A clinico-radiological review of chronic non-bacterial osteomyelitis in paediatrics, adolescents, and adults: demystifying a forgotten differential

Chronic non-bacterial osteomyelitis (CNO), also known as non-bacterial osteitis, is a chronic autoinflammatory disease of unknown aetiology that primarily occurs in the paediatric population, although rare cases of adult-onset disease also exist. CNO has non-specific clinical and radiological presentations, and the affected population often present with bone pain of insidious onset secondary to sterile bony inflammation that can be associated with swelling, focal tenderness, and warmth at the affected sites. The pattern of bony involvement appears to be dependent on the age of onset, with adults frequently having axial skeletal lesions and children and adolescents often being affected in the appendicular skeletal sites. CNO is a diagnosis of exclusion, and imaging is heavily relied on to identify and characterise the bony lesions in addition to exclude diseases that can mimic CNO. Magnetic resonance imaging is often the reference standard with biochemical and histopathological findings being complementary. Although combining imaging methods can be used to facilitate the diagnosis, a single technique could be adequate depending on the clinical picture. Given the relatively rare incidence of CNO, limited awareness of the disease among care providers, and its similarity in clinical and radiological presentation to various bony diseases, there are often long delays in diagnosis, with adults being unfavourably affected compared to paediatrics and adolescents. This review of CNO will describe the condition, overview its clinical presentation, highlight the radiological features, and emphasise clinical pearls that can aid in diagnosis and ruling out the mimics.

Nutritional care pathways in cancer patients with malignant bowel obstruction: A retrospective multi-centre study

INTRODUCTION

Variation in access to parenteral nutrition (PN) in patients with intestinal failure secondary to malignant bowel obstruction (MBO) exists due to differing practice, beliefs and resource access. We aimed to examine differences in nutritional care pathways and outcomes, by referral to nutrition team for PN in patients with MBO.

METHODS

This is a retrospective cohort study of MBO adults admitted to eight UK hospitals within a year and 1 year follow-up. Demographic, nutritional and medical data were analysed by comparing patients referred (R) or not referred (NR) for PN. Differences between groups were tested by Kruskal-Wallis, Chi-Squared tests and multi-level regression and survival using Cox regression.

RESULTS

232 patients with 347 MBO admissions [median 66yr, (IQR: 55-74yrs), 67 % female], 79/232 patients were referred for PN (R group). Underlying primary malignancies of gynaecological and gastrointestinal origin predominated (71 %) and 78 % with metastases. Those in the NR group were found to be older, weigh more on admission, and more likely to be treated conservatively compared to those in the R group. For 123 (35 %) admissions, patients were referred to a nutrition team, and for 204 (59 %) admissions, patients were reviewed by a dietician. Multi-disciplinary team discussion and dietetic contact were more likely to occur in the R group-123/347 admissions (R vs NR group: 27 % vs. 7 %, P = 0.001; 95 % vs 39 %, P < 0.0001). Median admission weight loss was 8 % (IQR: 0 to 14). 43/123 R group admissions received inpatient PN only, with 32 patients discharged or already established on home parenteral nutrition. Overall survival was 150 days (126-232) with no difference between R/NR groups.

CONCLUSION

In this multi-centre study evaluating nutritional care management of patients with malignant bowel obstruction, only 1 in 3 admissions resulted in a referral to the nutrition team for PN, and just over half were reviewed by a dietician. Further prospective research is required to evaluate possible consequences of these differential care pathways on clinical outcomes and quality of life.

The effect of subscapularis-specific rehabilitation following total shoulder arthroplasty: a prospective, double-blinded, randomized controlled trial

BACKGROUND

Patients undergoing a total shoulder arthroplasty (TSA) through a deltopectoral approach will require repair of the subscapularis tendon. There are no universal postoperative guidelines for rehabilitation of the subscapularis specifically. We hypothesize that the addition of a subscapularis-specific regimen will result in improved subscapularis strength and function.

METHODS

Adult patients undergoing anatomic TSA for the treatment of primary glenohumeral osteoarthritis were included. Patients were randomized into either the traditional rehabilitation (TR) control group or the subscapularis rehabilitation (SR) group, which consisted of the traditional therapy along with early and additional subscapularis exercises. Baseline demographics, patient-reported outcome measures (PROMs), range of motion (ROM), provocative tests, and subscapularis strength using a handheld dynamometer were measured preoperatively at the initial clinic visit (ICV) as well as 3 months, 6 months, and 1 year postoperatively. The primary outcome of interest was a comparison of subscapularis strength between cohorts relative to preoperative baseline, whereas secondary outcomes were functional, ROM, and PROMs.

RESULTS

Sixty-six patients were included in the final analysis (32 TR vs. 34 SR). There were no statistically significant differences between cohorts at the ICV with regard to demographics, baseline subscapularis strength, functional testing, or PROMs. All postoperative time points demonstrated similar subscapularis strength testing between TR and SR groups (P > .05). Additionally, peak and average subscapularis strength testing at 3, 6, and 12 months postoperatively were similar to baseline ICV testing in both groups. Both groups demonstrated improvements across several provocative tests, ROM, and PROM outcome metrics at every postoperative time point as compared to baseline ICV values (P < .05).

CONCLUSIONS

Patients undergoing anatomic TSA return to baseline internal rotation strength by 3 months postoperatively and demonstrate significant improvements in function, ROM, and several patient-reported outcome measures. The addition of early and focused subscapularis strengthening exercises does not appear to significantly impact any outcomes when compared to traditional rehabilitation programs.

