Early access flow rate predicts vascular access patency-related intervention in the first year: A retrospective cohort study

INTRODUCTION

Arteriovenous fistulas and grafts are lifelines for most hemodialysis patients, and a low access flow rate often requires patency-related intervention, such as angioplasty or thrombectomy, to prevent access failure. We examined whether early access flow rate, measured after initial fistula/graft cannulation, predicts vascular access patency-related intervention within 1 year.

METHODS

This was a single-center retrospective cohort study. Among 172 patients undergoing surgical creation of a fistula/graft, 52 (30.2%) had documented access flow rates measurement by the Transonic™ ultrasound dilution technique, performed within an average of 48 days from initial access cannulation. The need for a patency-related intervention, defined as undergoing a fistulogram, angioplasty, thrombectomy, or surgical revision, was ascertained within 1 year. A receiver-operating characteristic curve (ROC) was generated to evaluate the diagnostic performance of first and average access flow rates for predicting patency-related intervention within 1 year.

FINDINGS

Twenty-eight (53.8%) of the 52 study subjects required a patency-related intervention within 1 year. Their characteristics were not significantly different from those who did not require patency-related interventions. However, first access flow rates were significantly lower in patients requiring patency-related intervention compared to those who did not (898 vs. 1471 mL/min; p = 0.003), as were average access flow rates (841 vs. 1506 mL/min; p < 0.001). The ROC analyses revealed that first access flow rates and average access flow rates predicted the need for patency-related intervention within 1 year, with an area under-the-ROC curve of 0.743 (95% confidence interval [CI] 0.608, 0.877) and 0.775 (95% CI 0.648, 0.903), respectively, demonstrating acceptable discrimination.

DISCUSSION

In adults undergoing hemodialysis, early access flow rate measurement can predict patency-related intervention within 1 year after initial vascular access cannulation. Additional studies are required to confirm these findings and identify optimal access flow rate cut-off values to predict vascular accesses at higher risk of stenosis.

Forced Expiratory Volume in One Second Quotient (FEV1Q) as a Prognostic Factor in Amyotrophic Lateral Sclerosis Patients: Comparing Its Predictive Value to Other Lung Function Measurements

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder affecting the first and second motor neurons. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) have conventionally served as indicators of respiratory muscle strength. Recently, FEV1Q (FEV1 divided by the sex-specific first percentile values of absolute FEV1 in adults with lung disease) has been suggested as a predictor of mortality. While FVC has been utilized as a prognostic factor, FEV1Q has not yet been examined.

METHODS

This retrospective unicenter study evaluated FEV1Q as a predictor of mortality in ALS patients, comparing its predictive efficacy with other measurements, including FEV1, FVC, sniff nasal inspiratory pressure, and maximal inspiratory pressure. The study utilized univariate analysis for each variable employing the Cox proportional hazards model to determine the statistical significance and predictive power of each measurement.

RESULTS

Forty-five patients were included, female predominant (60%) and an average age at diagnosis of 69.2 ± 11 years. Almost all (95%) met the criteria for non-invasive ventilation (NIV) and initiated (93%) during the study period, a mean of 137 days after diagnosis. The mortality rate observed was 57%, occurring at a median of 398 days post-diagnosis. On average, patients underwent 1.7 pulmonary function tests, revealing a decline in various parameters, including FEV1, FEV1Q, and FVC. However, only FEV1Q was a statistically significant predictor of mortality (p < 0.0083) in a Cox regression analysis. A negative coefficient for FEV1Q indicated that higher values were associated with a reduced mortality risk, with an average FEV1Q of 2.68 observed at the time of death.

CONCLUSION

FEV1Q emerged as the only statistically significant predictor of mortality among the evaluated respiratory measurements in ALS patients. This study is the first to focus on applying FEV1Q in the clinical evaluation of ALS, marking an initial step in understanding its potential role in patient follow-up. However, further studies are needed before these findings can be incorporated into clinical practice.

Impact of Diagnostic and Treatment Delays on Survival and Treatment-Related Toxicities in Portuguese Patients With Head and Neck Cancer

INTRODUCTION

Delays in diagnosis and initiation of treatment have a negative impact on the prognosis and survival of head and neck cancer (HNC) patients. These delays also involve more intensive treatments with greater toxicity, dysfunction, and morbidity.

METHODS

This was a retrospective observational study with patients diagnosed with HNC between January 1, 2018, and December 31, 2021. The main objective was to estimate whether the time to diagnosis (TD) and time until treatment initiation (TIT) translated into changes in the patient's overall survival (OS). Multivariate data analysis was performed with the Cox regression model. Significance was considered for p<0.05.

