Intraoperative augmented reality fiber tractography complements cortical and subcortical mapping

Augmented reality (AR) has been found to be advantageous in enhancing visualization of complex neuroanatomy intraoperatively and in neurosurgical education. Another key tool that allows neurosurgeons to have enhanced visualization, namely of white matter tracts, is diffusion tensor imaging (DTI) that is processed with high-definition fiber tractography (HDFT). There remains an enduring challenge in the structural-functional correlation of white matter tracts that centers on the difficulty in clearly assigning function to any given fiber tract when evaluating them through separated as opposed to integrated modalities. Combining the technologies of AR with fiber tractography shows promise in helping to fill in this gap between structural-functional correlation of white matter tracts. This novel study demonstrates through a series of three cases of awake craniotomies for glioma resections a technique that allows the first and most direct evidence of fiber tract stimulation and assignment of function or deficit in vivo through the intraoperative, real-time fusion of electrical cortical stimulation, AR, and HDFT. This novel technique has qualitatively shown to be helpful in guiding intraoperative decision making on extent of resection of gliomas. Future studies could focus on larger, prospective cohorts of glioma patients who undergo this methodology and further correlate the post-operative imaging results to patient functional outcomes.

AB0884 Disease outcomes in patients with psoriatic arthritis completing 12 months of apremilast treatment - Real-world data from the REWARD study

Background

Patients with moderately active psoriatic arthritis (PsA) and limited joint involvement have considerable disease burden1,2. Recent data shows these patients have a high likelihood of achieving treatment goals if treated with apremilast3. This is the first report of outcomes in patients with PsA who received apremilast for 12 months in Dutch clinical practice.

Objectives

We report disease outcomes, including the PsA Impact of Disease (PsAID) 12-item questionnaire, swollen joint count (SJC), tender joint count (TJC), dactylitis and enthesitis, among patients in the prospective, multicenter, observational REWARD study who completed 12 months of apremilast treatment.

Methods

The ongoing REWARD study enrolled patients who had initiated apremilast for the treatment of PsA in the Netherlands between 13 April 2017 and 24 March 2021, and includes up to 12 months follow-up1,4. We report interim data from patients with data available as of 16 September 2021. Baseline data are summarized separately for patients who discontinued apremilast before their month 12 study visit (stoppers) and patients still receiving apremilast at their month 12 visit (completers). Post baseline data are summarized for completers. Continuous data are summarized using mean and SD, categorical data are summarized using n and percent.

Results

98 patients were included in this interim analysis; 32 had completed 12 months of apremilast treatment (completers), 54 had discontinued apremilast before month 12 (stoppers), 12 were ongoing in the study. Compared with stoppers, completers were more likely to be biologic naïve and have dactylitis, and had lower BSA. All other baseline characteristics were similar (Table 1). Among completers, all PsAID domains improved after 3 months of apremilast treatment and these improvements were maintained through month 12 (Figure 1). Mean SJC and TJC decreased between baseline and month 12 (SJC, 4.2 and 1.0 at baseline and month 12, respectively; TJC, 7.1 and 3.3, respectively). The proportion of completers with SJC, TJC, enthesitis and dactylitis scores of 0 increased from baseline to month 12 (Figure 1B). The proportion of completers reporting at least one adverse event (AE) was comparable to the overall study population (14/32 [44%] and 48/98 [49%], respectively); the reported adverse events were similar to the known safety profile of apremilast.

Table 1.

Baseline characteristics

All=all patients included in this interim analysis; Completers= patients that received apremilast for 12 months; Stoppers= patients that stopped apremilast treatment prior to 12 months.

BMI=Body Mass Index, PsO=Psoriasis, BSA PsO= Body Surface Area Psoriasis, SJC=Swollen Joint Count, TJC=Tender Joint Count, PsAID=Psoriatic Arthritis Impact of Disease, VAS=Visual Analog Scale, CRP= C-reactive protein, cDAPSA=Clinical Disease Activity in Psoriatic Arthritis, Rem=Remission, Mod=Moderate, PsA= Psoriatic Arthritis

Figure 1.

(A) PSAID scores in completers and (B) percentage of completers with no swollen joints, no tender joints, no dactylitis and no enthesitis at baseline (BSL), month 3, 6 and 12 (M3, M6, M12).

Conclusion

In this interim analysis of the REWARD study, patients completing 12 months of apremilast treatment were more likely to be biologic naïve than patients who discontinued apremilast within 12 months of initiation, and had significant decreases in TJC, SJC, dactylitis and enthesis during apremilast treatment. Completed patients also reported decreased PsAID scores during apremilast treatment, indicating improvements in their quality of life.

References

[1]Jansen TL, et al. Ann Rheum Dis. 2019; 78:913 [abstract FRI0442]

[2]Wervers et al. J Rheumatol. 2018;45:1526.

