The effects of short-term, progressive exercise training on disease activity in smouldering multiple myeloma and monoclonal gammopathy of undetermined significance: a single-arm pilot study

BACKGROUND

High levels of physical activity are associated with reduced risk of the blood cancer multiple myeloma (MM). MM is preceded by the asymptomatic stages of monoclonal gammopathy of undetermined significance (MGUS) and smouldering multiple myeloma (SMM) which are clinically managed by watchful waiting. A case study (N = 1) of a former elite athlete aged 44 years previously indicated that a multi-modal exercise programme reversed SMM disease activity. To build from this prior case study, the present pilot study firstly examined if short-term exercise training was feasible and safe for a group of MGUS and SMM patients, and secondly investigated the effects on MGUS/SMM disease activity.

METHODS

In this single-arm pilot study, N = 20 participants diagnosed with MGUS or SMM were allocated to receive a 16-week progressive exercise programme. Primary outcome measures were feasibility and safety. Secondary outcomes were pre- to post-exercise training changes to blood biomarkers of MGUS and SMM disease activity- monoclonal (M)-protein and free light chains (FLC)- plus cardiorespiratory and functional fitness, body composition, quality of life, blood immunophenotype, and blood biomarkers of inflammation.

RESULTS

Fifteen (3 MGUS and 12 SMM) participants completed the exercise programme. Adherence was 91 ± 11%. Compliance was 75 ± 25% overall, with a notable decline in compliance at intensities > 70% V̇O2PEAK. There were no serious adverse events. There were no changes to M-protein (0.0 ± 1.0 g/L, P =.903), involved FLC (+ 1.8 ± 16.8 mg/L, P =.839), or FLC difference (+ 0.2 ± 15.6 mg/L, P =.946) from pre- to post-exercise training. There were pre- to post-exercise training improvements to diastolic blood pressure (- 3 ± 5 mmHg, P =.033), sit-to-stand test performance (+ 5 ± 5 repetitions, P =.002), and energy/fatigue scores (+ 10 ± 15%, P =.026). Other secondary outcomes were unchanged.

CONCLUSIONS

A 16-week progressive exercise programme was feasible and safe, but did not reverse MGUS/SMM disease activity, contrasting a prior case study showing that five years of exercise training reversed SMM in a 44-year-old former athlete. Longer exercise interventions should be explored in a group of MGUS/SMM patients, with measurements of disease biomarkers, along with rates of disease progression (i.e., MGUS/SMM to MM).

REGISTRATION

https://www.isrctn.com/ISRCTN65527208 (14/05/2018).

Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report

This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.

Abstract HUP9: Racial Disparities In Acute Ischemic Stroke At A Large Metropolitan Stroke Center

Background: Race and ethnicity can have a major impact on the quality of care patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of race and ethnicity on quality benchmarks of AIS therapy and clinical outcomes at a comprehensive stroke center (CSC).

Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores, time to thrombolysis, discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent racial-ethnic groups including Non-Hispanic White (NHW), Hispanic, Black, Asian, Other and Unknown.

Results: 3,735 AIS patients were identified. NHW represented 53.3% (n=1992),Black 21.3% (n=797), Hispanic 10.4% (n=390), Asian 7.2% (n=267), Other 4.6% (n=170) and Unknown 3.2% (n=119). There were no significant differences in door to needle (P=0.93), door to puncture time (P=0.98), intravenous thrombolysis (P=0.32) and mechanical thrombectomy utilization (P=0.19) by race-ethnicity. In univariable analysis, there was a higher rate of 30-day mortality in Unknown 23.5% vs NHW 7.3% (P< 0.0001). A significantly (P>0.05) higher rate of 30-day readmission was noted in NHW 20.3% vs Black 15.7%, Hispanics 15.6%, Others 11.8% and Unknown 8.4%. Black 67.6%, Hispanic 64.9% and Unknown 80.5% had a significantly (P<0.05) higher rate of post stroke disability (mrs>2) vs NHW 60.3%. A significant difference (P<0.05) in LOS with Black patients staying 8.4, Hispanic 10.8, Asians 11.9 and Unknown 11.2 days vs NHW 7.7.Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression continued to show differences in post stroke disability for Black (OR=1.40, P=0.003), Hispanic (OR=1.49, P=0.008) and Unknown (OR=2.03, P=0.016) vs NHW. Median LOS was 0.85 and 0.77 days longer for Asian and Hispanic (P=0.006, P=0.014) respectively vs NHW.

Conclusions: Our analysis reveals persistent disparities in stroke outcomes, with Black and Hispanic patients suffering greater disability post stroke. Further investigation is needed to uncover how race-ethnicity mediates stroke care and outcomes.

Abstract HUP2: Assessment Of Acute Ischemic Stroke Disparities By Primary Language In A High Patient Volume Comprehensive Stroke Center Serving A Diverse Metropolitan City

Background: Language barriers can have a major impact on the quality of care that patients with acute ischemic stroke (AIS) receive. We sought to assess the impact of patient language on quality benchmarks of AIS therapy and clinical outcomes at a high-volume comprehensive stroke center (CSC).

Methods: A retrospective analysis of AIS patients presenting to a CSC between 2015 to 2020 was performed. Data included demographics, NIH Stroke Scale scores (NIHSS), discharge diabetic and hypertensive medications, length of stay (LOS), discharge functional status, 30-day readmission, and 30-day mortality. Quality benchmarks and outcomes were analyzed by the five most prevalent primary languages including English, Spanish, Russian, Farsi, Korean and Other. All non-English speaking patients received medical interpretation via digital or in-person translation.

Results: 3,812 AIS patients were identified. English language represented 80.2% (n=3091), Spanish 7.6% (n=238), Russian 4.1% (n=184), Farsi 3.0% (n=129), Korean 1.5% (n=47) and Other 3.6% (n=122).There were no significant differences in the rate of intravenous thrombolysis (P=0.52), door-to-needle time (P=0.91), door-to-puncture time (P=0.85), LOS (P=0.089) and 30 day readmission (P=0.74) among groups. In univariable analysis, Spanish 74.7%, Korean 84.4%, Russian 73.4%, Farsi 78.2% and Other 70.0% had significantly (P< 0.05) higher rates of post stroke disability (mRS> 2) compared to the English group 60.7%. A higher rate of 30-day mortality was noted in the Korean 17.8% compared to the English group 7.3%. The Spanish group had a higher rate of mechanical thrombectomy than the English group (11.8 vs 6.5%, P=0.009). Adjusting for age, sex, NIHSS and comorbidities, multivariable logistic regression models for post stroke disability (mRS>2) continued to show significant differences with Spanish (OR=1.66, P=0.008) and Farsi (OR=1.89, P=0.017) vs English.

