Pine needle abortions in cattle due to consumption of Pinus ponderosa in Argentina: Case reports

Two outbreaks of pine needle abortions in cattle are here reported for the first time in Argentina. The cases occurred in Chubut and Neuquén provinces in the Patagonia region, causing 29.6% and 9% of abortions in each herd respectively. In both outbreaks, the dams were in the last third of gestation, and, due to a period of cold, snow and lack of available forage, they gained access to Pinus ponderosa and Pinus contorta forests. No pathological lesions, serological, molecular, or microbiological evidence of infectious causes were observed in any of the six fetuses analyzed. Microhistological analysis of feces confirmed higher presence of fragments of Pinus spp. needles in the diet of affected dams than in that of non-affected ones (12.2 vs 3.0%). Moreover, toxicological analysis showed higher tetrahydroagathic acid in the sera of affected dams than in that of non-affected ones (10.05 vs 2.81 ppm). In addition, this acid was detected in different fetal fluids (3.6-8.1 ppm) of the six fetuses analyzed. Interestingly, isocupressic acid was detected only in needles of P. ponderosa, and its content was lower than that found in other areas of the world (0.31 and 0.5% in Chubut and Neuquén respectively). These results confirm that the consumption of P. ponderosa by dams could have been the cause of these abortion outbreaks, a fact that should be considered as differential diagnosis in abortions of cattle, especially in silvopastoral systems of Argentina.

Genitocrural Island Perforator Flap (GIP-Flap): An ideal surgical technique for covering uni- or bilateral vulvar loss tissue

Vulvar loss of soft tissue leads to urinary, sexual and morphological dysfunctions. Most patients affected are comorbid making it difficult to perform a flap, which is the most appropriate way to reconstruct. Our multidisciplinary plastic and gynecologic surgery team has developed a new technique using a pedicled internal pudendal island flap. Reconstruction is reliable, quick and applicable to all patients, with a highly satisfactory final appearance.

Hybrid wind-solar energy resources mapping in the European Atlantic

The complementarity of offshore wind and solar resources can enhance the energy output of a hybrid farm and reduce its variability relative to a stand-alone, conventional offshore wind farm. In this work offshore wind and solar resources are characterised and mapped in a large study area covering the European Atlantic, the North and Baltic Seas, and the Canary Islands. The intra-annual and overall variabilities of wind power density and solar irradiance are investigated, and their complementarity is evaluated on the basis of their correlation. Negatively correlated regions include the seas around Ireland and Great Britain, with vast wind resources (mean wind power density ~1500 Wm-2 off W Ireland) and comparatively limited solar resources (mean solar irradiance ~100 Wm-2). Positively correlated regions include notably the Canary Islands, with the highest values of solar irradiance in the study area (mean values of ~280 Wm-2). Two study sites are chosen for more detailed investigation - one with a negative correlation, off W Ireland; the other with a positive correlation, off the Canary Islands. Even in the positively correlated regions, it is found that the correlation coefficient is never large (always under 0.2), which signals an opportunity for reducing power output variability through hybrid or co-located wind-solar farms. This, along with the other advantages of hybrid or co-located wind-solar farms (optimised use of scarce marine space, shared electrical infrastructure, shared O&M crews and vessels, etc.), attests to their potential in the European Atlantic. This potential could be realised through new hybrid or co-located wind-solar farms, or by retrofitting floating solar PV into existing offshore wind farms.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Evaluation of the toxicological effects of Neltuma alpataco (Prosopis alpataco) pod alkaloid extract

The pods of Neltuma spp. have shown potential as a source of protein and energy in livestock. However, prolonged consumption of some of these species can lead to neurological symptoms in ruminants. This study aimed to determine the alkaloid content, as well as the in vitro and in vivo effects of an alkaloid-enriched extract (AEE) from N. alpataco pods. High performance liquid chromatography-high resolution mass spectrometry (HPLC-HRMS) identified juliprosine and juliprosopine as primary alkaloids, with juliprosine being most abundant. AEE from N. alpataco demonstrated dose-dependent cytotoxicity on glioma cells after 48 h, with a 50% cytotoxic concentration (CC50) of 24.69 μg/mL. However, the release of LDH was observed only at the highest tested concentration, indicating cellular damage. Further examination through phase-contrast microscopy and dual acridine orange/ethidium bromide fluorescence staining revealed morphological changes consistent with an apoptotic mechanism of cell death, ultimately leading to secondary necrosis. Finally, the LD50 after intraperitoneal injection in mice was determined to be 12.98 mg/kg. Taken together, these findings demonstrated for the first time the in vivo and in vitro toxicity of the AEE from N. alpataco pods.

Techno-economic assessment of potential zones for offshore wind energy: A methodology

This work presents a methodology for the techno-economic assessment and comparison of potential zones for the development of offshore wind energy. The methodology is illustrated through a case study in North Spain, using the high-potential zones designated by the Spanish government. The main elements considered include the bathymetry (water depths), energy production and total working hours based on the wind climate, maintenance windows based on the wave climate, and distance to selected port facilities that can accommodate the installation and operational and maintenance phases of an offshore wind farm. An interesting dichotomy arises moving from west to east along N Spain - energy production and working hours decrease, but maintenance windows increase. Given that both aspects play a role in the costs of an offshore wind project, pondering them adequately is crucial, and the selection of a particular zone for development may depend on project-specific cost models. Water depths may preclude the installation of bottom-fixed structures in certain areas; importantly, they may also represent a constraint for the deployment of certain floating concepts, particularly in the high-potential zones of the Cantabrian Sea. Finally, ports capable of servicing the offshore wind farms are identified and distances to all high-potential zones, calculated. By examining the unique properties of the high-potential zones, this methodology, which can be applied to other regions of interest for offshore wind, provides valuable insights into the advantages and challenges of offshore wind development at each site and thereby contributes to informed decision-making.