Use of rituximab in SARS-CoV-2-positive renal transplant recipient with EBV reactivation and probable haemophagocytic lymphohistiocytosis

We present a case of a rapid clinical recovery in a critically ill kidney transplant recipient with SARS-CoV-2 positivity, Epstein-Barr virus (EBV) reactivation and probable secondary hemophagocytic lymphohistiocytosis (HLH) treated with etoposide-free regimen, based on dexamethasone and a single dose of rituximab. Although rituximab is often a part of EBV-HLH treatment strategy, its use in simultaneous Coronavirus 2019 disease (COVID-19) and solid-organ transplantation has not been reported yet. We review the current evidence for the potential of SARS-CoV-2 to trigger EBV reactivation, leading to a severe clinical illness. Finally, we compare the clinical features of hyper-inflammatory response typical for severe COVID-19 and classical secondary HLH and discuss the benefits of therapeutic B-cell depletion in both conditions.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Attenuation of Human Growth Hormone-Induced Rash With Graded Dose Challenge

Adult growth hormone (GH) deficiency is rare and requires replacement with extrinsic/synthetic injection. GH hypersensitivity has been reported; specifically, atopic patients may develop rashes from somatotropin therapy. Allergic and non-allergic skin reactions to recombinant human GH are uncommon and infrequently reported. We describe a graded-dose challenge with intravenous Norditropin® in a 65-year-old atopic adult woman who developed a severe whole-body rash with Norditropin FlexPro® administration on several occasions but was negative on skin-prick testing to Norditropin® percutaneously and intradermally, but the patch testing was positive for gold and nickel.

The patient was registered as a direct admission to the emergency room at a university hospital for a rapid antigen coronavirus disease 2019 (COVID-19) testing after having received two COVID-19 vaccinations and re-testing four months after vaccination. She was then directly admitted to a non-COVID-19 intensive care unit with direct bedside supervision by a registered nurse and a physician board certified in internal medicine, allergy/immunology, and pulmonary diseases. The patient brought a Norditropin® pen which our pharmacy team attached to a compatible syringe for dilutions. A graded dose challenge at a final dosage of 0.1 mL was performed and the patient was monitored for allergic and other adverse drug reactions, which did not occur. At the time of writing this case report, the patient has been maintained on Norditropin FlexPro® 0.1 mL and has not experienced any adverse reactions, including recurrent skin eruptions.

The case presented is the first to describe a patient who successfully tolerated a graded dose challenge of an adult patient to GH replacement therapy (as Norditropin®) under supervision in an intensive care unit, whereas prior to reporting of this case, a graded dose challenge to GH replacement therapy had only been successfully performed in a child using another formulation of somatotropin (Humatrope®). Hence, this case lends support that graded dose challenge with somatotropin analogs may be considered for patients with isolated GH deficiency such as in the case presented here.

A systematic review and meta-analysis of the role of doxycycline in chronic rhinosinusitis

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the role of doxycycline in the management of chronic rhinosinusitis.

METHOD

This was a systematic review using Ovid Medline, Cinahl, Scopus and Cochrane and was limited to meta-analyses, systematic reviews and randomised, clinical trials. A combination of the following search terms was used: 'sinusitis', 'nasal polyps', 'doxycycline' and 'tetracycline'. Raw means and standard deviations were extracted from the included studies. The meta-analysis was performed using mean differences of pre- versus post-doxycycline treatment.

RESULTS

A total of 279 studies were screened, of which 5 studies met the criteria (all randomised, controlled trials published between 2010 and 2021). The interventions, endpoints and measured outcomes varied across all studies. Meta-analysis performed on pre- versus post-doxycycline treatment for Sino-Nasal Outcome Test-22, nasal polyp scores and symptom scores did not yield statistically significant results.

CONCLUSION

This review identified a small number of high-quality studies on the use of doxycycline in chronic rhinosinusitis. There does not seem to be convincing evidence for the routine use of doxycycline in patients with chronic rhinosinusitis. Further research may try to identify certain phenotypes of chronic rhinosinusitis that may better respond to doxycycline.

Treating acutely ill patients at home: Data from Singapore

INTRODUCTION

Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes.

METHODS

We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge.

RESULTS

A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again.

CONCLUSION

Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.

Imaging the acute abdomen in pregnancy: a radiological decision-making tool and the role of MRI

Acute abdominal pain in pregnancy poses a significant diagnostic challenge. The differential diagnosis is wide, clinical assessment is difficult, and the use of conventional imaging methods is restricted due to risks to the fetus. This can lead to delay in diagnosis, which increases the risk of maternal and fetal harm. Imaging techniques not involving ionising radiation are preferred. Sonography remains first line, but anatomical visualisation can be limited due to displacement of adjacent structures by the gravid uterus. MRI provides excellent cross-sectional soft-tissue assessment of the abdomen and pelvis, and no study to date has demonstrated significant deleterious effects to the fetus at any gestation; however, there remains a theoretical risk of tissue heating by radiofrequency pulses, and there must be consideration of benefit versus potential risk for any use of magnetic resonance imaging (MRI) in pregnancy. With a limited protocol of sequences, a broad spectrum of pathologies can be evaluated. Computed tomography carries the highest exposure of ionising radiation to the fetus, but may be necessary, particularly in cases of trauma. The patient must be kept informed and any potential risks to the patient and fetus should be clearly explained. We present a radiological decision-making tool to guide choice of imaging and best establish the underlying diagnosis in the acute pregnant abdomen. In addition, using illustrative examples from our practice at a large tertiary centre, we review the advantages and disadvantages of each imaging method, with particular focus on the utility of MRI.

AB0887 Designing a Phase 3b, Multicenter, Randomized, Double-blind, Placebo-controlled Study to Investigate the Effect of Guselkumab Dosing Interval in Psoriatic Arthritis Patients with Inadequate Response to Tumor Necrosis Factor Inhibition

Background

Tumor necrosis factor inhibitors (TNFi) are frequently chosen as the first biologic therapy for patients (pts) with psoriatic arthritis (PsA), though a sizeable proportion of pts have an inadequate response (IR), and some may also have intolerance. Guselkumab (GUS), a human mAb that targets the IL-23 p19 subunit, provides an alternative mechanism of action to treat PsA. In the Phase 3 (Ph3) DISCOVER-1 study of GUS in active PsA, GUS every 4 weeks (Q4W) and Q8W clinical response rates were generally consistent between TNFi-naïve (263 pts) and TNFi-experienced (118 pts) cohorts. In the TNFi-experienced cohort and the limited number of DISCOVER-1 pts with IR to their prior TNFi (N=44), American College of Rheumatology 50% improvement (ACR50) and ACR70 response rates at W24 were numerically higher in GUS Q4W- than Q8W-treated pts.1

Objectives

To further investigate whether GUS Q4W could provide incremental benefit to some TNFi-IR PsA pts by analyzing the existing DISCOVER-1 dataset to facilitate the design of a new clinical trial.

