Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Modelling the effects of post-FESS middle turbinate synechiae on sinonasal physiology: A computational fluid dynamics study

OBJECTIVE(S)

Chronic rhinosinusitis (CRS) is common and often requires surgical intervention. Surgical failure may lead to persistent symptoms and recalcitrant disease, often secondary to synechiae between the middle turbinate (MT) and lateral nasal wall. Synechiae prevention techniques have been extensively investigated, however evidence for the effect of synechiae on sinonasal physiology is lacking. We aimed to model the effects of MT synechiae on a post-functional endoscopic sinus surgery (FESS) sinonasal cavity using computational fluid dynamics (CFD).

METHODS

DICOM data from a CT-sinus of a healthy 25-year-old female was segmented to create a three-dimensional model. Virtual surgery was performed to simulate a "full-house" FESS procedure. Multiple models were created, each with a single unilateral virtual MT synechia of varying extent. CFD analysis was performed on each model and compared with a post-FESS control model without synechiae. Airflow velocity, humidity and mucosal surface and air temperature values were calculated.

RESULTS

All synechiae models demonstrated aberrant downstream sinonasal airflow. There was reduced ventilation of the ipsilateral frontal, ethmoid and sphenoid sinuses, with a concentrated central "jet" in the middle meatus region. Effects were proportionate to the size of synechiae. The impact on bulk inspired airflow was negligible.

CONCLUSION

Post-FESS synechiae between the MT and lateral nasal wall significantly disrupt local downstream sinus ventilation and nasal airflow. These findings may explain the persistent symptoms seen in post-FESS CRS patients with MT synechiae, reinforcing the importance of prevention and adhesiolysis. Larger cohort studies with multiple models of actual post-FESS patients with synechiae are required to validate these findings.

Combined genioplasty, chondrolaryngoplasty, and glottoplasty: A novel scarless procedure in facial feminization surgery

Facial feminization is a long process with multiple surgical steps that is known to improve quality of life in transgender patients. Visible scars are a frequent complaint by this community as it adds to the stigmatization in this population. Combined procedures have been shown to be effective, by reducing the number of hospitalizations and the total length of recovery periods. In this context, we propose a novel scarless procedure combining a chondrolaryngoplasty, a glottoplasty, and a genioplasty using solely a transoral approach. First, we perform a glottoplasty according to the technique described by Wendler et al. and then a contraction genioplasty. Finally, the thyroid cartilage is approached by a subplatysmal dissection, between the mandibular osteotomy fragments. For now, 15 patients have benefited from this procedure in our department. Preliminary results demonstrate that this is an easy and safe procedure with good esthetic results and good patient satisfaction.

An artificial intelligence algorithm for the classification of sphenoid sinus pneumatisation on sinus computed tomography scans

BACKGROUND

Classifying sphenoid pneumatisation is an important but often overlooked task in reporting sinus CT scans. Artificial intelligence (AI) and one of its key methods, convolutional neural networks (CNNs), can create algorithms that can learn from data without being programmed with explicit rules and have shown utility in radiological image classification.

OBJECTIVE

To determine if a trained CNN can accurately classify sphenoid sinus pneumatisation on CT sinus imaging.

METHODS

Sagittal slices through the natural ostium of the sphenoid sinus were extracted from retrospectively collected bone-window CT scans of the paranasal sinuses for consecutive patients over 6 years. Two blinded Otolaryngology residents reviewed each image and classified the sphenoid sinus pneumatisation as either conchal, presellar or sellar. An AI algorithm was developed using the Microsoft Azure Custom Vision deep learning platform to classify the pattern of pneumatisation.

RESULTS

Seven hundred eighty images from 400 patients were used to train the algorithm, which was then tested on a further 118 images from 62 patients. The algorithm achieved an accuracy of 93.2% (95% confidence interval [CI] 87.1-97.0), 87.3% (95% CI 79.9-92.7) and 85.6% (95% CI 78.0-91.4) in correctly identifying conchal, presellar and sellar sphenoid pneumatisation, respectively. The overall weighted accuracy of the CNN was 85.9%.

CONCLUSION

The CNN described demonstrated a moderately accurate classification of sphenoid pneumatisation subtypes on CT scans. The use of CNN-based assistive tools may enable surgeons to achieve safer operative planning through routine automated reporting allowing greater resources to be directed towards the identification of pathology.

A novel approach using electroacupuncture for erectile dysfunction after radical prostatectomy: A case report

INTRODUCTION

Research shows that electrical stimulation to damaged peripheral nerves has promising effects on nerve regeneration and recovery of function.

DESCRIPTION

A 71 yr. old male, who was 12 months post left intrafacial and right incremental nerve sparing robotic radical prostatectomy received 6 sessions of sacral electroacupuncture/acupuncture at weekly intervals, commencing 12 months post operatively.

METHODS

CARE guidelines informed the case study report. Positive changes in erectile function after electroacupuncture was recorded using validated scores (IIEF-5 and EHS). Qualitative information was collected via a feedback box.

DISCUSSION

Given that current treatments for post radical prostatectomy erectile dysfunction are invasive and largely unsuccessful, further investigation into electroacupuncture for this population should be pursued.

Smell-related quality of life changes after total laryngectomy: a multi-centre study

PURPOSE

A total laryngectomy creates an alternate airway for gas exchange that bypasses the upper aerodigestive tract. The subsequent reduction in nasal airflow, and therefore, reduction in deposition of particles to the olfactory neuroepithelium leads to hyposmia or anosmia. The aim of this study was to assess the quality of life impairment conferred by anosmia following laryngectomy and identify any specific patient-related risk factors that are associated with poorer outcomes.

METHODS

Consecutive patients with a total laryngectomy presenting for review at three tertiary head and neck services (in Australia, the United Kingdom and India) over a 12-month period were recruited. Patient demographic and clinical data were collected, and each subject completed the validated assessment of self-reported olfactory functioning and olfaction-related quality of life questionnaire (ASOF). Dichotomous comparisons were performed using the student's unpaired t-test for continuous variables (SRP), a chi-squared test for categorical variables, and a Kendall's tau-b for ordinal variables (SOC) to assess for a correlation with poorer questionnaire scores.

RESULTS

A total of 66 laryngectomees (13.4% female; age 65.7 ± 8.6 years) were included in the study. The mean SRP score of the cohort was found to be 15.6 ± 7.4, while the mean ORQ score was noted to be 16.4 ± 8.1. No other specific risk factors associated with poorer quality of life were identified.

CONCLUSION

A significant quality of life detriment from hyposmia is conferred following laryngectomy. Further research to assess treatment options and the patient population that would best benefit from these interventions is required.

