Cardiopulmonary, Functional, Cognitive and Mental Health Outcomes Post-COVID-19, Across the Range of Severity of Acute Illness, in a Physically Active, Working-Age Population

BACKGROUND

The COVID-19 pandemic has led to significant morbidity and mortality, with the former impacting and limiting individuals requiring high physical fitness, including sportspeople and emergency services.

METHODS

Observational cohort study of 4 groups: hospitalised, community illness with on-going symptoms (community-symptomatic), community illness now recovered (community-recovered) and comparison. A total of 113 participants (aged 39 ± 9, 86% male) were recruited: hospitalised (n = 35), community-symptomatic (n = 34), community-recovered (n = 18) and comparison (n = 26), approximately five months following acute illness. Participant outcome measures included cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests and questionnaires on mental health and function.

RESULTS

Hospitalised and community-symptomatic groups were older (43 ± 9 and 37 ± 10, P = 0.003), with a higher body mass index (31 ± 4 and 29 ± 4, P < 0.001), and had worse mental health (anxiety, depression and post-traumatic stress), fatigue and quality of life scores. Hospitalised and community-symptomatic participants performed less well on sub-maximal and maximal exercise testing. Hospitalised individuals had impaired ventilatory efficiency (higher VE/V̇CO₂ slope, 29.6 ± 5.1, P < 0.001), achieved less work at anaerobic threshold (70 ± 15, P < 0.001) and peak (231 ± 35, P < 0.001), and had a reduced forced vital capacity (4.7 ± 0.9, P = 0.004). Clinically significant abnormal cardiopulmonary imaging findings were present in 6% of hospitalised participants. Community-recovered individuals had no significant differences in outcomes to the comparison group.

CONCLUSION

Symptomatically recovered individuals who suffered mild-moderate acute COVID-19 do not differ from an age-, sex- and job-role-matched comparison population five months post-illness. Individuals who were hospitalised or continue to suffer symptoms may require a specific comprehensive assessment prior to return to full physical activity.

318 CARER STRESS REVIEW IN COMPLEX CASES REQUIRING INTERVENTION BY A COMMUNITY-BASED OLDER PERSONS TEAM

Background

Complex cases of older adults suffering from multimorbidity are continuing to increase in number. The integrated care team, overseen by a consultant geriatrician, aims to facilitate the management of stable complex cases in the community. Patient care is largely affected by their support system at home; therefore, it is of great importance to ensure that the patient’s primary carer is receiving the support they require to facilitate the older patients’ management in the community. Our aim is to assess carer stress levels before and after Multi-Disciplinary Team (MDT) integrated care intervention.

Methods

Study Population were carers of patients identified as complex cases by the integrated care team. Caregiver stress index was administered during the initial assessment and on the closing of active cases. The maximum score on this index is 13 with high stress classified as &gt;7. Scores were added to a spreadsheet. This spreadsheet was reviewed, and relevant data was collated. One year assessed March 2021- March 2022.

Results

Carer stress information was collected on 62 of 112 identified complex cases (55%). Of these 55 of 96 individual patients were represented (57%). Average age 82 years old. 65% female and 35%, male. Range of carer stress scores observed 0- to 12. Of the 62 cases, 85% (53 cases) had a reduction in carer stress post-intervention(p&lt;0.01). Of these 65% had a reduction below 7 (p&lt;0.01). Mean score improvement 7. No carer stress indices disimproved post-treatment.

Conclusion

Multidisciplinary, patient-centred community care has a clear positive impact on the patient carer. Improvements in carer stress scores could be further evaluated as to the benefits of specific interventions in time. In future, a more large-scale collection and interpretation of data would need to occur for a more conclusive positive impact of the community based integrated care team to be confirmed.

209 THE ADVANCED NURSE PRACTITIONER CANDIDATE: PALLIATIVE CARE IN END-STAGE DEMENTIA UTILISING A CARE COORDINATED APPROACH IN THE COMMUNITY SETTING

Background

Palliative care in the context of dementia is a relatively new concept. Over recent years, there has been an increased emphasis on extending palliative care for those with dementia worldwide, supported by the 2014 white paper from the European Association of Palliative Care (EAPC) defining optimal palliative care for people with dementia. Individualized care coordination for older adults in the community improves high quality care and sets the scene for this care-coordinated approach initiative led by the Advanced Nurse Practitioner candidate (ANPc)

Methods

Developing a robust pathway of care in partnership with community palliative care service will enhance the support given to achieve optimal and quality driven palliative and end of life care outcomes. The pathways achieved involve a three-step integrated pathway structure. Step one involves care intervention by the ANPc, step 2 a care coordinated approach with the ANPc and Community Palliative Care Team (CPCT) and step 3 CPCT with collaborative interactions with the ANPc. Inclusion criteria include patients with end stage dementia who have reached a FAST scale of seven or over. All patients accepted onto this pathway must reside within the healthcare area set out and experience at least one or more symptoms resulting from their dementia.

Results

Results to date have shown how this pathway has achieved significant care interventions meeting the need of people living with dementia at end stages of their journey in the community setting. Additionally, families have indicated the overall satisfaction of the service and with significant reductions in Carer stress.

Conclusion

Research indicates that individualized care coordination in the community is crucial to optimise quality care interventions, which this pathway achieves.

314 COMMUNITY-BASED INTEGRATED CARE TEAMS EFFECTIVENESS IN PREVENTING CRISIS EMERGENCY DEPARTMENT ATTENDANCES

Background

Community based integrated care Multi-Disciplinary Teams (MDT) are a mainstay for future management of older adults. They have evolved to meet the needs of many different sub-types of clinical cases in the community. Complex Cases, are patients over 65 who reside within the catchment area, suffer from at least 2 frailty traits, and would be at increased risk of crisis emergency department (ED) attendance. Can the crisis ED attendances be prevented by integrated care team intervention?

Methods

The study population comprised adults identified as complex cases as per integrated care team standard operating procedure. Collated data was reviewed, and electronic medical records assessed as to whether any complex cases had been admitted within 30 days, 60 days, and 1 year of community team review. The study time frame was March 2021- to March 2022. As many patients have more than one unique identifying number, all patients were double-checked with an assessment based on their name and date of birth.

