Effects of diazepam on hippocampal blood flow in people at clinical high risk for psychosis

Elevated hippocampal perfusion has been observed in people at clinical high risk for psychosis (CHR-P). Preclinical evidence suggests that hippocampal hyperactivity is central to the pathophysiology of psychosis, and that peripubertal treatment with diazepam can prevent the development of psychosis-relevant phenotypes. The present experimental medicine study examined whether diazepam can normalize hippocampal perfusion in CHR-P individuals. Using a randomized, double-blind, placebo-controlled, crossover design, 24 CHR-P individuals were assessed with magnetic resonance imaging (MRI) on two occasions, once following a single oral dose of diazepam (5 mg) and once following placebo. Regional cerebral blood flow (rCBF) was measured using 3D pseudo-continuous arterial spin labeling and sampled in native space using participant-specific hippocampus and subfield masks (CA1, subiculum, CA4/dentate gyrus). Twenty-two healthy controls (HC) were scanned using the same MRI acquisition sequence, but without administration of diazepam or placebo. Mixed-design ANCOVAs and linear mixed-effects models were used to examine the effects of group (CHR-P placebo/diazepam vs. HC) and condition (CHR-P diazepam vs. placebo) on rCBF in the hippocampus as a whole and by subfield. Under the placebo condition, CHR-P individuals (mean [±SD] age: 24.1 [±4.8] years, 15 F) showed significantly elevated rCBF compared to HC (mean [±SD] age: 26.5 [±5.1] years, 11 F) in the hippocampus (F(1,41) = 24.7, pFDR < 0.001) and across its subfields (all pFDR < 0.001). Following diazepam, rCBF in the hippocampus (and subfields, all pFDR < 0.001) was significantly reduced (t(69) = -5.1, pFDR < 0.001) and normalized to HC levels (F(1,41) = 0.4, pFDR = 0.204). In conclusion, diazepam normalized hippocampal hyperperfusion in CHR-P individuals, consistent with evidence implicating medial temporal GABAergic dysfunction in increased vulnerability for psychosis.

34 RELATIONSHIP BETWEEN SERUM CAROTENOID CONCENTRATIONS AND FRAILTY, PROBABLE SARCOPENIA, AND PHYSICAL FUNCTION IN THE IRISH LONGITUDINAL STUDY ON AGEING (TILDA)

Background

Lutein and zeaxanthin are antioxidant and anti-inflammatory carotenoids derived from foods such as fruit and vegetables. Serum concentrations of Lutein (Ls) and Zeaxanthin (Zs) reflect habitual dietary intake. This study examined the cross-sectional and longitudinal relationships between Ls and Zs and frailty, probable sarcopenia, and indices of physical function in TILDA.

Methods

The cross-sectional analysis included n=4672 community-dwelling adults aged ≥50 years with Ls and Zs at Wave 1 (2010). For the longitudinal analyses, changes in usual gait speed (at Wave 3, 2014), grip strength (Wave 4, 2016) and Timed Up-and-Go (TUG; Wave 5, 2018), incident probable sarcopenia (defined as grip strength &lt;27 kg in men, &lt;16 kg in women, at Wave 4) and incident frailty (Fried, at Wave 5) were determined. Multivariable linear and logistic regression analyses were adjusted for age, sex, waist circumference, education, malnutrition, smoking, chronic disease, alcohol intake and physical activity.

Results

Cross-sectionally, Ls and Zs were positively associated with gait speed (B [95% CI] per 100-nmol/L higher concentration: Ls 0.67 [0.22, 1.12], Zs 1.3 [0.21, 2.48] cm/s) and inversely associated with TUG time (Ls –0.07 [-0.11, –0.02], Zs –0.14 [-0.25, –0.03] s) and with frailty (OR: Ls 0.61 [0.42, 0.87], Zs 0.23 [0.08, 0.68]), all p &lt;0.05), but not with grip strength or probable sarcopenia. Longitudinally, Ls was inversely associated incident frailty (OR 0.85 [0.04, 0.84], p=0.03), whereas Zs was not (0.83 [0.56, 1.23], p=0.36). Neither Ls or Zs were related to changes in physical function measures or incident probable sarcopenia (p&gt;0.05).