[3]Mease PJ, et al. Arthritis Care Res. 2020; 72, 6, 814–821

[4]Bos R, et al. Ann Rheum Dis. 2021; 80:805 [POS1053]

Acknowledgements

Sylvia de Jong and Claire Desborough, Amgen employees, provided medical writing and editorial assistance.

Disclosure of Interests

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Grant/research support from: Galapagos, Tim Jansen Speakers bureau: Grunenthal, Sobi, Consultant of: AbbVie, Celgene Corporation, Grant/research support from: ReumaNederland, Olatec, Grunenthal, Ian Bridges Shareholder of: Amgen, Employee of: Amgen, Sylvia de Jong Shareholder of: Amgen, Employee of: Amgen, Novartis, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer

A first dedicated heart valve unit: safe and streamlined patient care for the rapidly growing field of transcatheter heart valve interventions

Background

A dedicated Heart Valve Unit was launched in 2018 to meet the demands of the growing transcatheter heart valve program by optimizing patient care in a single dedicated unit.

Purpose

To assess the performance of the heart valve unit (all steps of patient care in a single unit with intermediate care facilities) over a conventional approach (preparation on a normal ward, postprocedural intensive care unit (ICU) monitoring and transfer to an additional monitoring ward before discharge) in a high volume center.

Methods

Retrospective analysis including patients undergoing transcatheter mitral or tricuspid valve repair who were admitted to the Heart Valve Unit (02/2018–01/2020) compared to a conventional patient care approach (02/2016–01/2018). Patients who were already preprocedurally admitted to the ICU or in whom ICU monitoring postprocedurally was mandatory (direct annuloplasty, valve replacement) were excluded. The Heart Valve Unit patient care algorithm is presented in figure 1. We assessed procedural numbers, length of hospital stay, length and need for ICU monitoring, patient transfers between wards and periprocedural safety including in-hospital mortality.

Results

We observed a 164% increase in procedures (521 vs. 316 in total, 369 vs 282 with mitral valve procedures and 152 vs 34 tricuspid valve procedures) with the launch of the Heart Valve Unit over the 2-year-interval compared to the earlier time period. Length of in-hospital stay was significantly decreased compared to a conventional approach (9±7 vs. 12±11 days, p<0.001). In particular, postprocedural stay could be shortened from 7±7 to 5±6 days (p<0.001). Patients were less transferred between different wards in the Heart Valve Unit setting (p<0.001). Whereas all patients were postprocedurally transferred to the ICU in the conventional setting, only 16% of patients required an ICU bed immediately after the procedure due to complex interventions, intraprocedural events or high-risk comorbidities. The length of stay on ICU declined from 1.4±1.4 to 0.5±2.2 days. Among the patients re-transferred to the Heart Valve Unit directly after the procedure, 2% (10 patients) required an ICU bed in the further course due to hemodynamic instability (2), severe bleeding (4), seizures (1), ventricular fibrillation (1), anaesthetic overhang (1) or after urgent surgery due to a atrioventricular fistula (1). After stabilization, all patients were re-transferred to the Heart Valve Unit and discharged hereinafter. There was no intra-hospital death among these patients.

Conclusions

A dedicated Heart Valve Unit allows a safe and optimized patient care structure for transcatheter valvular interventions by combining all pre- and postprocedural steps in a single unit, thereby decreasing length of in-hospital stay to meet increasing economic demands. ICU capacity can be specifically used for complex procedures aftercare and complication monitoring.

Funding Acknowledgement

Type of funding sources: None.

POS1053 COMPARISON OF BASELINE CHARACTERISTICS BETWEEN PATIENTS CONTINUING OR DISCONTINUING APREMILAST AT TWELVE MONTHS IN THE REWARD STUDY (THE NETHERLANDS)

Background:

Previous analysis of the REWARD study reported that patients with limited joint involvement have a considerable burden of disease1. Recent data suggest that patients with moderately active psoriatic arthritis (PsA) and a limited joint involvement have a high likelihood of achieving treatment goals when treated with apremilast2. According to EULAR recommendations a PDE4 inhibitor may be considered in patients with mild disease and an inadequate response to at least one csDMARD, in whom neither a bDMARD nor a JAK inhibitor is appropriate and the value of apremilast may be found in treating patients with relatively mild disease (oligoarticular)3.

Objectives:

The objective of this prospective, multicentre, non-interventional study is to describe patient reported outcomes, effectiveness and real-life use of apremilast in patients with PsA. Patients will be followed up for a maximum of 12 months. This interim analysis compared the baseline characteristics and experience on apremilast for two subgroups of patients, those remaining on apremilast versus the ones that discontinued.

Methods:

In this interim analysis we included patients with data available at cut-off date of 03 November 2020. Patient enrollment and follow up of current subjects is ongoing. Descriptive statistics (n’s and percents for categorical data, means for continuous data) were used to summarize the baseline data by subgroup. Kaplan Meier plots are presented to show patients’ experience on apremilast by subgroup.