Methods

Study feasibility assessments included comparison of key efficacy endpoints by treatment group at W24 among TNFi-experienced pts receiving GUS Q8W and Q4W in DISCOVER-1. Results from the DISCOVER-1 study also informed sample size power calculations for a primary endpoint of ACR20 response at W24 in a future study in a TNFi-IR PsA pt population.

Results

Comparison of several efficacy endpoints (ACR70 response, minimal disease activity, Investigator’s Global Assessment [IGA] of psoriasis 0/1 response) across treatment groups in the TNFi-experienced DISCOVER-1 cohort supports a potential dose response, with more frequent GUS administration eliciting numerically higher response rates (Table 1). A similar trend was observed for ACR20/50/70 responses in the smaller TNFi-IR population1, though these findings should be interpreted with caution due to limited sample size. ACR20 response rates at W24 of DISCOVER-1 were employed to estimate sample size requirements for a new study. Assuming comparable rates of GUS treatment effect seen in DISCOVER-1, a sample size of 150 randomized pts per group for PBO, GUS Q8W, and GUS Q4W would provide >90% power to detect a significant difference between each GUS group and PBO for ACR20 response at W24. Based on these findings, a new Ph3b, multicenter, randomized, double-blind, PBO-controlled study, SOLSTICE, was designed to further evaluate the efficacy and safety of GUS in approximately 450 pts with active PsA who had IR to one prior TNFi, and to investigate the effect of GUS dosing interval in this important cohort of pts with PsA (Figure 1).

Table 1.

Clinical efficacy at W24 among DISCOVER-1 TNFi-experienced pts

PlaceboGUS Q8WGUS Q4WACR2017.9% (7/39)56.1% (23/41)57.9% (22/38)ACR505.1% (2/39)26.8% (11/41)34.2% (13/38)ACR702.6% (1/39)2.4% (1/41)21.1% (8/38)MDA2.6% (1/39)17.1% (7/41)26.3% (10/38)IGA 0/1a7.7% (2/26)48.3% (14/29)67.9% (19/28)

aIGA score of 0 (clear) or 1 (almost clear) among pts with ≥3% body surface area of psoriatic involvement and an IGA score ≥2 (mild-to-severe psoriasis) at baseline.

ACR20/50/70, American College of Rheumatology 20%/50%/70% improvement; GUS, guselkumab; IGA, Investigator’s Global Assessment; MDA, minimal disease activity; Q4W, every 4 weeks; Q8W, every 8 weeks; TNFi, tumor necrosis factor inhibitor; W, week

Conclusion

PsA pts with TNFi-IR are typically difficult to treat. Overall data from the pivotal DISCOVER-1 study of GUS in pts with active PsA showed consistent clinical response between doses and between TNFi-naïve and TNFi-experienced pts. Analyses based on limited numbers of TNFi-experienced pts from DISCOVER-1 demonstrated potential incremental benefit for achievement of higher response criteria with more frequent dosing in some TNFi-IR pts. SOLSTICE, a Ph3b, randomized, placebo-controlled study, will test this hypothesis.

References

[1]Deodhar A, et al. Lancet. 2020;395:1115-1125.

Figure 1.

Disclosure of Interests

Alexis Ogdie Shareholder of: Her husband has received royalties from Novartis, Consultant of: AbbVie, Amgen, BMS, Celgene, Corrona, Gilead, Global Health Living Foundation, Janssen, Eli Lilly, Novartis, Pfizer, and UCB Pharma, Grant/research support from: Abbvie, Pfizer and Novartis/Amgen to the University of Pennsylvania, Joseph F. Merola Paid instructor for: AbbVie, Arena, Biogen, Bristol Myers Squibb, Dermavant, Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Arena, Biogen, Bristol Myers Squibb, Dermavant, Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Christopher T. Ritchlin Consultant of: UCB Pharma, Amgen, AbbVie, Lilly, Pfizer, Novartis, Gilead, and Janssen, Grant/research support from: UCB Pharma, AbbVie, and Amgen, Jose U. Scher Consultant of: Janssen, Novartis, Pfizer, Abbvie, Sanofi, Kaleido and UCB Pharma, Grant/research support from: Novartis, Pfizer and Janssen (for investigator-initiated studies), Daphne Chan Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Soumya D Chakravarty Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Wayne Langholff Employee of: Janssen Research & Development, LLC, and may own stock or stock options in Johnson & Johnson, Olivia Choi Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Yevgeniy Krol Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Katelyn Rowland Employee of: Janssen Scientific Affairs, LLC, and may own stock or stock options in Johnson & Johnson, Alice B Gottlieb Consultant of: AnaptsysBio, Avotres Therapeutics, Beiersdorf, Boehringer Ingelheim, Bristol-Myers Squibb Co., Incyte, GSK, Janssen, LEO Pharma, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical Industries, Inc., UCB Pharma, Dermavant, and Xbiotech, Grant/research support from: Boehringer Ingelheim, Incyte, Janssen, Novartis, UCB Pharma, Xbiotech, and Sun Pharma

AB0893 An Analysis of Fatigue in Patients With Psoriatic Disease Utilizing SF-36 Vitality Scores: Results Through Week 24 in Phase 3 Trials of Guselkumab in Patients With Psoriasis and Psoriatic Arthritis

Background

Patients with chronic inflammatory diseases can experience significant fatigue, negatively impacting health-related quality-of-life.1,2

Objectives

This post-hoc analysis evaluated baseline fatigue severity among patients with psoriasis and/or psoriatic arthritis (PsA) and the effect of guselkumab treatment on patient-reported fatigue.