Impact of Lymphopenia on Treatment Outcomes in Unresectable Non-Small Cell Lung Cancer

PURPOSE/OBJECTIVE(S)

The purpose of this study was to investigate associations between lymphopenia and radiotherapy (RT) parameters. Moreover, to investigate the prognostic role of lymphopenia, and treatment and patient-related factors. Definitive chemoradiation (CRT) with consolidative durvalumab offers the best chance for cure in patients with unresectable, locally advanced non-small cell lung cancer. However, treatment-related lymphopenia (TRL) may negatively impact outcomes.

MATERIALS/METHODS

Fifty-four patients treated with CRT and durvalumab from 2017 to 2021 at a single academic center were prospectively included. Absolute lymphocyte counts (ALC), absolute neutrophil counts (ANC), and neutrophil-to lymphocyte ratio (NLR) were analyzed before (TLR1), and after CRT (TRL2), before durvalumab initiation (TRL3), and 3 months after CRT (TRL4). Patients were prospectively enrolled in the study. Categorical variables were analyzed using Pearson's chi-squared or Fisher's Exact tests. Nonparametric continuous variables were analyzed using Wilcoxon Rank-Sum test. Association of continuous clinical and dosimetric variables with hematologic toxicity was performed with Spearman's correlation. Kaplan-Meier analysis and the log-rank test were used to assess the probability of PFS and OS Cox proportional hazard models were used to estimate the effect of covariates on disease control rate. Variables that were strongly associated in univariate Cox regression analyses were entered into a multivariable Cox model. All statistical tests were two-sided, and statistical significance was set at p < 0.05. All analyses were performed using STATA version 15.1.

RESULTS

The median follow-up was 28.4 months (m). N2-3 disease showed worse TRL2 compared to N0-1 (p = 0.013). Table 1 shows RT parameters related to TLR2. Median time to durvalumab initiation after CRT was 47 days. Patients who started durvalumab later than 42 days had a greater decrease in lymphocytes at the end of CRT compared to those who started earlier. (70.1 vs 58.8%, p = 0.025). Median overall survival (OS) and progression-free survival (PFS) were 39.4 and 22.4m, respectively. Disease control rate (DCR) with durvalumab consolidation was 70.8%. Patients with NLR >4 prior to durvalumab initiation achieved a lower DCR compared to those with a NLR ≤4 (85.7 vs 14.3%, p = 0.005).

CONCLUSION

CRT-related immunosuppression is associated with delayed durvalumab initiation and worse DCR. Larger PTV and higher lung and heart doses are associated with TRL. Median real-world OS and PFS are similar to those in the PACIFIC trial.

A Phase II Trial of Intraoperative Radiotherapy after Surgical Resection of Brain Metastases: Feasibility and Efficacy NCT04847284

PURPOSE/OBJECTIVE(S)

Intraoperative radiation therapy (IORT) is an alternative to local radiation therapy for brain metastases, reducing total treatment time, and improving patient comfort, but the most effective dose is unknown. The objective of this study is to evaluate the efficacy and safety of IORT in patients with surgical excision of brain metastases at a dose of 20 Gy.

MATERIALS/METHODS

This trial is a single-institution, open-label, prospective, non-randomized study for intraoperative radiotherapy immediately after resection of brain metastases. Registered in January 2021, currently ongoing, planned to enroll 25 patients with IK ≥70, brain damage newly diagnosed by MRI, without dural contact and at least 1 cm to the optic nerve, chiasm and brainstem. In the baseline visit, the General Cognitive State will be carried out: Minimum Mental State Exams. Specific cognitive study: 1- Processing speed (SYmbol digit modalities test), 2- Executive function (TMT, back and forward digit span test, phonological and semantic verbal fluency test, Stroop color-word test), 3- Verbal memory (FCSRT). Quality of life will be monitored by completing the EORTC QL-C30 and BN20 questionnaires. Intraoperative radiation therapy will be performed with a 50 kV low energy X-ray portable linear accelerator using spherical applicators ranging from 1.5 to 4 cm kV to deliver 20 Gy to the surface. During IORT a maximum dose (DMax) of 8 Gy will be allowed to the optic nerve/chiasm and brainstem structures. MRI will be performed 72 hours after IORT. Neurocognitive Test and MRI after 6 weeks and every 3 months. The primary endpoint will be local progression free survival (PFS). Secondary endpoints will be overall survival, time to save cancer therapy, cognitive performance and quality of life, as well as IORT-related neurotoxicity complications will be evaluated according to the scale of the CTACAE version 4. The analysis of the median local progression free survival, overall survival will be analyzed using the Kaplan-Meier curve (long range test). All results will be considered statistically significant with a p value < 0.05. The statistical analysis will be carried out with statistical software.

RESULTS

The trial is open and ongoing to recruitment; we have included 7 patients. The 85.7% were male, mean age was 61.4 years range (43-74). The 57.1% were lung cancer metastases. For now, no tumor recurrence or neurocognitive complications have been observed and then once you have the results ready, we will publish them.

CONCLUSION

The limited current literature on the use of IORT in brain metastases appears to show efficacy and safety, but the most effective dose is unknown as well as whether it is as effective as other radiotherapy alternatives. Our study is ongoing and needs to be completed and evaluated with more follow-up in order to reach definitive conclusions.

Diagnostic Utility of PSMA 18F-DCFPyL PET/TC in Occult Biochemical Recurrence of Prostate Carcinoma with PSA Values <2ng/ml More than Two Years of Experience

PURPOSE/OBJECTIVE(S)

To analyze the diagnostic capability of PET-PSMA in clinical practice in patients with occult biochemical recurrence of prostate carcinoma with PSA values less than 2ng/ml.

MATERIALS/METHODS

The first 116 patients who underwent PSMA 18F-DCFPyL PET/TC at the centers participating in the study for occult biochemical recurrence of prostatic neoplasia were selected. All patients had low PSA values (<2ng/ml). The studies were visually assessed by two experts in Nuclear Medicine, and classified dichotomously as positive or negative/inconclusive. The diagnostic capacity of the test was determined according to the PSA values, as well as the densities by groups. Descriptive statistical analysis was performed. The AUC was evaluated, determining the optimal cut-off point and its precision parameters.

