B - 37 Cognitive Aging in Rural Communities: Preliminary Characterization of Memory in a Community Cohort from Southern Nevada

OBJECTIVE

Rural-dwelling older adults face unique health challenges that may increase risk for Alzheimer's disease and related dementias; however, they are severely underrepresented in aging research. Here we present an initial characterization of memory functioning in a prospectively followed rural community cohort, with comparisons to an urban cohort from the same region.

METHODS

Community-dwelling adults over age 50 currently living in a non-metropolitan area are eligible for enrollment. Clinical characterization includes the NACC Uniform Data Set supplemented with additional verbal list learning and nonverbal memory measures. Primary comparisons explored group differences between urban and rural-dwellers, stratified by cognitive diagnosis. The influence of neighborhood disadvantage on memory was also assessed.

RESULTS

There were no differences in demographics or overall clinical status between the rural (n = 81) and urban samples (n = 129). Approximately half of each sample was cognitively normal. Differences in verbal memory were found for learning (d = 0.45), recall (d = 0.48), and recognition such that rural-dwelling older adults demonstrated a memory advantage relative to urban-dwelling adults; however, the magnitude of impairment within each cohort was larger among rural-dwelling older adults (d = 1.65-2.06) compared to urban-dwelling adults (d = 0.8-1.45). No differences in nonverbal memory were found, and there were no effects of neighborhood disadvantage on any memory measure.

CONCLUSIONS

Although rural living may increase risk for dementia, we found a small to moderate memory advantage for rural-dwellers. Taken together, our findings suggest that late-life rural living in this geographical region is not necessarily associated with an increased burden of memory impairment, and could actually be protective for some individuals.

The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Head and neck cancers survival in Europe, Taiwan, and Japan: results from RARECAREnet Asia based on a privacy-preserving federated infrastructure

Background

The head and neck cancers (HNCs) incidence differs between Europe and East Asia. Our objective was to determine whether survival of HNC also differs between European and Asian countries.

Methods

We used population-based cancer registry data to calculate 5-year relative survival (RS) for the oral cavity, hypopharynx, larynx, nasal cavity, and major salivary gland in Europe, Taiwan, and Japan. We modeled RS with a generalized linear model adjusting for time since diagnosis, sex, age, subsite, and histological grouping. Analyses were performed using federated learning, which enables analyses without sharing sensitive data.

Findings

Five-year RS for HNC varied between geographical areas. For each HNC site, Europe had a lower RS than both Japan and Taiwan. HNC subsites and histologies distribution and survival differed between the three areas. Differences between Europe and both Asian countries persisted even after adjustments for all HNC sites but nasal cavity and paranasal sinuses, when comparing Europe and Taiwan.

Interpretation

Survival differences can be attributed to different factors including different period of diagnosis, more advanced stage at diagnosis, or different availability/access of treatment. Cancer registries did not have stage and treatment information to further explore the reasons of the observed survival differences. Our analyses have confirmed federated learning as a feasible approach for data analyses that addresses the challenges of data sharing and urge for further collaborative studies including relevant prognostic factors.

Outcomes of skin cancer excision in frail patients: A retrospective cohort study

BACKGROUND

Non-melanoma skin cancer (NMSC) is the most common cancer type and incidence increases with age. As a consequence, an increasing number of frail patients are being referred for consideration of skin cancer surgery. However, some of these patients may not live long enough to experience benefit from surgery, while being at risk of postoperative complications.

OBJECTIVES

To investigate the treatment burden of surgical excision of skin cancers in frail individuals.

METHODS

We conducted a single-center retrospective cohort study analyzing outcomes of skin cancer excision in frail versus non-frail patients.

RESULTS

Eighty-eight patients were included. The complication rate was higher in frail versus non-frail patients: 12 (27.9%) versus 9 (18.8%), with 5 unplanned postoperative hospital attendances leading to 3 hospital admissions in the frail cohort. Nine patients in the frail group (21%) died within 6 months of their procedure versus no deaths in the non-frail group (p < 0.001 Fisher's Exact test), with no deaths attributed to skin cancer.

CONCLUSION

Treatment-related complications and mortality are common in frail patients after surgical excision of skin lesions clinically suspicious for skin cancer. Careful consideration should be given, and patients should be adequately counseled about treatment risks and alternative management options, including active surveillance, in particular, if the lesions are expected to remain asymptomatic.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

An evaluation of knowledge of circular economy among Therapeutic Radiographers/Radiation Therapists (TR/RTTs): Results of a European survey to inform curriculum design

INTRODUCTION

Global warming and the increase in greenhouse gases are a current concern worldwide. The healthcare sector constitutes about 4.4% of all emissions. This study aims to evaluate the knowledge, awareness and attitudes of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) regarding environment-related concepts to inform the development of educational curriculum.

METHODS

A validated self-designed survey was distributed to TR/RTTs across Europe by the SAFE EUROPE partners and via social media between October 2021 and February 2022. The survey was divided into six sections: (i) demographics, (ii) knowledge of Circular Economy (CE) and Green Skills (GS), (iii) personal attitudes, (iv) TR/RTTs attitudes, (v) the importance of CE, and (vi) education. Questions consisted of mostly Likert scales complemented with other closed- and open-ended questions.

RESULTS

31%-42% of participants are aware of national and departmental policies in CE and GS concepts. Even though half of the participants considered that they advocate and practice CE, the open questions indicated that participants only focus on waste management, ignoring all the other dimensions of CE in healthcare. Personal attitudes and lifestyles also did not reflect CE. TR/RTTs considered CE practices and GS development essential. However, the suggested academic level at which these skills should be developed was split between High School (44%) and Bachelor's degree (32%).

CONCLUSION

It is essential to raise awareness among TR/RTTs about the various dimensions of CE applied to healthcare: "green transportation", "environment-friendly procurement", "hospital building design", "food process optimisation", "water reduction", "energy efficiency", and "waste management".

IMPLICATIONS FOR PRACTICE

These GS must be developed by TR/RTTs to decrease their impact on the environment. Their training may need to be lifelong, starting during basic high school education and continuing as healthcare professionals after graduation.

Characterizing the Network Structure of Post-Concussion Symptoms

OBJECTIVE

Assessment of post-concussion symptoms is implemented at secondary, post-secondary, and professional levels of athletics. Network theory suggests that disorders can be viewed as a set of interacting symptoms that amplify, reinforce, and maintain one another. Examining the network structure of post-concussion symptoms may provide new insights into symptom comorbidity and may inform targeted treatment. We used network analysis to examine the topology of post-concussion symptoms using the Post-Concussion Symptom Scale (PCSS) in high school athletes with recent suspected sport-related concussion.

METHOD

Using a cross-sectional design, the network was estimated from Post Concussion Symptom Scale scores from 3,292 high school athletes, where nodes represented symptoms and edges represented the association between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network.

RESULTS

The network consisted of edges within and across symptom domains. "Difficulty concentrating" and "dizziness" were the most central symptoms in the network. Although not highly central in the network, headaches were the highest rated symptom.

CONCLUSIONS

The interconnectedness among symptoms supports the notion that post-concussion symptoms are interrelated and mutually reinforcing. Given their central role in the network, "difficulty concentrating" and "dizziness" are expected to affect the activation and persistence of other post-concussion symptoms. Interventions targeting difficulties with concentration and dizziness may help alleviate other symptoms. Our findings could inform the development of targeted treatment with the aim of reducing overall symptom burden. Future research should examine the trajectory of post-concussion symptom networks to advance the clinical understanding of post-concussive recovery.

Catalyzing action on HIV/SRH integration: lessons from Kenya, Malawi, and Zimbabwe to spur investment

The HIV pandemic has long revealed the inequities and fault lines in societies, one of the most tenacious being the pandemic's disproportionate impact on adolescent girls and young women. In east and southern Africa, renewed global action is needed to invigorate an effective yet undervalued approach to expanding HIV prevention and improving women's health: integration of quality HIV and sexual and reproductive health (SRH) services. The urgency of advancing effective integration of these services has never been clearer or more pressing. In this piece, national health officials from Kenya, Malawi, and Zimbabwe and global health professionals have joined together in a call to catalyze actions by development partners in support of national strategies to integrate HIV and SRH information and services. This agenda is especially vital now because these adolescent girls and young women are falling through the cracks due to the cascading effects of COVID-19 and disruptions in both SRH and HIV services. In addition, the scale-up of pre-exposure prophylaxis (PrEP) has been anemic for this population. Examining the opportunities and challenges of HIV/SRH integration implemented recently in three countries - Kenya, Malawi, and Zimbabwe - provides lessons to spur integration and investments there and in other nations in the region, aimed at improving health outcomes for adolescent girls and young women and curbing the global HIV epidemic. While gaps remain between strong national integration policies and program implementation, the experiences of these countries show opportunities for expanded, quality integration. This commentary draws on a longer comparative analysis of findings from rapid landscaping analyses in Kenya, Malawi, and Zimbabwe, which highlighted cross-country trends and context-specific realities around HIV/SRH integration.