Conclusion

Cross-sectionally, lower Ls and Zs were independently associated with frailty, slower gait speed and worse TUG performance. However, Wave 1 Ls and Zs were not predictive of changes in these outcomes over 4-8 years of follow up, with the exception of Ls which was inversely associated with incident frailty after 8 years.

148 ORTHOSTATIC HEMODYNAMICS AND ACCELERATED BRAIN AGING

Background

Impaired recovery of blood pressure (BP) in response to standing up is a prevalent condition in older individuals. We evaluated the relationship between the recovery of hemodynamic responses to standing and brain health in adults over 50.

Methods

Participants from The Irish Longitudinal Study on Aging (TILDA) (n=418) performed an active stand challenge while BP and heart rate (HR) were continuously monitored. The recovery of these parameters was determined as the difference in measurements taken at 10 s and 20 s after standing, in relation to the baseline value. The difference between biological and chronological brain age was determined using BrainPAD, a novel validated measure of accelerated brain ageing. The data was fitted using linear regression models, using age, sex, weight, height, cardiac disease prevalence, antihypertensive and antidepressant use, smoking status, standing speed and pulse wave velocity as covariates.

Results

Adjusting for age and sex only, each additional year of BrainPAD was associated with a –0.35 mmHg (95% CI: –0.54 – –0.16, P&lt;.001) change in orthostatic systolic BP recovery. In a fully adjusted model, the regression coefficient was estimated at –0.29 mmHg (95% CI: –0.48 – –0.10, P&lt;.01). Similarly, a year increase in BrainPAD was associated with –0.21 mmHg (95% CI: –0.32– –0.10, P&lt;0.001) and –0.14 mmHg (95% CI: –0.25– –0.04, P&lt;.01) change in orthostatic diastolic BP recovery, for minimally and fully adjusted models respectively. HR recovery was not significantly associated with BrainPAD.

Conclusion

These results demonstrate that impaired systolic and diastolic BP recovery after standing is associated with accelerated brain aging in older individuals. This suggests that the BP response to standing, measured using beat-to-beat monitoring, has potential to be used as a marker of accelerated brain aging, relying on a simple procedure and devices that are easily accessible for clinical use.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

76 PREDICTIVE MODEL FOR MOBILITY DECLINE: INDIVIDUAL TRIAL MISTAKE THRESHOLDS IN SUSTAINED ATTENTION TO RESPONSE TASK (SART)

Background

The Sustained Attention to Response Task (SART) is a standard computer-based cognitive test designed to measure the sustained attention, fundamental for completing tasks that require supervision over time (Robertson et al., 1997). However, commonly used average features may result in loss of information and data misinterpretation, leading to inability to detect clinically expected associations (O’Halloran et al., 2014).

Methods

Here, we present a new method to visualise the full information obtained from the SART test, ordering by age, and categorising in groups based on mobility status in a large population-based study of ageing in Ireland. A new threshold, derived from the visualisation and based on the individual trial number of mistakes, was employed to individuate poorer SART performances, and to predict mobility and cognitive decline after 4 years in binary logistic regression models.

Results

Raw SART data were available for 4,864 participants aged 50 years and over at baseline. The new variable bad performances, expressing the number of SART trials with at least 4 mistakes, was the most significant predictor of mobility decline, defined as the transition from Timed Up-and-Go (TUG) &lt; 12 to TUG ≥12 seconds (Odds Ratio (OR) = 1.29; 95% Confidence Interval (CI) 1.14–1.46; p &lt; 0.001), and the only significant predictor of new falls (OR = 1.11; 95% CI 1.03–1.21; p = 0.011) compared to traditional SART variables in models adjusted for multiple covariates. No SART-related variables resulted significant predictors of cognitive decline, defined as a decrease of at least 2 points in the Mini-Mental State Examination (MMSE) score.

Conclusion

This multimodal visualisation and the new threshold approach could help clinicians to easily develop relevant hypotheses, and better identify subjects at higher risk of future mobility decline.

