Potential Mediators for Treatment Effects of Novel Diabetes Medications on Cardiovascular and Renal Outcomes: A Meta-Regression Analysis

BACKGROUND

Prior research suggests clinical effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are mediated by changes in glycated hemoglobin, body weight, systolic blood pressure, hematocrit, and urine albumin-creatinine ratio. We aimed to confirm these findings using a meta-analytic approach.

METHODS AND RESULTS

We updated a systematic review of 9 GLP-1RA and 13 SGLT2i trials and summarized longitudinal mediator data. We obtained hazard ratios (HRs) for cardiovascular, renal, and mortality outcomes. We performed linear mixed-effects modeling of LogHRs versus changes in potential mediators and investigated differences in meta-regression associations among drug classes using interaction terms. HRs generally became more protective with greater glycated hemoglobin reduction among GLP-1RA trials, with average HR improvements of 20% to 30%, reaching statistical significance for major adverse cardiovascular events (ΔHR, 23%; P=0.02). Among SGLT2i trials, associations with HRs were not significant and differed from GLP1-RA trials for major adverse cardiovascular events (Pinteraction=0.04). HRs for major adverse cardiovascular events, myocardial infarction, and stroke became less efficacious (ΔHR, -15% to -34%), with more weight loss for SGLT2i but not for GLP-1RA trials (ΔHR, 4%-7%; Pinteraction<0.05). Among 5 SGLT2i trials with available data, HRs for stroke became less efficacious with larger increases in hematocrit (ΔHR, 123%; P=0.09). No changes in HRs by systolic blood pressure (ΔHR, -11% to 9%) and urine albumin-creatinine ratio (ΔHR, -1% to 4%) were found for any outcome.

CONCLUSIONS

We confirmed increased efficacy findings for major adverse cardiovascular events with reduction in glycated hemoglobin for GLP1-RAs. Further research is needed on the potential loss of cardiovascular benefits with increased weight loss and hematocrit for SGLT2i.

Left Behind: Medicaid Immigrant Exclusions and Access to Maternal Health Care Across the Reproductive-Perinatal Continuum

Noncitizen immigrants are often excluded from accessing critical safety-net programs, such as Medicaid. Access to health care plays a central role in current policy debates on maternal health. Yet, immigrant exclusions are rarely considered in maternal health policy research. Through open-ended interviews with 31 policymakers, researchers, and program administrators, we examined state variations in approaches to providing care for pregnant, post, and intrapartum immigrant women. We found four themes: (a) a patchwork safety-net exists that provides some access to immigrants ineligible for Medicaid; (b) patchwork coverage leads to patchwork care, which can contribute to maternal health inequities; (c) immigrant Medicaid policy is assembled along a hierarchy of deservingness based on documentation status; (d) Trump-era public charge rules and political climate may have a substantial chilling effect on benefit uptake regardless of eligibility. We discuss implications for efforts to expand Medicaid postpartum and address the maternal health crisis.

Recent Telehealth Utilization at a Large Federally Qualified Health Center System: Evidence of Disparities Even Within Telehealth Modalities

Objective: To explore overall trends as well as racial/ethnic disparities in utilization of different telehealth modalities (telephone vs. televideo) at federally qualified health centers (FQHCs) during the COVID-19 pandemic. Methods: Using electronic health record data from a large New York-based FQHC system, we aggregated (separately) Behavioral Health and Family Practice visits per month occurring in-person, by telephone, or by televideo and graphed monthly trends in visits across the pre-pandemic, peak-pandemic, and post-peak-pandemic periods. We calculated fractions of visits conducted by modality for each patient demographic (race/ethnicity, primary language, age, gender, insurance type, and geography) and conducted bivariate assessments to test relationships between patient characteristics and modality. Results: Our data contained 121,072 unique patients and 811,105 visits overall. Telehealth use peaked in April 2020 but continued to account for a significant fraction of FQHC visits-nearly 25% (N = 4,908) of monthly Family Practice visits and a massive 98% (N = 14,173) of Behavioral Health visits as late as June 2021. Of all telehealth visits, nearly half were by telephone. Moreover, demographic factors differed between FQHC patients using telephone visits versus those using televideo: Black, non-English speaking, older, and Medicaid patients had significantly higher utilization of telephone visits than televideo visits (e.g., 25.9% of all Black patients' visits were via telephone vs. 17.1% via televideo; p < 0.001). In contrast, younger, Asian, and privately insured patients had significantly higher televideo visits. Conclusions: Our results suggest that telephone visits remain critical to the provision of health care for FQHC patients. They also suggest that disparities extend beyond the telehealth versus in-person dichotomy and inequities exist even within the type of telehealth used. This has implications for patient health, FQHC quality outcomes, as well as optimal Medicaid telehealth reimbursement policy.

Barriers to Telehealth Utilization Among Patients of Limited Income with Chronic Conditions and a Gap in Care

Objective: This study assessed barriers and facilitators to telehealth utilization among patients living in New York City public housing with chronic conditions and a gap in clinical care. Methods: Community health workers performed outreach to eligible patients by telephone between January and March 2021. Consenting respondents answered questions about telehealth barriers, including internet and cell phone access, ownership of digital devices, comfort with using digital devices, comfort with telehealth, cost, awareness, and availability of written materials in patients' preferred language. We obtained demographic and medical information from patients' electronic health records. We used multivariable logistic regression to estimate the association of barriers with the odds of self-reported prior telehealth utilization. Results: A total of 304 consenting patients participated in the program. The average patient had 3.1 telehealth barriers; 76% reported at least one barrier. Regression analysis showed sizable reductions in prior telehealth utilization associated with the barriers of unlimited cell phone minutes (odds ratio [OR]: 0.21 [0.05-0.88], p = 0.033), technological comfort (OR: 0.33 [0.13-0.82], p = 0.016), conceptual comfort with telehealth (OR: 0.15 [0.04-0.54], p = 0.004), and materials in the patient's preferred language (OR: 0.23 [0.07-0.79], p = 0.02). Discussion: With a high prevalence of telehealth barriers, patients with limited income, a chronic condition, and a care gap may benefit from greater technological access and supportive programs for awareness, telehealth comfort, and navigation support. Addressing telehealth barriers could increase the quality of medical care and improve health outcomes for this population.

Cardiovascular and Renal Benefits of Novel Diabetes Drugs by Baseline Cardiovascular Risk: A Systematic Review, Meta-analysis, and Meta-regression

BACKGROUND

Eligibility for glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) has been expanded to patients with diabetes at lower cardiovascular risk, but whether treatment benefits differ by risk levels is not clear.

PURPOSE

To investigate whether patients with varying risks differ in cardiovascular and renal benefits from GLP-1RA and SGLT2i with use of meta-analysis and meta-regression.

DATA SOURCES

We performed a systematic review using PubMed through 7 November 2022.

STUDY SELECTION

We included reports of GLP-1RA and SGLT2i confirmatory randomized trials in adult patients with safety or efficacy end point data.

DATA EXTRACTION

Hazard ratio (HR) and event rate data were extracted for mortality, cardiovascular, and renal outcomes.