Visceral Obesity Is Associated with Shorter Progression-Free Survival in Well-Differentiated Gastro-Entero-Pancreatic Neuroendocrine Neoplasia

The association of well-differentiated gastro-entero-pancreatic neuroendocrine neoplasia (WD GEP-NEN) with metabolic syndrome (MetS), abdominal obesity, and fasting glucose abnormalities was recently described. However, whether obesity and metabolic syndrome risk factors are associated with GEP-NEN adverse outcomes and the poorer prognosis was unknown. The present study aimed to evaluate whether the presence of MetS or any of its individual components at WD GEP-NEN diagnosis influenced disease outcomes. A cohort of patients with non-localized WD GEP-NETs (n = 81), was classified according to the primary tumor site (gastrointestinal or pancreatic), pathological grading (G1 (Ki67 ≤ 2%) and G2 (3% ≤ Ki67 ≤ 20%) (WHO 2010)), disease extension (loco-regional or metastatic disease), presence of hormonal secretion syndrome (functioning or non-functioning), and evaluated for the presence of MetS criteria at diagnosis. MetS was present in 48 (59.3%) patients. During a median follow-up of 95.0 months (16.8–262.5), 18 patients died of the disease (10 with MetS vs. 8 without MetS). Overall survival (OS) at 5 years was 87.1% (95% CI: 73.6–94.0) for MetS and 90.9% (95% CI: 74.4–97.0) for non-Mets group, while OS at 10 years was 72.5% (95% CI: 55.3–84.0) for MetS, and 76.4% (95% CI: 53.6–89.0) for non-MetS group. Progression-Free Survival (PFS) at 5 years was 45.9% (95% CI: 30.8–59.8) for MetS and 40.0% (95% CI: 21.3–58.1) for non-MetS group, and PFS at 10 years was 18.1% (95% CI: 7.0–33.5) for MetS and 24.4% (95% CI: 9.0–43.7) for non-MetS group. Waist circumference (WC), a surrogate measure for visceral obesity, was associated with significantly shorter PFS (HR = 1.03; 95% CI: 1.01–1.06), although did not influence OS (HR = 1.01; 95% CI: 0.97–1.06). The findings of this study reinforce a potential link between visceral obesity and GEP-NEN and further suggest that obesity could influence disease prognosis.

Constructing custom-made radiotranscriptomic signatures from CT angiograms: an application in COVID-19 vascular inflammation

Background

Advances in computational methodologies have enabled processing of large datasets originating from imaging studies. However, most imaging biomarkers suffer from a lack of direct links with underlying biology, as they are only observationally correlated with pathophysiology.

Purpose

To develop and validate a novel AI-assisted image analysis platform, by applying quantitative radiotranscriptomics that quantifies cytokine-driven vascular inflammation from routine CT angiograms (CTA) performed as part of clinical care in COVID-19.

Methods

We used this platform to train the radiotranscriptomic signature C19-RS, derived from the perivascular space around the aorta and the internal mammary artery in routine chest CTAs, to best describe cytokine-driven vascular inflammation, defined using transcriptomic profiles from RNA sequencing data from human arterial biopsies (A). This signature was validated externally in 358 clinically indicated CT pulmonary angiograms from patients with or without COVID-19 from 3 different geographical regions.

Results

First, 22 patients who had a CTA before the pandemic underwent repeat CTA <6 months post COVID-19 infection (B). Compared with 22 controls (matched for age, gender, and BMI) C19-RS was increased only in the COVID-19 group (C). Next, C19-RS was calculated in a cohort of 331 patients hospitalised during the pandemic, and was higher in COVID-19 positives (adjusted OR=2.97 [95% CI: 1.43–6.27], p=0.004, D). C19-RS had prognostic value for in-hospital mortality in COVID-19, with HR=3.31 ([95% CI: 1.49–7.33], p=0.003) and 2.58 ([95% CI: 1.10–6.05], p=0.028) in two testing cohorts respectively (E, F), adjusted for clinical factors and biochemical biomarkers of inflammation and myocardial injury. The corrected HR for in-hospital mortality was 8.24 [95% CI: 2.16–31.36], p=0.002 for those who received no treatment with dexamethasone, but only 2.27 [95% CI: 0.69–7.55], p=0.18 in those who received dexamethasone subsequently to the C19-RS based image analysis, suggesting that vascular inflammation may have been a therapeutic target of dexamethasone in COVID-19. Finally, C19-RS was strongly associated (r=0.61, p=0.0003) with a whole blood transcriptional module representing dysregulation of coagulation and platelet aggregation pathways.

Conclusion

We present the first proof of concept study that combines transcriptomics with radiomics to provide a platform for the development of machine learning derived radiotranscriptomics analysis of routine clinical CT scans for the development of non-invasive imaging biomarkers. Application in COVID-19 produced C19-RS, a marker of cytokine-driven inflammation driving systemic activation of coagulation, that predicts in-hospital mortality and identifies people who will have better response to anti-inflammatory treatments, allowing targeted therapy. This AI-assisted image analysis platform may have applications across a wide range of vascular diseases, from infections to autoimmune diseases.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): EPSRC, British Heart Foundation, NIHR

O045 A systematic review of observational management of cutaneous basal cell carcinoma

Background

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of BCC.

Methods

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

Results

From 2529 titles, four full-text articles reporting on 2298 individuals were eligible. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6–12 weeks. Clearance rates ranged from 52–100% for imiquimod and 2–19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

Conclusion

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility adjusted survival following interventional or observational management of BCC.

Take-home message

This systemic review identifies a lack of data reporting outcomes following observational management of BCC, despite possible advantages of this treatment strategy. Future RCTs should compare quality of life outcomes and utility-adjusted survival following interventional or observational management of BCC.

LINC-24. Survival and genetic evaluation of patients diagnosed with choroid plexus tumor treated at a Brazilian institution

INTRODUCTION: Choroid plexus tumors (CPT) are rare intraventricular neoplasms of epithelial origin. They usually occur in the 2nd year of life, corresponding to 0.4-0.6% of intracranial tumors in this age group. They are classified, according to WHO 2021: choroid plexus carcinoma (CPC), atypical choroid plexus papilloma (ACPP) and choroid plexus papilloma (CPP). Li-Fraumeni syndrome (LFS) is present in 50% of patients with CPC. In Brazil, the TP53p.R337H mutation affects 0.3% of the population in the South/Southeast. OBJECTIVE: Evaluate the genetic assessment and overall-survival (OS) of patients with CPT treated at IOP/GRAACC/UNIFESP. PATIENTS/METHODS: Between 1995-2021, 48 patients were diagnosed with CPT in our institution, 27 CPC, 18 CPP and 3 ACPP. From 2012-2021 patients were referred for genetic evaluation, 16 of which had CPC (2 had previously CPP). Family history for neoplasms was present in 87.5%, 37.5% compatible with Li-Fraumeni Syndrome (LFS) of which 50% with positive mutations. The molecular investigation of TP53 gene in patients with CPC was performed and positive in 62,5%:R337H(6 patients), R110C*, R158H*, H179R*, R196* (*1 patient each). For those with R337H, p53 protein immunohistochemistry resulted in 90-100% positivity. Treatment strategies consisted of surgery with gross total resection being achieve in all ACPP, 94,4% CPP and 55,5% CPC. Chemotherapy was performed in only 1 case of ACPP and all CPC with a variety of schemas, including high dose of chemotherapy and autologous bone marrow transplant for slow responders or recurrent disease. The three- and five-years OS for CPC was 72.5% and 61.7%, respectively. For CPP and ACPP 5y OS was 100%. CONCLUSION: The present study is in agreement with the literature showing an excellent survival for CPP and ACPP but an inferior outcome for patients with CPC and TP53 mutation despite being assisted by a well-prepared multidisciplinary team with an adequate treatment.

