Using a Claims-Based Frailty Index to Investigate Frailty, Survival, and Healthcare Expenditures among Older Adults Hospitalized for COVID-19 at an Academic Medical Center

BACKGROUND

Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization.

OBJECTIVE

To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19.

DESIGN

Retrospective cohort study.

PARTICIPANTS

136 patients aged 65 and older enrolled in an Accountable Care Organization (ACO) risk contract at an academic medical center and hospitalized for COVID-19 between March 11, 2020 - June 3, 2020.

MEASUREMENTS

We linked a COVID-19 Registry with administrative claims data to quantify a frailty index and its relationship to mortality, healthcare utilization, and expenditures over 6 months following hospital discharge. Kaplan Meier curves and Cox Proportional Hazards models were used to evaluate survival by frailty. Kruskal-Wallis tests were used to compare utilization. A generalized linear model with a gamma distribution was used to evaluate differences in monthly Medicare expenditures.

RESULTS

Much of the cohort was classified as moderate to severely frail (65.4%), 24.3% mildly frail, and 10.3% robust or pre-frail. Overall, 27.2% (n=37) of the cohort died (n=26 during hospitalization, n=11 after discharge) and survival did not significantly differ by frailty. Among survivors, inpatient hospitalizations during the 6-month follow-up period varied significantly by frailty (p=0.02). Mean cost over follow-up was $856.37 for the mild and $4914.16 for the moderate to severe frailty group, and monthly expenditures increased with higher frailty classification (p <.001).

CONCLUSIONS

In this cohort, claims-based frailty was not significantly associated with survival but was associated with follow-up hospitalizations and Medicare expenditures.

POS0004 WHAT DOES WORSENING IN DAPSA DISEASE ACTIVITY CATEGORIES MEAN FOR PATIENTS WITH PSORIATIC ARTHRITIS? AN ANALYSIS OF 222 PATIENTS

Background

In psoriatic arthritis (PsA), disease activity states have been defined using the DAPSA (Disease Activity index for Psoriatic Arthritis) score (1). The disease activity states have been validated using structural progression as the gold standard (2). However, the worsening in DAPSA states has not been compared to the patient’s perspective.

Objectives

To assess the association between a worsening in disease activity (i.e., change in DAPSA disease activity category) versus the patient’s judgement of disease worsening.

Methods

ReFlap (NCT03119805) was a longitudinal study in 14 countries of consecutive adult patients with definite PsA and more than 2 years of disease duration. Patients were seen twice in the context of usual care, around 4 months apart (3). Worsening in disease activity between the 2 visits was defined as a transition to a more active disease category, based on the DAPSA categories [(remission, low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA)] (1).This change was compared to (a) patient perceived-flares collected according to a patient-reported question: “At this time, are you having a flare of your psoriatic arthritis, if this means the symptoms are worse than usual?”; and (b) a worsening according to the MCID (Minimal Clinical Important Difference) question. The agreement between the definitions of worsening were calculated by frequency, Cohen’s kappa and prevalence adjusted bias adjusted kappa (PABAK). There was no imputation of missing data.

Results

Overall, 222 patients were analyzed: 127 (58.8%) were male, aged 53.5±12.3 years and with 10.8±8.3 years of disease duration. Disease activity was moderate: 35.9% had no current psoriasis skin lesions, mean tender joint count (TJC, 0-68) was 3.0±7.5, mean swollen joint count (SJC, 0-66) was 1.6±6.6, and mean DAPSA was 11.5±14.0.

At 4.5±2.2 months follow-up, the proportion of DAPSA worsening was 40.1% [95% confidence interval, 33.9-46.7] (n=89). Most of the changes corresponded to patients going from remission to LDA (N=24, 27.0% of worsened patients) or from LDA to MDA (N=24, 27.0%).

Patient-reported flares were reported in 27.0% [21.6-33.2] (n=60), and MCID worsening was reported in 14.0% [33.9-46.5] (n=31).

Figure 1 shows the distribution of patients with worsening in DAPSA category, versus patient-defined worsening. Of the 89 patients who worsened according to DAPSA categories, 41 (46.1%) had self-perceived flares and 20 (22.5%) had worsening according to MCID. Among patients who worsened in DAPSA category, the mean change in DAPSA was higher in patients with self-perceived flares (increase of 22.2±15.0) than in patients without self-perceived flares (increase of 14.3±12.3). Of 133 patients with no worsening according to DAPSA, 114 (85.7%) had no self-perceived flares and 122 (91.7%) had no MCID worsening. The kappa [95% confidence interval] (PABAK) coefficients between DAPSA and either patient flare or MCID worsening were 0.34 [0.21-0.46] (0.40) and 0.16 [0.05-0.27] (0.28), respectively.

Figure 1.

Venn diagram for disease worsening between 2 visits

Conclusion

After 4 months of follow-up, 40.1% patients with long-standing PsA had a change in DAPSA category corresponding to more active disease. Most of these changes reflected transitions from remission to LDA, or from LDA to MDA. Among patients changing DAPSA category, only 46.1% reported themselves in flare at the second visit and only 22.5% reported themselves as worsened by MCID, leading to only fair (for flares) to low (for MCID worsening) agreement between the assessments of worsening. It is important to assess both disease activity, and the patient’s perspective of flare.

