Remnant cholesterol is correlated with retinal vascular morphology and diabetic retinopathy in type 2 diabetes mellitus: a cross-sectional study

BACKGROUND

The association between remnant cholesterol (RC) and diabetic retinopathy (DR) in type 2 diabetes mellitus (T2DM) remains unclear. Morphological changes in retinal vessels have been reported to predict vascular complications of diabetes, including DR.

METHODS

This cross-sectional study included 6535 individuals with T2DM. The RC value was calculated using the recognized formula. The retinal vascular parameters were measured using fundus photography. The independent relationship between RC and DR was analyzed using binary logistic regression models. Multiple linear regression and subgroup analyses were employed to investigate the link between RC and vascular parameters, including the retinal arteriolar diameter (CRAE), venular diameter (CRVE), and fractal dimension (Df). Mediation analysis was performed to assess whether the vascular morphology could explain the association between RC and DR.

RESULTS

RC was independently associated with DR in patients with a longer duration of T2DM (> 7 years). Patients with the highest quartile RC levels had larger CRAE (5.559 [4.093, 7.025] μm), CRVE (7.620 [5.298, 9.941] μm) and Df (0.013 [0.009, 0.017]) compared with patients with the lowest quartile RC levels. Results were robust across different subgroups. The association between RC and DR was mediated by CRVE (0.020 ± 0.005; 95% confidence interval: 0.012-0.032).

CONCLUSIONS

RC may be a risk factor for DR among those who have had T2DM for a longer period of time. Higher RC levels were correlated with wider retinal arterioles and venules as well as higher Df, and it may contribute to DR through the dilation of retinal venules.

Artificial Intelligence-based quantitative evaluation of retinal vascular parameters in thyroid-associated ophthalmopathy

PURPOSE

Thyroid-associated ophthalmopathy (TAO) may result in increased metabolism and abnormalities in microcirculation. The fractal dimension (Df) of retinal vessels has been shown to be related to the pathology of a number of ophthalmic disorders, but it hasn't been investigated in TAO.

METHODS

We analyzed 1078 participants aged 18 to 72 (548 healthy volunteers and 530 TAO). Images were captured using a non-mydriatic 45-degree fundus camera. Baseline retinal characteristics, such as vessel width, tortuosity, and Df were measured using semiautomated software from fundus images. The average retinal parameters were compared between the two groups. The receiver operation curve (ROC) was used to assess the diagnostic efficacy of various retinal vascular parameters for TAO.

RESULTS

Despite controlling for potential confounding variables, Df, vessel width, and tortuosity significantly increased in TAO compared to healthy volunteers. Compared to active TAO, patients in the inactive phase had a larger retinal venous caliber (p < 0.05), but there was no difference in Df or arterial caliber. Moderate and severe cases had a higher Df compared with mild cases (EUGOGO guidelines). The area under the ROC for Df, tortuosity, and vascular caliber in the diagnosis of TAO was 0.904 (95% CI: 0.884-0.924), 0.638 (95% CI: 0.598-0.679), and 0.617 (95% CI: 0.576-0.658), respectively.

CONCLUSIONS

Due to its accessibility, affordability, and non-invasive nature, retinal vascular Df may serve as a surrogate marker for TAO and might be used to identify severe cases. With relatively high diagnostic performance, the Df is of some utility for the detection of TAO.

Distinctive Imaging Characteristics of Retinal and Cerebral Vessels between Central and Branch Retinal Vein Occlusion by MRI and AI-Based Image Analyzer

Retinal vessels have been good predictive and prognostic imaging biomarkers for systemic or eye diseases. Numerous studies have shown that the two retinal vein occlusion entities may correlate with cardiovascular and cerebrovascular events or primary open-angle glaucoma. This study aims to investigate if there is a disparity in the correlations between branch RVO (BRVO) and central RVO (CRVO) with systemic disorders or POAG, thus explaining the pathogenic difference between BRVO and CRVO. This retrospective case-control study enrolled 59 RVO subjects (118 eyes), including 25 CRVO and 34 BRVO subjects, who received routine eye and brain MRI examinations. The geometric characteristics of the caliber of the retinal and cerebral blood vessels and the optic nerve subarachnoid space width (ONSASW) were measured. Multivariable logistic regression analysis showed that ONSASW at 3 mm behind the globe (p = 0.044) and the relative retinal venular calibers (p = 0.031) were independent risk factors for the CRVO-affected eyes group in comparison with the BRVO-affected eyes group after adjusting for age, duration of hypertension, BMI, and IOP. In the CRVO-affected eyes, narrower relative retinal arteriolar calibers (p = 0.041) and wider relative venular calibers (p = 0.011) were independent risk factors compared with the CRVO-contralateral normal eyes when adjusting for IOP. We concluded that BRVO may be more associated with cerebrovascular diseases, and CRVO may be correlated with primary angle glaucoma. The geometric characteristics difference between the retinal and cerebrovascular may explain the pathological difference between CRVO and BRVO.

Quantization of Optic Disc Characteristics in Young Adults Based on Artificial Intelligence

PURPOSE

This study aimed to automatically and quantitatively analyse the characteristics of the optic disc by applying artificial intelligence (AI) to fundus images.

METHODS

A total of 1084 undergraduates were recruited in this cross-sectional study. The optic disc area, cup-to-disc ratio (C/D), optic disc tilt, and the area, width, and height of peripapillary atrophy (PPA) were automatically and quantitatively detected using AI. Based on axial length (AL), participants were divided into five groups: Group 1 (AL ≤ 23 mm); Group 2 (23 mm < AL≤ 24 mm); Group 3 (24 mm < AL≤ 25 mm); Group 4 (25 mm < AL< 26 mm) and Group 5 (AL ≥ 26 mm). Relationships between ocular parameters and optic disc characteristics were analysed.