Dissociative and Epileptic seizures: how to distinguish them?

Introduction

Dissociative seizures (DS) are classified as dissociative convulsions within the group of dissociative disorders. Although they share many features with epileptic seizures (ES), they are not a consequence of abnormal brain discharges and may be related to psychogenic causes. DS represent a common diagnostic and are often confounded with ES.

Objectives

The aim of this study is to review the current evidence about the differential diagnosis between DS and ES.

Methods

We conducted a non-sytematic review on the topic, using Pubmed/Medline database.

Results

Studies emphasize a correct diagnosis before treatment of seizures. DS and ES respond differently to anticonvulsant medication and early or incorrect prescription of can even exacerbate DS. Clinical features and a neuropsychiatric history can also help. The presence of a dissociative “stigmata”, such as unexplained sensory loss, may support a non-epileptic diagnosis. EEG videorecording method is the gold standard diagnosis for DS, however often displays rhythmic movement artifacts that may resemble seizure activity and confound the interpretation. The absence of ictal EEG discharges characteristic of epilepsy is a sign of DS. However, this may not be true for some partial ES, particularly those from temporal lobes, whom also tend to report shorter duration of seizures, whereas patients with DPD often describe experiences lasting for hours or longer.

Conclusions

Distinguish DS from ES can be challenging. However, there are features that can help in the differential diagnosis. A correct diagnosis is essential for an adequate therapeutic approach, better prognosis, reduction of medical costs and also a referral to the right medical specialty.

Disclosure

No significant relationships.

How did the Covid-19 Pandemic Impact the Life of Patients with Schizophrenia Spectrum Disorders?

Introduction

Since the first outbreak, the Covid-19 pandemic has had and still has several implications worldwide, particularly in severe mentally ill patients, leading to multiple challenges in their management.

Objectives

We aim to assess the impact and implications of the Covid-19 pandemic on patients with Schizophrenia Spectrum Disorders (SSD) and the treatment recommendations available.

Methods

We conduct an integrative review using PubMed database. Search terms included: “psychosis” AND “COVID-19 pandemic”, “schizophrenia and COVID-19”, “severe mental illness” AND “COVID-19”. The search period was between 1^st January 2020 and 31^th July 2021.

Results

Studies postulated that people with SSD are at a higher risk of COVID-19 infection with a poorer medical and social outcome which is attributed to factors such as higher rates of disadvantageous lifestyle behaviours, medical comorbidities, antipsychotic medication metabolic effects, psychosocial adversities, smaller social networks and poor engagement with general health services. The Covid-19 pandemic also demanded adjustments in treatment guidelines and monitoring, particularly in patients with SSD on Clozapine. Many studies address the importance of psychiatric care and treatment during the pandemic. They emphasize rapid implementation of measures to decrease the risk of COVID-19 transmission and maintain continuity care and research. An individualized and flexible approach is needed to promote safety of SSD patients.

Conclusions

Particular attention is required by clinicians to help SSD patients face the current pandemic situation. Future epidemiological studies are needed in order to better understand the impact of the COVID-19 pandemic in this population and provide proper care.

Disclosure

No significant relationships.

Methylenedioxymethamphetamine-assisted Psychotherapy For Posttraumatic Stress Disorder: A Review

Introduction

Posttraumatic stress disorder (PTSD) is a psychiatric condition which can be developed following traumatic experience. Treatment guidelines have long considered psychotherapy as a first line treatment. Despite that, PTSD remains an illness with high rates of comorbidity. Therefore, exploring novel therapies is of utmost importance.

Objectives

Clarifying methylenedioxymethamphetamine (MDMA)-assisted psychotherapy efficacy in symptom relief in people with PTSD. Explaining clinical MDMA mechanism of action. Assessing safety of MDMA clinical use.

Methods

PubMed database search, with “MDMA for PTSD” keyword expression. 12 Articles published in the last ten years were selected among the 112 best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Mithoefer et al. (2010) carried out the first controlled clinical study with MDMA-assisted psychotherapy in people with PTSD. Twenty patients with treatment-resistant PTSD were selected. They were given either placebo or two or three sessions of MDMA. 83% of the experimental group no longer met the criteria for PTSD (mean remission lasted 45 months without further MDMA doses) compared with 25% of the placebo group. Further studies were also suggestive of improvements in treatment-resistant PTSD patients undergoing MDMA-assisted psychotherapy. MDMA may increase exposure therapy effectiveness, allowing patients to stay emotionally involved while revisiting past traumas without being overwhelmed by anxiety and fear.

Conclusions

To date, MDMA-assisted psychotherapy studies demonstrated consistently positive results. However, they have been carried out with small groups of individuals. Therefore, larger trials should be conducted to assess MDMA’s efficacy and safety for it to become a licensed medicine.

Disclosure

No significant relationships.

A Link Between Gut Microbiota and Schizophrenia

Introduction

Microorganisms distributed in our tissues and fluids make up the human microbiota. During our lifetime, gastrointestinal microbiota acts as an important modulator of brain development and, in turn, adult behavior and health. Immune response may be triggered by gut microbiota, releasing mediators that penetrate the blood-brain barrier (BBB).

Objectives

Understanding if gut microbiota can influence schizophrenia pathogenesis. Clarifying how gut microbiota can influence schizophrenia treatment, and vice-versa.

Methods

PubMed database search, with “gut microbiota and schizophrenia” keyword expression. Eight articles published in the last ten years were selected among the most recent best match results. Reference lists of articles were reviewed to identify additional articles.

Results

There could be an association between the development of gut microbiota starting during pregnancy and schizophrenia pathogenesis, through an immune-mediated process. Schwarz et al. (2018) investigated the differences in faecal microbiota between individuals with first-episode psychosis and controls. They found psychotic patients to have an increased amount of Lactobacillus bacteria. Yuan et al. (2018) studied microbiota changes in patients with schizophrenia, before and after treatment. Individuals diagnosed with schizophrenia had less faecal Bifidobacterium, Escherichia coli and Lactobacillus. After treatment with risperidone, there was a significant increase in the amount of fecal Bifidobacterium and E. Coli.

Conclusions

Microorganisms living inside our gastrointestinal tract are vital for proper central nervous system (CNS) development. Patients with schizophrenia have anomalies in the composition of the microbiota. It remains unclear if microbiota changes after treatment further influence the course of the disease.

Disclosure

No significant relationships.

Therapeutic potential of serotoninergic psychedelic substances in the treatment of Obsessive Compulsive Disorder

Introduction

Obsessive Compulsive Disorder (OCD) is a psychiatric disorder associated with suffering and disability. The serotoninergic system is implicated in the neurobiological processes of OCD and serotonin reuptake inhibitors (SRIs) are the first-line treatment. However, clinical improvement after starting SRIs can take long and patients may not fully recover. Meanwhile, recent data suggests that activation of 5-HT receptors may exert a therapeutic action in obsessional symptoms. Some psychedelics are strong 5-HT2 receptor agonists and there is a growing research interest as they can be a promising therapeutic approach to OCD.

Objectives

We aim to provide an overview on the current evidence on the therapeutic potential of serotoninergic psychoactive substances in the treatment of OCD.

Methods

Non-systematic review. Literature search in the PubMed database using the terms psychedelics and obsessive-compulsive disorder.

Results

Although research is currently limited to a few small studies, the ones conducted so far showed clinically meaningful acute reduction of OCD symptoms after treatment with serotoninergic psychoactive drugs, as well as possible longer-lasting benefits, particularly with psilocybin and lysergic acid diethylamide (LSD). Furthermore, substance-assisted psychotherapy with psychedelics has been showing promising results, being suitable for OCD treatment. It is important to add that, to date, studies have indicated relatively good tolerability to these drugs.

Conclusions

These promising early findings highlight the role of psychedelics in OCD treatment and the need for further research into efficacy, therapeutic mechanisms and safety, in order to determine whether these drugs may be worthy options for OCD treatment in the future.

Disclosure

No significant relationships.

