No-Shave Long Hair Follicular Unit Excision Using an All-Purpose Skin-Responsive Device

Background

Current no-shave long hair-follicular unit excision (LH-FUE) techniques employ recesses (slots, notches, or grooves) in punch tips to reduce the long-hair shaft break rate (SBR) and graft transection rate (GTR). However, these methods demand advanced skills and extended procedure time.

Objective

We aimed to evaluate a skin-responsive FUE technique without the use of recess-tipped punches, accommodating diverse hair and skin types in LH-FUE procedures.

Methods and Materials

We retrospectively analyzed patients who underwent this technique using a UGraft Zeus device at five multinational clinics (Mexico, Colombia, India, United States, and Türkiye) from August 9, 2021, to April 11, 2023. Donor zones were pre-operatively graded for expected difficulty using the Sanusi FUE Scoring (SFS) Scale, ranging from class I (low difficulty) to V (high difficulty).

Results

Among 152 patients (mean age, 46 years; 146 straight-wavy, 6 curly-coiled hair), most (n=107) were class I donors. The GTR ranged 2.2%-4.3%, and was highest in class IV donors and those with thick-firm scalps. The SBR was 12.2%, and the average graft excision rate (GER; speed) was 440 grafts/h. Only 19G and 18G punches were used. All patients were satisfied with the procedure, with 57.4% reporting that they were "very happy". Surgeon willingness to perform no-shave LH-FUE significantly increased from 1.25 to 4.20 (on a scale of 1-5) after adopting this device. SFS class, skin thickness, and firmness, more than hair curliness, influenced the GTR, SBR, torque, and punch movement duration.

Conclusion

Our findings reveal consistent success in conducting no-shave LH-FUE using this skin-responsive device across diverse patients. Notably, success was achieved without recess-tipped punches, resulting in low GTR and SBR, along with a high GER and increased patient satisfaction. These outcomes suggest enhanced procedure speed and ease of use, contributing to a greater willingness among surgeons to adopt this technique.

Harnessing a real-time location system for contact tracing in a busy emergency department

BACKGROUND

With the persistent threat of emerging infectious diseases (EIDs), digital contact tracing (CT) tools can augment conventional CT for the prevention of healthcare-associated infectious disease transmission. However, their performance has yet to be evaluated comprehensively in the fast-paced emergency department (ED) setting.

OBJECTIVE

This study compared the CT performance of a radiofrequency identification (RFID)-based real-time location system (RTLS) with conventional electronic medical record (EMR) review against continuous direct observation of close contacts ('gold standard') in a busy ED during the coronavirus disease 2019 pandemic period.

METHODS

This cross-sectional study was conducted at the ED of a large tertiary care hospital in Singapore from December 2020 to April 2021. CT performance [sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and kappa] of the RTLS, EMR review and a combination of the two approaches (hybrid CT) was compared with direct observation. Finally, the mean absolute error (MAE) in the duration of each contact episode found via the RTLS and direct observation was calculated.

RESULTS

In comparison with EMR review, both the RTLS and the hybrid CT approach had higher sensitivity (0.955 vs 0.455 for EMR review) and a higher NPV (0.997 vs 0.968 for EMR review). The RTLS had the highest PPV (0.777 vs 0.714 for EMR review vs 0.712 for hybrid CT). The RTLS had the strongest agreement with direct observation (kappa=0.848). The MAE between contact durations of 80 direct observations and their respective RTLS contact times was 1.81 min.

CONCLUSION

The RTLS was validated to be a high-performing CT tool, with significantly higher sensitivity than conventional CT via EMR review. The RTLS can be used with confidence in time-strapped EDs for time-sensitive CT for the prevention of healthcare-associated transmission of EIDs.

Follicular Unit Excision in Patients of African Descent: A Skin-Responsive Technique

BACKGROUND

Follicular unit excision is a favored minimally invasive hair transplantation method. However, it is suboptimal for many patients of African descent because of wide variations in hair and skin characteristics.

OBJECTIVE

To evaluate the performance of a skin-responsive follicular unit excision device, which accommodates hair curliness, skin thickness, and firmness in patients of African descent.

MATERIALS AND METHODS

The authors retrospectively evaluated patients who underwent scalp follicular unit (FU) excision using a skin-responsive technique at 7 multinational clinics. The preoperative donor grading for the anticipated difficulty used a scale with Class V indicating the highest degree of hair curliness, skin thickness, and firmness.

RESULTS

Of 64 eligible patients (45 males and 19 females), 28 had Class V FU excision donor grades. The mean transection rate for all patients was 3%-6%, which was highest in class V patients. Skin thickness and firmness had a greater effect on the maximum transection rate than hair curliness. Only 19 or 18 G punches were used.

CONCLUSION

The authors report consistence success of a new skin-responsive FU excision device for all patients of African descent with a mean graft transection rate of less than 10%. The findings support skin thickness and firmness as major influencers of graft attrition rate.

A221 EFFECT OF PROXIMITY TO A SPECIALTY TERTIARY CENTRE ON OUTCOMES IN INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED RETROSPECTIVE COHORT STUDY

Background

The etiology of inflammatory bowel disease (IBD) is unknown; however, developed nations such as Canada ranking amongst the highest worldwide. With many diseases patients in urban and rural areas have different access to care and resources.

Purpose

To describe the differences in outpatient healthcare utilization, use of biologic agents and complication of IBD based on proximity to a tertiary health care centre.

Method

A retrospective cohort study was conducted comparing IBD patients seen in IBD clinics at affiliated with Western University in London, Canada between August 2019 – December 2019. IBD patients were compared on their use of outpatient healthcare utilization, biologic agents and IBD complications based on their proximity to a tertiary care centre (>100 km and <100 km). Patients residing >100 km from a tertiary centre were termed “rural” while <100 km from a tertiary centre were termed “urban.” Retrospective chart review occurred over a six-month period between January to June 2021.

Result(s)

A total of 481 were reviewed. Of those, 97 (UC, n=29; CD, n=68) and 95 (UC, n=30; CD, n=65) met inclusion for the urban and rural groups respectively. Patient demographics were similar between the two groups except IBD disease location with pancolitis seen more commonly in urban patients compared to ileocolonic in rural patients (urban, n=39; rural, n=34). IBD patients in both groups had similar number of appointments (urban, n=20.1 ± 13.8; rural, n=17.5 ± 12.1) and endoscopic procedures (urban, n= 4.9 ± 3.1; rural, n= 4.7 ± 3.2) with their gastroenterologists. More urban patients were managed with no therapy for their IBD (urban, n=16; rural, n=5). A higher rate of rural patients were managed with biologics (urban, n=56; rural, n=66) and combination therapy (urban, n=16; rural, n=27). The most common related IBD-related complications were IBD flares (urban, n=55; rural, n=60), intestinal strictures (urban, n=25; rural, n=34), intestinal obstructions (urban, n=10; rural, n=23) and rectal/genitourinary fistulas (urban, n=6; rural, n=21). Similar numbers of intra-abdominal surgery were seen between both groups with partial bowel resection (urban, n=13; rural, n=12) and right hemicolectomy (urban, n=10; rural, n=18) as the predominant surgery in urban and rural patients, respectively.