Conclusions: Our analysis reveals persistent disparities in AIS outcomes by primary language, with patients with limited English proficiency suffering worse disability after AIS. The effect of communication barriers on outcomes of stroke care in the inpatient setting requires further evaluation to close this gap.

Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high risk, early breast cancer

BACKGROUND

The randomized, double-blind OlympiA trial compared 1 year of the oral poly(adenosine diphosphate-ribose) polymerase inhibitor, olaparib, to matching placebo as adjuvant therapy for patients with pathogenic or likely pathogenic variants in germline BRCA1 or BRCA2 (gBRCA1/2pv) and high-risk, human epidermal growth factor receptor 2-negative, early breast cancer (EBC). The first pre-specified interim analysis (IA) previously demonstrated statistically significant improvement in invasive disease-free survival (IDFS) and distant disease-free survival (DDFS). The olaparib group had fewer deaths than the placebo group, but the difference did not reach statistical significance for overall survival (OS). We now report the pre-specified second IA of OS with updates of IDFS, DDFS, and safety.

PATIENTS AND METHODS

One thousand eight hundred and thirty-six patients were randomly assigned to olaparib or placebo following (neo)adjuvant chemotherapy, surgery, and radiation therapy if indicated. Endocrine therapy was given concurrently with study medication for hormone receptor-positive cancers. Statistical significance for OS at this IA required P < 0.015.

RESULTS

With a median follow-up of 3.5 years, the second IA of OS demonstrated significant improvement in the olaparib group relative to the placebo group [hazard ratio 0.68; 98.5% confidence interval (CI) 0.47-0.97; P = 0.009]. Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group (Δ 3.4%, 95% CI -0.1% to 6.8%). Four-year IDFS for the olaparib group versus placebo group was 82.7% versus 75.4% (Δ 7.3%, 95% CI 3.0% to 11.5%) and 4-year DDFS was 86.5% versus 79.1% (Δ 7.4%, 95% CI 3.6% to 11.3%), respectively. Subset analyses for OS, IDFS, and DDFS demonstrated benefit across major subgroups. No new safety signals were identified including no new cases of acute myeloid leukemia or myelodysplastic syndrome.

CONCLUSION

With 3.5 years of median follow-up, OlympiA demonstrates statistically significant improvement in OS with adjuvant olaparib compared with placebo for gBRCA1/2pv-associated EBC and maintained improvements in the previously reported, statistically significant endpoints of IDFS and DDFS with no new safety signals.

Extensive spontaneous cervical epidural hematoma due to oral anticoagulant (dabigatran) successfully treated with reversal agent idarucizumab alone

Background:

Dabigatran is an anticoagulant (novel oral anticoagulant) that is a direct thrombin inhibitor and only recently has a reversal agent, idarucizumab, been made available (2015).

Case Description:

An 86-year-old male taking dabigatran for atrial fibrillation, acutely presented with the spontaneous onset of neck pain and quadriparesis. When the MRI demonstrated a C2-T2 spinal epidural hematoma, the patient was given the reversal agent idarucizumab. Due to his attendant major comorbidities, he was managed nonoperatively. Over the next 7 days, the patient’s neurological deficits resolved, and within 2 weeks, he had regained normal neurological function.

Conclusion:

In this case, a C2-T2 epidural cervical hematoma attributed to dabigatran that was responsible for an acute, spontaneous quadriparesis was successfully treated with the reversal agent idarucizumab without surgical intervention being warranted.

POS0888 NON-SURGICAL LOCAL TREATMENTS FOR DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers(DUs) in systemic sclerosis(SSc) represent a major clinical challenge. There are no recommendations for the local management of SSc-DUs. Systemic therapy is considered the standard of care. However, there is a strong rationale for local approaches to DU by avoiding side effects from systemic therapies. The World Scleroderma Foundation DU Working Group intends to develop evidence-based recommendations for DU management including local, non-surgical treatment(ln-sT).

Objectives

To summarise the literature on the safety and efficacy of ln-sT for SSc-DUs.

Methods

A systematic literature review(SLR) of papers describing the use of ln-sT for DU in SSc was performed up to May 2021 according to the PICO framework. References were independently screened by two reviewers who independently assessed the full text of eligible articles and extracted data.

Results

Among 790 retrieved references, 12 were included. Median(range) number of patients per study was 9(7–84), mean age ranging from 37 to 62.5 years. In 5(41%) studies a control group was included. Background systemic therapies are summarized in Table 1. The most studied treatment was botulin toxin A(BTA). It was used as hand injection in 3 studies (median dose ranging from 90 to 150 U) and as 50 U single finger injection in 1 study. Healing rate after a median time of 8-49 weeks ranged from 71% to 100%. In 2 studies a reduction in VAS pain was observed from 20% to 100%. Transient muscle weakness was the most common side effect in 10% of patients. Amniotic(Am) and hydrocolloid membranes(HyM) were used in 1 study each. They were associated with a good healing rate, statistically significant for the HyM. Tadalafil 2% cream was studied in 1 study and was associated with a reduction in the median DU number from 1.6 to 1 per patient after a median time of 4 weeks and a reduction by 1.4 point in the 10-mm VAS scale. Vitamin E gel was shown to be associated with a statistically significant reduction in the healing time compared to SoC alone in 1 RCT(13.2 ± 2.7 versus 20.9 ± 3.6 weeks, P=<0.001). Low-level light therapy, hydrodissection and corticosteroid injection and extracorporeal shock wave(ESW) were evaluated in 1 study each. They were all associated with positive outcomes which was statistically significant only for the ESW. The only negative trial examined dimethyl sulfoxide and was associated with local toxicity.

Table 1.

Characteristics of the studies.

