Dealing with complications in interventional radiology

It is widely accepted that most misadventures, which lead to harm have not occurred because of a single individual but rather due to a failure of process that results in healthcare workers making mistakes. This failure of process and the pervasiveness of adverse events is just as prevalent in Interventional Radiology (IR) as it is in other specialities. The true prevalence and prevailing aetiology of complications in IR are not exactly known as there is a paucity of investigative literature into this area; especially when compared with other more established disciplines such as Surgery. Some IR procedures have a higher risk profile than others. However, published data suggests that many adverse events in IR are preventable (55-84%) and frequently involve a device related complication such as improper usage or malfunction. This article aims to discuss factors that contribute to complications in IR along with tools and strategies for dealing with them to achieve optimal patient outcomes.

Effect of HIV infection on plasma exposure to first-line TB drugs and target attainment in children

BACKGROUND: Whether HIV infection adversely affects exposure to first-line TB drugs in children is debatable. It is also not known whether HIV infection increases the risk of plasma underexposure or overexposure to TB drugs. This study sought to address these questions.DESIGN/METHODS: Children on TB treatment were enrolled. After 4 weeks on therapy, blood samples were collected at pre-dose, 1, 2, 4, 8, and 12 h post-dose for pharmacokinetic analysis. Plasma drug exposure below and above the lower and upper bounds of the 95% confidence intervals of the reference mean for children were considered underexposure and overexposure, respectively. The effect of HIV infection on drugs exposure and risk of underexposure were examined using multivariate analysis.RESULTS: Of 86 participants (median age: 4.9 years), 45 had HIV coinfection. HIV coinfection was associated with lower pyrazinamide (PZA) and ethambutol exposures in adjusted analysis. Patients with TB-HIV coinfection were three times more likely to have PZA underexposure than those with TB only. Underexposure of rifampin was common irrespective of HIV coinfection status.CONCLUSIONS: HIV coinfection was associated with a higher risk for PZA underexposure in children. This effect should be accounted for in models and simulations to determine optimal PZA dose for children.

Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage

AIM

To describe the clinical presentation, imaging evaluation, endovascular management, and outcomes of multifocal renal capsular haemorrhage, "weeping sponge kidney", and to identify associated risk factors and the pathophysiological mechanism behind this condition.

MATERIALS AND METHODS

This is a case series in which clinical information for each of the cases was collected retrospectively from electronic patient notes as well as the radiology information and picture archiving and communication systems.

RESULTS

Four consecutive cases were included in the series. All of the cases were treated successfully with embolisation. Three of the four patients had chronic renal failure with renal atrophy, which are patient factors that appear to be associated with multifocal renal capsular haemorrhage. Based on the procedural findings and the published literature, a pathophysiological mechanism is described to explain this condition and the relevance of the collateral arterial supply to the kidney in such cases is discussed.

CONCLUSION

Small subcapsular haematomas are usually self-limiting but in patients with renal failure, there may be an increased risk of developing a weeping sponge kidney, which can be life-threatening. The endovascular treatment for multifocal haemorrhage differs from that for a single bleeding point, especially if preservation of renal function is not a priority.

Vascular Interventions in Oncology

Vascular interventions are an important and established tool in the management of the oncology patient. The goal of these procedures may be curative, palliative or adjunctive in nature. Some of the common vascular interventions used in oncology include transarterial embolisation or chemoembolisation, selective internal radiation therapy, chemosaturation, venous access lines, superior vena cava stenting and portal vein embolisation. We provide an overview of the principles, technology and approach of vascular techniques for tumour therapy in both the arterial and venous systems. Arterial interventions are currently mainly used in the management of hepatocellular carcinoma. Transarterial embolisation, chemoembolisation and selective internal radiation therapy deliver targeted catheter-delivered treatments with the aim of reducing tumour burden, controlling tumour growth or increasing survival in patients not eligible for transplantation. Chemosaturation is a regional chemotherapy technique that delivers high doses of chemotherapy directly to the liver via the hepatic artery, while reducing the risks of systemic effects. Venous interventions are more adjunctive in nature. Venous access lines are used to provide a means of delivering chemotherapy and other medications directly into the bloodstream. Superior vena cava stenting is a palliative procedure that is used to relieve symptoms of superior vena cava obstruction. Portal vein embolisation is a procedure that allows hypertrophy of a healthy portion of the liver in preparation for liver resection. Interventional radiology-led vascular interventions play an essential part of cancer management. These procedures are minimally invasive and provide a safe and effective adjunct to traditional cancer treatment methods. Appropriate work-up and discussion of each patient-specific problem in a multidisciplinary setting with interventional radiology is essential to provide optimum patient-centred care.