RESULTS

The retrospective analysis showed that 66/116 patients (56.9%) were positive, with statistically significant differences in the medians of the positive group (AUC 0.77) and 50/116 (43.1%) patients were negative (AUC 0.42). The study of densities by group showed a marked clustering of the negative/ inconclusive studies in PSA values less than 0.5 ng/ml. Correlation was observed between the PSA values and the detection capability of the test (AUC: 0,74). The optimal cut-off point calculated was 0,55 which showed a sensitivity of 0,75 and specificity of 0,68.

CONCLUSION

PET-PSMA shows excellent diagnostic capability even in strictly selected patients with PSA values < 2ng/ml. Its indication with values < 0.5ng/mL should be assessed according to individual risk. In 56.9% of the patients in the study the positive result could influence changes in therapeutic strategy.

Change in Therapeutic Approach after PET/TC PSMA-18F DCFPyL in Occult Biochemical Recurrence of Prostate Carcinoma with Low PSA Values

PURPOSE/OBJECTIVE(S)

To analyze changes in therapeutic attitude after PET-PSMA. in patients with occult biochemical recurrence after primary treatment with low PSA values.

MATERIALS/METHODS

Retrospective study of patients diagnosed with prostate carcinoma who after primary treatment with curative intent present biochemical recurrence with low PSA values (<2ng/ml) and negative imaging tests (ultrasound, CT-Scan, MRI, GGO and/or PET-Choline). The assessment was performed by two expert nuclear physicians. All patients underwent a study with 300-350MBq PSMA-18F DCFPyL PET/TC, and after a follow-up of no less than six months we assessed whether there were changes in therapeutic attitude directly related to the results of the test. The clinical/therapeutic evaluation was performed by expert radiation oncologists. Descriptive statistical analysis was performed. RoC curves (sensitivity vs. 1-specificity) and the corresponding areas under the curve were calculated to assess the predictive power of the study.

RESULTS

PET-PSMA with complete follow-up was performed on 85 patients aged 48-78 years (mean age 69 years) with occult biochemical recurrence. Most patients were staged T2 (50.58%) - T3 (48.23%), cases N1 (10.58%), Gleason score ≥ 7 (96%) with mean PSA level 11.24 ng/ml at diagnosis. The mean nadir PSA values of 0.13 mg/dl following primary treatment with radical intent. In 48.2% of patients (41/85) had a positive PET-PSMA during follow-up, pre-study the median PSA levels were 0,62 ng/dl. There is a correlation between the PSA value and the ability to detect disease in the PET-PSMA study (AUC: 0,74). In 75% of patients with positive PET-PSMA (31/41) there were changes in the therapeutic approach. This proportion was significantly lower (25%) in those without pathological PET findings (11/44). In PET-PSMA-positive patients the therapeutic changes found were classified as indicating or changing the planning of salvage radiotherapy treatment and/or initiating systemic treatment with hormone therapy (median PSA levels after treatment changes were 0.08 ng/dl). In cases with negative PET-PSMA a watchful waiting attitude was adopted.

CONCLUSION

PET-PSMA is a powerful diagnostic tool that conditions significant changes in the therapeutic approach in those patients with occult biochemical recurrence with low PSA, changing the treatment in 75% of the cases when the study is positive.

Tuberculin skin testing and QuantiFERON™-TB Gold Plus positivity among household contacts in Vietnam

SETTING

TB infection (TBI) is diagnosed using the technique-dependent tuberculin skin test (TST) or costly, more accurate interferon-gamma release assays. The TST (⩾10 mm) threshold was indicated by previous research among household contacts in Vietnam, but routine implementation with a different tuberculin reagent showed unexpectedly low TST positivity.

OBJECTIVE

TST (⩾5 mm and ⩾10 mm) results were compared to QuantiFERON™-TB Gold Plus (QFT) results in household contacts during community campaigns in 2020 and 2021.

DESIGN

This was a cross-sectional multi-center implementation study.

RESULTS

Among 1,330 household contacts in 2020, we found a TBI prevalence of 38.6% (QFT), similar to TST ⩾5 mm (37.4%) and higher than TST ⩾10 mm (13.1%). QFT+/TST+ was higher for TST ⩾5 mm (20.7%) than TST ⩾10 mm (9.4%). QFT was not discordant with TST ⩾5 mm (McNemar's test = 0.6, P = 0.5) but was discordant with TST ⩾10 mm (McNemar's test = 263.9, P < 0.01). Older age and Southern region increased odds for positive TST ⩾5 mm and QFT with weaker associations for TST ⩾10 mm. Agreement and discordance were similar in 2021 for 1,158 household contacts.

CONCLUSION

Tuberculin reagents affect TST positivity rates. High TB burden countries should monitor reliability of TBI diagnosis, including tuberculin potency, cold chain, and TST technique to optimize eligibility for TB preventive treatment.

Relationship between fat-free mass and metabolic syndrome in obese females

OBJECTIVE

A greater fat-free mass (FFM) could be negatively or positively associated with metabolic syndrome (MS). The objective of this work was to evaluate the relationship of FFM with MS, through three determinations; absolute FFM, relative to body weight FFM% and relative to squared height (FFMi).

PATIENTS AND METHODS

We conducted a cross-sectional study on 1,008 obese Caucasian females. Fat-free mass index (FFMi) was calculated by dividing FFM by squared height [FFM (kg)/height (m2)]. Fat-free mass percentage (FFM%) was calculated (absolute FFM/body weight) x100.