TreatmentType of studyPatientsBaseline DUBackground therapy (%) ETA CCB APA PG ARB ACE-I PDE-5i ISFollow-up (weeks)Healing rate(%)*Pain Reduction (VAS/10)ComparatorHydrodissection and corticosteroid injectionP1202334.4Rheumatoid ArthritisTadalafil 2% Vitamin E gelRRCT15131.6(1)3.5±2.30462700130704 241(1)Reduced time to heal**1.4SoCAmHyMRP67310001002800002817033143810090**SoCBTAMedian 90 U per handHigh-concentration hand100 U non-dominant handSingle finger 50 URRPP772010314571140718558551008514201001414718 4981277717510020%100%Untreated CHLow-level light therapyP8102537025378100ESWP9493355661144441**1.31Dimethyl sulfoxideDBRCT84No change, skin toxicity with 70% formulation

*Unless otherwise stated. **Statistically significant. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. APA= anti-platelet agents. CCB= calcium channel blockers. CH= contralateral hand. DBRCT= double blind randomized-controlled trial. ETA = endothelin antagonist. IS= immunosuppression. PG= prostaglandins. PDE-5i= Phosphodiesterase type-5 inhibitors. P = prospective. R = retrospective. SoC= standard of care (as per local protocol).

Conclusion

Our SLR supports interest to develop ln-sTs for SSc-DUs. The number of studies is limited and mainly case reports and small single studies are present. Treatments were well tolerated and there was evidence of efficacy for BTA, vitamin E, ESW and HyM in refractory DUs. The evidence is not robust and confounding factors (vasodilators background therapies) could impact on the findings. Future research is indicated to conduct larger, well-designed studies.

Disclosure of Interests

Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Michael Hughes Speakers bureau: Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work., Jan Schoones: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Nancy Maltez: None declared, Laura Ross: None declared, Murray Baron: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0898 SURGICAL MANAGEMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Management of digital ulcers (DUs) in systemic sclerosis (SSc) is a major clinical challenge. To date, systemic therapy is generally considered as the ‘standard of care’ for significant SSc-DUs. However, there is a strong rationale to develop local approaches to DUs, to avoid side effects from systemic therapies. World Scleroderma Foundation DU Working Group intends to develop practical, evidence-based recommendations for DU management including local, Surgical Treatment (L-ST).

Objectives

To summarize the literature on the safety and efficacy of L-ST for SSc-DUs.

Methods

A systematic literature review (SLR) was conducted up to May 2021. According to the PICO framework, eligibility criteria were defined and original research articles about surgical treatment of SSc DUs in adult patients were included. References were independently screened by 2 reviewers who assessed the full text of eligible articles and extracted data.

Results

Thirteen eligible articles out of 790 total publications were identified (Table 1). Due to the paucity of randomized controlled trials of surgical treatments for SSc-DU, we included retrospective studies and case series with at least 4 patients. Autologous fat (adipose tissue AT) grafting was the surgical modality mostly identified (7 studies of which 1 RCT and 6 prospective open label single arm). The healing rate (HR) with autologous fat grafting (4 studies) ranged from 66-100 %. In the RCT, two age and sex matched groups were included, adipose tissue (AT)group (n=25 pts) and sham procedure (SP) group (n=13), DU healing was reported in 23/25 in AT group versus 1/13 in the SP group in 8 wks, (p<0.0001), 12 pts in the SP group, received rescue AT injection, all of them healed after 8 wks. Three studies reported autologous adipose-derived stromal vascular fraction(SVF) grafting and the HR ranged from 32-60%, followed up to 12 months. Transient edema and paresthesia were reported in 2 studies, and amputation in 2 ulcers in 1 study, and no complications were reported in other studies. Surgical sympathectomy was reported in 3 studies, with a median healing rate of 81%. Bone marrow derived cell transplantation in a single study showed 87% healing rate over (4-24 wks). Two surgical studies (of direct microsurgical revascularization N=4, and microsurgical arteriolysis, N=6), showed 100% healing of ulcers, no complications reported.

Table 1.

Characteristics of the extracted studies.

StudydesignPatients (n)Baseline DU (n)Background therapy (%)Follow-upOutcomeHealed ulcers(%) Adipose tissue graftAutologous fat graftp9.15PG, CCB—100ETA 26PDE-5i 138-12 wks66Adipose tissue graftingRCT25 case13- Ctr25-case13- CtrPG- 100CCB 1008 wks92-case7-CtrAdipose tissue implantp1515no therapy7 wks100Adipose tissue graftp129PG,CCB-100ETA6 month88adipose derived SVFp1215PDE-5i, ccb, PG allowed22m6Adipose derived SVFp1215CCB 50ETA166 m63 Adipose derived SVFp1819CCB 50PG 27ETA 5IS 7124 wks32SympathectomySympathectomyR611CCB-10020 m81SympathectomyR1335PGCCBAPA35Sympathectomy, vascular bypass (+vein graftR1726Ccb 35APA 47PDE-i5 589 m100Bone marrow derived cells transplantation)p88PG-6236 m87Direct microsurgical revascularizationR44m100Limited microsurgical arteriolysisR61712 m100

SVF =stromal vascular fraction P = prospective. R = retrospective. RCT= double blind randomized-controlled trial. ETA = endothelin antagonist. CCB= calcium channel blockers. APA= anti-platelet agents. PG= prostaglandins. ARB= angiotensin receptor antagonist. ACEi= ACE inhibitors. PDE-5i= PDE-5 inhibitors. IS= immunosuppression. M=median. SoC= standard of care. HR= healing rate

Conclusion

Our SLR has identified several surgical modalities for SSc-DUs. L-STseemed generally effective and safe for DU healing, thus Significant methodological issues emerged including small numbers of pts, lack of comparator, failure to report confounders such as background therapies and variable follow up. Future research is warranted to rigorously investigate surgical interventions for Dus.

