Utilization of texture features of volumetric ADC maps in differentiating between serous cystadenoma and intraductal papillary neoplasms

INTRODUCTION

The rising incidence of incidental detection of pancreatic cystic neoplasms has compelled radiologists to determine new diagnostic methods for the differentiation of various kinds of lesions. We aim to demonstrate the utility of texture features extracted from ADC maps in differentiating intraductal papillary mucinous neoplasms (IPMN) from serous cystadenomas (SCA).

METHODS

This retrospective study was performed on 136 patients (IPMN = 87, SCA = 49) split into testing and training datasets. A total of 851 radiomics features were extracted from volumetric contours drawn by an expert radiologist on ADC maps of the lesions. LASSO regression analysis was used to determine the most predictive set of features and a radiomics score was developed based on their respective coefficients. A hyper-optimized support vector machine was then utilized to classify the lesions based on their radiomics score.

RESULTS

A total of four Wavelet features (LHL/GLCM/LCM2, HLL/GLCM/LCM2, /LLL/First Order/90percent, /LLL/GLCM/MCC) were selected from all of the features to be included in our classifier. The classifier was optimized by altering hyperparameters and the trained model was applied to the validation dataset. The model achieved a sensitivity of 92.8, specificity of 90%, and an AUC of 0.97 in the training data set, and a sensitivity of 83.3%, specificity of 66.7%, and AUC of 0.90 in the testing dataset.

CONCLUSION

A support vector machine model trained and validated on volumetric texture features extracted from ADC maps showed the possible beneficence of these features in differentiating IPMNs from SCAs. These results are in line with previous regarding the role of ADC maps in classifying cystic lesions and offers new evidence regarding the role of texture features in differentiation of potentially neoplastic and benign lesions.

Radiomics Features in Predicting Human Papillomavirus Status in Oropharyngeal Squamous Cell Carcinoma: A Systematic Review, Quality Appraisal, and Meta-Analysis

We sought to determine the diagnostic accuracy of radiomics features in predicting HPV status in oropharyngeal squamous cell carcinoma (SCC) compared to routine paraclinical measures used in clinical practice. Twenty-six articles were included in the systematic review, and thirteen were used for the meta-analysis. The overall sensitivity of the included studies was 0.78, the overall specificity was 0.76, and the overall area under the ROC curve was 0.84. The diagnostic odds ratio (DOR) equaled 12 (8, 17). Subgroup analysis showed no significant difference between radiomics features extracted from CT or MR images. Overall, the studies were of low quality in regard to radiomics quality score, although most had a low risk of bias based on the QUADAS-2 tool. Radiomics features showed good overall sensitivity and specificity in determining HPV status in OPSCC, though the low quality of the included studies poses problems for generalizability.

Utilization of Radiomics Features Extracted From Preoperative Medical Images to Detect Metastatic Lymph Nodes in Cholangiocarcinoma and Gallbladder Cancer Patients: A Systemic Review and Meta-analysis

OBJECTIVES

This study aimed to determine the methodological quality and evaluate the diagnostic performance of radiomics features in detecting lymph node metastasis on preoperative images in patients with cholangiocarcinoma and gallbladder cancer.

METHODS

Publications between January 2005 and October 2022 were considered for inclusion. Databases such as Pubmed/Medline, Scopus, Embase, and Google Scholar were searched for relevant studies. The quality of the methodology of the manuscripts was determined using the Radiomics Quality Score and Quality Assessment of Diagnostic Accuracy Studies 2. Pooled results with corresponding 95% confidence intervals (CIs) were calculated using the DerSimonian-Liard method (random-effect model). Forest plots were used to visually represent the diagnostic profile of radiomics signature in each of the data sets pertaining to each study. Fagan plot was used to determine clinical applicability.

RESULTS

Overall sensitivity was 0.748 (95% CI, 0.703-0.789). Overall specificity was 0.795 (95% CI, 0.742-0.839). The combined negative likelihood ratio was 0.299 (95% CI, 0.266-0.350), and the positive likelihood ratio was 3.545 (95% CI, 2.850-4.409). The combined odds ratio of the studies was 12.184 (95% CI, 8.477-17.514). The overall summary receiver operating characteristics area under the curve was 0.83 (95% CI, 0.80-0.86). Three studies applied nomograms to 8 data sets and achieved a higher pooled sensitivity and specificity (0.85 [0.80-0.89] and 0.85 [0.71-0.93], respectively).

CONCLUSIONS

The pooled analysis showed that predictive models fed with radiomics features achieve good sensitivity and specificity in detecting lymph node metastasis in computed tomography and magnetic resonance imaging images. Supplementation of the models with biological correlates increased sensitivity and specificity in all data sets.

Predictors of mTICI 2c/3 over 2b in patients successfully recanalized with mechanical thrombectomy

OBJECTIVE

For patients presenting with acute ischemic stroke (AIS) caused by large vessel occlusions (LVO), mechanical thrombectomy (MT) is the treatment standard of care in eligible patients. Modified Thrombolysis in Cerebral Infarction (mTICI) grades of 2b, 2c, and 3 are all considered successful reperfusion; however, recent studies have shown achieving mTICI 2c/3 leads to better outcomes than mTICI 2b. This study aims to investigate whether any baseline preprocedural or periprocedural parameters are predictive of achieving mTICI 2c/3 in successfully recanalized LVO patients.

METHODS

We conducted a retrospective multicenter cohort study of consecutive patients presenting with AIS caused by a LVO from 1 January 2017 to 1 January 2023. Baseline and procedural data were collected through chart review. Univariate and multivariate analysis were applied to determine significant predictors of mTICI 2c/3.

RESULTS

A total of 216 patients were included in the study, with 159 (73.6%) achieving mTICI 2c/3 recanalization and 57 (26.4%) achieving mTICI 2b recanalization. We found that a higher groin puncture to first pass time (OR = 0.976, 95%CI: 0.960-0.992, p = 0.004), a higher first pass to recanalization time (OR = 0.985, 95%CI: 0.972-0.998, p = 0.029), a higher admission NIHSS (OR = 0.949, 95%CI: 0.904-0.995, p = 0.031), and a lower age (OR = 1.032, 95%CI: 1.01-1.055, p = 0.005) were associated with a decreased probability of achieving mTICI 2c/3.