RESULTS

The odds ratio adjusted by age of having MS per tertiles were significantly higher in tertile 3 of FFM (OR=1.74, 95% CI=1.26-2.41; p=0.01) and FFMi (OR=3.38, 95% CI=2.42-3.72; p=0.001) and tertile 2 of FFM (OR=1.45, 95% CI=1.08-1.94; p=0.02) and FFMi (OR=2.37, 95% CI=1.75-3.20; p=0.01) compared with its reference (tertile-1). In contrast, odds ratio adjusted by age of having MS per tertiles were significantly lower in tertile-3 of FFM% (OR=0.29, 95% CI=0.20-0.41; p=0.01) and tertile- 2 of FFM% (OR=0.68, 95% CI=0.51-0.91; p=0.01) compared with its reference (tertile-1).

CONCLUSIONS

The prevalence of MS relative to FFM varies depending on the method used to represent it.

Impacts of climate change on wind energy potential in Australasia and South-East Asia following the Shared Socioeconomic Pathways

Wind energy is poised to play a major role in the energy transition. Fluctuations in global atmospheric circulation are expected as a result of climate change, and wind projections based on the most up-to-date scenarios of climate change, the Shared Socioeconomic Pathways (SSPs), anticipate significant changes in wind energy potential in many regions; so far, these changes have not been studied in Southeastern Asia and Australasia, a region with notable wind energy potential. This work investigates the evolution of wind power density and its temporal variability considering the latest scenarios of climate change, the SSPs. More specifically, two scenarios are considered, SSP2-4.5 and SSP5-8.5, corresponding to moderate and high emissions, respectively. As many as 18 global climate models are considered and compared against past-present data, and those that perform best are retained to build a large multi-model ensemble. The results show that projected changes in mean wind power density at the end of the 21st century are of little significance (typically below 5 %); nevertheless, this value can be far surpassed locally. In certain areas (e.g., Vietnam, Borneo) and seasons, remarkable changes in wind power density (exceeding 150 %) are anticipated. Typically, mean values and temporal variability changes are greater in the high-emissions scenario, however, seasonal variability is projected to be more pronounced in the moderate-emissions scenario. These effects of climate change on wind energy potential must be taken into account in the development of wind power in the region, for they will affect the energy production and, therefore, the economic viability of wind farms - not least in those areas where drastic changes are projected.

A150 MODERATE AGREEMENT IN ENDOSCOPIC DISEASE SCORING OF PEDIATRIC EOSINOPHILIC ESOPHAGITIS AMONG PEDIATRIC GASTROENTEROLOGISTS IN CANADA

Background

Endoscopy is an important tool in assessing the severity of gastrointestinal diseases including Eosinophilic Esophagitis (EoE). Agreement regarding endoscopy outcomes is important when using tools such as the Endoscopic Reference Score for EoE (EREFS).

Purpose

Our goal was to determine interrater and intrarater agreement of EREFS among Canadian pediatric gastroenterologists.

Method

Survey-based study of interrater and intrarater reliability amongst pediatric gastroenterologists with interest in pediatric EoE. Participants were sourced from the Canadian Pediatric EoE Network. Participants were asked how many years of training they’ve had with endoscopy for pediatric EoE and their comfort in disease scoring for pediatric EoE. Pediatric EoE cases were identified from the pediatric EoE registry at the Stollery Children’s Hospital with an endoscopic video associated with each case. Participants were asked to score each video using the EREFS questionnaire for the proximal, middle and distal segments of the esophagus. 15 endoscopic videos were evaluated, with 3 cases provided each week over a period of 5 weeks. Additional data included ratings of the video quality and endoscopy quality. Of 15 cases, 12 were unique cases, distributed evenly in severity between no active disease to severe disease. 3 cases were repeated to assess intrarater reliability. The maximum grade of the proximal, middle and distal segments of the esophagus for each component endoscopic finding (edema, rings, exudates, furrows, strictures) were used for reliability calculations. Fleiss Kappa was calculated for all EREFS items and for each component endoscopic finding. Cohen’s Kappa was calculated to assess intrarater reliability.

Result(s)

Fifteen participants were recruited for the study. The participants had a median of 12 years (IQR: 7, 19) of clinical experience in endoscopy for pediatric EoE. The majority of participants were “comfortable” (i.e., 4 on 5-point scale) with EREFS scoring for pediatric EoE. Fleiss Kappa for all EREFS items was 0.481. For each component endoscopic finding (edema, rings, exudates, furrows, strictures), Fleiss Kappa was 0.365, 0.293, 0.548, 0.263, 0.445 respectively. Cohen’s Kappa had a median of 0.620 (IQR: 0.593, 0.704). The majority of raters rated video quality and endoscopy quality as “good” (i.e., 4 on 5-point scale).

Conclusion(s)

There is moderate interrater reliability in EREFS scoring for pediatric EoE. Interrater reliability was between fair to moderate for each component endoscopic finding. Intrarater reliability was good. This study shows there is room for improvement in disease scoring for pediatric EoE. This could be in the form of additional training, expert-defined conventions, or centralized reading which have reduced variability in endoscopic reporting for adult GI disease in past studies and could be used in a follow-up study to attempt to improve agreement. Additionally, incorporating EREFS into routine clinical practice may increase agreement amongst endoscopists.

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Disclosure of Interest

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Impact of Delivering a Healthy Lifestyle Intervention: Promotora Findings from Familias Sanas y Activas II

Background

Community health workers, promotoras, have been identified as effective change agents of their community members' health behaviors and health status. However, few studies have examined the effects of delivering an intervention on the promotoras themselves.

Objectives

This study assessed whether promotoras delivering a healthy lifestyle intervention for adults improved their health behaviors and health status from baseline to 6- and 12-months post-baseline.

Methods

Volunteer promotoras were trained to promote healthy lifestyles including physical activity through workshops and free group exercise classes throughout their communities. Twenty completed all required trainings and delivered at least one class during the period between baseline and 12-month assessments. The promotoras were measured on the following variables: Systolic and diastolic blood pressure, waist circumference, weight, and height. Additionally, they reported their health behaviors and status including moderate-to-vigorous physical activity, beverage consumption, sleep duration, and depressive symptoms.