Genomic analyses of germline and somatic variation in high-grade serous ovarian cancer

BACKGROUND

High-grade serous ovarian cancers (HGSCs) display a high degree of complex genetic alterations. In this study, we identified germline and somatic genetic alterations in HGSC and their association with relapse-free and overall survival. Using a targeted capture of 557 genes involved in DNA damage response and PI3K/AKT/mTOR pathways, we conducted next-generation sequencing of DNA from matched blood and tumor tissue from 71 HGSC participants. In addition, we performed the OncoScan assay on tumor DNA from 61 participants to examine somatic copy number alterations (SCNA).

RESULTS

Approximately one-third of tumors had loss-of-function (LOF) germline (18/71, 25.4%) or somatic (7/71, 9.9%) variants in the DNA homologous recombination repair pathway genes BRCA1, BRCA2, CHEK2, MRE11A, BLM, and PALB2. LOF germline variants also were identified in other Fanconi anemia genes and in MAPK and PI3K/AKT/mTOR pathway genes. Most tumors harbored somatic TP53 variants (65/71, 91.5%). Using the OncoScan assay on tumor DNA from 61 participants, we identified focal homozygous deletions in BRCA1, BRCA2, MAP2K4, PTEN, RB1, SLX4, STK11, CREBBP, and NF1. In total, 38% (27/71) of HGSC patients harbored pathogenic variants in DNA homologous recombination repair genes. For patients with multiple tissues from the primary debulking or from multiple surgeries, the somatic mutations were maintained with few newly acquired point mutations suggesting that tumor evolution was not through somatic mutations. There was a significant association of LOF variants in homologous recombination repair pathway genes and high-amplitude somatic copy number alterations. Using GISTIC analysis, we identified NOTCH3, ZNF536, and PIK3R2 in these regions that were significantly associated with an increase in cancer recurrence and a reduction in overall survival.

CONCLUSIONS

From 71 patients with HGCS, we performed targeted germline and tumor sequencing and provided a comprehensive analysis of these 557 genes. We identified germline and somatic genetic alterations including somatic copy number alterations and analyzed their associations with relapse-free and overall survival. This single-site long-term follow-up study provides additional information on genetic alterations related to occurrence and outcome of HGSC. Our findings suggest that targeted treatments based on both variant and SCNA profile potentially could improve relapse-free and overall survival.

Impact of site of occlusion in proximal splenic artery embolisation for blunt splenic trauma

Background

Proximal splenic artery embolisation (PSAE) can be performed in stable patients with Association for the Surgery of Trauma (AAST) grade III-V splenic injury. PSAE reduces splenic perfusion but maintains viability of the spleen and pancreas via the collateral circulation. The hypothesized ideal location is between the dorsal pancreatic artery (DPA) and great pancreatic artery (GPA). This study compares the outcomes resulting from PSAE embolisation in different locations along the splenic artery.

Materials and methods

Retrospective review was performed of PSAE for blunt splenic trauma (2015–2020). Embolisation locations were divided into: Type I, proximal to DPA; Type II, DPA-GPA; Type III, distal to GPA. Fifty-eight patients underwent 59 PSAE: Type I (7); Type II (27); Type III (25). Data was collected on technical and clinical success, post-embolisation pancreatitis and splenic perfusion. Statistical significance was assessed using a chi-squared test.

Results

Technical success was achieved in 100% of cases. Clinical success was 100% for Type I/II embolisation and 88% for Type III: one patient underwent reintervention and two had splenectomies for ongoing instability. Clinical success was significantly higher in Type II embolisation compared to Type III (p = 0.02). No episodes of pancreatitis occurred post-embolisation. Where post-procedural imaging was obtained, splenic perfusion remained 100% in Type I and II embolisation and 94% in Type III. Splenic perfusion was significantly higher in the theorized ideal Type II group compared to Type I and III combined (p = 0.01).

Conclusion

The results support the proposed optimal embolisation location as being between the DPA and GPA.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Paths towards greater consensus building in experimental biology

In a recent editorial, the Editors-in-Chief of Journal of Experimental Biology argued that consensus building, data sharing, and better integration across disciplines are needed to address the urgent scientific challenges posed by climate change. We agree and expand on the importance of cross-disciplinary integration and transparency to improve consensus building and advance climate change research in experimental biology. We investigated reproducible research practices in experimental biology through a review of open data and analysis code associated with empirical studies on three debated paradigms and for unrelated studies published in leading journals in comparative physiology and behavioural ecology over the last 10 years. Nineteen per cent of studies on the three paradigms had open data, and 3.2% had open code. Similarly, 12.1% of studies in the journals we examined had open data, and 3.1% had open code. Previous research indicates that only 50% of shared datasets are complete and re-usable, suggesting that fewer than 10% of studies in experimental biology have usable open data. Encouragingly, our results indicate that reproducible research practices are increasing over time, with data sharing rates in some journals reaching 75% in recent years. Rigorous empirical research in experimental biology is key to understanding the mechanisms by which climate change affects organisms, and ultimately promotes evidence-based conservation policy and practice. We argue that a greater adoption of open science practices, with a particular focus on FAIR (Findable, Accessible, Interoperable, Re-usable) data and code, represents a much-needed paradigm shift towards improved transparency, cross-disciplinary integration, and consensus building to maximize the contributions of experimental biologists in addressing the impacts of environmental change on living organisms.