Conclusion(s)

This study demonstrated outpatient healthcare utilization when attending specialty gastroenterology appointments and outpatient endoscopies were numerically similar in rural and urban patients. IBD patient residing further from a tertiary care centre were numerically more likely to be managed with biologics and combination therapy. However the dataset is small and generalizations cannot be made.

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None

Disclosure of Interest

None Declared

A86 CANNABIS USE IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE IS HIGHER FOLLOWING LEGALIZATION OF CANNABIS IN CANADA AND IS ASSOCIATED WITH LOWER QUALITY OF LIFE

Background

Patients with inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), often experience fluctuating and unpredictable symptoms. Most individuals require chronic therapy with immunomodulators or novel biologics to maintain disease remission. In addition to conventional medical therapy, many patients also seek out alternative therapies such as cannabis. Reports in the USA suggest that cannabis is used by ~12% of UC and ~16% of CD patients, despite it being legally prohibited.

Purpose

The aim of our study is to evaluate the use of cannabis in a cohort of patients with IBD following its legalization in Canada, and to assess its effects on IBD disease severity.

Method

We conducted a prospective cohort study of adult IBD patients seen in clinic at a tertiary care center in London, ON. Patients completed an online 40-question survey that collected data on demographics, IBD disease history, cannabis use, and included the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). The survey was distributed and collected by the REDCap platform maintained by Western University. The study was approved by the Western University Ethics Committee.

Result(s)

Completed surveys were obtained from 254 individuals (148 individuals with CD, 90 with UC and 16 with indeterminate colitis). Over half of participants were between 35-64 years of age and female. Fifty-three percent of participants reported life-time cannabis use and 51% of users started using cannabis only in the preceding 3 years. Individuals with CD had higher rates of recent use, defined as use within the past 6 months, when compared with UC (41% vs 31%). Cannabis was taken multiple times per week by 57% of users. Cannabis was used to treat GI symptoms by 30% of users, as well as to help with sleep (26%) and for recreation (27%). Despite side effects such as dry mouth, anxiety and concentration issues, 79% of users felt the benefits of cannabis outweighed its harms. Interestingly, only 46% of cannabis users discussed their use with their family physician or gastroenterologist. Recent cannabis users did not differ in the use of IBD medication or self-reported rates of GI symptoms. Furthermore, recent users did not differ in the rates of surgical procedures for IBD (recent 35% vs non-recent 32%). Recent cannabis users did have a significantly lower quality of life as indicated by SIBDQ scores when compared to non-recent users (recent use 37 vs non-recent use 40).

Conclusion(s)

Cannabis use among patients with IBD after its legalization is more than double the rate previously reported in the literature. Importantly, physicians are likely to be unaware of its prevalence in their practice. Cannabis was used by patients to treat GI and non-GI symptoms, and it was associated with lower SIBDQ scores. Our results suggest that physicians should inquire about Cannabis use amongst their patients with IBD, and that further studies are required to determine its effects on disease severity.

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CIHR

Disclosure of Interest

None Declared

A222 EFFECT OF CLINICAL FACTORS ON IBD TREATMENT RESPONSE: FINDINGS FROM A NOVEL SINGLE CENTER PATIENT REGISTRY

Background

Inflammatory bowel disease (IBD), comprising both Crohn’s disease as well as ulcerative colitis, has shown heterogenous response to therapy. Over the past decades, targeted biologic therapies have become the mainstay of treatment. Even with the rapid pace of progress in this field, roughly a third of patients do not show an initial response to these treatments. The ability to accurately predict treatment response to therapy would both improve patient safety and satisfaction as well as decrease costs from ineffective therapies.

Purpose

The primary aim of this project is to identify clinical factors predictive of disease response to induction biologic therapy in inflammatory bowel disease through the creation of a novel single center patient registry.

Method

Initially, a single center tissue biopsy registry of IBD patients receiving colonoscopy was created. Retrospective clinical data was subsequently collected on patients identified to have initiated or changed biologic therapy after entry into the registry. Clinical data regarding age, sex, comorbidities, lifestyle factors, time since initial diagnosis, extra intestinal manifestations, serum markers, prior IBD treatments, planned treatment, clinical response, as well as endoscopic response were collected. A Pilot study of the first 30 patients identified was undertaken. Individual clinical factors were compared between patients with a documented clinical response to biologic therapy and non-responders at the group level as well as by biologic therapy initiated.

Result(s)

No statistically significant differences in collected clinical data parameters were observed between treatment responders and non responders in aggregate as well as when sub selected by individual biologic therapy initiated, bio-naive status, and steroid dependence.

Conclusion(s)

This project has demonstrated that clinical factors alone do not adequately predict disease response in inflammatory bowel disease. Future work will expand this data registry to further clinical factors and continue patient enrolment. Next steps also include the addition of tissue level data, in particular tissue level RNA data. It is hoped that these parameters, either individually or in combination, will provide a robust and accessible predictor of response to biologic therapy in inflammatory bowel disease.

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Other

Please indicate your source of funding below:

Western University Department of Medicine

Disclosure of Interest

None Declared

A104 INVISIBLE COLONIC MALIGNANCY AND POSSIBLE IDIOSYNCRATIC DRUG-INDUCED LIVER INJURY FROM VEDOLIZUMAB IN A PATIENT WITH ULCERATIVE COLITIS, PRIMARY SCLEROSING CHOLANGITIS AND AUTOIMMUNE HEPATITIS OVERLAP SYNDROME

Background

Inflammatory bowel disease (IBD) is characterized by chronic inflammation of the gastrointestinal tract. Due to an increased risk of developing colorectal cancer, regular surveillance for dysplastic lesions via colonoscopy is recommended. Invisible dysplasia is the abnormal development of cells noted on pathology with no visible lesion seen during colonoscopy. Primary sclerosing cholangitis (PSC) is an immune-mediated liver disease leading to progressive stricturing and fibrosis of the bile ducts. There is significant association between PSC and IBD, as up to 80% of patients with PSC having underlying IBD. Drug induced liver injury (DILI) is a common cause of acute liver failure in most Western countries. Most cases of DILI are self-limited, with resolution of laboratory and clinical findings after cessation of the offending agent.

Purpose

To describe a case of invisible colonic malignancy and possible idiosyncratic drug-induced liver injury from vedolizumab (VDZ) in a patient with ulcerative colitis (UC), PSC and autoimmune hepatitis (AIH) overlap syndrome.