Results:

85 patients were included in the analysis. 30 patients have completed the study, 39 patients have discontinued and 16 are ongoing. At baseline 22 (26%) patients were biologic experienced and 62 (74%) were biologic naïve. Both groups had a comparable disease activity measured with clinical disease activity in psoriatic arthritis (cDAPSA) scores. Biologic experienced patients had a longer disease duration compared to biologic naïve patients (mean 9.7 vs 6.2 years). Inefficacy of previous medication was the main reason for starting apremilast in both subgroups. Overall, 86% (n=69) of patients were still receiving apremilast at month 3, 60% (n=46) at month 6, and 41% (n=26) at month 12 (Figure 1). Drug survival (length of time until discontinuation of apremilast) for biologic naïve patients was 93% at month 3, 73% at month 6 and 58% at month 12. Drug survival of biologic experienced patients was 67%, 20%, and 0% at months 3, 6, and 12, respectively. At baseline mean values of body mass index (BMI), swollen joint count (SJC), tender joint count (TJC), psoriatic arthritis impact of disease (PsAID) were comparable between both groups (Table 1). Reasons for discontinuation were mainly lack of efficacy (49%) and adverse events (44%). In this analysis the nature and frequency of adverse events is in line with the known profile of apremilast.

Conclusion:

In this interim analysis, patients who were biologic naïve had a better probability to remain on treatment than those who were biologic experienced. Baseline characteristics were similar between the two groups, apart from disease duration that was longer in the biologic experienced group. Best drug survival is achieved when apremilast is prescribed earlier in the PsA treatment course, before biologics and after csDMARDs, as per apremilast EU label.

References:

[1]Jansen TL, et al. Ann Rheum Dis. 2019;78:913 [abstract FRI0442]

[2]Mease PJ, et al. Arthritis Care Res 2020 72 6 814–821

[3]Gossec L, et al. Ann Rheum Dis 2020;79:700–712

Disclosure of Interests:

Reinhard Bos Consultant of: AbbVie BV, Genzyme Europe, Janssen-Cilag, Novartis, Pfizer, Grant/research support from: Galapagos, Tim Jansen Consultant of: AbbVie, Celgene Corporation – consultant, Speakers bureau: Grunenthal, Sobi – speakers bureau, Grant/research support from: ReumaNederland, Olatec, Grunenthal – grant/research support, Sylvia de Jong Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Antonio Castiglia Shareholder of: Employee of Amgen Inc, Employee of: Employee of Amgen Inc, Marijn Vis Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Grant/research support from: Novartis, Pfizer, AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer.

POS1124 IDENTIFYING POTENTIAL CLASSIFICATION CRITERIA FOR CALCIUM PYROPHOSPHATE DEPOSITION DISEASE (CPPD): RESULTS FROM THE INITIAL PHASES

Background:

Classification criteria for calcium pyrophosphate deposition disease (CPPD) will facilitate clinical research on this common crystalline arthritis. ACR/EULAR are jointly sponsoring development of CPPD classification criteria using a multi-phase process.

Objectives:

To report preliminary results from the first two phases of a four-phase process for developing CPPD classification criteria.

Methods:

CPPD classification criteria development is overseen by a 12-member Steering Committee. Item generation (Phase I) included a scoping literature review of five literature databases and contributions from a 35-member Combined Expert Committee and two Patient Research Partners. Item reduction and refinement (Phase II) involved a Combined Expert Committee meeting, discussions among Clinical, Imaging, and Laboratory Advisory Groups, and an item rating exercise to assess the influence of individual items toward classification. The Steering Committee reviewed the modal rating score for each item (range -3 [strongly pushes away from CPPD] to +3 [strongly pushes toward CPPD]) to determine items to retain for future phases of criteria development.

Results:

Item generation yielded 420 items (312 from the literature, 108 from experts/patients). The Advisory Groups eliminated items they agreed were unlikely to distinguish between CPPD and other forms of arthritis, yielding 127 items for the item rating exercise. Fifty-six items, most of which had a modal rating of +/- 2 or 3, were retained for future phases (see Table 1). As numerous imaging items were rated +3, the Steering Committee recommended focusing on imaging of the knee, wrist, and one additional affected joint for calcification suggestive of CPP crystal deposition.

Conclusion:

The ACR/EULAR CPPD classification criteria working group has adopted both data- and expert-driven approaches, leading to 56 candidate items broadly categorized as clinical, imaging, and laboratory features. Remaining steps for criteria development include domain establishment, item weighting through a multi-criteria decision analysis exercise, threshold score determination, and criteria validation.

Table 1.

