New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline

BACKGROUND

Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes.

METHODS

We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel.

RESULTS

The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197.

CONCLUSIONS

The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.

Atrial Fibrillation (AFIB) in the ICU: Incidence, Risk Factors, and Outcomes: The International AFIB-ICU Cohort Study

OBJECTIVES

To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF.

DESIGN

Multicenter, prospective, inception cohort study.

SETTING

Forty-four ICUs in 12 countries in four geographical regions.

SUBJECTS

Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8-17.6), of which newly developed AF was 13.3% (11.5-15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16-23), magnesium 16% (13-20), potassium 15% (12-19), amiodarone 51% (47-55), beta-1 selective blockers 34% (30-38), calcium channel blockers 4% (2-6), digoxin 16% (12-19), and direct current cardioversion in 4% (2-6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95-1.99).

CONCLUSIONS

In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.

POS0298 OCCURRENCE AND PREDICTION OF FLARE AFTER TAPERING OF TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Patients with axial spondyloarthritis (axSpA) in clinical remission tapered Tumor Necrosis Factor inhibitor (TNFi) therapy according to a clinical guideline and had 2 years´ follow-up [1].

Objectives

We aimed to investigate flare frequency, dose at which flare occurred, type of flare (clinical/ Bath ankylosing spondylitis disease activity index (BASDAI)/magnetic resonance imaging (MRI)) and predictors of flare.

Methods

Patients in clinical remission (BASDAI<40, physician global score<40 and without disease activity the previous year) tapered TNFi to 2/3 standard dose at baseline, 1/2 at week (w)16, 1/3 at w32 and 0 (discontinuation) at w48. Patients who flared were increased to previous dose. Predictors of flare at each dose step were investigated by regression analyses.

Results

Of 108 patients, 106 (99%) flared before year 2 (flare occurring mean (SD) 99(44.3) days after last tapering). Twenty-nine patients (27%) flared at 2/3 standard dose, 21 (20%) at 1/2 dose, 29 (27%) at 1/3 dose and 27 (25%) after discontinuation. One-hundred-and-five (99%) had clinical flare, 25 (24%) BASDAI flare and 23 (29% of patients with MRI at flare) MRI flare; and forty-one patients (41%) fulfilled the ASAS-definition of clinically important worsening (≥0.9 increase since baseline) (Figure 1). Most common flare symptoms were back/buttock pain (n=93 (89%)) and pain in peripheral joints/entheseal regions (n=48 (46%)). Higher baseline physician global score was an independent predictor of flare after tapering to 2/3 (Odds ratio=1.19 (95% Confidence Interval=1.05-1.41); p=0.011) (Table 1). Changes in clinical and/or imaging variables in the 16 weeks prior to tapering did not predict flare (data not shown).

Table 1.

Prediction of flare within 16 weeks after tapering to 2/3 dose (n=74)

Values are from timepoint of tapering from full dose to 2/3 doseUnivariate analysesFinal multivariable analyses*OR(95% CI)p-valueOR(95% CI)p-valueMale gender0.96(0.25 - 4.14)0.955Age1.00(0.96 - 1.04)0.880Time since diagnosis1.00(0.95 - 1.06)0.863Current smoker0.70(0.20 - 2.20)0.543HLA-B27 positive0.66(0.18 - 2.41)0.515Previous bDMARDs1.28(0.66 - 2.49)0.458Patient pain VAS1.02(0.98 - 1.06)0.310Physician global VAS1.19(1.04 - 1.41)0.0121.19(1.04 - 1.41)0.011ASDAS1.66(0.70 - 4.10)0.251mNYc positive0.78(0.29 - 2.09)0.615SPARCC SIJ Inflammation Index1.01(0.90 - 1.12)0.861CANDEN Total inflammation0.95(0.65 - 1.25)0.702SPARCC SSS Erosion1.11(0.91 - 1.37)0.293CANDEN Fat0.99(0.96 - 1.02)0.705AUC (95% CI)0.66 (0.54 - 0.78)

Predictors were selected by applying backward selection in stacked data. p-values by likelihood ratio tests. Bold indicates p-values<0.1 in univariate analyses. Predictors were selected by backward selection in stacked imputed datasets after applying a fixed weight to all observations, accounting for the average fraction of missing data across all variables under consideration. *Results were derived in non-imputed data (no missing values in selected predictors). CIs given as profile likelihood CIs. AUC estimated based on internal validation by bootstrapping with 1000 samples.

ASDAS, Ankylosing Spondylitis Disease Activity Score; bDMARDs, biological disease modifying anti-rheumatic drugs; AUC, Area Under the receiver operating characteristic Curve; CANDEN, Canada-Denmark MRI scoring system of the spine in patients with axial spondyloarthritis; CI, confidence interval; mNYc, modified New York criteria; SIJ, sacroiliac joint; SPARCC SIJ inflammation, Spondyloarthritis Research Consortium of Canada Sacroiliac joint inflammation; SPARCC SSS, Spondyloarthritis Research Consortium of Canada Sacroiliac joint Structural Score; VAS, visual analogue scale.

Conclusion

Almost all (99%) axSpA patients in clinical remission flared during tapering to discontinuation, but above half not before receiving 1/3 dose or less. Higher physician global score was the only independent predictor of flare.

References

[1]Wetterslev M, et al. Rheumatology (Oxford) 2021;10.1093/rheumatology/keab755.