INTERPRETATION

A lower groin puncture to first pass time, a lower first pass to recanalization time, a lower admission NIHSS, and a higher age were independent predictors of mTICI 2c/3 recanalization.

International Medical Graduates in Radiology Residencies: Demographics, Performance, and Visa Issues

RATIONALE AND OBJECTIVES

The number of international medical graduates (IMG) in radiology residencies has varied from year to year even as the number of candidates continues to grow. It is unclear from which countries the IMGs are arriving and what visas are being used to accommodate them.

MATERIALS AND METHODS

We sent a survey to 195 program directors (PD) in diagnostic radiology (DR) inquiring about the number and nationality of IMG residents in their program, their attitudes about IMG candidates, the performance of their IMG trainees, and the visas that are offered.

RESULTS

We received responses from 121 of 195 (62.1%) DR programs (121/149 =81.2% of actionable emails). 80/121 (66.1%) had at least one IMG in their DR residency program and the countries of origin included India (36), Iran (30), Saudi Arabia (24), Egypt (16), Canada (14), Brazil (14), and Pakistan (9), as the most common. While most programs (76/104, 73.1%) offered J1 visas, 23/99 (23.2%) provided H-1B visas to trainees. IMG DR residents overall performed as well as American graduates, with an equal number of PDs saying IMGs performed better and worse than American graduates. PDs' issues with IMGs centered on visas: (1) expense, (2) lack of familiarity, (3) Educational Commission for Foreign Medical Graduates regulations, and (4) time commitment in submitting paperwork.

CONCLUSION

Most radiology IMG residents originate from India and Middle Eastern countries. Once enrolled, IMG residents perform similarly to US graduates. However, adding IMG candidates to the training program requires overcoming bureaucratic and monetary hurdles around visas.

SUMMARY SENTENCE

Most DR international medical graduate residents are from India or the Middle East. Although their performance is the same as American graduates in general, PDs note the monetary and bureaucratic hassles accompanying their recruitment.

Unsolicited Invitations to Scientific Meetings: Radiologists' Experience

OBJECTIVE

Unsolicited invitations to speak at medical meetings have proliferated as a type of spam email and phishing strategy to scam unsuspecting victims. We sought to determine the prevalence of such invitations to questionable meetings and determine the factors associated with receiving such solicitations.

MATERIALS AND METHODS

Data was collected for the number of speakers' invitations received over a 2-week period (April -May 2023) by radiologists of different subspecialties, academic ranks, and histories of publications and speaking engagements in the past 2-5 years. We analyzed the number of invitations received based on the variables.

RESULTS

Thirty-three of 45 (73.3%) faculty members received 188 inappropriate invitation emails in the 2-week observation period. The mean number of invitation emails was 4.13 for each faculty (SD: 5.03, range 0-20). There was no correlation between the number of invitations and radiologists' subspecialty, academic rank (3.8 ± 5, 3.0 ± 4, and 5.5 ± 5.7 invitations for full, associate, and assistant professors respectively) and previous legitimate speaker invites. Only 6 (3.2%) out of 188 invitations to speak sent to radiologists were for radiology-related meetings. Having more than 10 publications since 2022 was associated with a 5.0 (1.2, 19.4) times higher odds of receiving more than 4 solicitations.

CONCLUSIONS

A total of 73.3% of the faculty surveyed received unsolicited invitations to meetings in the 2-week study period and over 96% of the invitations were unrelated to their field of practice. Our results show that publications since 2022 was the most significant factor associated with receiving more solicitations.

CLINICAL RELEVANCE/APPLICATION

Invitations to questionable meetings targeting radiologists are frequent and often are unrelated to their specialties. The risk factors for receiving the invitations are unclear. Understanding these risk factors may enable educators especially junior investigators, to be better prepared to appropriately address such solicitations.

Response Assessment of Primary Liver Tumors to Novel Therapies: an Imaging Perspective

The latest developments in cancer immunotherapy, namely the introduction of immune checkpoint inhibitors, have led to a fundamental change in advanced cancer treatments. Imaging is crucial to identify tumor response accurately and delineate prognosis in immunotherapy-treated patients. Simultaneously, advances in image acquisition techniques, notably functional and molecular imaging, have facilitated more accurate pretreatment evaluation, assessment of response to therapy, and monitoring for tumor recurrence. Traditional approaches to assessing tumor progression, such as RECIST, rely on changes in tumor size, while new strategies for evaluating tumor response to therapy, such as the mRECIST and the EASL, rely on tumor enhancement. Moreover, the assessment of tumor volume, enhancement, cellularity, and perfusion are some novel techniques that have been investigated. Validation of these novel approaches should rely on comparing their results with those of standard evaluation methods (EASL, mRECIST) while considering the ultimate outcome, which is patient survival. More recently, immunotherapy has been used in the management of primary liver tumors. However, little is known about its efficacy. This article reviews imaging modalities and techniques for assessing tumor response and survival in immunotherapy-treated patients with primary hepatic malignancies.

Pervasiveness of Open Journal Invitations Across Radiology Specialties

This study examines the patterns of faculty solicitations by open-access (OA) publishers in radiology. The purpose of the research is to determine the factors that predict the likelihood of receiving such solicitations. We recruited 6 faculty members from 7 subspecialties in radiology to collect emails from OA journals for 2 weeks. We assessed the number of publications by each faculty member in 2022 and 2023, the previous 5 years, and entire career in PubMed. For each email, the solicitation was categorized for article submission, article review, and editorial board membership. An invitation to submit a manuscript was the most common type of solicitation received, followed by editorial boards and reviewer invites. Faculty with more than 10 indexed articles in PubMed since January 2022 were significantly more likely to receive article solicitations than those with 10 or fewer publications. Additionally, scholars with more than 40 articles since 2018 were significantly more likely to receive more than 10 article solicitations. Full professors were significantly more likely to receive solicitations to serve on editorial boards. A multivariate linear regression model predicted that publications since 2022 had the highest predictive value for the number of article solicitations and total solicitations. This study provides insight into the patterns of mass communication and various solicitations by OA publishers in radiology. The study highlights the importance of publication productivity as a predictor of article and total email solicitations and of professorial rank for editorial board invitations.