Results

Repeated measures ANOVAs showed statistically significant decreases from baseline to 6 months for systolic blood pressure (p ≤ 0.05), diastolic blood pressure (p ≤ 0.001) and body mass index (p ≤ 0.05). Changes in self-reported measures were not statistically significant although trends were observed with increases in water consumption.

Conclusions

Findings from this study suggest positive effects associated with delivery of a PA intervention. This is one of the first studies to focus on a cohort of promotoras to examine health outcomes from delivering a healthy lifestyle intervention. It is important to further explore these impacts on the community health workers as they have become increasingly essential to the health of some communities.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

COST-EFFECTIVENESS OF BENRALIZUMAB VERSUS MEPOLIZUMAB AND DUPILUMAB IN PATIENTS WITH SEVERE UNCONTROLLED EOSINOPHILIC ASTHMA IN SPAIN

OBJECTIVE

To assess the cost-effectiveness of benralizumab (benra) vs. mepolizumab (mepo) and dupilumab (dupi) for the treatment of patients with severe uncontrolled asthma from the Spanish Health System perspective.

METHODS

Exacerbations avoided, quality-adjusted life years (QALYs) gained and costs in a 5-year period were estimated with a Markov model for a cohort of 1,000 patients in which, based on published evidence, 31% of the patients received biologics + oral corticosteroids (OCS) and 69% received only biologics. Efficacy data (exacerbation reduction and OCS elimination) were derived from a matching-adjusted indirect comparison. Published EQ-5D utilities per health state (biologic alone, biologic + OCS, standard of care + OCS, exacerbations, and post-exacerbations) were used for QALY estimation. Utility decrements associated with exacerbation management [-0.1 (OCS or emergency visits), -0.2 (hospitalization)] derived from the literature were applied. Costs (€, 2022) included drug acquisition (ex-factory price), administration and disease management. An expert panel (2 pneumologists and 1 pharmacist) validated all inputs.

RESULTS

Benra was more effective (52.21 QALYs) than mepo (51.39 QALYs) and dupi (51.30 QALYs). Benra avoided more exacerbations (2.87 exacerbations) compared to mepo (4.70 exacerbations) and dupi (5.11 exacerbations) for the 5-year horizon. Total costs/patient were €56,093.77 (benra), €59,280.45 (mepo) and €62,991.76 (dupi), resulting in benra dominating (more QALYs with lower costs) vs. mepo and dupi.

CONCLUSIONS

Benralizumab can be considered as a dominant treatment alternative vs. other biologic drugs for the treatment of uncontrolled severe eosinophilic asthma patients in Spain.

Sex differences in adrenal cortex beta-catenin immunolocalisation of the Saharan gerbil, Libyan jird (Meriones libycus, Lichtenstein, 1823)

BACKGROUND

The adrenal cortex provides adequate steroidogenic responses to environmental changes. However, in desert rodents, the adrenocortical activity varies according to several factors especially sex, age, and seasonal variations. Herein, we examined the sex differences in the adrenal cortex activity and explored the involvement of sex hormones in the regulation of this function in Libyan jird Meriones libycus.

MATERIALS AND METHODS

Twenty-four adult male and female animals weighing 109-110 g were captured in the breeding season and equally assigned into control and gonadectomised groups. Animal euthanasia was performed 50 days after the gonadectomy. Adrenal gland was processed for structural and immunohistochemistry study of b-catenin, whereas plasma was used for cortisol assay.

RESULTS

The results showed that female adrenal gland weight was heavier than male and gonadectomy reduced this dimorphism. The adrenal cortex thickness was greater in the female than in the male, mainly due to significant development of the zona fasciculata. Females presented higher cell density in fasciculata and reticularis zones. The plasma cortisol was higher in females than in males. The immunolocalisation of beta-catenin showed that the expression was particularly glomerular in both sexes. However, in the female, the immunostaining was present in the zona reticularis while it was absent in the control male. Orchiectomy reduced zona glomerulosa cell density and induced hypertrophy of zona reticularis characterised by strong beta-catenin immunoreactivity.

CONCLUSIONS

Results indicated that sex hormones had a major role in the regulation of the Saharan gerbil's adrenal homeostasis by modulating beta-catenin signalling. Androgens seem to inhibit the Wnt-beta-catenin pathway and oestrogens are activators of the adrenal inner zones.

Knight Scholars Program: A Tiered Three-Year Mentored Training Program for Urban and Rural High School High School Students Increases Interest and Self-Efficacy in Interprofessional Cancer Research

Cancer research training programs build our future biomedical workforce. Training is often centered for students residing close to research institutions, making access more challenging for rural students. A cancer research training program was developed for high school students residing in five geographical regions across Oregon. Training was tiered in duration and intensity across the three years, including a one-week Introduction program and subsequent 10-week summer research training programs (Immersion and Intensive). A total of 60 students participated in in-person and/or virtual training, with Immersion students receiving mentored shadowing experiences in clinical care, public health, and outreach in their home communities. Laboratory rotations at a research-intensive institution enabled students to sample research environments before selecting an area of interest for Intensive training the following summer. Aligning with Self-Determination Theory, the Knight Scholars Program aims to build competence, relatedness, and autonomy of its trainees in biomedical sciences. The program exposed students to a wide range of interprofessional careers and collaborative teams, enabling scholars to envision themselves in various paths. Results show strong gains in interest and research self-efficacy for both Introduction and Immersion scholars, with findings highlighting the importance of representation within mentoring and training efforts.