DATA SYNTHESIS

We analyzed 9 GLP-1RA and 13 SGLT2i trials comprising 154,649 patients. Summary HRs were significant for cardiovascular mortality (GLP-1RA 0.87 and SGLT2i 0.86), major adverse cardiovascular events (0.87 and 0.88), heart failure (0.89 and 0.70), and renal (0.84 and 0.65) outcomes. For stroke, efficacy was significant for GLP-1RA (0.84) but not for SGLT2i (0.92). Associations between control arm cardiovascular mortality rates and HRs were nonsignificant. Five-year absolute risk reductions (0.80-4.25%) increased to 11.6% for heart failure in SGLT2i trials in patients with high risk (Pslope < 0.001). For GLP1-RAs, associations were nonsignificant.

LIMITATIONS

Analyses were limited by lack of patient-level data, consistency in end point definitions, and variation in cardiovascular mortality rates for GLP-1RA trials.

CONCLUSIONS

Relative effects of novel diabetes drugs are preserved across baseline cardiovascular risk, whereas absolute benefits increase at higher risks, particularly regarding heart failure. Our findings suggest a need for baseline risk assessment tools to identify variation in absolute treatment benefits and improve decision-making.

Abstract P140: Potential Mediators for Cardiovascular Benefits of Novel Diabetes Medications: A Meta-Regression Analysis

Background: Prior research suggests cardiovascular (CV) benefits of glucose-lowering interventions may be mediated by changes in hemoglobin A1c (HbA1c), bodyweight, systolic blood pressure (SBP), hematocrit, and urine albumin-creatinine ratio (uACR). We evaluated the heterogeneity of CV benefits by these potential mediators for sodium-glucose transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) using a meta-analytic approach.

Methods: We performed a systematic review and meta-regression analyses of 12 SGLT2i and 9 GLP-1RA CV outcome trials using linear mixed models of treatment efficacy measured as log hazard ratios (HRs) vs changes in potential mediators. We extracted follow-up mediator data for treatment and control, preferably at 12 months post randomization. Outcomes included MI, stroke, and MACE (a composite of MI, stroke, or CV death). We investigated slope differences between drug classes using interaction terms and likelihood-ratio tests.

Results: Treatment efficacy for MACE improved with more HbA1c reduction among GLP-1RA (slope .26; P slope .02) but not among SGLT2i trials (slope -.22; P slope .39; P interaction .06), see Figure . Treatment efficacy for MACE, MI, and stroke decreased with more weight loss for SGLT2i (slope –.17, –.29, –.39; P slope <.05) but not for GLP-1RA trials (slope .05, .03, .07; P slope .30, .62, .32). Slopes differed significantly between drug classes: P interaction <.05. For stroke, we observed a trend of less treatment efficacy with increases in hematocrit among five SGLT2i trials with available data (slope .96; P slope .07). We did not find any indication of mediation effects by SBP and uACR for SGLT2i or GLP-1RAs (slopes -.11 -.07; P slopes ≥ .05).

Conclusion: We confirm previous findings of increased CV benefits with reductions in HbA1c for GLP1-RAs. Further research is needed to investigate the potential loss of SGLT2i efficacy with greater weight loss and increase in hematocrit.

Economic Evaluation of an Intervention to Prevent Adolescent Dating Violence (Me & You)

Me & You: Building Healthy Relationships (Me & You) is a multilevel, technology-enhanced adolescent dating violence (DV) prevention program that aimed to reduce DV among ethnic-minority, early adolescent, urban youth. A group-randomized control trial of Me & You, conducted with 10 middle schools from a large urban school district in Southeast Texas in 2014-2015, found it to be effective in reducing DV perpetration and decreasing some forms of DV victimization. Economic evaluations of DV interventions are extremely limited, despite calls for more economic analyses to be incorporated in research. We help fill this gap by evaluating the cost-effectiveness from the payer and societal perspectives of implementing the Me & You program. Using cost data collected alongside the Me & You group-randomized trial, we computed incremental cost-effectiveness ratios. Our primary outcome was "any DV perpetrated" within 12 months of the intervention. We conducted a cost-benefit analysis beyond the intervention endpoint by using literature estimates of per-victim lifetime costs of DV. We performed sensitivity analyses to assess effects of uncertain parameters. Under the base-case scenario, the cost of the Me & You curriculum compared to the standard curriculum was $103.70 per-student from the societal perspective, and the effectiveness was 34.84 perpetrations averted, implying an incremental cost per perpetration averted of $2.98, which ranged from $0.48 to $73.24 in sensitivity analysis. Thus, we find the Me & You curriculum is cost-effective and cost-saving in most scenarios. Policymakers should carefully consider school-based DV prevention programs, and cost data should be regularly collected in adolescent prevention program evaluations.

Inconsistent Surgical Implant Documentation: A Case Study in Total Knee and Hip Arthroplasty

Value-based care initiatives require accurate quantification of resource utilization. This study explores hospital resource documentation performance for total knee and hip arthroplasty (TKA, THA) implants and how this may differ between hospitals. This retrospective study utilized the Premier discharge database, years 2006 to 2020. TKA/THA cases were categorized into 5 tiers based upon the completeness of implant component documentation: Platinum, Gold, Silver, Bronze, Poor. Correlation between TKA and THA documentation performance (per-hospital percentage of Platinum cases) was assessed. Logistic regression analyses measured the association between hospital characteristics (region, teaching status, bed size, urban/rural) and satisfactory documentation. TKA/THA implant documentation performance was compared to documentation for endovascular stent procedures. Individual hospitals tended to have very complete (Platinum) or very incomplete (Poor) documentation for both TKA and THA. TKA and THA documentation performance were correlated (correlation coefficient = .70). Teaching hospitals were less likely to have satisfactory documentation for both TKA (P = .002) and THA (P = .029). Documentation for endovascular stent procedures was superior compared to TKA/THA. Hospitals' TKA and THA-related implant documentation performance is generally either very proficient or very poor, in contrast with often well-documented endovascular stent procedures. Hospital characteristics, other than teaching status, do not appear to impact TKA/THA documentation completeness.

An epidemiologic retrospective study of maxillofacial traumatology in the elderly

INTRODUCTION

The elderly population, which is more active than before, is increasingly suffering from trauma (loss of reflexes and systemic pathologic conditions). Surgical management may be more controversial due to the potential consequences of general anesthesia and the sometimes negligible consequences of functional management. The main objective of this study was to analyze the causes and location of facial fractures in subjects older than 65 years. The secondary objective was to evaluate the management of these fractures (surgical or functional) according to comorbidities.

MATERIAL & METHODS

In this retrospective study (over a five-year period), we analyzed the causes and management of facial fractures in patients aged over 65 years, and the medical history of each patient was investigated.

RESULTS

One hundred and nineteen patients with 198 facial fractures were included. The main cause of fractures was a fall (50%). The zygomatic region (39.9%) and mandible (27.8%) were the sites of the most frequent fractures. Comorbidities were found in 84.9% of patients, the majority of which were cardiovascular diseases (82.3%). 75.8% of fractures were treated surgically and 4.8% of patients had complications.

DISCUSSION

This work is a help to understanding the causes and consequences of facial trauma in the elderly population. The management of these facial fractures requires a multidisciplinary assessment, taking into account the patient's medical history and evaluating the risks and benefits of a surgical procedure with general anesthesia.

