 emission sensitivity simulations using an updated global atmospheric chemistry-transport model, input with a newly developed detailed anthropogenic emissions dataset that includes emissions specific to source sector and fuels. These simulation results were integrated with newly available high-resolution satellite-derived PM2.5 exposure estimates and disease-specific concentration-response relationships consistent with the GBD project to quantify contributions of specific source sector and fuel to the ambient PM2.5 disease burden across all regions, countries, and subnational areas. To improve the transparency and reproducibility of this and future work, we publicly provided the global atmospheric chemistry-transport model source code, emissions dataset and emissions model source code, analysis scripts, and source sensitivity results, and further described the emissions dataset and source contribution results in two publications.

We found that nearly 1.05 million (95% uncertainty interval [UI]: 0.74-1.36 million) deaths worldwide (27.3% of the total mortality attributable to PM2.5) would be avoidable by eliminating fossil fuel combustion, with coal contributing over half of that burden. Residential (19.2%; 736,000 deaths [95% UI: 521,000-955,000]), industrial (11.7%; 448,000 deaths [95% UI: 318,000-582,000]), and energy (10.2%; 391,000 deaths [95% UI: 277,000-507,000]) sector emissions are among the dominant global sources Uncertainty in these estimates reflects those of the input datasets. Regions with the largest anthropogenic contributions generally have the highest numbers of attributable deaths, which clearly demonstrates the importance of reducing these emissions to realize reductions in global air pollution and its disease burden.

Referral pattern and co-management of keratoconus patients in primary eye care: A survey of three European countries

PURPOSE

To explore current primary care practices in keratoconus management in Portugal and compare with previous reported results in two European countries (the UK and Spain), with a special focus on interdisciplinary collaboration and referral practice patterns.

METHODS

An online survey adapted to European professional practice was distributed (via newsletters) by the Portuguese Optometrist Association to explore keratoconus patient management and referral practice patterns among Portuguese practitioners.

RESULTS

Responses of 119 optometrists were compared with previous reported of 464 eye-care practitioners (126 in the UK and 338 in Spain). Most respondents (79% in Portugal, 71% in the UK and 76% in Spain; p = 0.31) had < 5 new keratoconus patients each year. No accepted referral criterion was found (p < 0.01) because small number of the respondents (14%) in Portugal referred out at initial diagnosis (50% in the UK and Spain); 32% referred out when progression was detected (17% in the UK and 30% in Spain); and a minority (10% in Portugal, 9% in the UK, and 6% in Spain) referred out when visual acuity was affected. A majority of respondents (83%) in Portugal reported no co-management with ophthalmologists (60% in the UK and 73% in Spain; p < 0.01).

CONCLUSION

The results of this study suggest that it is necessary to encourage interdisciplinary collaboration between practitioners to improve referral of patients with suspected keratoconus to an ophthalmology specialist to change the course of this disease, to reduce keratoconus progression and visual acuity impairment and to minimize the impact of this disease on patients' quality of life.

External Waveguide Magnetic Resonance Imaging for lower limbs at 3 T

INTRODUCTION

We report a method based on the travelling-wave MRI approach, in order to acquire images of human lower limbs with an external waveguide at 3 T.

METHOD

We use a parallel-plate waveguide and an RF surface coil for reception, while a whole-body birdcage is used for transmission. The waveguide and the surface coil are located right outside the magnet, in the MR conditional devices zone. We ran numerical simulations to investigate the B₁ field generated by the surface coil located at one of the waveguides, as well as a saline-solution phantom positioned on the opposite side (150 cm away) inside the magnet.

RESULTS

We obtained phantom images by varying the distance between the coil and the phantom, in order to investigate the signal-to-noise ratio and to validate our numerical simulations. Lower limb images of a healthy volunteer were also acquired, demonstrating the viability of this approach. Standard pulse sequences were used and no physical modifications were made to the MR imager.