RESULT

A total of 999 undergraduates were included in the analysis. The prevalence of optic disc tilting and PPA were 47.1% and 92.5%, respectively, and increased with the severity of myopia. The mean optic disc area, PPA area, C/D, and optic disc tilt ratio were 1.97 ± 0.46 mm2, 0.84 ± 0.59 mm2, 0.18 ± 0.07, and 0.81 ± 0.08, respectively. In Group 5, the average optic disc area (1.84 ± 0.41 mm2) and optic disc tilt ratio (0.79 ± 0.08) were significantly smaller and the PPA area (1.12 ± 0.61 mm2) was significantly larger than those in the other groups. AL was negatively correlated with optic disc area and optic disc tilt ratio (r=-0.271, -0.219; both p < 0.001) and positively correlated with PPA area, width, and height (r = 0.421, 0.426, 0.345; all p < 0.01). A greater AL (β = 0.284, p < 0.01) and a smaller optic disc tilt ratio (β=-0.516, p < 0.01) were related to a larger PPA area.

CONCLUSION

The characteristics of the optic disc can be feasibly and efficiently extracted using AI. The quantization of the optic disc might provide new indicators for clinicians to evaluate the degree of myopia.

Prevalence of Fundus Tessellation and Its Screening Based on Artificial Intelligence in Chinese Children: the Nanjing Eye Study

INTRODUCTION

To investigate the prevalence of fundus tessellation (FT), and the threshold for screening FT using an artificial intelligence (AI) technology in Chinese children.

METHODS

The Nanjing Eye Study was a population-based cohort study conducted in children born between September 2011 and August 2012 in Yuhuatai District of Nanjing. The data presented in this paper were obtained in 2019, when these children were 7 years old and underwent 45° non-mydriatic fundus photography. FT in whole fundus, macular area, and peripapillary area was manually recognized from fundus photographs and classified into three grades. Fundus tessellation density (FTD) in these areas was obtained by calculating the average exposed choroid area per unit area using artificial intelligence (AI) technology based on fundus photographs. The threshold for screening FT using FTD was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 1062 enrolled children (mean [± standard deviation] spherical equivalent: - 0.28 ± 0.70 D), the prevalence of FT was 42.18% in the whole fundus (grade 1: 36.53%; grade 2: 5.08%; grade 3: 0.56%), 45.57% in macular area (grade 1: 43.5%; grade 2: 1.60%; grade 3: 0.50%), and 49.72% in peripapillary area (grade 1: 44.44%; grade 2: 4.43%; grade 3: 0.85%), respectively. The threshold value of FTD for screening severe FT (grade ≥ 2) was 0.049 (area under curve [AUC] 0.985; sensitivity 98.3%; specificity 92.3%) in the whole fundus, 0.069 (AUC 0.987; sensitivity 95.5%; specificity 96.2%) in the macular area, and 0.094 (AUC 0.980; sensitivity 94.6%; specificity 94.2%) in the peripapillary area, respectively.

CONCLUSION

Fundus tessellation affected approximately 40 in 100 children aged 7 years in China, indicating the importance and necessity of early FT screening. The threshold values of FTD provided by this study had high accuracy for detecting severe FT and might be applied for rapid screening.

Fundus Tessellated Density Assessed by Deep Learning in Primary School Children

Purpose

To explore associations of fundus tessellated density (FTD) and compare characteristics of different fundus tessellation (FT) distribution patterns, based on artificial intelligence technology using deep learning.

Methods

Comprehensive ocular examinations were conducted in 577 children aged 7 years old from a population-based cross-sectional study, including biometric measurement, refraction, optical coherence tomography angiography, and 45° nonmydriatic fundus photography. FTD was defined as the average exposed choroid area per unit area of the fundus, and obtained by artificial intelligence technology. The distribution of FT was classified into the macular pattern and the peripapillary pattern according to FTD.

Results

The mean FTD was 0.024 ± 0.026 in whole fundus. Multivariate regression analysis showed that greater FTD was significantly correlated with thinner subfoveal choroidal thickness, larger parapapillary atrophy, greater vessel density inside the optic disc, larger vertical diameter of optic disc, thinner retinal nerve fiber layer, and longer distance from optic disc center to macular fovea (all P < 0.05). The peripapillary distributed group had larger parapapillary atrophy (0.052 ± 0.119 vs 0.031 ± 0.072), greater FTD (0.029 ± 0.028 vs 0.015 ± 0.018), thinner subfoveal choroidal thickness (297.66 ± 60.61 vs 315.33 ± 66.46), and thinner retinal thickness (285.55 ± 10.89 vs 288.03 ± 10.31) than the macular distributed group (all P < 0.05).

Conclusions

FTD can be applied as a quantitative biomarker to estimate subfoveal choroidal thickness in children. The role of blood flow inside optic disc in FT progression needs further investigation. The distribution of FT and the peripapillary pattern correlated more with myopia-related fundus changes than the macular pattern.

Translational Relevance

Artificial intelligence can evaluate FT quantitatively in children, and has potential value for assisting in myopia prevention and control.

A262 NEONATAL ACUTE LIVER FAILURE DUE TO PRESUMED GESTATIONAL ALLOIMMUNE LIVER DISEASE - A CASE REPORT

Background

Neonatal acute liver failure (NALF) is a rare disease that is distinct from acute liver failure seen in older children and adults. Gestational alloimmune liver disease (GALD) is the most frequent cause, is initiated in utero by sensitization of the maternal immune system to a fetal hepatocyte antigen and subsequent production of maternal immunoglobulin G antibodies that cross the placenta. Maternal IgG binds to a fetal hepatocyte antigen and initiates an innate immune response involving the terminal complement cascade and membrane attach complex. The understanding of the alloimmune origin has led to the use of intravenous immunoglobulin (IVIG) treatment and exchange transfusion, significantly increasing survival. However, approximately 25% of patients may not respond and require salvage liver transplantation. In spite of an increased rate of comorbidities, concern for technical difficulties and limited graft availability, young infants eligible for transplant have been shown to have similar overall patient and graft survival rates compared to older children with other indications for liver transplant.