397 Seasonal Variation in Acute Cholecystitis; An Analysis to Predict Resources Allocation

Background

Acute cholecystitis accounts for 20% of Emergency General Surgical admissions. The concept of seasonal variation is still a developing concept in surgical literature. Whether acute cholecystitis also follows a seasonal trend remains to be established.

Aim

Given the struggle healthcare system has been facing towards resource and staff allocation to deliver best possible patient care, we thought this may be a step forward to predict North Wales demand of resources seasonally and make appropriate arrangements ahead of time.

Method

We performed a retrospective analysis of patients across North Wales who had a discharging diagnosis of acute cholecystitis from January 2010 to December 2019. Chi-square goodness-of-fit test was used to analyse seasonality of acute cholecystitis adjusting for variation in number of days between seasons. The number of days for seasons were taken as 92, 92, 91, and 90.25 for spring, summer, fall, and winter, respectively.

Results

Overall, 4100 patients presented to the three hospitals across North Wales with acute cholecystitis during the study period. The frequency of hospital admissions varied between months (minimum February n = 302, maximum July n = 373) and seasons (minimum winter n = 971, maximum spring n = 1067). After applying chi-square goodness-of-fit test to check significant seasonality, we did not find any significant seasonal variation in acute cholecystitis (p-value = 0.262).

Conclusions

Our data failed to show any significant seasonal variation in patients presenting with acute cholecystitis in North Wales. We recommend prospective collection of data at national level to validate our results.

Assessing the quality of research examining change in children’s mental health in the context of COVID-19

In their policy brief on the impact of COVID-19 on children and youth, the United Nations identified the need for “a rapid accumulation of data on the scale and nature of impacts among children.”1(p14) Although an important goal, this call to action defies how research typically unfolds. Science is a slow, methodical process that requires careful consideration of prior evidence, ethics, measurement, sampling, analysis, and implications, to name a few. Still, we appreciate the call to shift priorities and allocate resources to conduct research about this global event. The stakes are high and information is needed to guide us on how children and youth are faring during this unprecedented time. One problem is that sub-standard studies, often released as non-peer reviewed preprints, are being promoted on social media and in news outlets, and this attention can influence the public’s perception of risk, the credibility of scientists, and policy makers’ decisions related to funding and programming. Some scholars and medical professionals see preprints as a necessity during the pandemic to circumvent the lengthy review process and to arm professionals with the most up-to-date data.2 Others see this growing trend as facilitating the spread of misinformation because, unlike scientists who approach non-peer reviewed research with caution, popular news outlets and the public may take preprints at face value.3,4 Our goal is thus to remind readers of what constitutes good science in the field of child and youth mental health.

Every three weekly irinotecan for refractory/relapsed small cell lung cancer

e20584

Background: Current NCCN guidelines support weekly irinotecan regimen for refractory/relapsed SCLC (small cell lung cancer). Despite prior studies that used irinotecan for other solid malignancies included both weekly and three weekly regimens, NCCN do not acknowledge three weekly regimen for SCLC due to insufficient data, especially from United States patient population. We aimed to study clinical efficacy, side effect profile and cost analysis of three weekly irinotecan regimens for refractory/relapsed SCLC. Methods: Retrospective analysis of relapsed/refractory SCLC or high-grade neuroendocrine carcinoma (HGNEC) patients treated with every 3 weekly irinotecan (300 mg/m2) regimen between 2010 and 2020 at NCI-designated Markey Cancer Center/University of Kentucky healthcare was performed. Median PFS and adverse events per CTCAE 5.0 were determined. Results: A total of thirty-eight patients were included in our analysis, 32 with SCLC and 6 with HGNEC. Of 6 patients with HGNEC, primary site included bladder (n=1), prostate(n=1), gastroesophageal junction(n=1) and unknown primary (n=3). Mean age at diagnosis was 58 years. Mean prior line of therapies were 1.8 (range=1 to 4) and mean number of irinotecan cycles were 3.5 (range=1 to 12). Median progression free survival was 2.1 months (95% CI-1.6 to 8.1). Grade (G) 2, 3 and 4 adverse events were noted among 20.5%, 33.3% and 7.8% respectively. G3 and G4 neutropenia was seen in 2.6% and 5.3%; neutropenic fever was noted among 5.3%; G2 and G3 diarrhea among 7.9% and 15.8%; ileus among 5.3%; enterocolitis among 2.6%; G2 and G3 nausea and vomiting among 7.9% and 10.5%; G3 transaminitis among 2.6%; G3 and G4 acute kidney injury was seen among 5.1% and 2.6% respectively. Estimated overall costs (including infusion related expenses, cost of pre-medications and irinotecan) to deliver three 100mg/m2 doses with every weekly regimen was $661 compared to only $268 for a single 300mg/m2 dose with every three-weekly regimen. Conclusions: In previously treated patients with refractory/relapsed SCLC, every three weekly irinotecan regimen was found to have comparable efficacy and adverse event profile. Diarrhea, nausea, vomiting and neutropenia are the most common adverse events reported. Moreover, cost effectiveness of every 3 weekly regimen and reduced number of infusions should potentially benefit patients who live far from health care facility as is the case in rural Appalachia and also help reduce financial toxicity.