Categories of items retained for future phases of classification criteria development

Age in decade at symptom onsetAcute inflammatory arthritis (e.g. knee, wrist, 1st MTP joint*)Recurrence and pattern of joint involvement (e.g. 1 self-limited episode, >1 self-limited episode)Physical findings (e.g. palpable subcutaneous tophus*, psoriasis*)Co-morbidities and family history (e.g. Gitelman disease, hemochromatosis, familial CPPD)Osteoarthritis location and features (e.g. 2nd or 3rd MCP joint, wrist)Synovial fluid findings (e.g. CPP crystals present, CPP crystals absent on 1 occasion* or 2 occasions*, monosodium urate crystals present*)Laboratory findings (e.g. hypomagnesemia, hyperparathyroidism, rheumatoid factor*, anti-CCP*)Plain radiograph: calcification in regions of fibro- or hyaline cartilage+Plain radiograph: calcification of the synovial membrane/capsule/tendon+Conventional CT: calcification in regions of fibro- or hyaline cartilage+Conventional CT: calcification of the synovial membrane/capsule/tendon+Ultrasound: CPP crystal deposition in fibro- or hyaline cartilage+Ultrasound: CPP crystal deposition in synovial membrane/capsule/tendons+Dual-energy CT: CPP crystal deposition in fibro- or hyaline cartilage+Dual-energy CT: CPP crystal deposition in synovial membrane/capsule/tendon+

*Potential negative predictor +Assessed in the knee, wrist, and/or 1 additional affected joint

Disclosure of Interests:

Sara Tedeschi Consultant of: NGM Biopharmaceuticals, Tristan Pascart: None declared, Augustin Latourte Consultant of: Novartis, Cattleya Godsave: None declared, Burak Kundaki: None declared, Raymond Naden: None declared, William Taylor: None declared, Nicola Dalbeth Speakers bureau: Abbvie and Janssen, Consultant of: AstraZeneca, Dyve, Selecta, Horizon, Arthrosi, and Cello Health, Tuhina Neogi: None declared, Fernando Perez-Ruiz: None declared, Ann Rosenthal: None declared, Fabio Becce Consultant of: Horizon Therapeutics, Grant/research support from: Siemens Healthineers, Eliseo Pascual: None declared, Mariano Andrés: None declared, Thomas Bardin: None declared, Michael Doherty: None declared, Hang Korng Ea: None declared, Georgios Filippou: None declared, John FitzGerald: None declared, Marwin Gutierrez: None declared, Annamaria Iagnocco: None declared, Tim Jansen Speakers bureau: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Consultant of: Abbvie, Amgen, BMS, Grunenthal, Olatec, Sanofi Genzyme, Minna Kohler Speakers bureau: Lilly, Consultant of: Novartis, Frederic Lioté: None declared, Mark Matza: None declared, Geraldine McCarthy Consultant of: PK Med, Roberta Ramonda: None declared, Anthony Reginato: None declared, Pascal Richette: None declared, Jasvinder Singh Speakers bureau: Simply Speaking, Consultant of: Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Adept Field Solutions, Clinical Care options, Clearview healthcare partners, Putnam associates, Focus forward, Navigant consulting, Spherix, Practice Point communications, Francisca Sivera: None declared, Alexander So: None declared, Lisa Stamp: None declared, Janeth Yinh: None declared, Chio Yokose: None declared, Robert Terkeltaub Consultant of: Sobi, Horizon Therapeutics, Astra-Zeneca, Selecta, Grant/research support from: Astra-Zeneca, Hyon Choi: None declared, Abhishek Abhishek Consultant of: NGM Biopharmaceuticals.

AB0915-PARE DEVELOPMENT AND USABILITY OF A WEB-BASED PATIENT-TAILORED TOOL TO SUPPORT ADHERENCE TO URATE-LOWERING THERAPY IN GOUT PATIENTS

Background:

Adherence to prescribed urate-lowering therapy (ULT) among gout patients is considered to be among the poorest of all chronic conditions. eHealth programs can be a possible opportunity to foster ULT adherence.

Objectives:

This study describes the development and usability evaluation of a web-based tool to support ULT adherence among gout patients, specifically designed for a complement to usual care.

Methods:

The Integrated Change (I-Change) model was used as theoretical basis for the development. The model combines various socio-cognitive theories and differentiates between three phases: a pre-motivational, a motivational, and a post-motivational phase. In practices, the I-Change gout tool contains three sessions, following the three phases of the I-Change model. Patients receive tailored feedback based on their answers in the form of animated videos and text messages after each session, and are prompted to set specific goals and action plans for their ULT adherence. The content and development of the I-Change gout tool was determined along an iterative process within a steering group of clinicians and researchers, supported by patient interviews and gout specific literature related to key aspects of medication adherence behavior. A cross-sectional mixed methods design was used to test usability of the support tool consisting of a think aloud method and a usability questionnaire.