Purpose

The primary aim of our study is to report a case of NALF with successful liver transplant.

Method

We present the case of a preterm girl with NALF due to GALD refractory to medical management, requiring liver transplantation.

Result(s)

This is a 35-week preterm girl, with scant pre-natal care, birth weight of 1.825 kg and Apgar 9/9. She is the seventh child of non-consanguineous parents, with healthy siblings. On day-of-life (DOL) 1 she presented with acute kidney injury, progressive worsening metabolic acidosis and hyperammonemia and was found to be profoundly coagulopathic (INR 6), with normal liver enzymes and liver failure was diagnosed. Initial investigation ruled out congenital infections, sepsis, neonatal hemophagocytic lymphohistiocytosis and metabolic diseases. Magnetic resonance imaging of the body demonstrated findings in keeping with iron deposition in the thyroid, liver and pancreas, suggestive of GALD. Completed double volume exchange transfusion and IVIG on DOL 9 and repeat IVIG on DOL 13 and 15, with partial improvement in INR. Due to persistent ascites, conjugated hyperbilirubinemia and hyperammonemia she was transferred for urgent liver transplant assessment. Persistent liver dysfunction in the form of hyperammonemia, hypoglycemia and progressive coagulopathy led to transplant listing on DOL 30. ABO incompatible deceased donor liver transplant was completed on DOL 62 (4.075 kg, estimated dry weight 3.5 kg). The procedure was uncomplicated, liver enzymes normalized, coagulopathy and hypoglycemia resolved. She was transferred to the ward on post-operative day (POD) 6. and weaned off sedatives and transitioned to oral feeds within 2 weeks of transplant, with complex abdominal wound closure on POD 29.

Conclusion(s)

Successful liver transplantation is possible in neonates with acute liver failure due to GALD refractory to medical management and weighing 4kg or less.

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Disclosure of Interest

None Declared

MICROBIOME & MICROBIAL THERAPY

Application of Artificial Intelligence to Quantitative Assessment of Fundus Tessellated Density in Young Adults with Different Refractions

INTRODUCTION

The aim of this study was to quantitatively assess fundus tessellated density (FTD) and associated factors by artificial intelligence (AI) in young adults.

METHODS

A total of 1,084 undergraduates (age, 17-23 years old) were enrolled in November 2021. The students were divided into three groups according to axial length (AL): group 1 (AL <24.0 mm, n = 155), group 2 (24 mm ≤ AL <26 mm, n = 578), and group 3 (AL ≥26 mm, n = 269). FTD was calculated by extracting the fundus tessellations as the regions of interest (circle 1, diameter of 3.0 mm; circle 2, diameter of 6.0 mm) and then calculating the average exposed choroid area per unit area of fundus.

RESULTS

Among 1,084 students, 1,002 (92.5%) students' FTDs were extracted. The mean FTD was 0.06 ± 0.06 (range, 0-0.40). In multivariate analysis, FTD was significantly associated with male sex, longer AL, thinner subfoveal choroid thickness (SFCT), increased choriocapillaris vessel density (VD), and decreased deeper choroidal VD (all p < 0.05). In circle 1 (diameter of 3.0 mm) and circle 2 (diameter of 6.0 mm), analysis of variance showed that the FTD of the nasal region (p < 0.05) was significantly larger than that of the superior, inferior, and temporal regions.

CONCLUSION

AI-based imaging processing could improve the accuracy of fundus tessellation diagnosis. FTD was significantly associated with a longer AL, thinner SFCT, increased choriocapillaris VD, and decreased deeper choroidal VD.

Optic disc and retinal vascular features in first 6 years of Chinese children

Purpose

Retinal microvasculature plays an important role in children's fundus lesions and even in their later life. However, little was known on the features of normal retina in early life. The purpose of this study was to explore the normal retinal features in the first 6 years of life and provide information for future research.

Methods

Children, aged from birth to 6 years old and diagnosed with various unilateral ocular diseases were included. Venous phase fundus fluorescein angiography images with the optic disc at the center were collected. Based on the ResUNet convolutional neural network, optic disc and retinal vascular features in the posterior retina were computed automatically.

Results

A total of 146 normal eyes of 146 children were included. Among different age groups, no changes were shown in the optic disc diameter (y = -0.00002x + 1.362, R² = 0.025, p = 0.058). Retinal vessel density and fractal dimension are linearly and strongly correlated (r = 0.979, p < 0.001). Older children had smaller value of fractal dimension (y = -0.000026x + 1.549, R²= 0.075, p = 0.001) and narrower vascular caliber if they were less than 3 years old (y = -0.008x + 84.861, R²= 0.205, p < 0.001). No differences were in the density (y = -0.000007x + 0.134, R²= 0.023, p = 0.067) and the curvature of retinal vessels (lnC = -0.00001x - 4.657, R²= 0.001, p = 0.667).

Conclusions

Age and gender did not impact the optic disc diameter, vessel density, and vessel curvature significantly in this group of children. Trends of decreased vessel caliber in the first 3 years of life and decreased vessel complexity with age were observed. The structural characteristics provide information for future research to better understand the developmental origin of the healthy and diseased retina.

Treatment of Patients with Waldenström Macroglobulinaemia: Clinical practice update from the Myeloma Foundation of Australia Medical and Scientific Advisory Group

Waldenström macroglobulinaemia (WM) is an indolent B-cell malignancy characterised by the presence of IgM paraprotein, bone marrow infiltration by clonal small B lymphocytes with plasmacytic differentiation and the MYD88 L265P mutation in >90% of cases. Traditionally, WM has been treated with chemoimmunotherapy. Recent trials have demonstrated the efficacy and safety of Bruton tyrosine kinase inhibitors in WM, both as monotherapy and in combination with other drugs. There is emerging evidence on use of other agents including BCL2 inhibitors and on treatment of rare presentations of WM. In this update, the Medical and Scientific Advisory Group of Myeloma Australia review the available evidence on the treatment of WM since the last publication in 2017 and provide specific recommendations to assist Australian clinicians in the management of this disease.