Methods

VOYAGE-2 evaluated guselkumab every 8 weeks (Q8W) versus placebo (W16→guselkumab) and adalimumab in treating moderate-to-severe psoriasis.3 DISCOVER-14 and DISCOVER-25 evaluated guselkumab Q4W and Q8W versus placebo in treating active PsA. Fatigue was assessed using 36-item Short Form (SF-36) vitality scale score (includes 4 questions on fatigue/energy level); the US population norm=50±10; 5-10-point decrements are typically observed in conditions known to cause fatigue2; scores ≤35 indicate clinically important fatigue1; increases ≥5 indicate clinically meaningful improvement.2

Results

Across randomized groups at baseline, mean SF-36 vitality scores were 47.7-48.5 in psoriasis and 42.2-44.0 in PsA patients; 11%-15% of psoriasis and 20%-28% of PsA patients had scores <35. In psoriasis patients, mean increases in SF-36 vitality score at W16 were: placebo, 1.1; adalimumab, 3.9 (p<0.001 versus placebo); guselkumab, 5.6 (p<0.001 versus placebo); at W24: placebo→guselkumab, 4.6; adalimumab, 3.9; guselkumab, 5.8 (p=0.0148 versus adalimumab). In PsA patients, mean increases at W24 were: placebo, 2.3-4.0; guselkumab, 5.5-7.5 (p≤0.001 versus placebo). Through the placebo-controlled periods, significantly greater proportions of guselkumab-treated patients achieved clinically meaningful improvement in fatigue versus placebo (W16 psoriasis: guselkumab, 48%; placebo, 32%; p<0.001; W24 PsA: guselkumab, 53%-55%; placebo, 34%-44%; p<0.05).

Conclusion

At baseline, patients with psoriatic disease experienced clinically important fatigue, more so with PsA (20%-28%) than psoriasis (11%-15%). In guselkumab-treated psoriasis and PsA patients, clinically meaningful improvements in fatigue were achieved at W16 and W24, respectively.

References

[1]Skoie IM et al. Br J Dermatol. 2017;177:505-12

[2]Bjorner JB et al. Curr Med Res Opin. 2007;23:731-9

[3]Reich K et al. J Am Acad Dermatol. 2017;76:418-31

[4]Deodhar A et al. Lancet. 2020;395:1115-25

[5]Mease PJ et al. Lancet. 2020;395:1126-36

Disclosure of Interests

Joseph F. Merola Consultant of: AbbVie, Arena, Biogen, Bristol-Myers Squibb, Dermavant, Eli Lilly, Janssen, Novartis, Pfizer, Sun Pharma, and UCB Pharma, Yi-Hsuan Liu Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson, Ya-Wen Yang Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Megan Miller Employee of: Janssen Research & Development, LLC and may own stock or stock options in Johnson & Johnson, May Shawi Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, and may own stock or stock options in Johnson & Johnson, Daphne Chan Employee of: Janssen Scientific Affairs, LLC and may own stock or stock options in Johnson & Johnson, Saakshi Khattri Speakers bureau: Abbvie, Eli Lilly, UCB, Janssen, Paid instructor for: Abbvie, Eli Lilly, UCB, Janssen, Consultant of: Abbvie, Eli Lilly, UCB, Janssen, Grant/research support from: Pfizer, Abbvie, Leo, BMS, Eli Lilly, Laura Savage Speakers bureau: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Consultant of: AbbVie, Almirall, Amgen, Celgene, Celltrion, Eli Lilly, Galderma, Janssen, LEO Pharma, MSD, Novartis, Sanofi and UCB Pharma, Grant/research support from: Janssen and Pfizer, Wolf-Henning Boehncke Speakers bureau: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Consultant of: AbbVie, Almirall, Celgene, Eli Lilly, Janssen, LEO Pharma, Novartis, and UCB Pharma; and has received a research grant from Pfizer, Chenglong Han Employee of: Janssen Global Services, LLC and may own stock or stock options in Johnson & Johnson

AB1473 EFFICACY RESPONSES ACROSS DISEASE SEVERITY AND TREATMENT HISTORY SUBGROUPS OF PATIENTS WITH MODERATE TO SEVERE PLAQUE PSORIASIS TREATED WITH GUSELKUMAB: POOLED RESULTS FROM VOYAGE-1 AND VOYAGE-2 THROUGH 5 YEARS

Background

The VOYAGE-1 and VOYAGE-2 phase 3 studies evaluated efficacy and safety of guselkumab (GUS) in patients with moderate-to-severe plaque psoriasis.

Objectives

To assess the five-year efficacy of GUS by baseline disease characteristics and treatment history.

Methods

This study evaluated 1829 patients randomized to GUS, placebo (PBO)→GUS, and adalimumab (ADA) →GUS from the VOYAGE-1 and VOYAGE-2 trials. All patients received open-label GUS 100 mg every 8 weeks (Q8W) during Week (W) 52 to W252 in VOYAGE-1 and during W76 to W252 in VOYAGE-2. The proportions of combined GUS patients (including PBO→GUS and ADA→GUS) achieving Investigator’s Global Assessment of cleared or minimal (IGA-0/1) and Psoriasis Area and Severity Index (PASI) 90 response were evaluated from W100 to W252 by baseline PASI (<20/≥20) and IGA (<4/=4) scores, body surface area (BSA; <20%/≥20%), and prior psoriasis treatments. Analysis was performed using observed data after applying treatment failure rules.

Results

At W252, proportions of combined GUS patients achieving IGA 0/1 or PASI 90, respectively, were comparable or numerically greater for patients with baseline PASI < 20 (85.4%; 81.1%) vs PASI ≥ 20 (81.4%; 83.8%); IGA < 4 (85.1%; 82.7%) vs IGA = 4 (78.9%; 81.1%); BSA < 20% (85.1%; 82.7%) vs BSA ≥ 20% (82.6%; 82.0%); no prior phototherapy (83.3%; 84.0%) vs prior phototherapy (83.8%; 81.1%); no prior non-biologic systemic therapy (84.5%; 83.0%) vs prior non-biologic systemic therapy (83.2%; 82.0%); and no prior biologics (85.3%; 83.8%) vs prior biologics (76.7%; 76.3%). This trend was consistent at each timepoint evaluated from W100 to W252.

Conclusion

This analysis demonstrated that the high degree of efficacy of GUS treatment is durable through 5 years among broad subpopulations of patients with varying disease severity characteristics and previous psoriasis treatments.