Results:

The steering group decided on the content of the three sessions of the I-Change gout tool. Depending on the intention to change ULT adherence behavior patients were navigated through the I-Change gout tool, patients with a low intention go through all 3 sessions and patients with a high intention go through the pre- and post-motivational session (figure 1). In total, the I-Change gout tool contains three sessions with 80 questions, 66 tailored textual feedback messages, and 40 tailored animated videos.

Figure 1.

Flowchart of the computer-tailored I-Change gout tool for urate-lowering therapy adherence.

Twenty gout patients and seven healthcare professionals participated in the usability tests. The program end score rating for the gout tool was on average 8.4±0.9 (range 6-10) for patients and 7.7±1.0 (range 6-9) for healthcare professionals. Furthermore, participants reported a high intention to use and/or recommend the program in the future. Yet, participants identified some issues for further improvement of the systems user-friendliness by addressing barriers (e.g. more explicitly navigation) and weaknesses (e.g. technical and health literacy). The I-Change gout tool was updated according suggestions of improvements of the participants.

Conclusion:

This study provides initial support for the usability by patients and healthcare professionals of a ULT adherence I-Change gout tool. Further studies need to be conducted to assess its efficacy and (cost-) effectiveness in daily practice.

Disclosure of Interests:

None declared

Managing COVID-19 within and across health systems: why we need performance intelligence to coordinate a global response

Background

The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems’ decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic.

Discussion

A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance.

Conclusion

Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution.

Attitudes of Dutch intensive care unit clinicians towards oxygen therapy

BACKGROUND

Over the last decade, there has been an increasing awareness for the potential harm of the administration of too much oxygen. We aimed to describe self-reported attitudes towards oxygen therapy by clinicians from a large representative sample of intensive care units (ICUs) in the Netherlands.

METHODS

In April 2019, 36 ICUs in the Netherlands were approached and asked to send out a questionnaire (59 questions) to their nursing and medical staff (ICU clinicians) eliciting self-reported behaviour and attitudes towards oxygen therapy in general and in specific ICU case scenarios.

RESULTS

In total, 1361 ICU clinicians (71% nurses, 24% physicians) from 28 ICUs returned the questionnaire. Of responding ICU clinicians, 64% considered oxygen-induced lung injury to be a major concern. The majority of respondents considered a partial pressure of oxygen (PaO2) of 6-10 kPa (45-75 mmHg) and an arterial saturation (SaO2) of 85-90% as acceptable for 15 minutes, and a PaO2 7-10 kPa (53-75 mmHg) and SaO2 90-95% as acceptable for 24-48 hours in an acute respiratory distress syndrome (ARDS) patient. In most case scenarios, respondents reported not to change the fraction of inspired oxygen (FiO2) if SaO2 was 90-95% or PaO2 was 12 kPa (90 mmHg).

CONCLUSION

A representative sample of ICU clinicians from the Netherlands were concerned about oxygen-induced lung injury, and reported that they preferred PaO2 and SaO2 targets in the lower physiological range and would adjust ventilation settings accordingly.

AB0784 COMPARABLE IMPACT AND BURDEN OF DISEASE OF PSORIATIC ARTHRITIS PATIENTS WITH LIMITED JOINT INVOLVEMENT VS. THOSE WITH MORE EXTENSIVE JOINT INVOLVEMENT: INTERIM RESULTS FROM THE REWARD STUDY, A PROSPECTIVE, MULTICENTER, REAL-WORLD STUDY IN PATIENTS TREATED WITH APREMILAST

Background:

Psoriatic arthritis (PsA) is associated with a high burden of disease and an increased risk of comorbidities. Recent data suggest that patients with moderate PsA benefit most from apremilast (APR) treatment.1Results from an earlier analysis of the REWARD study suggest that patients with limited joint involvement may benefit from APR treatment, with improvements in the perceived impact of disease.2Patients with limited joint involvement or comorbidities are underrepresented in randomised controlled trials; therefore, evidence from real-world patient cohorts is needed to assess and compare the impact and burden of disease on patients with limited vs. extensive joints who may also have comorbidities.

Objectives:

To compare the burden of disease and comorbidities in patients with PsA who have limited joint involvement with patients with PsA who have extensive joint involvement.

Methods:

The prospective, multicenter, observational REWARD study assessed the impact of using the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire (score range: 0-10), presence of domains of PsA (enthesitis, dactylitis, skin psoriasis, nail psoriasis, axial involvement), and ongoing or history of comorbidities of interest on PsA patients considered for apremilast treatment in The Netherlands. This interim analysis compared results in patients with limited joint involvement (swollen joint count [SJC] ≤4) vs. more extensive joint involvement (SJC >4).