The Role of N-Acetylcysteine in Obsessive-Compulsive (OCD) and Related Disorders

Introduction

N-acetylcysteine is known for its uses in non-psychiatric conditions, such as paracetamol overdose and as a mucolytic. The rationale for its administration in psychiatric conditions is based on its ability reducing synaptic glutamate release, which was found to be increased in the cerebrospinal fluid of OCD patients.

Objectives

Evaluating N-acetylcysteine efficacy in OCD symptoms. Studying mechanisms underlying its action. Identifying the frequency of side effects.

Methods

PubMed database search, with the “N-acetylcysteine obsessive compulsive” keyword expression. The search was restricted to English-only articles, published in the last ten years. Twenty-five results among the best match correspondence were selected. Reference lists of articles were reviewed to identify additional articles.

Results

Oliver et al. found that a daily dose of 2.400 to 3.000 milligrams of N-acetylcysteine reduced the severity of obsessive-compulsive symptoms with minimal side effects; Smith et al. found inconclusive evidence on its efficacy. A clinical trial from Ghazinadeh et al. revealed N-acetylcysteine to be effective as an add-on to citalopram, reducing the score of resistance/control to obsessions after supplementing with N-acetylcysteine. Costa et al. found out it was superior to placebo in anxiety control as a secondary outcome.

Conclusions

The potential efficacy of N-acetylcysteine in the treatment of psychiatric disorders attracted interest. Mixed evidence was found that N-acetylcysteine may have some benefits controlling compulsions, both as an adjunctive as and as monotherapy. Thus, larger and more robust studies are required to further investigate the clinical effectiveness of N-acetylcysteine in this area.

Disclosure

No significant relationships.

Dealing With Clozapine-Induced Sialorrhea

Introduction

Clozapine is the first atypical antipsychotic. It is used in refractory schizophrenia. It has a heavy side effect burden, including weight gain, dizziness, blurred vision, and sialorrhea. Not only is sialorrhea bothersome, but it can also have with serious consequences, such us aspiration pneumonia, neutropenia, agranulocytosis, myocarditis, and may be responsible for low self-esteem, leading to low treatment compliance and discontinuation.

Objectives

Identifying the mechanism behind clozapine-induced sialorrhea. Finding how frequent clozapine-induced sialorrhea is compared to other antipsychotics. Finding effective ways to prevent clozapine-induced sialorrhea.

Methods

PubMed database search, with “clozapine sialorrhea” keyword expression. 12 Articles published in the last ten years were selected among the 112 best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Clozapine is a muscarinic M1-5 receptor antagonist, explaining its anticholinergic effects. Due to its strong anticholinergic action, sialorrhea is a paradoxical side effect. To prevent it, several drugs can be used, such us scopolamine, pirenzepine, sublingual atropine solutions, clonidine, botulinum neurotoxin, and others. Sialorrhea was relatively more frequently reported in clozapine (1.1%) compared with other antipsychotics (0.31%). Mubaslat and Lambert (2020) found that drops of atropine reduce the rate of saliva secretion significantly better than placebo. Uzun, et al. (2019) observed the adjunction of N‐acetylcysteine allowed a significant decrease of the severity of sialorrhea and was well tolerated.

Conclusions

Although effective in refractory schizophrenia, clozapine side effects, namely sialorrhea, can be bothersome and may affect treatment adherence. Fortunately, we have tools at our disposal to help patients better handle it.

Disclosure

No significant relationships.

Couvade Syndrome: Origin, Characterization, and Frequency

Introduction

The word couvade originated from the French verb couver, meaning to hatch, nest, or brood. Custom of Couvade or Couvade Syndrome (CS) is a poorly understood phenomenon observed since ancient times, in which the expectant father experiences somatic and psychological symptoms of pregnancy.

Objectives

Defining what is CS. Identifying possible origin. Hypothesizing causes. Identifying CS frequency.

Methods

PubMed database search, with “Couvade syndrome” keyword expression. Seven articles were selected among the best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Currently, there are several views on this phenomenon, including religious, cultural, medical, psychoanalytic, and psychological. CS is used in Psychiatry to describe somatic symptoms resembling pregnancy and/or childbirth in expecting fathers, such as weight gain, diarrhea or constipation, toothache, and headache. Lipkin and Lamb (1982) studied 300 couples from New York: they diagnosed Couvade Syndrome in 22,5% of fathers. Nevertheless, Brennan et al. (2007) found different incidence rates of CS diagnose in different areas of the world: 20% in Sweden; 25–97% in United States; 61% in Thailand; 68% in China; 35% in Russia.

Conclusions

Whether CS constitutes a disease entity, or it should be considered a ritual or custom remains a matter of debate. Different rates of CS around the globe may indicate that culture plays an important role. It may be a way for fathers-to-be to cope with changes imposed by pregnancy in the mother and in the couple. Overall, it is a fascinating intersection between the physiological and psychological realms.

Disclosure

No significant relationships.

A systematic review of observational management of cutaneous basal cell carcinoma

BACKGROUND

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom and United States. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of cutaneous BCC.

METHODS

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

RESULTS

We identified 2529 titles, from which 4 full-text articles were eligible, reporting on 2298 individuals. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6-12 weeks. Clearance rates ranged from 52-100% for imiquimod and 2-19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

CONCLUSION

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility-adjusted survival following interventional or observational management of BCC.

Integration of HIV prevention and sexual and reproductive health in the era of anti-retroviral-based prevention: findings from assessments in Kenya, Malawi and Zimbabwe

Background: Though substantial progress has helped curb the HIV epidemic, high rates of new HIV infections persist among adolescent girls and young women (AGYW) in sub-Saharan Africa, reflecting critical gaps in reaching them with integrated HIV prevention and sexual and reproductive health (SRH) services. The scale-up of oral pre-exposure prophylaxis (PrEP) and multiple novel HIV prevention products on the horizon offer countries a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV prevention/SRH services. Methods: This article comparatively analyzes findings from rapid assessments in Kenya, Malawi and Zimbabwe across key themes to highlight cross-country trends and contextual realities around HIV prevention/SRH integration, with a focus on oral PrEP and contraception. In Kenya and Zimbabwe, assessments were completed by Ministries of Health (MOH) and the HIV Prevention Market Manager and include 20 health facility assessments, 73 key informant interviews (KIIs) and six community dialogues. In Malawi, the assessment was completed by the MOH and Georgetown University Center for Innovation in Global Health and includes 70 KIIs and a review of national policies and program implementation in Blantyre. Findings were contextualized through a review of literature and policies in each country. Results: Across countries, the policy environment is conducive to HIV prevention/SRH integration, though operationalization presents ongoing challenges, with most policies preceding and not accounting for oral PrEP rollout. National coordination mechanisms, youth-friendly health services and prevention of mother-to-child transmission programs are promising practices, while siloed and resource-constrained health systems, limited provider capacity, underfunded demand generation and structural factors exacerbate barriers to achieving integration. Conclusions: As new HIV prevention products are introduced, demand for integrated HIV prevention/SRH services is likely to grow. Investing in HIV prevention/SRH integration can help to ensure a sustainable response to the HIV epidemic, streamline service delivery and improve the health outcomes and lives of AGYW.

183 A Systematic Review of Sample Size Calculations in High-Profile Surgical Trials That Use Patient-Reported Outcome Measures

Background

Patient reported outcome measures (PROMs) are increasingly recognised as a measure of treatment efficacy in randomised controlled trials (RCTs). It can be difficult to determine meaningful target differences in PROM scores for sample size calculations and this can risk over-recruitment and/or erroneous trial conclusions. The Difference ELicitation in TriAls (DELTA2) statement sets recommendations for sample size calculations in RCTs including target difference determination. We aimed to evaluate sample size calculations from high-profile surgical RCTs that used PROMs as their primary outcome, against DELTA2 standards, with a focus on target differences.

Method

Pubmed was systematically searched for surgical RCTs published in the five highest ranking journals, by Thomson Reuters impact factor, for medicine and surgery. Studies were included if surgery was the intervention and/or comparator arm, and a PROM was the primary outcome. Surgery was defined as using instrumentation to change macro-anatomy with the aim of improving health. Data were extracted with a piloted data collection sheet that included the DELTA2 reporting recommendations.

Results

Most target differences used in sample size calculations were determined with suboptimal techniques and target difference justification was overall poor. In this sample, £28 million of UK public research spending supported trials with poor target difference justification.