Results

112 complex cases were identified within one year, and 96 individual patients were represented. Average age 83 years old. 65% female and 35% male. 11% were admitted to hospital within 30 days, a further 6% were admitted within 60 days and by one year 30% of reviewed complex cases had been admitted to hospital.

Conclusion

In one year 70% of complex cases have been successfully maintained in the community. This has been achieved based on a multidisciplinary-based, patient-centred care approach. Given that 53% of hospital inpatient bed days are occupied by those over 65. This review concurs with previous research suggesting that an increase in community based integrated care teams is justified and should the aim for a fully staffed team per 150,000 patients over 65 come to fruition more than two-thirds of even the most complicated geriatric cases could be managed in the community.

How do children view and categorise human and dog facial expressions?

Children are often surrounded by other humans and companion animals (e.g., dogs, cats); and understanding facial expressions in all these social partners may be critical to successful social interactions. In an eye-tracking study, we examined how children (4-10 years old) view and label facial expressions in adult humans and dogs. We found that children looked more at dogs than humans, and more at negative than positive or neutral human expressions. Their viewing patterns (Proportion of Viewing Time, PVT) at individual facial regions were also modified by the viewed species and emotion, with the eyes not always being most viewed: this related to positive anticipation when viewing humans, whilst when viewing dogs, the mouth was viewed more or equally compared to the eyes for all emotions. We further found that children's labelling (Emotion Categorisation Accuracy, ECA) was better for the perceived valence than for emotion category, with positive human expressions easier than both positive and negative dog expressions. They performed poorly when asked to freely label facial expressions, but performed better for human than dog expressions. Finally, we found some effects of age, sex, and other factors (e.g., experience with dogs) on both PVT and ECA. Our study shows that children have a different gaze pattern and identification accuracy compared to adults, for viewing faces of human adults and dogs. We suggest that for recognising human (own-face-type) expressions, familiarity obtained through casual social interactions may be sufficient; but for recognising dog (other-face-type) expressions, explicit training may be required to develop competence. We conducted an eye-tracking experiment to investigate how children view and categorise facial expressions in adult humans and dogs Children's viewing patterns were significantly dependent upon the facial region, species and emotion viewed Children's categorisation also varied with the species and emotion viewed, with better performance for valence than emotion categories Own-face-types (adult humans) are easier than other-face-types (dogs) for children, and casual familiarity (e.g., through family dogs) to the latter is not enough to achieve perceptual competence This article is protected by copyright. All rights reserved.

P23 Antibody negative Systemic Sclerosis

Introduction/Background

This case explores some classic rheumatology topics - systemic sclerosis and antibodies. It is now well recognised that there are a magnitude of different antibodies, beside the typical anti-Scl-70, anticentromere or anti-RNA polymerase III, that can be associated with systemic sclerosis however in 5-10% of cases all antibody tests are negative, yet the patient still displays characteristic clinical features of the disease. We need to ensure such patients are correctly diagnosed, followed up and managed.

Description/Method

This case looks at the uncommon presentation of systemic sclerosis without any positive antibody results. I consulted with a 53-year-old male with a past medical history of hypertension, type 2 diabetes, GORD, hypothyroidism, depression and hyperlipidaemia. He had previously been seen in the rheumatology clinic with costochondritis and Raynaud’s phenomenon. At this time, he had antibody tests which were all negative (ANA and ENA). He had nailfold capillaroscopy which showed some concerns with widening of capillaries in areas and some linear haemorrhages. This was felt to not be diagnostic of Systemic sclerosis but advised continued follow up and repeat tests. Unfortunately, he failed to attend a subsequent clinic appointment and was lost to follow up. He was referred back to the Rheumatology department in 2021 with worsening symptoms of Raynaud’s. At this time he also described symptoms of reflux and dysphagia. He was suffering from generalised fatigue and pains. On examination he had tightening of the skin on his hands and was prayer sign positive. His antibody tests were repeated, again all coming back negative. We then arranged for repeat nailfold capillaroscopy and thermographic testing. This showed very little rewarming after cold challenge with delay even at 30 degrees. The nailfold capillaroscopy showed generalised widening of the capillaries with occasional distortion and tortuosity. There were multiple linear haemorrhages. This study was reported showing definite abnormality in keeping with a diagnosis of systemic sclerosis.

Discussion/Results

This highlights the rare but now well recognised phenomenon of antibody negative systemic sclerosis which makes up around 5-10% of cases. It also shows how nailfold capillaroscopy can be a key tool in diagnosing this, and the features to look out for in order to do so - capillary widening, haemorrhage and loss of architecture. The case demonstrates some of the more common features of antibody negative systemic sclerosis including a higher proportion of male patients and prominent GI features. There are generally less severe vascular features including pulmonary hypertension and telangiectasia, with Raynaud’s less often leading to digital ulcers and pitting. In this case we suggested uptitration of his nifedipine to try and help control his Raynaud’s symptoms. Given the significant GI features this patient was experiencing we referred him on for further evaluation by the gastroenterology team. I think some aspects of this case were blurred by his comorbidities, especially diabetes, and some of his skin disease and pains were attributed to this. However, with hindsight and seeing how his symptoms progressed, I think we could question if more could have been done earlier in the course of this patient’s disease - maybe when the initial abnormal, if not diagnostic, capillaroscopy results were available. Unfortunately, the patient not attending further clinic appointments reduced the opportunities to do this, but this also raised a good question about how we try to ensure patient engagement and deal with patients who don’t attend follow up.

Key learning points/Conclusion

This was an excellent case for us to be able to learn about systemic sclerosis and the spectrum of disease it encompasses. It was interesting to learn about the different features and presentations of the disease, and how these different phenotypes correlate to certain antibodies classically being present, or as in this case, not present. It also enabled me to consider how we manage complex patients with multiple comorbidities and variable compliance. I feel that this conference would allow us to learn from other complex cases and how to best manage patients with similar issues, including systemic sclerosis, prominent pain issues, and gastrointestinal issues within rheumatology.