A Generic Pixel Pitch Calibration Method for Fundus Camera via Automated ROI Extraction

Pixel pitch calibration is an essential step to make the fundus structures in the fundus image quantitatively measurable, which is important for the diagnosis and treatment of many diseases, e.g., diabetes, arteriosclerosis, hereditary optic atrophy, etc. The conventional calibration approaches require the specific parameters of the fundus camera or several specially shot images of the chess board, but these are generally not accessible, and the calibration results cannot be generalized to other cameras. Based on automated ROI (region of interest) and optic disc detection, the diameter ratio of ROI and optic disc (ROI-disc ratio) is quantitatively analyzed for a large number of fundus images. With the prior knowledge of the average diameter of an optic disc in fundus, the pixel pitch can be statistically estimated from a large number of fundus images captured by a specific camera without the availability of chess board images or detailed specifics of the fundus camera. Furthermore, for fundus cameras of FOV (fixed field-of-view), the pixel pitch of a fundus image of 45° FOV can be directly estimated according to the automatically measured diameter of ROI in the pixel. The average ROI-disc ratio is approximately constant, i.e., 6.404 ± 0.619 in the pixel, according to 40,600 fundus images, captured by different cameras, of 45° FOV. In consequence, the pixel pitch of a fundus image of 45° FOV can be directly estimated according to the automatically measured diameter of ROI in the pixel, and results show the pixel pitches of Canon CR2, Topcon NW400, Zeiss Visucam 200, and Newvision RetiCam 3100 cameras are 6.825 ± 0.666 μm, 6.625 ± 0.647 μm, 5.793 ± 0.565 μm, and 5.884 ± 0.574 μm, respectively. Compared with the manually measured pixel pitches, based on the method of ISO 10940:2009, i.e., 6.897 μm, 6.807 μm, 5.693 μm, and 6.050 μm, respectively, the bias of the proposed method is less than 5%. Since our method doesn't require chess board images or detailed specifics, the fundus structures on the fundus image can be measured accurately, according to the pixel pitch obtained by this method, without knowing the type and parameters of the camera.

AB1392 COVID-19 HAD AN ADVERSE IMPACT ON DENOSUMAB TREATMENT PROVISION - COMPARISON WITH PRE-PANDEMIC WAITING TIMES AT A UK-BASED RHEUMATOLOGY DEPARTMENT

Background

Denosumab treatment is licensed for prevention of osteoporotic fractures. It can cause hypocalcaemia, so bone profile blood tests must be checked prior to treatment. In our department, we have a Standard that patients have blood tests within 1 month before their denosumab injection, and that they receive the injection within 1 month from its due date. A customized MS Access database to record this information and generate a date for the next dose was established in 2015 after a quality improvement project (QIP)1. At the onset of the COVID-19 pandemic, UK national guidance recommended continued provision of denosumab as an essential service.

Objectives

1. To re-audit delay from due date to actual injection date after establishment of our database.

2. To compare delay from due date to actual injection date before and after onset of COVID-19.

3. To compare the time between blood tests and actual injection date, before and after onset of COVID-19.

Methods

Data for 2 time-periods were extracted from the database: Time Period 1 (pre-COVID-19) 01-03-2019 – 29-02-2020; Time Period 2 (post-COVID-19 onset) 01-03-2020 – 28-02-2021. For each patient attendance, dates of blood test, due date and actual injection date were extracted. All patient details were anonymised, with a decryption key to identifiers held on a secure server at the host Trust. It was manually determined whether blood tests and injections were within 1 month of when they were due. Statistical analyses were carried out in Stata v.14.0. The Kolmogorov-Smirnov test was used to compare distributions between Time Periods 1 and 2.

Results

TIME PERIOD 1: 100 appointments were audited from 68 patients. 20% of blood tests were within 1 month of actual injection date. Median time between blood tests and actual injection was 45 days [IQR 35 – 59]. 52% of actual injections were given within 1 month from due date. (This compares favourably with our 2015 QIP, when 40% of actual injections were within 1 month from due date1). Median time between due date and actual injection was 29.5 days [IQR 13 – 50.5]. TIME PERIOD 2: 77 appointments were audited from 66 individual patients. 24.7% of blood tests were within 1 month of actual injection. Median time between blood tests and actual injection was 45 days [IQR 35 – 59]. 16.6% of actual injections were given within 1 month of due date. Median time between due date and actual injection was 82 days [IQR 40 – 141]. There were no significant differences in time between blood tests and actual injection between Time Periods 1 and 2. However, the time between due date and actual injection date was significantly longer in Time Period 2 (p<0.005).

Conclusion

The introduction of our customized database promoted an improvement in time between due date and actual injection date of denosumab. However, this improvement significantly declined after the onset of the COVID-19 pandemic. Resources may need to be increased and processes adapted to minimise the impact of future emergencies on denosumab provision.

References

[1]Ammori M et al. Rheumatology 2015;54(Suppl1):i105.

Disclosure of Interests

None declared

POS0509 DEVELOPMENT OF A MULITNOMIAL PREDICTION MODEL OF TREATMENT RESPONSE TO ETANERCEPT IN A MULTI-CENTRE COHORT OF PATIENTS WITH ESTABLISHED RA

Background

Treatment response in rheumatoid arthritis (RA) is assessed through EULAR response groups of good, moderate, and poor response. Clinical prediction models from the literature typically frame this as a binary model, to differentiate poor from good and moderate responders. Here, we develop a multinomial model, to predict each group separately, after 3 months on the anti-TNF drug Etanercept (ETN).

Objectives

Develop and validate a multinomial prediction model of treatment response to ETN in RA, based on baseline clinical covariates.