Analysis of State Medicaid Expansion and Access to Timely Prenatal Care Among Women Who Were Immigrant vs US Born

IMPORTANCE

Disparities exist in access to timely prenatal care between immigrant women and US-born women. Exclusions from Medicaid eligibility based on immigration status may exacerbate disparities.

OBJECTIVE

To examine changes in timely prenatal care by nativity after Medicaid expansion.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional difference-in-differences (DID) and triple-difference analysis of 22 042 624 singleton births from January 1, 2011, to December 31, 2019, in 31 states was conducted using US natality data. Data analysis was performed from February 1, 2021, to August 24, 2022.

EXPOSURES

Within 16 states that expanded Medicaid in 2014, the rate of timely prenatal care by nativity in years after expansion was compared with the rate in the years before expansion. Similar comparisons were conducted in 15 states that did not expand Medicaid and tested across expansion vs nonexpansion states.

MAIN OUTCOMES AND MEASURES

Timely prenatal care was categorized as prenatal care initiated in the first trimester. Individual-level covariates included age, parity, race and ethnicity, and educational level. State-level time-varying covariates included unemployment, poverty, and Immigrant Climate Index.

RESULTS

A total of 5 390 814 women preexpansion and 6 544 992 women postexpansion were included. At baseline in expansion states, among immigrant women, 413 479 (27.3%) were Asian, 110 829 (7.3%) were Black, 752 176 (49.6%) were Hispanic, and 238 746 (15.8%) were White. Among US-born women, 96 807 (2.5%) were Asian, 470 128 (12.1%) were Black, 699 776 (18.1%) were Hispanic, and 2 608 873 (67.3%) were White. Prenatal care was timely in 75.9% of immigrant women vs 79.9% of those who were US born in expansion states at baseline. After Medicaid expansion, the immigrant vs US-born disparity in timely prenatal care was similar to the preexpansion level (DID, -0.91; 95% CI, -1.91 to 0.09). Stratifying by race and ethnicity showed an increase in the Asian vs White disparity after expansion, with 1.53 per 100 fewer immigrant women than those who were US born accessing timely prenatal care (95% CI, -2.31 to -0.75), and in the Hispanic vs White disparity (DID, -1.18 per 100; 95% CI, -2.07 to -0.30). These differences were more pronounced among women with a high school education or less (DID for Asian women, -2.98; 95% CI, -4.45 to -1.51; DID for Hispanic women, -1.47; 95% CI, -2.48 to -0.46). Compared with nonexpansion states, differences in DID estimates were found among Hispanic women with a high school education or less (triple-difference, -1.86 per 100 additional women in expansion states who would not receive timely prenatal care; 95% CI, -3.31 to -0.42).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that exclusions from Medicaid eligibility based on immigration status may be associated with increased health care disparities among some immigrant groups. This finding has relevance to current policy debates regarding Medicaid coverage during and outside of pregnancy.

Bendamustine is safe and effective for lymphodepletion before tisagenlecleucel in patients with refractory or relapsed large B-cell lymphomas

BACKGROUND

Anti-CD19 chimeric antigen receptor T-cell immunotherapy (CAR-T) is now a standard treatment of relapsed or refractory B-cell non-Hodgkin lymphomas; however, a significant portion of patients do not respond to CAR-T and/or experience toxicities. Lymphodepleting chemotherapy is a critical component of CAR-T that enhances CAR-T-cell engraftment, expansion, cytotoxicity, and persistence. We hypothesized that the lymphodepletion regimen might affect the safety and efficacy of CAR-T.

PATIENTS AND METHODS

We compared the safety and efficacy of lymphodepletion using either fludarabine/cyclophosphamide (n = 42) or bendamustine (n = 90) before tisagenlecleucel in two cohorts of patients with relapsed or refractory large B-cell lymphomas treated consecutively at three academic institutions in the United States (University of Pennsylvania, n = 90; Oregon Health & Science University, n = 35) and Europe (University of Vienna, n = 7). Response was assessed using the Lugano 2014 criteria and toxicities were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 and, when possible, the American Society for Transplantation and Cellular Therapy (ASTCT) consensus grading.

RESULTS

Fludarabine/cyclophosphamide led to more profound lymphocytopenia after tisagenlecleucel infusion compared with bendamustine, although the efficacy of tisagenlecleucel was similar between the two groups. We observed significant differences, however, in the frequency and severity of adverse events. In particular, patients treated with bendamustine had lower rates of cytokine release syndrome and neurotoxicity. In addition, higher rates of hematological toxicities were observed in patients receiving fludarabine/cyclophosphamide. Bendamustine-treated patients had higher nadir neutrophil counts, hemoglobin levels, and platelet counts, as well as a shorter time to blood count recovery, and received fewer platelet and red cell transfusions. Fewer episodes of infection, neutropenic fever, and post-infusion hospitalization were observed in the bendamustine cohort compared with patients receiving fludarabine/cyclophosphamide.

CONCLUSIONS

Bendamustine for lymphodepletion before tisagenlecleucel has efficacy similar to fludarabine/cyclophosphamide with reduced toxicities, including cytokine release syndrome, neurotoxicity, infectious and hematological toxicities, as well as reduced hospital utilization.

Factors associated with U.S. hospital payer-specific negotiated mammography charges

e13633

Background: The Hospital Price Transparency Rule, effective 1/1/2021, requires hospitals to publish payer-specific negotiated charges and cash prices. Given differences in insurance coverage for screening versus diagnostic mammography, we evaluate factors associated with these payer-negotiated charges. Methods: We conducted a cross-sectional study of U.S. acute care and critical access hospitals in CMS’ Care Compare linked to Turquoise Health (payer-negotiated charges), Healthcare Cost Report Information System (hospital characteristics) and Social Vulnerability Indices by county. Negotiated charges for mammography (CPT: screening 77067; diagnostic unilateral 77065, bilateral 77066) were estimated by payer type (self-pay, managed Medicare/Medicaid, or commercial). Adjusted models estimated commercial charges accounting for hospital factors. Results: Most hospitals (N=4212) were non-profits (61%) and acute care hospitals (69%). Median operating margin was .03 (IQR:-.03, .09), asset-to-liability ratio was 1.79 (1.06, 2.96), and social vulnerability index was .53 (.29, .74). 48-50% reported mammography charges. Charges were greater for commercial insurance compared to Medicare/Medicaid (+$55-$82 screening, +$122-$132 bilateral diagnostic; P<.001, all tests). Charges for commercial insurance were similar to self-pay for bilateral screening (p=.41) and diagnostic (p=.08) mammography. See Table for adjusted analysis of commercial charges. Conclusions: Our analysis showed U.S. negotiated mammography charges are similar for self-pay and commercial payers. Commercial charges are higher at private hospitals and those with higher operating margins for diagnostic exams, and lower in socially vulnerable areas. Price transparency may promote competition to lower healthcare prices and highlight any financial toxicity associated with self-pay charges. [Table: see text]

COVID-19 pandemic-related change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery hospitalization: a differences-in-differences analysis

OBJECTIVE

Exclusive breastmilk feeding during the delivery hospitalization, a Joint Commission indicator of perinatal care quality, is associated with longer-term breastfeeding success. Marked racial and ethnic disparities in breastfeeding exclusivity and duration existed prior to COVID-19. The pandemic, accompanied by uncertainty regarding intrapartum and postpartum safety practices, may have influenced disparities in infant feeding practices. Our objective was to examine whether the first wave of the COVID-19 pandemic in New York City was associated with a change in racial and ethnic disparities in exclusive breastmilk feeding during the delivery stay.