References

None

Disclosure of Interests

Kenneth Gordon Grant/research support from: AbbVie, Almirall, Amgen, BMS, Celgene, Dermira, Dermavant, Eli Lilly, Janssen, LEO Pharma, Novartis, Ortho Dermatologics, Pfizer, Sun Pharma, and UCB Pharma, Joseph F. Merola Consultant of: AbbVie, Arena, Avotres, Biogen, Bristol-Myers Squibb, Celgene, Dermavant, Eli Lilly, EMD Sorono, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron, Sanofi, Sun Pharma, and UCB pharma, Peter Foley Speakers bureau: AbbVie, Celgene, Eli Lilly, Galderma, GSK, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, and Valeant, Consultant of: AbbVie, Amgen, Arcutis, Aslan, AstraZeneca, BMS, Boehringer Ingelheim, Celgene, Celtaxsys, CSL, Cutanea, Dermira, Eli Lilly, Galderma, Genentech, GSK, Hexima, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals Inc, Reistone, Roche, Sanofi, Sun Pharma, UCB Pharma, and Valeant, Grant/research support from: grant/research support from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Sanofi, and Sun Pharma; and travel grants from AbbVie, Eli Lilly, Galderma, Janssen, Leo Pharma, Merck, Novartis, Pfizer, Roche, Sanofi, and Sun Pharma, Olivia Choi Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Daphne Chan Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Megan Miller Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yin You Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Yaung-Kaung Shen Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Ya-Wen Yang Shareholder of: may own stock or stock options in Johnson & Johnson, Employee of: Immunology Global Medical Affairs, Janssen Pharmaceutical Companies of Johnson & Johnson, Andrew Blauvelt Speakers bureau: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma, Consultant of: AbbVie, Almirall, Arena, Athenex, Boehringer Ingelheim, Bristol-Myers Squibb, Dermavant, Eli Lilly, Evommune, Forte, Galderma, Incyte, Janssen, Leo Pharma, Novartis, Pfizer, Rapt, Regeneron, Sandoz, Sanofi Genzyme, Sun Pharma, and UCB Pharma

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

A74 SURVEILLANCE IMAGING FOLLOWING COMPLETELY RESECTED GASTROENTEROPANCREATIC NEUROENDOCRINE TUMORS: A SINGLE CENTER AUDIT OF LOCAL PRACTICE PATTERNS

Background

Neuroendocrine tumours (NET) are a heterogenous group of neoplasms that secrete peptides and neuroamines. For patients with potentially malignant gastroenteropancreatic (GEP) NET, surgical resection represents the only curative option. GEP NETs are characterized by long periods of disease-free survival and time-to-recurrence following surgical resection. Clinical guidelines recommend surveillance with cross sectional imaging, either CT or MRI, for at least 10 years.

Aims

The purpose of this study was to characterize local practice patterns of imaging surveillance (modality, frequency, and duration of follow-up) and how this compares to guideline recommendations.

Methods

We retrospectively reviewed clinical and imaging records from patients diagnosed with well-differentiated GEP NET at our center from January 2005 to July 2020 inclusive. Eligible cases were identified by a data analyst from the Alberta Cancer Board with each case being manually screened for eligibility. Exclusion criteria included patients with metastatic disease at presentation, G1 appendiceal NET &lt; 1 cm, R0 G1 T1 rectal NET, and insulinoma. Location of primary NET, modality of surveillance imaging, date of test and duration of follow-up collected. The mean number of surveillance scans per person and per person-year follow-up based on the location of the primary NET were calculated.

Results

A total of 387 cases were initially retrieved with 62 eligible cases identified. The mean length of follow-up was 71 months (range 8 to 147). The mean number of surveillance scans was 7 (range 2 to 14) and the mean number of surveillance scans per person year was 1.1. Frequency of surveillance scans per year of follow-up did not differ based on the location of the primary tumor (p=0.966). Imaging modalities included cross sectional imaging (MRI and contrast enhanced CT) and nuclear medicine imaging (octreotide, MIBG, F-18 FDG-PET, and Gallium-68 DOTATATE PET CT). Most commonly, cross-sectional imaging was performed with CT or MRI representing 38% (n=166) and 39% (n=170) of all surveillance respectively. Nuclear medicine imaging was used in 15% (n=61) of surveillance scans and 3% used combined cross-sectional and nuclear medicine. Amongst cases with resection date &gt;10 years (n=8) mean length of follow-up was 119 months (9.9 years).

Conclusions

Frequency and modality of imaging at our center is generally in accordance with current clinical guidelines, though the role of nuclear medicine imaging in this setting has not been established. CT and MRI were utilized equally during surveillance. The burden of these modalities in terms of radiation exposure and cost warrants further evaluation.

Funding Agencies

None

Application of an organotypic ocular perfusion model to assess intravitreal drug distribution in human and animal eyes

Intravitreal (ITV) drug delivery is a new cornerstone for retinal therapeutics. Yet, predicting the disposition of formulations in the human eye remains a major translational hurdle. A prominent, but poorly understood, issue in pre-clinical ITV toxicity studies is unintended particle movements to the anterior chamber (AC). These particles can accumulate in the AC to dangerously raise intraocular pressure. Yet, anatomical differences, and the inability to obtain equivalent human data, make investigating this issue extremely challenging. We have developed an organotypic perfusion strategy to re-establish intraocular fluid flow, while maintaining homeostatic pressure and pH. Here, we used this approach with suitably sized microbeads to profile anterior and posterior ITV particle movements in live versus perfused porcine eyes, and in human donor eyes. Small-molecule suspensions were then tested with the system after exhibiting differing behaviours in vivo. Aggregate particle size is supported as an important determinant of particle movements in the human eye, and we note these data are consistent with a poroelastic model of bidirectional vitreous transport. Together, this approach uses ocular fluid dynamics to permit, to our knowledge, the first direct comparisons between particle behaviours from human ITV injections and animal models, with potential to speed pre-clinical development of retinal therapeutics.