Conclusions

In this sample of trials, sample size calculations were generally not reported to DELTA2 standards. There was frequent use of sub-optimal methods to determine the target difference. This risks over-recruitment and/or erroneous trial conclusions. Clinicians should be aware of these potential pitfalls when interpreting published trials.

Anesthesia or seizure-like behavior? The effects of two Amazonian plants, Acmella oleracea and Piper alatabaccum in zebrafish (Danio rerio)

Abstract Currently, available fish anesthetics can produce important side effects, including respiratory arrest and distress. Easy-to-implement alternatives with low toxicity are needed to ensure fish health as well as to help artisanal fisheries and fish sellers in handling and transporting fishes, and native plants seems to be the best alternative. We aimed to implement an anesthetic protocol using crude ethanolic extracts from flowers and leaves of two Amazonian plants, the Acmella oleracea and Piper alatabaccum. We first tested the extracts for anesthesia, using the zebrafish as model. Even though in some treatments the animals apparently entered deep anesthesia, many of them presented aberrant behaviors and even died. Thus, we performed new experiments testing the extracts effects on seizure-like behaviors of the fish. Only the leaf extract of A. oleracea has potential effects for fish anesthesia. Both the flower extract from this plant and the leaf extract from P. alatabaccum induced seizure-like behavior in the animals. In conclusion, besides bringing a possible new anesthetic protocol for fish, our work draws attention for the neurotoxic effects the anesthetic solutions may cause, since several studies defend other Piper species as anesthetic for fish and A. oleracea flowers’ extract was already pointed as fish anesthetic.

Correlations between oral Pre-Exposure Prophylaxis (PrEP) initiations and policies that enable the use of PrEP to address HIV globally

Policies facilitating access to HIV prevention services, specifically for pre-exposure prophylaxis (PrEP), can foster enabling environments for service uptake. This analysis aims to establish whether policies enabling broad PrEP eligibility, HIV self-testing, and lowered age of consent to HIV testing and treatment services are correlated with PrEP uptake. Ages of consent vary by country, therefore this analysis focused on how age of consent policies, in general, affect adolescent PrEP uptake. Data was collected from the HIV Policy Lab and AVAC's Global PrEP Tracker, a database of approximately 334 PrEP projects operating across 95 countries, and linear regression and correlation analyses were conducted via STATA to examine relationships amongst national oral PrEP eligibility, HIV self-testing, lowered age of consent, and national cumulative oral PrEP initiations, as of December 2021. Of all 194 countries tracked by the HIV Policy Lab, only about 7% have adopted all three policies (HIV self-testing, lowered age of consent, and PrEP eligibility policies). Less than 50% have adopted have adopted at least one of these policies. Of the 54 countries that have fully adopted PrEP eligibility policies, less than 30% have co-adopted HIV self-testing or lowered age of consent policies. About 30% of these 194 countries have yet to adopt any of these policies, of which about 14% have indicated information is "unavailable" for at least one of the policies. Analyses conducted for the 91 countries tracked by both the HIV Policy Lab and the Global PrEP Tracker revealed a significant and positive relationship between cumulative individuals initiated on oral PrEP and adoption of HIV self-testing policies (p = 0.01, r = 0.26), lowered age of consent policies (p = 0.01, r = 0.25), and PrEP eligibility policies (p = 0.01, r = 0.26). Stronger advocacy efforts towards approving public health policies, such as those outlined in our analysis, that enshrine and enable access to HIV prevention are necessary.

HIV PrEP is more than ART-lite: Longitudinal study of real-world PrEP services data identifies missing measures meaningful to HIV prevention programming

INTRODUCTION

Evidence indicates HIV oral pre-exposure prophylaxis (PrEP) is highly efficacious and effective. Substantial early discontinuation rates are reported by many programs, which may be misconstrued as program failure. However, PrEP use may be non-continuous and still effective, since HIV risk fluctuates. Real-world PrEP use phenomena, like restarting and cyclical use, and the temporal characteristics of these use patterns are not well described. The objective of our study was to characterize and identify predictors of use patterns observed in large PrEP scale-up programs in Africa.

METHODS

We analysed demographic and clinical data routinely collected during client visits between 2017 and 2019 in three Jhpiego-supported programs in Kenya, Lesotho and Tanzania. We characterized duration on/off PrEP and, using ordinal regression, modelled the likelihood of spending additional time off and identified factors associated with increasing cycle number. The Andersen-Gill model was used to identify predictors of time to PrEP discontinuation. To analyse factors associated with a client's first return following initiation, we used a two-step Heckman probit.

RESULTS

Among 47,532 clients initiating PrEP, approximately half returned for follow-up. With each increase in cycle number, time off PrEP between use cycles decreased. The Heckman first-step model showed an increased probability of returning versus not by older age groups and among key and vulnerable population groups versus the general population; in the second-step model older age groups and key and vulnerable populations were less likely in Kenya, but more likely in Lesotho, to return on-time (refill) versus delayed (restarting).

CONCLUSIONS

PrEP users frequently cycle on and off PrEP. Early discontinuation and delays in obtaining additional prescriptions were common, with broad predictive variability noted. Time off PrEP decreased with cycle number in all countries, suggesting normalization of use with experience. More nuanced measures of use are needed than exist for HIV treatment if effective use of PrEP is to be meaningfully measured. Providers should be equipped with measures and counselling messages that recognize non-continuous and cyclical use patterns so that clients are supported to align fluctuating risk and use, and can readily restart PrEP after stopping, in effect empowering them further to make their own prevention choices.

Sex disparities in lipid-lowering therapy and dyslipidemia control in a coronary rehabilitation program

Introduction

Lipid control is one of the most important secondary cardiovascular prevention targets. Although cardiovascular disease is the most common cause of death for both genders, several studies have consistently shown that women are less likely to receive guideline-recommended secondary prevention medications after an acute coronary syndrome (ACS).

Purpose

To compare sex disparities in dyslipidemia control in a secondary prevention population with ACS in light of the ESC Dyslipidemia Guidelines.

Methods

We retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an ACS from January 2011 to October 2019. Clinical data was collected at presentation and during 12 months follow-up. Doses of atorvastatin ≥40 mg, rosuvastatin ≥20 mg or a combination of a statin and ezetimibe were considered high-intensity LDL-lowering therapy (HIT).

Results

Of a total of 881 patients enrolled, mean age 55.0±10.0 year-old, 16.1% were female. At baseline there were no differences respecting clinical features between genders. At admission, 51.4% of patients had ST-elevation myocardial infarction and, concerning to cardiovascular risk factors, 63% patients had dyslipidemia, 46% had hypertension, 19% were diabetic, 76% were smokers or previous smokers, 27% had family history of coronary disease and 12% had previous coronary disease (ACS or &gt;50% coronary artery stenosis). At hospital admission, females and males had similar mean LDL-levels [120.7 vs 118.1 mg/dL, t(708)=0.691, p=0.496]. The vast majority of patients from both genders were prescribed with statins on hospital discharge (99.5%) and maintain it during follow-up (99.3%). Female patients received more HIT during follow-up (67.8% vs 53.9% at baseline, p=0.015; 75.6% vs 59.0% after CRP, p=0.003; and 79.8% vs 65.1% at 1-year-follow-up, p=0.007). During follow-up, at the end of the CRP (about 3 months after event), male patients exhibit a better control of LDL [82.0 vs 75.6 mg/dL, t(597)=2.4, p=0.016)] with 12.8% vs 16.4% below 55 mg/dL and 29.8% vs 44.5% below 70 mg/dL (p=0.008). At 1-year follow-up, both genders exhibited similar LDL-control due to a worsening control of the male population (81.9 vs 80.6 mg/dL, t(540)=0.52, p=0.605). Only 13.3% of females had LDL below 55 mg/dL (vs 12.9%, p=0.921) and 32.5% below 70 mg/dL (vs 37.0%, p=0.432).

Conclusion

This real-life study showed that guideline recommended LDL target is not achieved in the majority of patients, even under a structured CRP. Unlike other reports, there were more women receiving potent anti-dyslipidemic therapy. Nevertheless, women showed a poor control of LDL-concentration after three months of ACS and a similar control after 1-year; this highlights the uncertainties concerning the efficacy of lipid-lowering therapy in women, an underrepresented population in clinical trials.