Disclosure of Interests

Yossra A. Suliman: None declared, Corrado Campochiaro: None declared, Michael Hughes Speakers bureau: speaking fees from Actelion pharmaceuticals, Eli Lilly, and Pfizer, outside of the submitted work, Jan Schoones: None declared, Dilia Giuggioli: None declared, Nancy Maltez: None declared, Pia Moinzadeh Speakers bureau:: speaking fees from Actelion pharmaceuticals and Boehringer Ingelheim, Laura Ross: None declared, Lorinda Chung: None declared, Yannick Allanore: None declared, Murray Baron: None declared, Christopher P Denton: None declared, Oliver Distler Shareholder of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Speakers bureau: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Consultant of: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Grant/research support from: Consultancy relationship with and/or has received research funding from and/or has served as a speaker for the following companies in the area of potential treatments for systemic sclerosis and its complications in the last three calendar years: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Speakers bureau: Janssen and Eicos Sciences, Inc., Paid instructor for: Janssen and Eicos Sciences, Inc., Consultant of: Janssen and Eicos Sciences, Inc., Thomas Krieg: None declared, Masataka KUWANA Speakers bureau: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Paid instructor for: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Consultant of: Speakers fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and Consultant fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida, outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

POS0900 SYSTEMIC PHARMACOLOGICAL TREATMENT OF DIGITAL ULCERS IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITERATURE REVIEW

Background

Digital ulcers (DU) are common in systemic sclerosis (SSc) and associated with reduced survival, high morbidity and poor quality of life. Recommendations have previously been proposed for DU management yet there remains significant unmet patient need. Therefore the World Scleroderma Foundation DU Working Group intends to develop practical evidence based recommendations for DU management.

Objectives

To summarise data on efficacy and safety of systemic treatments for SSc DU.

Methods

A systematic literature review to May 2021 was performed. PubMed, MEDLINE, Embase, Web of Science, Cochrane Library, Emcare (OVID) and Academic Search Premier databases were searched for original studies on adult patients with SSc DU treated with systemic pharmacological treatment. Based on the PICO framework, eligibility criteria were defined and references were independently screened by two reviewers. Reviewers independently assessed the full text of eligible articles. Owing to interstudy heterogeneity narrative summaries were used to present data.

Results

The search strategy identified 1271 references of which 45 eligible articles were included. Seventeen studies were randomised placebo controlled trials (RCT) pertaining to PDE5 antagonists (PDE5i) (n=3), endothelin receptor antagonists (ERA) (n=3), prostanoids (n=7), antiplatelet agents (n=1) and other (n=3) (Table 1). No head to head RCT was retrieved. All other studies were observational studies (OBS). Studies were highly heterogeneous with application of differing definition of DU, variable study eligibility criteria, clinical endpoints and follow up periods. This limited the calculation of effect size and comparison across studies.

Table 1.

Characteristics of placebo controlled randomised controlled trials

Author YearInterventionnFollow upOutcomeFavours interventionHachulla 2016Sildenafil8312 weeksTime to DU healing-Andrigueti 2017Sildenafil4112 weeksDU healing+Shenoy 2010Tadalafil246 weeksNew DU+Khanna 2016Macitentan55416 weeksNew DU-Matucci-Cerinic 2011Bosentan18832 weeksNew DU Time to healing of DU+-Korn 2004Bosentan12212 weeksNew DU+Kawald 2008IV iloprost5012 monthsDU healing-Wigley 1992IV iloprost3510 weeksDU healing+Wigley 1994IV iloprost739 weeks50% reduction in DU score-Seibold 2017Treprostinil14820 weeksNet DU burden-Vayssairat 1999Beraprost10725 weeks% patients with new DU-Denton 2017Selexipag7412 weeksNumber of new DU DU healing-Lau 1993Cicaprost334 weeksNumber of DU-Abou-Raya 2008Atorvastatin844 monthsNumber of DU+Au 2010Cyclophosphamide15812 monthsNumber of patients with DU-Beckett 1984Dipyridamole / aspirin412 yearsChange in general SSc-Nagaraja 2019Riociguat1732 weeksNet DU burden-

+ significantly superior to comparator

- non significantly different from comparator

DU: digital ulcers IV: intravenous SSc: systemic sclerosis

Several RCT found improved DU healing with treatment: two with PDE5i, one with iloprost and one showed improved DU healing and prevention with atorvastatin. Two RCT demonstrated effective prevention of new DU with bosentan. OBS studies with a total of 621 patients showed variable improvements in the healing of DU with CCB, PDE5i, ERA, statins, N-acetylcysteine, prostanoids and ketanserin and prevention of new DU with ERA.

Regarding safety, all treatments were generally tolerated with few serious adverse events. Treatment was ceased in 6.25-17.5% of patients in RCT due to treatment related side effects.

Conclusion

Despite several studies assessing the efficacy and safety of systemic pharmacological treatment of SSc DU, it is not possible to draw solid conclusions due to study heterogeneity. Small RCT have shown treatment benefit with PDE5i, iloprost and atorvastatin. Large studies demonstrated effective prevention of new DU with bosentan. Our results highlight the urgent need for improved clinical trial design to generate more robust evidence and novel therapies to guide the management SSc DU.

Acknowledgements

This work was supported by the World Scleroderma Foundation.

Disclosure of Interests

Nancy Maltez: None declared, Laura Ross: None declared, Michael Hughes Speakers bureau: Actelion Pharmaceuticals, Eli Lilly and Pfizer outside of the submitted work., Jan Schoones: None declared, Murray Baron: None declared, Lorinda Chung Consultant of: Eicos, Corrado Campochiaro: None declared, Yossra A. Suliman: None declared, Dilia Giuggioli: None declared, Pia Moinzadeh Speakers bureau: Actelion Pharmaceuticals, Boehringer Ingelheim, Yannick Allanore: None declared, Christopher P Denton: None declared, Oliver Distler Speakers bureau: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Grant/research support from: Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143), Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Medscape, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur., Tracy Frech: None declared, Daniel Furst: None declared, Dinesh Khanna Consultant of: Eicos Sciences Inc, Janssen, Thomas Krieg: None declared, Masataka Kuwana Speakers bureau: Speaker fees from AbbVie, Asahi Kasei Pharma, Astellas, Boehringer Ingelheim, Chugai, Eisai, GlaxoSmithKline, Janssen, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, and consultancy fees from AstraZeneca, Boehringer Ingelheim, Corbus, Kissei, Mochida outside of the submitted work., Marco Matucci-Cerinic: None declared, Janet Pope: None declared, Alessia Alunno: None declared

Augmented Reality in Spinal Surgery: Highlights From Augmented Reality Lectures at the Emerging Technologies Annual Meetings

Introduction

Augmented reality (AR) is an advanced technology and emerging field that has been adopted into spine surgery to enhance care and outcomes. AR superimposes a three-dimensional computer-generated image over the normal anatomy of interest in order to facilitate visualization of deep structures without the ability to directly see them.