Climate change impacts on wind energy resources in North America based on the CMIP6 projections

The mid- and long-term evolution of wind energy resources in North America is investigated by means of a multi-model ensemble selected from 18 global climate models. The most recent scenarios of greenhouse gases emissions and land use, the Shared Socioeconomic Pathways (SSPs), are considered - more specifically, the SSP5-8.5 (intensive emissions) and SSP2-4.5 (moderate emissions). In both scenarios, onshore wind power density in the US and Canada is predicted to drop. Under SSP5-8.5, the reduction is of the order of 15% overall, reaching as much as 40% in certain northern regions - Quebec and Nunavut in Canada and Alaska in the US. Conversely, significant increases in wind power density are predicted in Hudson Bay (up to 25%), Texas and northern Mexico (up to 15%), southern Mexico and Central America (up to 30%). As for the intra-annual variability, it is poised to rise drastically, with monthly average wind power densities increasing up to 120% in certain months and decreasing up to 60% in others. These changes in both the mean value and the intra-annual variability of wind power density are of consequence for the Levelised Cost of Energy from wind, the planning of future investments and, more generally, the contribution of wind to the energy mix.

Lymphovascular invasion has a significant prognostic impact in patients with early breast cancer, results from a large, national, multicenter, retrospective cohort study

Background

We determined the prognostic impact of lymphovascular invasion (LVI) in a large, national, multicenter, retrospective cohort of patients with early breast cancer (BC) according to numerous factors.

Patients and methods

We collected data on 17 322 early BC patients treated in 13 French cancer centers from 1991 to 2013. Survival functions were calculated using the Kaplan–Meier method and multivariate survival analyses were carried out using the Cox proportional hazards regression model adjusted for significant variables associated with LVI or not. Two propensity score-based matching approaches were used to balance differences in known prognostic variables associated with LVI status and to assess the impact of adjuvant chemotherapy (AC) in LVI-positive luminal A-like patients.

Results

LVI was present in 24.3% (4205) of patients. LVI was significantly and independently associated with all clinical and pathological characteristics analyzed in the entire population and according to endocrine receptor (ER) status except for the time period in binary logistic regression. According to multivariate analyses including ER status, AC, grade, and tumor subtypes, the presence of LVI was significantly associated with a negative prognostic impact on overall (OS), disease-free (DFS), and metastasis-free survival (MFS) in all patients [hazard ratio (HR) = 1.345, HR = 1.312, and HR = 1.415, respectively; P < 0.0001], which was also observed in the propensity score-based analysis in addition to the association of AC with a significant increase in both OS and DFS in LVI-positive luminal A-like patients. LVI did not have a significant impact in either patients with ER-positive grade 3 tumors or those with AC-treated luminal A-like tumors.

Conclusion

The presence of LVI has an independent negative prognostic impact on OS, DFS, and MFS in early BC patients, except in ER-positive grade 3 tumors and in those with luminal A-like tumors treated with AC. Therefore, LVI may indicate the existence of a subset of luminal A-like patients who may still benefit from adjuvant therapy.

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In a study of 17 322 early BC patients, LVI had a significant independent negative prognostic impact on survival.

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LVI negatively impacted survival in almost every patient category and cancer subtype, with and without AC.

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LVI did not have a negative survival impact in patients with ER+ grade 3 or with luminal A-like tumors with chemotherapy.

•

Results suggest a possible benefit of AC in LVI-positive luminal A-like patients.

Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials

STUDY OBJECTIVE

There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) ≥80 years old.

METHODS

Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (≥70 years old) with moderate-to-severe OSA (apnea-hipopnea index ≥15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients ≥80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements.

RESULTS

From the initial 369 randomized individuals with ≥70 years, 97 (26.3%) with ≥80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (-1.2 points, 95%CI, 0.2 to -2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels.

CONCLUSIONS

The present study does not support the use of CPAP in very elderly patients with moderate-to-severe OSA.

Alpha-mannosidosis caused by toxic plants in ruminants of Argentina

It is well known that several of the swainsonine-containing plant species found widespread around the world have a negative economic impact in each country. In Argentina, most of the information on the poisonous plant species that produce α-mannosidosis is published in Spanish and thus not available to most English-speaking researchers interested in toxic plants. Therefore, the aim of this review is to summarize the information about swainsonine-containing plants in Argentina, which are extensively distributed throughout different ecoregions of the country. To date, five species from three genera have been shown to induce α-mannosidosis in livestock in Argentina: Ipomoea carnea subsp. fistulosa, Ipomoea hieronymi subsp. calchaquina (Convolvulaceae), Astragalus garbancillo, Astragalus pehuenches (Fabaceae), and Sida rodrigoi (Malvaceae). These species contain the indolizidine alkaloid swainsonine, which inhibits the lysosomal enzyme α-mannosidase and consequently affects glycoprotein metabolism, resulting in partially metabolized sugars. The prolonged consumption of these poisonous plants produces progressive weight loss and clinical signs related to a nervous disorder, characterized by tremors of head and neck, abnormalities of gait, difficulty in standing, ataxia and wide-based stance. Histological lesions are mainly characterized by vacuolation of different cells, especially neurons of the central nervous system. The main animal model used to study α-mannosidosis is the guinea pig because, when experimentally poisoned, it exhibits many of the characteristics of naturally intoxicated livestock.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them

INTRODUCTION AND AIMS

Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation.

MATERIALS AND METHODS

A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment.

RESULTS

The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2 months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs.

CONCLUSIONS

A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

Interobserver variation in the classification of tumor deposits in rectal cancer-is the use of histopathological characteristics the way to go?

The focus on lymph node metastases (LNM) as the most important prognostic marker in colorectal cancer (CRC) has been challenged by the finding that other types of locoregional spread, including tumor deposits (TDs), extramural venous invasion (EMVI), and perineural invasion (PNI), also have significant impact. However, there are concerns about interobserver variation when differentiating between these features. Therefore, this study analyzed interobserver agreement between pathologists when assessing routine tumor nodules based on TNM 8. Electronic slides of 50 tumor nodules that were not treated with neoadjuvant therapy were reviewed by 8 gastrointestinal pathologists. They were asked to classify each nodule as TD, LNM, EMVI, or PNI, and to list which histological discriminatory features were present. There was overall agreement of 73.5% (κ 0.38, 95%-CI 0.33–0.43) if a nodal versus non-nodal classification was used, and 52.2% (κ 0.27, 95%-CI 0.23–0.31) if EMVI and PNI were classified separately. The interobserver agreement varied significantly between discriminatory features from κ 0.64 (95%-CI 0.58–0.70) for roundness to κ 0.26 (95%-CI 0.12–0.41) for a lone arteriole sign, and the presence of discriminatory features did not always correlate with the final classification. Since extranodal pathways of spread are prognostically relevant, classification of tumor nodules is important. There is currently no evidence for the prognostic relevance of the origin of TD, and although some histopathological characteristics showed good interobserver agreement, these are often non-specific. To optimize interobserver agreement, we recommend a binary classification of nodal versus extranodal tumor nodules which is based on prognostic evidence and yields good overall agreement.