Convolutional Neural Networks in ENT Radiology: Systematic Review of the Literature

INTRODUCTION

Convolutional neural networks (CNNs) represent a state-of-the-art methodological technique in AI and deep learning, and were specifically created for image classification and computer vision tasks. CNNs have been applied in radiology in a number of different disciplines, mostly outside otolaryngology, potentially due to a lack of familiarity with this technology within the otolaryngology community. CNNs have the potential to revolutionize clinical practice by reducing the time required to perform manual tasks. This literature search aims to present a comprehensive systematic review of the published literature with regard to CNNs and their utility to date in ENT radiology.

METHODS

Data were extracted from a variety of databases including PubMED, Proquest, MEDLINE Open Knowledge Maps, and Gale OneFile Computer Science. Medical subject headings (MeSH) terms and keywords were used to extract related literature from each databases inception to October 2020. Inclusion criteria were studies where CNNs were used as the main intervention and CNNs focusing on radiology relevant to ENT. Titles and abstracts were reviewed followed by the contents. Once the final list of articles was obtained, their reference lists were also searched to identify further articles.

RESULTS

Thirty articles were identified for inclusion in this study. Studies utilizing CNNs in most ENT subspecialties were identified. Studies utilized CNNs for a number of tasks including identification of structures, presence of pathology, and segmentation of tumors for radiotherapy planning. All studies reported a high degree of accuracy of CNNs in performing the chosen task.

CONCLUSION

This study provides a better understanding of CNN methodology used in ENT radiology demonstrating a myriad of potential uses for this exciting technology including nodule and tumor identification, identification of anatomical variation, and segmentation of tumors. It is anticipated that this field will continue to evolve and these technologies and methodologies will become more entrenched in our everyday practice.

Spatiotemporally dynamic electric fields for brain cancer treatment

OBJECTIVE

The treatment of glioblastoma (GBM) using low intensity electric fields (~1 V/cm) is being investigated using multiple implanted bioelectrodes, which was termed intratumoral modulation therapy (IMT). Previous IMT studies theoretically optimized treatment parameters to maximize coverage with rotating fields, which required experimental investigation. In this study, we employed computer simulations to generate spatiotemporally dynamic electric fields, designed and purpose-built an IMT device for in vitro experiments, and evaluated the human GBM cellular responses to these fields. &#xD;Approach: After measuring the electrical conductivity of the in vitro culturing medium, we designed experiments to evaluate the efficacy of various spatiotemporally dynamic fields: (a) different rotating field magnitudes, (b) rotating vs. non-rotating fields, (c) 200 kHz vs. 10 kHz stimulation, and (d) constructive vs. destructive interference. A custom printed circuit board (PCB) was fabricated to enable four-electrode IMT in a 24-well plate. Patient-derived GBM cells were treated and analyzed for viability using bioluminescence imaging. &#xD;Main results: The optimal PCB design had electrodes placed 6.3 mm from the center. Spatiotemporally dynamic IMT fields at magnitudes of 1, 1.5, and 2 V/cm reduced GBM cell viability to 58%, 37% and 2% of sham controls respectively. Rotating vs. non-rotating, and 200 kHz vs. 10 kHz fields showed no statistical difference. The rotating configuration yielded a significant reduction (p<0.01) in cell viability (47±4%) compared to the voltage matched (99±2%) and power matched (66±3%) destructive interference cases.&#xD;Significance: We found the most important factors in GBM cell susceptibility to IMT are electric field strength and homogeneity. Spatiotemporally dynamic electric fields have been evaluated in this study, where improvements to electric field coverage with lower power consumption and minimal field cancellations has been demonstrated. The impact of this optimized paradigm on cell susceptibility justifies its future use in preclinical and clinical trial investigations.

A116 OPTIMIZING CROHN’S DISEASE ENDOSCOPIC SCORING OPERATING CHARACTERISTICS TO ASSIST WITH THE ADVENT OF ARTIFICIAL INTELLIGENCE

Background

To date, no studies have used Artificial Intelligence (AI) to produce standard endoscopic scores for Crohn’s Disease (CD). These scores are essential to clinical practice and have a major cost in clinical trials.

Purpose

We aimed to re-examine the components of the Simple Endoscopic Score for Crohn’s Disease (SES-CD) and Modified Multiplier (MM-SES-CD) to see if scoring of individual colonic segments could be combined while maintaining predictive value accuracy, thus simplifying scoring for AI.

Method

Data from 279 participants in the UNITI and EXTEND trials as well as an infliximab biosimilar trial (NCT02096861) were used in this retrospective study. The primary outcome was endoscopic remission (ER-1) of the colon, defined as absence of ulcers. Secondary outcomes included alternative definitions of colonic endoscopic remission including SES-CD score of 0 (ER-2), SES-CD <3 (ER-3), and SES-CD reduction by 50% or greater from baseline (colonic endoscopic response).

Result(s)

The mean baseline SES-CD score was 13.7 (SD 7.7) and the mean MM-SES-CD score was 22.8 (SD 12.4). Among all possible colonic segment combinations, the combination of Right + Rectum + worst of Left or Transverse performed best for prediction of one-year ER-1, with fair accuracy (AUC 0.71, 95% CI 0.65-0.78, p < 0.0001). Accuracy of prediction of one-year ER-2 was poor (AUC 0.68, 95% CI 0.62-0.75, p < 0.0001), ER-3 was fair (AUC 0.71, 95% CI 0.65-0.77, p < 0.0001), and prediction of endoscopic response was poor (AUC 0.64, 95% CI 0.56-0.72, p > 0.01). These results were very similar to conventional scoring (without combining any “worst of” segments) with all of the colonic MM-SES-CD scores, with AUCs of 0.70, 0.69, 0.71, and 0.61 for the respective outcomes. Assessing only for the presence of ulcers was as accurate as the full assessment and exclusion of scoring stenosis had minimal impact on scores.

Image

Conclusion(s)

By combining assessment of colonic segments accuracy was maintained compared with currently used endoscopic scoring. Assessing for features other than ulceration had no significant impact on overall scores. By combining colonic segments and limiting assessment to ulceration, it may be simpler to develop AI algorithms reliably scoring endoscopic severity of CD for clinical practice and trials.

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Disclosure of Interest

None Declared

1304 LAXATIVES PRESCRIPTION MONITORING FOR AN OVERLOOKED PROBLEM

Introduction

Constipation is a common diagnosis among hospitalized patients. It results in considerable morbidity in elderly patients, healthcare utilization and economic burden. Laxatives are commonly prescribed but poorly monitored due to benign side effect perception.