Methods

We identified patients treated with ETN or biosimilars (N = 778) from the Biologics in RA Genetics and Genomics Study Syndicate (BRAGGSS). Response groups were derived from the CRP based 4C-DAS28 at baseline and 3 month follow up, yielding 310 good, 320 moderate, and 148 poor responders. A multinomial logistic regression model was fitted, using good responders as reference category. Multiple imputation by chained equations was used to impute missing data, and models were internally validated via bootstrapping. We report model accuracy, as well as calibration, and compare effect sizes across response groups. Table 1shows the baseline statistics, and odds ratios for the included covariates.

Table 1.

Baseline covariate statistics and odds ratios (in bold: significant at p < 0.05); HADS: Hospital Anxiety and Depression Scale

VariableMean (± SD)ORModerate [95% CI]pORPoor [95% CI]por % YesSwollen Joint8.84450.980.350.948e-3Count (SJC)(± 5.20)[0.95 1.02][0.89 0.98]Tender Joint14.68771.076e-61.050.01Count (TJC)(± 6.74)[1.04 1.10][1.01 1.08]General Health74.74291.000.60.981e-3Visual Analog Scale (GHVAS)(±17.79)[0.99 1.01][0.97 0.99]CRP19.07391.000.220.990.26(±25.07)[1.00 1.01][0.98 1.00]BMI30.30351.000.481.000.41(±23.28)[0.99 1.01][0.99 1.01]Age of47.33301.010.121.020.06onset(±13.86)[1.00 1.03][1.00 1.04]Disease9.94011.000.840.990.45duration(±10.35)[0.98 1.02][0.96 1.02]HAQ1.60851.480.022.951e-6(± 0.65)[1.06 2.08][1.91 4.54]HADS-Anxiety8.08681.040.191.060.12(± 4.54)[0.98 1.10][0.99 1.13]HADS-Depression7.38411.060.120.970.55(± 4.02)[0.99 1.13][0.89 1.06]Concurrent81.49%0.412e-40.520.03DMARD[0.26 0.66][0.28 0.94]Female78.66%1.390.121.110.71[0.92 2.10][0.65 1.87]Seropositive77.89%0.540.020.470.01[0.33 0.89][0.26 0.86]1st Biologic90.62%1.060.860.480.03[0.55 2.06][0.24 0.94]

Results

Adjusted for optimism, the multinomial model achieves an accuracy of 50.7% (IQR: 50 – 51.3%), with calibration slopes of 0.574 (IQR: 0.569 - 0.579) and 0.534 (IQR: 0.525 - 0.544) for moderate and poor response, respectively. Figure 1 shows a comparison of odds ratios (OR) for the different outcome groups. The Health Assessment Questionnaire (HAQ) score is the biggest driver of both moderate and poor response. Previous biologic treatment also predicts poor but not moderate response. Compared to the multinomial model, a binary model, that discriminates poor from moderate and good responders, underestimates the effect size of HAQ.

Figure 1.

Odds ratios of FIRSTBIO and HAQ for moderate and poor response. Size of crosses indicate 95% confidence intervals.

Conclusion

The model predicts EULAR response groups moderately well but is poorly calibrated, which can partly be explained by the generally higher sample size requirement of multinomial modelling. In the multinomial model, moderate and poor response is largely driven by the same covariates, which leads to blurred boundaries between good and poor responders, when response groups are merged to create a binary problem. Future research should consider the most appropriate model choice to describe data, including the use of multinomial instead of binomial models. More research and bigger sample sizes are required to improve on this multinomial model.

Disclosure of Interests

Michael Stadler: None declared, Stephanie Ling: None declared, Nisha Nair: None declared, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer, Kimme Hyrich Speakers bureau: Abbvie, Grant/research support from: Pfizer and BMS, Ann Morgan Speakers bureau: Roche/ Chuga, Consultant of: GSK, Roche, Chugai, AstraZeneka, Regeneron, Sanofi, Vifor, Grant/research support from: Roche, Kiniksa Pharmaceuticals, Anthony G Wilson: None declared, Darren Plant: None declared, John Bowes: None declared, Anne Barton Grant/research support from: Pfizer, Galapagos, Scipher Medicine, and Bristol Myers Squibb.

Prediction of the Fundus Tessellation Severity With Machine Learning Methods

Purpose

To predict the fundus tessellation (FT) severity with machine learning methods.

Methods

A population-based cross-sectional study with 3,468 individuals (mean age of 64.6 ± 9.8 years) based on Beijing Eye Study 2011. Participants underwent detailed ophthalmic examinations including fundus images. Five machine learning methods including ordinal logistic regression, ordinal probit regression, ordinal log-gamma regression, ordinal forest and neural network were used.

Main Outcome Measure

FT precision, recall, F1-score, weighted-average F1-score and AUC value.

Results

Observed from the in-sample fitting performance, the optimal model was ordinal forest, which had correct classification rate (precision) of 81.28%, while 34.75, 93.73, 70.03, and 24.82% in each classified group by FT severity. The AUC value was 0.7249. And the F1-score was 65.05%, weighted-average F1-score was 79.64% on the whole dataset. For out-of-sample prediction performance, the optimal model was ordinal logistic regression, which had precision of 77.12% on the validation dataset, while 19.57, 92.68, 64.74, and 6.76% in each classified group by FT severity. The AUC value was 0.7187. The classification accuracy of light FT group was the highest, while that of severe FT group was the lowest. And the F1-score was 54.46%, weighted-average F1-score was 74.19% on the whole dataset.

Conclusions

The ordinal forest and ordinal logistic regression model had the strong prediction in-sample and out-sample performance, respectively. The threshold ranges of the ordinal forest model for no FT and light, moderate, severe FT were [0, 0.3078], [0.3078, 0.3347], [0.3347, 0.4048], [0.4048, 1], respectively. Likewise, the threshold ranges of ordinal logistic regression model were ≤ 3.7389, [3.7389, 10.5053], [10.5053, 13.9323], > 13.9323. These results can be applied to guide clinical fundus disease screening and FT severity assessment.