Comprehensive clinical assessment identifies specific neurocognitive deficits in working-age patients with long-COVID

INTRODUCTION

There have been more than 425 million COVID-19 infections worldwide. Post-COVID illness has become a common, disabling complication of this infection. Therefore, it presents a significant challenge to global public health and economic activity.

METHODS

Comprehensive clinical assessment (symptoms, WHO performance status, cognitive testing, CPET, lung function, high-resolution CT chest, CT pulmonary angiogram and cardiac MRI) of previously well, working-age adults in full-time employment was conducted to identify physical and neurocognitive deficits in those with severe or prolonged COVID-19 illness.

RESULTS

205 consecutive patients, age 39 (IQR30.0-46.7) years, 84% male, were assessed 24 (IQR17.1-34.0) weeks after acute illness. 69% reported ≥3 ongoing symptoms. Shortness of breath (61%), fatigue (54%) and cognitive problems (47%) were the most frequent symptoms, 17% met criteria for anxiety and 24% depression. 67% remained below pre-COVID performance status at 24 weeks. One third of lung function tests were abnormal, (reduced lung volume and transfer factor, and obstructive spirometry). HRCT lung was clinically indicated in <50% of patients, with COVID-associated pathology found in 25% of these. In all but three HRCTs, changes were graded 'mild'. There was an extremely low incidence of pulmonary thromboembolic disease or significant cardiac pathology. A specific, focal cognitive deficit was identified in those with ongoing symptoms of fatigue, poor concentration, poor memory, low mood, and anxiety. This was notably more common in patients managed in the community during their acute illness.

CONCLUSION

Despite low rates of residual cardiopulmonary pathology, in this cohort, with low rates of premorbid illness, there is a high burden of symptoms and failure to regain pre-COVID performance 6-months after acute illness. Cognitive assessment identified a specific deficit of the same magnitude as intoxication at the UK drink driving limit or the deterioration expected with 10 years ageing, which appears to contribute significantly to the symptomatology of long-COVID.

The effect of medium-term recovery status after COVID-19 illness on cardiopulmonary exercise capacity in a physically active adult population

A failure to fully recover following coronavirus disease 2019 (COVID-19) may have a profound impact on high-functioning populations ranging from frontline emergency services to professional or amateur/recreational athletes. The aim of the study is to describe the medium-term cardiopulmonary exercise profiles of individuals with “persistent symptoms” and individuals who feel “recovered” after hospitalization or mild-moderate community infection following COVID-19 to an age, sex, and job-role matched control group. A total of 113 participants underwent cardiopulmonary functional tests at a mean of 159 ± 7 days (∼5 mo) following acute illness; 27 hospitalized with persistent symptoms (hospitalized-symptomatic), 8 hospitalized and now recovered (hospitalized-recovered); 34 community managed with persistent symptoms (community-symptomatic); 18 community managed and now recovered (community-recovered); and 26 controls. Hospitalized groups had the least favorable body composition (body mass, body mass index, and waist circumference) compared with controls. Hospitalized-symptomatic and community-symptomatic individuals had a lower oxygen uptake (V̇o₂) at peak exercise (hospitalized-symptomatic, 29.9 ± 5.0 mL/kg/min; community-symptomatic, 34.4 ± 7.2 mL/kg/min; vs. control 43.9 ± 3.1 mL/kg/min, both P < 0.001). Hospitalized-symptomatic individuals had a steeper V̇e/V̇co₂ slope (lower ventilatory efficiency) (30.5 ± 5.3 vs. 25.5 ± 2.6, P = 0.003) versus. controls. Hospitalized-recovered had a significantly lower oxygen uptake at peak (32.6 ± 6.6 mL/kg/min vs. 43.9 ± 13.1 mL/kg/min, P = 0.015) compared with controls. No significant differences were reported between community-recovered individuals and controls in any cardiopulmonary parameter. In conclusion, medium-term findings suggest that community-recovered individuals did not differ in cardiopulmonary fitness from physically active healthy controls. This suggests their readiness to return to higher levels of physical activity. However, the hospitalized-recovered group and both groups with persistent symptoms had enduring functional limitations, warranting further monitoring, rehabilitation, and recovery.

NEW & NOTEWORTHY At 5 mo postinfection, community-treated individuals who feel recovered have comparable cardiopulmonary exercise profiles to the physically trained and active controls, suggesting a readiness to return to higher intensity/volumes of exercise. However, both symptomatic groups and the hospital-recovered group have persistent functional limitations when compared with active controls, supporting the requirement for ongoing monitoring, rehabilitation, and recovery.

Dysautonomia following COVID-19 is not associated with subjective limitations or symptoms but is associated with objective functional limitations

Background

Individuals who contract coronavirus disease 2019 (COVID-19) can suffer with persistent and debilitating symptoms long after the initial acute illness. Heart rate (HR) profiles determined during cardiopulmonary exercise testing (CPET) and delivered as part of a post-COVID recovery service may provide insight into the presence and impact of dysautonomia on functional ability.

Objective

Using an active, working-age, post–COVID-19 population, the purpose of this study was to (1) determine and characterize any association between subjective symptoms and dysautonomia; and (2) identify objective exercise capacity differences between patients classified “with” and those “without” dysautonomia.

Methods

Patients referred to a post–COVID-19 service underwent comprehensive clinical assessment, including self-reported symptoms, CPET, and secondary care investigations when indicated. Resting HR >75 bpm, HR increase with exercise <89 bpm, and HR recovery <25 bpm 1 minute after exercise were used to define dysautonomia. Anonymized data were analyzed and associations with symptoms, and CPET outcomes were determined.

Results

Fifty-one of the 205 patients (25%) reviewed as part of this service evaluation had dysautonomia. There were no associations between symptoms or perceived functional limitation and dysautonomia (P >.05). Patients with dysautonomia demonstrated objective functional limitations with significantly reduced work rate (219 ± 37 W vs 253 ± 52 W; P <.001) and peak oxygen consumption (V̇o₂: 30.6 ± 5.5 mL/kg/min vs 35.8 ± 7.6 mL/kg/min; P <.001); and a steeper (less efficient) V̇e/V̇co₂ slope (29.9 ± 4.9 vs 27.7 ± 4.7; P = .005).