Aim

We undertook a review of the quality of laxative prescribing and subsequent monitoring amongst an inpatient cohort. We propose new standards:

- Medication review at least once weekly;

- Documented rationale for choice of medication

- Specified timeframe review and outcome documentation

We reviewed current hospital trust policy of laxative prescribing and produced a new constipation management guideline in response to early audit data.

Method

Data collected across medical wards in Trafford General Hospital, Manchester. Data was collected on types of laxatives, reason for prescription, date of review, length of course, compliance and effect of laxatives. Two rounds of audit were performed 6 months apart, with an interim intervention of staff education and local introduction of a new constipation management guideline. The guideline consisted of decision algorithm and suggested treatment.

Results

47 individual prescriptions were audited in round 1 and 72 prescriptions in round 2, this represented 23 and 32 patients respectively. Review of medications within first week of prescription improved from 17% to 83.7% across the two cycles. Documentation of constipation diagnosis improved from 52.2% to 97.2%. There were large percentage improvements in documentation of specified treatment outcomes across all audited fields, despite overall poorer medication compliance among patients in round 2 (56.9% versus 66% in round 1). The average length of laxative use decreased from 18.6 days to 15.3 with overall percentage of patient with constipation resolved increased from 65% in round 1 to 73% in Round 2

Conclusion

Staff education and implementation of treatment guidelines made a substantial improvement to the medical management of constipation in hospitalized patients.

A systematic review of interventions in the early course of bipolar disorder I or II: a report of the International Society for Bipolar Disorders Taskforce on early intervention

BACKGROUND

Given the likelihood of progressive illness in bipolar disorder (BD), it is important to understand the benefits and risks of interventions administered early in illness course. We conducted a systematic review of the effectiveness of interventions in the early course of BD I or II.

METHODS

We completed a systematic search on MEDLINE, PsycINFO, EMBASE, the Cochrane Central Register of Controlled Trials, CINAHL and Google Scholar from 1/1/1979 till 14/9/2022. We included controlled trials examining intervention effects on symptomatic, course, functional and tolerability outcomes of patients in the 'early course' of BD I or II. We classified patients to be in early course if they (a) were seeking help for the first time for a manic episode, (b) had a lifetime history of up to 3 manic episodes, or (c) had up to 6 lifetime mood episodes. Evidence quality was assessed using the GRADE approach.

RESULTS

From 4135 unique publications we included 25 reports representing 2212 participants in 16 randomized studies, and 17,714 participants from nine non-randomized studies. Available evidence suggested that in early illness course, lithium use was associated with lower recurrence risk compared with other mood stabilizers. Mood stabilizers were also associated with better global functioning, compared with the use of antipsychotics in the medium term. While summative findings regarding psychological therapies were limited by heterogeneity, family-focused and cognitive-behavioral interventions were associated with reduced recurrence risk or improved symptomatic outcomes. There was some evidence that the same pharmacological interventions were more efficacious in preventing recurrences when utilized in earlier rather than later illness course.

CONCLUSIONS AND RECOMMENDATIONS

While there are promising initial findings, there is a need for more adequately powered trials to examine the efficacy and tolerability of interventions in youth and adults in early illness course. Specifically, there is a compelling need to compare the relative benefits of lithium with other pharmacological agents in preventing recurrences. In addition to symptomatic outcomes, there should be a greater focus on functional impact and tolerability. Effective pharmacological and psychological interventions should be offered to those in early course of BD, balancing potential risks using shared decision-making approaches.

The Impact of Adhesions on Nasal Airflow: A Quantitative Analysis Using Computational Fluid Dynamics

Background

Nasal adhesions (NAs) are a known complication of nasal airway surgery. Even minor NAs can lead to significant postoperative nasal airway obstruction (NAO). Division of such NAs often provides much greater relief than anticipated.

Objective

We examine the impact of NAs at various anatomical sites on nasal airflow and mucosal cooling using computational fluid dynamics (CFD) and multiple test subjects.

Methods

CT scans of healthy adult subjects were used to construct three-dimensional nasal airway computational models. A single virtual 2.5 mm diameter NA was placed at one of five sites commonly seen following NAO surgery within each nasal cavity bilaterally, resulting in 10 NA models and 1 NA-free control for each subject. CFD analysis was performed on each NA model and compared with the subject's NA-free control model.

Results

4 subjects were recruited to create 44 computational models. The NAs caused the airflow streamlines to separate, leading to a statistically significant increase in mucosal temperature immediately downstream to the NAs (wake region). Changes in the mucosal temperature in the wake region of the NAs were most prominent in anteriorly located NAs with a mean increase of 1.62 °C for the anterior inferior turbinate NAs ( P < .001) and 0.63 °C for the internal valve NAs ( P < .001).

Conclusion

NAs result in marked disruption to airflow patterns and reduced mucosal cooling on critical surfaces, particularly in the wake region. Reduced wake region mucosal cooling may be a contributing factor to the exaggerated perception of nasal obstruction experienced by patients with NAs.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Posterior scoliosis correction with thoracoplasty: effect on pulmonary function with a mean follow-up of 4.8 years

PURPOSE

To perform a study to investigate the influence of posterior scoliosis surgery and thoracoplasty on pulmonary function.

METHODS

This was a retrospective observational study of 37 patients with AIS who underwent posterior instrumented surgical correction with thoracoplasty. There was a minimum of 2 years follow-up. Clinical outcomes were measured using the SRS-22 questionnaires. Radiological outcomes were evaluated using standing posteroanterior and lateral radiographs. All patients had pulmonary function tests to evaluate pulmonary volume and flow (forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC)) both before surgery and at the final follow-up.

RESULTS

There were three males and 34 females. The mean age of patients was 14.6 years (range 11-21 years). The mean length of follow was 58 months (range 24-124 months). The average main thoracic Cobb angle in the coronal plane was corrected from 50.0° ± 12.4° preoperatively to 16.6° ± 6.3° postoperatively. The average thoracolumbar Cobb angle in the coronal plane was corrected from 28.2° ± 10.6° preoperatively to 10.1° ± 7.2°. The average thoracic kyphosis angle was corrected from 17.4° ± 11.0° preoperatively to 21.8° ± 10.5°. In terms of the Quality of life Outcomes (QoL), there was a significant increase (p < 0.001) in the mean SRS 22 scores from 3.8 preoperatively to 4.3 postoperatively. A statistically significant increase in the absolute forced expiratory volume in one second (FEV1) from pre-operative values with a p value < 0.001 was seen. There was a statistically significant increase in percentage predicted forced expiratory volume in one second from preoperative values with a p value of 0.008. There was also a statistically significant increase in the absolute forced vital capacity (FVC) from preoperative values with a p value < 0.001. The average percentage predicted forced vital capacity did increase on final follow-up from before surgery, but the increase was not statistically significant.