81 LONGER CHAIR-STAND TIME IS ASSOCIATED WITH ORTHOSTATIC INTOLERANCE IN AN OLDER IRISH POPULATION

Background

Hospital admissions for orthostatic hypotension (OH) have risen more than two-fold in the past ten years. OH can lead to orthostatic intolerance (OI), and both OH and OI are common causes of falls and injuries in older persons. Sarcopenia is also common in older persons and associated with adverse health outcomes. The 5-chair stand test (5-CST) can be used as a marker of sarcopenia and a cut-off of 15 s has been proposed. We hypothesized that those with a worse performance on the 5-CST would be at greater risk of OH and sought to investigate this in an older Irish population cohort study.

Methods

5-CST was measured in keeping with a standardised protocol. Beat-to-beat blood pressure was measured with the Finometer device according to the active stand protocol. Multivariable logistic regressions were performed to investigate the associations between OH at 40 seconds after standing (OH40), OI (dizziness after standing), and 5-CST time. Potential confounders were controlled for in the model including age, sex, education, body mass index and medications.

Results

Data from 3,119 participants were available for analysis. Mean age was 63.8 years, 55% were female, 25% took longer than 15s on the 5-CST and mean baseline blood pressure was 141/76 mmHg. Proportion of OH40 was 12.5% and 4.4% reported OI. In the multivariable model, OH40 was not independently associated with 5-CST time after controlling for age (p &gt; 0.05). Worse performance on the chair stands test was however an independent predictor of OI (odds ratio 1.06, p = 0.039).

Conclusion

Longer time taken on the 5-CST, a marker of sarcopenia, was an independent predictor of OI in a large population study. The relationship between sarcopenia and orthostatic blood pressure response is not well elucidated. We plan to further investigate this area in a future clinical cohort.

123 ACUTE-PHASE BED-REST DURATION WAS ASSOCIATED WITH LOWER GRIP STRENGTH IN A POST-COVID-19 COHORT

Background

Though age-related muscle loss is traditionally associated with older cohorts, strong evidence suggests a life-spanning precipitation of decreasing muscle mass and strength beginning as early as the fourth decade of life, with established deleterious consequences for later-life morbidity and mortality. Periods of low activity and bed rest (LA/BR) can further compound this depletion of muscle strength. Our aim was to examine such associations in a post-COVID-19 cohort.

Methods

Participants reporting ongoing symptomatology and fatigue post COVID-19 underwent assessments of grip strength via hand-held dynamometry (2 measures on each hand). Demographics of COVID-19 illness, including time since diagnosis, duration of LA/BR during acute illness, and levels of fatigue were captured via self-reported questionnaires. Independent predictors of mean grip strength were investigated using a linear regression model.

Results

Forty-nine participants underwent assessments (69% female, mean age 44(12) years). At the time of assessment, days post COVID-19 diagnosis ranged from 39–522 (mean 262(140)). The mean self-reported period of LA/BR during the acute illness was 15(18) days. In general, participants reported significant levels of fatigue (median Chalder Fatigue Scale score 22(8)). Mean grip strength was 41.3(6.3) Kg for men and 22.8(6.7) Kg for women. When predictors of grip strength were investigated, an increased duration of LA/BR was found to be associated with lower grip strength, independently of age, gender, time since COVID-19 diagnosis, and self-reported fatigue (Beta = −0.158, 95% Confidence Interval − 0.242 to −0.074, p = 0.001).

Conclusion

In this cohort, every day of LA/BR during acute COVID-19 illness was independently associated with subsequent lower grip strength of approximately 150 g. These results underscore the importance of early mobilization and discouraging bed rest in the acute phase of COVID-19. Patients who are isolating should be encouraged to maintain physical activity and muscle strength as part of a modified isolation-friendly rehabilitation programme.

78 HIGHER NEUROVASCULAR SIGNAL ENTROPY IS ASSOCIATED WITH ACCELERATED BRAIN AGEING

Background

Often chronological age is not the most accurate marker of an individual’s health status since ageing is a heterogeneous process across individuals. Machine learning can be used to quantify the relationship between structural brain MRI data and chronological age, to estimate an individual’s ‘brain age’, which, when subtracted from chronological age, provides a brain predicted-age difference score (BrainPAD) [1]. BrainPAD reflects the biological ageing of the brain. Increased complexity in neurovascular signals has been shown to be associated with poorer cognitive performance and physical frailty [2]. The aim of this study was to investigate associations between the complexity of frontal-lobe oxygenation (tissue saturation index (TSI)) data and BrainPAD in a cohort of older community-dwelling adults.