Objective

To summarize the latest literature and highlight AR from the annual “Spinal Navigation, Emerging Technologies and Systems Integration” meeting lectures presented by the Seattle Science Foundation (SSF) on the development and use of augmented reality in spinal surgery. 

Methods

 We performed a comprehensive literature review from 2016 to 2020 on PubMed to correlate with lectures given at the annual “Emerging Technologies” conferences. After the exclusion of papers that concerned non-spine surgery specialties, a total of 54 papers concerning AR in spinal applications were found. The articles were then categorized by content and focus.

Results

The 54 papers were divided into six major focused topics: training, proof of concept, feasibility and usability, clinical evaluation, state of technology, and nonsurgical applications. The greatest number of papers were published during 2020. Each paper discussed varied topics such as patient rehabilitation, proof of concept, workflow, applications in neurological and orthopedic spine surgery, and outcomes data.

Conclusions

The recent literature and SSF lectures on AR provide a solid base and demonstrate the emergence of an advanced technology that offers a platform for an advantageous technique that is superior, in that it allows the operating surgeon to focus directly on the patient rather than a guidance screen.

Epidural hematoma in patients with ankylosing spondylitis requiring surgical stabilization: a single-institution retrospective review with literature analysis

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic inflammatory disease affecting the sacroiliac joints and axial spine that is closely linked with human leukocyte antigen-B27. There appears to be an increased frequency of associated epidural hematomas in spine fractures in patients with AS. The objective was to review the incidence within the literature and a single-institution experience of the occurrence of epidural hematoma in the context of patients with AS requiring spine surgery.

METHODS

Deep 6 AI software was used to search the entire database of patients at a single level I trauma center (since the advent of the institution's modern electronic health record system) to look at all patients with AS who underwent spinal surgery and who had a diagnosis of epidural hematoma. Additionally, a systemic literature review was performed of all papers evaluating the incidence of epidural hematoma in patients with spine fractures.

RESULTS

A single-institution, retrospective review of records from 2009 to 2020 yielded a total of 164 patients with AS who underwent spine surgery. Of those patients, 17 (10.4%) had epidural hematomas on imaging, with the majority requiring surgical decompression. These spine fractures occurred close to the cervicothoracic or thoracolumbar junction. The patients ranged in age from 51 to 88 years, and there were 14 males and 3 females in the cohort. Eight patients were administered an antiplatelet and/or anticoagulant agent, and the rest were not. All patients required surgical stabilization, with 64.7% of patients also requiring decompressive laminectomies for evacuation of the hematoma and spinal cord decompression. Only 1 death was reported in the series. There was a tendency toward neurological improvement after surgical intervention.

CONCLUSIONS

AS has been a well-described pathologic process that leads to an increased risk of three-column injury in spine fracture, with an increased incidence of symptomatic epidural hematoma compared with patients without AS. Early recognition of this entity is important to ensure that appropriate surgical management includes addressing compression of the neural elements in addition to surgical stabilization.

Home-based virtual reality for chronic pain: protocol for an NIH-supported randomised-controlled trial

INTRODUCTION

Chronic pain is highly prevalent and associated with a large burden of illness; there is a pressing need for safe, home-based, non-pharmacological, interventions. Virtual reality (VR) is a digital therapeutic known to be effective for acute pain, but its role in chronic pain is not yet fully elucidated. Here we present a protocol for the National Institute of Health (NIH) Back Pain Consortium (BACPAC) VR trial that evaluates the effectiveness of three forms of VR for patients with chronic lower back pain (cLBP), a highly prevalent form of chronic pain.

METHODS AND ANALYSIS

The NIH BACPAC VR trial will randomise 360 patients with cLBP into one of three arms, each administered through a head-mounted display: 1) skills-based VR, a program incorporating principles of cognitive behavioural therapy, mindful meditation and physiological biofeedback therapy using embedded biometric sensors; 2) distraction-based VR, a program using 360-degree immersive videos designed to distract users from pain; and 3) sham VR, a non-immersive program using two-dimensional videos within a VR headset. Research participants will be monitored for 12 weeks using a combination of patient-reported outcomes administered via REDCap (Research Electronic Data Capture), wearable sensor data collected via Fitbit Charge 4 and electronic health record data. The primary outcome will be the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference scale. Secondary outcomes will include PROMIS Anxiety, PROMIS Sleep Disturbance, opioid prescription data and Pain Catastrophizing Scale Short Form. A subgroup analysis will explore patient level predictors for VR efficacy.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Institutional Review Board of Cedars-Sinai Health System in April 2020. The results will be disseminated in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04409353.

Video-assisted thoracoscopic image-guided spine surgery: evolution of 19 years of experience, from endoscopy to fully integrated 3D navigation

OBJECTIVE

The purpose of this study was to describe the evolution of thoracoscopic spine surgery from basic endoscopic procedures using fluoroscopy and anatomical localization through developmental iterations to the current technology use in which endoscopy and image-guided surgery are merged with intraoperative CT scanning.

METHODS

The authors provided detailed explanations of their thoracoscopic spine surgery techniques, beginning with their early-generation endoscopy with fluoroscopic localization, which was followed with point surface matching techniques and early image guidance. The authors supplanted this with the modern era of image guidance, thoracoscopic spine surgery, and seamless integration that has reached its current level of refinement.

RESULTS

A retrospective review of single-institution thoracoscopic procedures performed by the senior author over the course of 19 years yielded a total of 160 patients, including 73 women and 87 men. The mean patient age was 55 years, and the range included patients 16-94 years of age. There were no patients with worsened neurological function. One hundred sixteen patients underwent surgery for thoracic disc herniation, 18 for underlying neoplasms with spinal cord compression, 14 for osteomyelitis and discitis, 12 for thoracic deformity with neurological changes, and 8 for traumatic etiologies.

CONCLUSIONS

More than 19 years of experience has revealed the benefits of integrating thoracoscopic spine surgery with intraoperative CT scanning and image-guided surgery, including direct decompression without manipulation of neural elements, superior 3D spatial orientation, and localization of complex spinal anatomy. With the exponential growth of machine learning, robotics, artificial intelligence, and advances in imaging techniques and endoscopic imaging, there may be further refinements of this technique on the horizon.