CONCLUSIONS

We have demonstrated that pulmonary function post-thoracoplasty not only reaches pre-operative levels, but significantly surpasses it with regards to the majority of the pulmonary parameters measured in this study. We also demonstrated satisfactory radiological correction and clinical outcomes.

Planning System for the Optimization of Electric Field Delivery using Implanted Electrodes for Brain Tumor Control

BACKGROUND

The use of non-ionizing electric fields from low intensity voltage sources (<10 V) to control malignant tumor growth is showing increasing potential as a cancer treatment modality. A method of applying these low intensity electric fields using multiple implanted electrodes within or adjacent to tumor volumes has been termed as intratumoral modulation therapy (IMT).

PURPOSE

This study explores advancements in the previously established IMT optimization algorithm, and the development of a custom treatment planning system for patient specific IMT. The practicality of the treatment planning system is demonstrated by implementing the full optimization pipeline on a brain phantom with robotic electrode implantation, post-operative imaging, and treatment stimulation.

METHODS

The integrated planning pipeline in 3D Slicer begins with importing and segmenting patient magnetic resonance images (MRI) or computed tomography (CT) images. The segmentation process is manual, followed by a semi-automatic smoothing step that allows the segmented brain and tumor mesh volumes to be smoothed and simplified by applying selected filters. Electrode trajectories are planned manually on the patient MRI or CT by selecting insertion and tip coordinates for a chosen number of electrodes. The electrode tip positions, and stimulation parameters (phase shift and voltage) can then be optimized with the custom semi-automatic IMT optimization algorithm where users can select the prescription electric field, voltage amplitude limit, tissue electrical properties, nearby organs at risk, optimization parameters (electrode tip location, individual contact phase shift and voltage), desired field coverage percent, and field conformity optimization. Tables of optimization results are displayed, and the resulting electric field is visualized as a field-map superimposed on the MR or CT image, with 3D renderings of the brain, tumor, and electrodes. Optimized electrode coordinates are transferred to robotic electrode implantation software to enable planning and subsequent implantation of the electrodes at the desired trajectories.

RESULTS

An IMT treatment planning system was developed that incorporates patient specific MRI or CT, segmentation, volume smoothing, electrode trajectory planning, electrode tip location and stimulation parameter optimization, and results visualization. All previous manual pipeline steps operating on diverse software platforms were coalesced into a single semi-automated 3D Slicer based user interface. Brain phantom validation of the full system implementation was successful in pre-operative planning, robotic electrode implantation, and post-operative treatment planning to adjust stimulation parameters based on actual implant locations. Voltage measurements were obtained in the brain phantom to determine the electrical parameters of the phantom and validate the simulated electric field distribution.

CONCLUSIONS

A custom treatment planning and implantation system for IMT has been developed in this study, and validated on a phantom brain model, providing an essential step in advancing IMT technology towards future clinical safety and efficacy investigations. This article is protected by copyright. All rights reserved.

Efficacy of Vidian Neurectomy and Posterior Nasal Neurectomy in the Management of Nonallergic Rhinitis: A Systematic Review

BACKGROUND

Nonallergic rhinitis (NAR) is characterized by rhinorrhea, nasal obstruction, and sneezing, in the absence of systemic sensitization to allergens. For cases refractory to medical therapy and conservative surgical interventions, more targeted procedures, such as endoscopic vidian neurectomy (EVN) and posterior nasal neurectomy (PNN), including surgical (SPNN) and cryoablative (CPNN) methods, may reduce symptoms of NAR.

OBJECTIVE

The purpose of this study was to compare the efficacy, side effect profile, and complication rate between EVN and PNN for NAR.

METHODS

A systematic review of primary articles that reported original patient data for either EVN or PNN was conducted using Embase, Medline, PubMed, and Cochrane databases since 2006, according to PRISMA guidelines. The primary outcome of the study was an improvement in NAR symptom severity. Secondary outcomes included the incidence of postoperative side effects or complications.

RESULTS

In total, 58 articles met the search criteria with a total of 9 studies (including 2 RCTs) eligible for inclusion. There was a pooled sample of 229 NAR patients that underwent EVN (n = 65; 28.4%), SPNN (n = 50; 21.8%), or CPNN (n = 114; 49.8%). For all 3 techniques, there was a statistically significant improvement in nasal symptoms, particularly rhinorrhea, nasal congestion, and obstruction along with quality of life. Heterogeneity in outcome reporting prevented meta-analysis and direct comparison of efficacy. The pooled incidence of postoperative complications for EVN (n = 65), SPNN (n = 50), and CPNN (n = 70) was 30.8% versus 0% versus 2.9% for dry eye, 16.9% versus 0% versus 1.4% for palatal/cheek numbness, and 0% versus 6% versus 4.3% for bleeding.

CONCLUSION

EVN, SPNN, and CPNN are similarly efficacious for patients with NAR refractory to medical management. SPNN and CPNN are associated with lower rates of complications (dry eye and palatal/cheek numbness) compared with EVN.

An Artificial Intelligence Computer-vision Algorithm to Triage Otoscopic Images From Australian Aboriginal and Torres Strait Islander Children

OBJECTIVE

To develop an artificial intelligence image classification algorithm to triage otoscopic images from rural and remote Australian Aboriginal and Torres Strait Islander children.

STUDY DESIGN

Retrospective observational study.

SETTING

Tertiary referral center.

PATIENTS

Rural and remote Aboriginal and Torres Strait Islander children who underwent tele-otology ear health screening in the Northern Territory, Australia between 2010 and 2018.

INTERVENTIONS

Otoscopic images were labeled by otolaryngologists to classify the ground truth. Deep and transfer learning methods were used to develop an image classification algorithm.

MAIN OUTCOME MEASURES

Accuracy, sensitivity, specificity, positive predictive value, negative predictive value, area under the curve (AUC) of the resultant algorithm compared with the ground truth.

RESULTS

Six thousand five hundred twenty seven images were used (5927 images for training and 600 for testing). The algorithm achieved an accuracy of 99.3% for acute otitis media, 96.3% for chronic otitis media, 77.8% for otitis media with effusion (OME), and 98.2% to classify wax/obstructed canal. To differentiate between multiple diagnoses, the algorithm achieved 74.4 to 92.8% accuracy and an AUC of 0.963 to 0.997. The most common incorrect classification pattern was OME misclassified as normal tympanic membranes.

CONCLUSIONS

The paucity of access to tertiary otolaryngology care for rural and remote Aboriginal and Torres Strait Islander communities may contribute to an under-identification of ear disease. Computer vision image classification algorithms can accurately classify ear disease from otoscopic images of Indigenous Australian children. In the future, a validated algorithm may integrate with existing telemedicine initiatives to support effective triage and facilitate early treatment and referral.