Method

Patient consent was obtained. Information from electronic records was extracted, including admission notes and procedural reports. A literature review was performed using Pubmed.

Result(s)

A 32-year-old Caucasian female with UC on VDZ with PSC and AIH had multiple colonoscopies performed demonstrating multifocal low-grade dysplasia. However, she remained resistant to surgery. She presented to clinic with tea-coloured urine, fatigue, and scleral icterus. Investigations revealed conjugated hyperbilirubinemia with elevation in hepatocellular liver enzymes. Imaging was consistent with large duct PSC, and liver biopsy showed grade 2 chronic hepatitis raising the possibility of large bile duct obstruction. She underwent liver transplant assessment and VDZ was held. Her bilirubin and liver enzymes recovered. Given multiple colonoscopies showing multifocal dysplastic changes and the patient declining other biologics, she would ultimately undergo total proctocolectomy with end ileostomy. Pathology demonstrated mucinous adenocarcinoma with a signet ring component.

Conclusion(s)

Both mucinous adenocarcinoma and signet ring carcinoma are more aggressive malignancies associated with poor prognosis. Found more often in younger patients, they are often diagnosed in later stages with lymphovascular invasion. Here, there was no evidence of metastases in any of the 40 lymph nodes examined, which indicated more favourable prognosis.

The mechanism by which VDZ potentially causes liver injury is unknown. Multiple therapies for PSC-AIH overlap and IBD were entertained as causative agents. However, significant improvement in clinical symptoms and serologic parameters following cessation of VDZ was temporally suggestive.

This case simultaneously highlights the importance of both timely colectomy in IBD patients with high-risk features during surveillance and early recognition and cessation of potential causative medications which induce liver injury.

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None

Disclosure of Interest

None Declared

DIFFERENCES IN OUTCOMES AMONG PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING CATHETER ABLATION WITH VERSUS WITHOUT INTRACARDIAC ECHOCARDIOGRAPHY

Background

Intracardiac echocardiography (ICE) use can lead to early detection of periprocedural complications and may improve patient outcomes by providing real‐time visualization of catheter location and the treatment area during cardiac ablation (CA) for atrial fibrillation (AF).

Objective

Examine complications and 12‐month healthcare use among patients with AF undergoing CA with versus without ICE use during the procedure in a real‐world setting.

Methods

The 2015–2020 IBM MarketScan® Database was used to identify non‐elderly adults (age 18–64 years) undergoing CA for AF. Patients were classified into ICE/non‐ICE groups based on the presence or absence of ICE procedure codes. Patients in each group were matched on study covariates using propensity scores. Peri‐procedural complications, 12‐month cardiovascular (CV) or AF‐related inpatient admission, repeat CA, and cardioversion were compared using a Cox proportional hazard model.

Results

1371 patients were identified in each study cohort (ICE and non‐ICE) after propensity matching. Patients who had CA with ICE had a significantly lower rate of complications than those without (2.9% vs. 5.8%; p < .001). The risk of complications was 50% lower with ICE use (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.34–0.72). For assessment of 12‐month healthcare utilization, 1250 patients were identified in each cohort after propensity matching. ICE use was associated with a 36% lower risk of 12‐month repeat ablation (HR 0.64; 95% CI 0.49–0.83). No differences in CV‐ or AF‐related inpatient admission and cardioversion were observed.

Conclusion

Among patients with AF, the use of ICE during an ablation procedure was associated with lower incidence of complications and repeat ablation.

What's Race Got to Do With It? CRP Levels in Immune Mediated Skin Diseases: Considerations for Hidradenitis Suppurativa

Currently, there is a lack of racial/ethnic heterogeneity in research databases, exposing a systematic issue in studies exploring inflammation-mediated diseases, such as hidradenitis suppurativa (HS). HS is a chronic inflammatory skin condition that disrupts normal structure and functioning of terminal hair follicles, resulting in the formation of recurrent abscesses, nodules, and sinus tracts within intertriginous regions. Studies have described higher serum levels of inflammation-mediated C-reactive protein (CRP) in patients with HS, a disease that predominantly affects skin of color (SOC) populations. Herein, we explore the role of CRP levels in the context of HS disease presentation, management, and psychosocial implications in SOC patients to determine existing disparities in research studies.

Mitigating emotional responses to stressors: coping strategies, modifiers and support

OBJECTIVE

The stressful nature of the intensive care unit (ICU) environment is increasingly well characterised. The aim of this paper was to explore modifiers, coping strategies and support pathways identified by experienced Intensivists, in response to these stressors.

METHOD

Prospective qualitative study employing interviews with Intensivists in two countries. Participants were asked how they mitigated their emotional responses to the stressors of the ICU. Audio-recordings were transcribed and analysed by all researchers who agreed upon emerging themes and subthemes.

RESULTS

A wide range of strategies were reported. Although several participants had sought professional help and all supported its utility, few disclosed accessing such help to others indicating stigma. Many felt a sense of responsibility for the well-being of other staff but identified barriers that suggest alternate support pathways are required. Further implications of these findings to training considerations are described.

CONCLUSIONS

Several approaches were described as regularly employed by Intensivists to mitigate ICU environmental stressors. Intensivists perceive themselves to have limited training to provide support to others; they also perceive stigma in seeking professional help.

Barriers to Treatment of Hallucinations and Delusions in People With Dementia Residing in Long-Term Care

Importance: Most people with dementia will experience neuropsychiatric symptoms, including psychosis characterized by hallucinations and delusions. Across dementia subtypes, hallucinations and delusions are common, though their prevalence and presentation may vary. These symptoms have been associated with worse outcomes compared with dementia alone, including accelerated functional decline and mortality. Many people with dementia reside in long-term care facilities, and identification and management of hallucinations and delusions in this setting are critical. Observations: For residents in long-term care facilities, the following factors can hinder management of hallucinations and delusions related to dementia: (1) delayed recognition of symptoms; (2) reluctance of staff and family members to acknowledge psychiatric issues; (3) lack of approved pharmacotherapies to treat hallucinations and delusions associated with dementia-related psychosis; and (4) regulatory and institutional guidelines, including the long-term care regulatory guidelines established by the Centers for Medicare and Medicaid Services and the 5-star rating system. Conclusions and Relevance: Barriers to the treatment of hallucinations and delusions in patients with dementia in the long-term care setting are myriad and complex. Early diagnosis of dementia-related psychosis and new treatment options for managing hallucinations and delusions are needed to improve care of this patient population.

A103 META-ANALYSIS: NEOPLASIA OF THE POUCH IN PATIENTS WITH ULCERATIVE COLITIS POST ILEAL POUCH-ANAL ANASTOMOSIS

Background

Ileal anal pouch anastomosis (IPAA) is often used for patients with severe ulcerative colitis that is refractory to medical treatment or for patients with neoplasia/dysplasia to maintain intestinal continuity. Patients with ulcerative colitis have an increased risk of developing dysplasia or colorectal cancer compared to the general population, however the need for pouch surveillance is debated. A meta-analysis was performed to identify the risk and prevalence of pouch related malignancy in patient with ulcerative colitis following IPAA.