Validation of alternative behavioral observation methods in young broiler chickens

Continuous sampling provides the most complete data set for behavioral research; however, it often requires a prohibitive investment of time and labor. The objectives of this study were to validate behavioral observation methods of young broiler chickens using 1) 7 scan sampling intervals (0.5, 1, 3, 5, 10, 15, and 30 min) and 2) an automated tracking software program (EthoVision XT 14) compared to continuous behavioral observation, considered the gold standard for behavior observation. Ten 19-day-old Ross 708 broiler cockerels were included in this study. All behavior was video recorded over an 8-h period, and data were collected using a continuous sampling methodology. The same video files were utilized for analysis for scan sampling and automated tracking software analysis. For both analyses, the following criteria were used to identify which method accurately reflected the true duration and frequency for each behavior, as determined by continuous observation: R² ≥ 0.9, slope was not different from 1 (P > 0.05), and intercept was not different from 0 (P > 0.05). Active, eating, drinking, and maintenance behaviors were accurately estimated with 0.5-min scan sample intervals. Active, inactive, eating, and maintenance behaviors were accurately estimated with 1-min scan sample intervals. Inactive behavior was accurately estimated with 5-min scan sample intervals. The remainder of sampling intervals examined did not provide accurate estimates, and no scan sampling interval accurately estimated the number of behavior bouts. The automated tracking software was able to accurately detect true duration of inactive behavior but was unable to accurately detect activity. The results of this study suggest that high-frequency behaviors can be accurately observed with instantaneous scan sampling up to 1-min intervals. Automated tracking software can accurately identify inactivity in young broiler chickens, but further behavior identification will require refinement.

Determination of Chlormequat and Mepiquat in Foods by Liquid Chromatography/Mass Spectrometry or Liquid Chromatography/Tandem Mass Spectrometry: Interlaboratory Study

Interlaboratory validation studies have been performed on 2 methods for the determination of chlormequat (CLQ) and mepiquat (MPQ). Both methods used identical extraction procedures and stable isotope internal standardization but differed in the use of liquid chromatography/mass spectrometry (LC/MS) or LC/tandem mass spectrometry (LC/MS/MS) for the determination, the amount of internal standard used, and the expected limit of detection. After addition of deuterated internal standards, CLQ and MPQ were extracted with methanol–water and determined by LC/MS or LC/MS/MS with positive electrospray ionization. Eight European laboratories participated in the LC/MS method study, analyzing mushroom, pear, wheat flour, and fruit puree with residues of CLQ in the range 0.040–1.19 mg/kg and of MPQ in the range 0.041–0.39 mg/kg. For CLQ, the Horwitz ratio (HoRat) values for individual test materials/levels were in the range 0.85–1.13 with amean of 1.00, showing good method performance. For MPQ, the Ho values for mushroom, pear (both levels), and wheat flour were in the range 0.83–0.94, again indicating good method performance. For the determination of MPQ in infant food (fruit puree) at 0.041 mg/kg, the Ho was 1.7 when a value of 0 reported by one participant was excluded. In the LC/MS/MS study, in which 11 laboratories participated, a separate sample set was analyzed with residues of CLQ in the range 0.007–1.03 mg/kg and of MPQ in the range 0.008–0.72 mg/kg. Ho values for CLQ were in the range 0.27–1.36 and for MPQ in the range 0.51–2.10, all corresponding to acceptable method performance.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Effect of clinical signs, endocrinopathies, timing of surgery, hyperlipidemia, and hyperbilirubinemia on outcome in dogs with gallbladder mucocele

Gallbladder mucocele (GBM) is a common extra-hepatic biliary syndrome in dogs with death rates ranging from 7 to 45%. Therefore, the aim of this study was to identify the association of survival with variables that could be utilized to improve clinical decisions. A total of 1194 dogs with a gross and histopathological diagnosis of GBM were included from 41 veterinary referral hospitals in this retrospective study. Dogs with GBM that demonstrated abnormal clinical signs had significantly greater odds of death than subclinical dogs in a univariable analysis (OR, 4.2; 95% CI, 2.14-8.23; P<0.001). The multivariable model indicated that categorical variables including owner recognition of jaundice (OR, 2.12; 95% CI, 1.19-3.77; P=0.011), concurrent hyperadrenocorticism (OR 1.94; 95% CI, 1.08-3.47; P=0.026), and Pomeranian breed (OR, 2.46; 95% CI 1.10-5.50; P=0.029) were associated with increased odds of death, and vomiting was associated with decreased odds of death (OR, 0.48; 95% CI, 0.30-0.72; P=0.001). Continuous variables in the multivariable model, total serum/plasma bilirubin concentration (OR, 1.03; 95% CI, 1.01-1.04; P<0.001) and age (OR, 1.17; 95% CI, 1.08-1.26; P<0.001), were associated with increased odds of death. The clinical utility of total serum/plasma bilirubin concentration as a biomarker to predict death was poor with a sensitivity of 0.61 (95% CI, 0.54-0.69) and a specificity of 0.63 (95% CI, 0.59-0.66). This study identified several prognostic variables in dogs with GBM including total serum/plasma bilirubin concentration, age, clinical signs, concurrent hyperadrenocorticism, and the Pomeranian breed. The presence of hypothyroidism or diabetes mellitus did not impact outcome in this study.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Do stroke patients screened as lower-nutritional-risk still receive dietitian assessment if indicated? A retrospective evaluation of two dietetic models of care for adult stroke patients

BACKGROUND

Dietetic models of care at Logan Hospital changed from all patients with a confirmed stroke receiving dietitian assessment (Old pathway) to only those patients screened as high-nutritional-risk (Modified pathway). However, it was unknown whether all low-nutritional-risk patients who were indicated for dietitian assessment for nutrition support actually received assessment. This pre-post retrospective study evaluated whether the Old pathway and the Modified pathway were equally effective in identifying low-nutritional-risk stroke patients who were indicated for dietitian assessment and compared the time spent providing Dietetic care.

METHODS

For both pathways, medical charts were reviewed for low-nutritional-risk patients admitted between December 2012 and November 2017 with a confirmed stroke, who were given a standard food and fluid diet code and scored MST < 2 (Malnutrition Screening Tool) on admission. Data collected included demographics, anthropometrics, malnutrition assessment, dietetic intervention and time spent caring for patients. Malnutrition-related clinical indicators were used to classify patients as either Dietitian Assessment for Nutrition Support Indicated or Not Indicated.