Artificial intelligence to classify ear disease from otoscopy: A systematic review and meta-analysis

Objectives

To summarise the accuracy of artificial intelligence (AI) computer vision algorithms to classify ear disease from otoscopy.

Design

Systematic review and meta‐analysis.

Methods

Using the PRISMA guidelines, nine online databases were searched for articles that used AI computer vision algorithms developed from various methods (convolutional neural networks, artificial neural networks, support vector machines, decision trees and k‐nearest neighbours) to classify otoscopic images. Diagnostic classes of interest: normal tympanic membrane, acute otitis media (AOM), otitis media with effusion (OME), chronic otitis media (COM) with or without perforation, cholesteatoma and canal obstruction.

Main outcome measures

Accuracy to correctly classify otoscopic images compared to otolaryngologists (ground truth). The Quality Assessment of Diagnostic Accuracy Studies Version 2 tool was used to assess the quality of methodology and risk of bias.

Results

Thirty‐nine articles were included. Algorithms achieved 90.7% (95%CI: 90.1–91.3%) accuracy to difference between normal or abnormal otoscopy images in 14 studies. The most common multiclassification algorithm (3 or more diagnostic classes) achieved 97.6% (95%CI: 97.3–97.9%) accuracy to differentiate between normal, AOM and OME in three studies. AI algorithms outperformed human assessors to classify otoscopy images achieving 93.4% (95%CI: 90.5–96.4%) versus 73.2% (95%CI: 67.9–78.5%) accuracy in three studies. Convolutional neural networks achieved the highest accuracy compared to other classification methods.

Conclusion

AI can classify ear disease from otoscopy. A concerted effort is required to establish a comprehensive and reliable otoscopy database for algorithm training. An AI‐supported otoscopy system may assist health care workers, trainees and primary care practitioners with less otology experience identify ear disease.

Glial activation positron emission tomography imaging in radiation treatment of breast cancer brain metastases

Brain metastases affect more breast cancer patients than ever before due to increased overall patient survival with improved molecularly targeted treatments. Approximately 25–34% of breast cancer patients develop brain metastases in their lifetime. Due to the blood–brain barrier (BBB), the standard treatment for breast cancer brain metastases (BCBM) is surgery, stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT). At the cost of cognitive side effects, WBRT has proven efficacy in treating brain metastases when used with local therapies such as SRS and surgery. This review investigated the potential use of glial activation positron emission tomography (PET) imaging for radiation treatment of BCBM. In order to put these studies into context, we provided background on current radiation treatment approaches for BCBM, our current understanding of the brain microenvironment, its interaction with the peripheral immune system, and alterations in the brain microenvironment by BCBM and radiation. We summarized preclinical literature on the interactions between glial activation and cognition and clinical studies using translocator protein (TSPO) PET to image glial activation in the context of neurological diseases. TSPO-PET is not employed clinically in assessing and guiding cancer therapies. However, it has gained traction in preclinical studies where glial activation was investigated from primary brain cancer, metastases and radiation treatments. Novel glial activation PET imaging and its applications in preclinical studies using breast cancer models and glial immunohistochemistry are highlighted. Lastly, we discuss the potential clinical application of glial activation imaging to improve the therapeutic ratio of radiation treatments for BCBM.

Radiotherapy and radiosensitization in breast cancer: Molecular targets and clinical applications

Relatively poor survival outcomes are observed in advanced or metastatic breast cancer, where local control of the primary or metastatic disease may be achieved by surgical resection, local ablative and radiation therapies. Radioresistance, poses a major challenge in achieving durable oncologic outcomes, mandating development of novel management strategies. Although multimodality approaches that combine radiotherapy with chemotherapy, or systemic agents, are utilized for radiosensitization and treatment of various malignancies, this approach has not yet found its clinical application in breast cancer. Some agents for breast cancer treatment can serve as radiosensitizers, creating an opportunity to enhance effects of radiation while providing systemic disease control. Hence, combination of radiotherapy with radiosensitizing agents have the potential to improve oncologic outcomes in advanced or metastatic breast cancer. This review discusses molecular targets for radiosensitization and novel systemic agents that have potential for clinical use as radiosensitizers in breast cancer.

Influence of the first wave of COVID-19 on asthma inhaler prescriptions

In the beginning of the COVID-19 pandemic, there were major concerns regarding the huge demand for asthma inhalers. Using the primary-care medical records for 614,700 asthma patients between January and June 2020, we found that there was a substantial increase in inhalers solely in March 2020. Patients significantly associated with receiving higher inhaled corticosteroid prescriptions were younger, of higher socioeconomic status, and had milder asthma.

Prevalence and Disparities in Folate and Vitamin B12 Deficiency Among Preschool Children in Guatemala

BACKGROUND AND OBJECTIVE

Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6-59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers.

OBJECTIVE

To describe national and regional post-fortification folate and vitamin B12 status of children aged 6-59 months in Guatemala.

METHODS

A multistage, cluster probability study was carried out with national and regional representation of children aged 6-59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148-221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest.

RESULTS

The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3-46.6%) and was significantly higher among children 6-11 months and 12-23 months (46.6 and 37.0%, respectively), compared to older children aged 48-59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6-42.0%) and geographic region (27.2-46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively.

CONCLUSIONS

In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children.

Inhalation and deposition of spherical and pollen particles after middle turbinate resection in a human nasal cavity

Middle turbinate resection significantly alters the anatomy and redistributes the inhaled air. The superior half of the main nasal cavity is opened up, increasing accessibility to the region. This is expected to increase inhalation dosimetry to the region during exposure to airborne particles. This study investigated the influence of middle turbinate resection on the deposition of inhaled pollutants that cover spherical and non-spherical particles (e.g. pollen). A computational model of the nasal cavity from CT scans, and its corresponding post-operative model with virtual surgery performed was created. Two constant flow rates of 5 L/min, and 15 L/min were simulated under a laminar flow field. Inhaled particles including pollen (non-spherical), and a spherical particle with reference density of 1000 kg/m³ were introduced in the surrounding atmosphere. The effect of surgery was most prominent in the less patent cavity side, since the change in anatomy was proportionally greater relative to the original airway space. The left cavity produced an increase in particle deposition at a flow rate of 15 L/min. The main particle deposition mechanisms were inertial impaction, and to a lesser degree gravitational sedimentation. The results are expected to provide insight into inhalation efficiency of different aerosol types, and the likelihood of deposition in different nasal cavity surfaces.