CONCLUSIONS

These numerical and experimental results show that travelling-wave MRI can produce high-quality images with only a simple waveguide and an RF coil located outside the magnet. This can be particularly favorable when acquiring images of lower limbs requiring a larger field of view.

Measurement and prevalence of adult physical activity levels in Arab countries

OBJECTIVES

This study aims to examine the reported prevalence of sufficient physical activity among adults in Arab countries and to determine the use of validated instruments for assessing physical activity.

STUDY DESIGN

This is a systematic literature review.

METHODS

This review follows recommendations outlined in the Meta-Analysis of Observational Studies in Epidemiology guidelines. The protocol for this study was preregistered with PROSPERO. Cross-sectional, cohort and intervention studies with a minimum of 300 adults aged ≥18 years assessing physical activity using a questionnaire or other self-report measure in the Arabic language were identified from seven electronic databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, CINAHL, PsycINFO, SPORTDiscu and PubMed). Databases were searched from 1st January 2008 to 17th September 2018. Descriptive analysis was performed using frequency and percentages. The prevalence of physical activity was calculated as the average prevalence for the reported percentages from the studies with similar tools.

RESULTS

Fifty studies involving 298,242 participants were included in this review. The mean (range) sample size was 5964.8.1 (323-197,681). Data were collected from participants in 16 of the 22 Arab countries. Great variation exists across the studies in determining whether adults were sufficiently active or not. Twenty studies reported usable data from the Global Physical Activity Questionnaire and the International Physical Activity Questionnaire (moderate & high categories). In these studies, prevalence of physical activity ranged from 34.2 to 96.9%. It was not possible to compare the other studies owing to variation in instruments used to assess physical activity and in the case definition used for 'physically active'.

CONCLUSIONS

This study highlights the need for wider reporting of physical activity and the adoption of valid and reliable instruments to support the development of evidence-informed policy and programmes at both country and regional level. International tools need to be correctly validated, or context-specific tools must be developed to accurately measure physical activity.

POS1044 EFFECT OF SECUKINUMAB VERSUS ADALIMUMAB ON ACR CORE COMPONENTS AND HEALTH-RELATED QUALITY OF LIFE IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM THE EXCEED STUDY

Background:

EXCEED (NCT02745080) was the first fully blinded head-to-head trial to evaluate the efficacy and safety of secukinumab (SEC) versus (vs) adalimumab (ADA) monotherapy in patients with active psoriatic arthritis (PsA) with a primary endpoint of American College of Rheumatology (ACR) 20 at Week 52. Although SEC narrowly missed statistical significance for superiority vs ADA, numerically higher response for other musculoskeletal endpoints and composite indices were observed with SEC.1

Objectives:

To explore the effect of SEC and ADA on ACR core components, function and Health-related Quality of Life (HRQoL) outcomes.

Methods:

Patients were randomised 1:1 to receive SEC 300 mg (N=426) subcutaneous (s.c.) at baseline, Week 1-4, followed by every 4 weeks until Week 48 or ADA 40 mg (N=427) s.c. at baseline followed by same dosing every 2 weeks until Week 50. The primary, key secondary and some exploratory endpoints at Week 52 were previously reported.1 A supportive analysis for ACR50 response using logistic regression model and trimmed means model for Health Assessment Questionnaire-Disability Index (HAQ-DI) with gender and smoking status as factors was performed to adjust for imbalances in baseline characteristics. An exploratory analysis of ACR core components with SEC vs ADA at Week 52 was conducted using a mixed-effects repeated measures model that included tender and swollen joint counts, patient and physician global assessment, PsA pain (VAS) and erythrocyte sedimentation rate. HRQoL variables were also exploratory and assessed based on Short Form Health Survey Physical/Mental Component Summary (SF-36 PCS/MCS) scores and Dermatology Life Quality Index (DLQI).