METHODS

We conducted a cross-sectional study of electronic medical records from 14,964 births in two New York City hospitals. We conducted a difference-in-differences (DID) analysis to compare Black-white, Latina-white, and Asian-white disparities in exclusive breastmilk feeding in a pandemic cohort (April 1-July 31, 2020, n=3122 deliveries) to disparities in a pre-pandemic cohort (January 1, 2019-February 28, 2020, n=11,842). We defined exclusive breastmilk feeding as receipt of only breastmilk during delivery hospitalization, regardless of route of administration. We ascertained severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection status from reverse transcription-polymerase chain reaction tests from nasopharyngeal swab at admission. For each DID model (e.g. Black-white disparity), we used covariate-adjusted log binomial regression models to estimate racial and ethnic risk differences, pandemic versus pre-pandemic cohort risk differences, and an interaction term representing the DID estimator.

RESULTS

Exclusive breastmilk feeding increased from pre-pandemic to pandemic among white (40.8% to 46.6%, p<0.001) and Asian (27.9% to 35.8%, p=0.004) women, but not Black (22.6% to 25.3%, p=0.275) or Latina (20.1% to 21.4%, p=0.515) women overall. There was an increase in the Latina-white exclusive breastmilk feeding disparity associated with the pandemic (DID estimator=6.3 fewer cases per 100 births (95% CI=-10.8, -1.9)). We found decreased breastmilk feeding specifically among SARS-CoV-2 positive Latina women (20.1% pre-pandemic vs. 9.1% pandemic p=0.013), and no change in Black-white or Asian-white disparities.

CONCLUSIONS

We observed a pandemic-related increase in the Latina-white disparity in exclusive breastmilk feeding, urging hospital policies and programs to increase equity in breastmilk feeding and perinatal care quality during and beyond this health emergency.

Surviving a global pandemic: The experience of depression, anxiety, and loneliness among individuals with multiple sclerosis

Background

The world has been experiencing one of the most significant worldwide health pandemics in modern history. The result has been increased depression, anxiety, and loneliness in the general population. However, populations who demonstrated pre-pandemic emotional disturbance and social isolation, such as individuals with multiple sclerosis (MS), are likely uniquely vulnerable to such symptoms.

Objective

The purpose of the present investigation was to examine the emotional outcomes, including reports of loneliness, in individuals with MS during the COVID-19 pandemic. We additionally sought to examine how individuals’ experiences during the pandemic may contribute to a specific COVID-19-related depression or anxiety.

Methods

142 individuals with MS who previously participated in a national, online, survey-based study were asked to complete an online survey assessing their current level of depression, anxiety, loneliness, and perceived impact of the COVID-19 pandemic.

Results

Increases in the rates of depression and anxiety were noted, with approximately 54% and 33% reporting “new” depression or anxiety, respectively. Given this increase, we examined how individuals with “new” depression or anxiety differed from those without depression and anxiety and those with pre-pandemic depression and/or anxiety. Significant differences in person-specific factors (e.g., personality, self-efficacy) were noted between the groups. Increased loneliness was also found among both those with depression or anxiety regardless of whether “new” or pre-pandemic. Finally, all those depressed or anxious reported greater disruption and distress related to the COVID-19 pandemic with a trend for increased anxiety specifically related to the pandemic (e.g., fear or dying due to COVID-19) among those with new depression or anxiety when compared to those with existing depression or anxiety, suggesting an influence of the pandemic that is specific to reports of new depression or anxiety.

Conclusion

Findings suggest increased depression, anxiety, and loneliness among individuals with MS following the COVID-19 pandemic, with reports of “new” depression or anxiety, which appears to be related to the pandemic, specifically. Moreover, factors commonly associated with depression or anxiety in MS (e.g., personality, self-efficacy) were more common among those with existing depression or anxiety but not among those experiencing new depression or anxiety. These differences should be considered when attempting to ameliorate the impact of the COVID-19 among those experiencing emotional distress.

POS0020 EFFICACY AND SAFETY OF SECUKINUMAB IN PATIENTS WITH ROTATOR CUFF TENDINOPATHY: A 24-WEEK, RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED, PHASE II PROOF-OF-CONCEPT TRIAL

Background:

Rotator cuff tendinopathy (RC TP) is a multifactorial condition and one of the most common causes of musculoskeletal burden. Current standard of care (SoC) is limited to pain relief with NSAIDs and physiotherapy. Recent evidence indicates that IL-17A-expressing tendon-resident immune cells are present in human overuse tendinopathy, and IL-17A levels are increased in early human tendinopathic tissue samples [1, 2]. Secukinumab (SEC) is a fully human, monoclonal antibody that binds to and neutralises IL-17A.

Objectives:

To evaluate the efficacy and safety of SEC in patients with active overuse RC TP refractory to oral NSAIDs/acetaminophen, physiotherapy or corticosteroid injections.

Methods:

96 patients with symptomatic RC TP with no or <50% rupture were randomly assigned to receive seven subcutaneous injections of SEC 300 mg or placebo (PBO) at baseline and Weeks 1, 2 and 3, followed by every 4 weeks starting at Week 4. The primary endpoint was change from baseline in the Western Ontario Rotator Cuff (WORC) index score at Week 14 for SEC vs PBO (two-sided p<0.1). Secondary endpoints included, visual analogue scale (VAS) pain score, Disability of Arm, Shoulder and Hand Questionnaire (QuickDASH) score, American Shoulder and Elbow Surgeons Shoulder Evaluation Form (ASES), EQ-5D-5L score and patient global assessment (PGA) score. All endpoints were assessed through 24 weeks.

Results:

Clinically relevant improvement in both SEC and PBO groups on top of SoC treatment was observed, with no statistically significant difference demonstrated in the full study population on physical symptoms and function (Table 1). Similar results were observed in the secondary endpoints with marked improvement in both groups over time. Exploratory post-hoc analyses in a subpopulation of 39% of the study subjects with non-acute, moderate to severe disease, SEC provided significant and clinically relevant improvements vs PBO through Week 24 in total WORC score (overall treatment difference: 19.2, p <0.01) and pain (VAS, overall treatment difference: 15, p = 0.02) with early effect observed after two weeks (Figure 1). A favourable treatment effect in the more severe subgroup was demonstrated in other patient-reported outcomes. No serious adverse events were reported.

Conclusion:

Although SEC did not demonstrate a significant benefit vs PBO in the overall patient population with active overuse RC TP, SEC did provide benefit in the subpopulation with non-acute, moderate to severe disease. Larger clinical trials of SEC in this area are warranted.

References:

[1]Millar NL, et al. Sci Rep. 2016;6:27149.

[2]Millar NL, et al. Nat Rev Rheumatol.2017;13:110-122.

Table 1.