The impact of nasal adhesions on airflow and mucosal cooling - A computational fluid dynamics analysis

Nasal adhesions are a known postoperative complication following surgical procedures for nasal airway obstruction (NAO); and are a common cause of surgical failure, with patients often reporting significant NAO, despite relatively minor adhesion size. Division of such nasal adhesions often provides much greater relief than anticipated, based on the minimal reduction in cross-sectional area associated with the adhesion. The available literature regarding nasal adhesions provides little evidence examining their quantitative and qualitative effects on nasal airflow using objective measures. This study examined the impact of nasal adhesions at various anatomical sites on nasal airflow and mucosal cooling using computational fluid dynamics (CFD). A high-resolution CT scan of the paranasal sinuses of a 25-year-old, healthy female patient was segmented to create a three-dimensional nasal airway model. Virtual nasal adhesions of 2.5 mm diameter were added to various locations within the nasal cavity, representing common sites seen following NAO surgery. A series of models with single adhesions were created. CFD analysis was performed on each model and compared with a baseline no-adhesion model, comparing airflow and heat and mass transfer. The nasal adhesions resulted in no significant change in bulk airflow patterns through the nasal cavity. However, significant changes were observed in local airflow and mucosal cooling around and immediately downstream to the nasal adhesions. These were most evident with anterior nasal adhesions at the internal valve and anterior inferior turbinate. Postoperative nasal adhesions create local airflow disruption, resulting in reduced local mucosal cooling on critical surfaces, explaining the exaggerated perception of nasal obstruction. In particular, anteriorly located adhesions created greater disruption to local airflow and mucosal cooling, explaining their associated greater subjective sensation of obstruction.

'Stability' of Assessment: Extending the Utility Equation

This article was migrated. The article was marked as recommended. The COVID-19 pandemic has brought many challenges to medical education, necessitating a rapid transition to digital delivery. The widespread move to online exams has introduced novel risks, including the risk of catastrophic IT failure. These are not 'black swan' events - something so unexpected and devastating that we could not anticipate them and prepare accordingly. The phrase 'black elephants', a cross between a black swan and 'the elephant in the room' has been coined to describe these events. Moving to high-stakes online examinations introduces another element that needs to be considered and managed: the 'stability' of the assessment format used. This dimension incorporates notions of 'platform reliability' and 'internal risk management' and can be caused by both unplanned events eg IT failures, and planned events like security breaches Developing approaches to mitigate this new risk suggests another dimension to the well-known assessment 'utility equation': stability of the platform used. This paper explores the concept of stability from the perspectives of educational institutions and candidates and offers some approaches to achieving stability. The delivery of assessment in the digital age, requires the 'utility equation' to be recalibrated and establishment of a new "sweet spot" for each assessment program.

POS0670 ROUTINE ASSESSMENT OF PATIENT INDEX DATA 3 (RAPID3) IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH LONG-TERM UPADACITINIB THERAPY

Background:

Routine Assessment of Patient Index Data 3 (RAPID3) is a pooled index of 3 patient-reported measures: patient global assessment, pain, and physical function. RAPID3 was shown to correlate with other composite measures of disease activity1 and is recommended by the American College of Rheumatology for use in clinical practice.2

Objectives:

To evaluate the impact of upadacitinib (UPA) versus comparators on RAPID3 over 60 weeks, as well as the correlation of RAPID3 scores with other disease measures in the UPA phase 3 SELECT clinical program.

Methods:

This post hoc analysis included placebo-controlled (SELECT-NEXT, -BEYOND, and -COMPARE) and active comparator-controlled (SELECT-EARLY, -MONOTHERAPY, and -COMPARE) trials. Patients received UPA as monotherapy or in combination with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). Mean change from baseline in RAPID3 and the proportion of patients reporting RAPID3 remission (≤3), low (LDA, >3 to ≤6), moderate (MDA, >6 to ≤12), and high disease activity (HDA, >12) were assessed. Correlations between absolute scores for RAPID3 and Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), and 28-joint Disease Activity Score with C-reactive protein (DAS28[CRP]) were assessed using Spearman correlation coefficients. All data are as observed.

Results:

A total of 661, 498, 648, 1629, and 945 patients were included from SELECT-NEXT, -BEYOND, -MONOTHERAPY, -COMPARE, and -EARLY. At baseline, the majority of patients across all studies were in RAPID3 HDA (mean baseline RAPID3 [across all studies], 17.2–19.2) (Table 1 and Figure 1). Improvements from baseline in RAPID3 were observed with UPA 15 mg and 30 mg through Week 60, with numerically greater improvements observed with UPA compared with active comparators (Table 1). Across studies, mean improvements in RAPID3 exceeded the minimal clinically important difference (MCID) with UPA and adalimumab (ADA) treatment (MCID=3.83). By Week 60, approximately one-half of UPA-treated patients were in RAPID3 remission or LDA, with only 10–25% remaining in HDA, except for the more refractory population in SELECT-BEYOND, in which ~38% of patients remained in HDA (Figure 1). RAPID3 scores moderately to strongly correlated with CDAI (ρ=0.69–0.83), SDAI (ρ=0.69–0.82), and DAS28(CRP) (ρ=0.58–0.77), across all studies, at Week 60 (all p<0.001).

Conclusion:

UPA, as monotherapy or in combination with csDMARDs, was associated with improvements in patient-reported disease activity, pain, and physical function, as assessed by RAPID3 over 60 weeks in the phase 3 SELECT clinical program. RAPID3 continues to be an important tool in clinical practice to assess disease activity, as it was shown to correlate to other disease activity measures and allows for rapid scoring.

References:

[1]Pincus T, et al. Arthritis Care Res (Hoboken) 2010;62:181–9.

[2]England BR, et al. Arthritis Care Res (Hoboken) 2019;71:1540–55.

[3]Ward MM, et al. J Rheumatol 2019;46:27–30.

Table 1.