Disclosure of Interests

Marie Wetterslev: None declared, Stylianos Georgiadis: None declared, Sara Nysom Christiansen Speakers bureau: BMS and GE, Grant/research support from: Novartis, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Inge Juul Sørensen: None declared, Merete Lund Hetland Consultant of: MSD, Biogen, Pfizer, Eli Lilly, Orion Pharma, CellTrion, Samsung Bioepis, and Janssen Biologics BV, Grant/research support from: MSD, Biogen, Pfizer, Bristol-Myers Squibb, AbbVie, Roche and Novartis, Anne Duer: None declared, Mikael Boesen Speakers bureau: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Consultant of: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Grant/research support from: Image Analysis Group, Esaote, AbbVie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, UCB, Novo, GSK, Takeda, Geurbet, Biogen, Radiobotics and Chondrometrics, Kasper K Gosvig: None declared, Jakob Møllenbach Møller: None declared, Mads Bakkegaard: None declared, Cecilie Heegaard Brahe: None declared, Niels Steen Krogh: None declared, Bente Jensen: None declared, Ole Madsen: None declared, Jan Christensen: None declared, Annette Hansen Speakers bureau: speaker fees from Elly Lilly, Jesper Noerregaard: None declared, Henrik Røgind: None declared, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

POS0995 VALIDATION OF THE SPARCC MRI-RETIC E-TOOL FOR INCREASING SCORING PROFICIENCY OF MRI LESIONS IN AXIAL SPONDYLOARTHRITIS

Background

The web-based Spondyloarthritis Research Consortium of Canada (SPARCC) real-time iterative calibration (RETIC) modules for scoring MRI lesions in axial spondyloarthritis (axSpA) have been created by SPARCC developers to enable remote training of readers to appropriately use the SPARCC MRI inflammation and structural damage instruments and to attain adequate scoring proficiency.

Objectives

We aimed to test the performance of these modules in enhancing scoring proficiency in comparison to SPARCC developers.

Methods

The SPARCCRETIC SIJ inflammation and structural damage modules are each comprised of 50 DICOM axSpA cases with baseline and follow up scans and an online scoring interface based on SIJ quadrants. Continuous visual real-time feedback regarding concordance/discordance of scoring per SIJ quadrant with expert readers is provided by a color-coding scheme. Reliability is assessed in real-time by intra-class correlation coefficient (ICC), ICC data being provided every 10 cases, which are scored until proficiency targets for ICC are attained. In the present exercise, participants (n=15) from the EuroSpA Imaging project were randomized, stratified by reader expertise in scoring with SPARCC, to one of two reader training strategies (groups A and B) that each comprised 3 stages (25 patients per stage, 2 timepoints, blinded to chronology; independent assessment of Inflammatory and structural lesions): Group A. 1. Review of original SPARCC manuscript describing scoring method. 2. Review of PowerPoint summary of SPARCC method plus completion of SPARCCRETIC module. 3. Re-review of PowerPoint summary. Group B. Same 3-step strategy as A except SPARCCRETIC module completed at stage 3. The reliability of scoring was compared to an expert radiologist (SPARCC developer).

Results

Very good scoring proficiency for status and change scores was evident for SPARCC BME even by non-experienced readers with similar levels of reliability irrespective of prior expertise. The beneficial impact of the SPARCCRETIC module on scoring proficiency was most consistently evident for the scoring of structural lesions and for Strategy B, where the impact was evident for all structural lesions, level of reader expertise, and status as well as change scores (Table 1). Scoring proficiency improved the most for the least experienced readers (Figure 1).

Table 1.

Inter-rater reliability (Status/Change ICC) compared to radiologist SPARCC developer

MRI LesionReader expertiseStrategy AStrategy BStage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)Stage 1 cases (n=25)Stage 2 cases (n=25)Stage 3 cases (n=25)BMENone (n=4)0.91 / 0.940.83/0.820.77/0.780.82/0.880.65/0.820.88/0.90Intermediate (n=6)0.88/0.880.90/0.900.85/0.900.93/0.940.78/0.800.83/0.80Experienced (n=5)0.92/0.940.90/0.880.92/0.930.83/0.880.84/0.900.89/0.89ANKYLOSISNone (n=4)0.86/0.660.83/0.280.86/0.780.66/0.410.69/0.340.88/0.80Intermediate (n=6)0.89/0.570.83/0.370.92/0.810.82/0.680.74/0.470.93/0.84Experienced (n=5)0.96/0.760.93/0.640.94/0.860.97/0.240.83/0.410.91/0.79BACKFILLNone (n=4)-0.08/-0.050.38/0.220.59/0.380.64/0.130.05/-0.090.47/0.27Intermediate (n=6)0.41/0.130.44/0.420.69/0.390.50/0.220.30/0.300.70/0.42Experienced (n=5)0.82/0.380.55/0.400.91/0.640.65/0.240.21/0.260.71/0.30EROSIONNone (n=4)0.13/-0.080.67/0.420.51/0.330.34/0.330.23/0.080.38/0.37Intermediate (n=6)0.42/0.180.56/0.120.51/0.440.33/0.270.45/0.180.53/0.39Experienced (n=5)0.61/0.330.64/0.340.64/0.420.51/0.270.58/0.110.62/0.31FAT METAPLASIANone (n=4)0.62/0.540.30/0.170.57/0.290.43/0.530.38/0.070.83/0.63Intermediate (n=6)0.49/0.380.59/0.300.79/0.510.57/0.780.50/0.420.81/0.47Experienced (n=5)0.75/0.620.81/0.340.91/0.700.84/0.900.56/0.130.78/0.37

Conclusion

Attaining scoring proficiency for MRI structural lesions in axSpA is difficult but can be consistently improved by using the SPARCCRETIC module, even for experienced readers.

Figure 1.