References

[1]Schoels M, et al. Ann Rheum Dis. 2016;75(5):811-8.

[2]Aletaha D, et al. Ann Rheum Dis. 2017;76(2):418-421.

[3]Gorlier C, et al. Ann Rheum Dis 2019;78:201-208.

Disclosure of Interests

None declared

A96 GENDER DIFFERENCES IN GASTROENTEROLOGY AND HEPATOLOGY AUTHORSHIP AND EDITORIAL BOARDS

Background

Women are numerically under-represented in the field of gastroenterology and hepatology.

Aims

To characterize the gender distribution of first and senior authors and editorial board members of the highest impact factor journals in gastroenterology and hepatology.

Methods

Using Clarivate Journal Citation Report 2019, the 28 highest ranked journals within gastroenterology and hepatology were selected for review, along with the Journal of the Canadian Association of Gastroenterology. Publications between January 1 to December 31, 2019 were included. Gender of board members and authors was identified using publicly available data. Spearman correlation coefficients were calculated using SPSS to assess for a relationship between editorial board, first author, and senior author gender as well as impact factor.

Results

Of 29 journals assessed with a median impact factor of 5.55 (IQR 3.72–9.10), 357 journal issues and 8036 articles were reviewed. Three journals were headed by female chief editors, constituting 7.7% of all editors-in-chief (3/39). In total, females made up 17.1% of editorial board members (n=584). Of 8036 first authors, 2547 (31.7%) were female. Of 7335 senior authors, 1390 (19.3%) were female. There were no statistically significant correlations between impact factor and gender. Chief editor gender did not significantly correlate with gender distribution of editorial boards, first or senior authors. There was a significant positive correlation between male-dominated editorial boards and male first and senior authorship, versus a significant negative correlation between male-dominated editorial boards and female first and senior authorship. A positive correlation exists for the same gender between first and senior authors.

Conclusions

Although gender distribution of female first and senior authorship approaches current distributions in the field of gastroenterology and hepatology, editor-in-chief positions and editorial board membership on journals continue to be occupied by men in higher proportions. Future endeavors such as diversity statements and mentorship may help to balance these distributions in the future.

Funding Agencies

None

A228 WHEN ASCITES & VARICEAL BLEEDING ARE NOT FROM CIRRHOSIS: A CASE OF MUTIPLE ARTERIOPORTAL FISTULAE CAUSING PORTAL HYPERTENSION

Background

Portal hypertension is usually due to increased resistance from cirrhosis. However, pressures can also be elevated due to increased flow.

Aims

To describe a peculiar case of non-cirrhotic portal hypertension.

Methods

A case report and literature review was performed.

Results

A 47-year-old previously well man presented with a 6 month history of rapidly progressive weight loss, ascites and variceal bleed. Workup ruled out common causes of primary liver disease. Initial imaging demonstrated a heterogenous liver, splenomegaly, ascites, patent hepatic/portal veins and multiple poorly defined low-density hepatic lesions with the largest measuring 2.1 cm. Transient elastography was 7.3 kPa (F1-mild fibrosis). At transjugular liver biopsy, hepatic venogram ruled out Budd-Chiari and hepatic vein pressure gradient was normal at 3–4 mmHg. Histology unfortunately showed hemangioma. A percutaneous liver biopsy suggested nodular regenerative hyperplasia, minimal fibrosis and mild cholestasis. Given worsening ascites, hyponatremia and 7 months of rapidly progressive decline, transjugular intrahepatic portosystemic shunt (TIPSS) was inserted. Intra-procedure, portal vein pressure was noted to be 51 mmHg, with a portosystemic gradient of 42 mmHg. Although numerous abdominal CT and MRI did not show AV shunting, ultrasound post-TIPSS showed hepatic pseudoaneurysms & arterioportal fistulae (APF). Direct angiogram showed numerous hepatic pseudoaneurysms and intrahepatic fistulae making embolization impossible. CT showed no evidence of pseudoaneurysms or fistulae outside of the liver. Workup for autoimmune rheumatological diseases and congenital telangiectatic syndromes were negative. Given the high pressures being directed through the new TIPSS, right heart failure is an ongoing concern.

APF are rarely encountered causes of presinusoidal portal hypertension, with communications most commonly arising from the hepatic (65%) & splenic arteries (11%) & the portal vein. Causes include traumatic (28%), iatrogenic (16%), vascular/telangiectatic malformations (15%), tumors (15%), aneurysms (14%) & congenital disease. Endovascular embolization can be used to treat single lesions. In complex cases with mulitple APF, surgery and/or liver transplantation may be required.

Conclusions

We report a rare case of non-cirrhotic portal hypertension due to increased flow rather than increased resistance secondary to APF.

Funding Agencies

None

Cost-effectiveness of bivalent versus monovalent vaccines against hand, foot and mouth disease

OBJECTIVES

Enterovirus 71 (EV71) and coxsackievirus A16 (CA16) were responsible for 43.3% (235 123/543 243) and 24.8% (134 607/543 243) of all laboratory-confirmed hand, foot and mouth disease (HFMD) cases during 2010-2015 in China. Three monovalent EV71 vaccines have been licensed in China while bivalent EV71/CA16 vaccines are under development. A comparative cost-effectiveness analysis of bivalent EV71/CA16 versus monovalent EV71 vaccination would be useful for informing the additional value of bivalent HFMD vaccines in China.