Aims

Our aim is to assess of the rate of dysplasia and malignancy post IPAA in patients with ulcerative colitis and also assess what the factors associated with developing malignancy post IPAA

Methods

A search of Embase and Ovid MEDLINE was conducted to identify studies from 2014 to June 2021 that reported the incidence of dysplasia or malignancy following IPAA in patients with ulcerative colitis. Abstracts and conferences were not included in the search. The studies were assessed for relevance and data were extracted independently by two reviewers.

Results

This analysis included 11, 268 patients with variable follow-up. The evidence was graded as low-certainty due to significant heterogeneity and low-quality studies. The pooled prevalence of carcinoma or dysplasia (low or high grade) in pouch or the rectal cuff was 0.4% [95% CI 0.2- 0.7]. However, in patients with prior colectomy for colorectal cancer the odds ratio was 32.20 [95% CI 15.58 - 66.53] for pouch malignancy. Significant heterogeneity and variability of the pooled studies was identified (I2 = 77.5%).

Conclusions

Although the rate of dysplasia or malignancy was 0.4% for all IPAA, the odds ratio for these outcomes in patients with IPAA for prior malignancy was 32.20 [95% CI 15.58 - 66.53]. Further studies are required to validate these findings.

Funding Agencies

None

A142 IMPACT OF HLADQA1*05G>A GENETIC-SCREENING FOR OPTIMAL ANTI-TNF THERAPY IN INFLAMMATORY BOWEL DISEASE: A PRELIMINARY REPORT

Background

Genetic variation in the human leukocyte antigen ( HLA) gene is strongly associated with the formation of anti-drug antibodies to tumor necrosis factor-alpha antagonists (anti-TNF) in inflammatory bowel disease (IBD). It is also associated anti-TNF loss of response and treatment discontinuation.

Aims

We aimed to evaluate the utility of preemptive HLADQA1*05G&gt;A screening to reduce the incidence of treatment-related adverse events in an IBD population by lessening the need for combination therapy in those who do not carry the risk allele. We also assessed for the occurrence of anti-TNF anti-drug antibody (ADA) formation, anti-TNF loss of response, treatment discontinuation compared to an unscreened population.

Methods

A non-randomized open label study is ongoing in IBD patients being considered for anti-TNF therapy. Participants received either pre-treatment HLADQA1*05G&gt;A screening (prospective-screening group, n=25/110 recruited), with the addition of one of azathioprine or methotrexate to anti-TNF therapy (combination therapy) if identified as a high risk variant carrier (G/A or A/A) or received combination therapy without undergoing prospective HLADQA1*05A&gt;G screening (control group, n=25/110 recruited). All participants will be followed for up to 1 year and observed for the occurrence of any adverse drug events, formation of anti-TNF drug antibodies (ADA), anti-TNF loss of response and anti-TNF discontinuation.

Results

To date, the prevalence of HLADQA1*05 G/A and A/A was 20% in the prospective-screening group and thus 20% (n=5/25) received combination therapy and 80% (n=20) received anti-TNF monotherapy. All participants in the control group (n=25/25) received combination therapy. Considering all groups, 78% (n=39/50) received infliximab, while 22% (n=11/50) received adalimumab. To date, the median follow-up period is 5 (IQR=4) months. Fewer adverse drug events have been reported in the prospective-screening group versus the control group (16.7% vs 33.3%, odds ratio 0.40, 95%CI=0.12–1.56, p=0.18). Anti-TNF ADA formation and treatment discontinuation were similar between groups (prospective-screening, 0% versus control, 4.2%). A higher proportion of controls experienced anti-TNF loss of response (16.7% vs 8.3%, p=0.38).

Conclusions

Preemptive HLADQA1*05G&gt;A screening appears to reduce the need for combination therapy when using anti-TNF agents in an IBD population. Fewer drug-related adverse events are reported to date in the screened cohort without a concomitant increase in deleterious outcomes such as ADA formation or anti-TNF discontinuation. Completion of this study will help define whether or not HLADQA1*05G&gt;A-screening is a clinically-actionable and relevant tool for guiding the application of combination therapy in IBD.

Funding Agencies

Lawson Health Research Institute

A225 VACCINE-PREVENTABLE DISEASES IN HOSPITALIZED PATIENTS WITH END-STAGE LIVER DISEASE/CIRRHOSIS: A NATIONWIDE COHORT ANALYSIS

Background

Cirrhosis is associated with immune dysfunction, which increases susceptibility to infection and subsequent hospitalization. Vaccination of this high-risk patient population can mitigate the risk of infection.

Aims

Data from the National Inpatient Sample (NIS) was analyzed to compare the prevalence of vaccine-preventable diseases (VPD) among hospitalized patients both with and without cirrhosis.

Methods

The 2013 NIS database was interrogated using ICD-9-CM codes to identify patients with cirrhosis and VPD. Baseline characteristics were compared (see: Table 1). Univariate and multivariate regression models identified risks associated with VPD adjusting for survey procedures.

Results

313,710 patients were hospitalized for VPD, including 13,080 patients (4.1%) with cirrhosis (see: Table 1) Patients with cirrhosis were more likely to be hospitalized with pneumococcal pneumonia (odds ratio [OR] = 1.45 [95% CI 1.29 – 1.63], P <0.001), hepatitis A (OR = 7.04 [95% CI 5.96 – 8.31], P <0.001) and hepatitis B (OR = 14.41 [95% CI 12.53 – 14.36], P <0.001) infections compared to patients without liver cirrhosis. Patients with cirrhosis were less likely to have an infection with influenza (OR = 0.55 [95% CI 0.49 – 0.62], P <0.001), human papillomavirus (HPV) (OR = 0.57 [95% CI 0.43 – 0.75, P < 0.001) and varicella zoster (OR = 0.78 [95% CI 0.69 – 0.89], P <0.001). Minimal differences in hospitalizations for haemophilus influenzae or meningococcal infections were noted between groups.

Odds ratios for VPD adjusting for age, sex, race, patient location, patient income, hospital type and bed-size, mortality risk, type 2 diabetes mellitus, malignancy, human immunodeficiency virus (HIV), organ transplantation and immunodeficiency:

pneumococcal pneumonia (OR = 1.27 [95% CI 1.13 – 1.44], P < 0.001), hepatitis A (OR = 5.99 [95% CI 5.02 – 7.15], P < 0.001); and hepatitis B (OR = 11.07 [95% CI 10.24 – 11.97], P < 0.001).

Conclusions

These results emphasize the importance of vaccinating patients with cirrhosis against pneumococcal pneumonia, hepatitis A and hepatitis B infections to reduce hospitalization

Table 1: Baseline characteristics of patients with cirrhosis and without cirrhosis presenting with a vaccine preventable disease.