Priming immunotherapy with radiotherapy (RT) in advanced non-small cell lung cancer (NSCLC) and head and neck squamous cell cancer (HNSCC): Interim analysis of phase II clinical trial

2628

Background: Preclinical models demonstrate that combined RT with immune checkpoint inhibitor (ICI) results in specific CD8+ T-cell phenotype associated with a tumor-reactive population resulting in significant tumor response. Sequential treatment could allow radiation to release tumor antigens from immune inaccessible areas and provide robust anti-tumor immune response with ICI. We report an interim analysis of the phase II clinical trial evaluating the efficacy and safety of the combination. Methods: Advanced NSCLC and HNSCC patients who had initiated on FDA approved single-agent ICI were eligible. Patients were given SBRT (BED>100Gy) or 30 Gy fractionated RT delivered as a 3-dimensional dose to a single metastatic site within 14 days of the first ICI dose. Primary objective was 6-month PFS and secondary objectives were safety and tolerability, 1Y PFS and OS. This interim analysis was done after enrollment of 43 patients. Results: Between 10/2017 to 1/2021, 43 patients were enrolled, and 38 included in this analysis. Median age was 62 years; 26 patients were male. 9 patients received ICI for NSCLC as first-line, 7 for NSCLC second-line and 22 for HNSCC second-line. 24 patients received pembrolizumab and 14 nivolumab; 21 had SBRT and 17 fractionated RT. Median follow up duration was 11.8m (range: 2.7 - 31.4m) for patients without progressive disease (PD). 10 patients were off-study, 7 continuing treatment. 15 died and 26 had PD. 14 patients died of malignancy and cause of death for one patient was unknown. 6-month PFS was 49.19% with median PFS of 5.5 months. (table) Fifty-two grade-3-5 adverse events (AEs) were reported among 21 subjects. Most common were transaminitis (n=15), lymphopenia (n=8), and GI side effects (n=4). Treatment related AEs included 19 grade-3 events, and none were grade 4/5. Two grade-5 AEs were from PD (oral bleeding and unspecified). There were 20 grade-1/2 and 3 grade-3 immune related adverse events (IRAEs). No grade-4/5 IRAEs were reported. Two patients discontinued treatment due to grade 3 transaminitis. Conclusions: Interim analysis shows that 6m PFS was acceptable with majority of patients being second-line metastatic HNSCC who historically had mPFS of 2.1-2.3 months and mOS 7.7-8.4 months in Checkmate-141/KEYNOTE-040 trials. Hence, the combination is of further interest and accrual will continue to reach the goal. The combination therapy was tolerable without unexpected AEs. Majority of deaths were from disease progression. No treatment related grade 4/5 adverse events were reported. Two patients discontinued treatment due to grade-3 IRAE. Clinical trial information: NCT03313804. [Table: see text]

Dark Energy Survey Year 1 Results: Cosmological Constraints from Cluster Abundances, Weak Lensing, and Galaxy Correlations

We present the first joint analysis of cluster abundances and auto or cross-correlations of three cosmic tracer fields: galaxy density, weak gravitational lensing shear, and cluster density split by optical richness. From a joint analysis (4×2pt+N) of cluster abundances, three cluster cross-correlations, and the auto correlations of the galaxy density measured from the first year data of the Dark Energy Survey, we obtain Ω_{m}=0.305_{-0.038}^{+0.055} and σ_{8}=0.783_{-0.054}^{+0.064}. This result is consistent with constraints from the DES-Y1 galaxy clustering and weak lensing two-point correlation functions for the flat νΛCDM model. Consequently, we combine cluster abundances and all two-point correlations from across all three cosmic tracer fields (6×2pt+N) and find improved constraints on cosmological parameters as well as on the cluster observable-mass scaling relation. This analysis is an important advance in both optical cluster cosmology and multiprobe analyses of upcoming wide imaging surveys.