Results:

Currently, 77 patients have been included in the analysis (SJC ≤4: n=53; SJC >4: n=24) (Table 1). Mean baseline PsAID scores were 4.4 vs. 4.8 for the SJC ≤4 vs. SJC >4 groups (Figure 1). The proportions of patients who were not in the PsAID-defined Patient Acceptable Symptom State (PASS) were 58.7% for the SJC ≤4 group and 62.5% for the SJC >4 group. Mean pain visual analog scale (VAS) scores (0-100 mm) were 45.9 vs. 53.4 for the SJC ≤4 group vs. for the SJC >4 group. Mean scores for the individual PsAID domains for the SJC ≤4 vs. SJC >4 groups were generally comparable (Figure 2). Presence of specific manifestations of PsA for patients in the SJC ≤4 group vs. the SJC >4 group, respectively, were: moderate to severe psoriasis (psoriasis-involved body surface area [BSA] >3: 31.4% vs. 21.7%), nail psoriasis (45.3% vs. 41.7%), enthesitis (Leeds Enthesitis Index >0: 43.4% vs. 45.8%), dactylitis (18.9% vs. 33.3%), and axial involvement (3.8% vs 8.3%). Comorbidities in ≥5% of either group (SJC ≤4 vs. SJC >4) included hypertension (30.2% vs. 37.5%), hypercholesterolemia (13.2% vs. 16.7%), uveitis (1.9% vs. 8.3%), malignancy (0.0% vs. 8.3%), heart failure (5.7% vs. 8.3%), and depression (5.7 vs. 4.2%).

Table 1.

Patient Characteristics

DemographicsSJC ≤4n=53SJC >4n=24Age, mean53.154.4Female, %46.266.7Body mass index, mean, kg/m228.628.7PsA CharacteristicsSJC, mean1.210.2TJC, mean4.313.7PsAID, mean4.44.8Pain VAS, mean45.953.4Moderate to severe psoriasis (BSA >3), %31.421.7Dactylitis, %18.933.3Enthesitis, %43.445.8Nail psoriasis, %45.341.7Axial spondyloarthritis, %3.88.3ComorbiditiesHypertension, %30.237.5Hypercholesteremia, %13.216.7Uveitis, %1.98.3Malignancy, %0.08.3Heart failure, %5.78.3Depression, %5.74.2

Conclusion:

In this real-world study, no strong associations between SJC and patient-reported impact of disease or pain were observed. Similar to patients with more extensive joints involvement, patients with limited joint involvement had an associated substantial burden of disease, with more than half not achieving PsAID PASS.

References:

[1]Mease PJ, et al. Arthritis Care Res (Hoboken). 2020 Jan 7. Epub. 2. Jansen TL, et al. Ann Rheum Dis. 2019;78:913. Abstract FRI0442.

Disclosure of Interests:

Tim Jansen Grant/research support from: Olatec, Grunenthal – grant/research support, Consultant of: AbbVie, Celgene Corporation – consultant, Speakers bureau: Grunenthal, Sobi – speakers bureau, Arie Van Vliet Employee of: Amgen Inc. – employment; Celgene – employment at the time of study conduct, Marijn Vis Grant/research support from: Novartis, Pfizer – grant/research support, Consultant of: AbbVie, Celgene Corporation, Eli Lilly, Novartis, Pfizer – consultant

ARoCuS Web application promotes standardized treatment and documentation of rotator cuff tears

Purpose

To program a Web application for simplified calculation of the Advanced Rotator Cuff tear Score (ARoCuS), which is a 5-part, 18-item treatment-oriented intraoperative scoring system for intraoperative evaluation of rotator cuff tears.

Methods

ARoCuS characteristics (torn tendon, tear size, tissue quality and tear pattern) were assessed intraoperatively on 40 consecutive patients with rotator cuff tears for calculation of defect category ΔV. Video recordings were used to re-calculate the ARoCuS after surgery and to assess inter-observer reliability.

Results

The Web application “ARoCuS App” was built using Angular and transformed to a native iOS application. The intraoperative use of the app proved to be simple and intuitive. There were inter-/intra-observer differences neither in ARoCuS defect categories ΔV nor in ARoCuS characteristics (p > 0.05).

Conclusion

The ARoCuS app is a supportive tool for integration of standardized treatment procedures and documentation of rotator cuff tears in clinical routine.

Temporary epiphysiodesis using the FlexTack™ implant (tension band) featuring a modified explantation technique

OBJECTIVE

Presenting the implantation of the PediatrOS™ FlexTack™ (Merete, Berlin, Germany) for growth guidance and a modified explantation procedure to facilitate explantation and prevent bone and soft tissue damage.

INDICATIONS

Implantation: Genua vara and valga, coxa vara, varus and valgus deviation of the ankle joint, the elbow joint and the wrist Modified Explantation: Removal of the implant after successful limb correction or dislocation of the implant.

CONTRAINDICATIONS

Implantation: Closed growth plates, insufficient remaining growth potential, acute or chronic infection, insufficient osseous structures, severe muscular, nervous or vessel diseases endangering the respective limb Explantation: General inoperability of the patient.