Conclusion

Dysautonomia is associated with objective functional limitations but is not associated with subjective symptoms or limitation.

The plate-to-rod transition in trabecular bone loss is elusive

Changes in trabecular micro-architecture are key to our understanding of osteoporosis. Previous work focusing on structure model index (SMI) measurements have concluded that disease progression entails a shift from plates to rods in trabecular bone, but SMI is heavily biased by bone volume fraction. As an alternative to SMI, we proposed the ellipsoid factor (EF) as a continuous measure of local trabecular shape between plate-like and rod-like extremes. We investigated the relationship between EF distributions, SMI and bone volume fraction of the trabecular geometry in a murine model of disuse osteoporosis as well as from human vertebrae of differing bone volume fraction. We observed a moderate shift in EF median (at later disease stages in mouse tibia) and EF mode (in the vertebral samples with low bone volume fraction) towards a more rod-like geometry, but not in EF maximum and minimum. These results support the notion that the plate to rod transition does not coincide with the onset of bone loss and is considerably more moderate, when it does occur, than SMI suggests. A variety of local shapes not straightforward to categorize as rod or plate exist in all our trabecular bone samples.

Bodily emotional expressions are a primary source of information for dogs, but not for humans

Dogs have remarkable abilities to synergise their behaviour with that of people, but how dogs read facial and bodily emotional cues in comparison to humans remains unclear. Both species share the same ecological niche, are highly social and expressive, making them an ideal comparative model for intra- and inter-species emotion perception. We compared eye-tracking data from unrestrained humans and dogs when viewing dynamic and naturalistic emotional expressions in humans and dogs. Dogs attended more to the body than the head of human and dog figures, unlike humans who focused more on the head of both species. Dogs and humans also showed a clear age effect that reduced head gaze. Our results indicate a species-specific evolutionary adaptation for emotion perception, which is only partly modified for heterospecific cues. These results have important implications for managing the risk associated with human-dog interactions, where expressive and perceptual differences are crucial.

Alpelisib plus fulvestrant for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: final overall survival results from SOLAR-1

BACKGROUND

Activation of the phosphatidylinositol-3-kinase (PI3K) pathway via PIK3CA mutations occurs in 28%-46% of hormone receptor-positive (HR+), human epidermal growth factor receptor-2-negative (HER2-) advanced breast cancers (ABCs) and is associated with poor prognosis. The SOLAR-1 trial showed that the addition of alpelisib to fulvestrant treatment provided statistically significant and clinically meaningful progression-free survival (PFS) benefit in PIK3CA-mutated, HR+, HER2- ABC.

PATIENTS AND METHODS

Men and postmenopausal women with HR+, HER2- ABC whose disease progressed on or after aromatase inhibitor (AI) were randomized 1 : 1 to receive alpelisib (300 mg/day) plus fulvestrant (500 mg every 28 days and once on day 15) or placebo plus fulvestrant. Overall survival (OS) in the PIK3CA-mutant cohort was evaluated by Kaplan-Meier methodology and a one-sided stratified log-rank test was carried out with an O'Brien-Fleming efficacy boundary of P ≤ 0.0161.

RESULTS

In the PIK3CA-mutated cohort (n = 341), median OS [95% confidence interval (CI)] was 39.3 months (34.1-44.9) for alpelisib-fulvestrant and 31.4 months (26.8-41.3) for placebo-fulvestrant [hazard ratio (HR) = 0.86 (95% CI, 0.64-1.15; P = 0.15)]. OS results did not cross the prespecified efficacy boundary. Median OS (95% CI) in patients with lung and/or liver metastases was 37.2 months (28.7-43.6) and 22.8 months (19.0-26.8) in the alpelisib-fulvestrant and placebo-fulvestrant arms, respectively [HR = 0.68 (0.46-1.00)]. Median times to chemotherapy (95% CI) for the alpelisib-fulvestrant and placebo-fulvestrant arms were 23.3 months (15.2-28.4) and 14.8 months (10.5-22.6), respectively [HR = 0.72 (0.54-0.95)]. No new safety signals were observed with longer follow-up.

CONCLUSIONS

Although the analysis did not cross the prespecified boundary for statistical significance, there was a 7.9-month numeric improvement in median OS when alpelisib was added to fulvestrant treatment of patients with PIK3CA-mutated, HR+, HER2- ABC. Overall, these results further support the statistically significant prolongation of PFS observed with alpelisib plus fulvestrant in this population, which has a poor prognosis due to a PIK3CA mutation. CLINICALTRIALS.

GOV ID

NCT02437318.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Time course and management of key adverse events during the randomized phase III SOLAR-1 study of PI3K inhibitor alpelisib plus fulvestrant in patients with HR-positive advanced breast cancer

BACKGROUND

Alpelisib (α-selective phosphatidylinositol 3-kinase inhibitor) plus fulvestrant is approved in multiple countries for men and postmenopausal women with PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer following progression on or after endocrine therapy. A detailed understanding of alpelisib's safety profile should inform adverse event (AE) management and enhance patient care.

PATIENTS AND METHODS

AEs in the phase III SOLAR-1 trial were assessed in patients with and without PIK3CA mutations. The impact of protocol-specified AE-management recommendations was evaluated, including an amendment to optimize hyperglycemia and rash management.