RESULTS

Low-nutritional-risk patients were similar on the Old (n = 180) and Modified (n = 206) pathways [mean (SD) 66 (13) years, 63% male, 4% malnutrition]. Those classified as Dietitian Assessment for Nutrition Support Indicated (n = 61 of 180) were older, had a longer length of stay (P < 0.05), and were all identified by the Dietitian on both pathways. Ten minutes less dietetic time per patient was required on the Modified pathway (P < 0.001).

CONCLUSIONS

The Modified Nutrition Stroke pathway performed more efficiently than the Old pathway and was equally effective at ensuring that stroke patients who were determined as being low-nutritional-risk received dietitian assessment during admission if indicated.

Fish consumption is associated with a decreased risk of death among adults with diabetes: 18-year follow-up of a national cohort

BACKGROUND

There is a paucity of studies examining the beneficial effects of fish consumption on cardiovascular diseases (CVDs) among adults with diabetes, who experience a substantially high risk of CVDs.

METHODS AND RESULTS

We analyzed the data of 1136 adults with diabetes mellitus aged 18 years and older who participated in the National Health and Nutrition Examination Survey, 1988-1994, and were followed up through December 31, 2010. We used Cox regression to estimate the adjusted hazard ratios (HRs) for the relative risk across the levels of fish consumption. A total of 698 deaths were recorded at the end of 11,465 person-years follow-up with a mortality rate of 60.88 per 1000 person-years. CVDs were listed as a contributing cause for 326 deaths, thus accounting for 46.4% of total deaths. Stroke-specific mortality rate among patients who ate fish less than once a week was more than twice as high as that among patients who ate fish more than twice a week, 6.23 vs. 2.36 per 1000 person-years, respectively. The corresponding CVD-specific rate was 34.38 vs. 22.99 per 1000 person-years, respectively. The adjusted HRs of death due to stroke were 1.00 (reference), 0.55 (95% confidence interval = 0.28-1.07), and 0.30 (0.11-0.80) among patients who ate fish <1, 1-2, and 2 + times a week, and the corresponding HRs of death due to CVDs were 1.00 (reference), 0.78 (0.60-1.02), and 0.69 (0.50-0.96), respectively.

CONCLUSIONS

A high consumption of fish was associated with a low risk of death due to CVDs, especially stroke, among adults with diabetes.

Improving the management and care of refugees in Australian hospitals: a descriptive study

Objectives The aim of the present study was to investigate healthcare provider perceptions of the impact of refugee patients at two public hospitals, one rural and one urban, in designated refugee resettlement areas. Healthcare professionals' views regarding improvements that could be made in this area were also sought. Methods Two-page anonymous questionnaires containing demographic, quantitative and open-ended questions were distributed to 150 healthcare providers at each research site. Results Response rates at the rural and urban sites were 50% and 49%, respectively. Refugees were seen at least monthly by 40% of respondents. Additional support was requested by 70% of respondents. Confidence was associated with being born overseas (P=0.029) and increased time working with refugees (r_s=0.418, P<0.001). Only 47% of respondents felt confident managing social and psychological needs of refugees. Midwives saw refugees more than nursing and allied healthcare staff combined, and this was significant at the rural hospital (P<0.001). Rural respondents reported that working with refugees enhanced their practice (P=0.025), although felt significantly less confident (P<0.001) than urban respondents. Themes that arose regarding barriers to care included language and cultural barriers, paucity of knowledge and issues accessing available services, including appropriate interpreters, Medicare eligibility and patient factors, including lack of patient trust in government systems. Desire for support was more pronounced in the rural setting (P=0.001). Conclusions Refugees were seen frequently in both settings and most respondents requested additional support, highlighting that caring for refugees in Australian hospitals is a significant challenge. Additional support and education should be targeted to those caring for refugees most frequently, particularly midwifery services, to reduce barriers to care. What is known about the topic? Refugees are a vulnerable group, often with complex health needs. These needs are often unmet because of issues including language and cultural barriers. What does this paper add? Refugees were seen frequently in the two public hospital settings involved in the present study and most often by midwifery services. Healthcare professionals require more support, more information about available services and better access to interpreter services. These issues were more pronounced in the rural setting where very limited research exists. What are the implications for practitioners? Implementing additional support and education regarding refugee health needs could increase knowledge and confidence when managing refugees, reducing barriers to care and improving quality of care.

Vanishing calcification associated with a spontaneous ventral spinal cerebrospinal fluid leak

Background

Some patients with spontaneous intracranial hypotension have a ventral spinal cerebrospinal fluid (CSF) leak and these CSF leaks may be associated with calcified disk herniations. Identifying these calcifications is helpful in directing treatment. We report here the unusual case of a patient with a ventral CSF leak in whom the associated calcification absorbed over a five-month period.

Case report

A 42-year-old woman developed orthostatic headaches and bilateral abducens nerve palsies. Magnetic resonance imaging of her brain showed typical findings of spontaneous intracranial hypotension. Magnetic resonance imaging of her spine showed an extensive cervicothoracic CSF leak. Computed tomographic myelography showed calcification at the Th1–2 disk space. Three epidural blood patches were performed, but her symptoms persisted. Digital subtraction myelography performed five months later showed an upper thoracic ventral CSF, but the calcification was no longer present. A dural tear, found at surgery at the Th1–2 level, was repaired and the patient made an uneventful recovery.

Discussion

The resorption of calcifications at the level of a ventral spinal CSF leak could explain the absence of any calcifications in at least some patients with such leaks and demonstrates the usefulness of reviewing previous imaging in patients with ventral CSF leaks if the exact site of the leak remains unknown.