Development and validation of a predictive risk model based on retinal geometry for an early assessment of diabetic retinopathy

AIMS

This study aimed to develop and validate a risk nomogram prediction model based on the retinal geometry of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM) and to investigate its clinical application value.

METHODS

In this study, we collected the clinical data of 410 patients with T2DM in the Second Affiliated Hospital of Chongqing Medical University between October 2020 and March 2022. Firstly, the patients were randomly divided into a development cohort and a validation cohort in a ratio of 7:3. Then, the modeling factors were selected using the least absolute shrinkage and selection operator (LASSO). Subsequently, a nomogram prediction model was built with these identified risk factors. Two other models were constructed with only retinal vascular traits or only clinical traits to confirm the performance advantage of this nomogram model. Finally, the model performances were assessed using the area under the receiver operating characteristic curve (AUC), calibration plot, and decision curve analysis (DCA).

RESULTS

Five predictive variables for DR among patients with T2DM were selected by LASSO regression from 33 variables, including fractal dimension, arterial tortuosity, venular caliber, duration of diabetes mellitus (DM), and insulin dosage (P< 0.05). A predictive nomogram model based on these selected clinical and retinal vascular factors presented good discrimination with an AUC of 0.909 in the training cohort and 0.876 in the validation cohort. By comparing the models, the retinal vascular parameters were proven to have a predictive value and could improve diagnostic sensitivity and specificity when combined with clinical characteristics. The calibration curve displayed high consistency between predicted and actual probability in both training and validation cohorts. The DCA demonstrated that this nomogram model led to net benefits in a wide range of threshold probability and could be adapted for clinical decision-making.

CONCLUSION

This study presented a predictive nomogram that might facilitate the risk stratification and early detection of DR among patients with T2DM.

Diabetes in adults with intellectual disability: prevalence and associated demographic, lifestyle, independence and health factors

BACKGROUND

As people with intellectual disabilities (ID) are now living longer, they are more at risk of developing non-communicable diseases, including type 2 diabetes mellitus. However, understanding of factors associated with diabetes for targeted management and prevention strategies is limited. This study aimed to investigate prevalence of diabetes in adults (aged ≥18 years) with ID and its relationship with demographic, lifestyle, independence and health factors.

METHOD

This was a cross-sectional analysis of interview data from 1091 adults with ID from the Leicestershire Learning Disability Register from 1 January 2010 to 31 December 2016. Logistic regression models were used to identify factors associated with diabetes in the study population.

RESULTS

The study population did not have healthy lifestyles: just under half reported having lower physical activity levels than people without ID of a similar age; one-quarter consumed fizzy drinks daily; and 20% consumed five or more fruit and/or vegetables per day. Prevalence of carer/self-reported diabetes was 7.3% (95% confidence interval 5.9-9.0). After adjustment, diabetes was positively associated with South Asian ethnicity (P = 0.03) and older age groups (P < 0.001). Diabetes was less common in people living with family members (P = 0.02). We did not find a relationship between any of the lifestyle, independence and health factors investigated.

CONCLUSIONS

A significant proportion of people with ID are living with diabetes. Diabetes management and prevention strategies should be tailored to individuals' complex needs and include consideration of lifestyle choices. Such strategies may want to focus on adults of South Asian ethnicity and people living in residential homes where prevalence appears to be higher.

The diagnostic accuracy of an intelligent and automated fundus disease image assessment system with lesion quantitative function (SmartEye) in diabetic patients

BACKGROUND

With the diabetes mellitus (DM) prevalence increasing annually, the human grading of retinal images to evaluate DR has posed a substantial burden worldwide. SmartEye is a recently developed fundus image processing and analysis system with lesion quantification function for DR screening. It is sensitive to the lesion area and can automatically identify the lesion position and size. We reported the diabetic retinopathy (DR) grading results of SmartEye versus ophthalmologists in analyzing images captured with non-mydriatic fundus cameras in community healthcare centers, as well as DR lesion quantitative analysis results on different disease stages.

METHODS

This is a cross-sectional study. All the fundus images were collected from the Shanghai Diabetic Eye Study in Diabetics (SDES) program from Apr 2016 to Aug 2017. 19,904 fundus images were acquired from 6013 diabetic patients. The grading results of ophthalmologists and SmartEye are compared. Lesion quantification of several images at different DR stages is also presented.

RESULTS

The sensitivity for diagnosing no DR, mild NPDR (non-proliferative diabetic retinopathy), moderate NPDR, severe NPDR, PDR (proliferative diabetic retinopathy) are 86.19, 83.18, 88.64, 89.59, and 85.02%. The specificity are 63.07, 70.96, 64.16, 70.38, and 74.79%, respectively. The AUC are PDR, 0.80 (0.79, 0.81); severe NPDR, 0.80 (0.79, 0.80); moderate NPDR, 0.77 (0.76, 0.77); and mild NPDR, 0.78 (0.77, 0.79). Lesion quantification results showed that the total hemorrhage area, maximum hemorrhage area, total exudation area, and maximum exudation area increase with DR severity.

CONCLUSIONS

SmartEye has a high diagnostic accuracy in DR screening program using non-mydriatic fundus cameras. SmartEye quantitative analysis may be an innovative and promising method of DR diagnosis and grading.

Effect of daily short-duration weight-bearing on disuse-induced deterioration of musculoskeletal system

OBJECTIVES

To investigate deterioration of musculoskeletal system due to prolonged disuse and the potential of daily short-duration weight-bearing as countermeasures.

METHODS

Twenty-four adult male Sprague-Dawley rats were divided into Control Group (CG, no intervention), Tail-suspension Group (TG, tail-suspension without treatment), and Weight-Bearing Group (WBG, tail-suspension with 20 min/day, 5 days/week body weight loading). After four weeks of treatment, femur and tibia, soleus and extensor digitorum longus were evaluated for bone and muscle quality respectively. Tensile properties of bone-tendon insertion (BTI) were evaluated using patella-patellar tendon complex.