RESULTS

Patients were randomly assigned to receive fulvestrant plus alpelisib (n = 284) or placebo (n = 287). The most common grade 3/4 AEs with alpelisib were hyperglycemia (grade 3, 32.7%; grade 4, 3.9%), rash (grade 3, 9.9%), and diarrhea (grade 3, 6.7%). Median time to onset of grade ≥3 toxicity was 15 days (hyperglycemia, based on fasting plasma glucose), 13 days (rash), and 139 days (diarrhea). Metformin alone or in combination with other antidiabetic agents was used by most patients (87.1%) with hyperglycemia. Preventive anti-rash medication resulted in lower incidence (any grade, 26.7% versus 64.1%) and severity of rash (grade 3, 11.6% versus 22.7%) versus no preventative medication. Discontinuations due to grade ≥3 AEs were lower following more-detailed AE management guidelines (7.9% versus 18.1% previously). Patients with PIK3CA mutations had a median alpelisib dose intensity of 248 mg/day. Median progression-free survival with alpelisib was 12.5 and 9.6 months for alpelisib dose intensities of ≥248 mg/day and <248 mg/day, respectively, compared with 5.8 months with placebo.

CONCLUSIONS

Hyperglycemia and rash occurred early during alpelisib treatment, while diarrhea occurred at a later time point. Early identification, prevention, and intervention, including concomitant medications and alpelisib dose modifications, resulted in less severe toxicities. Reductions in treatment discontinuations and improved progression-free survival at higher alpelisib dose intensities support the need for optimal AE management. CLINICALTRIALS.

GOV ID

NCT02437318.

Towards a fuller assessment of the economic benefits of reducing air pollution from fossil fuel combustion: Per-case monetary estimates for children's health outcomes

BACKGROUND

Impacts on children's health are under-represented in benefits assessments of policies related to ambient air quality and climate change. To complement our previous compilation of concentration-response (C-R) functions for a number of children's health outcomes associated with air pollution, we provide per-case monetary estimates of the same health outcomes.

OBJECTIVES

Our goal was to establish per-case monetary estimates for a suite of prevalent children's health outcomes (preterm birth, low birth weight, asthma, autism spectrum disorder, attention-deficit/hyperactivity disorder, and IQ reduction) that can be incorporated into benefits assessments of air pollution regulations and climate change mitigation policies.

METHODS

We conducted a systematic review of the literature published between January 1, 2000 and June 30, 2018 to identify relevant economic costs for these six adverse health outcomes in children. We restricted our literature search to studies published in the U.S., with a supplemental consideration of studies from the U.K. and prioritized literature reviews with summary cost estimates and papers that provided lifetime cost of illness estimates.

RESULTS

Our literature search and evaluation process reviewed 1065 papers and identified 12 most relevant papers on per-case monetary estimates for preterm birth, low birth weight, asthma, autism spectrum disorder, and attention-deficit/hyperactivity disorder. Details are presented in full. We separately identified estimates of the lost lifetime earnings associated with the loss of a single IQ point. The final per-case cost estimates for each outcome were selected based on the most robust evidence. These estimates range from $23,573 for childhood asthma not persisting into adulthood to $3,109,096 for a case of autism with a concurrent intellectual disability.

CONCLUSION

To our knowledge, this is the first time that the child-specific health outcomes of preterm birth, low birth weight, asthma, autism spectrum disorder, attention-deficit/hyperactivity disorder, and IQ reduction have been systematically valued and presented in one place. This is an important addition to the body of health-related valuation literature as these outcomes have substantial economic costs that are not considered in most assessments of the benefits of air pollution and climate mitigation policies. In general, however, the available per-case estimates presented here did not incorporate the broad societal and long-term costs and are likely underestimates. Although our context has been air pollution and climate policies, the per-case monetary estimates presented here can be applied to other environmental exposures. Fuller assessments of health benefits to children and their corresponding economic gains will improve decision-making on environmental policy.

Nanostrain sensitivity in a wire torsion experiment

The feasibility of a thin-wire torsion stress-strain experiment with nanostrain sensitivity is demonstrated. A gauge length of 50 m was made possible by using The Monument, London, thereby restoring it to its original purpose as a scientific instrument. A wire of 150 μm diameter was studied using the load-unload method, and data were recorded in the elastic regime and through the elastic-plastic transition. Analysis of this preliminary experiment suggested some necessary improvements to the equipment and methods. Progress towards definitive experiments is described together with difficulties still to be overcome.

Automated microchannel alignment using innate opto-signature for microchip electrophoresis

In laser-induced fluorescence (LIF) detection, optimal alignment is essential in maximizing the fluorescent signal and, hence, detection sensitivity. Micro-total analysis systems (μTAS) involving microchip electrophoresis (ME) are challenged with alignment of the optics to the separation channel each run due to the single-use nature. Furthermore, μTAS devices that are designed to operate autonomously and by non-experts face additional challenges in performing alignment with micrometer resolution without human intervention. As part of the development of a total DNA analysis system, we set out to develop an automated alignment (AA) method to locate a 50-by-50 μm separation channel on a freely rotating microfluidic device in the absence of a fluorescent dye, accomplished without additional hardware. We detail the innate fluorescent signature attainable from laser excitation and the optimization of the algorithm to achieve AA at 84.6% success rate from 26 microchips. This AA method was a key element in realizing complete automation of the DNA analysis process in order to advance our instrument to a technology readiness level of 7. This is the first description of an AA method for ME (and centrifugal ME) with the purpose of providing transparent technical details to bridge the gap from 'fully integrated' to 'fully automated' instruments for point-of-detection, sample in-answer-out use cases. Written in the context of a forensic application, the AA method is adaptable for a wide range of bioanalytical applications involving LIF detection.

Therapeutic plasma exchange in neurological disorders: Experience from a tertiary neuroscience centre

Therapeutic plasma exchange (TPE) involves the extracorporeal separation of plasma from the cellular components of blood with replacement fluid, such as human albumin or fresh frozen plasma. A number of studies across the world revealed that more than one third of TPE procedures were performed for neurological disorders. Myasthenia gravis (MG), Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP) were the most frequently cited indications for TPE, followed by multiple sclerosis (MS). However, treatments of these conditions have evolved over the years and it is likely that this has impacted on clinical practice. Here we present our experience of using TPE to treat neurological disorders. We reviewed the medical records of all 63 patients who received 349 procedures over 70 therapeutic cycles between 2012 and 2015 in a tertiary neurology centre. In total only 2 patients with GBS and MG were treated with TPE. The commonest indication was voltage gated potassium channel (VGKC) complex antibody associated disorders followed by CIDP and MS. There were 11 patients with limbic encephalitis. Nine of them had antibodies against VGKC complex and two had N-methyl-D-aspartate (NMDA) receptor antibodies. Sixty four percent of patients with limbic encephalitis and overall 78% of patients responded to TPE. The complication rate associated with this procedure was 8.6 per 100 therapeutic cycle. There was no treatment related mortality. We observed a change in indications of TPE compared to historical studies. It was less frequently used to treated GBS and MG. It was found to be safe and effective.