Change from baseline in the SEC versus PBO groups in WORC index and pain (VAS)

VisitSEC 300 mgPBOp-valueTotal treated population N=96WORC Index percentage score (0 worst -100 best)aDay 2922.3519.490.45Day 9937.0037.770.87Day 16943.4140.970.64Pain (VAS, 0 best - 100 worst)bDay 29−26.04−23.130.57Day 99−46.11−40.560.28Day 169−52.23−50.740.78Post-hoc population* N=37WORC Index percentage score (0 worst - 100 best)cDay 2930.0910.840.002Day 9948.2631.830.048Day 16955.9835.240.028Pain (VAS, 0 best - 100 worst)dDay 29−29.20−14.850.125Day 99−51.48−35.370.045Day 169−57.01−46.640.217

aDay 1: SEC 42.47, PBO 40.47; bSEC 67.04, PBO 64.85; cSEC 35.93, PBO 32.90, dSEC 71.72, PBO 67.58. Day 1 values are given as absolute values to describe baseline WORC/Pain status

*Post-hoc subpopulation: Baseline: (Disease duration 2-6 months) AND (WORC ≤40 OR Tear Thickness (Bauer) ≥1 OR Sein ≥2)

PBO, placebo; SEC, secukinumab; SoC, standard of care; WORC, Western Ontario Rotator Cuff Index; VAS, visual analogue scale

Figure 1.

Post-hoc analysis of function (WORC) in the treatment groups in non-acute, moderate to severe subpopulation

SEC

SE, standard error; SEC, secukinumab; WORC, Western Ontario Rotator Cuff Index

Disclosure of Interests:

Neal L Millar Grant/research support from: Honoraria or research funding from Novartis and Stryker, Iain McInnes Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Lilly, Novartis, Pfizer, and UCB, Linda Mindeholm Employee of: Employee of Novartis, Abdelkader Seroutou Employee of: Employee of Novartis, Jens Praestgaard Employee of: Employee of Novartis, Ursula Schramm Employee of: Employee of Novartis, Rafael Levitch Employee of: Employee of Novartis, Eckhard Weber Employee of: Employee of Novartis, Didier Laurent Employee of: Employee of Novartis, Jeffrey Rosen Consultant of: Research advisor for Novartis, Georg Schett Speakers bureau: Received speakers honoraria from Abbvie, Amgen, BMS, Eli Lilly, Gilead, Janssen, Novartis, UCB, Ronenn Roubenoff Employee of: Employee of Novartis, Matthias Schieker Employee of: Employee of Novartis.

Racial/Ethnic Disparities in Very Preterm Birth and Preterm Birth Before and During the COVID-19 Pandemic

IMPORTANCE

The coronavirus disease 2019 (COVID-19) pandemic may exacerbate existing racial/ethnic inequities in preterm birth.

OBJECTIVE

To assess whether racial/ethnic disparities in very preterm birth (VPTB) and preterm birth (PTB) increased during the first wave of the COVID-19 pandemic in New York City.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 8026 Black, Latina, and White women who gave birth during the study period. A difference-in-differences (DID) analysis of Black vs White disparities in VPTB or PTB in a pandemic cohort was compared with a prepandemic cohort by using electronic medical records obtained from 2 hospitals in New York City.

EXPOSURES

Women who delivered from March 28 to July 31, 2020, were considered the pandemic cohort, and women who delivered from March 28 to July 31, 2019, were considered the prepandemic cohort. Reverse transcription-polymerase chain reaction tests for the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were performed using samples obtained via nasopharyngeal swab at the time of admission.

MAIN OUTCOMES AND MEASURES

Clinical estimates of gestational age were used to calculate VPTB (<32 weeks) and PTB (<37 weeks). Log binomial regression was performed to estimate Black vs White risk differences, pandemic cohort vs prepandemic cohort risk difference, and an interaction term representing the DID estimator. Covariate-adjusted models included age, insurance, prepregnancy body mass index, and parity.

RESULTS

Of 3834 women in the pandemic cohort, 492 (12.8%) self-identified as Black, 678 (17.7%) as Latina, 2012 (52.5%) as White, 408 (10.6%) as Asian, and 244 (6.4%) as other or unspecified race/ethnicity, with approximately half the women 25 to 34 years of age. The prepandemic cohort comprised 4192 women with similar sociodemographic characteristics. In the prepandemic cohort, VPTB risk was 4.4% (20 of 451) and PTB risk was 14.4% (65 of 451) among Black infants compared with 0.8% (17 of 2188) VPTB risk and 7.1% (156 of 2188) PTB risk among White infants. In the pandemic cohort, VPTB risk was 4.3% (21 of 491) and PTB risk was 13.2% (65 of 491) among Black infants compared with 0.5% (10 of 1994) VPTB risk and 7.0% (240 of 1994) PTB risk among White infants. The DID estimators indicated that no increase in Black vs White disparities were found (DID estimator for VPTB, 0.1 additional cases per 100 [95% CI, -2.5 to 2.8]; DID estimator for PTB, 1.1 fewer case per 100 [95% CI, -5.8 to 3.6]). The results were comparable in covariate-adjusted models when limiting the population to women who tested negative for SARS-CoV-2. No change was detected in Latina vs White PTB disparities during the pandemic.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of women who gave birth in New York City during the COVID-19 pandemic, no evidence was found for increased racial/ethnic disparities in PTB, among women who tested positive or tested negative for SARS-CoV-2.

Characteristics of telehealth users in NYC for COVID-related care during the coronavirus pandemic

OBJECTIVE

To explore whether racial/ethnic differences in telehealth use existed during the peak pandemic period among NYC patients seeking care for COVID-19 related symptoms.

MATERIALS AND METHODS

This study used data from a large health system in NYC - the epicenter of the US crisis - to describe characteristics of patients seeking COVID-related care via telehealth, ER, or office encounters during the peak pandemic period. Using multinomial logistic regression, we estimated the magnitude of the relationship between patient characteristics and the odds of having a first encounter via telehealth versus ER or office visit, and then used regression parameter estimates to predict patients' probabilities of using different encounter types given their characteristics.

RESULTS

Demographic factors, including race/ethnicity and age, were significantly predictive of telehealth use. As compared to Whites, Blacks had higher adjusted odds of using both the ER versus telehealth (OR: 4.3, 95% CI: 4.0-4.6) and office visits versus telehealth (OR: 1.4, 95% CI: 1.3-1.5). For Hispanics versus Whites, the analogous ORs were 2.5 (95% CI: 2.3-2.7) and 1.2 (95% CI: 1.1-1.3). Compared to any age groups, patients 65+ had significantly higher odds of using either ER or office visits versus telehealth.

CONCLUSIONS

The response to COVID-19 has involved an unprecedented expansion in telehealth. While older Americans and minority populations among others are known to be disadvantaged by the digital divide, few studies have examined disparities in telehealth specifically, and none during COVID-19. Additional research into sociodemographic heterogeneity in telehealth use is needed to prevent potentially further exacerbating health disparities overall.