Striped catfish (Pangasianodon hypophthalmus) use air-breathing and aquatic surface respiration when exposed to severe aquatic hypercarbia

We investigated the extent to which the facultative air-breathing fish, the striped catfish (Pangasianodon hypophthalmus), uses air-breathing to cope with aquatic hypercarbia, and how air-breathing is influenced by the experimental exposure protocol and level of hypercarbia. We exposed individuals to severe aquatic hypercarbia (up to P_w CO₂  = 81 mmHg) using step-wise and progressive exposure protocols while measuring gill ventilation rate, heart rate, mean arterial blood pressure, and air-breathing frequency, as well as arterial blood pH and PCO₂ . We confirm that P. hypophthalmus is tolerant of hypercarbia. Under both protocols gill ventilation rate, heart rate, and mean arterial blood pressure were maintained near control levels even at very high CO₂ levels. We observed a marked amount of individual variation in the PwCO₂ at which air-breathing was elicited, with some individuals not responding at all. The experimental protocol also influenced the onset of air-breathing. Air-breathing began at lower P_w CO₂ in the step-wise protocol (23 ± 4.1 mmHg) compared with the progressive protocol (46 ± 7.8 mmHg). Air-breathing was often followed by aquatic surface respiration, at higher PCO₂ (71 ± 5.2 mmHg) levels. On average, the blood PCO₂ was approximately 43% lower (46 ± 2.5 mmHg) than water P_w CO₂ (~81 mmHg) at our highest tested CO₂ level. While this suggests that aerial CO₂ elimination is an effective, and perhaps critical, respiratory strategy used by P. hypophthalmus to cope with severe hypercarbia, this observation may also be explained by a long lag time required for equilibration.

Low potential for evolutionary rescue from climate change in a tropical fish

Climate change is increasing global temperatures and intensifying the frequency and severity of extreme heat waves. How organisms will cope with these changes depends on their inherent thermal tolerance, acclimation capacity, and ability for evolutionary adaptation. Yet, the potential for adaptation of upper thermal tolerance in vertebrates is largely unknown. We artificially selected offspring from wild-caught zebrafish (Danio rerio) to increase (Up-selected) or decrease (Down-selected) upper thermal tolerance over six generations. Selection to increase upper thermal tolerance was also performed on warm-acclimated fish to test whether plasticity in the form of inducible warm tolerance also evolved. Upper thermal tolerance responded to selection in the predicted directions. However, compared to the control lines, the response was stronger in the Down-selected than in the Up-selected lines in which evolution toward higher upper thermal tolerance was slow (0.04 ± 0.008 °C per generation). Furthermore, the scope for plasticity resulting from warm acclimation decreased in the Up-selected lines. These results suggest the existence of a hard limit in upper thermal tolerance. Considering the rate at which global temperatures are increasing, the observed rates of adaptation and the possible hard limit in upper thermal tolerance suggest a low potential for evolutionary rescue in tropical fish living at the edge of their thermal limits.

Rapid-warming tolerance correlates with tolerance to slow warming but not growth at non-optimal temperatures in zebrafish

Global warming is predicted to increase both acute and prolonged thermal challenges for aquatic ectotherms. Severe short- and medium-term thermal stress over hours to days may cause mortality, while longer sub-lethal thermal challenges may cause performance declines. The inter-relationship between the responses to short, medium and longer thermal challenges is unresolved. We asked if the same individuals are tolerant to both rapid and slow warming challenges, a question that has so far received little attention. Additionally, we investigated the possibility of a thermal syndrome where individuals in a population are distributed along a warm-type to cold-type axis. We tested whether different thermal traits correlate across individuals by acclimating 200 juvenile zebrafish (Danio rerio) to sub- or supra-optimal temperatures for growth (22 and 34°C) for 40 days and measuring growth and thermal tolerance at two different warming rates. We found that tolerance to rapid warming correlated with tolerance to slow warming in the 22°C treatment. However, individual tolerance to neither rapid nor slow warming correlated with growth at the supra-optimal temperature. We thus find some support for a syndrome-like organisation of thermal traits, but the lack of connection between tolerance and growth performance indicates a restricted generality of a thermal syndrome. The results suggest that tolerance to rapid warming may share underlying physiological mechanisms with tolerance to slower heating, and indicate that the relevance of acute critical thermal tolerance extends beyond the rapid ramping rates used to measure them.

Optimal Timing of CT Scanning in the Rapid Access Lung Cancer Clinic

Aims To investigate whether a ‘CT first’ approach to Rapid Access Lung Cancer Clinic (RALC) review could be feasible in an Irish context. Methods A retrospective review of our institution’s Lung Cancer Database was performed. All RALC first attendances from 2012-2018 were identified. Timing of CT was assessed as well as CT imaging findings. Results Total first attendances in this period were 2372, of whom 91% had CT thorax as part of their evaluation. 866 patients (37%) were diagnosed with lung cancer, all had an abnormal CT. 1290 patients (54%) underwent CT but did not have lung cancer after clinical work up. 34% of patients diagnosed with Lung Cancer had their CT scan post RALC. Time to diagnosis was longer in those who had post RALC CT (34.5 versus 21 days) Conclusion CT scanning plays a vital role in the RALC pathway. Initial delays in obtaining CT can result in delayed time to diagnosis. These findings warrant close consideration when devising future national lung cancer policy.