Funding Agencies

None

A166 CANNABIS USE IN CANADIAN INDIVIDUALS WITH INFLAMMATORY BOWEL DISEASE FOLLOWING LEGALIZATION OF CANNABIS

Background

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), are characterized by remitting and relapsing symptoms of abdominal pain, diarrhea, nausea, fatigue, and poor sleep. Most patients with IBD require chronic immunosuppressive therapy to maintain their disease in remission. Due to their disease chronicity, individuals often seek additional complementary or alternative medicines such as cannabis to treat their symptoms. Reports from the US show cannabis use in 12% of UC and 16% of CD patients. However, these numbers are likely underestimates given that cannabis remains illegal in many states.

Aims

The aim of our study is to evaluate the use of cannabis in a cohort of patients with IBD and to assess its association with IBD disease severity.

Methods

We conducted a prospective cohort survey of adult patients with IBD seen in tertiary care in London Health Sciences Centre. A 40-question online survey was completed by consenting patients and collected data on demographics, IBD disease history, cannabis use, and included the Short Inflammatory Bowel Disease Questionnaire (SIBDQ) as a measure of disease severity. The study was approved by the Western University Ethics Committee. Statistical analyses was performed using a Chi squared test for categorical data, and a two-tailed t-test for continuous data.

Results

Completed surveys were obtained from 210 individuals (135 individuals with CD and 75 with UC) and demographics were similar between the CD and UC cohort. Fifty-six percent of participants reported cannabis use at least once in their lifetime, with 38% of participants reporting cannabis use in the preceding 6 months. Interestingly, 46 percent of life-time cannabis users did not divulge their cannabis use to their physicians. In patients with UC, those who actively used cannabis were less likely to be on 5-ASA therapy (9 active users vs 22 non-users, p&lt;0.05). Medical therapy was otherwise similar between cannabis users and non-users. Surgical rates were similar between cannabis users and non-users amongst both IBD subtypes. With respect to the burden of disease, patients with CD reported higher rates of abdominal pain if they were active users, however, overall SIBDQ scores were not altered by cannabis use (21 user vs 20 non-user). Similarly, SIBDQ scores were similar amongst patients with UC who were cannabis users and non-users (20 user vs 16 non-user).

Conclusions

Cannabis use in patients with IBD is very common and much higher than previously reported prior to the legalization in Canada, but its use is not associated with lower disease severity based on patient reported outcomes. Our study also reveals that patients often do not report this use to their doctors so physicians must be aware of its prevalence amongst their IBD patient population.

Funding Agencies

None

Randomized comparison of proximal and distal radial access for coronary angiography and interventions

Funding Acknowledgements

Type of funding sources: None.

Introduction

Vascular access for coronary procedures is of paramount important not only for successful procedure but also to prevent complications. In comparison to femoral access, proximal radial artery (PRA) access at wrist is associated with decreased bleeding complications and mortality.  The most important complication of PRA access is radial artery occlusion Use of the proximal radial artery (PRA) approach at wrist has several limitations:  the need to supinate the hand, which can exacerbate chronic joint pain, the depth of the radial artery in large arms, which could make arterial puncture challenging even under ultrasound guidance, the risk of sporadic bleeding in the forearm, and the risk of radial artery occlusion. All above limitations can be overcome by distal radial artery (DRA) access in anatomical snuff box.  Randomized Studies are lacking for the comparison between DRA and PRA approach in coronary procedures.

Aims and objective

To compare safety, efficacy and feasibility between PRA and DRA approach in randomized fashion.

Material and methods

This was single center randomized controlled trial. 320 patients were randomized in PRA and DRA groups. PRA approach was in wrist and DRA approach was in anatomical snuff box. Primary endpoint was cannulation failure (failure to achieve radial access) and transradial failure (failure to complete procedure after successful access). Secondary safety outcome includes major (compartment syndrome, need for vascular surgery, hand dysfunction, nerve palsy ,arteriovenous fistula, hematoma requiring blood transfusion, proximal radial artery occlusion) and minor (radial artery spasm, hematoma not requiring transfusion or causing compartment syndrome, ecchymosis, local edema, paresthesia, pseudoaneurysm) complications; secondary efficacy outcome were puncture attempts, cannulation time, procedure time, radiation dose, hemostasis time  and quality of life endpoint  was pain score .

Results

 Each group was having 160 patients. In DRA group 73.9 % were CAG and 26.1 % were PCI; in PRA group and 75.7 were CAG and 24.3 were PCI. Cannulation failure was more in DRA group (7.5 % vs 2.5 %, P &lt; 0.001) without difference in transradial failure (n = 3 vs 4, p =0.764). There were no major complications in both groups except PRAO which was significantly less in DRA group (0 % vs 5.2 %, p= 0.007). Puncture attempts, cannulation time, pain score were more in DRA (1.65 vs 1.29, P &lt; 0.001;3.23 vs 2.62 minutes, p &lt; 0.001;25.5 vs 21.6 minutes, p = 0.039 respectively). There was no significant difference for minor complications in both groups.

Conclusion

DRA approach is as safe and feasible as PRA approach and causes significantly less PRAO. DRA approach may be advocated as default approach where radial access is chosen for coronary procedures. Abstract Figure. primary outcome  Abstract Figure. Procedural characteristic

Clinical significance of epicardial fat in suspected angina pectoris: an observational study

Funding Acknowledgements

Type of funding sources: None.

Background

Epicardial adipose tissue (EAT) is the visceral fat between pericardium and visceral epicardium and is the source of several endocrine and inflammatory mediators. It also has paracrine affects in the neighboring coronary arteries.

Objective

 To evaluate the association of EAT with subclinical atherosclerosis (carotid intima media thickness & flow mediated vasodilation), ultrasonic and anthropometric measures of abdominal fat, metabolic syndrome and coronary artery disease (CAD) concurrently.

Material and methods

Patients who underwent computed tomography (CT) coronary angiography for suspected CAD were prospectively included. All underwent anthropometric measurements, laboratory investigations, ultrasonic measurement of liver fat grade & B-mode hepatorenal ratio, carotid intima media thickness (CIMT), flow mediated vasodilation (FMD), CT measurement of epicardial fat thickness (EFT) & epicardial fat volume (EFV) along with CT coronary angiography. Study population was divided into 2 groups on the basis of presence or absence of CAD and were compared. The relationship between risk factors and presence of CAD was assessed by logistic regression analysis. To define EFT and EFV value predictive of the presence of significant CAD, the area under (AUC) the receiver operating characteristic (ROC) curve was calculated. Correlation between EFT as well as EFV with anthropometric and laboratory parameters, CIMT and FMD were assessed by Pearson correlation coefficient.