Multimodality imaging of hepatocellular carcinoma and intrahepatic cholangiocarcinoma

Hepatocellular carcinoma and intrahepatic cholangiocarcinoma are the two most common primary malignant tumors of the liver. The similarities and variations in imaging characteristics that may aid in distinguishing between these two primary tumors will be discussed and outlined in this review. Knowledge of imaging techniques that are currently available would assist in the differentiation between these primary malignancies.

Predictive role of radiomics features extracted from preoperative cross-sectional imaging of pancreatic ductal adenocarcinoma in detecting lymph node metastasis: a systemic review and meta-analysis

Lymph node metastases are associated with poor clinical outcomes in pancreatic ductal adenocarcinoma (PDAC). In preoperative imaging, conventional diagnostic modalities do not provide the desired accuracy in diagnosing lymph node metastasis. The current review aims to determine the pooled diagnostic profile of studies examining the role of radiomics features in detecting lymph node metastasis in PDAC. PubMed, Google Scholar, and Embase databases were searched for relevant articles. The quality of the studies was examined using the Radiomics Quality Score and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tools. Pooled results for sensitivity, specificity, likelihood, and odds ratios with the corresponding 95% confidence intervals (CIs) were calculated using a random-effect model (DerSimonian-Liard method). No significant publication bias was detected among the studies included in this meta-analysis. The pooled sensitivity of the validation datasets included in the study was 77.4% (72.7%, 81.5%) and pooled specificity was 72.4% (63.8, 79.6%). The diagnostic odds ratio of the validation datasets was 9.6 (6.0, 15.2). No statistically significant heterogeneity was detected for sensitivity and odds ratio (P values of 0.3 and 0.08, respectively). However, there was significant heterogeneity concerning specificity (P = 0.003). The pretest probability of having lymph node metastasis in the pooled databases was 52% and a positive post-test probability was 76% after the radiomics features were used, showing a net benefit of 24%. Classifiers trained on radiomics features extracted from preoperative images can improve the sensitivity and specificity of conventional cross-sectional imaging in detecting lymph node metastasis in PDAC.

Global, regional, and national burden of meningitis and its aetiologies, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Although meningitis is largely preventable, it still causes hundreds of thousands of deaths globally each year. WHO set ambitious goals to reduce meningitis cases by 2030, and assessing trends in the global meningitis burden can help track progress and identify gaps in achieving these goals. Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we aimed to assess incident cases and deaths due to acute infectious meningitis by aetiology and age from 1990 to 2019, for 204 countries and territories.

METHODS

We modelled meningitis mortality using vital registration, verbal autopsy, sample-based vital registration, and mortality surveillance data. Meningitis morbidity was modelled with a Bayesian compartmental model, using data from the published literature identified by a systematic review, as well as surveillance data, inpatient hospital admissions, health insurance claims, and cause-specific meningitis mortality estimates. For aetiology estimation, data from multiple causes of death, vital registration, hospital discharge, microbial laboratory, and literature studies were analysed by use of a network analysis model to estimate the proportion of meningitis deaths and cases attributable to the following aetiologies: Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, group B Streptococcus, Escherichia coli, Klebsiella pneumoniae, Listeria monocytogenes, Staphylococcus aureus, viruses, and a residual other pathogen category.

FINDINGS

In 2019, there were an estimated 236 000 deaths (95% uncertainty interval [UI] 204 000-277 000) and 2·51 million (2·11-2·99) incident cases due to meningitis globally. The burden was greatest in children younger than 5 years, with 112 000 deaths (87 400-145 000) and 1·28 million incident cases (0·947-1·71) in 2019. Age-standardised mortality rates decreased from 7·5 (6·6-8·4) per 100 000 population in 1990 to 3·3 (2·8-3·9) per 100 000 population in 2019. The highest proportion of total all-age meningitis deaths in 2019 was attributable to S pneumoniae (18·1% [17·1-19·2]), followed by N meningitidis (13·6% [12·7-14·4]) and K pneumoniae (12·2% [10·2-14·3]). Between 1990 and 2019, H influenzae showed the largest reduction in the number of deaths among children younger than 5 years (76·5% [69·5-81·8]), followed by N meningitidis (72·3% [64·4-78·5]) and viruses (58·2% [47·1-67·3]).

INTERPRETATION

Substantial progress has been made in reducing meningitis mortality over the past three decades. However, more meningitis-related deaths might be prevented by quickly scaling up immunisation and expanding access to health services. Further reduction in the global meningitis burden should be possible through low-cost multivalent vaccines, increased access to accurate and rapid diagnostic assays, enhanced surveillance, and early treatment.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Diabetes is one of the leading causes of death and disability worldwide, and affects people regardless of country, age group, or sex. Using the most recent evidentiary and analytical framework from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), we produced location-specific, age-specific, and sex-specific estimates of diabetes prevalence and burden from 1990 to 2021, the proportion of type 1 and type 2 diabetes in 2021, the proportion of the type 2 diabetes burden attributable to selected risk factors, and projections of diabetes prevalence through 2050.

METHODS

Estimates of diabetes prevalence and burden were computed in 204 countries and territories, across 25 age groups, for males and females separately and combined; these estimates comprised lost years of healthy life, measured in disability-adjusted life-years (DALYs; defined as the sum of years of life lost [YLLs] and years lived with disability [YLDs]). We used the Cause of Death Ensemble model (CODEm) approach to estimate deaths due to diabetes, incorporating 25 666 location-years of data from vital registration and verbal autopsy reports in separate total (including both type 1 and type 2 diabetes) and type-specific models. Other forms of diabetes, including gestational and monogenic diabetes, were not explicitly modelled. Total and type 1 diabetes prevalence was estimated by use of a Bayesian meta-regression modelling tool, DisMod-MR 2.1, to analyse 1527 location-years of data from the scientific literature, survey microdata, and insurance claims; type 2 diabetes estimates were computed by subtracting type 1 diabetes from total estimates. Mortality and prevalence estimates, along with standard life expectancy and disability weights, were used to calculate YLLs, YLDs, and DALYs. When appropriate, we extrapolated estimates to a hypothetical population with a standardised age structure to allow comparison in populations with different age structures. We used the comparative risk assessment framework to estimate the risk-attributable type 2 diabetes burden for 16 risk factors falling under risk categories including environmental and occupational factors, tobacco use, high alcohol use, high body-mass index (BMI), dietary factors, and low physical activity. Using a regression framework, we forecast type 1 and type 2 diabetes prevalence through 2050 with Socio-demographic Index (SDI) and high BMI as predictors, respectively.