Disclosure of Interests

Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, Boehringer Ingelheim, Celgene, Eli-Lilly, Galapagos, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, UCB, Anna Enevold Fløistrup Hadsbjerg Grant/research support from: Novartis, Mikkel Østergaard Consultant of: AbbVie, BMS, Boehringer-Ingelheim, Celgene, Eli Lilly and Company, Galapagos, Gilead, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, UCB, Grant/research support from: AbbVie, BMS, Merck, Celgene, Novartis, Raphael Micheroli: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis, Adrian Ciurea: None declared, Nora Vladimirova Grant/research support from: Novartis, Michael J Nissen Speakers bureau: Eli-Lilly, Janssen, Novartis, Consultant of: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Kristyna Bubova: None declared, Stephanie Wichuk: None declared, Manouk de Hooge: None declared, Ashish Jacob Mathew Grant/research support from: Novartis, Karlo Pintaric: None declared, Monika Gregová: None declared, Ziga Snoj: None declared, Marie Wetterslev: None declared, Karel Gorican: None declared, Joel Paschke: None declared, Iris Eshed: None declared, Robert G Lambert Paid instructor for: Novartis

Treatments of new-onset atrial fibrillation in critically ill patients: a systematic review with meta-analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is common in hospitalised patients with critical illness and associated with worse outcomes. Several interventions are available in the management of NOAF, but the overall effectiveness and safety of these interventions compared with placebo or no treatment are unknown.

METHODS

We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials (RCT) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses, the Cochrane Collaboration, and Grading of Recommendations Assessment, Development and Evaluation statements. We searched RCTs assessing any pharmacological and non-pharmacological treatment compared with placebo or no treatment in critically ill hospitalised patients with NOAF. The primary outcomes were all-cause mortality, adverse events, and health-related quality of life.

RESULTS

We included 16 trials (n = 1891) evaluating seven interventions. All trials were adjudicated 'some concerns' or 'high risk' of bias. The evidence is very uncertain for mortality (RR 0.53, 95% CI 0.03-8.30), adverse events (RR 1.28, 95% CI 0.85-1.92), and treatment efficacy i.e. rhythm control (RR 1.54, 95% CI 1.20-1.97; TSA-adjusted CI 0.56-4.53) between pharmacological treatment and placebo/no treatment (very low certainty evidence). There were no data for health-related quality of life or most of our secondary outcomes.

CONCLUSIONS

The existing data are insufficient to firmly conclude on effects of any intervention against NOAF on any outcome in hospitalised patients with critical illness. Randomised trials of the most frequently used interventions against NOAF are warranted in these patients.

Management of acute atrial fibrillation in the intensive care unit: An international survey

BACKGROUND

Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients.

METHOD

We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy.

RESULTS

A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%-100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants.

CONCLUSION

This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia: The COVID STEROID randomised, placebo-controlled trial

Background

In the early phase of the pandemic, some guidelines recommended the use of corticosteroids for critically ill patients with COVID‐19, whereas others recommended against the use despite lack of firm evidence of either benefit or harm. In the COVID STEROID trial, we aimed to assess the effects of low‐dose hydrocortisone on patient‐centred outcomes in adults with COVID‐19 and severe hypoxia.

Methods

In this multicentre, parallel‐group, placebo‐controlled, blinded, centrally randomised, stratified clinical trial, we randomly assigned adults with confirmed COVID‐19 and severe hypoxia (use of mechanical ventilation or supplementary oxygen with a flow of at least 10 L/min) to either hydrocortisone (200 mg/d) vs a matching placebo for 7 days or until hospital discharge. The primary outcome was the number of days alive without life support at day 28 after randomisation.

Results

The trial was terminated early when 30 out of 1000 participants had been enrolled because of external evidence indicating benefit from corticosteroids in severe COVID‐19. At day 28, the median number of days alive without life support in the hydrocortisone vs placebo group were 7 vs 10 (adjusted mean difference: −1.1 days, 95% CI −9.5 to 7.3, P = .79); mortality was 6/16 vs 2/14; and the number of serious adverse reactions 1/16 vs 0/14.

Conclusions

In this trial of adults with COVID‐19 and severe hypoxia, we were unable to provide precise estimates of the benefits and harms of hydrocortisone as compared with placebo as only 3% of the planned sample size were enrolled.

Trial registration: ClinicalTrials.gov: NCT04348305. European Union Drug Regulation Authorities Clinical Trials (EudraCT) Database: 2020‐001395‐15.

Cardiac arrhythmias in critically ill patients with coronavirus disease 2019: A retrospective population-based cohort study

BACKGROUND

Coronavirus disease 2019 (COVID-19) may be associated with cardiac arrhythmias in hospitalized patients, but data from the ICU setting are limited. We aimed to describe the epidemiology of cardiac arrhythmias in ICU patients with COVID-19.

METHODS

We conducted a multicenter, retrospective cohort study including all ICU patients with an airway sample positive for severe acute respiratory syndrome corona-virus 2 from March 1st to June 1st in the Capital Region of Denmark (1.8 million inhabitants). We registered cardiac arrhythmias in ICU, potential risk factors, interventions used in ICU and outcomes.

RESULTS

From the seven ICUs we included 155 patients with COVID-19. The incidence of cardiac arrhythmias in the ICU was 57/155 (37%, 95% confidence interval 30-45), and 39/57 (68%) of these patients had this as new-onset arrhythmia. Previous history of tachyarrhythmias and higher disease severity at ICU admission were associated with cardiac arrhythmias in the adjusted analysis. Fifty-four of the 57 (95%) patients had supraventricular origin of the arrhythmia, 39/57 (68%) received at least one intervention against arrhythmia (eg amiodarone, IV fluid or magnesium) and 38/57 (67%) had recurrent episodes of arrhythmia in ICU. Patients with arrhythmias in ICU had higher 60-day mortality (63%) as compared to those without arrhythmias (39%).

CONCLUSION

New-onset supraventricular arrhythmias were frequent in ICU patients with COVID-19 and were related to previous history of tachyarrhythmias and severity of the acute disease. The mortality was high in these patients despite the frequent use of interventions against arrhythmias.

New-onset atrial fibrillation in the intensive care unit: Protocol for an international inception cohort study (AFIB-ICU)

INTRODUCTION

New-onset atrial fibrillation (NOAF) is frequently observed in critically ill patients and may be associated with prolonged hospital stay and increased mortality. Considerable variation exists in the reported frequencies of NOAF due to the lack of a standardised definition and detection method. Importantly, there are limited data on NOAF in the intensive care unit (ICU). Thus, we aim to provide contemporary epidemiological data on NOAF in the ICU.