METHODS

We used a static model parameterized with the national HFMD surveillance data during 2010-2013, virological HFMD surveillance records from all 31 provinces in mainland China during 2010-2013 and caregiver survey data of costs and health quality of life during 2012-2013. We estimated the threshold vaccine cost (TVC), defined as the maximum additional cost that could be paid for a cost-effective bivalent EV71/CA16 vaccine over a monovalent EV71 vaccine, as the outcome. The base case analysis was performed from a societal perspective. Several sensitivity analyses were conducted by varying assumptions governing HFMD risk, costs, discounting and vaccine efficacy.

RESULTS

In the base case, choosing the bivalent EV71/CA16 over monovalent EV71 vaccination would be cost-effective only if the additional cost of the bivalent EV71/CA16 compared with the monovalent EV71 vaccine is less than €4.7 (95% CI 4.2-5.2). Compared with the TVC in the base case, TVC increased by up to €8.9 if all the test-negative cases were CA16-HFMD; decreased by €1.1 with an annual discount rate of 6% and exclusion of the productivity loss; and increased by €0.14 and €0.3 with every 1% increase in bivalent vaccine efficacy against CA16-HFMD and differential vaccine efficacy against EV71-HFMD, respectively.

CONCLUSIONS

Bivalent EV71/CA16 vaccines can be cost-effective compared with monovalent EV71 vaccines, if suitably priced. Our study provides further evidence for determining the optimal use of HFMD vaccines in routine paediatric vaccination programme in China.

A133 DEVELOPMENT OF TYPE 3 ACHALASIA WITH DISTANT PANCREATIC MALIGNANCY

Background

Pseudoachalasia is often caused by malignant involvement at the gastroesophageal junction (GEJ) leading to dysphagia.

Aims

We describe a case of type 3 achalasia presenting in a woman with metastatic pancreatic cancer with no direct involvement at the GEJ, fundus or cardia.

Methods

A case report and literature review were performed.

Results

A 53-year-old woman presented with a 2-month-history of progressive abdominal pain, nausea and vomiting with a 30-pound weight loss. She had a remote history of breast cancer in remission after surgery and chemoradiation. On presentation, she denied chest pain, reflux, dysphagia or odynophagia. Abdominal exam revealed focal epigastric tenderness and jaundice. Abdominal CT showed a 6.7 x 5.8 cm conglomerate mass involving the hepatic hilum, pancreatic head, duodenum, common bile duct, and portal vein with gastric outlet and biliary obstruction. This mass was confirmed to be a pancreatic adenocarcinoma on pathology. She then underwent nasogastric tube decompression. Initial esophagogastroduodenoscopy (EGD) confirmed a stenotic area at the distal duodenal cap. A duodenal stent and common bile duct stent were placed during a second EGD. The esophagus and GEJ were unremarkable on both endoscopic exams. She was started on chemotherapy with gemcitabine and abraxane. Two weeks after her stent placement, she rapidly developed severe retrosternal squeezing discomfort and choking occurring with swallowing. CT chest and abdomen were negative for any intrathoracic and diaphragmatic involvement with stability of the mass. A barium swallow study demonstrated tertiary contractions in the thoracic esophagus with marshmallow hold-up in the distal esophagus. She then underwent a high-resolution esophageal manometry study that demonstrated an elevation of integrated residual pressure (IRP) of the lower esophageal sphincter (LES) and absence of peristalsis, with the distal 2/3rds of the esophagus showing a simultaneous and prolonged pressure front consistent with type 3 achalasia, Chicago classification v3.0 [Figure 1]. All contractions had a distal contractile integral (DCI) of &gt;8000 mmHg-cm-s. She experienced significant symptom improvement with pinaverium bromide, a gut-specific calcium channel antagonist.

A review of the literature revealed that there have been 4 English-language cases published on pseudoachalasia associated with pancreatic cancer, with all cases describing direct infiltration of pancreatic cancer in the GEJ, cardia or fundus with manometric features of type I achalasia.

Conclusions

We report the first case of type 3 achalasia with no evidence of direct malignant infiltration at the GEJ on radiographic and endoscopic evaluations. Possible mechanisms to explain this phenomenon include paraneoplastic antibody-mediated impairment of enteric neurons that decrease nitric oxide availability, or microscopic disease involvement at the GEJ.

Funding Agencies

None

A220 A COMPREHENSIVE SYSTEMATIC REVIEW AND META-ANALYSIS OF THE RISK OF ADVERSE NEONATAL OUTCOME IN INFLAMMATORY BOWEL DISEASE AND PREGNANCY

Background

Inflammatory bowel disease (IBD) often affects women in their child-bearing years. These women may be at an increased risk of adverse neonatal outcomes.

Aims

The aim of this study was to evaluate the risk of these outcomes in this population of patients, with an emphasis of determining risk factors for development of these conditions.