Methods

To calculate BrainPAD, machine learning was applied to 1,359 T1-weighted MRI brain scans from various open-access repositories, and this model was subsequently applied to MRI data acquired from the study cohort. TSI was non-invasively measured in the left frontal lobe using near-infrared spectroscopy. TSI data were acquired continuously during five minutes of supine rest and the last minute was utilized in this analysis. The complexity of TSI signals was quantified using sample entropy (SampEn). Multivariable linear regression was employed, controlling for age, sex, education, antihypertensive medications, diabetes, cardiovascular conditions, smoking, alcohol, depression, BMI, physical activity, and blood pressure.

Results

Complete data were available for 397 individuals (age: 67.9 ± 7.7 years; 53.7% female). An increase in TSI SampEn of 0.1 was associated with an increase in BrainPAD of 0.9 years (P = 0.007, 95%CIs: 0.3 to 1.6). Similar results were found with and without the inclusion of chronological age in the models.

Conclusion

This study reports significant associations between higher complexity in peripherally measured frontal lobe oxygenation concentration and accelerated brain ageing.

References

1. Boyle R. et al. Brain Imaging and Behavior. 15,327–345 (2021) https://doi.org/10.1007/s11682-020-00260-3.

2. Knight S. et al. Entropy. 23(1):4 (2021) https://doi.org/10.3390/e23010004.

590 Influence of Hospital Characteristics on Patient Outcomes Following Cancer Surgery: An International, Mixed Methods Study Across 66 Countries

Aim

Early death after cancer surgery is higher in low- and middle-income settings, yet the impact of hospital characteristics on early postoperative outcomes following cancer surgery worldwide are unknown.

Method

A mixed-methods analysis was performed using data from the GlobalSurg 3 study, a multicentre, international prospective cohort study of patients who underwent surgery for breast, gastric or colorectal cancer. The primary outcomes were 30-day mortality and major complication rates. Hierarchical clustering identified distinct hospital characteristics to create a facility capacity framework. Adjusted outcomes were determined after accounting for patient characteristics and country-income group.

Results

Hospital-level data were available for 9685 patients across 238 hospitals. The facility capacity framework consisted of seven distinct hospital resources and processes: presence of CT scan, postoperative recovery area, critical care facilities, opioid analgesia availability, oncologist, pathology and radiotherapy services. While complication rates were similar across hospitals with varying facility capacities, hospitals with five or less capacities (116 hospitals, 2251 patients) had increased mortality (aOR 1.67, 95% CI 1.13-2.48; P = 0.010). After adjustment for case-mix and country income group, patients undergoing surgery for gastric and colorectal cancer in hospitals with reduced capacities had higher mortality (6.2 vs. 4.0%; P &lt; 0.001), predominantly explained by limited capacity to rescue following the development of major complications (61.3 vs. 72.1%; P &lt; 0.001).

Conclusions

Hospitals with certain system capacities achieve better outcomes following cancer surgery, independent of country-income group. For cancers amenable to surgical treatment, national cancer care plans should include both surgical capacity building and concurrent hospital facility development to maximise reductions in cancer-associated mortality.

427 The Effect of Malnutrition on Early Outcomes after Cancer Surgery: An International Prospective Cohort Study in 82 Countries

Background

Malnutrition is a state linked to worse postoperative outcomes, and cancer patients are particularly vulnerable due to cachexia. We aimed to explore the effect of malnutrition on 30-day mortality following gastric and colorectal cancer surgery.

Method

GlobalSurg3 was multicentre international cohort study which collected data from consecutive patients undergoing emergency or elective surgery for gastric and colorectal cancer. Malnutrition was defined using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multilevel variable regression approaches determined the relationship between malnutrition and early postoperative outcomes.

Results

6438 patients were included in the final analysis (1184 gastric cancer; 5254 colorectal cancer). Severe malnutrition was common across all income-strata, affecting 1 in 4 patients overall, with a higher burden in low and lower-middle income countries (64%). In patients undergoing elective surgery (n = 5709), severe malnutrition was independently associated with increased mortality (aOR = 1.62 (1.07-2.48, P = 0.024) after accounting for patient factors, disease stage and country effects.