THU0475 THE EFFICACY OF ORAL GLUCOCORTICOSTEROIDS FOR PAIN IN RHEUMATOID ARTHRITIS: A PRELIMINARY REPORT OF A META-ANALYSIS

Background:

Glucocorticosteroids (GCs) are used to provide rapid relief of symptoms in people with active RA. Their use is recommended by most RA management guidelines and systematic reviews, although the magnitude of their benefit above placebo is uncertain. Persistent pain remains a problem in RA, even despite optimal immunomodulatory management. Systemic GC use may be associated with important adverse events.

Objectives:

To quantify the specific effects of oral GCs for RA pain.

Methods:

A systematic literature review was performed for RCTs using GCs in RA compared to inactive treatment. Trials were included whether or not participants received DMARD treatments, so long as a specific effect could be assigned to GCs. Medline, Embase and Cochrane databases were searched until November 2019 and 2 reviewers independently assessed titles, abstracts and full texts. Data for pain were synthesized in a meta-analysis. This study is part of a wider review (PROSPERO CRD42019111562).

For subgroup analyses, follow up time points of 0-3 months, >3 - 6 months and >6 months were selected to address duration of effect. Individual studies could contribute to each of the 3 follow up subgroups.

Meta-analysis was performed on standardized mean differences (SMDs, bodily pain data) and mean differences (MDs, 100mm VASpain only) of change from baseline (sd), using the Meta and Metafor packages in R. Heterogeneity was quantified using I2and tau statistics. Bias was assessed with a funnel plot and Eggers test.

Results:

15983 papers, 470 abstracts and 152 full texts were assessed. Pain data from 12 RCTs were suitable for the meta-analyses. The most common pain metric was the 100mm VASpain (9 trials).

Study populations ranged from n=12 to n=350 participants, 50% to 71% were female with mean ages from 43 to 66 years. Baseline scores for VASpain ranged from to 34 to 66 mm. Means were reported for DAS28 (from 4.9 to 5.8), ESR (25 to 60mm) and CRP (5 to 27mg/L).

Data synthesis at the reported primary time point/end point showed a statistically significant reduction in bodily pain in participants treated with GCs; SMD = -0.36 (10 studies, 1377 participants, 95% CI, -0.59 to -0.14, p=0.002) with significant heterogeneity (I2= 66%, tau = 0.27, p<0.01). The Funnel plot suggested asymmetry, favouring GCs (Eggers p = 0.007).

Subgroup analyses were used to investigate the time course of specific effects on pain. Efficacy displayed time-related decreases after initiation. From 0-3 months SMD= -0.56 (95% CI, -0.76 to -0.36, p<0.001, 9 studies, 936 participants, I2= 43%, Eggers p= 0.002). Efficacy was lower at >3 - 6 months (SMD= -0.32, 95%CI -0.52 to -0.11, p=0.002, 3 studies, 382 participants, I2=0%, Eggers p=0.75) and further reduced at >6 months (SMD= -0.07, 95%CI, -0.23 to 0.08, p=0.357, 4 studies, 665 participants, I2= 7%, Eggers p=0.43).

For trial data collected during concomitant oral GC dosage, mean difference (MDs) in 100mm VASpain was -14mm (95% CI, -20mm to -9mm) greater improvement in GC than control in the 0-3 month period (8 studies, 1047 participants, I2= 70%). For later follow ups, MDs at >3 to 6 months were -6mm (95% CI, -11mm to -1mm, 3 studies, 537 participants), and -1mm (95% CI, -6mm to 4mm, 3 studies, 369 participants) at >6 months.

Conclusion:

Oral GCs have efficacy for pain in RA but the mean effect is of borderline clinical importance, and greatest shortly after steroids are commenced. GCs were usually used alongside other treatments as part of a combination. Future research might determine who might gain most benefit from systemic GCs, and improve other treatments to reduce the burden of pain.

Acknowledgments:

Dr Douglas Grindley for help devising search strategy

Disclosure of Interests: :

Daniel McWilliams Grant/research support from: Grant support from Pfizer Ltd, Divya Thankaraj: None declared, Rheinallt Morgan: None declared, Julie Jones-Diette: None declared, David Walsh Grant/research support from: Grant support from Pfizer Ltd and Eli Lilly, Consultant of: Consultancy to Eli Lilly, Pfizer, Abbvie and GSK (all payments made to University of Nottingham). Consultancy to Love Productions(all payments made to the University of Nottingham).