Results

Total 54 patients were included in study. Mean age was 54 years, 66% were diabetic and 33% were hypertensive. Mean CIMT, FMD, EFT and EFV were 0.70 + 0.27 cm; 5.64 + 2.64%; 5.51 + 2.50 mm and 60.6 + 28.6 cc, respectively. Total 34 (62.96%) patients were detected to have CAD. EFT as well as EFV were significantly higher in CAD group (3.31 + 2.34 vs 6.24 + 1.91mm; p= &lt;0.001, 72.5 + 22.3 vs 40.4 + 27.1cc; p= &lt;0.001); in patients with metabolic syndrome (83.3 + 18.4 vs 49.2 + 26.1cc; p &lt; 0.001, 7.13 + 1.49 vs 4.16 + 2.32mm; p &lt; 0.001). Both, EFV & EFT were significantly correlated with the abdominal fat, CIMT and FMD. Smoking, age and EFV were the independent predictors for CAD.  EFV &gt;31.65cc predicted the presence of CAD (sensitivity 91.25%, specificity 60%, AUC = 0.798, 95% CI = 0.665-0.930) and EFT &gt;2.85mm predicted the presence of CAD (sensitivity 94.1%, specificity 65%, AUC= 0.820, 95% CI= 0.687-0.953).

Conclusions

Epicardial fat is significantly associated with presence of CAD, metabolic syndrome, visceral fat, CIMT and FMD. CT measured epicardial fat may be included with CT based CAD lesion assessment and CT coronary calcium score to screen the patients of suspected angina pectoris. Abstract Figure. Epicardial adipose tissue  Abstract Figure. EFV and CAD

Behavioural responses of Intensivists to stressors in Intensive Care

BACKGROUND

The hospital intensive care unit (ICU) environment encompasses sick patients who present for care in health crisis. Healthcare in this setting is complex, often involving the co-ordination of multiple professional teams, all under significant time pressures. The sequelae for staff interacting in this dynamic and often volatile setting are variable, depending upon their coping skillset and their familiarity with the stressors.

AIMS

The primary aim of this study was to describe and in doing so, normalize the behavioural responses expressed by ICU doctors (Intensivists) in response to stressful workplace events. The secondary aim was to identify those responses that contributed to resilience.

METHODS

A prospective qualitative study of senior Intensivists using a semi-scripted iterative interview. Data were transcribed and thematically analysed with verbatim quotations selected to support coding choices.

RESULTS

Nineteen experienced Intensivists from three sites in Australia and Israel participated. Clinicians described conscious, physiological and professional responses to stressors, including sense-making and taking time to process information with appropriate support. Two of the most important mitigation processes revealed were the use of reflective learning and preventative practice changes to prevent future errors. These were overlaid with the importance of disclosure and transparency in clinical work.

CONCLUSIONS

Repeated exposure to stressful events potentiates burnout, wherein staff no longer experience satisfaction and enjoyment in what they do. This paper presents the behavioural responses that experienced Intensivists described in relation to stressful events in the ICU, including steps taken to mitigate the effects of these events on their personal well-being.

Distal radial access in the right anatomical snuffbox for coronary angiography and interventions: a prospective observational study

Background

Distal radial access in the anatomical snuffbox is a novel technique for vascular access. However, limited clinical data is available, mainly limited to the left distal radial access. In view of the paucity of data on right distal radial access; this study was conducted to assess the feasibility, efficacy and safety of the right distal radial approach as a default access route for transradial catheterization.

Methods

We enrolled 159 consecutive patients with a palpable right distal radial pulse prospectively at a single center. A detailed clinical evaluation, laboratory tests and echocardiographic examination was done. Doppler examination of distal radial artery for its patency and size was done before puncture attempt. The right distal radial artery was punctured using the back wall technique. Primary outcome was successful puncture of distal right radial artery. Secondary outcomes were number of puncture attempts, pain score, radial artery spasm, forearm and distal radial hematoma, proximal and distal radial artery occlusion, bleeding and other vascular complications, access site crossover due to distal radial access failure, contrast volume used, and radiation dose.

Results

Distal radial puncture was successful in 144/159 (90.1%) patients. The mean distal radial artery diameter was 2.2±0.25 mm. Mean pain score by visual analogue scale was 2.36±1.9. There were no bleeding events. Snuffbox hematoma was seen in 11 (7.6%) patients and forearm hematoma occurred in 5 (3.5%) patients. There were 9 (6.3%) cases of radial spasm, 4 (2.8%) cases of radial occlusion at distal access site and 1 (0.7%) forearm radial artery occlusion.

Conclusions

The right distal radial access is a feasible, safe and efficacious alternative approach for coronary angiogram and interventions.

Funding Acknowledgement

Type of funding sources: None.

An innovative route for valorising iron and aluminium oxide rich industrial wastes: Recovery of multiple metals

Several industrial wastes including biomass, fly ashes, red mud, mill scales, water treatment residues, have significant concentrations of metal oxides: Fe₂O₃, Al₂O₃, TiO₂, SiO₂ etc. Several efforts have been made towards recovering metals within these wastes. Rather than recovering one metal at a time, we report a novel approach for simultaneously extracting multiple metals from mixed oxides in a single process step. Using three distinct furnaces/heating regimes, the carbothermic reduction of Fe₂O₃/Al₂O₃/SiO₂ system was investigated at 1450-1700 °C for up to 2 h over a wide composition range. Complete reduction was achieved for both Fe₂O₃ and SiO₂ in all cases leading to the formation of Fe and Fe-Si alloys. The reduction of alumina at moderate temperatures was the key challenge. No alumina reduction was observed during reductions at 1450 °C. A partial reduction of alumina and the formation of Fe-Al alloys was detected in the Al₂O₃/Fe₂O₃/C system at 1550 °C. The formation of Fe-Si-Al alloys was also observed in the Fe₂O₃/SiO₂/Al₂O₃/C system at 1550 °C. Complete reduction of alumina was observed at 1600-1700 °C, even for up to 50 wt% alumina in the system. Optimal operating conditions and reference standards were established for the simultaneous recovery of multiple metals from waste oxides. While conserving natural resources, this novel route will lower the burden on waste storage facilities with significant contributions to the economic and environmental sustainability of industrial waste management.