SURGICAL TECHNIQUE

Implantation: Localization of the growth plate. Insertion of K‑wire parallel to joint line on the joint side. Setting of the implant. Insertion of second K‑wire and insertion with the implantation instrument and hammer. Modified Explantation: Cutting of the implant bridging part. Both ends of the bridging part are bent vertically to prevent soft tissue damage. Dissection of both implant arms from the bone with the chisel. Extraction in 360° motion using tooth extraction pliers.

POSTOPERATIVE MANAGEMENT

Implantation: Full weight bearing. X‑ray controls every 3 months to control growth correction. Explantation: Full weight bearing.

RESULTS

Complications such as breaking of the k‑wires, breaking of the chisel or extraction of adhering bone tissue occurred in 14 of the 64 (21.9%) explanted FlexTack implants. Complication-free removal using the original instruments provided by the manufacturer was possible for five implants. The modified explantation procedure as described above was applied in 45 explanted implants (70.3%) with complete removal of the implant without further complications within the follow up period.

[A Comparison of Dorsal Decompression and Dorsal Decompression Combined with the Dynamic Stabilisation Device LimiFlex™]

BACKGROUND

Lumbar spinal canal stenosis is commonly treated by dorsal decompression. However, resection of posterior elements increases the biomechanical instability and may lead to further complications. In order to prevent this, fusion of the involved segments is often performed. But further complications may be associated with this, for example, highly reduced flexibility. In order to overcome fusion-related problems, dynamic stabilisation devices, like the new LimiFlex™ Paraspinous Tension Band (PSB), have been developed. This prospective study compares dorsal decompression without stabilisation and dorsal decompression with stabilisation using the PSB in patients with lumbar canal stenosis.

METHODS

Sixty-three patients with stenosis involving one or two lumbar vertebral levels were treated with dorsal decompression. Forty received the PSB following decompression surgery. Back, hip and leg pain as well as patient's degree of disability were assessed preoperatively and at 3, 6 and 12 months postoperatively for all patients. Evaluations were conducted using the visual analogue scale (VAS) and the Oswestry disability index (ODI). Adverse events during the study period were evaluated.

RESULTS

Patients who received the PSB experienced a better pain relief and improvement in disability compared to patients who received treatment through decompression only. A significant difference of VAS and ODI development was found between both groups when treating two vertebral levels. Furthermore, the total number of adverse events was lower in the PSB group compared to the decompression group.

CONCLUSION

Dynamic stabilisation using the PSB delivers better results in terms of VAS and ODI values when compared to only dorsal decompression. In addition, it is also associated with a lower number of complications. The PSB is most favourable when 2 levels are treated.

[Metastatic malignant melanoma. Successfull treatment with ipilimumab]

A 73-year-old man, in whom 26 years ago a malignant melanoma with cervical lymph node metastases of the right retroauricular region was diagnosed, developed BRAF V600E-negative distant metastases, which progressed during both monochemotherapy and polychemotherapy. Therefore he was started on ipilimumab in a dose of 3 mg/kg body weight four times in intervals of 3 weeks. Subsequently, there was an almost complete regression of distant metastases. In several phase III trials a significant survival benefit has been identified for patients treated with ipilimumab. The human monoclonal antibody has been approved since July 2011 as a second-line treatment in Germany and was incorporated in January 2013 into the new guidelines for the treatment of malignant melanoma. The CTLA-4 antibody is the first drug that can improve significantly survival in patients with metastatic melanoma. In advanced (unresectable or metastatic) melanoma, immunostimulatory treatment with ipilimumab represents a new therapeutic option.

Absence of the spleen(s) in conjoined twins: a diagnostic clue of laterality defects? Radiological study of historical specimens

BACKGROUND

Laterality defects are quite common in thoracoileopagus and parapagus dicephalus but rare in other types of conjoined twins.

OBJECTIVE

To present the presumed laterality defects in cephalothoracoileopagus and prosopothoracoileopagus conjoined twins, based on the unilateral or bilateral absence or duplication of the spleen.

MATERIALS AND METHODS

Three human anatomical specimens of craniothoracoileopagus (CTIP) twins and one of prosopothoracoileopagus (PTIP) twins were investigated. The specimens were part of the Museum Vrolik collection of the Department of Anatomy and Embryology of the Academic Medical Centre, University of Amsterdam, The Netherlands. The specimens were taken out of their jars and scanned with multidetector CT and volumetric T2-weighted MRI at 1.5 T.

RESULTS

The internal anatomy of the specimens was largely in accordance with previous reports. However, there was no recognisable spleen in the right twin in one CTIP specimen, in the left twin in one other CTIP specimen, and in both twins in the third CTIP specimen and in the PTIP specimen.