FINDINGS

In 2021, there were 529 million (95% uncertainty interval [UI] 500-564) people living with diabetes worldwide, and the global age-standardised total diabetes prevalence was 6·1% (5·8-6·5). At the super-region level, the highest age-standardised rates were observed in north Africa and the Middle East (9·3% [8·7-9·9]) and, at the regional level, in Oceania (12·3% [11·5-13·0]). Nationally, Qatar had the world's highest age-specific prevalence of diabetes, at 76·1% (73·1-79·5) in individuals aged 75-79 years. Total diabetes prevalence-especially among older adults-primarily reflects type 2 diabetes, which in 2021 accounted for 96·0% (95·1-96·8) of diabetes cases and 95·4% (94·9-95·9) of diabetes DALYs worldwide. In 2021, 52·2% (25·5-71·8) of global type 2 diabetes DALYs were attributable to high BMI. The contribution of high BMI to type 2 diabetes DALYs rose by 24·3% (18·5-30·4) worldwide between 1990 and 2021. By 2050, more than 1·31 billion (1·22-1·39) people are projected to have diabetes, with expected age-standardised total diabetes prevalence rates greater than 10% in two super-regions: 16·8% (16·1-17·6) in north Africa and the Middle East and 11·3% (10·8-11·9) in Latin America and Caribbean. By 2050, 89 (43·6%) of 204 countries and territories will have an age-standardised rate greater than 10%.

INTERPRETATION

Diabetes remains a substantial public health issue. Type 2 diabetes, which makes up the bulk of diabetes cases, is largely preventable and, in some cases, potentially reversible if identified and managed early in the disease course. However, all evidence indicates that diabetes prevalence is increasing worldwide, primarily due to a rise in obesity caused by multiple factors. Preventing and controlling type 2 diabetes remains an ongoing challenge. It is essential to better understand disparities in risk factor profiles and diabetes burden across populations, to inform strategies to successfully control diabetes risk factors within the context of multiple and complex drivers.

FUNDING

Bill & Melinda Gates Foundation.

The Effects of an Empathic Communication Workshop on Internal Medicine Residents' Self-Perceived Empathy and Their Patients' Perception of Physician's Empathy: A Single-Group Experimental Study

Background: Empathetic communication improves the physician-patient relationship and enhances patient and physician satisfaction. This study aims to evaluate the impact of empathic communication skills training on physicians' self-perceived performance and patient satisfaction regarding the empathetic quality of their relationship with their physicians. Methods: In this single-group before-after experimental study, we recruited 50 internal medicine residents at a large teaching hospital. We assessed the residents' empathy using the Jefferson Scale of Empathy before and 3 weeks after an 8-hour workshop on empathic communication skills. We also recruited 50 of their patients before and another 50 patients 3 weeks after the training to assess the patient's perceptions of their physician's empathy using the Consultation and Relational Empathy scale. Physicians' and patients' mean scores on empathetic care at the beginning of the study were then compared using paired t-tests with their scores after the workshop. Results: The residents' mean score on Jefferson Empathy Scale increased from 81.1(95%CI:78.8-83.3) at baseline to 96.8(95%CI:93.6-100) following the workshop (p < 0.001). Before the empathetic communication skills training, patients assessed their doctors' empathy at 68.3(95%CI:63.5-73.2). After the intervention, this improved to 84.9(95%CI:82.2-87.5) (p < 0.001). Conclusion: In this study, both the residents and their patients stated that the residents' empathy skills had significantly improved after an empathetic communication workshop for internal medicine residents.

POS1546-HPR DISEASE ACTIVITY BURDEN FOR LONG TERM RHEUMATOLOGY FOLLOW-UP PATIENTS

Background

There has been a lot of emphasis for early diagnosis and treatment for immune mediated rheumatology conditions such as Treat to target (T2T) for inflammatory arthritis, Fast track pathway for Giant cell arteritis. However, the data regarding burden of disease activity, nature and proportion of long term rheumatology follow up patients in rheumatology clinics have not been explored. There are conditions which are refractory to treatment or affected by recurrent flare-ups requiring long term follow-ups and constant monitoring. With increasing life expectancy and better treatment of the long term conditions, emphasis on long term disease activity monitoring is under strain. It is important to understand the nature of illnesses and treatment of long term follow-up patients to decide management strategies.

Objectives

The aim of this quality improvement project was to understand profile of disease and management of patient being seen as long term follow-up (defined as >2 years follow-up after their first presentation in specialist clinic).

Methods

This was a single point, retrospective cohort analysis of patients seen in rheumatology clinics in a district general hospital, UK in March 2021. We reviewed consecutive 120 follow-up patients and recruited 80 patients who had >2yrs follow-up. We have a community rheumatology service arm where all patients with stable inflammatory arthritis on non-biologic treatments are reviewed while patients with multisystem complicated illness and biologics are seen in secondary care. The stable patients from community clinics have not been included in this analysis. The data was reviewed using clinic letters, date of first appointment & last appointment. We looked at gender, age, diagnosis, number of follow ups in the first and last year, disease activity scores of the respective diagnosis and treatment given.