Gender dynamics in digital health: overcoming blind spots and biases to seize opportunities and responsibilities for transformative health systems

Much remains to ensure that digital health affirms rather than retrenches inequality, including for gender. Drawing from literature and from the SEARCH projects in this supplement, this commentary highlights key gender dynamics in digital health, including blind spots and biases, as well as transformative opportunities and responsibilities. Women face structural and social barriers that inhibit their participation in digital health, but are also frequently positioned as beneficiaries without opportunities to shape such projects to better fit their needs. Furthermore, overlooking gender relations and focussing on women in isolation can reinforce, rather than address, women’s exclusions in digital health, and worsen negative unanticipated consequences. While digital health provides opportunities to transform gender relations, gender is an intimate and deeply structural form of social inequality that rarely changes due to a single initiative or short-term project. Sustained support over time, across health system stakeholders and levels is required to ensure that transformative change with one set of actors is replicated and reinforced elsewhere in the health system. There is no one size prescriptive formula or checklist. Incremental learning and reflection is required to nurture ownership and respond to unanticipated reactions over time when transforming gender and its multiple intersections with inequality.

EPID-17. ANALYSIS OF THE USE OF BEVACIZUMAB FOR THE TREATMENT OF GLIOBLASTOMA IN THE UNITED STATES

INTRODUCTION

Bevacizumab is an antibody against vascular endothelial growth factor that has been well investigated for glioblastoma, however, has limited proven efficacy. The drug has, however, demonstrated survival benefit in non-small cell lung carcinoma, renal cell carcinoma and colorectal carcinoma. We provide an overview of its use in the United States for select cancers.

METHODS

We queried the IQVIA database for all cases of glioblastoma diagnosed between January 2014 and June 2018 to analyze the use of bevacizumab for glioblastoma, non-small cell lung carcinoma, and colorectal carcinoma in the United States, and was compared to the standard of care for each indication (temozolomide for glioblastoma, pemetrexed for non-small cell lung carcinoma, and oxaliplatin for colorectal carcinoma).

RESULTS

A total of 85,351 patients were treated for glioblastoma as captured by IQVIA. Bevacizumab was prescribed in 17,958 patients, with a projected median annual total of 3,718 patients. The use of bevacizumab for glioblastoma during the study period decreased from 2014 to 2018 (p< 0.0001). The use of temozolomide has remained stable since 2014 to 2018 (p=0.49). For non-small cell lung cancer, we saw a significant decrease in the use of both bevacizumab and pemetrexed (p< 0.0001), with bevacizumab being used in less than 2% of the cases since 2017. For colorectal carcinoma, the use of bevacizumab has overall decreased with a peak use in 2016 (p< 0.0001). The use of oxaliplatin has increased (p< 0.0001).

CONCLUSIONS

Our findings demonstrated a decreased use of bevacizumab in oncology for three indications, likely associated with a changing role due to the benefit of novel therapy such as immunotherapy. The use of bevacizumab has decreased in glioblastoma, that may be associated to the lack of overall survival benefits in randomized clinical trials.

On the Observation of Wild Zebrafish (Danio rerio) in India

Zebrafish is one of the world's most widely used laboratory species, and it is utilized to answer important research questions in disparate fields such as biomedicine, genetics, developmental biology, pharmacology, toxicology, physiology, and evolution. Despite their popularity, very little is known about the biology of zebrafish in their natural habitat. This may, in part, be due to the difficulties associated with undertaking field trips to the remote areas of northern India, Nepal, and Bangladesh, which is the natural distribution range of zebrafish. Here, we present a field report describing a recent trip where we, together with local collaborators, visited several rivers in West Bengal, India, to observe wild zebrafish and their habitat. We present an overview of our observations on the biology of wild zebrafish, and the great variability of the different environments where they were found. We also include data collected on water chemistry parameters at 12 zebrafish sites, and weight data and photos of fish from these sites. We present extensive underwater videos of wild zebrafish and photographs of the sites, including video footage of courtship behavior. We show that the breeding period of wild zebrafish can be extended from the previous record of April-August to April-October. In addition, we provide practical advice for future zebrafish expeditions to this rural and inaccessible area. The goals of this article are to shed some light on the ecology of wild zebrafish, and to facilitate scientists in their future research trips. We hope that by observing zebrafish in the wild, we can increase our understanding of the natural ecology of this important model organism.

Brain cooling marginally increases acute upper thermal tolerance in Atlantic cod

Physiological mechanisms determining thermal limits in fishes are debated but remain elusive. It has been hypothesised that motor function loss, observed as loss of equilibrium during acute warming, is due to direct thermal effects on brain neuronal function. To test this, we mounted cooling plates on the heads of Atlantic cod (Gadus morhua) and quantified whether local brain cooling increased whole-organism acute upper thermal tolerance. Brain cooling reduced brain temperature by 2-6°C below ambient water temperature and increased thermal tolerance by 0.5 and 0.6°C on average relative to instrumented and uninstrumented controls, respectively, suggesting that direct thermal effects on brain neurons may contribute to setting upper thermal limits in fish. However, the improvement in thermal tolerance with brain cooling was small relative to the difference in brain temperature, demonstrating that other mechanisms (e.g. failure of spinal and peripheral neurons, or muscle) may also contribute to controlling acute thermal tolerance.