Results:

The demographic and baseline disease characteristics were comparable across treatment groups, except for an imbalance in sex (females: 51.2% vs 46.4%) and smoking status (yes: 21.8% vs 17.8%) in SEC and ADA group, respectively. At Week 52, ACR50 responses were 49.0% and 44.8% (P=0.0929) and HAQ-DI mean change from baseline were −0.69 and −0.58 (P=0.0314) in SEC and ADA treatment groups, respectively after adjusting for gender and smoking status. No major difference across ACR core components was observed in both treatment groups at Week 52 (Table 1). At Week 52, SEC presented similar improvement in SF-36 PCS/MCS score and numerically higher improvement in DLQI compared to ADA (Figure 1).

Conclusion:

Secukinumab provided similar improvements in ACR core components and SF-36 based quality of life at Week 52 with adalimumab. Greater improvement in HAQ-DI response and DLQI was demonstrated with secukinumab compared to adalimumab.

References:

[1]McInnes IB, et al. Lancet. 2020; 395:1496–505.

Table 1.

ACR Core Components at Week 52

VariablesSecukinumab 300 mg(N=426)Adalimumab 40 mg(N=427)P-valueBL, mean ± SELSM change from BL ± SEBL, mean ± SELSM change from BL ± SETender joint score(based on 78 joints)19.4 ± 13.86−14.27 ± 0.4420.6 ± 14.81−13.90 ± 0.450.5549Swollen joint score(based on 76 joints)9.7 ± 7.30−8.41 ± 0.1910.2 ± 7.86−8.06 ± 0.200.1962Patients global assessment64.0 ± 19.67−33.81 ± 1.1461.9 ± 20.75−31.61 ± 1.190.1825Physicians global assessment60.0 ± 17.12−46.24 ± 0.8061.4 ± 15.92−43.63 ± 0.840.0243Psoriatic arthritis pain (VAS)58.6 ± 23.49−30.21 ± 1.1857.9 ± 22.42−29.44 ± 1.230.6500Erythrocyte sedimentation rate (mm/h)23.8 ± 18.93−9.63 ± 0.6223.9 ± 17.99−9.28 ± 0.640.7029

LS mean and nominal P-values are from a mixed-effects repeated measures model with treatment group, analysis visit as factors, weight and BL score as covariates, and by treatment and BL score as interaction terms, unstructured covariance structure. ACR, American College of Rheumatology; BL, baseline; LSM, least squares mean; N, total number of randomised patients; SE, standard error; VAS, visual analogue scale

Figure 1.

HRQoL Analysis at Week 52

Disclosure of Interests:

Philippe Goupille Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Eli Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Eli Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Janssen, Eli Lilly, Medac, MSD, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Frank Behrens Paid instructor for: Eli Lilly, Consultant of: Pfizer, AbbVie, Sanofi, Eli Lilly, Novartis, Genzyme, Boehringer Ingelheim, Janssen, MSD, Celgene, Roche and Chugai, Grant/research support from: Pfizer, Janssen, Chugai, Celgene and Roche, Laura C Coates Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Biogen, BMS, Celgene, Domain, Eli Lilly, Gilead, GSK, Janssen, Medac, Novartis, Pfizer, Serac and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Jordi Gratacos-Masmitja Speakers bureau: AbbVie, Amgen, BMS, Celgene, Janssen, Eli Lilly, Novartis and Pfizer, Consultant of: AbbVie, Amgen, BMS, Celgene, Janssen, Eli Lilly, Novartis and Pfizer, Grant/research support from: AbbVie, Amgen, BMS, Celgene, Janssen, Eli Lilly, Novartis and Pfizer, Philip J Mease Speakers bureau: AbbVie, Amgen, Genentech, Janssen, Eli Lilly, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Boehringer Ingelheim, Galapagos, Celgene, Genentech, Gilead, Janssen, Eli Lilly, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Galapagos, Genentech, Gilead, Janssen, Eli Lilly, Merck, Novartis, Pfizer, SUN Pharma, and UCB, Dafna D Gladman Consultant of: Amgen, AbbVie, BMS, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: Amgen, AbbVie, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Peter Nash Speakers bureau: Novartis, Abbvie, Roche, Pfizer, BMS, Janssen, Celgene, UCB, Eli Lilly, MSD, Sanofi, Gilead, Consultant of: Novartis, Abbvie, Roche, Pfizer, BMS, Janssen, Celgene, UCB, Eli Lilly, MSD, Sanofi, Gilead, Grant/research support from: Novartis, Abbvie, Roche, Pfizer, BMS, Janssen, Celgene, UCB, Eli Lilly, MSD, Sanofi, Gilead, Arthur Kavanaugh Consultant of: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, and UCB, Grant/research support from: AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, and UCB, Ruvie Martin Shareholder of: Novartis, Employee of: Novartis, Weibin Bao Shareholder of: Novartis, Employee of: Novartis, Corine Gaillez Shareholder of: Novartis and BMS, Employee of: Novartis, Iain McInnes Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly, Novartis, Pfizer, and UCB.