Results

Sixty six percent of follow-up patients are long term with complicated illness or treatment. Of these 52 patients (65%) were female with median age 64 years (range 23-94 years). Median duration of follow up for this group of patients was 6 years (range 2-11 years). Inflammatory arthritis was the most common diagnosis in 75% of patients (11 patients were Psoriatic arthritis, 30- Rheumatoid arthritis, 7- undifferentiated inflammatory arthritis and 7- Axial spondyloarthritis), 17.5% connective tissue disease, 11.2% vasculitis and others (Still’s disease) 3.7%. Some patients had more than one diagnoses. The number of follow ups in the first year ranged from 1-13 (median 4). In final year of analysis, patients were seen median of 3 times (range1-8). Amongst them, 25% of patients were seen 4 or more times. The commonly prescribed drugs were methotrexate (41.2%), sulfasalazine(17.5%), hydroxychloroquine(15%), leflunomide (7.5%),biologics (8.7%), mycophenolate mofetil and azathioprine (6.5%).The activity scores such as DAS28, BVAS, PsARC and BASDAI were documented in 46 patients (57.5%).

Conclusion

This study shows that 66.6% of follow-up patients in rheumatology clinics are complicated long term conditions on immunomodulatory treatment. Despite T2T approach, use of combination DMARDs and early use of biologics, majority are inflammatory arthritis. It also shows that even after median follow-up of 6 years, these patients require an average review 3 or more times per year. The reasons for this may be poor disease control, disease complications, comorbidities and medication side effects. Further analysis is ongoing to look into these aspects for better disease control and long term outcome.

Disclosure of Interests

None declared

AB1012 MANAGEMENT OF BREAST CANCER TREATMENT INDUCED BONE LOSS- RE-AUDIT

Background

Breast cancer treatment therapies (aromatase inhibitors (AI)) are associated with early menopause and adverse effect on bone density. Identifying high-risk patients and managing them appropriately will help reduce their fracture risk.

Objectives

We wanted to ascertain whether our management of breast cancer patients on aromatase inhibitors (AI) referred to osteoporosis clinic were as per guidelines. A consensus position statement from a UK expert group regarding breast cancer treatment induced bone loss, published with the support of the National Osteoporosis Society, the National Cancer Research Institute, Breast Cancer Study Group and the International Foundation.

The guideline recommend lifestyle advice for low risk patients; calcium plus vitamin D supplementation and lifestyle advice for medium risk; bisphosphonate, calcium plus vitamin D supplementation and lifestyle advice for high risk.

Methods

This is a re-audit cycle conducted for all patients referred to the osteoporosis clinic who were treated with aromatase inhibitors for breast cancer between 2016-2020. Patients were divided into two algorithms:

Algorithm 1: women who had experienced premature menopause associated with ovarian suppression with or without AI.

Algorithm 2: Postmenopausal women receiving treatment with an AI.

T-scores were used to stratify patients in algorithm 1 into high risk (HR- T score <-2), medium risk (MR-T score -1 to -2) and low risk (LR- T score >-1).

Algorithm 2 into high risk (HR-T score <-1) medium risk (MR -T score >-1).

Results:

Table 1.

Showing the results of Audit 1 and Re-audit

Audit 1Re-auditTotal Patients5472Data collected2014-20162016-2020GenderFemale 100 (%)Female 100 (%)Age in years45-9638-92Median age7768No of Osteoporotic patients3141No of Osteopenic patients2331Algorithm 1:Total patients=23• 18 HR• 5MR• LR nilTotal patients = 20• 19HR • 1 MRAlgorithm 2:Total patients =31• 31 HR • MR-nil • LR nilTotal patients =52• 45HR • 5MR • 2LRDrug therapy4563Bisphosphonates2149Denosumab2314Teriparatide10Declined treatment01Lifestyle/Vit D & Cal96Lifestyle advice only02

Conclusion

Re-audit showed all patients were on AI and treated appropriately. As compare to audit 1, all high risk group patients were treated with drug therapy and bisphosphonate was the first line therapy as per guidelines. It was recommended that patients with risk of osteoporosis should be referred and treated according to their risk stratification. It is a collective responsibility of Breast surgeons, Geriatrician, Frailty team, Oncologist, Rheumatology and General Practitioners).All patients should have repeat bone density scan in 2 years’ time after initial bisphosphonate therapy. The next audit cycle will be conducted in five years’ time.

Disclosure of Interests

None declared

AB0262 CLINICAL EFFICACY OF SWITCHING FROM ORAL TO SUBCUTANEOUS METHOTREXATE IN MANAGEMENT OF RHEUMATOID ARTHRITIS: EXPERIENCE FROM OUT-PATIENT SETTING OF A DISTRICT GENERAL HOSPITAL IN UK

Background:

Methotrexate (MTX) is an anchor drug in the treatment of Rheumatoid arthritis. The literature review has shown that subcutaneous (SC) methotrexate has shown better efficacy, less adverse side effects and better compliance in inflammatory arthritis. Our department modified Inflammatory arthritis pathway in 2018 where all patient with moderate or severe disease are switched from oral to SC Methotrexate injection for improved management.

Objectives:

The aim of our study is to review whether switching of oral methotrexate (PO MTX) to subcutaneous methotrexate (SC MTX) helps to improve disease activity in patients with rheumatoid arthritis and avoids the need to introduce biologic therapy.

Methods:

We conducted a retrospective audit of patients with rheumatoid arthritis seen between January 2018 to January 2020 recording their age, gender, diagnosis, date of MTX switch and disease activity score 6 months after switching to SC MTX. Significance of change was calculated with test of proportion/chi square test.

Results:

Fifty patients were reviewed, thirty eight (76%) were female and twelve (24%) were male with age ranging between 34 - 86 years (median 61.5 years). Switching to MTX injection was done within 2 yrs of diagnosis in 21 (42%) patients, between 2-5 yrs of diagnosis in 11 (22%) patients and more than 5 yrs after diagnosis in 18 (36%) patients. The main reasons of switching were either maximum MTX dose (25mg) or intolerance to oral MTX at any dose.

After switching methotrexate, review at 6 months showed 26 patients (52%) in remission (compared to 6 at baseline) and 3 (6%) patients avoided the need to go on biologic therapy. Five patient commenced on biologic therapy between 3 and 6 months.

Table 1.