Conclusions

Severe malnutrition represents a high global burden in cancer surgery, particularly within lower income settings. Malnutrition is an independent risk-factor for 30-day mortality following elective surgery for gastric and colorectal cancer, suggesting perioperative nutritional interventions may improve outcomes after cancer surgery.

Development of the Scalp Hair Assessment PRO™ measure for alopecia areata

BACKGROUND

Valid patient-reported outcome (PRO) measures are required to evaluate alopecia areata (AA) treatments.

OBJECTIVES

To develop a content-valid and clinically meaningful PRO measure to assess AA scalp hair loss with scores comparable with the five-response-level Alopecia Areata Investigator Global Assessment (AA-IGA™).

METHODS

A draft PRO measure was developed based on input from 10 clinical experts in AA. The PRO measure was cognitively debriefed, modified and finalized through two rounds of qualitative semistructured interviews with patients with AA who had experienced ≥ 50% scalp hair loss. Data were thematically analysed.

RESULTS

Adults (round 1: n = 25; round 2: n = 15) and adolescents aged 15-17 years (round 1: n = 5) in North America participated. All patients named scalp hair loss as a key AA sign or symptom. Patients demonstrated the ability to self-report their current amount of scalp hair using percentages. In round 1 not all patients interpreted the measurement concept consistently; therefore, the PRO was modified to clarify the measurement concept to improve usability. Following modifications, patients in round 2 responded without difficulty to the PRO measure. Patients confirmed that they could use the five-level response scale to rate their scalp hair loss: no missing hair, 0%; limited, 1-20%; moderate, 21-49%; large, 50-94%; nearly all or all, 95-100%. Almost all patients deemed hair regrowth resulting in ≤ 20% scalp hair loss a treatment success.

CONCLUSIONS

The Scalp Hair Assessment PRO™ is a content-valid, clinically meaningful assessment of distinct gradations of scalp hair loss for evaluating AA treatment for patients with ≥ 50% hair loss at baseline.

Australian clinical consensus guideline for the subacute rehabilitation of childhood stroke

Childhood stroke results in long-term, multifaceted difficulties, affecting motor, cognitive, communication, and behavioral domains of function which impact on participation and quality of life. The Childhood Stroke Consensus Rehabilitation Guideline was developed to improve the care of children with stroke by providing health professionals with recommendations to assist in their rehabilitative treatment. Clinical questions were formulated to inform systematic database searches from 2001 to 2016, limited to English and pediatric studies. SIGN methodology and the National Health and Medical Research Council system were used to screen and classify the evidence. The Grade of Recommendation, Assessment, Development and Evaluation system was used to grade evidence as strong or weak. Where evidence was inadequate or absent, a modified Delphi consensus process was used to develop consensus-based recommendations. The guideline provides 56 recommendations (1 evidence-based recommendation and 55 consensus recommendations). These relate to the framework of rehabilitation service delivery as well as domain-specific rehabilitation treatment strategies for each domain of function. It is anticipated that this guideline will provide health professions with recommendations to improve the subacute care of children with stroke both in Australia and internationally.

The Alopecia Areata Investigator Global Assessment scale: a measure for evaluating clinically meaningful success in clinical trials

BACKGROUND

Content-valid and clinically meaningful instruments are required to evaluate outcomes of therapeutic interventions in alopecia areata (AA).

OBJECTIVES

To develop an Investigator's Global Assessment (IGA) to interpret treatment response in AA treatment studies.

METHODS

Qualitative interviews were conducted in the USA with expert dermatologists and with patients with AA who had experienced ≥ 50% scalp-hair loss. Thematic data analysis identified critical outcomes and evaluated the content validity of the new IGA.