Prurigo Nodularis Is Characterized by Systemic and Cutaneous T Helper 22 Immune Polarization

Prurigo nodularis (PN) is an understudied, chronic inflammatory skin disease that disproportionately affects African Americans and presents with intensely pruritic nodules of unknown etiology. To better characterize the immune dysregulation in PN, PBMCs and skin biopsies were obtained from patients with PN and healthy subjects (majority African American) matched by age, race, and sex. Flow cytometric analysis of functional T-cell response comparing patients with PN with healthy subjects identified increased γδT cells (CD3+CD4-CD8-γδTCR+) and Vδ2+ γδT enrichment. Activated T cells demonstrated uniquely increased IL-22 cytokine expression in patients with PN compared with healthy controls. CD4+ and CD8+ T cells were identified as the source of increased circulating IL-22. Consistent with these findings, RNA sequencing of lesional PN skin compared with nonlesional PN skin and biopsy site‒matched control skin demonstrated robust upregulation of T helper (Th) 22‒related genes and signaling networks implicated in impaired epidermal differentiation. Th22‒related cytokine upregulation remained significant, with stratifications by race and biopsy site. Importantly, the expression of the IL-22 receptors IL22RA1 and IL22RA2 was significantly elevated in lesional PN skin. These results indicate that both systemic and cutaneous immune responses in patients with PN are skewed toward a Th22/IL-22 profile. PN may benefit from immunomodulatory therapies directed at Th22‒mediated inflammation.

Health-related quality of life and economic burden of prurigo nodularis

BACKGROUND

Prurigo nodularis (PN) is an understudied, pruritic inflammatory skin disease. Little is known about the effect of PN on quality of life and its associated economic burden.

OBJECTIVE

To quantify the impact of PN on quality of life and its economic implications.

METHODS

A cohort study of PN patients (n = 36) was conducted using the Health Utilities Index Mark 3 questionnaire. Control data from US adults (n = 4187) were obtained from the 2002-2003 Joint Canada/United States Survey of Health. Quality-adjusted life year loss and economic costs were estimated by comparing the Health Utilities Index Mark 3 scores of the PN patients with those of the controls.

RESULTS

The PN patients had lower overall health performance compared to the controls, (mean ± SE, 0.52 ± 0.06 vs 0.86 ± 0.003, respectively, P < .001). In multivariable regression, PN was found to be associated with worse health performance (coefficient -0.34, 95% CI [-0.46 to -0.23]), most prominent in the pain subdomain (coefficient -0.24, 95% CI [-0.35 to -0.13]). This correlated to an average of 6.5 lifetime quality-adjusted life years lost per patient, translating to an individual lifetime economic burden of $323,292 and a societal burden of $38.8 billion.

CONCLUSION

These results demonstrate that PN is associated with significant quality-of-life impairment, similar to the level of other chronic systemic conditions. PN is also associated with a substantial individual economic burden, emphasizing the necessity of research on effective treatment options.

Transcriptomic analysis of atopic dermatitis in African Americans is characterized by Th2/Th17-centered cutaneous immune activation

Atopic dermatitis (AD) often presents more severely in African Americans (AAs) and with greater involvement of extensor areas. To investigate immune signatures of AD in AAs with moderate to severe pruritus, lesional and non-lesional punch biopsies were taken from AA patients along with age-, race-, and sex-matched controls. Histology of lesional skin showed psoriasiform dermatitis and spongiotic dermatitis, suggesting both Th2 and Th17 activity. Gene Set Variation Analysis showed upregulation of Th2 and Th17 pathways in both lesional versus non-lesional and lesional versus control (p < 0.01), while Th1 and Th22 upregulation were observed in lesional versus control (p < 0.05). Evidence for a broad immune signature also was supported by upregulated Th1 and Th22 pathways, and clinically may represent greater severity of AD in AA. Furthermore, population-level analysis of data from TriNetX, a global federated health research network, revealed that AA AD patients had higher values for CRP, ferritin, and blood eosinophils compared to age-, sex-, and race-matched controls as well as white AD patients, suggesting broad systemic inflammation. Therefore, AA AD patients may feature broader immune activation than previously thought and may derive benefit from systemic immunomodulating therapies that modulate key drivers of multiple immune pathways.

A103 PIVOTING IN A PANDEMIC: THE IMPACT OF COVID-19 ON THE PROVISION OF CARE FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A PRELIMINARY ANALYSIS

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak, also known as COVID-19, was declared a worldwide pandemic in March of 2020. Since the onset of the pandemic, the focus of many healthcare systems has shifted toward limiting non-essential visits to hospitals in order to prioritize and allocate resources toward treating those affected by COVID-19, and preventing further exposures. While the effect of COVID-19 has been felt amongst many patient populations, those with inflammatory bowel disease (IBD) have been particularly impacted through delayed appointments and endoscopy, which is critical in disease monitoring.

Aims

We aimed to determine how changes to the provision of IBD care due to the COVID-19 pandemic have affected IBD patients.

Methods

A retrospective cohort study was conducted using administrative data comparing IBD patients admitted to the gastroenterology ward from March 17 to August 31 2019, with IBD patients admitted from March 17 to August 31 2020 at a tertiary care centre in London, Ontario. Patients were reviewed to assess differences in care utilization and IBD-related outcomes such as hospitalization, surgery and length of stay and in-patient drug therapy.

Results

A total of 538 patients (259 in 2019 cohort and 279 in 2020 cohort) were reviewed with 48 and 60 IBD patients meeting the inclusion criteria for 2019 and 2020 respectively. Patient demographics were similar between 2019 and 2020 cohort for age, sex, rurality, disease type, and biologic exposure. A greater proportion of patients were admitted with IBD flares in 2020 (86.7% vs 75%, p=0.03). Furthermore, the 2020 cohort also had a 45% increase in in-patient surgical consultations (p=0.07), a 50% increase in in-patient IBD-related surgeries (p=0.39), a 69% increase in inpatient Remicade prescription (p=0.13) and a 70% increase in infectious complications at presentation to hospital (p=0.21). A shorter median length of stay was reported for patients in the 2020 cohort (4 days IQR 3.95 vs 5.85 IQR 4.65, p=0.09).

Conclusions

Preliminary data suggest that during the COVID-19 pandemic, we have seen more deleterious outcomes in our IBD patients such as increased flares necessitating hospital admission. There was also a non-significant trend toward increased infectious complications as well as in-patient surgeries and need for in-patient Remicade. Though these results cannot be fully interpreted due to the need for further sampling, they suggest that IBD patients may be at-risk for poor outcomes in the current climate of medical care. Completion of this study will help define the full impact of care shifts related to reducing the spread of the novel coronavirus on IBD patients and highlight areas of care that need careful assessment and consideration to protect IBD patient health.

Funding Agencies

None

A224 LIVER CIRRHOSIS AND VENOUS THROMBOEMBOLISM: A NATIONAL INPATIENT SAMPLE STUDY

Background

The sequelae of decompensated cirrhosis include a reduction in both hepatic coagulation factors and platelets. While historically it was felt that patients with cirrhosis were naturally anticoagulated, recent studies have refuted this. As a result, cirrhotic patients may be a risk for development of venous thromboembolism (VTE). Conflicting data regarding VTE risks limits guidance for clinicians.

Aims

National Inpatient Sample (NIS) data were analyzed to compare the prevalence of VTE among hospitalized patients with and without cirrhosis.