Towards a fuller assessment of benefits to children's health of reducing air pollution and mitigating climate change due to fossil fuel combustion

BACKGROUND

Fossil fuel combustion by-products, including particulate matter (PM_2.5), polycyclic aromatic hydrocarbons (PAH), nitrogen dioxide (NO₂) and carbon dioxide (CO₂), are a significant threat to children's health and equality. Various policies to reduce emissions have been implemented to reduce air pollution and mitigate climate change, with sizeable estimated health and economic benefits. However, only a few adverse outcomes in children have been considered, resulting in an undercounting of the benefits to this vulnerable population.

OBJECTIVES

Our goal was to expand the suite of child health outcomes addressed by programs to assess health and economic benefits, such as the Environmental Protection Agency (EPA) Benefits Mapping and Analysis Program (BenMAP), by identifying concentration-response (C-R) functions for six outcomes related to PM_2.5, NO₂, PAH, and/or PM₁₀: preterm birth (PTB), low birthweight (LBW), autism, attention deficit hyperactivity disorder, IQ reduction, and the development of childhood asthma.

METHODS

We conducted a systematic review of the literature published between January 1, 2000 and April 30, 2018 to identify relevant peer-reviewed case-control and cohort studies and meta-analyses. In some cases meta-analyses were available that provided reliable C-R functions and we assessed their consistency with subsequent studies. Otherwise, we reviewed all eligible studies published between our search dates.

RESULTS

For each pollutant and health outcome, we present the characteristics of each selected study. We distinguish between C-R functions for endpoints having a causal or likely relationship (PTB, LBW, autism, asthma development) with the pollutants for incorporation into primary analyses and endpoints having a suggestive causal relationship with the pollutants (IQ reduction, ADHD) for secondary analyses.

CONCLUSION

We have identified C-R functions for a number of adverse health outcomes in children associated with air pollutants largely from fossil fuel combustion. Their incorporation into expanded assessments of health benefits of clean air and climate mitigation policies will provide an important incentive for preventive action.

Projecting Changes in Expected Annual Damages From Riverine Flooding in the United States

Inland flood risk in the United States is most often conveyed through maps of 1% annual exceedance probability (AEP) or "100-year" floodplains. However, monetary damages from flooding arise from a full distribution of events, including floods both larger and smaller than the 1% AEP event. Furthermore, floodplains are not static, since both the frequency and magnitude of flooding are likely to change in a warming climate. We explored the implications of a changing frequency and magnitude of flooding across a wide spectrum of flood events, using a sample of 376 watersheds in the United States where floodplains from multiple recurrence intervals have been mapped. Using an inventory of assets within these mapped floodplains, we first calculated expected annual damages (EADs) from flooding in each watershed under baseline climate conditions. We find that the EAD is typically a factor of 5-7 higher than the expected damages from 100-year events alone and that much of these damages are attributable to floods smaller than the 1% AEP event. The EAD from flooding typically increases by 25-50% under a 1 °C warming scenario and in most regions more than double under a 3 °C warming scenario. Further increases in EAD are not as pronounced beyond 3 °C warming, suggesting that most of the projected increases in flood damages will have already occurred, for most regions of the country, by that time. Adaptations that protect against today's 100-year flood will have increasing benefits in a warmer climate by also protecting against more frequent, smaller events.

Steroidal pheromones and their potential target sites in the vomeronasal organ

Steroids are important olfactory signals in most mammalian species. The vomeronasal organ has been suspected to be the primary target of pheromones. In rat vomeronasal sensory neurons express steroid binding proteins and nuclear receptors. Some binding globulins were found also in single ciliated cells of the non-sensory vomeronasal epithelium. Immunoelectron microscopy revealed VDR in olfactory microvilli and DPB in apical membrane protrusions of supporting sells within the sensory epithelium. Pilot behavioral studies with dogs showed increased sniffing duration upon exposure to low concentrations of vitamin D while higher concentrations were less effective. It has been shown that vitamin D has pheromone-like properties in lizards. Our histochemical and behavioral observations indicate that the mammalian vomeronasal organ may be a vitamin D target. Olfactory functions of vitamin D involve most likely rapid membrane mediated effects rather than actions through nuclear receptors.

Comparison of the Efficacy of Different Fluoride Varnishes on Dentin Remineralization During a Critical pH Exposure Using Quantitative X-Ray Microtomography

OBJECTIVES:

The objective of this in vitro study was to quantify the amount of mineral change in demineralized dentin at pH 5.5 after the application of dental varnishes containing fluoride with casein phosphopeptide-amorphous calcium phosphate, fluoride and bioglass, or fluoride alone.

METHODS AND MATERIALS:

A total of 12 extracted human sound mandibular premolar root samples were coated with an acid-resistant varnish, leaving a 2 × 3 mm window at the outer root surface. These root specimens were then randomly divided into four groups and separately subjected to the demineralizing cycle at a pH of 4.8 for five days to create artificial caries-like lesions in dentin. Subsequently, each sample was imaged using quantitative x-ray microtomography (XMT) at a 15-μm voxel size. Each test group then received one of the following treatments: dental varnish containing casein phosphopeptide-amorphous calcium phosphate and fluoride (CPP-ACP, MI varnish, GC Europe), bioglass and fluoride (BGA, Experimental, Dentsply Sirona), or fluoride alone (NUPRO, Dentsply Sirona), as well as a control group, which received no treatment. These samples were kept in deionized water for 12 hours. The thin layer of varnish was then removed. All samples including the nonvarnish group were subjected to the second demineralizing cycle at pH 5.5 for five days. The final XMT imaging was then carried out following the second demineralizing cycle. XMT scan was also carried out to varnish samples at 25 μm voxel size. The change in mineral concentration in the demineralized teeth was assessed using both qualitative and quantitative image analysis.