Diagnostic performance of mobile cone beam computed tomography versus conventional multi-detector computed tomography in orbital floor fractures: a study on human specimens

The aim of this study was to evaluate the diagnostic accuracy of mobile cone beam computed tomography (MCBCT) versus multi-detector computed tomography (MDCT) in orbital floor fractures. Twenty-four fresh cadaver heads were used, and one orbital floor was fractured for each head by transconjunctival approach. MDCT and MCBCT were performed on each of the heads. The images obtained were then analysed independently by eight evaluators. The radiological characteristics of the orbital floor fractures were visualized with good interpretation agreement between the two images. The location of the fracture and enophthalmos were identified in a comparable manner with strong agreement (κ=0.93 and κ=0.85, respectively). Measurements of fatty hernias and bone defects showed a strong correlation between the two imaging modalities (Pearson coefficient between 0.64 and 0.71 and between 0.67 and 0.71, respectively). The fracture limits and the presence of bone fragments, an intrasinus fatty hernia, and a fracture of the associated medial orbital wall were visualized in both examinations with good agreement (κ=0.68, κ=0.51, κ=0.57, and κ=0.46, respectively). The soft tissue study showed superiority for MDCT, with a κ<0.0009. MCBCT showed good diagnostic performance in the study of orbital floor fracture characteristics.

How useful is intraoperative cone beam computed tomography in maxillofacial surgery? An overview of the current literature

Intraoperative imaging is increasingly used by surgeons and has become an integral part of many surgical procedures. This study was performed to provide an overview of the current literature on the intraoperative use of cone beam computed tomography (CBCT) imaging in maxillofacial surgery. A bibliographic search of PubMed was conducted in March 2020, without time limitation, using "intraoperative imaging" AND "maxillofacial surgery" AND "cone beam computed tomography" as key words. Ninety-one articles were found; after complete reading, 16 articles met the eligibility criteria and were analysed. The results showed that the majority of the indications were related to maxillofacial trauma, particularly zygomaticomaxillary complex fractures. Final verification with intraoperative CBCT before wound closure was the most common use of this device. However, innovative uses of intraoperative CBCT are expanding, such as CBCT coupling with mirror computational planning, and even the combined use of initial intraoperative CBCT acquisition with navigation. Immediate, fast, and easy evaluation of bone repositioning to avoid the need for further surgical revision is the main advantage of this technique. Imaging quality is comparable to that of multi-slice computed tomography, but with lower radiation exposure. Nevertheless, CBCT is still not widely available in maxillofacial centres, probably because of its cost, and perhaps because not everyone is aware of its advantages and versatility, which are reported in this review.

Vesicoamniotic shunting for fetal megacystis in the first trimester with a Somatex® intrauterine shunt

Purpose

The objective was to evaluate the feasibility of vesicoamniotic shunting (VAS) in the first trimester with the Somatex^® intrauterine shunt and report on complications and neonatal outcome.

Methods

Retrospective cohort study of all VAS before 14 weeks at two tertiary fetal medicine centres from 2015 to 2018 using a Somatex^® intrauterine shunt. All patients with a first trimester diagnosis of megacystis in male fetuses with a longitudinal bladder diameter of at least 15 mm were offered VAS. All patients that opted for VAS after counselling by prenatal medicine specialists, neonatologists and pediatric nephrologists were included in the study. Charts were reviewed for complications, obstetric and neonatal outcomes.

Results

Ten VAS were performed during the study period in male fetuses at a median GA of 13.3 (12.6–13.9) weeks. There were two terminations of pregnancy (TOP) due to additional malformations and one IUFD. Overall there were four shunt dislocations (40%); three of those between 25–30 weeks GA.

Seven neonates were born alive at a median GA of 35.1 weeks (31.0–38.9). There was one neonatal death due to pulmonary hypoplasia. Neonatal kidney function was normal in the six neonates surviving the neonatal period. After exclusion of TOP, perinatal survival was 75%, and 85.7% if only live-born children were considered.

Conclusion

VAS in the first trimester is feasible with the Somatex^® Intrauterine shunt with low fetal and maternal complication rates. Neonatal survival rates are high due to a reduction in pulmonary hypoplasia and the rate of renal failure at birth is very low. VAS can be safely offered from the late first trimester using the Somatex^® intrauterine shunt.

The high sub-mandibular approach: Our experience about 496 procedures

INTRODUCTION

The potential drawbacks of surgical approaches to neck and base fractures of the mandibular condyle (visible scare, facial nerve injury) are still considered by many surgeons as a brake for open reduction and internal fixation. The aim of our study was to analyze the results in terms of access, scare quality and complications that could be noticed in a 12 years period of time with the use of the high sub-mandibular approach (HSMA) we first described in 2006 for the surgical treatment of neck and base fractures.

MATERIAL AND METHOD

All the files of patients operated on for condylar neck and base fractures approached by mean of a HSMA between January 2006 and December 2018 in our department and containing information concerning age, sex, type of fracture, kind of osteosynthesis material, operating time, name of the surgeon, postoperative complication linked to the approach, scare quality at 6 months follow-up at least were included. The skin incision and the dissection planes followed the original publication of Meyer et al. in 2006.

RESULTS

434 patients (sex ratio: 2.06, mean age: 32, 496 approaches) met the inclusion criteria. Following the AO classification, 21.2% of the fractures were classified as neck fractures and 78.8% as base fractures. 97.6% of all fractures were stabilized by mean of a 3D plate (TCP® plate, Medartis, Basel-CH), the remaining ones by mean of a combination of 1.2, 1.5 and 2.0 straight plates. Mean operating time was 40minutes per side. Patients were operated on by senior surgeons in 71.7% of the cases and by trainees under supervision for the others. Concerning the complications linked to the approach, we noticed 11 (2.2%) temporary (0 definitive) paresis of the facial nerve, 1 (0.2%) hematoma and 1 (0.2%) abscess that both needed revision. Scare was hypertrophic or considered as unaesthetic by the patient in 5 cases (1%).

DISCUSSION

The HSMA, if performed as initially described, is a safe and quick procedure compared to other cutaneous approaches. It gives access to all base fractures and to most of neck fractures. The very low rate of facial nerve complications is mainly explained by the plane by plane dissection making it very easy to avoid the facial nerve branches or to check them when encountered. The HSMA is particularly suited to the use of TCP plates as the upper holes of these plates, placed horizontally, are easy to reach from below. The HSMA is therefore still our preferred cutaneous approach to the condylar process.

Acute renal and splenic infarctions: a review

BACKGROUND

Renal and splenic infarctions are close entities, with few data concerning their clinical, biological and radiological features.

AIM

The aim of this study was to compare the clinical presentations, etiologies and outcomes of acute renal infarctions (RI) and splenic infarctions (SI).

DESIGN

A retrospective multicentric cohort study included patients of the 6 university hospitals in Lyon with RI, SI, or associated RI-SI infarctions was conducted.

METHODS

All consecutive cases diagnosed by CT imaging, between January 2013 and October 2016, were included. The exclusion criteria were causes of infarction that did not require additional investigations.