The role of marshall bundle epicardial connections in atrial tachycardias after atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial tachycardias (ATs) are often seen in the context of AF ablation.

Objectives

We evaluated the role of the Marshall bundle (MB) network in left atrial (LA) ATs using high-density high-spatial resolution 3D mapping.

Methods

199 post-AF ablation LA tachycardias were mapped in 140 consecutive patients (112 (80%) males, mean age: 61.8 years); 133 (66.8%) were macro-reentrant and 66 (33.2%) were scar-related re-entry. MB-dependent perimitral AT (PMAT) was diagnosed where the difference between the post pacing interval and the tachycardia cycle length (PPI-TCL) was &lt;20ms in parts of the expected MB-dependent perimitral circuit (within the VOM, the ridge between the left pulmonary veins and LA appendage (LAA), the anterior LA and between 6- and 11-o’clock of the mitral annulus) and the PPI-TCL was &gt;20ms in areas bypassed by the VOM (the distal coronary sinus (CS), the posterior LA and the mitral isthmus). MB-related re-entry was diagnosed by PPI-TCL &lt;20ms at the left lateral ridge, posterior base of LAA, inferolateral LA or VOM ostium; and PPI-TCL &gt;20ms in the septal annulus. Typically, in MB-dependent localized re-entry, the earliest activation was found along the MB-LA endocardial connection or MB-CS epicardial connection. 

Results

The MB network was found to participate in 60 (30.2%) re-entrant ATs, 31 PMATs and 29 localized re-entries. High-frequency multiphasic fragmented electrograms with long duration were often recorded endocardially or epicardially at the MB-LA or MB-CS connections. The amplitude and duration of these signals were 0.5 ± 0.79 mV and 65 ± 40 ms for MB-PMATs and 0.26 ± 0.28mV and 122 ± 67 ms for MB-localized re-entries. Unipolar EGMs at the site of endocardial-epicardial breakthrough had a rS pattern in all MB-related ATs. Of 60 MB-related ATs, 49 (81.6%) terminated with RF ablation, 44 (73.3%) at the MB-LA junction and 5 (8.3%) at the MB-CS junction, while 9 (15%) terminated after 2.5-5 cc of alcohol infusion inside the vein of Marshall (VOM). Of the 31 MB-related macroreentrant ATs, 17 (54.8%) terminated at the MB-LA junction, 5 (16.1%) at the MB-CS junction and 7 (22.6%) with alcohol infusion inside the VOM. Two macroreentries (6.5%) using the MB did not terminate with RF energy either endocardially at the MB-LA junction or epicardially at the MB-CS junction, and we were unable to identify or cannulate the VOM for ethanol infusion. Of the 29 localized re-entrant ATs using the MB, 27 (93.1%) terminated at the MB-LA junction, none terminated at the MB-CS junction and 2 (6.9%) terminated after alcohol infusion. After a mean follow up of 12 months, only 4 patients (6.7%) had AT recurrence.

Conclusions

MB re-entrant ATs accounted for up to 29% of the left ATs after AF ablation. Ablation of the MB-LA or CS-MB connections or alcohol infusion inside the VOM is required to treat these arrhythmias. Abstract Figure.