RESULTS

Expert clinicians (n = 10) judged AA treatment success by the amount of scalp-hair growth (median 80% scalp hair). Adult (n = 25) and adolescent (n = 5) patients participated. Scalp-hair loss was the most bothersome AA sign/symptom for most patients. Perceived treatment success - short of 100% scalp hair - was the presence of ~ 70-90% scalp hair (median 80%). Using additional clinician and patient insights, the Alopecia Areata Investigator Global Assessment (AA-IGA™) was developed. This clinician-reported outcome assessment is an ordinal, static measure comprising five severity categories of scalp-hair loss. Nearly all clinicians and patients in this study agreed that, for patients with ≥ 50% scalp-hair loss, successful treatment would be hair regrowth resulting in ≤ 20% scalp-hair loss.

CONCLUSIONS

We recommend using the Severity of Alopecia Tool to assess the extent (0-100%) of scalp-hair loss. The AA-IGA is a robust ordinal measure providing distinct and clinically meaningful gradations of scalp-hair loss that reflects patients' and expert clinicians' perspectives and treatment expectations. What is already known about this topic? The Severity of Alopecia Tool is widely used to assess the extent of scalp-hair loss in patients with alopecia areata. Guidelines define treatment success as a 50% improvement in scalp hair, and clinical trials have used dynamic thresholds of 50% and 90%. However, there is no clinical consensus on these endpoints, and patient perspectives on treatment success are unknown. What does this study add? Through qualitative interviews with 10 expert dermatologists and 30 patients with alopecia areata who had experienced ≥ 50% scalp-hair loss, we developed the Alopecia Areata Investigator Global Assessment (AA-IGA™) to measure five clinically meaningful gradations of alopecia areata scalp-hair loss that reflects patients' and clinicians' perspectives and expectations of treatment success in alopecia areata treatment studies. What are the clinical implications of this work? The AA-IGA is a robust ordinal measure that can inform clinical evaluation of alopecia areata treatment outcomes. The AA-IGA can be used to determine clinically meaningful treatment success for alopecia areata, with success defined by patients and clinicians as reaching ≤ 20% scalp-hair loss. Linked Comment: Blome. Br J Dermatol 2020; 183:609.

Determination of Ochratoxin A in Currants, Raisins, Sultanas, Mixed Dried Fruit, and Dried Figs by Immunoaffinity Column Cleanup with Liquid Chromatography: Interlaboratory Study

An interlaboratory study was performed on behalf of the Food Standards Agency to evaluate the effectiveness of an affinity column cleanup liquid chromatographic (LC) method for the determination of ochratoxin A in a variety of dried fruit at European regulatory limits. To ensure homogeneity before analysis, laboratory samples are normally slurried with water in the ratio of 5 parts fruit to 4 parts water, and test materials in this form were used in the study. The test portion was extracted with acidified methanol. The extract was filtered, diluted with phosphate-buffered saline, and applied to an affinity column. The column was washed and ochratoxin A was eluted with methanol. Ochratoxin A was quantified by reversed-phase LC. The use of post-column pH shift to enhance the fluorescence of ochratoxin A by the addition of 1.1M ammonia solution to the column eluant is optional. Determination was by fluorescence. Currants, sultanas, raisins, figs, and mixed fruit (comprising dried pineapple, papaya, sultanas, prunes, dates, and banana chips), both naturally contaminated and blank (very low level), were sent to 24 collaborators in 7 European countries. Participants were asked to spike test portions of all test samples at a level equivalent to 5 ng/g ochra toxin A. Average recoveries ranged from 69 to 74%. Based on results for 5 naturally contaminated test samples (blind duplicates) the relative standard deviation for repeatability (RSDr) ranged from 4.9 to 8.7%, and the relative standard deviation for reproducibility (RSDR)rangedfrom14to28%. The method showed acceptable within-and be-tween-laboratory precision for all 5 matrixes, as evidenced by HORRAT values &lt;1.3.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Can we use robotic surgery for the treatment of pelvic recurrence and locally advanced tumors in gynecological surgery?

Over the past 20 years, feasibility of laparoscopic approaches has been validated in gynecologic surgery. This procedure has specific challenges due its longer learning curve and the limits imposed by the technique. For the surgical treatment of recurrent pelvic cancers or locally advanced tumors, open surgery remains the gold standard for most surgical teams. Robotic assistance could be an interesting alternative. The aim of this study is to present our department's robotic surgical procedures in this specific field and show its feasibility and reproducibility on several patients.