METHODS AND ANALYSIS

We have designed an international inception cohort study including at least 1,000 consecutive adult patients acutely admitted to the ICU without prior history of persistent or permanent AF. We will present data on the incidence, risk factors, used management strategies and outcomes of NOAF. We will register data daily during stay in the ICU for a maximum of 90 days after admission. The incidence of NOAF and management strategies used will be presented descriptively, and we will use Cox regression analyses including competing risk analyses to assess risk factors for NOAF and any association with 90-day mortality.

CONCLUSION

The outlined international AFIB-ICU inception cohort study will provide contemporary data on the incidence, risk factors, used management strategies and outcomes of NOAF in adult ICU patients.

ETHICS AND DISSEMINATION

This observational study poses no risk to the included patients. All participating sites will obtain relevant approvals according to national laws before patient enrollment. Funding sources will have no influence on data handling, analyses or writing of the manuscript. The study report(s) will be submitted to an international peer-reviewed journal.

OP0149 RELIABILITY AND RESPONSIVENESS OF TWO OMERACT WHOLE-BODY MRI SCORES OF ENTHESEAL AND JOINT INFLAMMATION IN THE KNEE REGION IN SPONDYLOARTHRITIS

Background:

Inflammation in peripheral joints and entheses is common in spondyloarthritis (SpA). Whole-body magnetic resonance imaging (WB-MRI) allows assessment of the overall inflammatory status of arthritis patients including joints and entheses. The OMERACT MRI Whole-body scoring system for Inflammation in Peripheral joints and Entheses (MRI-WIPE) [1] has been developed and validated for the entire body assessment, including the knee, but not separately validated for the knee joint region. Detailed MRI scoring systems exist for heels, hands and feet, but although knee arthritis is a key cause of functional impairment, no detailed scoring system has been validated for inflammatory arthritides. The Knee Inflammation MRI Scoring System (KIMRISS) [2] was developed and validated in osteoarthritis and demonstrated good reliability.

Objectives:

To perform region-based development of whole-body MRI through validation of two knee region scoring systems in SpA.

Methods:

Assessment of inflammation was performed in the knee region on sagittal WB-MRIs using 2 scoring systems, MRI-WIPE and KIMRISS (Figure 1), in 4 iterative multi-reader exercises. In the final exercise, images (psoriatic arthritis, axial and peripheral SpA) were obtained before and after TNF-inhibitor.

Results:

In the final exercise (exercise 4), reliability was mostly good for experienced readers with the overall highest interreader agreement in the previous exercise (exercise 3). Median pairwise single measure intraclass correlation coefficients for osteitis and synovitis/effusion for status/change were 0.71/0.48 (WIPE osteitis), 0.48/0.77 (WIPE synovitis/effusion), 0.59/0.91 (KIMRISS osteitis) and 0.92/0.97 (KIMRISS synovitis/effusion) (Table 1). Wilcoxon signed-rank test showed significant change in synovitis/effusion for both methods and they correlated significantly regarding status in osteitis (0.92, p<0.001) and synovitis/effusion (0.89, p=0.001) and change in synovitis/effusion (0.89, p<0.001). Standardized response mean was 0.74 (WIPE synovitis/effusion) and 0.78 (KIMRISS synovitis/effusion).

Table 1.

MRI-WIPE knee and KIMRISS interreader reliability for OMERACT exercises 3 and 4

MRI-WIPE KneeKIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patientsType of scoreMean scoreICCMean scoreICCMean scoreICCMean scoreICCExercise 39 readers11Status3.6 (0-16)0.57 (-0.06-0.98)1.8 (0-4)0.47 (0.05-0.85)32.3 (1-224)0.87 (0.66-0.99)29.9 (11-60)0.34 (-0.62-0.87)11Change1.1 (-2-6)0.53 (0.03-0.90)0 (-2-1)0.32 (-0.13-0.76)27.7 (-9-131)0.58 (-0.30-0.96)-1.6 (-33-11)0.48 (-0.32-0.95)Exercise 33 readers11Status3.1 (0-16)0.83 (0.71-0.97)2.5 (0-5)0.59 (0.51-0.71)34.4 (0-233)0.89 (0.83-0.99)36.5 (16-78)0.59 (0.08-0.86)11Change0.9 (-3-6)0.72 (0.57-0.83)0 (-2-1)0.63 (0.49-0.76)19.3 (-23-86)0.46 (0.18-0.83)-1.8 (-45-17)0.89 (0.82-0.95)Exercise 49 readers10Change-0.25 (-4-5)0.38 (-0.35-0.94)-1.0 (-3-1)0.30 (-0.43-0.89)-0.45 (-37-65)0.26 (-0.86-0.97)-14.7 (-48-0.20)0.48 (-0.39-0.99)20Status2.9 (0-7)0.50 (-0.01-0.84)2.1 (0-4)0.44 (-0.21-0.79)15.2 (0-66)0.35 (-0.04-0.89)55.6 (1-122)0.54 (0.01-0.96)Exercise 43 readers10Change0.2 (-2-6)0.48 (0.16-0.66)-1.4 (-5-0)0.77 (0.70-0.82)5.8 (-27-111)0.92 (0.90-0.94)-20.7 (-65-28)0.97 (0.96-0.98)20Status2.3 (0-6)0.71 (0.60-0.80)2.7 (0-5)0.48 (0.42-0.57)11.4 (0-36)0.59 (0.39-0.71)69.4 (1-153)0.91 (0.87-0.93)

Sum scores are mean (range) of the patients scores. ICC values are mean (range). ICC is 2-way mixed model, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and KIMRISS may both be useful as part of modular whole-body evaluation in clinical studies.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. RMD Open. 2017;3(1):e000355

Acknowledgements:

We thank CARE Aarthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, the scoring exercises, and the web-based meetings. We thank all who participated in the SIG (Special Interest Group) virtual OMERACT meeting 29 October 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed in this study are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Robert G Lambert Consultant of: Parexel and Pfizer, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Violaine Foltz: None declared, Ashish Jacob Mathew: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Consultant of: AbbVie, AstraZeneca, BMS, Eli Lilly, EMD Serono, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer and Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

OP0252 ARTHRITIS AND ENTHESITIS IN THE HIP AND PELVIS REGION IN SPONDYLOARTHRITIS – VALIDATION OF TWO WHOLE-BODY MRI METHODS

Background:

Whole-body MRI (WB-MRI) allows assessment of the overall inflammation in arthritis patients, including joint and entheses. To enhance the use of WB-MRI in clinical trials, the OMERACT MRI in Arthritis Working Group developed the OMERACT MRI Whole-body score for Inflammation in Peripheral joints and Entheses in inflammatory arthritis (MRI-WIPE) [1]. This has been validated for the entire body, including the hip/pelvis region, but not for each individual region. More detailed scoring systems exist for heels, hands and feet but although hip arthritis is a key cause of functional impairment in spondyloarthritis (SpA), no detailed scoring system has been published for use in SpA. The Hip Inflammation Magnetic Resonance Imaging Scoring System (HIMRISS) was developed and validated in osteoarthritis showing good reliability.

Objectives:

To validate reliability, correlation and responsiveness of two WB-MRI scores for the hip/pelvis region in SpA.

Methods:

Inflammation in the hip/pelvis region was assessed on coronal WB-MRIs in 4 iterative multi-reader exercises using MRI-WIPE for the hip/pelvis region and HIMRISS (Figure 1). In final exercises, images (axial/peripheral SpA and psoriatic arthritis) were obtained before and after TNF-inhibitor.

Results:

In final exercises reliability was mostly good for the best calibrated readers. Median single-measure intraclass correlation coefficients were 0.58-0.65 (WIPE osteitis), 0.10-0.88 (HIMRISS osteitis), 0.38-0.72/0.52-0.60 (WIPE synovitis/effusion) and 0.68-0.89/0.78-0.85 (HIMRISS synovitis/effusion) (Table 1). The methods correlated significantly for status in osteitis (0.72, p=0.019) and for synovitis/effusion status (0.83, p=0.003) and change (0.73, p=0.017) (Table 1). In exercise 4 Wilcoxon signed-rank test showed significant change in osteitis between timepoints using WIPE hip/pelvis and SRM was large (1.23), while lower for WIPE synovitis/effusion and HIMRISS.

Table 1.

MRI-WIPE hip/pelvis and HIMRISS interreader reliability for OMERACT exercises 3-4

MRI-WIPE hip/pelvisHIMRISSOsteitisSynovitis/effusionOsteitisSynovitis/effusionVariablesNo. patients(cases)Type of scoreMeanscoreICCMeanscoreICCMeanscoreICCMeanscoreICCExercise 39 readers11Status2.3 (0-10)0.69 (0.23-0.93)1.4 (0-4)0.58 (-0.06-0.96)8.2 (1-60)0.84 (0.56-0.99)12.8 (3-25)0.52 (0.00-.91)11Change-0.2 (-1-1)NA-0.2 (-3-1)0.50 (0.10-0.87)-0.35 (-3-1)NA-1.8 (-17-10)0.50 (-0.05-0.89)Exercise 33 readers11Status1.8 (0-10)0.63 (0.46-0.93)1.7 (0-5)0.60 (0.34-0.80)6.6 (0-65)0.88 (0.77-0.94)12.8 (2-28)0.89 (0.87-0.91)11Change-0.12 (-1-1)NA-0.12 (-3-2)0.60 (0.48-0.83)-0.7 (-7-0)NA-1.6 (-21-8)0.78 (0.70-0.87)Exercise 49 readers10 (1-10)Status1.2 (0-4)0.21 (-0.39-0.91)1.1 (0-2)0.19 (-0.31-0.69)1.8 (0-6)0.07 (-0.17-0.83)16.4 (9-23)0.31 (0.00-0.89)10 (11-20)Status1.6 (0-6)0.51 (-0.08-0.99)1 (0-3)0.40 (-0.17-0.88)3.5 (1-8)0,08 (-0.21-0.95)11.2 (5-24)0.49 (0.00-0.94)10 11-20)Change-0.4 (-2-0)NA-0.39 (-2-0)0.22 (-0.68-0.83)-2.2 (-7-2)NA-5.2 (-18-0)0.57 (0.02-0.92)20 (1-20)Status1.4 (0-6)0.41 (-0.35-0.92)1.0 (0-3)0.27 (-0.07-0.75)2.7 (0-9)0.09 (-0.17-0.85)13.8 (5-25)0.45 (0.01-0.90)Exercise 43 readers10 (1-10)Status0.8 (0-4)0.29 (0.01-0.78)1.3 (0-2)-0.02 (-0.29-0.12)0.4 (0-2)-0.04 (-0.04-0.04)15.8 (5-26)0.73 (0.59-0.89)10 (11-20)Status1.8 (0-9)0.65 (0.52-0.76)1.2 (0-4)0.72 (0.62-0.81)1.7 (0-5)0.06 (-0.17-0.35)9.2 (2-26)0.68 (0.53-0.88)10 (11-20)Change-0.6 (-2-0)NA-0.5 (-3-1)0.52 (0.49-0.55)-0.2 (-2-1)NA-2.8 (-19-6)0.85 (0.82-0.88)20 (1-20)Status1.3 (0-9)0.58 (0.43-0.69)1.2 (0-4)0.38 (0.31-0.44)1.0 (0-5)0.10 (-0.09-0.33)12.5 (2-26)0.73 (0.69-0.77)

Sum scores and ICCs are mean (range). ICC is 2-way mixed, single measure, by absolute agreement.