RESULTS

A total of 139 patients were included in this study. Median TD was 126 days and median TIT was 43 days. No association between TD, TIT, treatment toxicity, and OS was found. Being a smoker was associated with a longer TD (p=0.05, hazard ratios {HR}=1.01). TIT was significantly shorter in higher grades (p=0.03, HR=0.57) and during coronavirus disease 2019 (COVID-19) (p=0.04, HR=0.57), but higher in larger disease (tumor {T}) (p=0.04, HR=1.39). A higher T (p=0.01, HR=2.67) and lymph node metastasis (nodes {N}) (p=0.02, HR=2.24) were identified as risk factors with a negative impact on OS, whereas grade was positively correlated (p=0.05, HR=0.32).

CONCLUSIONS

Even though there was no correlation between TD and TIT, and OS, action still needs to be taken to shorten these times. T and N remain negative predictive prognostic markers of HNC.

Targeting Inhibitor of Apoptosis Proteins to Overcome Chemotherapy Resistance-A Marriage between Targeted Therapy and Cytotoxic Chemotherapy

Precision oncology is the ultimate goal of cancer treatment, i.e., to treat cancer and only cancer, leaving all the remaining cells and tissues as intact as possible. Classical chemotherapy and radiotherapy, however, are still effective in many patients with cancer by effectively inducing apoptosis of cancer cells. Cancer cells might resist apoptosis via the anti-apoptotic effects of the inhibitor of apoptosis proteins. Recently, the inhibitors of those proteins have been developed with the goal of enhancing the cytotoxic effects of chemotherapy and radiotherapy, and one of them, xevinapant, has already demonstrated effectiveness in a phase II clinical trial. This class of drugs represents an example of synergism between classical cytotoxic chemo- and radiotherapy and new targeted therapy.

Immunotherapy around the Clock: Impact of Infusion Timing on Stage IV Melanoma Outcomes

Although the impact of circadian timing on immunotherapy has yet to be integrated into clinical practice, chronoimmunotherapy is an emerging and promising field as circadian oscillations are observed in immune cell numbers as well as the expression of immunotherapy targets, e.g., programmed cell death protein-1 and its ligand programmed death ligand 1. Concurrent retrospective studies suggest that morning infusions may lead to higher effectiveness of immune checkpoint inhibitors in melanoma, non-small cell lung cancer, and kidney cancer. This paper discusses the results of a retrospective study (2016-2022) exploring the impact of infusion timing on the outcomes of all 73 patients with stage IV melanoma receiving immunotherapy at a particular medical center. While the median overall survival (OS) was 24.2 months (95% confidence interval [CI] 9.04-39.8), for a median follow-up of 15.3 months, our results show that having more than 75% of infusions in the afternoon results in shorter median OS (14.9 vs. 38.1 months; hazard ratio 0.45 [CI 0.23-0.86]; p < 0.01) with more expressive impacts on particular subgroups: women, older patients, and patients with a lower tumor burden at the outset of immunotherapy. Our findings highlight the potential benefits of follow-up validation in prospective and translational randomized studies.

Radiotherapy, Chemotherapy and Immunotherapy-Current Practice and Future Perspectives for Recurrent/Metastatic Oral Cavity Squamous Cell Carcinoma

Oral squamous cell carcinoma is the most common malignant epithelial neoplasm affecting the oral cavity. While surgical resection is the cornerstone of a multimodal curative approach, some tumors are deemed recurrent or metastatic (R/M) and often not suitable for curative surgery. This mainly occurs due to the extent of lesions or when surgery is expected to result in poor functional outcomes. Amongst the main non-surgical therapeutic options for oral squamous cell carcinoma are radiotherapy, chemotherapy, molecular targeted agents, and immunotherapy. Depending on the disease setting, these therapeutic approaches can be used isolated or in combination, with distinct efficacy and side effects. All these factors must be considered for treatment decisions within a multidisciplinary approach. The present article reviews the evidence regarding the treatment of patients with R/M oral squamous cell carcinoma. The main goal is to provide an overview of available treatment options and address future therapeutic perspectives.

AB0510 THE ROLE OF BONE SCINTIGRAPHY FOR THE FOLLOW-UP EVALUATION OF INFLAMMATORY ACTIVITY IN PATIENTS WITH SERONEGATIVE SPONDYLOARTHRITIS

Background:

The use of bone scintigraphy (Sc) in spondyloarthritis (SpA) as a technique for diagnosis, assessment of activity and treatment decision has been questioned by the scientific community. Due to its low cost compared to Magnetic Resonance Imaging - MRI (the gold standard)1, some studies proposed to evaluate Sc’s diagnostic accuracy. These studies have shown that Sc has a low diagnostic sensitivity of 50-55%2. Also, there is a poor correlation between symptoms and scintigraphic uptake3. We aimed to evaluate the use of Sc for management and follow-up of patients with SpA.