Methods

Medline, Embase, and Cochrane library were searched through to May 2019 for studies reporting adverse neonatal outcomes in IBD patients. Weighted odds ratios (OR) with 95% confidence intervals (CI) were calculated to assess the risk of these outcomes in patients with IBD compared to healthy controls, with risk factors such as disease activity and medication exposure also being assessed.

Results

Sixty studies were included (8194 pregnancies with inflammatory bowel disease and 3253 healthy pregnancies). Compared to healthy controls, patients with inflammatory bowel disease were more likely to deliver infants with low birth weight (LBW) (OR 2.78, 95% CI 1.16–6.66) and infants who were admitted to the neonatal intensive care unit (NICU) (OR 3.33, 95% CI 1.83–6.05). Patients with Crohn’s disease had an increased risk of infants born with congenital anomalies (OR 3.03, 95% CI, 1.43–6.42), whereas patients with ulcerative colitis had an increased risk of preterm delivery (OR 2.68, 95% CI, 1.12–6.43). Active disease increased the risk of preterm birth (OR 2.06, 95% CI 1.21–3.51), LBW (OR 2.96, 95% CI 1.54–5.70), and small for gestation age (OR 2.62, 95% CI 1.18–5.83) compared to disease in remission. Tumor necrosis factor antagonists was associated with increased risk of NICU admission (OR 2.42, 95% CI 1.31–4.45) and LBW (OR 1.54, 95% CI, 1.01–2.35).

Conclusions

Patients with inflammatory bowel disease are at an increased risk of developing adverse neonatal outcomes such as preterm birth, LBW, congenital anomalies, and NICU admissions. Patients with clinically active disease and those exposed to anti-TNF therapy may be at higher risk of developing these adverse outcomes. The findings of this study are important to communicate to patients and healthcare providers alike. Furthermore, this information may help to mitigate these risks through collaborative specialized care during pregnancy in order to reduce the overall morbidity and mortality for both mother and baby.

Funding Agencies

None

A250 SYSTEMATIC REVIEW WITH META-ANALYSIS: ADVERSE PREGNANCY-RELATED OUTCOMES WITH INFLAMMATORY BOWEL DISEASE

Background

Inflammatory bowel disease (IBD) is a chronic inflammatory condition. While it is reported that IBD may result in adverse pregnancy-related outcomes, its effects on placental related diseases are relatively not known.

Aims

The aim of our work was to determine the risk of adverse pregnancy outcomes in patients with IBD.

Methods

Medline, Embase, and Cochrane library were searched for studies that reported adverse maternal and obstetrical outcomes in patients with IBD. Weighted odds ratios (OR) with 95% confidence intervals (CI) were calculated for the risk of these outcomes in patients with IBD compared to healthy controls.

Results

Fifty-three studies were included (7917 patients with IBD and 3253 healthy controls). Cesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16–2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21–2.90) but not CD (OR 1.48, 95% CI, 0.94–2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47–5.98). Furthermore, the incidences of placental diseases were low, 2.0% (95% CI, 0.9–3.1%) for pre-eclampsia, 3.3% (95% CI, 0–7.2%) for placental abruption, 0.5% (95% CI, 0.2–0.9%) for placenta previa, and 0.3% (95% CI, 0–0.5%) for chorioamnionitis. Finally, patients with IBD were more likely to experience preterm premature rupture of membranes (PPROM, OR 12.10, 95% CI, 2.15–67.98), but not an early pregnancy loss (OR 1.63, 95% CI 0.49–5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16–7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83- 2.64), and placenta previa (OR 1.58, 95% CI, 0.30–8.47).

Conclusions

Patients with IBD are more likely to develop adverse pregnancy-related outcomes such as Gestational Diabetes and PPROM. Pregnancy in patients with IBD should be considered a high-risk period and as such, a multi-disciplinary team, including gastroenterologists, obstetricians and maternal-fetal medicine specialists, is necessary to recognize and effectively manage adverse obstetrical outcomes in order to reduce overall morbidity and mortality.

Funding Agencies

None

Febrile neutropenia and its associated hospitalization in breast cancer patients on docetaxel-containing regimen: A retrospective cohort study on duration of prophylactic GCSF administration

PURPOSE

To compare febrile neutropenia (FN) incidence and hospitalization among breast cancer patients on docetaxel with no granulocyte colony-stimulating factors (GCSF) primary prophylaxis (PP), 4/5-day PP, or 7-day PP.

METHODS

We identified 3916 breast cancer patients using docetaxel-cyclophosphamide (TC), doxorubicin-cyclophosphamide then docetaxel (AC-T), fluorouracil-epirubicin-cyclophosphamide then docetaxel (FEC-T), docetaxel-carboplatin-trastuzumab (TJH), or docetaxel-doxorubicin-cyclophosphamide (TAC) from a hospital pharmacy dispensing database in Hong Kong between 2014 and 2016. Patients were offered GCSF within 5 days since administering docetaxel. Outcomes included FN incidence, time to first hospitalization, hospitalization rate, and duration.