RESULTS

A total of 161 patients were selected for analysis: 34 patients with RI, 104 patients with SI and 23 patients with both RI-SI. Mean ± SD age of patients was 63.2 ± 16.6 years; 59.6% were male. Only 5/161 (3.1%) were healthy prior to the event. The main symptoms were diffuse abdominal pain (26.4%), followed by nausea/vomiting (18.3%) and fever (16.4%).The causes of RI or SI varied significantly within the three groups. Hypercoagulable state was associated with SI, and embolic disease and arterial injury were associated with RI. Extensive (i.e.>2/3 of organ volume) (OR 6.22, 95%CI 2.0119.22) and bilateral infarctions (OR 15.05, 95%CI 1.79-126.78) were significantly associated with hemodynamic shocks. The survival at 1 month follow-up did not significantly differ between the three groups.

CONCLUSION

Acute RI and SI are heterogenous entities in regards to their clinical presentation, etiology, associated venous or arterial thrombosis, but prognoses were not different at short term follow-up.

Peering Behind the Veil: Trends in Types of Contracts Between Private Health Plans and Hospitals

Contracting between private health plans and hospitals has been described as "chaos behind a veil of secrecy." We develop a novel algorithm that classifies inpatient claims as one of three contract types-discounted charges, fixed rates, or per diems-and apply it to the 2009-2014 Colorado All Payer Claims Database. Of $1.1 billion in classifiable private health plan payments for inpatient care in Colorado, we find that 42.1% were fixed rates, 41.1% were discounted charges, and 16.0% were per diems. We find wide variation in contract types among private health plans and hospital types, and a pronounced shift over the study period in private plans' contract types, away from discounted charges, and toward fixed rates. To test our algorithm's validity, we apply it to Colorado Medicare and Medicaid claims-both of which are known primarily to pay using fixed rates-and find, reassuringly, that 86.3% of Medicare payments (98.6% when we exclude Medicare claims with special payment rules) and 79.7% of Medicaid payments are classified as fixed rates.

Effects of Sulfated Polysaccharides on Inhibition of Thrombus Formation initiated by Different Stimuli

To test the possibility that different doses of heparin or other sulfated polysaccharides are required to inhibit thrombosis initiated by different stimuli, we compared the effects of heparin (HEP), pentosan polysulfate (SP54) and dermatan sulfate (DS) on the inhibition of thrombus formation induced by either I) tissue thromboplastin; II) thrombin; or III) factor Xa. Inhibition of thrombus formation induced by the stimuli was measured in a rabbit jugular vein hypercoagulation/stasis model. First, we determined the minimum dose of each sulfated polysaccharide which inhibited tissue thromboplastin-induced thrombus formation by ∼75%, and then compared the relative effectiveness of this dose to prevent thrombus formation initiated with the other two stimuli. HEP and SP54 were less effective when thrombin was the thrombogenic stimulus, while DS was more effective. HEP was the most effective agent when factor Xa was the stimulus. We conclude that the antithrombotic effectiveness of a given dose of a sulfated polysaccharide may vary depending on the stimulus which initiates thrombus formation.

Zur Enantioselektivität von Phenprocoumon beim Menschen*

Enantiomere sind Moleküle, die sich wie Bild zu Spiegelbild verhalten; sie weisen fast identische chemische oder physikalische Eigenschaften auf, unterscheiden sich aber in ihren physiologischen Wirkungen. Es wird über das unterschiedliche pharmakokinetische Verhalten und die differierenden pharmakodynamischen Eigenschaften der Enantiomeren der oralen Antikoagulanzien Phenoprocoumon (PH), Warfarin (WA) und Acenocoumarol (AC) beim Menschen und über die daraus resultierenden therapeutischen Konsequenzen berichtet.

Für eigene Untersuchungen zur enantioselektiven Elimination von PH bei einer großen Zahl von Patienten unter Langzeit-Antikoagulation wurden die Enantiomere aus Plasmaund Urinproben mit HPLC an chiralen Säulen getrennt und quantifiziert. Die Ergebnisse zeigten folgendes: 1. Bei 50% der Patienten wird das S-Enantiomer langsamer aus dem Plasma eliminiert als das R-Enantiomer, bei 25% mit gleicher Geschwindigkeit und bei weiteren 25% schneller. Dies weist auf eine große interindividuelle Variabilität hin. 2. Das S/R-Verhältnis im Plasma war über die Zeit konstant (intraindividuell konstantes S/R-Verhältnis). 3. Im Durchschnitt wird das S-Enantiomer jedoch nach Abbruch der PHTherapie schneller eliminiert als das R-Enantiomer. Die Eliminationshalbwertszeiten aus dem Plasma betragen 123,7 ± 43,6 h für das Sund 156,5 ± 72,4 h für das R-Enantiomer. 4. Die Plasmaproteinbindung für das Sund R-Enantiomer ist unterschiedlich (fu%: 0,198 für S; 0,322 für R). 5. Der enantioselektive Effekt der Elimination ist bei PH nicht so ausgeprägt wie bei WA und könnte das beobachtete unterschiedliche Spektrum an Interaktionen mit anderen Arzneimitteln erklären.

Veränderungen der freien Thrombozytennukleotide beim Sanarelli-Shwartzman-Phänomen

Beim Sanarelli-Shwartzman-Phänomen des Kaninchens findet man neben anderen Gerinnungsstörungen auch eine verminderte Retraktionsfähigkeit des Blutes. Ursache hierfür ist ein Verlust von energiereichem Phosphat (ATP) in den Thrombozyten, welches offenbar mit anderen Nukleotiden die geschädigten Plättchen verläßt. Es kann dabei eine quantitative Beziehung zwischen dem ATP-Gehalt der Plättchen und dem m-Wert des TEG nachgewiesen werden. Für die Thrombozytenschädigung wird intravasal auftretendes Thrombin verantwortlich gemacht, welches die viskose Metamorphose startet, die Permeabilität verändert und so die Blutplättchen zum Untergang vorbereitet. Quantitative und qualitative Plättchenveränderungen sind die Folge. Freiwerdende Plättchen- lipide gehen im Rahmen der Thrombokinasefunktion des Blutes in den ubiquitären intravasalen Gerinnungsprozeß ein. Die konsekutive Thrombozytopathie bzw. experimentelle “Thrombasthenie” bietet gewissermaßen im Modell weitere Ansatzpunkte für Thrombozytenstudien.

Über die Wirkung von Lipidemulsionen auf Blutplättchen

In vorliegenden Untersuchungen konnte gezeigt werden, daß zahlreiche Lipid-Wasser-Emulsionen zu einer ausgeprägten und rasch einsetzenden Steigerung der Thrombozytenaggregation führen. Bei Abwesenheit von Kalziumionen in EDTA-Plasma ließ sich ein Lipideffekt an Thrombozyten nicht mehr nachweisen. Mehrfach gewaschene Plättchen zeigten jedoch auch ohne Kalziumionen eine deutliche Steigerung der Aggregation. Bei 4° C war der Ablauf der Aggregation deutlich verlangsamt. Die Zugabe von Albumin oder EPL verhinderte die aggregationssteigernde Wirkung einer Lipidemulsion. Adenosin führte lediglich zu einer teilweisen Hemmung der lipid -induzierten Klebrigkeitssteigerung. Aufgrund der Ergebnisse wird vermutet, daß der erste Schritt der Wirkung einer Lipidemulsion auf Thrombozyten mit der Oberflächenaktivität der Emulsionsteilchen in ursächlichem Zusammenhang steht. Im weiteren Verlauf kommt es zu einer Phagozytose von Lipidemulsionsteilchen durch Thrombozyten, was mit einer Zunahme einer Aggregationsneigung und erheblichen morphologischen und biochemischen Veränderungen verknüpft ist.