Osteomalacia as a result of phosphorus deficiency in beef cattle grazing subtropical native pastures in Uruguay

We investigated 2 outbreaks of osteomalacia as a result of phosphorus (P) deficiency in herds of lactating beef cows grazing subtropical native pastures in Uruguay. Cows exhibited pica, difficulty to stand and walk, rib fractures, and body weight loss even with adequate forage availability. Osteopenia and severe osteomalacia were observed on gross and histologic examination. The concentrations of bicarbonate-extractable P in soil (4.0, 4.1 mg P/kg), total P in pasture (0.9, 1.1 g P/kg), inorganic P in serum (1.0, 0.71 mmol P/L), and P in bone (73 mg P/mL) were all low. Although injectable and mineral salt supplements provided additional P in both outbreaks, these supplementary amounts were insufficient to prevent P deficiency. The P ingested by the cows from the pasture and supplements would have provided 20-55% of their daily P requirements of ~21 g P/d. Osteomalacia occurred in cattle at the 2 ranches as a result of severe P deficiency in the soil and forage, and inadequate P supplementation. Following diagnosis, control of P deficiency in beef cattle requires estimation of the amount of pasture P ingested and provision of sufficient additional supplementary P to meet the animals' requirements.

GSK3 Inhibitor-Induced Dentinogenesis Using a Hydrogel

Small-molecule drugs targeting glycogen synthase kinase 3 (GSK3) as inhibitors of the protein kinase activity are able to stimulate reparative dentine formation. To develop this approach into a viable clinical treatment for exposed pulp lesions, we synthesized a novel, small-molecule noncompetitive adenosine triphosphate (ATP) drug that can be incorporated into a biodegradable hydrogel for placement by syringe into the tooth. This new drug, named NP928, belongs to the thiadiazolidinone (TDZD) family and has equivalent activity to similar drugs of this family such as tideglusib. However, NP928 is more water soluble than other TDZD drugs, making it more suitable for direct delivery into pulp lesions. We have previously reported that biodegradable marine collagen sponges can successfully deliver TDZD drugs to pulp lesions, but this involves in-theater preparation of the material, which is not ideal in a clinical context. To improve surgical handling and delivery, here we incorporated NP928 into a specifically tailored hydrogel that can be placed by syringe into a damaged tooth. This hydrogel is based on biodegradable hyaluronic acid and can be gelled in situ upon dental blue light exposure, similarly to other common dental materials. NP928 released from hyaluronic acid-based hydrogels upregulated Wnt/β-catenin activity in pulp stem cells and fostered reparative dentine formation compared to marine collagen sponges delivering equivalent concentrations of NP928. This drug-hydrogel combination has the potential to be rapidly developed into a therapeutic procedure that is amenable to general dental practice.

Ovarian thecoma: A very unusual cause of postmenopausal bleeding

We describe a 67-year-old woman with postmenopausal bleeding having ceased estrogen plus progestogen therapy nine months before. Transvaginal ultrasonography showed endometrial thickening with normal ovarian appearance. Hormonal studies revealed high estradiol and inhibin B levels but normal androgens and adrenal hormones. Magnetic resonance image demonstrated a 13-mm left ovarian tumour. Hysterectomy and bilateral salpingo-oophorectomy were performed, and the pathological study revealed an 8 mm ovarian thecoma. This case illustrates a very unusual cause of postmenopausal bleeding. We suggest a study protocol and discuss the differential diagnosis of this case.

Lack of prognostic impact of sentinel node micro-metastases in endocrine receptor-positive early breast cancer: results from a large multicenter cohort☆

Background

Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm.

Patients and methods

We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i−), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status.

Results

As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS.

Conclusion

LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.

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LN micro-metastases have no detectable prognostic impact.

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pN1 status, but not pN1mi, significantly impacted overall survival, disease-free survival, metastasis-free survival.

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In the subgroup of patients with known tumor subtype, pN1=1, as pN1>1, but not pN1mi, had a significant prognostic impact on OS.

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LN micro-metastases should not be considered as a determining factor in indicating adjuvant chemotherapy.

Understanding the effect of mechanical forces on ovarian cancer progression

OBJECTIVE

Mechanical forces including tension, compression, and shear stress are increasingly implicated in tumor progression and metastasis. Understanding the mechanisms behind epithelial ovarian cancer (EOC) progression and metastasis is critical, and this study aimed to elucidate the effect of oscillatory and constant tension on EOC.

METHODS

SKOV-3 and OVCAR-8 EOC cell lines were placed under oscillatory tension for 3 days and compared to cells placed under no tension. Cell proliferation, migration, and invasion were analyzed while RNAseq and Western Blots helped investigate the biological mechanisms underlying the increasingly aggressive state of the experimental cells. Finally, in vivo experiments using SCID mice assisted in confirming the in vitro results.

RESULTS

Oscillatory tension (OT) and constant tension (CT) significantly increased SKOV-3 proliferation, while OT caused a significant increase in proliferative genes, migration, and invasion in this cell line. CT did not cause significant increases in these areas. Neither OT nor CT increased proliferation or invasion in OVCAR-8 cells, while both tension types significantly increased cellular migration. Two proteins involved in metastasis, E-cadherin and Snail, were both significantly affected by OT in both cell lines, with E-cadherin levels decreasing and Snail levels increasing. In vivo, tumor growth and weight for both cell types were significantly increased, and ascites development was significantly higher in the experimental OVCAR-8 group than in the control group.