Change from BL in RAPID3 at Week 60 (as observed)

Phase 3 studyGroupnaMean (SD) BL scoreMean (SD) change from BLbSELECT-EARLYc(MTX-naïve)MTX23618.5 (5.6)−9.6 (7.5)UPA 15 mg QD26918.9 (5.6)−12.0 (7.6)UPA 30 mg QD25318.2 (5.6)−13.4 (7.2)SELECT-NEXT(csDMARD-IR)UPA 15 mg QD17217.7 (5.1)−11.1 (7.3)UPA 30 mg QD17217.6 (5.3)−10.4 (6.8)SELECT-MONOTHERAPY(MTX-IR)UPA 15 mg QD17217.4 (5.8)−9.6 (7.4)UPA 30 mg QD18017.2 (5.9)−10.6 (7.2)SELECT-COMPAREc(MTX-IR)UPA 15 mg QD55218.5 (5.5)−10.2 (7.1)ADA 40 mg EOW26418.7 (5.4)−8.8 (6.7)SELECT-BEYOND(bDMARD-IR)UPA 15 mg QD13319.2 (5.1)−8.6 (6.8)UPA 30 mg QD11818.5 (5.3)−9.3 (7.3)

b, biologic; BL, baseline; EOW, every other week; IR, inadequate response; MTX, methotrexate; QD, once daily; SD, standard deviation

aNumber of patients with RAPID3 values at both BL and Week 60. bNegative values indicate improvement from BL. cObserved data include patients rescued to UPA and/or ADA; treatment effect may include both the randomized and switch treatments in these patients

Acknowledgements:

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. No honoraria or payments were made for authorship. Medical writing support was provided by Grant Kirkpatrick, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests:

Martin Bergman Shareholder of: Johnson & Johnson, Speakers bureau: AbbVie, Celgene, GSK, MSD, Novartis, Pfizer, and Sanofi/Regeneron, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Genentech/Roche, Gilead, Horizon, Janssen, MSD, Novartis, Pfizer, Sandoz, Sanofi/Regeneron, and Scipher, Maya H Buch Consultant of: AbbVie, Eli Lilly, Merck-Serono, Pfizer, Sandoz, and Sanofi, Grant/research support from: Pfizer, Roche, and UCB, Yoshiya Tanaka Speakers bureau: AbbVie, Asahi Kasei, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Mitsubishi Tanabe, Novartis, Pfizer, Sanofi, Takeda, UCB, and YL Biologics, Grant/research support from: AbbVie, Astellas, Bristol-Myers Squibb, Chugai, Daiichi Sankyo, Eisai, Mitsubishi Tanabe, MSD, Ono, Taisho Toyama, and Takeda, Gustavo Citera Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Genzyme, Pfizer, and Roche, Sami Bahlas: None declared, Ernest Wong Consultant of: AbbVie, Chugai, Eli Lilly, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Chugai, Novartis, and UCB, Yanna Song Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Namita Tundia Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Jessica Suboticki Shareholder of: May own stock or options in AbbVie, Employee of: AbbVie, Vibeke Strand Consultant of: AbbVie, Amgen, Arena, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Celltrion, Eli Lilly, Gilead, Ichnos, Inmedix, Janssen, Kiniksa, MSD, Myriad Genetics, Novartis, Pfizer, Regeneron, Samsung, Sandoz, Sanofi, Scipher, Setpoint, and UCB.

Direct-to-consumer marketing (DTC) of internet-based cognitive behavioral therapy (iCBT) using brief promotional video: Mapping modifiable mechanisms in pre-treatment acceptance

Introduction

Given the suboptimal acceptance of iCBT for depression, finding ways to increase the acceptance and uptake is crucial for its dissemination. Moreover, it remains unknown to what extend the Unified Theory of Acceptance and Use of Technology (UTAUT) could aid the design of DTC in psychological service.

Objectives

To explore whether the regulatory processes theorized in the UTAUT (Performance Expectancy, Effort Expectancy, Social Influence, and Facilitating Condition) could be modified and mediate the change of acceptance of iCBT.

Methods

This randomized controlled trial recruited 219 individuals with at least mild level of depression. Upon completion of pre-assessment, participants were randomly allocated to an intervention (IG) and a control group (CG). The IG received a 7-minute UTAUT-driven promotion video, while the CG received a video of same length on general psychoeducation. Both groups completed a post-assessment.

Results

Repeated measures ANOVA revealed a significant time by group effect on treatment acceptance. The video in IG was perceived to be clearer and more persuasive. Mediation analysis showed that the intervention effect was mediated by increase in perceived performance expectancy of iCBT, and the indirect effect was conditional on dispositional help seeking stigma.

Conclusions

Pre-treatment acceptance of iCBT can be improved by brief DTC promotion video. The finding casts light that performance expectancy was the most modifiable and mediatable regulatory process on iCBT acceptance, although such relation could be attenuated by high help-seeking stigma. In sum, DTC marketing could aid implementation of Internet-based interventions, effort in stigma reduction should continue to encourage uptake of effective treatment.

Disclosure

No significant relationships.

A catalog of associations between rare coding variants and COVID-19 outcomes

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causes coronavirus disease-19 (COVID-19), a respiratory illness that can result in hospitalization or death. We investigated associations between rare genetic variants and seven COVID-19 outcomes in 543,213 individuals, including 8,248 with COVID-19. After accounting for multiple testing, we did not identify any clear associations with rare variants either exome-wide or when specifically focusing on (i) 14 interferon pathway genes in which rare deleterious variants have been reported in severe COVID-19 patients; (ii) 167 genes located in COVID-19 GWAS risk loci; or (iii) 32 additional genes of immunologic relevance and/or therapeutic potential. Our analyses indicate there are no significant associations with rare protein-coding variants with detectable effect sizes at our current sample sizes. Analyses will be updated as additional data become available, with results publicly browsable at https://rgc-covid19.regeneron.com.

Clozapine and chemotherapy: a dangerous couple or a necessary partnership?

A 48-year-old man with a history of schizophrenia was diagnosed with B-cell lymphoma of the small bowel. Neutropaenia occurred secondary to chemotherapy, which led to clozapine being discontinued, which resulted in the deterioration of his mental state, in turn, affecting the treatment of lymphoma. Clozapine was later reintroduced alongside granulocyte colony-stimulating factor, leading to improved mental state without any further incidences of neutropaenia.

Optimization of multi-electrode implant configurations and programming for the delivery of non-ablative electric fields in intratumoral modulation therapy

PURPOSE

Application of low intensity electric fields to interfere with tumor growth is being increasingly recognized as a promising new cancer treatment modality. Intratumoral modulation therapy (IMT) is a developing technology that uses multiple electrodes implanted within or adjacent tumor regions to deliver electric fields to treat cancer. In this study, the determination of optimal IMT parameters was cast as a mathematical optimization problem, and electrode configurations, programming, optimization, and maximum treatable tumor size were evaluated in the simplest and easiest to understand spherical tumor model. The establishment of electrode placement and programming rules to maximize electric field tumor coverage designed specifically for IMT is the first step in developing an effective IMT treatment planning system.