RESULTS:

There was an increase in radiopacity in the subtracted images of all varnish groups; a significant increase in mineral content, 12% for the CPP-ACP and fluoride ( p≤0.05 and p≤0.001), 25% BGA ( p≤0.001), and 104% fluoride alone varnish ( p≤0.001). There was an increase in the size of radiolucency in the lesion area with a significant decrease in mineral content in the nonvarnish group, 10% ( p≤0.05 and p≤0.001).

CONCLUSIONS:

There was encouraging evidence of a remineralization effect following the application of dental varnish on dentin and also an observed resistance to demineralization during the acidic challenge in all cases. However, a dental varnish containing fluoride alone appeared to have a much greater effect on dentin remineralization when compared with CPP-ACP with fluoride and bioglass with fluoride.

THUR 153 Antibodies against the voltage-gated potassium channel complex

Voltage-gated potassium channel (VGKC) complex antibodies have been associated with a spectrum of presentations including peripheral nerve hyperexcitability (PNH), Morvan’s syndrome, autoimmune encephalopathy, epilepsy and recently psychosis.

We retrospectively reviewed the medical records of 70 patients from the Greater Manchester Neuroscience Centre, who had tested positive for VGKC-complex antibodies between 2012 and 2015 to identify the clinical relevance of positive results.

The majority were diagnosed with autoimmune encephalopathy(19) followed by epilepsy(14), psychosis(10) and PNH(6). The remaining fifteen had other neurological presentations and six had no primary neurological disorder. 39/70 patients who had antibody titres>400 pM, were diagnosed with autoimmune encephalopathy(19), epilepsy(9), psychosis(4), PNH(3) and other disorders(4). 24/39 patients, who received treatment with one or a combination of corticosteroids, intravenous immunoglobulins, cyclophosphamide, plasma exchange, azathioprine or rituximab, had a diagnosis of autoimmune encephalopathy(18), epilepsy(2), psychosis(2) and malignancy(2). 16/24 were treatment responsive. 3/31 patients with lower titres were also treated, but only one with the classic phenotype (PNH) responded to treatment.

The classic phenotype often had a titre >400 pM. PNH may have a titre ≤400 pM. The patients without classic presentations typically had titres≤400 pM. Consistent with previous studies, clinical phenotyping and antibody titre helped to determine the relevance of VGKC-complex antibodies.

A Sperm Spawn-Inducing Pheromone in the Silver Lip Pearl Oyster (Pinctada maxima)

Pheromones are considered to play an important role in broadcast spawning in aquatic animals, facilitating synchronous release of gametes. In oysters, the sperm has been implicated as a carrier for the spawn-inducing pheromone (SIP). In hatchery conditions, male pearl oysters (Pinctata maxima) can be stimulated to spawn through a variety of approaches (e.g. rapid temperature change), while females can only be induced to spawn through exposure to conspecific sperm, thus limiting development of targeted pairing, required for genetic research and management. The capacity for commercial production and improvement of genetic lines of pearl oysters could be greatly improved with access to a SIP. In this study, we prepared and sequenced crude and semi-purified P. maxima sperm extracts that were used in bioassays to localise the female SIP. We report that the P. maxima SIP is proteinaceous and extrinsically associated with the sperm membrane. Bioactivity from pooled RP-HPLC fractions, but not individual fractions, suggests that the SIP is multi-component. We conclude that crude sperm preparations, as described in this study, can be used as a sperm-free inducer of female P. maxima spawning, which enables for a more efficient approach to genetic breeding.

Emergency Department Visits and Ambient Temperature: Evaluating the Connection and Projecting Future Outcomes

The U.S. Global Climate Change Research Program has identified climate change as a growing public health threat. We investigated the potential effects of changes in ambient daily maximum temperature on hyperthermia and cardiovascular emergency department (ED) visits using records for patients age 64 and younger from a private insurance database for the May-September period for 2005-2012. We found a strong positive relationship between daily maximum temperatures and ED visits for hyperthermia but not for cardiovascular conditions. Using the fitted relationship from 136 metropolitan areas, we calculated the number and rate of hyperthermia ED visits for climates representative of year 1995 (baseline period), as well as years 2050 and 2090 (future periods), for two climate change scenarios based on outcomes from five global climate models. Without considering potential adaptation or population growth and movement, we calculate that climate change alone will result in an additional 21,000-28,000 hyperthermia ED visits for May to September, with associated treatment costs between $6 million and $52 million (2015 U.S. dollars) by 2050; this increases to approximately 28,000-65,000 additional hyperthermia ED visits with treatment costs between $9 million and $118 million (2015 U.S. dollars) by 2090. The range in projected additional hyperthermia visits reflects the difference between alternative climate scenarios, and the additional range in valuation reflects different assumptions about per-case valuation.

Sociability modifies dogs' sensitivity to biological motion of different social relevance

Preferential attention to living creatures is believed to be an intrinsic capacity of the visual system of several species, with perception of biological motion often studied and, in humans, it correlates with social cognitive performance. Although domestic dogs are exceptionally attentive to human social cues, it is unknown whether their sociability is associated with sensitivity to conspecific and heterospecific biological motion cues of different social relevance. We recorded video clips of point-light displays depicting a human or dog walking in either frontal or lateral view. In a preferential looking paradigm, dogs spontaneously viewed 16 paired point-light displays showing combinations of normal/inverted (control condition), human/dog and frontal/lateral views. Overall, dogs looked significantly longer at frontal human point-light display versus the inverted control, probably due to its clearer social/biological relevance. Dogs' sociability, assessed through owner-completed questionnaires, further revealed that low-sociability dogs preferred the lateral point-light display view, whereas high-sociability dogs preferred the frontal view. Clearly, dogs can recognize biological motion, but their preference is influenced by their sociability and the stimulus salience, implying biological motion perception may reflect aspects of dogs' social cognition.