Detecting impaired language processing in patients with mild cognitive impairment using around-the-ear cEEgrid electrodes

Mild cognitive impairment (MCI) is the term used to identify those individuals with subjective and objective cognitive decline but with preserved activities of daily living and an absence of dementia. Although MCI can impact functioning in different cognitive domains, most notably episodic memory, relatively little is known about the comprehension of language in MCI. In this study, we used around-the-ear electrodes (cEEGrids) to identify impairments during language comprehension in patients with MCI. In a group of 23 patients with MCI and 23 age-matched controls, language comprehension was tested in a two-word phrase paradigm. We examined the oscillatory changes following word onset as a function of lexico-semantic single-word retrieval (e.g., swrfeq vs. swift) and multiword binding processes (e.g., horse preceded by swift vs. preceded by swrfeq). Electrophysiological signatures (as measured by the cEEGrids) were significantly different between patients with MCI and controls. In controls, lexical retrieval was associated with a rebound in the alpha/beta range, and binding was associated with a post-word alpha/beta suppression. In contrast, both the single-word retrieval and multiword binding signatures were absent in the MCI group. The signatures observed using cEEGrids in controls were comparable with those signatures obtained with a full-cap EEG setup. Importantly, our findings suggest that patients with MCI have impaired electrophysiological signatures for comprehending single words and multiword phrases. Moreover, cEEGrid setups provide a noninvasive and sensitive clinical tool for detecting early impairments in language comprehension in MCI.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Induction of specific brain oscillations may restore neural circuits and be used for the treatment of Alzheimer's disease

Brain oscillations underlie the function of our brains, dictating how we both think and react to the world around us. The synchronous activity of neurons generates these rhythms, which allow different parts of the brain to communicate and orchestrate responses to internal and external stimuli. Perturbations of cognitive rhythms and the underlying oscillator neurons that synchronize different parts of the brain contribute to the pathophysiology of diseases including Alzheimer's disease, (AD), Parkinson's disease (PD), epilepsy and other diseases of rhythm that have been studied extensively by Gyorgy Buzsaki. In this review, we discuss how neurologists manipulate brain oscillations with neuromodulation to treat diseases and how this can be leveraged to improve cognition and pathology underlying AD. While multiple modalities of neuromodulation are currently clinically indicated for some disorders, nothing is yet approved for improving memory in AD. Recent investigations into novel methods of neuromodulation show potential for improving cognition in memory disorders. Here, we demonstrate that neuronal stimulation using audiovisual sensory stimulation that generated 40-HZ gamma waves reduced AD-specific pathology and improved performance in behavioural tests in mouse models of AD, making this new mode of neuromodulation a promising new avenue for developing a new therapeutic intervention for the treatment of dementia.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

POS0124 QUALITY OF LIFE FOR PATIENTS WITH KNEE OSTEOARTHRITIS WITH OR WITHOUT PAIN SENSITIZATION

Background:

Patients with central sensitization (CS) may have poorer quality of life (QOL).

Objectives:

We aim to evaluate whether different ways of classifying CS have an impact on a patient’s QOL among patients with knee osteoarthritis (KOA).

Methods:

We use the baseline pre-operative data from a cohort of consecutive KOA patients enlisted for knee replacement surgery (1). We collected demographics, number and position of painful sites of body. Quality of life was assessed by the Medical Outcome Survey Short-Form 36 (SF-36). Pain pressure threshold was measured at volar side of right forearm. We classify CS using three sets of criteria: 1). widespread pain (pain involving both upper/ lower trunk, and both side of body), 2). lowest 10th percentile of pressure pain threshold (PPT) measured at the forearm and 3) the painDETECT questionnaire >=13/38.

Results:

Of 233 patients (79.8% women) with complete data set for analysis, mean (standard deviation, SD) age was 66.0 (8.3) years. 15.5%, 25.8%, and 4.7% of patients were classified as having CS by widespread pain, low PPT and painDETECT criteria. KOA patients with CS have poorer QoL compared with those without. Low PPT identified patients with poorer general health, while widespread pain and PainDETECT criteria identified patients with poorer QoL in more domains including vitality mental health (Table 1).

Table 1.

Quality of life comparing patients with or without CS

Widespread painlowest 10th percentile of forearm PPTPainDETECT >=13/38No (n = 197)Yes (n= 36)No (n= 206)Yes (n= 27)No (n= 222)Yes(n= 11)SF-Physical functioning39.0 (21.8)32.6 (19.0)38.7 (21.8)32.8 (17.8)38.8 (21.3)22.3 (19.2)*SF-Role physical21.6 (33.3)8.3 (22.4)*20.3 (32.2)13.9 (32.0)19.7 (32.6)15.9 (23.1)SF-Bodily pain36.3 (19.5)28.1 (14.0)*35.1 (19.5)34.0 (14.7)35.5 (19.1)24.2 (13.3)SF-General health68.9 (21.1)64.6 (20.3)69.4 (20.6)59.3 (22.4)*68.7 (20.7)58.4 (25.7)SF-Vitality score69.7 (22.4)59.3 (20.4)**68.8 (22.5)63.1 (21.1)69.0 (21.8)51.8 (29.2)*SF-Social functioning57.7 (37.2)48.3 (39.2)57.3 (38.0)48.1 (33.7)56.7 (37.7)47.7 (42.1)SF-Role emotion86.1 (34.4)86.1 (33.2)86.7 (33.5)79.0 (38.3)86.9 (32.9)63.6 (50.5)SF-Mental health82.4 (16.2)77.4 (19.2)82.2 (16.8)77.8 (15.8)82.2 (16.3)70.2 (22.2)*Physical component score32.5 (10.1)30.3 (8.0)32.4 (9.8)30.6 (9.7)32.4 (9.9)28.8 (8.7)Mental component score53.0 (10.5)48.3 (10.0)*52.7 (10.6)48.5 (9.2)52.6 (10.2)44.2 (13.7)**

* p<0.05; **p<0.01

Conclusion:

KOA patients who have CS have poorer QoL compared to those without. Different criteria defined patients with different pattern of QoL impacts. In general, KOA patients who have CS have poorer QoL compared to those without. This highlight the importance of additional impact of CS to QoL

References:

[1]Leung YY, Lim Z, Fan Q, et al. Pre-operative pressure pain thresholds do not meaningfully explain satisfaction or improvement in pain after knee replacement: a cohort study. Osteoarthritis and cartilage 2019;27(1):49-58.

Disclosure of Interests:

None declared

Cardiovascular and behavioural risk factors in families with elevated lipoprotein(a)[Lp(a)]

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Elevated lipoprotein(a)[Lp(a)] is an inherited and independent risk factor for atherosclerotic cardiovascular diseases (ASCVD). However, it is an under detected condition with no specific therapy available at present for lowering Lp(a). Hence, identifying the distribution of modifiable cardiovascular and behavioural risk factors is important for implementing an effective intervention programme to mitigate the overall risk of ASCVD in high-risk individuals with elevated Lp(a).