Conclusion:

MRI-WIPE and HIMRISS may be useful tools in modular WB-MRI evaluation of hip/pelvis inflammation in clinical trials in SpA.

References:

[1]Krabbe S et al. J Rheum. 2019;46(9):1215-21

[2]Jaremko JL et al. J Rheum. 2019;46(9)1239-42

Acknowledgements:

We thank CARE Arthritis Limited (carearthritis.com) for help with setting up the web-based scoring interface, scoring exercises, and the web-based meetings. We acknowledge the contribution of SIG (Special Interest Group) participants at the virtual OMERACT meeting October 29, 2020. HMO, GDM and PGC are supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, United Kingdom. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

Disclosure of Interests:

Marie Wetterslev: None declared, Robert G Lambert Consultant of: Parexel and Pfizer, Walter P Maksymowych Speakers bureau: AbbVie, Janssen, Novartis, Pfizer and UCB, Consultant of: AbbVie, Boehringer Ingelheim, Celgene, Eli Lilly, Galapagos, Janssen, Novartis, Pfizer and UCB, Grant/research support from: AbbVie, Novartis, Pfizer and UCB, Iris Eshed: None declared, Susanne Juhl Pedersen Speakers bureau: MSD, Pfizer, AbbVie, Novartis and UCB, Consultant of: AbbVie and Novartis, Grant/research support from: AbbVie, MSD, and Novartis, Paul Bird Speakers bureau: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Consultant of: Janssen, Abbvie, UCB, Celgene, BMS, Novartis, Pfizer, Gilead, Eli-Lilly, Maria Stoenoiu: None declared, Simon Krabbe: None declared, Ashish Jacob Mathew: None declared, Violaine Foltz: None declared, Frederique Gandjbakhch: None declared, Joel Paschke: None declared, Gabriele De Marco: None declared, Helena Marzo-Ortega Speakers bureau: AbbVie, Celgene, Janssen, Lilly, Novartis, Pfizer, Takeda and UCB, Grant/research support from: Janssen and Novartis, Philippe Carron Speakers bureau: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Consultant of: Pfizer, MSD, Novartis, BMS, AbbVie, UCB, Eli Lilly, Gilead and Celgene, Grant/research support from: UCB, MSD and Pfizer, Anna Enevold Fløistrup Poulsen: None declared, Jacob L Jaremko: None declared, Philip G Conaghan Speakers bureau: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Consultant of: AbbVie, BMS, Eli Lilly, Flexion Therapeutics, Galapagos, Gilead, Novartis, Pfizer, Regeneron, Stryker, Mikkel Østergaard Speakers bureau: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB

Treatment strategies for new-onset atrial fibrillation in critically ill patients: Protocol for a systematic review

BACKGROUND

New-onset atrial fibrillation is frequent in critically ill patients and associated with poorer outcomes in these patients. Numerous interventions are used for the management of new-onset atrial fibrillation, but it is unknown if these interventions improve patient-important outcomes as compared with placebo or no active intervention in adult critically ill patients.

METHODS/DESIGN

We will conduct a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing pharmacological and non-pharmacological interventions of new-onset atrial fibrillation as compared with placebo or no active intervention in adult critically ill patients. The primary outcomes are mortality, adverse events and health-related quality of life. We will search the following databases: MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, Science Citation Index and BIOSIS and follow the recommendations by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We will evaluate the overall certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

DISCUSSION

New-onset atrial fibrillation is common in adult critically ill patients. However, the balance between the desirable and undesirable effects of pharmacological and non-pharmacological interventions is unknown. The outlined systematic review aims to provide updated data on this topic.

REGISTRATION

Submitted to PROSPERO (CRD42020187178 ). Status: accepted.

Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia (COVID STEROID) trial-Protocol and statistical analysis plan

Introduction

Severe acute respiratory syndrome coronavirus‐2 has caused a pandemic of coronavirus disease (COVID‐19) with many patients developing hypoxic respiratory failure. Corticosteroids reduce the time on mechanical ventilation, length of stay in the intensive care unit and potentially also mortality in similar patient populations. However, corticosteroids have undesirable effects, including longer time to viral clearance. Clinical equipoise on the use of corticosteroids for COVID‐19 exists.

Methods

The COVID STEROID trial is an international, randomised, stratified, blinded clinical trial. We will allocate 1000 adult patients with COVID‐19 receiving ≥10 L/min of oxygen or on mechanical ventilation to intravenous hydrocortisone 200 mg daily vs placebo (0.9% saline) for 7 days. The primary outcome is days alive without life support (ie mechanical ventilation, circulatory support, and renal replacement therapy) at day 28. Secondary outcomes are serious adverse reactions at day 14; days alive without life support at day 90; days alive and out of hospital at day 90; all‐cause mortality at day 28, day 90, and 1 year; and health‐related quality of life at 1 year. We will conduct the statistical analyses according to this protocol, including interim analyses for every 250 patients followed for 28 days. The primary outcome will be compared using the Kryger Jensen and Lange test in the intention to treat population and reported as differences in means and medians with 95% confidence intervals.

Discussion

The COVID STEROID trial will provide important evidence to guide the use of corticosteroids in COVID‐19 and severe hypoxia.

SAT0548 DEVELOPMENT AND VALIDATION OF THREE PRELIMINARY MRI SACROILIAC JOINT COMPOSITE STRUCTURAL DAMAGE SCORES IN A 5-YEAR LONGITUDINAL STUDY OF PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

In axial spondyloarthritis (axSpA), MRI reliably detects structural lesions in the sacroiliac joints (SIJs). The SPARCC SIJ Structural Score (SSS)(1) is a reliable and validated method to assess the individual structural lesions of the SIJs, i.e. fat lesion, erosion, backfill (fat metaplasia in an erosion cavity) and ankylosis. Several MRI studies have indicated that bone destruction, i.e. erosion, is often followed by formation of new bone in the erosion cavity (backfill), ultimately leading to ankylosis(2).