Past, Present, and Future of Dynamic Kidney and Liver Preservation and Resuscitation

The increased demand for organs has led to the increased usage of "higher risk" kidney and liver grafts. These grafts from donation after circulatory death or expanded criteria donors are more susceptible to preservation injury and have a higher risk of unfavorable outcomes. Dynamic, instead of static, preservation could allow for organ optimization, offering a platform for viability assessment, active organ repair and resuscitation. Ex situ machine perfusion and in situ regional perfusion in the donor are emerging as potential tools to preserve and resuscitate vulnerable grafts. Preclinical findings have ignited clinical organ preservation research that investigates dynamic preservation, its various modes (continuous, preimplantation) and temperatures (hypo-, sub, or normothermic). This review outlines the current status of dynamic preservation of kidney and liver grafts and describes ongoing research and emerging clinical trials.

Light Microscopy, Immunohistochemistry and Electron Microscopy of the Valves of the Lower Limb Veins and Jugular Veins

Objectives:

To demonstrate the light, electron microscopy and immunohistochemistry appearances of the valves of lower limb veins and jugular veins of subject with evidence of venous disease.

Design:

A prospective study of saphenous veins obtained at post mortem examination and jugular vein obtained at time of surgery.

Setting:

Health Service district general hospital.

Patients:

Patients with no evidence of venous disease being treated in the hospital for unrelated conditions, or examined at autopsy in the Department of Pathology.

Interventions:

Sections of saphenous vein from the lower limb and jugular vein were examined using conventional histology, immunohistochemical staining and electron microscopy.

Main outcome measures:

Microscopic and electron microscopic appearances of histological sections of venous valves.

Results:

The valve agger contains an increased amount of fibrous tissue compared with the vein wall and saphenous and jugular veins. However, in saphenous veins the muscle layer of the wall could be traced across the base of the agger, but this was deficient in jugular valves. Electron microscopic examination showed that most of the valve cusp was composed of collagen fibrils, aggregated in irregularly arranged bundles. Elastic fibre material was present in the subendothelial zones. Nerve and muscle fibres were not present in the cusp.

Conclusions:

Valve cusps in both high and low pressure systems are similar, and the authors suggest that cusp/agger/vein wall complex is important for valve function.

Cavity-enhanced optical Hall effect in two-dimensional free charge carrier gases detected at terahertz frequencies

The effect of a tunable, externally coupled Fabry-Perot cavity to resonantly enhance the optical Hall effect signatures at terahertz frequencies produced by a traditional Drude-like two-dimensional electron gas is shown and discussed in this Letter. As a result, the detection of optical Hall effect signatures at conveniently obtainable magnetic fields, for example, by neodymium permanent magnets, is demonstrated. An AlInN/GaN-based high-electron mobility transistor structure grown on a sapphire substrate is used for the experiment. The optical Hall effect signatures and their dispersions, which are governed by the frequency and the reflectance minima and maxima of the externally coupled Fabry-Perot cavity, are presented and discussed. Tuning the externally coupled Fabry-Perot cavity strongly modifies the optical Hall effect signatures, which provides a new degree of freedom for optical Hall effect experiments in addition to frequency, angle of incidence, and magnetic field direction and strength.

Bilateral scalp necrosis as a rare but devastating complication of giant cell arteritis

Giant cell arteritis (GCA) is a medium to large vessel vasculitis of unknown aetiology. Commonly, it affects the temporal arteries and is known as temporal arteritis. It has an association with polymyalgia rheumatica and can result in severe complications such as loss of vision and rarely scalp necrosis. There are approximately 100 cases of scalp necrosis in patients with GCA published in the literature to date. We report a case of a man who presented with a 4-week history of bilateral scalp necrosis associated with headache, jaw claudication, temporal artery tenderness, and raised inflammatory markers. He did not have any visual loss. A diagnosis of GCA was made and he was started on high-dose steroids immediately. The scalp lesions did improve and his symptoms resolved without any visual loss but, sadly he died due to severe sepsis. This case report is important as it describes a rare but severe complication of a common large vessel vasculitis seen by both primary care physicians and rheumatologists. Prompt recognition and early treatment by the physician are crucial to the patient to prevent visual loss or a fatal stroke. It also highlights complications associated with steroids which are the mainstay of treatment for this condition.