METHODS

Finite element method electric field computer simulations for tumor models with 2 to 7 implanted electrodes were performed to quantify the electric field over time with various parameters, including number of electrodes (2 to 7), number of contacts per electrode (1 to 3), location within tumor volume, and input waveform with relative phase shift between 0 and 2π radians. Homogeneous tissue specific conductivity and dielectric values were assigned to the spherical tumor and surrounding tissue volume. In order to achieve the goal of covering the tumor volume with a uniform threshold of 1 V/cm electric field, a custom least square objective function was used to maximize the tumor volume covered by 1 V/cm time averaged field, while maximizing the electric field in voxels receiving less than this threshold. An additional term in the objective function was investigated with a weighted tissue sparing term, to minimize the field to surrounding tissues. The positions of the electrodes were also optimized to maximize target coverage with the fewest number of electrodes. The complexity of this optimization problem including its non-convexity, the presence of many local minima, and the computational load associated with these stochastic based optimizations led to the use of a custom pattern search algorithm. Optimization parameters were bounded between 0 and 2π radians for phase shift, and anywhere within the tumor volume for location. The robustness of the pattern search method was then evaluated with 50 random initial parameter values.

RESULTS

The optimization algorithm was successfully implemented, and for 2 to 4 electrodes, equally spaced relative phase shifts and electrodes placed equidistant from each other was optimal. For 5 electrodes, up to 2.5 cm diameter tumors with 2.0 V, and 4.1 cm with 4.0 V could be treated with the optimal configuration of a centrally placed electrode and 4 surrounding electrodes. The use of 7 electrodes allow for 3.4 cm diameter coverage at 2.0 V and 5.5 cm at 4.0 V. The evaluation of the optimization method using 50 random initial parameter values found the method to be robust in finding the optimal solution.

CONCLUSIONS

This study has established a robust optimization method for temporally optimizing electric field tumor coverage for IMT, with the adaptability to optimize a variety of parameters including geometrical and relative phase shift configurations.

Monitoring Early Changes in Tumor Metabolism in Response to Therapy Using Hyperpolarized 13C MRSI in a Preclinical Model of Glioma

This study shows the use of hyperpolarized ¹³C magnetic resonance spectroscopic imaging (MRSI) to assess therapeutic efficacy in a preclinical tumor model. ¹³C-labeled pyruvate was used to monitor early changes in tumor metabolism based on the Warburg effect. High-grade malignant tumors exhibit increased glycolytic activity and lactate production to promote proliferation. A rodent glioma model was used to explore altered lactate production after therapy as an early imaging biomarker for therapeutic response. Rodents were surgically implanted with C6 glioma cells and separated into 4 groups, namely, no therapy, radiotherapy, chemotherapy and combined therapy. Animals were imaged serially at 6 different time points with magnetic resonance imaging at 3 T using hyperpolarized [1-¹³C]pyruvate MRSI and conventional ¹H imaging. Using hyperpolarized [1-¹³C]pyruvate MRSI, alterations in tumor metabolism were detected as changes in the conversion of lactate to pyruvate (measured as Lac/Pyr ratio) and compared with the conventional method of detecting therapeutic response using the Response Evaluation Criteria in Solid Tumors. Moreover, each therapy group expressed different characteristic changes in tumor metabolism. The group that received no therapy showed a gradual increase of Lac/Pyr ratio within the tumor. The radiotherapy group showed large variations in tumor Lac/Pyr ratio. The chemo- and combined-therapy groups showed a statistically significant reduction in tumor Lac/Pyr ratio; however, only combined therapy was capable of suppressing tumor growth, which resulted in low endpoint mortality rate. Hyperpolarized ¹³C MRSI detected a prompt reduction in Lac/Pyr ratio as early as 2 days post combined chemo- and radiotherapies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk factors associated with microbial colonisation and infection of tracheostomy tubes

BACKGROUND

A long-term tracheostomy tube has the potential to cause significant morbidity and mortality in both hospitalised patients and those in the community. This study aims to assess the rates of microbial colonisation and infection of tracheostomy tubes.

MATERIALS AND METHODS

Consecutive patients were enrolled from both inpatient and outpatient settings during their routine tracheostomy changes. During changes, culture swabs were taken from the cuff/outer-cannula and inner-cannula. Analysis were performed to compare culture results with risk factors.

RESULTS

65 patients were enrolled in the study. Inpatients (65.9% vs 38.1%, χ² 4.48, p = 0.03), increasing acuity of care (from outpatient; ward; HDU; and ICU in increasing acuity) (τ_b = 0.289, p = 0.012), cuffed tracheostomy tubes, (66.7% vs 39.1%; χ² 4.59, p = 0.032); diabetics (64.6% vs 35.3%; χ² 4.39, p = 0.036); and males were associated with increased colonisation (72.4% vs 44.4%; χ² 5.12, p = 0.024).

CONCLUSION

Factors associated with an increase in colonisation and infection of tracheostomy tubes were location, and in males, diabetics and in cuffed tubes.

1202 Validation Of A Novel Wearable Home Sleep Testing Device For Assessment Of Obstructive Sleep Apnea

Introduction

There is a substantial need for an accurate and easy-to-use tool for obstructive sleep apnea (OSA) assessment. Belun Ring Platform (BRP), a novel photoplethysmography (PPG)-based home sleep apnea testing system with a proprietary deep learning algorithm, has been shown to have good sensitivity and specificity in predicting OSA in subjects without significant comorbidities and medications known to affect heart rate (HR). In this study, we further tested its performance in subjects referred for in-lab polysomnography (PSG) assessment of sleep disorders without excluding those with non-arrhythmia comorbidities or the subjects on HR-affecting medications.

Methods

PSG was recorded simultaneously with the Ring in the sleep lab and the studies were manually scored by certified sleep technicians according to the AASM Scoring manual version 2.4. Exclusion criteria include age &lt;18, unstable cardiopulmonary status, recent hospitalization within 30 days, significant arrhythmias, baseline HR &lt;50 or &gt;100, home oxygen use, pacemaker/defibrillator, post-cardiac transplantation or Left ventricular assist device.

Results

A cohort of 78 individuals (26 males and 52 females, age 50.5) were studied with 26 taking HR-affecting medications. Of these, 35 (45%) had AHI &lt; 5; 14 (18%) had AHI 5-15; 15 (19%) had AHI 15-30; 14 (18%) had AHI &gt; 30. The Ring-REI correlated well with the PSG-AHI (r =0.83, P &lt;0.001). The accuracy, sensitivity, specificity in categorizing AHI &gt;15 were 0.808, 0.931, and 0.735 respectively. The positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were 0.675, 0.947, 3.509, and 0.094 respectively. The use of HR-affecting medications did not significantly affect the sensitivity and specificity of BRP in predicting OSA (P =0.16 and 0.44 respectively).

Conclusion

BRP is promising as a reasonable tool for OSA assessment and can potentially be incorporated into a broad spectrum of clinical practices for identification of patients with OSA.

Support

This study is supported by a Grant from Belun Technology Company Limited.