Purpose

The primary aim was to describe and compare the distribution of modifiable cardiovascular and behavioural risk factors in both index cases and their relatives with elevated Lp(a) identified through cascade testing at the Lipid Disorders Clinic, Royal Perth Hospital.

Methods

We studied 51 index cases and 71 relatives cascade tested with elevated Lp(a) (≥0.5 g/L).  Questionnaires were completed concerning aspects of cardiovascular health (cholesterol level, blood pressure and blood glucose level) and behavioural health metrics (diet, smoking, physical activity, body-mass-index [BMI]). Lp(a) was measured by an immunoassay having minimal dependence on apolipoprotein(a) isoform size. The health metrics were described as proportions and statistical analyses performed using Student’s t-test or Chi-square where appropriate.

Results

Compared with the index cases, a higher proportion of their affected relatives were female (62% vs 43%, p = 0.039), younger (43 years vs 53 years, p &lt; 0.001) and had lower Lp(a) levels (1.03 g/L vs 1.12 g/L, p = 0.003). A lower proportion of the affected relatives were treated for dyslipidaemia (31% vs 96%, p &lt; 0.001). The affected relatives also had a lower incidence of ASCVD events (3% vs 37%, p &lt; 0.001), hypertension (21% vs 43%, p = 0.003), and lower HbA1c levels (5.3% vs 5.9%, p = 0.031) compared with index cases. Additionally, a larger proportion of the affected relatives had ideal cardiovascular health (35% vs 14%, p = 0.008) compared with their index cases. However, more than half of the index cases and their relatives did not maintain a healthy diet (59% and 69%, respectively) and an ideal BMI (68% and 59%, respectively).

Conclusion(s)

Although the younger affected relatives with elevated Lp(a) have a lower cardiovascular risk compared with the index cases, a focus on modifiable behavioural changes, such as a healthy diet and an ideal body weight, is still required to mitigate the overall risk of ASCVD.

Radiological Society of North America/Quantitative Imaging Biomarker Alliance Shear Wave Speed Bias Quantification in Elastic and Viscoelastic Phantoms

OBJECTIVES

To quantify the bias of shear wave speed (SWS) measurements between different commercial ultrasonic shear elasticity systems and a magnetic resonance elastography (MRE) system in elastic and viscoelastic phantoms.

METHODS

Two elastic phantoms, representing healthy through fibrotic liver, were measured with 5 different ultrasound platforms, and 3 viscoelastic phantoms, representing healthy through fibrotic liver tissue, were measured with 12 different ultrasound platforms. Measurements were performed with different systems at different sites, at 3 focal depths, and with different appraisers. The SWS bias across the systems was quantified as a function of the system, site, focal depth, and appraiser. A single MRE research system was also used to characterize these phantoms using discrete frequencies from 60 to 500 Hz.

RESULTS

The SWS from different systems had mean difference 95% confidence intervals of ±0.145 m/s (±9.6%) across both elastic phantoms and ± 0.340 m/s (±15.3%) across the viscoelastic phantoms. The focal depth and appraiser were less significant sources of SWS variability than the system and site. Magnetic resonance elastography best matched the ultrasonic SWS in the viscoelastic phantoms using a 140 Hz source but had a - 0.27 ± 0.027-m/s (-12.2% ± 1.2%) bias when using the clinically implemented 60-Hz vibration source.

CONCLUSIONS

Shear wave speed reconstruction across different manufacturer systems is more consistent in elastic than viscoelastic phantoms, with a mean difference bias of < ±10% in all cases. Magnetic resonance elastographic measurements in the elastic and viscoelastic phantoms best match the ultrasound systems with a 140-Hz excitation but have a significant negative bias operating at 60 Hz. This study establishes a foundation for meaningful comparison of SWS measurements made with different platforms.

Applying a clinical decision-making model to a patient with severe shoulder pain ultimately diagnosed as neuralgic amyotrophy

OBJECTIVE AND PURPOSE

Shoulder symptoms are often encountered in physical therapy and a myriad of etiologies can cause these symptoms, either locally or remotely. The purpose of this case report is to describe the physical therapist's differential diagnostic process for a patient with acute and severe onset of shoulder pain. Case Description: The patient was a 37-year-old female with sudden onset of right shoulder pain that awakened her at night. Pain was associated with decreased range of motion and shoulder weakness. Faced with an uncertain diagnosis, the physical therapist followed a systematic approach to clinical decision-making. Outcomes: Neuralgic amyotrophy was the primary diagnostic hypothesis but other causes of shoulder pain could not be ruled out. Conclusion: The clinical decision-making process helped the physical therapist narrow down the differential diagnosis list and make a decision to send the patient for further testing. Magnetic resonance imaging and electromyogram confirmed the diagnosis of neuralgic amyotrophy.

Developmental genome-wide DNA methylation asymmetry between mouse placenta and embryo

In early embryos, DNA methylation is remodelled to initiate the developmental program but for mostly unknown reasons, methylation marks are acquired unequally between embryonic and placental cells. To better understand this, we generated high-resolution DNA methylation maps of mouse mid-gestation (E10.5) embryo and placenta. We uncovered specific subtypes of differentially methylated regions (DMRs) that contribute directly to the developmental asymmetry existing between mid-gestation embryonic and placental DNA methylation patterns. We show that the asymmetry occurs rapidly during the acquisition of marks in the post-implanted conceptus (E3.5-E6.5), and that these patterns are long-lasting across subtypes of DMRs throughout prenatal development and in somatic tissues. We reveal that at the peri-implantation stages, the de novo methyltransferase activity of DNMT3B is the main driver of methylation marks on asymmetric DMRs, and that DNMT3B can largely compensate for lack of DNMT3A in the epiblast and extraembryonic ectoderm, whereas DNMT3A can only partially compensate in the absence of DNMT3B. However, as development progresses and as DNMT3A becomes the principal de novo methyltransferase, the compensatory DNA methylation mechanism of DNMT3B on DMRs becomes less effective.

Variation in training requirements within general surgery: comparison of 23 countries

Background

Many differences exist in postgraduate surgical training programmes worldwide. The aim of this study was to provide an overview of the training requirements in general surgery across 23 different countries.