RESULTS

In TC regimen, FN incidence (with odds ratio, OR) of patients with no PP, 4/5-day PP, and 7-day PP was 21.69%, 7.95% (OR 0.31, p < 0.001), and 5.33% (OR 0.20, p < 0.001), respectively. In TJH regimen, FN incidence of patients with no PP, 4/5-day PP, and 7-day PP was 38.26%, 8.33% (OR 0.15, p < 0.001), and 8.57% (OR 0.15, p < 0.001), respectively. FN incidence of patients on AC-T regimen with no PP and 4/5-day PP was 20.93% and 6.84%, respectively (OR 0.28, p = 0.005); with FEC-T regimen, the incidence was 9.91% and 4.77%, respectively (OR 0.46, p = 0.035). Only 3.27% FN cases were not hospitalized. Mean (±standard deviation, SD) time to first hospitalization was 8.21 ± 2.44 days. Mean (±SD) duration of hospitalization for patients with no PP, 4/5-day PP, and 7-day PP was 4.66 ± 2.60, 4.37 ± 2.85, and 5.12 ± 2.97 days, respectively.

CONCLUSION

GCSF prophylaxis in breast cancer patients on docetaxel could reduce FN incidence and hospitalization. 4/5-day PP demonstrated similar efficacy to 7-day PP with superior saving benefits on healthcare expenditure.

Expression of inflammatory markers in women with perinatal depressive symptoms

Perinatal depression affects 10-20% of women and is associated with poor outcomes for mother and child. Inflammation is associated with depression in non-pregnant adults. Perinatal depression and inflammation in pregnancy are independently associated with morbidities including obesity, gestational diabetes, preeclampsia, and preterm birth. The role of inflammation in perinatal depression has received little attention. We hypothesized an association between self-reported perinatal depressive symptoms and serum inflammatory biomarkers TNF-α, IL-6, IL-1β, and CRP. 110 healthy gravidas were recruited in third trimester from an academic medical center, with a baseline study visit at a mean of 32.5 (SD ± 1.8) weeks gestational age. Sixty-three participants completed the Edinburgh Postnatal Depression Scale (EPDS) and provided demographic information and serum samples upon enrollment and at 3 and 6 months postpartum. Serum inflammatory markers were quantified by multiplex array. Multiple linear mixed effects models were used to evaluate trends of biomarkers with the EPDS score in the third trimester of pregnancy and the postpartum period. Elevated serum TNF-α was associated with lower EPDS total score (β = - 0.90, p = 0.046) after adjusting for demographics and medication use. In contrast, IL-6, CRP, and IL-1β did not demonstrate statistically significant associations with depressive symptoms by the EPDS in either crude or adjusted models. Study findings showed no association or an inverse (TNF-α) association between inflammatory markers and perinatal depressive symptoms. Relevant literature evaluating a role for inflammation in depression in the unique context of pregnancy is both limited and inconsistent, and further exploration is merited.

Weight gain in early pregnancy and risk of gestational diabetes mellitus among Latinas

AIM

To evaluate the association between gestational weight gain (GWG) in early pregnancy and incidence of abnormal glucose tolerance (AGT) and gestational diabetes mellitus (GDM) among Latinas.

METHODS

We conducted a retrospective cohort study of 2039 Latinas using pooled data from two medical centres in Massachusetts. Gestational weights were abstracted from medical records and GWG was categorized as low, appropriate and excessive according to 2009 Institute of Medicine Guidelines. Diagnosis of AGT and GDM was confirmed by study obstetricians.

RESULTS

A total of 143 women (7.0%) were diagnosed with GDM and 354 (17.4%) with AGT. After adjusting for age and study site, women with low GWG up to the time of GDM screen had a lower odds of GDM (OR: 0.51, 95% CI: 0.29-0.92). Among overweight women, women with excessive first-trimester GWG had 2-fold higher odds of AGT (OR: 1.96, 95% CI: 1.17-3.30) and GDM (OR: 2.07, 95% CI: 1.04-4.12) compared to those with appropriate GWG; however, these findings were not significant among normal weight or obese women.

CONCLUSION

Among Latinas, low GWG up to the time of GDM screen was associated with lower odds of AGT and GDM, while excessive GWG among overweight women was associated with higher odds. Findings highlight need for interventions in early pregnancy to help women meet GWG guidelines and to moderate GWG among overweight Latinas.

The reproducibility and clinical utility of the 3D camera for measuring scar height, with a protocol for administration

BACKGROUND

This study aimed to determine the reproducibility and clinical utility of a 3D camera for measuring burn scar height in adults.

METHODS

Participants from a larger prospective longitudinal study were included. Reproducibility data were collected using an immediate test-retest interval and a 1-2 week test-retest interval and included reliability and agreement. The LifeViz^™ 3D camera was used to measure scar height. Reproducibility was tested using the Intraclass Correlation Coefficient (ICC), percentage agreement within 1 mm between test and retest, standard error of measurement, smallest detectable change (SDC) and Bland Altman limits of agreement.

RESULTS

Burn scar images from 55 adult participants were included. Intra-rater reliability was acceptable using an immediate retest interval (maximum and minimum height ICC=0.85, 0.86 respectively). Agreement using an immediate retest interval was borderline acceptable (maximum and minimum height SDC=1.11, 0.69 respectively) to detect changes of close to 1 mm. Reproducibility was largely not acceptable using a 1-2 week test-retest interval (eg, maximum and minimum height ICC=0.34, 0.68 respectively; maximum and minimum height SDC=2.66, 1.16). The clinical utility of the camera was supported for scars over relatively flat areas and well-defined border margins. A protocol for administration of the camera was developed.