Comparing the Efficacy of Kneeling Stress Radiographs and Weighted Gravity Stress Radiographs to Assess Posterior Cruciate Ligament Insufficiency

BACKGROUND

Kneeling posterior cruciate ligament (PCL) stress radiographs are commonly used to evaluate PCL laxity. Patients, however, report significant pain, and the method's reproducibility may be challenged due to its dependence on patient body weight distribution to produce posterior tibial displacement. Weighted gravity stress radiography may offer better reproducibility and comfort than the kneeling technique, but its efficacy has not been studied.

HYPOTHESIS

Weighted gravity PCL stress radiographs will be more comfortable and produce similar measurements of side-to-side difference in posterior tibial displacement when compared with the kneeling technique.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 40 patients with nonoperatively or >6 months postoperatively treated PCL injuries (isolated or multiligamentous) underwent bilateral stress radiographs. Weighted gravity and kneeling stress radiographs were acquired, in random order, for each patient, as well as side-to-side difference in posterior tibial displacement between each knee, patient-reported visual analog scale knee pain (100 mm), time to acquire the images, and patient preference for technique. Paired t tests were used to compare the side-to-side difference, pain score, and time to complete the radiographs.

RESULTS

There was no difference between the 2 radiographic methods in the mean side-to-side difference (gravity: 6.45 ± 4.61 mm, kneeling: 6.82 ± 4.60 mm; P = .72), time required to acquire radiographs (kneeling: 307.3 ± 140.5 seconds, gravity: 318.7 ± 151.1 seconds; P = .073), or number of radiographs taken to obtain acceptable images (kneeling: 3.6 ± 1.6, gravity: 3.7 ± 1.7; P = .73). Patients reported significantly less knee pain during the weighted gravity views (kneeling: 31.8 ± 26.6, gravity: 4.0 ± 12.0; P < .0001). Of the patients, 88% preferred the weighted gravity method.

CONCLUSION

Weighted gravity stress radiographs produce similar side-to-side differences in posterior tibial translation compared with the kneeling stress technique, but do not rely on patient weightbearing and provide significantly better patient comfort. Clinicians should therefore consider the use of weighted gravity stress radiographs in clinical practice to minimize the pain associated with stress radiography while allowing for accurate decision making.

Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial

BACKGROUND AND PURPOSE

It is unknown when to start anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF). Early anticoagulation may prevent recurrent infarctions but may provoke hemorrhagic transformation as AF strokes are typically larger and hemorrhagic transformation-prone. Later anticoagulation may prevent hemorrhagic transformation but increases risk of secondary stroke in this time frame. Our aim was to compare early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals.

METHODS

AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was an open-label, randomized controlled trial comparing the safety of early use of apixaban at day 0 to 3 for TIA, day 3 to 5 for small-sized AIS (<1.5 cm), and day 7 to 9 for medium-sized AIS (≥1.5 cm, excluding full cortical territory), to warfarin, in a 1:1 ratio at 1 week post-TIA, or 2 weeks post-AIS.

RESULTS

Although AREST ended prematurely after a national guideline focused update recommended direct oral anticoagulants over warfarin for AF, it revealed that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA (14.6% versus 19.2%, P=0.78), death (4.9% versus 8.5%, P=0.68), fatal strokes (2.4% versus 8.5%, P=0.37), symptomatic hemorrhages (0% versus 2.1%), and the primary composite outcome of fatal stroke, recurrent ischemic stroke, or TIA (17.1% versus 25.5%, P=0.44). One symptomatic intracerebral hemorrhage occurred on warfarin, none on apixaban. Five asymptomatic hemorrhagic transformation occurred in each arm.

CONCLUSIONS

Early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. Potential efficacy of early initiation of anticoagulation remains to be determined from larger pivotal trials. Registration: URL: https://www.clinicaltrials.gov/; Unique identifier: NCT02283294.