Disease activity compared at Baseline and at 6 months

Disease ActivityBaselineAt 6 monthsRemission <2.6626 (p<0.0001)Mild (26-3.19)1110Mod (3.2 - 5.09)259 (p<0.01)Severe (>5.1)85

Conclusion:

Switching to SC Methotrexate even in patients with long duration of disease results in significant number of patients achieving remission or lower disease activity (P<0.001). This may obviate the need of biologics therapy

Disclosure of Interests:

None declared

Remineralization Effect of Topical NovaMin Versus Sodium Fluoride (1.1%) on Caries-Like Lesions in Permanent Teeth

OBJECTIVE

NovaMin, a synthetic mineral composed of calcium, sodium, phosphorous and silica releases deposits of crystalline hydroxyl-carbonate apatite (HCA) structurally similar to tooth mineral composition. The aim of this investigation was to compare the potential remineralization effect of topical NovaMin and Sodium Fluoride gel on caries like lesions in permanent teeth.

MATERIALS AND METHODS

A total of 60 sound human freshly extracted teeth were subjected to a pH-cycling protocol. Specimens were randomly assigned to one of the two treatment groups with NovaMin contained dentifrice applied to group 1, while group 2 received a dentifrice containing 1.1% neutral Sodium Fluoride. Pastes were applied five times after the samples received a demineralization from an earlier cariogenic challenge. Specimens were then evaluated by a Surface Micro Hardness test (SMH, 25G, 5s). Post-treatment SMH measurements were conducted and Mann Whitney test was employed for statistical analysis.

RESULTS

Mean post lesion SMH values were 221.99±26.27 and 224.50±28.64 for the first and second groups, respectively. Post treatment SMH values were 232.52±24.34 for NovaMin and 232.03 ±24.46 for the fluoride group. Two way ANOVA test showed a highly significant difference between the two different treatment protocols (p<0.001).

CONCLUSION

NovaMin dentifrice appears to have a greater effect on remineralization of carious-like lesions when compared to that of fluoride containing dentifrice in permanent teeth.

Microleakage assessment of pit and fissure sealant with and without the use of pumice prophylaxis

OBJECTIVES

This study evaluated the effect of pumice prophylaxis on the level of microleakage around and between the sealant and enamel.

MATERIALS AND METHODS

A total of 32 freshly extracted sound upper first premolars, assigned as suitable for sealant application, were chosen and divided randomly into two groups: (1) a test group, without prophylaxis; and (2) a control group, with prophylaxis. Sealant was applied to all teeth using the same conventional technique, with prophylaxis being omitted in the test group. The sealed teeth were thermocycled (120 x 30 s, 5 and 55 degrees C cycles) and then immersed in 2% Basic Fuchsin solution for 72 h. Each tooth was sectioned and examined for dye penetration under a stereomicroscope (x 60 magnification).

RESULTS

No dye penetration was seen in 19 (29.6%) of the teeth in the test group and 36 (56.2%) of the teeth in the control group. Dye had penetrated to the base of the fissure in 31 (48.4%) of the teeth in the test group and 23 (35.9%) of the teeth in the control group. Using a chi-square test for trend, the frequency of microleakage was significantly higher in the test group compared to the controls (P < 0.016).

CONCLUSION

Prophylaxis has a role in improving sealant retention. Removing this step may cause an increase in microleakage.

Chemomechanical caries removal in primary teeth in a group of anxious children

Chemomechanical removal of dental caries has considerable potential in the treatment of patients with management problems, especially in paediatric dentistry. The aim of this study was to assess the acceptance and success of the technique in young nervous patients. A group of 20 patients, aged between 4 and 10 years with a high level of dental anxiety was selected. The study achieved a success rate of over 90% in acceptance of cavity preparation by this procedure followed by placement of a restoration. The length of time required for cavity preparation was comparable with conventional methods. The need for local anaesthesia was reduced or eliminated and the children did not complain of any pain during the procedure. It is concluded that chemomechanical caries removal in vivo in primary teeth is an effective alternative to conventional mechanical caries removal and is advantageous in patients who have a phobia to the dental handpiece and/or injections.

Role of modified nucleosides of yeast tRNA(Phe) in ribosomal binding

Naturally occurring nucleoside modifications are an intrinsic feature of transfer RNA (tRNA), and have been implicated in the efficiency, as well as accuracy-of codon recognition. The structural and functional contributions of the modified nucleosides in the yeast tRNA(Phe) anticodon domain were examined. Modified nucleosides were site-selectively incorporated, individually and in combinations, into the heptadecamer anticodon stem and loop domain, (ASL(Phe)). The stem modification, 5-methylcytidine, improved RNA thermal stability, but had a deleterious effect on ribosomal binding. In contrast, the loop modification, 1-methylguanosine, enhanced ribosome binding, but dramatically decreased thermal stability. With multiple modifications present, the global ASL stability was mostly the result of the individual contributions to the stem plus that to the loop. The effect of modification on ribosomal binding was not predictable from thermodynamic contributions or location in the stem or loop. With 4/5 modifications in the ASL, ribosomal binding was comparable to that of the unmodified ASL. Therefore, modifications of the yeast tRNA(Phe) anticodon domain may have more to do with accuracy of codon reading than with affinity of this tRNA for the ribosomal P-site. In addition, we have used the approach of site-selective incorporation of specific nucleoside modifications to identify 2'O-methylation of guanosine at wobble position 34 (Gm34) as being responsible for the characteristically enhanced chemical reactivity of C1400 in Escherichia coli 16S rRNA upon ribosomal footprinting of yeast tRNA(Phe). Thus, effective ribosome binding of tRNA(Phe) is a combination of anticodon stem stability and the correct architecture and dynamics of the anticodon loop. Correct tRNA binding to the ribosomal P-site probably includes interaction of Gm34 with 16S rRNA C1400.