CONCLUSION

The 3D camera appears capable of detecting gross changes or differences in scar height above the normal skin surface, in adults with scars over relatively flat areas and well-defined border margins. However, further testing of reproducibility using a shorter test-retest interval than 1-2 week retest is recommended to confirm the suitability of the device for measuring changes or differences in scar height.

Abstract 5326: COSMIC: Enhancing the world's knowledge of somatic mutations in human cancer

COSMIC, the Catalogue Of Somatic Mutations In Cancer (http://cancer.sanger.ac.uk) is the world's largest and most comprehensive online resource for exploring the impact of somatic mutations in human cancer. Now running for over 10 years, the 67th release (Oct 2013) describes 1592109 mutations in 947213 tumour samples across 25606 genes. This information is curated manually from the scientific literature, and automatically from genome resequencing consortium data portals. Full curation of the scientific literature provides in-depth understanding of the impact that each gene has in human cancer, and this has been achieved for 127 point-mutated cancer genes, and 185 fusion gene pairs. Curated genes are selected from the Cancer Gene Census (http://cancer.sanger.ac.uk/census), a listing of all genes with substantial evidence implicating them in cancer promotion, currently numbering 513 and updated frequently.

The mutations discovered in the re-sequencing of over 8000 tumour genomes are now present in COSMIC (viewable in isolation from the genic curations, http://cancer.sanger.ac.uk/wgs). In addition, the Sanger has now fully exome sequenced 1015 common cancer cell lines, identifying 1146874 coding mutations annotated for functional significance, and this is available exclusively in COSMIC at (http://cancer.sanger.ac.uk/cell_lines). While COSMIC has focused on point mutations and gene fusions, many other mutation mechanisms cause oncogenesis and these are now being integrated. The 67th COSMIC release includes copy number mutations integrated into the database and major web page views. To allow easy graphical examination of this data, copy number information was reduced to ‘gain’ and ‘loss’ annotations for inclusion in histograms and tables, with much more precise detail available with a further click. Copy number data is available in detail for every gene in COSMIC, and also for every tissue. Exploring cancer via COSMIC’s Cancer Browser (http://cancer.sanger.ac.uk/cosmic/browse/tissue), results not just in a plot of the most mutated genes, but now also a circular genome plot summarizing the copy number gains and losses across all the samples from that tumour type, all explorable in more detail via clicks on the pictures.

As the genomic data increases in COSMIC, it is becoming more important to qualitatively annotate the information, indicating which is more important or significant to oncogenesis. We are now building systems to better highlight known or putative functional mutations, improving the signal-to-noise ratio of cancer genome resequencing.

Citation Format: C Boutselakis, S A. Forbes, P Gunasekaran, M Jia, D Beare, N Bindal, C Y. Kok, K Leung, D Minjie, R Shepherd, S Bamford, S Ward, C Cole, J W. Teague, M Stratton, P Campbell, U McDermott. COSMIC: Enhancing the world's knowledge of somatic mutations in human cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5326. doi:10.1158/1538-7445.AM2014-5326

Relationships between the racemic structures of substituted mandelic acids containing 8- and 10-membered hydrogen bonded dimer rings

The structures of 27 monosubstituted mandelic acids, including several of their polymorphs, plus unsubstituted mandelic acid itself (two polymorphs) are investigated for structural similarity.

Involvement of interleukin-1 in the differentiation-inducing activity of tumor necrosis factor-alpha on a murine myeloid leukemia (WEHI-3B JCS)

We have shown previously that tumor necrosis factor-alpha (TNF-alpha) inhibits the growth and induces the differentiation of a murine myelomonocytic leukemia (WEHI-3B JCS cells) into macrophage-like cells. In this study, using reverse transcription polymerase chain reaction, we found that both endogenous interleukin-1 alpha and beta (IL-1 alpha, IL-1 beta) mRNA were up-regulated upon TNF-alpha induction. Exogenous IL-1 alpha and IL-1 beta also inhibited the growth as well as induced the differentiation of JCS cells, with IL-1 beta exerting a greater growth-inhibitory effect. Neutralizing anti-IL-1 alpha, anti-IL-1 beta and anti-TNF-alpha antibodies were further used to elucidate the role of IL-1 alpha, IL-1 beta and TNF-alpha in JCS cell differentiation. The results show that the IL-1 alpha-induced monocytic differentiation of JCS cells was effectively blocked by anti-IL-1 beta as well as anti-IL-1 beta antibodies and to a lesser extent by anti-TNF-alpha antibody. In contrast, the differentiation-inducing effect of IL-1 beta on JCS cells was only blocked by anti-IL-1 beta antibody but not by anti-IL-1 alpha or anti-TNF-alpha antibody. Finally, the TNF-alpha-induced monocytic differentiation of JCS cells was significantly blocked by anti-TNF-alpha and to a lesser extent by anti-IL-1 alpha and anti-IL-1 beta antibodies. Collectively, our results suggest that IL-1 beta alone may directly trigger JCS cell differentiation whereas the differentiation-inducing effect of IL-1 alpha may be via the endogenous production of IL-1 beta and/or TNF-alpha. In addition, IL-1 alpha and IL-1 beta may be involved, at least in part, in TNF-alpha-induced monocytic differentiation of the JCS leukemia cells.