RESULTS

Disuse induced deterioration on bone, muscle, and BTI after four weeks. Compared with CG, TG and WBG showed significant decrease in bone mineral density (BMD) of trabecular bone in distal femur (4.3-15.2%), muscle mass (31.3-52.3%), muscle cross-sectional area (29.1-35%), and failure strength of BTI (23.9-29.4%). Tensile test showed that the failure mode was avulsion of bone at the BTI. No significant difference was detected between TG and WBG for all assessments on bone, muscle, and BTI.

CONCLUSIONS

Disuse caused deterioration of bone, muscle, and BTI while daily short-duration of weight-bearing did not prevent this deterioration. Mechanical stimulation with higher intensity and longer duration may be necessary to prevent musculoskeletal deterioration resulted from prolonged disuse.

Decreased microRNA-206 and its function in cervical cancer

OBJECTIVE

MicroRNA-206 plays important roles in tumorigenesis and tumor progression of various human malignancies. However, its involvement in cervical cancer has remained unclear.

OBJECTIVE

The aim of this study was to examine the expression patterns and clinical implications of miR-206 in cervical cancer.

MATERIALS AND METHODS

Quantitative RT-PCR was performed to evaluate the expression levels of miR-206 in cervical cancer cell lines and primary tumor tissues. The clinicopathologic significance and the prognostic value of miR-206 expression were further determined. Finally, the effects of miR-206 on HeLa cell proliferation, apoptosis, invasion, and migration were investigated.

RESULTS

MiR-206 expression was significantly downregulated in cervical cancer samples when compared with normal adjacent tissues. Low level of miR-206 was associated with advanced FIGO stage (p < 0.001), positive lymph node metastasis (p < 0.001), poor differentiation (p = 0.016), and human papillomavirus infection (p = 0.007). Multivariate Cox regression analysis revealed that decreased miR-206 expression was an independent unfavorable prognostic factor for overall survival. In addition, transfection of miR-206 mimics in HeLa cells was able to reduce cell proliferation, promote cell apoptosis, and inhibit cell invasion and migration.

CONCLUSIONS

miR-206 may act not only as a novel diagnostic and prognostic marker, but also as a potential target for molecular therapy of cervical cancer.

Expression and prognostic significance of microRNA-451 in human epithelial ovarian cancer

OBJECTIVE

MicroRNA-451 has been proved to be downregulated in many human malignancies and correlated with tumor progression. However, its expression and clinical significance in epithelial ovarian cancer (EOC) is still unclear. The aim of this study was to explore the effects of miR-451 in EOC tumorigenesis and development.

MATERIALS AND METHODS

The expression levels of miR-451 were quantified by qRT-PCR in 115 EOC and 34 normal ovarian tissues, and correlated with clinicopathological factors and prognosis. MTT, flow cytometric assay, and transwell invasion assay were used to test the proliferation, apoptosis, and invasion of SKOV-3 EOC cells transfected with miR-451 mimics or negative control (NC) RNA-oligonucleotides.

RESULTS

MiR-451 expression was significantly downregulated in EOC compared with normal ovarian tissues. Low level of miR-451 was associated with advanced FIGO stage (p = 0.005), higher serum CA125 expression level (p = 0.005), and lymph node metastasis (p = 0.002). Multivariate Cox regression analysis identified decreased miR-451 expression as an independent factor predicting poor prognosis for EOC patients. In addition, transfection of miR-451 mimics in SKOV-3 was able to reduce cell proliferation, promote cell apoptosis, and inhibit cell invasion.

CONCLUSIONS

miR-451 may act not only as a novel diagnostic and prognostic marker, but also as a potential target for molecular therapy of EOC.

Basiliximab with delayed introduction of calcineurin inhibitors as a renal-sparing protocol following liver transplantation in children with renal impairment

Renal impairment is frequently compromised in patients with end-stage liver disease and is associated with increased long-term mortality post-LT. In contrast to CNI, basiliximab is an immunosuppressive agent with minimal nephrotoxic potential. This study reviews the experience of a single pediatric liver transplant center's renal-sparing approach with the use of basiliximab and MMF to compensate for delayed entry of CNI in children with renal impairment at the time of organ availability. There were no differences in renal function between pediatric patients with and without pre-LT renal impairment within the first year (cGFR: 135 mL/min/1.73 m2 vs. 144 mL/min/1.73 m2 ; p = 0.56) or at 5-8 yr following LT, (129 mL/min/1.73 m2 vs. 130 mL/min/1.73 m2 ; p = 0.97). In addition, there was no difference in ACR rates (50% vs. 43%, p = 0.62) between patients in the basiliximab group and those patients receiving standard CNI and steroid strategies. The utilization of a renal-sparing approach with basiliximab alongside delayed entry and lower early target trough levels of CNI in children with renal impairment at the time of LT is safe and maintains excellent long-term kidney function.

A causal role for circulating miR-34b in osteosarcoma

PURPOSE

To investigate the associations between plasma miR-34b/c expression levels and osteosarcoma (OS).

SUBJECTS AND METHODS

A case-control study was conducted in 133 patients with OS and 133 controls. MiR-34b/c levels were detected by quantitative reverse transcriptase polymerase chain reaction (qRT-PCR) assays. Genotyping of SNP rs4938723 was done using the TaqMan assay. The causal association was examined by mendelian randomization analysis.

RESULTS

Plasma miR-34b level was significantly lower in OS patients than in controls (P = 0.001). Expression levels of miR-34b in OS tissues decreased (P = 3.22 × 10(-4)) and was significantly related with its expression in plasma (r = 0.21, P = 0.004). Compared with wild-type TT genotype, the variant genotypes of rs4938723 TC/CC were significantly associated with increased OS risk (TC vs. TT: OR, 1.97 [95% CI: 1.40-2.55], P = 0.021; CC vs. TT: OR, 2.76 [95% CI: 2.00-3.53], P = 0.009; TC + CC vs. TT: OR, 2.16 [95% CI: 1.61-2.70], P = 0.006), consistent with its decreased effect on plasma miR-34b (TC vs. TT: -0.32 (-0.43, -0.21), P < 0.001; CC vs. TT: -0.70 (-0.84, -0.56), P < 0.001; TC + CC vs. TT: -0.42 (-0.53, -0.32), P < 0.001). Adjustment for miR-34b completely abolished the association between SNP rs4938723 and OS risk (P > 0.05). In addition, plasma expression levels of miR-34b were significantly decreased in the metastatic patients compared with that in the non-metastatic ones (P = 0.004).