Methods

A collaborator affiliated with each country collected data from the country's official training body website, where possible. The information collected included: management, teaching, academic and operative competencies, mandatory courses, years of postgraduate training (inclusive of intern years), working‐hours regulations, selection process into training and formal examination.

Results

Countries included were Australia, Belgium, Canada, Colombia, Denmark, Germany, Greece, Guatemala, India, Ireland, Italy, Kuwait, the Netherlands, New Zealand, Russia, Saudi Arabia, South Africa, South Korea, Sweden, Switzerland, UK, USA and Zambia. Frameworks for defining the outcomes of surgical training have been defined nationally in some countries, with some similarities to those in the UK and Ireland. However, some training programmes remain heterogeneous with regional variation, including those in many European countries. Some countries outline minimum operative case requirement (range 60–1600), mandatory courses, or operative, academic or management competencies. The length of postgraduate training ranges from 4 to 10 years. The maximum hours worked per week ranges from 38 to 88 h, but with no limit in some countries.

Conclusion

Countries have specific and often differing requirements of their medical profession. Equivalence in training is granted on political agreements, not healthcare need or competencies acquired during training.

Acute Effects of Glucagon on Reproductive Hormone Secretion in Healthy Men

CONTEXT

Glucagon increases energy expenditure; consequently, glucagon receptor agonists are in development for the treatment of obesity. Obesity negatively affects the reproductive axis, and hypogonadism itself can exacerbate weight gain. Therefore, knowledge of the effects of glucagon receptor agonism on reproductive hormones is important for developing therapeutics for obesity; but reports in the literature about the effects of glucagon receptor agonism on the reproductive axis are conflicting.

OBJECTIVE

The objective of this work is to investigate the effect of glucagon administration on reproductive hormone secretion in healthy young men.

DESIGN

A single-blinded, randomized, placebo-controlled crossover study was conducted.

SETTING

The setting of this study was the Clinical Research Facility, Imperial College Healthcare NHS Trust.

PARTICIPANTS

Eighteen healthy eugonadal men (mean ± SEM: age 25.1 ± 1.0 years; body mass index 22.5 ± 0.4 kg/m2; testosterone 21.2 ± 1.2 nmol/L) participated in this study.

INTERVENTION

An 8-hour intravenous infusion of 2 pmol/kg/min glucagon or rate-matched vehicle infusion was administered.

MAIN OUTCOME MEASURES

Luteinizing hormone (LH) pulsatility; LH, follicle-stimulating hormone (FSH), and testosterone levels were measured.

RESULTS

Although glucagon administration induced metabolic effects (insulin area under the curve: vehicle 1065 ± 292 min.µU/mL vs glucagon 2098 ± 358 min.µU/mL, P < .001), it did not affect LH pulsatility (number of LH pulses/500 min: vehicle 4.7 ± 0.4, glucagon 4.2 ± 0.4, P = .22). Additionally, there were no significant differences in circulating LH, FSH, or testosterone levels during glucagon administration compared with vehicle administration.

CONCLUSIONS

Acute administration of a metabolically active dose of glucagon does not alter reproductive hormone secretion in healthy men. These data are important for the continued development of glucagon-based treatments for obesity.

Medication adherence teaching activity for first year pharmacy students in a Canadian university: Description and evaluation

BACKGROUND AND PURPOSE

Medication non-adherence is a significant health problem in Canada and pharmacists are ideally positioned to help patients adhere to their regimens. There is an urgent need for pharmacy schools to ensure graduates receive training in this area. In this paper, we describe a medication taking simulation activity for first year pharmacy students using a multi-method approach to evaluation.

EDUCATIONAL ACTIVITY AND SETTING

Students were provided with placebo capsules and instructed to take one capsule twice per day for two weeks, complete the Beliefs About Medications Questionnaire (BMQ) before the activity, and provide a pill count and reflection on their experiences afterwards. Quantitative analysis involved calculation of percent adherence from pill counts and establishing beliefs about medications from BMQ scores. Perceptions of the teaching activity were determined using qualitative inductive content analysis of a sub-set of student reflections.

FINDINGS

All 224 students participated and complete pill count and BMQ data was obtained from 190 students (85%). Applying a cut-off of 80% to categorize adherence status, 51.8% of students were adherent. BMQ analyses indicated collective student uncertainty in three BMQ sub-scales (specific-necessity, specific-concern, and general-overuse) and a significant difference between adherent and non-adherent students in the specific-necessity sub-scale. Qualitative analyses of a set of student reflections resulted in two major themes: (1) developing empathy and (2) learning about adherence.

SUMMARY

This activity provided opportunities for students to experience the challenges involved in medication-taking from the patient's perspective and to realize the pharmacist's role to facilitate medication adherence.

Utility of rapid plasmin reagin titres in assessing treatment response and re-infection for infectious syphilis

Background The rapid plasma reagin (RPR) assay is commonly used as a surrogate marker of infectious syphilis, but is non-specific, slow to change and variable in its rate of decline post treatment.

METHODS

Within an urban sexual health service testing predominantly men who have sex with men, a file review of RPR changes was undertaken in all subjects who had a dilution level of ≥1:4, between January 2015 to the end of December 2018.

RESULTS

Overall, 248 cases of infectious syphilis were identified in 215 subjects (165 HIV seropositive, 50 HIV seronegative). Among unique-subject cases with follow-up RPR recorded, seroreversion to a non-reactive titre was achieved in only 42.3% (71/168) cases at a median of 235 days (interquartile range: 138-348 days) and was significantly less likely if patients had HIV infection (P = 0.02), late latent syphilis (P = 0.003) or a subsequent syphilis infection (P < 0.0001). Having HIV infection (P = 0.03) or a subsequent episode of syphilis (P = 0.01) were associated with a lower likelihood of documented cure.

CONCLUSIONS

The slow decay in RPR titres post therapy and the inability of a significant number of subjects to achieve a non-reactive result over time makes RPR a poor test for assessing the adequacy of treatment or in diagnosing re-infection, especially in populations having repeated and frequent risk exposures. As the number of syphilis cases continue to climb, better tests that accurately assess pathogen presence are urgently needed.