Sodium thiosulfate-based treatment in calcific uremic arteriolopathy: a consecutive case series

BACKGROUND

Calcific uremic arteriolopathy (CUA) is a rare complication in end stage renal disease with high mortality. Numerous case reports and one case series of 3 patients report the benefit of sodium thiosulfate (STS) for treatment of CUA. The purpose of this evaluation was to examine the response to a STS-based treatment approach in patients with CUA with 1 year follow up.

METHODS

A retrospective case series of 6 consecutive patients from Manitoba, Canada who met predefined diagnostic criteria for CUA and received STS between 2006 and 2008 were included. STS responders were defined as improvement in at least one of the following three parameters: pain severity, wound size and diagnostic imaging/radiography. Mortality, STS dose, duration, adverse events and cost were also collected.

RESULTS

Four patients were classified as responders. The 2 responders who survived at 1 year of follow-up demonstrated an improvement in all 3 parameters examined including an improvement in their follow-up diagnostic imaging results within the first 4 - 6 weeks of STS treatment. At 1 year of follow-up, 3 patients died.

CONCLUSION

Using an STS-based multifaceted treatment approach for CUA, 4 patients responded but 3 of 6 patients died within 1 year. Further larger prospective studies are needed to delineate STS responders from non-responders.

Symbiotic Characteristics of Rhizobium leguminosarum bv. trifolii Isolates Which Represent Major and Minor Nodule-Occupying Chromosomal Types of Field-Grown Subclover (Trifolium subterraneum L.)

The symbiotic effectiveness and nodulation competitiveness of Rhizobium leguminosarum bv. trifolii soil isolates were evaluated under nonsoil greenhouse conditions. The isolates which we used represented both major and minor nodule-occupying chromosomal types (electrophoretic types [ETs]) recovered from field-grown subclover (Trifolium subterraneum L.). Isolates representing four ETs (ETs 2, 3, 7, and 8) that were highly successful field nodule occupants fixed between 2- and 10-fold less nitrogen and produced lower herbage dry weights and first-harvest herbage protein concentrations than isolates that were minor nodule occupants of field-grown plants. Despite their equivalent levels of abundance in nodules on field-grown subclover plants, ET 2 and 3 isolates exhibited different competitive nodulation potentials under nonsoil greenhouse conditions. ET 3 isolates generally occupied more subclover nodules than isolates belonging to other ETs when the isolates were mixed in 1:1 inoculant ratios and inoculated onto seedlings. In contrast, ET 2 isolates were less successful at nodulating under these conditions. In many cases, ET 2 isolates required a numerical advantage of at least 6:1 to 11:1 to occupy significantly more nodules than their competitors. We identified highly effective isolates that were as competitive as the ET 3 isolates despite representing serotypes that were rarely recovered from nodules of field-grown plants. When one of the suboptimally effective isolates (ET2-1) competed with an effective and competitive isolate (ET31-5) at several different inoculant ratios, the percentages of nodules occupied by the former increased as its numerical advantage increased. Although subclover yields declined as nodule occupancy by ET2-1 increased, surprisingly, this occurred at inoculant ratios at which large percentages of nodules were still occupied by ET31-5.

Serological and Ecological Characteristics of a Nodule-Dominant Serotype from an Indigenous Soil Population of Rhizobium leguminosarum bv. trifolii

Although at least 13 antigenically distinct serotypes of Rhizobium leguminosarum bv. trifolii exist in an Abiqua silty clay loam soil, one serotype, AS6, occupies >/=50% of the root nodules formed on field-grown subclover and between 33 and 78% of the nodules formed on five annual clover species grown in the same soil under laboratory conditions. The dominance of subclover nodules by serotype AS6 was reproducible over a 4-year sampling period and throughout the entire 200- by 100-m pasture examined. Serotype AS6 was composed of three antigenically distinct subtypes (AS6-a, AS6-b, and AS6-c). Each subtype contributed about one-third of the AS6 isolates recovered from nodules of field-grown subclover plants and maintained similar population densities in nonrhizosphere and rhizosphere soil. Rhizobia with the AS6 antigenic signature accounted for from 20 to 100% of the soil populations of R. leguminosarum in arable and pasture soils under legumes throughout the state of Oregon. Over a 12-month period, the population densities of the serotype AS6 complex and three minor nodule-occupying serotypes (AG4, AP17, and AS21) were measured in the rhizospheres of field-grown subclover and orchard grass and in nonrhizosphere Abiqua soil. Regardless of season or serotype, the orchard grass rhizosphere effect was minimal, with the ratio between rhizosphere and nonrhizosphere serotype population densities ranging between 2.5 (midsummer) and 10.5 (spring). In contrast, the magnitude of the subclover rhizosphere effect varied seasonally and among serotypes. Between October and December the ratios for all serotypes were similar (12.5 to 25.5). However, in the spring (April and May), the magnitude of the rhizosphere effect varied among the indigenous serotypes (ratios, 10.5 to 442) and for minor nodule-occupying serotypes AS21 (ratio, 442) and AP17 (ratio, 47) was as great as, or even greater than, the magnitude of the rhizosphere effect observed with the AS6 complex (ratio, 65.5).