Are model organisms representative for climate change research? Testing thermal tolerance in wild and laboratory zebrafish populations

Model organisms can be useful for studying climate change impacts, but it is unclear whether domestication to laboratory conditions has altered their thermal tolerance and therefore how representative of wild populations they are. Zebrafish in the wild live in fluctuating thermal environments that potentially reach harmful temperatures. In the laboratory, zebrafish have gone through four decades of domestication and adaptation to stable optimal temperatures with few thermal extremes. If maintaining thermal tolerance is costly or if genetic traits promoting laboratory fitness at optimal temperature differ from genetic traits for high thermal tolerance, the thermal tolerance of laboratory zebrafish could be hypothesized to be lower than that of wild zebrafish. Furthermore, very little is known about the thermal environment of wild zebrafish and how close to their thermal limits they live. Here, we compared the acute upper thermal tolerance (critical thermal maxima; CT_max) of wild zebrafish measured on-site in West Bengal, India, to zebrafish at three laboratory acclimation/domestication levels: wild-caught, F₁ generation wild-caught and domesticated laboratory AB-WT line. We found that in the wild, CT_max increased with increasing site temperature. Yet at the warmest site, zebrafish lived very close to their thermal limit, suggesting that they may currently encounter lethal temperatures. In the laboratory, acclimation temperature appeared to have a stronger effect on CT_max than it did in the wild. The fish in the wild also had a 0.85-1.01°C lower CT_max compared to all laboratory populations. This difference between laboratory-held and wild populations shows that environmental conditions can affect zebrafish's thermal tolerance. However, there was no difference in CT_max between the laboratory-held populations regardless of the domestication duration. This suggests that thermal tolerance is maintained during domestication and highlights that experiments using domesticated laboratory-reared model species can be appropriate for addressing certain questions on thermal tolerance and global warming impacts.

Effect of a whey protein and rapeseed oil gel feed supplement on milk fatty acid composition of Holstein cows

Isoenergetic replacement of dietary saturated fatty acids (SFA) with cis-monounsaturated fatty acids (MUFA) and polyunsaturated fatty acids (PUFA) can reduce cardiovascular disease risk. Supplementing dairy cow diets with plant oils lowers milk fat SFA concentrations. However, this feeding strategy can also increase milk fat trans fatty acids (FA) and negatively affect rumen fermentation. Protection of oil supplements from the rumen environment is therefore needed. In the present study a whey protein gel (WPG) of rapeseed oil (RO) was produced for feeding to dairy cows, in 2 experiments. In experiment 1, four multiparous Holstein-Friesian cows in mid-lactation were used in a change-over experiment, with 8-d treatment periods separated by a 5-d washout period. Total mixed ration diets containing 420 g of RO or WPG providing 420 g of RO were fed and the effects on milk production, composition, and FA concentration were measured. Experiment 2 involved 4 multiparous mid-lactation Holstein-Friesian cows in a 4 × 4 Latin square design experiment, with 28-d periods, to investigate the effect of incremental dietary inclusion (0, 271, 617, and 814 g/d supplemental oil) of WPG on milk production, composition, and FA concentration in the last week of each period. Whey protein gel had minimal effects on milk FA profile in experiment 1, but trans-18:1 and total trans-MUFA were higher after 8 d of supplementation with RO than with WPG. Incremental diet inclusion of WPG in experiment 2 resulted in linear increases in milk yield, cis- and trans-MUFA and PUFA, and linear decreases in SFA (from 73 to 58 g/100 g of FA) and milk fat concentration. The WPG supplement was effective at decreasing milk SFA concentration by replacement with MUFA and PUFA in experiment 2, but the increase in trans FA suggested that protection was incomplete.

A Winter Survey of Domestic Heating among Elderly Patients

Elderly people have a greater need for domestic heating given the time they spend at home and the decline in the body thermoregulation that occurs with ageing. The use of domestic heating by 200 mentally competent newly admitted elderly in patients was evaluated by means of a questionnaire survey. Most patients (69%) were aware of the addition of value added tax (VAT) to their fuel bill and 31 % said they had reduced the amount of heating they use because of this. A third of patients (29.5%) said they had difficulty keeping warm prior to this admission. The majority of patients said they could not manage to keep warm in the winter without financial hardship. In addition, 29% said they had reduced the amount spent on food in order to pay for fuel bills. This study suggests that cold may contribute to hospital admissions in elderly patients. This should have implications for government spending and taxation policy on domestic heating.