Über die Wirkung von Lipidemulsionen auf Blutplättchen

Der Einfluß emulgierter Lipide (Fettsäuren, Triglyzeride, Lipidgemische) und fettähnlicher Substanzen (Paraffin- und Silikonöl) auf die Struktur der Blutplättchen von Mensch und Schwein wurde licht- und elektronenmikroskopisch untersucht. Es zeigte sich, daß die Emulsionsteilchen aller geprüften Substanzen von den Plättchen durch Membraninvagination, wie das bei phagozytierenden Zellen bekannt ist, aufgenommen werden. Daneben beobachteten wir eine vermutlich ADP-induzierte Neigung der Plättchen zu aggregieren, die durch Adenosin gehemmt wurde. Emulsionen mit hohem Anteil unveresterter Fettsäuren oder reine Fettsäureemulsionen führten darüber hinaus zu starken Destruktionen der Plättchen, während nach Behandlung mit Triglyzeriden oder Lipidgemischen ohne freie Fettsäuren diese Erscheinungen erst nach langen Inkubationszeiten auftraten und sich vermindern ließen, wenn die intraplasmatische Lipolyse durch Protaminsulfat gehemmt wurde. Der Zusatz von Emulgatoren (Albumin, Phospholipide) setzte die Fettsäurewirkung und die Aggregationsneigung der Plättchen herab, EDTA verhinderte die Aggregatbildung völlig. Aus den Beobachtungen schließen wir, daß für die Aufnahme von Lipiden die Eigenschaften der Emulsionsteilchen bestimmend sind, während freie Fettsäuren aufgrund ihrer Moleküleigenschaften die Plättchenmembranen passieren und in hohen Konzentrationen zur Zellzerstörung führen.

Surgically assisted rapid palatal expansion in class III malocclusion: Our experience

INTRODUCTION

Maxillary transverse deficiency (MTD) is a common facial disharmony that may need surgical assisted rapid palatal expansion (SARPE). The aim of this study was to present our SARPE technique and to report about our experience.

MATERIEL AND METHOD

Medical records of all class III patients who underwent SARPE in our department from 2010 to 2015 and for whom a follow-up of at least 1year was available, were included in a retrospective study. The technique consisted, after short orthodontic preparation allowing for divergence of the upper central incisors, in a complete Le Fort I osteotomy without down fracture, and medial sagittal submucosal separation of the hard palate under general anesthesia in an inpatient procedure. Teeth-supported distracters were sealed preoperatively while bone-supported devices were inserted peroperatively. Activation of the distracter was allowed from day 2 at the rate of 2×0.25 per day during 4days and 2×0.5mm per day the following days. Distracters were left in place for about 4months. Orthodontic treatment resumption was allowed from the second month. The initial malocclusion, the amount and type (parallel or angular) of distraction that was needed, the type of distracter used, the amount of distraction obtained, the per- and postoperative complications and the clinical stability of the end result were analyzed.

RESULTS

The records of 23 patients (18 women, 5 men - average age: 25.4years, extremes: 16-55years) could be included. MTD was isolated in 6 cases, associated with a maxillary retrognathism in 5 cases, with a mandibular prognathism in 6 cases, and with both in 6 cases. The average amount of distraction needed was 7.2mm (range: 4-12), parallel in 20 cases and angular in 3 cases. The distracters were bone-supported (Rapid Palatal Expander^®, KLS Martin Group, Tuttlingen, Germany) in 3 patients and custom-made tooth-supported in 20 patients. The average amount of distraction obtained at the level of the distracter cylinder was 7.7mm (range: 5-13). We noted 2 cases of palatal fibromucosa perforations, 1 case of posterior excess of distraction, 1 case of nasal septum deviation, 1 case of iatrogenic necrosis of tooth No.°11, 1 case of naso-genial sulcus hematoma, 1 case of intraoperative mobility of tooth No.°21, 5 cases of asymmetric distraction. Seventeen patients needed a second orthognathic procedure and 22 had stable Class I occlusion after removal of appliances at 18 months follow-up on average.

DISCUSSION

SARPE is a quite safe procedure that allows for transverse coordination without dental extraction. Transverse discrepancies greater than 4mm are for us clear indications for SARPE. When a sagittal discrepancy is associated, we prefer performing SARPE first and correcting the sagittal plane in a second operation. The recent development of Le Fort I sliding osteosynthesis plates opens the way to one time correction and the development of double-action distracters fitted out with 2 cylinders will be helpful for performing angular distractions.

Pulmonary lymphatic vessel morphology: a review

Our understanding of lymphatic vessels has been advanced by the recent identification of relatively specific lymphatic endothelium markers, including Prox-1, VEGFR3, podoplanin and LYVE-1. The use of lymphatic markers has led to the observation that, contrary to previous assumptions, human lymphatic vessels extend deep inside the pulmonary lobule, either in association with bronchioles, intralobular arterioles or small pulmonary veins. Pulmonary lymphatic vessels may thus be classified into pleural, interlobular (in interlobular septa) and intralobular. Intralobular lymphatic vessels may be further subdivided in: bronchovascular (associated with a bronchovascular bundle), perivascular (associated with a blood vessel), peribronchiolar (associated with a bronchiole), and interalveolar (in interalveolar septa). Most of the intralobular lymphatic vessels are in close contact with a blood vessel, either alone or within a bronchovascular bundle. A minority is associated with a bronchiole, and small lymphatics are occasionally present even in interalveolar septa, seemingly independent of blood vessels or bronchioles. The lymphatics of the interlobular septa often contain valves, are usually associated with the pulmonary veins, and connect with the pleural lymphatics. The large lymphatics associated with bronchovascular bundles have similar characteristics to pleural and interlobular lymphatics and may be considered conducting vessels. The numerous small perivascular lymphatics and the few peribronchiolar ones that are found inside the lobule are probably the absorbing compartment of the lung responsible for maintaining the alveolar interstitium relatively dry in order to provide a minimal thickness of the air-blood barrier and thus optimize gas diffusion. These lymphatic populations could be differentially involved in the pathogenesis of diseases preferentially involving distinct lung compartments.

Tendon healing induced by chemically modified mRNAs

Tendon disorders are frequent both in human and veterinary medicine with high re-injury rates and unsatisfactory therapeutic treatments. Application of naked, chemically-modified mRNA (cmRNA), encoding for therapeutic proteins, is an innovative approach to address tendon healing. In the current study, we demonstrated that injection of naked cmRNA, diluted in a glucose-containing solution, into tendons resulted in high protein expression in healthy and experimentally-injured tendons. Injection of bone morphogenetic protein 7 (BMP-7)-encoding cmRNA resulted in a significantly higher expression of BMP-7 protein and reduced formation of collagen type III, compared to vehicle control. Moreover, in a large animal model, reporter protein expression was detectable not only in healthy, but also in experimentally-injured, severely inflamed tendons. Summarising, these results demonstrated the potential of cmRNAs encoding for therapeutic proteins as a new class of drugs for the treatment of tendon disorders.