Freezing inactivation of Escherichia coli and Enterococcus faecalis in water: response of different strains

The effect of freezing temperature (-7, -15, -30 and -80 degrees C), number of freeze/thaw cycles (1 to 5 cycles) and sample volume (100 mL and 100 microL) on the viability of a pathogenic and an opportunistically pathogenic Escherichia coli, a vancomycin-resistant and a vancomycin-sensitive Enterococcus faecalis were examined. About 3.3 to 4.3 and 1.5 to 2.4 log reduction in cell density were observed in E. coli and E. faecalis, respectively, in the 100 mL samples frozen at -30 degrees C or warmer. Freezing at -80 degrees C was the least effective in killing the microbes, on average the log reduction at -80 degrees C was approximately 1.0 to 1.5 units less than those achieved at the three warmer temperatures. Based on statistical analysis, cell inactivation levels achieved at -7, -15, or -30 degrees C were not significantly different (P-value = 0.1648). There were no statistical difference in terms of log reduction obtained under all experimental conditions for the two E. coli strains (P-value = 0.46) and the two E. faecalis strains (P-value = 0.10). The number of freezing/thaw cycles and sample volume, however, profoundly affected inactivation capacity of freezing. Freezing could be an effective method for further reduction of E. coli and Enterococcus in municipal wastewater/sludge.

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

BACKGROUND AND STUDY AIM

Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting.

METHODS

Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05.

RESULTS

368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores.

CONCLUSIONS

Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

Neuropathogenesis of chimeric simian/human immunodeficiency virus infection in pig-tailed and rhesus macaques

We recently reported that a chimeric simian/human immunodeficiency virus (SHIVKU-1) developed in our laboratory caused progressive depletion of CD4+ T lymphocytes and AIDS within 6 months of inoculation into pig-tailed macaques (M. nemestrina). None of the pig-tailed macaques showed productive SHIV infection in the central nervous system (CNS). In this report, we show that by further passage of the pathogenic virus in rhesus macaques [M. mulatta], we have derived a new strain of SHIV (SHIVKU-2) that has caused AIDS and productive CNS infection in 3 of 5 rhesus macaques infected with the virus. Productive replication of SHIV in the CNS was clearly shown by high infectivity titers and p27 protein levels in brain homogenates, and in 2 of the 3 rhesus macaques this was associated with disseminated, nodular, demyelinating lesions, including focal multinucleated giant cell reaction, largely confined to the white matter. These findings were reminiscent of HIV-1 associated neurological disease, and our immunohistochemical and in situ hybridization data indicated that the neuropathological lesions were associated with the presence of SHIV-specific viral antigens and nucleic acid respectively. However, the concomitant reactivation of opportunistic infections in these macaques suggested that such pathogens may have influenced the replication of SHIV in the CNS, or modified the neuropathological sequelae of SHIV infection in the rhesus species, but not in pig-tailed macaques. Our findings in the two species of macaques highlight the complexities of lentiviral neuropathogenesis, the precise mechanisms of which are still elusive.

Treatment of hepatitis B with lamivudine and tenofovir in HIV/HBV-coinfected patients: factors associated with response

As therapy for human immunodeficiency virus (HIV) infection evolves, optimizing hepatitis B virus (HBV) treatment and identifying factors that impact its response in the HIV/HBV-coinfected population is critical. We identified retrospectively 45 HBV/HIV-coinfected patients with detectable HBV DNA by the Bayer VERSANT HBV 3.0 bDNA assay (limit of quantification 2000 copies/mL) at baseline and/or year 1 of therapy. Patients were divided into three groups based on the active HBV agent in their antiretroviral regimen: group 1 (n = 15) received lamivudine; group 2 (n = 10), lamivudine plus tenofovir and group 3 (n = 20), lamivudine followed by lamivudine plus tenofovir. HBV genotypes and resistance profiles were determined by the Bayer Trugene HBV 1.0 assay. More patients in group 2 achieved HBV DNA suppression below 2000 copies/mL (80%), loss of HBe antigen (HBeAg) (40%) and loss of HBeAg and gain of anti-HBe (20%) than did patients in group 1 or 3. More patients with HBV genotype A, achieved HBV DNA suppression <2000 copies/mL than did patients with non-A genotypes [74% (26/35) vs 20% (2/10)], respectively (P = 0.003). Risk for virological nonresponse was significant in those with non-A genotypes [odds ratio (OR) 11.1; 95% CI: 2.0-50], previous HIV therapy (OR 6.5; 95% CI: 1.2-35) and <90% compliance (OR 3.7; 95% CI: 0.99-14.3). Simultaneous therapy with lamivudine/tenofovir suppresses HBV DNA more effectively than lamivudine or tenofovir added to lamivudine. More patients infected with HBV genotype A responded than the non-A patients, regardless of therapeutic regimen, compliance or prior HIV therapy.