Structural and functional roles of the N1- and N3-protons of psi at tRNA's position 39

Pseudouridine at position 39 (Psi(39)) of tRNA's anticodon stem and loop domain (ASL) is highly conserved. To determine the physicochemical contributions of Psi(39)to the ASL and to relate these properties to tRNA function in translation, we synthesized the unmodified yeast tRNA(Phe)ASL and ASLs with various derivatives of U(39)and Psi(39). Psi(39)increased the thermal stability of the ASL (Delta T (m)= 1.3 +/- 0.5 degrees C), but did not significantly affect ribosomal binding ( K (d)= 229 +/- 29 nM) compared to that of the unmodified ASL (K (d)= 197 +/- 58 nM). The ASL-Psi(39)P-site fingerprint on the 30S ribosomal subunit was similar to that of the unmodified ASL. The stability, ribosome binding and fingerprint of the ASL with m(1)Psi(39)were comparable to that of the ASL with Psi(39). Thus, the contribution of Psi(39)to ASL stability is not related to N1-H hydrogen bonding, but probably is due to the nucleoside's ability to improve base stacking compared to U. In contrast, substitutions of m(3)Psi(39), the isosteric m(3)U(39)and m(1)m(3)Psi(39)destabilized the ASL by disrupting the A(31)-U(39)base pair in the stem, as confirmed by NMR. N3-methylations of both U and Psi dramatically decreased ribosomal binding ( K (d)= 1060 +/- 189 to 1283 +/- 258 nM). Thus, canonical base pairing of Psi(39)to A(31)through N3-H is important to structure, stability and ribosome binding, whereas the increased stability and the N1-proton afforded by modification of U(39)to Psi(39)may have biological roles other than tRNA's binding to the ribosomal P-site.

Caries detector dyes--an in vitro assessment of some new compounds

Previous studies have shown that the caries detector dyes, basic fuchsin and acid red, lack specificity. Accordingly, their clinical use can lead to the unnecessary removal of sound tissue. In the present study, the specificity of three further dyes, Carbolan Green, Coomassie Blue and Lissamine Blue was studied. Carious dentine was removed in vitro by means of rotary instruments until the cavities were deemed caries free by conventional clinical criteria. Experimental dyes were applied to the cavity floors, all of which became stained. Stained dentine was removed from half the cavity by means of a burr, the other half remaining as a control. Further stain was then applied and the procedure repeated until no further reduction of the staining of the cavity floor could be achieved. Light microscopy of ground sections of experimental teeth showed that sound tissue had been removed unnecessarily from the experimental half of the cavity due to the lack of specificity of these dyes. This lack of specificity of staining was similar to basic fuchsin and acid red. Only Carbolan Green showed possible differential staining between control and experimental sites, but this was not caries specific. If a clinically useful dye is to be developed, it would need to specifically stain either bacteria in infected dentine and/or the carious degradation products of dentine matrix.

The uridine in "U-turn": contributions to tRNA-ribosomal binding

"U-turns" represent an important class of structural motifs in the RNA world, wherein a uridine is involved in an abrupt change in the direction of the polynucleotide backbone. In the crystal structure of yeast tRNAPhe, the invariant uridine at position 33 (U33), adjacent to the anticodon, stabilizes the exemplar U-turn with three non-Watson-Crick interactions: hydrogen bonding of the 2'-OH to N7 of A35 and the N3-H to A36-phosphate, and stacking between C32 and A35-phosphate. The functional importance of each noncanonical interaction was determined by assaying the ribosomal binding affinities of tRNAPhe anticodon stem and loop domains (ASLs) with substitutions at U33. An unsubstituted ASL bound 30S ribosomal subunits with an affinity (Kd = 140+/-50 nM) comparable to that of native yeast tRNAPhe (Kd = 100+/-20 nM). However, the binding affinities of ASLs with dU-33 (no 2'-OH) and C-33 (no N3-H) were significantly reduced (2,930+/-140 nM and 2,190+/-300 nM, respectively). Surprisingly, the ASL with N3-methyluridine-33 (no N3-H) bound ribosomes with a high affinity (Kd = 220+/-20 nM). In contrast, ASLs constructed with position 33 uridine analogs in nonstacking, nonnative, and constrained conformations, dihydrouridine (C2'-endo), 6-methyluridine (syn) and 2'O-methyluridine (C3'-endo) had almost undetectable binding. The inability of ASLs with 6-methyluridine-33 and 2'O-methyluridine-33 to bind ribosomes was not attributable to any thermal instability of the RNAs. These results demonstrate that proton donations by the N3-H and 2'OH groups of U33 are not absolutely required for ribosomal binding. Rather, the results suggest that the overall uridine conformation, including a dynamic (C3'-endo > C2'-endo) sugar pucker, anti conformation, and ability of uracil to stack between C32 and A35-phosphate, are the contributing factors to a functional U-turn.

Dentinal dysplasia type I: review of the literature and report of a family

A family is reported with dentinal dysplasia type I affecting both dentitions. Presenting features included unusual mobility of the teeth, followed by early exfoliation; normal clinical shape of the crowns of the teeth, but with an amber color without any sign of attrition or abnormal loss of enamel. Radiographic findings showed pulp-chamber and root-canal obliteration, poor root formation, radiolucent linear appearance of the pulp chamber parallel to the cementoenamel junction and frequent periapical radiolucencies. Histological studies have reported large masses of calcified tubular dentin, atypical osteodentin, and also true denticle.

Regional odontodysplasia: report of four cases

Four cases of regional odontodysplasia are described. Clinically erupted teeth appear hypoplastic and are often mobile. The radiographic appearance has given rise to the term 'ghost teeth' and the cases presented demonstrate this with short roots which are less well calcified than normal teeth. Clinical and radiographic findings showed that this condition affects only one side of the jaw, but can be seen in any part of the upper or lower jaws. This article represents cases in different parts of the mouth with varying degrees of involvement.

Front-line management of pulmonary tuberculosis: an analysis of tuberculosis and treatment practices in urban Sindh, Pakistan

SETTING

Karachi and Hyderabad, Pakistan.

OBJECTIVE

To describe the level and quality of tuberculosis (TB) case management by non-TB control program (TCP) physicians in urban Sindh, Pakistan.

DESIGN

We interviewed 152 adults with pulmonary TB confirmed by Karachi's TB control program regarding the initial management of their TB symptoms before entering the TCP. We also surveyed 65 general practitioners (GPs) attending continuing education seminars with a multiple choice test to assess their management of suspected pulmonary TB. We compared both results to guidelines from the World Health Organization (WHO) and the International Union Against Tuberculosis and Lung Disease (IUATLD).