Methods

NIS is a database of US inpatient admissions. The 2014 NIS database was interrogated using ICD-9-CM codes to identify adult patients with cirrhosis and VTE. Baseline characteristics for patients with and without cirrhosis were compared. Multivariate regression models identified risks of VTE adjusting for survey procedures. Data were presented with odds ratio (OR) with 95% confidence intervals (95% CI). A p-value &lt;0.05 was statistically significant.

Results

605,825 patients with cirrhosis were included. VTE occurred in 8,940 patients with cirrhosis and 627,490 controls (1.5% and 2.2% respectively). The corresponding values for PE were 0.5% and 1.1%; and for DVT were 1.1% and 1.4%. The OR for VTE in patients with cirrhosis was 0.547 [95% CI (0.520–0.576), p &lt;0.001] when adjusting for risk factors for VTE (table 1).

Conclusions

Prevalence of VTE was lower among inpatients with cirrhosis compared to controls. Use of anticoagulation was not controlled as these data were not available, which could limit some associations. Further prospective studies are needed to overcome the limitations of retrospective analysis.

Funding Agencies

None

Health-Related QOL and Economic Burden of Chronic Pruritus

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey on 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained from the Joint Canada/US Survey of Health. Quality-adjusted life-year loss and economic costs were estimated on the basis of Health Utilities Index Mark 3 scores of patients with CP versus controls. Patients with CP had lower overall health performance than the control (0.56 ± 0.03 vs. 0.86 ± 0.003, P < 0.001). In multivariable regression, CP was associated with worse overall health performance (coefficient = -0.30, 95% confidence interval = -0.33 to -0.27), most accentuated in the domains of pain (coefficient = -0.24, confidence interval = -0.28 to -0.21) and emotion (coefficient = -0.11, confidence interval = -0.13 to -0.10). The reduced Health Utilities Index Mark 3 score correlated with 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates for willingness to pay, the quality-adjusted life-year loss translated to an individual lifetime economic burden of $274,921 and a societal burden of $88.8 billion. CP is associated with significant QOL impairment. The economic burden of CP highlights the necessity for further research into management options.

Epidemiology and Comorbidities of Excoriation Disorder: A Retrospective Case-Control Study

Excoriation disorder is a psychocutaneous disorder characterized by repetitive skin-picking and associated with significant morbidity. Currently, epidemiological data in patients with excoriation disorder are lacking so we sought to characterize common patient demographics and comorbidities. We conducted a retrospective case-control study comparing 250 patients with excoriation disorder with 250 age-, race- and sex-matched controls identified between 2007 and 2019 at a single tertiary care center. We found that the majority of excoriation disorder patients were female (76%), Caucasian (82%) and unmarried (62%), with a mean age of 49 years. Compared to the matched controls, patients with excoriation disorder had increased odds of several psychiatric illnesses, including obsessive compulsive disorder (odds ratio (OR) 28.48, 95% confidence interval (CI): 1.68, 481.75), substance use disorder (OR 24.33, 95% CI: 5.81, 101.77), post-traumatic stress disorder (OR 8.23, 95% CI: 2.24, 129.40), depression (OR 8.19, 95% CI: 4.86, 13.80), bipolar disorder (OR 7.55, 95% CI: 2.22, 25.65), attention-deficit/hyperactivity disorder (OR 5.63, 95% CI: 1.62, 19.57), and anxiety (OR 5.01, 95% CI: 2.92, 8.62). Only a minority (42%) of patients were given psychiatry referrals and of those referred, a majority (64%) did not follow-up with psychiatry. The outcomes were also generally unfavorable as only 21% of patients experienced a resolution or improvement in their symptoms. This highlights the need for a multidisciplinary approach to manage patients with excoriation disorder, involving both dermatologists and psychiatrists.

Sleep disturbance in adults with chronic pruritic dermatoses is associated with increased C-reactive protein levels

BACKGROUND

Pruritus is a common symptom that can significantly reduce quality of life through sleep disruption.

OBJECTIVE

To examine features of disturbed sleep in patients with chronic pruritic dermatoses and test the hypothesis that systemic inflammation may serve as a biomarker for impaired sleep in these patients.

METHODS

Cross-sectional analysis of the National Health and Nutrition Examination Survey investigating systemic inflammation using C-reactive protein (CRP) levels. Logistic regression was used to compare patients with and without sleep disturbances, adjusting for demographics (model 1) and medical comorbidities (model 2).

RESULTS

Chronic pruritic dermatoses were associated with multiple sleep disturbances, including nighttime awakenings (model 1: odds ratio [OR], 1.646; 95% confidence interval [CI], 1.031-2.627; model 2: OR, 1.329; 95% CI, 0.888-1.989) and early morning awakening (model 1: OR, 1.669, 95% CI, 1.118-2.493; model 2: OR, 1.582; 95% CI, 1.008-2.481). Mean CRP levels were 52.8% higher among patients with pruritic dermatoses reporting trouble sleeping compared with those who did not (0.663 vs 0.434 mg/dL; P = .034). Trouble sleeping was also positively correlated with CRP levels (β = 0.142, P = .025).

LIMITATIONS

Potential recall bias among participants.

CONCLUSIONS

In addition to confirming sleep disturbances with pruritic dermatoses, we found these disturbances are more likely to present with elevated CRP levels. Clinicians should consider the potential risk for sleep-related and cardiac comorbidities in patients diagnosed with itchy skin conditions.

Factors influencing the release of potentially toxic elements (PTEs) during thermal processing of electronic waste

The release of potentially toxic elements as airborne fine particulates is a significant environmental risk associated with recycling e-waste. Some of these may redeposit near emission sites or be transported over long distances causing wide-spread pollution. With an aim to identify key factors affecting particulate emissions, we report novel investigations on the adsorptive capture of particulate matter (PM) released during low temperature pyrolysis (600 °C; 15 min) of waste printed circuit boards (PCBs). A significant proportion of the released particulates (5.3 to 37%) were captured by adsorbents located downstream and in close proximity to the emitting source. Data was collected for four different PCBs and three adsorbents: alumina, silica-gel and activated carbon. With sizes ranging from nanoparticles to over 10 µm, adsorbed particulates were present as fines, spheres, oblongs, clusters and larger particles with no specific shape. Of the 24 elements identified initially in waste PCBs, only 14 were detected in released particulates: major PTEs- Zn, Sn, Pb and Cu (up to 400 ppm); minor PTEs- Ni, Mn, Cd, Cr and Ba (up to 10 ppm); trace PTEs- Co, In, Bi, Be and Sb (up to 1 ppm). Key factors influencing the release of PTEs during thermal processing were identified as basic elemental characteristics, densities, melting points, vapor pressures, initial concentrations, local bonding and mechanical strength. These results show that the presence of low melting point/high vapour pressure elements (Zn, Pb, Sn) should be minimised for a significant reduction in PTE emissions during e-waste processing.