Evolutionary problems in centrosome and centriole biology

Centrosomes have been an enigma to evolutionary biologists. Either they have been the subject of ill-founded speculation or they have been ignored. Here, we highlight evolutionary paradoxes and problems of centrosome and centriole evolution and seek to understand them in the light of recent advances in centrosome biology. Most evolutionary accounts of centrosome evolution have been based on the hypothesis that centrosomes are replicators, independent of the nucleus and cytoplasm. It is now clear, however, that this hypothesis is not tenable. Instead, centrosomes are formed de novo each cell division, with the presence of an old centrosome regulating, but not essential for, the assembly of a new one. Centrosomes are the microtubule-organizing centres of cells. They can potentially affect sensory and motor characters (as the basal body of cilia), as well as the movements of chromosomes during cell division. This latter role does not seem essential, however, except in male meiosis, and the reasons for this remain unclear. Although the centrosome is absent in some taxa, when it is present, its structure is extraordinarily conserved: in most taxa across eukaryotes, it does not appear to evolve at all. And yet a few insect groups display spectacular hypertrophy of the centrioles. We discuss how this might relate to the unusual reproductive system found in these insects. Finally, we discuss why the fate of centrosomes in sperm and early embryos might differ between different groups of animals.

Recombination, chromosome number and eusociality in the Hymenoptera

Extraordinarily high rates of recombination have been observed in some eusocial species. The most popular explanation is that increased recombination increases genetic variation among workers, which in turn increases colony performance, for example by increasing parasite resistance. However, support for the generality of higher recombination rates among eusocial organisms remains weak, due to low sample size and a lack of phylogenetic independence of observations. Recombination rate, although difficult to measure directly, is correlated with chromosome number. As predicted, several authors have noted that chromosome numbers are higher among the eusocial species of Hymenoptera (ants, bees and wasps). Here, we present a formal comparative analysis of karyotype data from 1567 species of Hymenoptera. Contrary to earlier studies, we find no evidence for an absolute difference between chromosome number in eusocial and solitary species of Hymenoptera. However, we find support for an increased rate of chromosome number change in eusocial taxa. We show that among eusocial taxa colony size is able to explain some of the variation in chromosome number: intermediate-sized colonies have more chromosomes than those that are either very small or very large. However, we were unable to detect effects of a number of other colony characteristics predicted to affect recombination rate - including colony relatedness and caste number. Taken together, our results support the view that a eusocial lifestyle has led to variable selection pressure for increased recombination rates, but that identifying the factors contributing to this variable selection will require further theoretical and empirical effort.

The evolution of genomic imprinting: theories, predictions and empirical tests

The epigenetic phenomenon of genomic imprinting has motivated the development of numerous theories for its evolutionary origins and genomic distribution. In this review, we examine the three theories that have best withstood theoretical and empirical scrutiny. These are: Haig and colleagues' kinship theory; Day and Bonduriansky's sexual antagonism theory; and Wolf and Hager's maternal–offspring coadaptation theory. These theories have fundamentally different perspectives on the adaptive significance of imprinting. The kinship theory views imprinting as a mechanism to change gene dosage, with imprinting evolving because of the differential effect that gene dosage has on the fitness of matrilineal and patrilineal relatives. The sexual antagonism and maternal–offspring coadaptation theories view genomic imprinting as a mechanism to modify the resemblance of an individual to its two parents, with imprinting evolving to increase the probability of expressing the fitter of the two alleles at a locus. In an effort to stimulate further empirical work on the topic, we carefully detail the logic and assumptions of all three theories, clarify the specific predictions of each and suggest tests to discriminate between these alternative theories for why particular genes are imprinted.

Serum 25-hydroxy vitamin D concentrations are more deficient/insufficient in peritoneal dialysis than haemodialysis patients in a sunny climate

BACKGROUND

Research has identified associations between serum 25(OH)D and a range of clinical outcomes in chronic kidney disease and wider populations. The present study aimed to investigate vitamin D deficiency/insufficiency in dialysis patients and the relationship with vitamin D intake and sun exposure.

METHODS

A cross-sectional study was used. Participants included 30 peritoneal dialysis (PD) (43.3% male; 56.87 ± 16.16 years) and 26 haemodialysis (HD) (80.8% male; 63.58 ± 15.09 years) patients attending a department of renal medicine. Explanatory variables were usual vitamin D intake from diet/supplements (IU day(-1) ) and sun exposure (min day(-1) ). Vitamin D intake, sun exposure and ethnic background were assessed by questionnaire. Weight, malnutrition status and routine biochemistry were also assessed. Data were collected during usual department visits. The main outcome measure was serum 25(OH)D (nm).

RESULTS

Prevalence of inadequate/insufficient vitamin D intake differed between dialysis modality, with 31% and 43% found to be insufficient (<50 nm) and 4% and 33% found to be deficient (<25 nm) in HD and PD patients, respectively (P < 0.001). In HD patients, there was a correlation between diet and supplemental vitamin D intake and 25(OH)D (ρ = 0.84, P < 0.001) and average sun exposure and 25(OH)D (ρ = 0.50, P < 0.02). There were no associations in PD patients. The results remained significant for vitamin D intake after multiple regression, adjusting for age, gender and sun exposure.

CONCLUSIONS

The results highlight a strong association between vitamin D intake and 25(OH)D in HD but not PD patients, with implications for replacement recommendations. The findings indicate that, even in a sunny climate, many dialysis patients are vitamin D deficient, highlighting the need for exploration of determinants and consequences.

Atypical tumors of the facial nerve: case series and review of the literature

OBJECT

The authors present a series of 4 patients with rare facial nerve tumors. The relevant literature is reviewed and is discussed regarding diagnostic features, the role of operative management, and surgical approach.

METHODS

A retrospective chart review was conducted for patients with tumors of the facial nerve that were treated between 2008 and 2011. Patients undergoing observation with serial MRI and those who were treated with up-front radiosurgery and for whom tissue diagnosis was not available were excluded. In addition, patients with suspected vestibular schwannoma, facial nerve schwannoma, neurofibromatosis Type 2, and metastatic disease were also excluded. The charts of 4 patients (2 men and 2 women) with "atypical" tumors were reviewed and analyzed.

RESULTS

A total of 12 patients with tumors of the facial nerve were identified during the study period. Patient characteristics, preoperative imaging, operative approach, tumor histology, and outcomes are described.

CONCLUSIONS

Atypical facial nerve tumors must be distinguished from the more common facial nerve schwannoma. How the authors of this study treat rare facial nerve tumors is based on their experience with the more common facial nerve schwannomas, characterized by a slow progression of symptoms and growth. Less is known about the rare lesions, and thus a conservative approach may be warranted. Open questions include the role of radiosurgery, facial nerve decompression, and indications for resection of tumor and cable grafting for these rare lesions.