RESULTS

Eighty percent (122/152) of patients first sought GPs. Only 14% of GPs performed any sputum test. At most, 17 (40%) of the 42 patients recalling their GP's treatment, received the recommended 4-drug regimen. However, 68% (45/65) of surveyed GPs chose correct treatment from a multiple choice format. But their initial laboratory investigations, follow-up, and treatment cessation criteria (9%, 9-31%, and 11% correct, respectively) demonstrated under-utilization of sputum tests and over-reliance on unhelpful tests.

CONCLUSIONS

GPs first saw most of these TCP patients, but their weak management likely hinders TB control. A partnership between TB control programs and GPs could improve case management and hasten TB control.

Glucose intolerance in pulmonary tuberculosis

The frequency of glucose intolerance was studied in 106 patients with pulmonary tuberculosis attending Nazimabad Chest Clinic. Diagnosis was based on X-ray and a positive sputum smear. An oral glucose tolerance test (OGTT) was performed and evaluated according to the WHO criteria. Glucose intolerance was detected in 52 (49%) patients, 31 Impaired Glucose Tolerance (IGT), 21 Diabetes Mellitus (DM). After adequate antitubercular therapy and sputum conversion, the OGTT was repeated in 23 cases. Of these 13 (56.5%) patients had a normal glucose tolerance indicating that glucose intolerance observed during active pulmonary tuberculosis improves or normalizes after adequate therapy.

The effect of cholecystokinin-octapeptide on the hepatobiliary dysfunction caused by total parenteral nutrition

PURPOSE

Patients on total parenteral nutrition (TPN) commonly have hepatobiliary dysfunction. Interruption of the enterohepatic circulation (EHC) and gallbladder stasis are part of the pathogenesis. Cholecystokinin-octapeptide (CCK-OP), by emptying the gallbladder, stimulates the EHC. This study was performed to determine whether daily CCK-OP infusions can ameliorate the hepatobiliary dysfunction caused by TPN.

METHODS

Rabbits maintained on a standard TPN for 12 days were divided into two groups. One group (n = 6) received daily intravenous doses of CCK-OP, and the other (n = 13) received TPN only. A lab-chow-fed (LCF) group (n = 8) served as controls. The authors studied bile flow and bile acid secretion rates, sulfobromophthalein (BSP) secretion, gallbladder emptying in response to CCK-OP, and liver histology.

RESULTS

The LCF group had a bile flow of 82.3 microL/kg/min; that for the TPN-only group was 45.7 microL/kg/min (P < .001). The daily CCK-OP group did not improve more than the TPN-only group, with a bile flow of 45.8 microL/kg/min (P = NS). Bile acid secretion was 0.64 mumol/kg/min for the LCF group, 0.46 for the TPN-only group (P = NS), and 0.46 for the daily CCK-OP group (P = NS). TPN impaired the ability of the gallbladder to empty, and this was restored with daily CCK-OP. In the LCF group, the mean BSP secretion was 81.7% of a 5-mg/kg bolus within 60 minutes, compared with 72.5% in the daily CCK-OP group (P = NS) and 63.5% in the TPN-only group (P < .01). Histological examination of the liver showed that daily CCK-OP produced less periportal inflammation and fibrosis, although all TPN groups had hepatocyte damage in the centrilobular area.

CONCLUSION

Stimulation of the EHC with daily CCK-OP infusions during TPN decreased periportal inflammation and fibrosis, maintained gallbladder emptying capacity, and improved organic anion (BSP) secretion, although bile flow and bile acid secretion were not improved, and hepatocyte damage persisted.

Traumatic work related fatalities in commercial fishermen in Australia

OBJECTIVES

To describe the types and circumstances of traumatic work related fatalities in Australian commercial fishermen.

METHODS

Work related traumatic fishing fatalities were studied as part of a larger study of all work related traumatic fatalities in Australia from 1982 to 1984. Data on 47 cases were obtained from inspection of coroners' files.

RESULTS

The incidence of fatality of 143/100,000 person-years was 18 times higher than the incidence of fatality for the entire workforce, and considerably higher than that of the mining and agricultural workforces. 68% of decedents drowned and 13% died from physical trauma. Rough weather, non-seaworthy vessels, inadequate use of personal flotation devices, and inexperience were associated with many of the fatal incidents.

DISCUSSION

Improved vessel and equipment maintenance, better training of workers, greater use of personal flotation devices, and development of improved clothing and personal flotation devices are recommended.

Hepatobiliary dysfunction during total parenteral nutrition is caused by infusate, not the route of administration

Cholestatic jaundice is the major complication of total parenteral nutrition (TPN). Both the intravenous (IV) route of nutrition and the enteral fast have been implicated as causes of TPN-associated cholestasis (TPN-AC). The purpose of this study was to determine whether TPN-AC is caused by the TPN solution itself or the IV route of administration and enteral fast. Prepubescent rabbits (n = 24) were divided into four groups: CONTROL, fed standard lab chow; TPN, received a standard hyperalimentation solution of dextrose, Aminosyn, and lipids via the jugular vein; ENT, received the same hyperalimentation solution via a duodenostomy tube; and OSM, received a polymeric formula (Osmolite) via a duodenostomy tube. After 14 days on these diets, we measured bile flow, bile acid excretion, sulfobromophthalein (BSP) excretion, plasma amino acid profile, serum liver enzymes, and liver histology. Statistical analysis was by analysis of variance. Hyperalimentation solution significantly depressed hepatobiliary function, whether it was given IV or by gut. Bile flow in both the TPN (36.4 microL/kg/min) and ENT (46.2) groups was significantly less than CONTROL (84.5) or OSM (62.9). Hepatic secretory function, measured by excretion of the cholephilic dye BSP, was depressed in both TPN and ENT (57% and 55% of IV dose excreted in bile over 60 minutes, respectively) compared with CONTROL (84%) or OSM (71%). Serum liver enzymes were normal in all groups. Histological injury similar to TPN-AC in humans (portal inflammation and hepatocyte degeneration) was seen in both groups receiving the hyperalimentation solution.(ABSTRACT TRUNCATED AT 250 WORDS)