Objectives:

The aim was to combine SPARCC SSS for erosion, backfill and ankylosis into a composite score for SIJ structural damage and to test this score in a 5-year follow up study.

Methods:

Thirty-three patients fulfilling ASAS criteria for axSpA were followed for 5 years after initiation of TNF inhibitor in the BIOSPA study(3). T1-weighted and STIR MRI sequences of the SIJs acquired at week 0, 46 and year 2, 3, 4, 5 were evaluated with SPARCC SSS. In each of 5 slices of each SIJ, erosion is scored 0-1 per joint quadrant (score range 0-40), backfill 0-1 per joint half (score range 0-20) and ankylosis 0-1 per joint half (score range 0-20). Based on the scores for erosion, backfill and ankylosis 3 versions of a preliminary Composite axSpA MRI SIJ Structural Damage Score (CSDS) were calculated:

CSDS–A: (erosion score x0.5) + backfill score + ankylosis score

CSDS–B: (erosion score x1) + (backfill score x4) + (ankylosis score x6)

CSDS–C: (erosion score x1) < (backfill score x4) < (ankylosis score x6)

The “<” indicates a hierarchical order, meaning that erosion was not scored if backfill was present in the same joint half and erosion and backfill were not scored if ankylosis was present in the joint half.

Results:

Patients were divided into two groups: patients with almost complete bilateral ankylosis (baseline SPARCC SSS Ankylosis ≥18, n=10) and patients with no/minor ankylosis (baseline SPARCC SSS Ankylosis ≤7, n=23). At baseline patients with no/minor ankylosis were younger, had shorter symptom duration, lower BASMI, higher SPARCC SIJ Inflammation, lower SSS Fat, Erosion, Backfill and Ankylosis, as compared with patients with almost complete ankylosis.

At baseline, CSDS-A, -B and -C correlated positively with SPARCC SSS Fat and Ankylosis and modified New York criteria grading, and negatively with BASDAI and SPARCC inflammation. Change in CSDS-B and -C over 5 years correlated positively with change in SSS Fat and Ankylosis and negatively with change in SPARCC Inflammation. There was no change in the group with almost complete ankylosis.

The annual progression for CSDS-B and -C was statistically significantly larger in year 1 compared with year 4 (p=0.01) and numerically larger compared with year 2 (p=0.075), 3 (p=0.382) and 5 (p=0.073). Figure 1 shows the annual change in patients with no/minor ankylosis.

Conclusion:

Three preliminary Composite Structural Damage Scores for MRI assessment of the SIJs in patients with axSpA, which allows scoring of MRI progression of erosion through backfill to ankylosis, were introduced. Progression was most pronounced the first year after TNF inhibitor initiation. This novel approach may be useful for monitoring structural progression in axSpA. We suggest that these methods are further tested for responsiveness and ability to differentiate between different therapies in randomized controlled trials.

References:

[1]Maksymowych WP et al. J Rheum 2015;42:79-86.

[2]Maksymowych WP et al. Art Rheum 2014;66:2958-67.

[3]Pedersen SJ et al. Scand J Rheum 2019;48:185-197.

Disclosure of Interests:

Marie Wetterslev: None declared, Mikkel Ǿstergaard Grant/research support from: AbbVie, Bristol-Myers Squibb, Celgene, Merck, and Novartis, Consultant of: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Boehringer Ingelheim, Celgene, Eli Lilly, Hospira, Janssen, Merck, Novartis, Novo Nordisk, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Inge Juul Sørensen: None declared, Ulrich Weber: None declared, Anne Gitte Loft Grant/research support from: Novartis, Consultant of: AbbVie, MSD, Novartis, Pfizer and UCB, Speakers bureau: AbbVie, MSD, Novartis, Pfizer and UCB, Gina Kollerup Speakers bureau: Eli Lilly, Lars Juul: None declared, Gorm Thamsborg: None declared, Ole Madsen: None declared, Jakob Møllenbach Møller: None declared, Susanne Juhl Pedersen Grant/research support from: Novartis

Needle biopsy-derived myofascial tissue samples are sufficient for quantification of myofibroblast density

Quantification of myofibroblasts is a promising method for assessing tissue properties in the field of fascia research. This is commonly performed by immunohistochemistry for α-smooth muscle actin. However, usually larger tissue samples sizes are required for quantification. The aim of this investigation was to explore whether a microscopic quantification of myofibroblasts can be conducted with fascial tissue samples derived via percutaneous needle biopsy. Fascial tissues were derived via percutaneous needle biopsy from the fascia lata of 11 persons (aged 19-40 years). Following immunohistochemistry, selected fields for photomicroscopic analysis were chosen by a Monte Carlo method based randomization procedure. On these fields, a digital quantification for the relative density of α-smooth muscle actin was attempted. The newly developed quantification method could successfully be applied in all tissue samples. The median α-smooth muscle actin density in the selected tissue samples ranged between 0% and 1.7% (median 0%, IQR 0%-0.001%). The applied protocol proved to be workable for the purpose of an estimation of the α-smooth muscle actin density in fascial tissue samples derived via percutaneous needle biopsy. Since this type of biopsy is less invasive than the commonly performed open muscle biopsy, this offers a new and useful perspective for future histological investigations of fascial tissue properties in living patients. Clin. Anat. 31:368-372, 2018. © 2018 Wiley Periodicals, Inc.

[Bouveret's syndrome - a rare complication in connection with cholecystolithiasis and a variant of gallstone ileus]

Bouveret's syndrome is a very rare complication to cholecystolithiasis resulting in gallstone ileus. It is caused by ectopic gallstones in the duodenum due to a bilioenteric fistula. Symptoms may include vomiting and upper abdominal pains. The condition is associated with high mortality, making it important to recognize. The treatment includes surgical removal of the gallstone. However, the optimal therapeutic approach has still not been found. In this case report a 59-year-old female with Bouveret's syndrome is presented.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

Mechanism of injury and microbiological flora of the geographical location are essential for the prognosis in soldiers with serious warfare injuries

INTRODUCTION

Denmark has been engaged in the Afghanistan war and as a result, Rigshospitalet has received a number of multi-traumatized Danish soldiers. Lesions sustained in armed conflict differ from their civilian counterparts and knowledge of the pathophysiology related to these types of lesions is essential when engaging in the intensive care of these patients.