CONCLUSION

Plasma miR-34b was causally associated with OS risk and related with its metastatic status, suggesting that plasma miR-34b might be a novel biomarker and a potential treatment target for OS.

Cell adhesion molecules as pharmaceutical target in atherosclerosis

Cell adhesion molecules (CAMs) are transmembrane proteins that mediate adhesion and interactions between cells or cell and extra-cellular matrix. Increased expression and activation of CAMs in vascular endothelial cells and circulating leukocytes, as occurring in the settings of inflammation, hypercholesterolemia, hypertension and diabetes, stimulates leukocyte recruitment into the vascular endothelium, an important step in the pathogenesis of atherosclerosis. CAMs are a potential therapeutic target in clinical practice and in recent years pharmaceutical agents with specific effects on the production and function of these molecules have been studied and developed. This article reviews recent progress regarding pathophysiology of CAMs in atherogenesis and pharmaceutical products or chemicals that are active against CAMs, and assesses the possibilities for clinical developments in this area that might enhance the prevention, monitoring and treatment of atherosclerotic cardiovascular diseases.

Resistive vibration exercise retards bone loss in weight-bearing skeletons during 60 days bed rest

Countermeasures are desirable to retard bone loss during long-term space flight. We evaluated the effect of an intervention protocol on bed rest-induced bone loss.

INTRODUCTION

We developed a resistive vibration exercise (RVE) platform to test if an intervention RVE protocol would be effective to protect bed rest-induced bone loss.

METHODS

Fourteen male subjects were assigned randomly to either the RVE group (n = 7) that performed daily supervised resistive vibration exercise or to the no any exercise control (CON) group (n = 7). Both dual-energy X-ray absorptiometry and peripheral quantitative computed tomography were used to monitor changes in bone mineral density.

RESULTS

RVE significantly prevented bone loss at multiple skeletal sites, including calcaneus, distal tibia, hip, and lumbar spine (L2-L4). The ratio of urinary calcium and creatinine was found higher after starting bed rest in CON group while no significant changes were observed in RVE group. No significant temporal change was found for osteocalcin-N during and after bed rest in CON group. However, a significant increase was shown after bed rest in RVE group. In both groups, the urinary concentration of bone resorption markers, such as C-telopeptide of type I collagen (CTX-I) and deoxypyridinoline (DPD), were significantly elevated after bed rest. In the CON group, no significant temporal effect was found for hydroxyproline (HOP), CTX-I, and DPD during bed rest and the serum concentration of HOP and TGF-β significantly increased about 52.04% and 24.03%, respectively only after bed rest. However, all these markers tended to decrease in the RVE group.

CONCLUSIONS

Our results might imply that the intervention of RVE retarded bone loss induced by simulated microgravity in humans that was mainly attributed to its anabolic effects.

The PROMISE study: a phase 2b multicenter study of voclosporin (ISA247) versus tacrolimus in de novo kidney transplantation

Voclosporin (VCS, ISA247) is a novel calcineurin inhibitor being developed for organ transplantation. PROMISE was a 6-month, multicenter, randomized, open-label study of three ascending concentration-controlled groups of VCS (low, medium and high) compared to tacrolimus (TAC) in 334 low-risk renal transplant recipients. The primary endpoint was demonstration of noninferiority of biopsy proven acute rejection (BPAR) rates. Secondary objectives included renal function, new onset diabetes after transplantation (NODAT), hypertension, hyperlipidemia and pharmacokinetic-pharmacodynamic evaluation. The incidence of BPAR in the VCS groups (10.7%, 9.1% and 2.3%, respectively) was noninferior to TAC (5.8%). The incidence of NODAT for VCS was 1.6%, 5.7% and 17.7% versus 16.4% in TAC (low-dose VCS, p = 0.03). Nankivell estimated glomerular filtration rate was respectively: 71, 72, 68 and 69 mL/min, statistically lower in the high-dose group, p = 0.049. The incidence of hypertension and adverse events was not different between the VCS groups and TAC. VCS demonstrated an excellent correlation between trough and area under the curve (r(2) = 0.97) and no difference in mycophenolic acid exposure compared to TAC. This 6-month study shows VCS to be as efficacious as TAC in preventing acute rejection with similar renal function in the low- and medium-exposure groups, and potentially associated with a reduced incidence of NODAT.

Influence of prototropic reactions on the absorption and fluorescence spectra of methyl p-dimethylaminobenzoate and its two ortho derivatives

The influence of prototropic reactions on the spectral characteristics of methyl p-dimethylaminobenzoate (I) and its o-methoxy (II) and o-hydroxy (III) derivatives has been studied using steady-state spectroscopic technique and quantum-chemical calculations. This study concerns the solvent-induced shift of the absorption, locally excited (LE) and intramolecular charge transfer (ICT) fluorescence bands in the neat tetrahydrofuran (THF) and its hydrochloric acid solutions at different HCl concentrations. On the basis of the experimental results and quantum-chemical calculations, it was shown that in a hydrochloric acid solution the studied molecules exist as a mixture of neutral, mono-, and dicationic forms. Additionally, the results of spectroscopic measurements were used to calculate, according to the Benesi-Hildebrand method, the equilibrium constants of protopropic reactions in the ground, S(0), and excited, S(1), states. Our findings predestine molecules I and II to be used as acid fluorescence probes in a region of 0-2.5 M of [H(+)] concentrations.