Funding Acknowledgement

Type of funding sources: None.

FFRCT and Invasive Coronary Angiography – assessing concordance in an unselected UK real world population

Background/Introduction

CT coronary angiography (CTCA) Fractional Flow Reserve (FFRCT) is a key investigation in chronic coronary syndrome (CCS) guidelines. FFR calculated from CTCA may help improve CTCA specificity for flow limiting disease, preventing unnecessary invasive coronary angiography (ICA).

Purpose

To (1) assess the treatment planning potential of FFRCT by determining the concordance of FFRCT with an ICA +/− invasive physiological assessment for the detection of flow limiting CAD in a real world NHS setting and (2) concordance sub-analysis of concordance of invasive iFR and FFRCT.

Methods

A single-centre retrospective analysis of a prospectively maintained clinical CTCA database. We identified patients with CCS who had CTCA FFRCT and subsequent ICA from August 2018 to January 2021. Concordance was assessed on a per patient and per vessel basis (major epicardial vessels: left main stem [LMS], left anterior descending artery [LAD], circumflex [LCx], right coronary artery [RCA]). Two non-invasive ischaemia thresholds were examined an FFRCT ≤0.8 and &lt;0.75 (2 cm distal to stenosis). This was compared to a clinical ICA assessment where a flow limiting lesion was defined as a stenosis &gt;70% (or &gt;50% in the LMS) and/or an end vessel iFR ≤0.89 / FFR ≤0.8. All vessels that underwent an iFR, at the interventionists discretion, were then assessed relative to their end-vessel FFRCT.

Results

565 patients had a CTCA with FFRCT and 164 patients had a subsequent ICA and were suitable for analysis. On a per patient basis 69% of those referred to ICA with an FFRCT ≤0.8 of at least one major epicardial vessel had any flow limiting CAD at ICA. With an FFRCT &lt;0.75 this was 73%. Table 1 illustrates the per vessel concordance.

A total of 120 vessels were included in the iFR subsection analysis. The mean FFRCT was 0.71 (±0.13) and mean iFR was 0.89 (±0.1). Accuracy was 54% (95% CI 45–63%) with a sensitivity of 89% (95% CI 76–96%), specificity 32% (95% CI 22–44%), positive predictive value 45% (95% CI 40–50%) and negative predictive value of 83% (95% CI 66–92%). A Pearson's correlation coefficient of 0.23 was found.

Conclusion

This study demonstrated that the negative predictive value of FFRCT was excellent, including importantly for LMS analysis. The specificity on a per vessel basis was good with the exception of the LAD assessment. This may have implications for interventional planning with this imaging modality. FFRCT correlated poorly with invasive iFR in this subsection analysis although selection bias may be contributing. There remains a significant proportion of patients referred for an ICA where no flow limiting CAD is found.

Funding Acknowledgement

Type of funding sources: None. Table 1. Per vessel concordance analysis of potential flow limiting FFRCT relative to clinical ICA findings. Analysed with an ischaemia threshold of FFRCT ≤0.80 and &lt;0.75. PPV = Positive Predictive Value. NPV = Negative Predictive Value.

1237 Optimising Outpatient Care After Paediatric Burns: The Development of a Chatbot To Identify Complications And Provide Clinical Advice

Aim

More than 6000 children require specialist care from one of fourteen regional burns services in England and Wales each year. Families often have to travel long distances and may not have access to specialist care with restricted services due to Covid-19. This quality improvement project aimed to:

Method

We conducted a national service evaluation of children’s burns services in England and Wales. We then conducted a PRISMA compliant systematic review up to September 2020 to identify studies reporting chatbot use to deliver outpatient care. A chatbot was then developed using Dialogflow to identify complications and provide advice to families.

Results

Across England and Wales, 11 children’s burns services reported outpatient practice: six services follow up all children at three months, three have variable follow-up and two discharge all patients. Our systematic review identified 10 studies reporting chatbot use although none were used following burns. A frame-based system-focused chatbot was developed in conjunction with expert burns surgeons and patient representatives.

Conclusions

Chatbots are effective and acceptable alternatives for in-person follow up. We demonstrate national variation in the provision of outpatient paediatric burn care and have developed a chatbot that can address clinical concerns and provide reassurance to patients and family members. Future studies will determine the acceptability and safety of this chatbot.

Integration of HIV and sexual and reproductive health in the era of anti-retroviral-based prevention: findings from assessments in Kenya, Malawi and Zimbabwe

Background: Though substantial progress has been made to curb the HIV epidemic, high rates of new HIV infections persist among adolescent girls and young women (AGYW) in sub-Saharan Africa, reflecting critical gaps in reaching them with integrated HIV prevention and sexual and reproductive health (SRH) services. With the scale-up of oral pre-exposure prophylaxis (PrEP) and multiple novel HIV prevention products on the horizon, countries have a unique opportunity to expand innovative approaches to deliver comprehensive, integrated HIV/SRH services. Methods: This article is a comparative analysis of findings from rapid landscaping analyses in Kenya, Malawi and Zimbabwe to highlight cross-country trends and context-specific realities around HIV/SRH integration. The analyses in Kenya and Zimbabwe were completed by Ministries of Health (MOH) and the HIV Prevention Market Manager project and include 20 health facility assessments, 73 key informant interviews and six community dialogues. In Malawi, the analysis was completed by the MOH and Georgetown University Center for Innovation in Global Health and includes 70 key informant interviews and a review of national policies and program implementation in Blantyre. Findings were validated through a review of literature and policies in each country. Results: The policy environment in all three countries is conducive to HIV/SRH integration, though operationalization continues to present challenges, with most policies preceding and not accounting for oral PrEP rollout. National coordination mechanisms, youth-friendly health services and prevention of mother-to-child transmission programs are promising practices, while siloed and resource-constrained health systems, limited provider capacity, lack of support for demand generation and structural factors exacerbate barriers to achieving integration. Conclusions: As new HIV prevention products are introduced, demand for integrated HIV/SRH services is likely to grow. Investing in HIV/SRH integration can help to ensure sustainable, government-led responses to the HIV epidemic, streamline service delivery and improve the health outcomes and lives of AGYW.

A-96 Stability of ImPACT’s Latent Structure from Baseline to Post Concussion Assessment

Objective

ImPACT is commonly used for sport-concussion management. Baseline and post-concussion tests serve as within-athlete comparisons for return-to-play decision-making. Previous literature has questioned whether ImPACT’s five composites accurately represent the internal structure of its cognitive scores. A recent alternative four-factor structure has strong confirmatory evidence for baseline scores (Maietta et al., doi:10.1037/pas0001014). The present study examined the stability of these constructs post-concussion.

Method

The current study utilized a case-matched design (age, sex, sport category) to select a sample of 3560 high school athletes’ baseline (n = 1780) and post-concussion (n = 1780) assessments. Multi-group CFA of first-order, hierarchical, and bifactor models was conducted to assess measurement invariance (configural, metric, scalar, and residual invariance) between baseline and post-concussion samples. Change in comparative fit indices was interpreted as the primary indicator of model invariance.

Results

ImPACT’s five composite structure, as well as the hierarchical and bifactor models, exhibited inadequate fit to the baseline and post-concussion data. The four-factor model demonstrated superior fit in the baseline sample and good fit in the post-concussion sample. The four-factor structure demonstrated invariance across injury status (baseline to post-concussion).

Conclusion

Given that ImPACT’s scores are used for return-to-play decision-making, it is important that they are psychometrically sound. Recent literature suggests that ImPACT’s five composites are not an adequate representation of the cognitive constructs. Findings support validity of the four-factor structure despite injury status, suggesting these cognitive constructs are assessable at both pre- and post-concussion. Additional research is needed to determine implications of these findings for tracking cognitive change following sport-related concussion and making return-to-play decisions.