MATERIAL AND METHODS

The study was conducted as a retrospective survey of Danish soldiers evacuated from Afghanistan to the Intensive Care Unit at Rigshospitalet in the 2002-2012 period. The following data were recorded: age, gender, hospitalization (days), mortality, organ involvement, respiratory therapy, dialysis, circulatory supportive care, antibiotic treatment and bacteriology. Furthermore, Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score and Sequential Organ Failure Assessment scores were calculated.

RESULTS

A total of twenty patients were identified and included in the study. All patients had sustained serious blast injuries as a result of explosion. Primarily the central nervous system, respiratory, musculoskeletal and abdominal systems were affected by the explosions. Eighteen patients survived to discharge and two patients died.

DISCUSSION

Explosion was the most frequent cause of injury in all cases and caused damage to several organ systems. Infections after combat injuries are a major problem because of the different microbiological profile.

CONCLUSION

The use of explosives has been and remains a substantial part of warfare, and this review has showed us that the knowledge of the mechanism of injury is indeed essential, and that intelligence on the microbiological flora of the geographical location of the conflict is essential.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Clinical review: Predictive value of neutrophil gelatinase-associated lipocalin for acute kidney injury in intensive care patients

Neutrophil gelatinase-associated lipocalin (NGAL) may be an early marker of acute kidney injury (AKI), but elevated NGAL occurs in a wide range of systemic diseases. Because intensive care patients have high levels of comorbidity, our objective was to conduct a systematic review of the literature to evaluate the value of plasma and urinary NGAL to predict AKI in these patients. We conducted a systematic electronic literature search of MEDLINE through PubMed, EMBASE, and Cochrane Library for all English language research publications evaluating the predictive value of plasma or urinary NGAL (or both) for AKI in adult intensive care patients. Two authors independently extracted data by using a standardized extraction sheet including study characteristics, type of NGAL measurements, and type of outcome measures. The primary summary measure was area under receiver operating characteristic curve (AuROC) for NGAL to predict study outcomes. Eleven studies with a total of 2,875 (range of 20 to 632) participants were included: seven studies assessed urinary NGAL and six assessed plasma NGAL. The included studies varied in design, including observation period from NGAL sampling to AKI follow-up (range of 12 hours to 7 days), definition of baseline creatinine value, and urinary NGAL quantification method (normalizing to urinary creatinine or absolute concentration). AuROC values for the prediction of AKI ranged from 0.54 to 0.98. Five studies reported AuROC for use of renal replacement therapy ranging from 0.73 to 0.89, and four studies reported AuROC for mortality ranging from 0.58 to 0.83. There were no differences in the predictive values of urinary and plasma NGAL. The heterogeneity in study design and results made it difficult to evaluate the value of NGAL to predict AKI in intensive care patients. NGAL seems to have reasonable value in predicting use of renal replacement therapy but not mortality.

Hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin in patients with sepsis: systematic review with meta-analysis and trial sequential analysis

OBJECTIVE

To assess the effects of fluid therapy with hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin on mortality, kidney injury, bleeding, and serious adverse events in patients with sepsis.

DESIGN

Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials.

DATA SOURCES

Cochrane Library, Medline, Embase, Biosis Previews, Science Citation Index Expanded, CINAHL, Current Controlled Trials, Clinicaltrials.gov, and Centerwatch to September 2012; hand search of reference lists and other systematic reviews; contact with authors and relevant pharmaceutical companies.

STUDY SELECTION

Eligible trials were randomised clinical trials comparing hydroxyethyl starch 130/0.38-0.45 with either crystalloid or human albumin in patients with sepsis. Published and unpublished trials were included irrespective of language and predefined outcomes.

DATA EXTRACTION

Two reviewers independently assessed studies for inclusion and extracted data on methods, interventions, outcomes, and risk of bias. Risk ratios and mean differences with 95% confidence intervals were estimated with fixed and random effects models.

RESULTS

Nine trials that randomised 3456 patients with sepsis were included. Overall, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin did not affect the relative risk of death (1.04, 95% confidence interval 0.89 to 1.22, 3414 patients, eight trials), but in the predefined analysis of trials with low risk of bias the relative risk of death was 1.11 (1.00 to 1.23, trial sequential analysis (TSA) adjusted 95% confidence interval 0.95 to 1.29, 3016 patients, four trials). In the hydroxyethyl starch group, renal replacement therapy was used more (1.36, 1.08 to 1.72, TSA adjusted 1.03 to 1.80, 1311 patients, five trials), and the relative risk of acute kidney injury was 1.18 (0.99 to 1.40, TSA adjusted 0.90 to 1.54, 994 patients, four trials). More patients in the hydroxyethyl starch group were transfused with red blood cells (1.29, 1.13 to 1.48, TSA adjusted 1.10 to 1.51, 973 patients, three trials), and more patients had serious adverse events (1.30, 1.02 to 1.67, TSA adjusted 0.93 to 1.83, 1069 patients, four trials). The transfused volume of red blood cells did not differ between the groups (mean difference 65 mL, 95% confidence interval -20 to 149 mL, three trials).

CONCLUSION

In conventional meta-analyses including recent trial data, hydroxyethyl starch 130/0.38-0.45 versus crystalloid or albumin increased the use of renal replacement therapy and transfusion with red blood cells, and resulted in more serious adverse events in patients with sepsis. It seems unlikely that hydroxyethyl starch 130/0.38-0.45 provides overall clinical benefit for patients with sepsis.