Dogs and humans respond to emotionally competent stimuli by producing different facial actions

The commonality of facial expressions of emotion has been studied in different species since Darwin, with most of the research focusing on closely related primate species. However, it is unclear to what extent there exists common facial expression in species more phylogenetically distant, but sharing a need for common interspecific emotional understanding. Here we used the objective, anatomically-based tools, FACS and DogFACS (Facial Action Coding Systems), to quantify and compare human and domestic dog facial expressions in response to emotionally-competent stimuli associated with different categories of emotional arousal. We sought to answer two questions: Firstly, do dogs display specific discriminatory facial movements in response to different categories of emotional stimuli? Secondly, do dogs display similar facial movements to humans when reacting in emotionally comparable contexts? We found that dogs displayed distinctive facial actions depending on the category of stimuli. However, dogs produced different facial movements to humans in comparable states of emotional arousal. These results refute the commonality of emotional expression across mammals, since dogs do not display human-like facial expressions. Given the unique interspecific relationship between dogs and humans, two highly social but evolutionarily distant species sharing a common environment, these findings give new insight into the origin of emotion expression.

Abstract OT2-01-04: SOLAR-1: A phase III study of alpelisib and fulvestrant in men and postmenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (BC) progressing on or after aromatase inhibitor (AI) therapy

Background: The phosphatidylinositol 3-kinase (PI3K)/mammalian target of rapamycin (mTOR) pathway is often dysregulated in HR+ BC and is associated with resistance to endocrine therapy (ET). Alpelisib (BYL719; PI3Kα-specific inhibitor) and fulvestrant showed signs of antitumor activity in patients (pts) with estrogen receptor-positive (ER+), HER2– advanced BC (phase I), especially in PIK3CA-altered tumors (Janku et al. SABCS 2014, PD5-5).

Methods: SOLAR-1 (NCT02437318) is a phase III, randomized, double-blind study in men and postmenopausal women with HR+, HER2– advanced BC. Pts are assigned to 1 of 2 cohorts based on PIK3CA tumor status (mutant vs non-mutant), and randomized 1:1 to oral alpelisib/placebo (300 mg once daily) and intramuscular fulvestrant (500 mg on Day 1 and 15 of Cycle 1; Day 1 of Cycles ≥2 [28-day cycles]) until disease progression or discontinuation. Randomization is stratified by presence of liver and/or lung metastases and prior CDK4/6 inhibitor therapy. Key inclusion criteria: recurrence or progression on or after AI therapy, ≥1 measurable lesion (RECIST v1.1) or predominantly lytic bone lesion, and ECOG performance status ≤1. Key exclusion criteria: symptomatic visceral disease or disease burden precluding ET, acute pancreatitis ≤1 year prior to screening or history of chronic pancreatitis, and prior therapy with fulvestrant, chemotherapy (except [neo]adjuvant), or PI3K/AKT/mTOR inhibitors.

The primary and key secondary endpoints are progression-free survival (PFS; RECIST v1.1; local assessment) and overall survival (OS), respectively, in the PIK3CA-mutant cohort. Other secondary endpoints include PFS and OS in the PIK3CA non-mutant cohort, PFS (Blinded Independent Central Review; RECIST v1.1), the association between PFS and baseline PIK3CA status in circulating tumor DNA, overall response rate, clinical benefit rate, safety, and pharmacokinetics. The primary endpoint will be analyzed by a stratified log-rank test at one-sided 2% level of significance.

Recruitment of the planned 560 pts is ongoing.

Citation Format: Andre F, Kaufman B, Juric D, Ciruelos EM, Iwata H, Mayer IA, Rugo HS, Conte P, Liobl S, Rubovszky G, Inoue K, Tesch H, Lu Y-S, Ryvo L, Longin A-S, Mills D, Wilke C, Germa C, Campone M. SOLAR-1: A phase III study of alpelisib and fulvestrant in men and postmenopausal women with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2–) advanced breast cancer (BC) progressing on or after aromatase inhibitor (AI) therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-01-04.

Dogs recognize dog and human emotions

The perception of emotional expressions allows animals to evaluate the social intentions and motivations of each other. This usually takes place within species; however, in the case of domestic dogs, it might be advantageous to recognize the emotions of humans as well as other dogs. In this sense, the combination of visual and auditory cues to categorize others' emotions facilitates the information processing and indicates high-level cognitive representations. Using a cross-modal preferential looking paradigm, we presented dogs with either human or dog faces with different emotional valences (happy/playful versus angry/aggressive) paired with a single vocalization from the same individual with either a positive or negative valence or Brownian noise. Dogs looked significantly longer at the face whose expression was congruent to the valence of vocalization, for both conspecifics and heterospecifics, an ability previously known only in humans. These results demonstrate that dogs can extract and integrate bimodal sensory emotional information, and discriminate between positive and negative emotions from both humans and dogs.

Differences in Trait Impulsivity Indicate Diversification of Dog Breeds into Working and Show Lines

Impulsiveness describes the inability to inhibit behaviour in the presence of salient cues. Trait-level impulsivity exists on a continuum and individual differences can be adaptive in different contexts. While breed related differences in behavioural tendency in the domestic dog (Canis familiaris) are well established, the phenomenon within lines of a breed which have been selected more recently is not well studied, although it may challenge the popular notion of breed-typical behaviour. We describe differences in impulsivity between and within two dog breeds with working and show lines selected for different levels of impulsivity: Border Collies (herding work) and Labrador Retrievers (gun work). Recent show line selection might have lessened differences in impulsivity between breeds. We tested this hypothesis on a dataset of 1161 individuals assessed using a validated psychometric tool (Dog Impulsivity Assessment Scale - DIAS). Collies were more impulsive on average, consistent with the original purpose of breed selection. Regarding line, working Collies differed from working Labradors, but show lines from the two breeds were not significantly different. Altered or relaxed artificial selection for behavioural traits when appearance rather than behaviour become the primary focus for breeders may reduce average differences in impulsivity between breeds in show lines.