CONCLUSION

Asplenia and polysplenia are considered reliable indicators of right and left isomerism, respectively. However, three of our four specimens had laterality patterns that did not correspond with those previously reported. Since no other parameters of laterality defects could be verified in these specimens, we concluded that asplenia was unlikely to be caused by laterality defects.

Skin temperature measured by infrared thermography after specific ultrasound-guided blocking of the musculocutaneous, radial, ulnar, and median nerves in the upper extremity

BACKGROUND

Sympathetic block causes vasodilatation and increases in skin temperature (T(s)). However, the T(s) response after specific nerve blocking is unknown. In this study, we hypothesized that T(s) would increase after specific blocking of the nerve innervating that area.

METHODS

Forty-six patients undergoing hand surgery were included. We performed ultrasound-guided, specific nerve blocking of either the musculocutaneous, radial, ulnar, or median nerve in each patient and analysed T(s) in the forearm and hand at 2 min intervals in the following 22 min by the use of infrared thermography. Areas of interest corresponding to the cutaneous innervation area of each of the four nerves were defined and the mean T(s) in each area was analysed.

RESULTS

Specific blocking of the ulnar and median nerves caused a substantial increase in mean (sd) T(s) in the areas innervated by these nerves [5.2 (3.2)°C and 5.1 (2.5)°C, respectively; both P<0.0001]. The increase was even larger at the fingertips. Median nerve blocking also increased T(s) in the area of the hand innervated by the radial nerve (P<0.0001). However, T(s) did not increase in any area after either musculocutaneous or radial nerve blocking.

CONCLUSIONS

Specific blocking of the ulnar and median nerve causes substantial increases in T(s) in specific areas of the hand. In contrast, the specific blocking of the musculocutaneous or radial nerve does not increase T(s). Further studies are needed to clarify if these findings can be used to objectively evaluate brachial plexus block success.

High-dose inhaled salbutamol has no acute effects on aerobic capacity or oxygen uptake kinetics in healthy trained men

The prevalence of asthma is higher among elite athletes than in the general population. This has resulted in the frequent use of anti-asthmatic medication such as beta2-agonists among asthmatic athletes. Beta2-agonists are on the prohibited list of WADA. The use of the beta2-agonist salbutamol is only permitted in therapeutic inhaled doses. Most studies have reported the lack of ergogenic effects of therapeutic doses of inhaled beta2-agonists measured in maximal oxygen uptake. No previous studies have examined any possible effects of high-dose inhaled salbutamol on oxygen uptake kinetics. We enrolled nine healthy well-trained men in a randomized, blinded, placebo-controlled crossover study. Subjects were randomized to inhalation of 40 puffs of 0.2 mg salbutamol or two placebo tablets and performed an incremental test to exhaustion and three submaximal tests at 75% of peak power to determine oxygen uptake kinetics. During the incremental test, there were no effects of inhaled salbutamol on VO(2max) in absolute or relative terms, and no effect on peak power and lactate threshold. During the submaximal test, we found no effects on the time constant, time delay, the mean response time or O(2) deficit related to oxygen uptake kinetics. In conclusion, no ergogenic effect of a high dose of salbutamol on aerobic capacity was found.

Rosacea - global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group

BACKGROUND

The absence of specific histological or serological markers, the gaps in understanding the aetiology and pathophysiology of rosacea, and the broad diversity in its clinical manifestations has made it difficult to reach international consensus on therapy guidelines.

OBJECTIVES

The main objective was to highlight the global diversity in current thinking about rosacea pathophysiology, classification and medical features, under particular consideration of the relevance of the findings to optimization of therapy.

METHODS

The article presents findings, proposals and conclusions reached by the ROSacea International Expert group (ROSIE), comprising European and US rosacea experts.

RESULTS

New findings on pathogenesis provide a rationale for the development of novel therapies. Thus, recent findings suggest a central role of the antimicrobial peptide cathelicidin and its activator kallikrein-5 by eliciting an exacerbated response of the innate immune system. Cathelicidin/kallikrein-5 also provide a rationale for the effect of tetracyclines and azelaic acid against rosacea. Clinically, the ROSIE group emphasized the need for a comprehensive therapy strategy - the triad of rosacea care - that integrates patient education including psychological and social aspects, skin care with dermo-cosmetics as well as drug- and physical therapies. Classification of rosacea into stages or subgroups, with or without progression, remained controversial. However, the ROSIE group proposed that therapy decision making should be in accordance with a treatment algorithm based on the signs and symptoms of rosacea rather than on a prior classification.

CONCLUSION

The ROSIE group reviewed rosacea pathophysiology and medical features and the impact on patients and treatment options. The group suggested a rational, evidence-based approach to treatment for the various symptoms of the condition. In daily practice this approach might be more easily handled than prior subtype classification, in particular since patients often may show clinical features of more than one subtype at the same time.