Electrochemical and photoluminescence response of laser-induced graphene/electrodeposited ZnO composites

The inherent scalability, low production cost and mechanical flexibility of laser-induced graphene (LIG) combined with its high electrical conductivity, hierarchical porosity and large surface area are appealing characteristics for many applications. Still, other materials can be combined with LIG to provide added functionalities and enhanced performance. This work exploits the most adequate electrodeposition parameters to produce LIG/ZnO nanocomposites. Low-temperature pulsed electrodeposition allowed the conformal and controlled deposition of ZnO rods deep inside the LIG pores whilst maintaining its inherent porosity, which constitute fundamental advances regarding other methods for LIG/ZnO composite production. Compared to bare LIG, the composites more than doubled electrode capacitance up to 1.41 mF cm-2 in 1 M KCl, while maintaining long-term cycle stability, low ohmic losses and swift electron transfer. The composites also display a luminescence band peaked at the orange/red spectral region, with the main excitation maxima at ~ 3.33 eV matching the expected for the ZnO bandgap at room temperature. A pronounced sub-bandgap tail of states with an onset absorption near 3.07 eV indicates a high amount of defect states, namely surface-related defects. This work shows that these environmentally sustainable multifunctional nanocomposites are valid alternatives for supercapacitors, electrochemical/optical biosensors and photocatalytic/photoelectrochemical devices.

Anxiety and depression risk in patients with allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

Allergic diseases appear to be associated with mood disorders. However, particularly regarding allergic rhinitis (AR), such association has not been adequately systematically reviewed. Therefore, we conducted a systematic review and meta-analysis to quantify the association between AR and depression and anxiety.

METHODOLOGY

We performed an electronic search of PubMed, Web of Science and Scopus for observational studies assessing the association between AR and depression and anxiety. Such association was quantified by means of random-effects meta-analysis, with estimation of pooled odds ratio (OR). Sources of heterogeneity were explored by subgroup analysis.

RESULTS

We included a total of 24 primary studies, of which 23 assessed depression and 11 assessed anxiety. Of these, 12 studies presented OR from multivariable regression models and were included in our meta-analysis. AR was associated with higher odds of depression and anxiety.

CONCLUSIONS

AR appears to be associated with high risk of depression and anxiety. While our results point to the importance of mental comorbidities among patients with AR, longitudinal studies are needed adopting uniform definitions and presenting results stratified by AR severity.

Does every woman require a post-lumpectomy mammogram and ultrasound before radiotherapy when negative margins?

PURPOSE

Most studies regarding the value of post lumpectomy imaging (PLI) studies rely on mammography alone and are often focused on patients that present with suspicious microcalcifications or in situ disease. This way, its true benefit remains controversial, which explained the heterogeneity between centers. This is the first study to evaluate the role of mammography with breast and axillary ultrasound undertaken before radiotherapy in patients with conservatively managed invasive and/or in situ carcinoma with negative margins.

MATERIALS AND METHODS

In this retrospective study, medical records for patients referred to our External Radiotherapy Unit between January 2018 and December 2019 were reviewed.

RESULTS

A total of 1251 patients (1262 breasts) were analyzed. A total of 3.4% had suspicious findings for local residual breast disease, with 1.0% having a re-excision positive for residual malignancy. Presentation with microcalcifications alone (OR=4.854), extension of microcalcifications>3cm (OR=13.500), histologic subtype pure ductal carcinoma in situ (OR=12.348), presence of invasive carcinoma≤1mm of the pathological margins (OR=4.630), stage pTis (5.630), and absence of invasive component (OR=4.629), were associated with an increased risk for residual malignancy. Only one patient (0.1%) had nodal residual involvement.

CONCLUSION

PLI detected residual local cancer in 1.0% of the patients. PLI plays an important role in the evaluation of patients undergoing breast-conserving therapy with negative margins. The major question that remains is whether it changes survival outcomes.

Integrating Oral PrEP Into Family Planning Services for Women in Sub-saharan Africa: Findings From a Multi-Country Landscape Analysis

Integration of HIV and family planning (FP) services is a renewed focus area for national policymakers, donors, and implementers in sub-Saharan Africa as a result of high HIV incidence among general-population women, especially adolescent girls and young women (AGYW), and the perception that integrating HIV pre-exposure prophylaxis (PrEP) into FP services may be an effective way to provide comprehensive HIV and FP services to this population. We conducted a focused desk review to develop a PrEP-FP integration framework across five key categories: plans and policies, resource management, service delivery, PrEP use, and monitoring and reporting. The framework was refined via interviews with 30 stakeholders across seven countries at varying stages of oral PrEP rollout: Kenya, Lesotho, Malawi, South Africa, Uganda, Zambia, and Zimbabwe. After refining the framework, we developed a PrEP-FP integration matrix and assessed country-specific progress to identify common enablers of and barriers to PrEP-FP integration. None of the countries included in our analysis had made substantial progress toward integrated PrEP-FP service delivery. Although the countries made progress in one or two categories, integration was often impeded by lack of advancement in other areas. Our framework offers policymakers, program implementers, and health care providers a road map for strategically assessing and monitoring progress toward PrEP-FP integration in their contexts.

Detection of enteroparasites in foliar vegetables commercialized in street- and supermarkets in Aparecida de Goiânia, Goiás, Brazil

Foliar vegetables contaminated with fecal residues are an important route of transmission of intestinal parasites to humans. The aim of this study was to evaluate the presence of parasitic forms of protozoa and helminths on lettuces (Lactuca sativa) and collard greens (Brassica oleracea) sold in street- and supermarkets in the city of Aparecida de Goiânia, Goiás, Brazil. A total of 30 samples of each vegetable (15 samples from each supermarkets and street markets) was analyzed. All samples were processed by spontaneous sedimentation method and centrifugal flotation. In 45% of the samples, immature forms of intestinal parasites were identified with 66.7% helminths eggs and 33.3% protozoan cysts or oocysts. Significantly more lettuce samples were contaminated with eggs, cysts or oocyst of at least one parasite than collard green samples (U=216; Z=-3.45; P <0.001). The parasitic forms were identified morphologically up to the family level with eggs of Ancylostomatidae, Strongyloididae, Ascarididae and Taeniidae, or oocysts of Eimeriidae, to the genus with Cystoisospora sp. and Toxocara sp., and to the species level with Cystoisospora canis, Dipylidium caninum and Hymenolepis nana. The presence of these infective agents in lettuce and collard green from both street- and supermarkets highlights the high risk of spreading parasites by eating raw vegetables sold in Aparecida de Goiânia.

POS0162 PREDICTIVE FACTORS OF A NEW FRAGILITY FRACTURE AFTER WRIST FRAGILITY FRACTURE

Background:

Fragility fractures (FF) are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma.1 Studies have shown that history of wrist fracture increases the risk for subsequent FF.2

Objectives:

To assess predictive factors of FF occurring after a wrist fracture.

Methods:

Retrospective monocentric study that included patients with a wrist FF observed at the emergency department (ED) in a tertiary center, between 1st January 2017 and 31st December 2018. Wrist fractures were identified through the 10th International Classification of Diseases and FF were identified after revision of the clinical record. Patients with relevant missing data were excluded. Seven hundred thirty-three wrist FF were identified. After calculating a representative sample (90% confidence interval), 188 patients were included. Their clinical records until 31th December 2020 (2 to 3 years after FF) were reviewed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05. In multivariate analysis we included variables with a significant association in univariate analysis and those with clinical relevance (reported in others studies).

Results:

Wrist fractures represented 44.3% of the FF observed at the ED.

Most patients were woman (83.5%) with a mean age of 70.7 (SD=11.2) years-old at the time of their wrist fracture. A previous FF was seen in 22.9% of patients and 13.3% had a new FF during the follow-up period.

We found an association between the occurrence of a new FF and the number of comorbidities (p=0.012), number of visits to the ED due to falls (p<0.001), previous diagnosis of chronic pulmonary disease (p=0.029) and hematologic pathologies (p=0.047), and the need for hospitalization at time of the wrist FF (p=0.018).

No associations were found between the age at the wrist fracture time, number of drugs taken daily nor its type (anxiolytics, antiepileptics, corticoids), previous fractures (and localization), overweight/obesity and other cardiovascular risk factors, endocrinopathies, psychiatric or neurologic disease or other comorbidities.

After adjustment for age, gender, anti-osteoporotic treatment and comorbidities, the main predictors of a new FF were visits to the ED for falls (p=0.005), chronic pulmonary disease (p=0.040), hematologic pathologies (p=0.004) and need for hospitalization (p=0.040) (table 1).

Table 1.

Multivariate analyses: linear multiple regression for predictive factors of new fragility fracture.