CONCLUSIONS

This study found that mechanical forces are influential in EOC progression and metastasis. Further analysis of downstream mechanisms involved in EOC metastasis will be critical for improvements in EOC treatment.

Individual dynamics of daily life functioning of reward system can predict future level of depressive symptoms

Introduction

The reward system regulates the processes that motivate people to pursue evolutionary beneficial stimuli. Effective functioning of the reward system can protect against the development of anhedonia. In the daily life, the reward system can be expressed as the dynamic interplay of positive affect (liking), reward anticipation (wanting), and active behavior (engaging). Applying network analysis to daily life experience data allows us to identify such reward dynamics and use them to predict future depressive symptoms.

Objectives

We investigated whether at baseline (i) higher network positive affect in-strength, reflecting how strongly positive affect is influenced by other components and hence the level of anhedonia, and (ii) higher network connectivity, reflecting overall functioning of the reward system, are associated with fewer depressive symptoms on follow-up.

Methods

We used data from 43 participants with mild depressive symptoms from the SMARTSCAN study. The dynamic interplay between momentary positive affect, reward anticipation, and active behavior was assessed with individual vector-autoregressive models and the network analysis. Network positive affect in-strength and connectivity indices were used to predict a six-month depressive symptoms trajectory.

Results

Reward systems networks vary greatly between individuals. On the group level, higher positive affect in-strength (Beta=-3.66, p=0.05) and network connectivity (Beta=-4.06, p=0.03) at baseline were associated with fewer symptoms at follow-up.

Conclusions

Higher influences of reward anticipation and active behavior on positive affect and stronger connections between reward cycle components are associated with fewer future symptoms, suggesting the importance of daily life reward cycle dynamics in depression.

Disclosure

No significant relationships.

Fibrosis assessment in patients with nonalcoholic fatty liver disease: Adherence to proposed algorithms and barriers to complying with them

INTRODUCTION AND AIMS

Fibrosis staging in patients with nonalcoholic fatty liver disease (NAFLD) is carried out through the application of stepwise algorithms but there is little real-world data on their use. Our aim was to calculate the number of patients with NAFLD and indeterminate or high risk for fibrosis, assessed through noninvasive scores, that consequently underwent further staging evaluation.

MATERIALS AND METHODS

A cross-sectional multicenter cohort study was conducted on patients with NAFLD evaluated by hepatologists within the time frame of June 1 and July 31, 2018. The FIB-4 and NAFLD fibrosis scores were calculated in all the patients, and if at least one of the scores suggested indeterminate or high risk for fibrosis, we believed the patient should have undergone additional fibrosis staging assessment.

RESULTS

The study included 238 patients. The median time interval from NAFLD diagnosis and inclusion in the analysis was 12.2months (IQR 3.0-36.5). A total of 128 (54%) patients had at least one noninvasive score that suggested indeterminate or high risk for fibrosis but studies to confirm the fibrosis grade (elastography, biopsy, etc.) were performed on only 72 (56%). The main barriers encountered by the physicians for applying the staging algorithms were related to health insurance coverage and imaging study costs.

CONCLUSIONS

A high percentage of patients with NAFLD were at indeterminate or high risk for fibrosis, according to noninvasive scores, but additional studies were carried out on only half of them, showing low adherence to current recommendations.

A14 WIDE VARIATION IN CLINICAL MANAGEMENT OF PAEDIATRIC EOSINOPHILIC ESOPHAGITIS: A CANADIAN EXPERIENCE

Background

Eosinophilic esophagitis (EoE) is a chronic disorder treated by food elimination diet (FED), topical steroids and/or proton-pump inhibitors (PPI). Serial endoscopies and biopsies assess response to therapy. EoE management has evolved as guidelines are updated.

Aims

To identify practice variation among Canadian paediatric gastroenterologists (PG) who care for children with EoE.

Methods

An online survey using REDCap about decision-making in children with EoE was distributed to PG in Canada in November 2020.

Results

62 PG completed the survey (response rate 69%, 62/94). The majority work in academic centres (92%). 3 centers indicated an accrual of &gt;50 new patients per year; 9/16 centres have &gt;100 patients in follow-up. An EoE Clinic is present in 5 centres.

Diagnosis: Familiarity with the 2018 AGREE and 2020 AGA EoE guidelines was found to be 57% and 67% respectively. Criteria required to diagnose EoE according to current guidelines were correctly indicated by 42% of PG. (Figure 1).

Endoscopy: The majority of PG (95%) adhere to guidelines in terms of required number and location of biopsies for the initial diagnosis. Ideal timing of repeat endoscopy after change in therapy in patients who are not in histological remission was 8–12 weeks by 67% of PG, timing in stable patients on maintenance therapy varied (33% only if patient is symptomatic). 25% used the EREFS Score in reporting endoscopic findings.

Therapy: Improvement of symptoms was the highest ranked goal (64%), followed by remission of histologic findings (30%). A treatment algorithm was in place in 4 centers. The majority routinely assess adherence to therapy (73%) and consult a dietitian for FED (77%). Most (87%) do not consult an allergist for initial management. Preferred choices of 1st-line therapy varied among PG (Figure 2). When FED was selected, 32% of PG started with 1 food, 32% started with 2 foods, most frequently excluding dairy, followed by wheat. 14 (26%) start with ≥6 FED. Prescription of budesonide slurry was consistent among PG with doses of 1 and 2 mg/day in children &lt;10 and &gt;10 years, respectively.

Conclusions

The is the first Canadian study to assess the variation in management of children with EoE by PG. Overall, PG demonstrated good adherence to the guidelines in terms of initial diagnosis, but differences in maintenance therapy choice and timing of endoscopies. The results highlight a need for standardized management algorithms to deliver uniform care to this growing group. Grounding these guidelines in evidence will warrant a significant investment in further paediatric EoE research.

Funding Agencies

None