DeterminantsUnstandardized CoefficientsBStandardized Coefficients Beta95.0% CIp-valueAge-0.0250.9750.924 – 1.030NSGender2.0657.8890.757 – 82.165NSNumber of comorbidities0.1861.2040.846 – 1.713NSVisits to the emergency service for falls-2.1360.1180.026 – 0.5290.005Chronic pulmonary disease-1.3260.2660.075 – 0.9400.040Hematologic pathologies-4.2960.0140.001 – 0.2550.004Need for hospitalization-2.7640.0630.004 – 0.8870.040Anti-osteoporotic treatment0.1571.1700.227 – 6.017NS

CI: Confidence Interval; NS: non-significant;

Conclusion:

Certain comorbidities seem to be associated with new FF. Patients with visits to the emergency service after falls and those who needed hospitalization due to the wrist fracture were more prone to have a new FF. There might be a substantial missed opportunity for intervention in these patients.

References:

[1]Osteoporosis: assessing the risk of fragility fracture. London: National Institute for Health and Care Excellence (UK); 2017 Feb. PMID: 32186835.

[2]Crandall CJ, Hovey KM, Cauley JA, Andrews CA, Curtis JR, Wactawski-Wende J, Wright NC, Li W, LeBoff MS. Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women’s Health Initiative Study. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research. 2015;30(11):2086–2095. doi: 10.1002/jbmr.2559.

Disclosure of Interests:

None declared

AB0799 DO WE OVERDIAGNOSE SERONEGATIVE RHEUMATOID ARTHRITIS? – THE ROLE OF MUSCULOSKELETAL ULTRASOUND IN CLARIFYING SERONEGATIVE INFLAMMATORY ARTHRITIS

Background:

Several data indicate that seronegative rheumatoid arthritis (RA-) and seropositive RA (RA+) may have different mechanisms and prognosis, being well established that rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) have diagnostic and prognostic value. Several conditions, like peripheral spondyloarthritis (SpA), psoriatic arthritis or crystal-related arthropathies may mimic the presentation of RA. Mechanisms and treatment of each of these conditions differ significantly. The authors speculate that RA- may be overdiagnosed in the setting of seronegative chronic inflammatory arthritis and that musculoskeletal ultrasound (US) may help us to better classify these patients through the identification of characteristic lesions of the mentioned diseases.

Objectives:

To compare the frequency of US lesions found in joints and entheses between RA- and RA+ patients.

Methods:

Cross-sectional study: systematic US evaluation of ten joints, twelve entheses and both flexor and extensor tendons of four fingers (Table 1) in consecutive RA- patients. RA+ patients matched for sex and age were recruited. RA- patients included met every of the following criteria: history of chronic polyarthritis, RF and ACPA negativity, no extra-articular features of SpA or RA nor family history of SpA, no suspected crystal-related arthritis.

Results:

Twenty-one RA- patients were included and twenty RA+ patients were recruited as controls. No differences between groups were found in sex, age, body mass index, time of disease evolution or use of biological therapy.

RA- patients had a significantly higher number of entheseal structural and/or inflammatory lesions than RA+ patients (median 2.0 vs. 0.5, U 111.5, p=.008**), with triceps enthesitis being significantly more frequent in RA- patients (p=.036*). In total, 18.7% of RA- entheses had enthesitis lesions vs. only 8.3% of RA+ entheses. One RA- patient had ultrasonographic features of dactylitis which was not clinically evident.

As expected, considering the role of RF and ACPA in erosive RA, RA- patients had a significantly lower number of joints with erosions compared to RA+ patients (median 0.0 vs. 3.0, U 64.5, p<.001***), with significant differences in every considered joint. Erosions were found in 6.7% of RA- joints vs. 32.0% RA+ joints.

Additionally, two RA- patients had hyperechogenic foci in knee cartilage or carpal fibrocartilage suggestive of calcium pyrophosphate deposition.

Table 1.

Comparative frequency of ultrasound lesions found in joints and entheses of RA- and RA+ patients.

RA-(n=21)RA+(n=20)p-valueMdn number of ENTHESES with any lesion per patient ± IQR2.0 ± 3.00.5 ± 2.0.008**Triceps – n (%)8 (38.1%)2 (10.0%).036*Quadriceps – n (%)9 (42.9%)6 (30.0%).393Superior patellar – n (%)4 (19.0%)1 (5.0%).169Inferior patellar – n (%)---Achilles – n (%)9 (42.8%)4 (20.0%).116Plantar fascia – n (%)5 (23.8%)1 (5.0%).089DACTYLITIS – 2nd + 5th finger – n (%)1 (4.8%)--Mdn number of joints with EROSIONS per patient ± IQR0.0 ± 1.03.0 ± 3.0<.001***Ulnar styloid process – n (%)5 (23.8%)11 (55.0%).041*Metacarpophalangeal 2 – n (%)3 (14.3%)11 (55.0%).006**Metacarpophalangeal 5 – n (%)1 (4.8%)10 (50.0%).001**Metatarsophalangeal 1 – n (%)-3 (15.0%)-Metatarsophalangeal 5 – n (%)3 (14.3%)11 (55.0%).006**CHONDROCALCINOSIS – triangular fibrocartilage + knee – n (%)2 (9.5%)--DOUBLE CONTOUR – any joint – n (%)---

RA- – seronegative rheumatoid arthritis; RA+ – seropositive rheumatoid arthritis Mdn – median; IQR – interquartile range; n (%) – absolute number (percentage) of patients with the indicated lesion.

Conclusion:

We found that some patients diagnosed with RA- had, in fact, ultrasonographic features of different diseases, namely enthesitis/dactylitis and crystal deposition. These data suggest that RA- may be overdiagnosed in clinical practice. Systematic US evaluation of joints and entheses may provide valuable diagnostic information in patients with chronic inflammatory seronegative arthritis and improve patient care.

Disclosure of Interests:

None declared

Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study

BACKGROUND

Colorectal cancer screening programmes and uptake vary substantially across Europe. We aimed to compare changes over time in colorectal cancer incidence, mortality, and stage distribution in relation to colorectal cancer screening implementation in European countries.

METHODS

Data from nearly 3·1 million patients with colorectal cancer diagnosed from 2000 onwards (up to 2016 for most countries) were obtained from 21 European countries, and were used to analyse changes over time in age-standardised colorectal cancer incidence and stage distribution. The WHO mortality database was used to analyse changes over time in age-standardised colorectal cancer mortality over the same period for the 16 countries with nationwide data. Incidence rates were calculated for all sites of the colon and rectum combined, as well as the subsites proximal colon, distal colon, and rectum. Average annual percentage changes (AAPCs) in incidence and mortality were estimated and relevant patterns were descriptively analysed.

FINDINGS

In countries with long-standing programmes of screening colonoscopy and faecal tests (ie, Austria, the Czech Republic, and Germany), colorectal cancer incidence decreased substantially over time, with AAPCs ranging from -2·5% (95% CI -2·8 to -2·2) to -1·6% (-2·0 to -1·2) in men and from -2·4% (-2·7 to -2·1) to -1·3% (-1·7 to -0·9) in women. In countries where screening programmes were implemented during the study period, age-standardised colorectal cancer incidence either remained stable or increased up to the year screening was implemented. AAPCs for these countries ranged from -0·2% (95% CI -1·4 to 1·0) to 1·5% (1·1 to 1·8) in men and from -0·5% (-1·7 to 0·6) to 1·2% (0·8 to 1·5) in women. Where high screening coverage and uptake were rapidly achieved (ie, Denmark, the Netherlands, and Slovenia), age-standardised incidence rates initially increased but then subsequently decreased. Conversely, colorectal cancer incidence increased in most countries where no large-scale screening programmes were available (eg, Bulgaria, Estonia, Norway, and Ukraine), with AAPCs ranging from 0·3% (95% CI 0·1 to 0·5) to 1·9% (1·2 to 2·6) in men and from 0·6% (0·4 to 0·8) to 1·1% (0·8 to 1·4) in women. The largest decreases in colorectal cancer mortality were seen in countries with long-standing screening programmes.

INTERPRETATION

We observed divergent trends in colorectal cancer incidence, mortality, and stage distribution across European countries, which appear to be largely explained by different levels of colorectal cancer screening implementation.

FUNDING

German Cancer Aid (Deutsche Krebshilfe) and the German Federal Ministry of Education and Research.