Objectives:

To determine if Sc activity correlates with patients’ complaints (peripheral and axial), inflammatory markers, disease activity scores and whether it influenced physicians’ treatment decisions during the follow-up of the disease.

Methods:

We performed a retrospective review of all patients at our department with SpA with at least one Sc from 2018 to 2020. The following variables were analyzed: demographic data, spondyloarthropathy subtype (ankylosing, enteropathic, psoriatic and undifferentiated SpA), axial or peripheral pain, Sc findings (inflammatory vs no-inflammatory activity), inflammatory markers (sedimentation rate - ESR and C-Reactive Protein - CRP), disease activity scores within one year since the Sc (Ankylosing Spondylitis Disease Activity Score with Erythrocyte Sedimentation Rate - ASDAS-ESR and Bath Ankylosing Spondylitis Disease Activity Index - BASDAI) and treatment at the time of the Sc (non-steroidal anti-inflammatory drugs, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), target synthetic DMARDs and biologic DMARD. Treatment decisions (escalation, de-escalation or maintenance) in accordance to Sc results were also reviewed.

We used the non-parametric Mann-Whitney’s U test for comparisons between ordinal or numerical variables. For correlations between categorical variables we used the Fisher’s exact test and the χ2-independence test. Tests with p < 0.05 were statistically significant.

Results:

Fifty-five patients were reviewed, 75% women; median age of 48 years. Seventy-one percent had ankylosing SpA, 15% enteropathic SpA, 5% psoriatic SpA, 5% undifferentiated and 4% reactive SpA. Sixty-two percent of the patients had both axial and peripheral pain and 24% only axial complaints. Sixty-two percent of the patients had a Sc with no inflammatory changes, 27% had peripheral and 25% had axial inflammatory changes; 15% had evidence of both peripheral and axial inflammation. For ankylosing SpA, the median ASDAS-ESR was 2.89 and according to the BASDAI, 66% had active disease. The median CRP and ESR in patients with inflammatory vs a normal Sc was not different (p=0.02 vs p=0.36, respectively). Similarly, Sc findings were not correlated with patients’ axial (p=0.10) or peripheral pain (p=1.0), neither with the ASDAS-ESR (p=0.29) or the BASDAI (p=0.29). There was no correlation between inflammatory activity in Sc and the decision to maintain, escalate or de-escalate treatment (p=0.65), including the decision to start a biological DMARD (p=1.0) or to switch between biological DMARDs (p=0.19).

Conclusion:

There was no correlation between Sc findings and ESR, patients’ complaints, disease activity or treatment decisions. Considering previous research showing a low diagnostic sensitivity, our findings seem to support a limited role of bone Sc for the follow-up and management of patients with seronegative SpA.

References:

[1]Khmelinskii N, Regel A, Baraliakos X. The Role of Imaging in Diagnosing Axial Spondyloarthritis. Front Med. 2018;5. doi:10.3389/fmed.2018.00106

[2]Poddubnyy D. Classification vs diagnostic criteria: the challenge of diagnosing axial spondyloarthritis. Rheumatology. 2020;59(Supplement_4):iv6-iv17. doi:10.1093/rheumatology/keaa250

[3]Shim JS, Kim C, Ryu JJ, Choi SJ. Correlation between TM joint disease and rheumatic diseases detected on bone scintigraphy and clinical factors. Sci Rep. 2020;10(1):4547. doi:10.1038/s41598-020-60804-x

Disclosure of Interests:

None declared.

Psychoactive substance use in patients with tuberculosis, treatment adherence, Brief Interventions

Background

Psychoactive substance use associated with tuberculosis therapy is an urgent public health issue in the contemporary world.

Objective

To characterize the profile and psychoactive substance use of patients undergoing tuberculosis treatment and to analyze the association between health-related variables, consumption, and treatment adherence, from the perspective of Brief Interventions.

Methodology

Descriptive transversal epidemiological study, carried out in primary care units, with 114 patients undergoing tuberculosis treatment, from June 2016 to July 2017. The Self-Reporting Questionnaire (SRQ-20) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were used.

Results

Smokers who drank alcohol (p = 0.058) and those who reported not having chronic diseases (p = 0.024) had a need to receive brief interventions. Cannabis use was more frequent among smokers (p = 0.009). With regard to cocaine use, a significant association was found between smoking and the number of chronic diseases. In this sample, 40% of smokers, 21.1% of alcohol drinkers, 10.5% of cannabis users, and 13.7% of cocaine/crack users adhered to treatment.

Conclusions

These results demonstrated the vulnerability of this population to psychoactive substance use based on treatment adherence and the importance of using Brief Interventions for monitoring, especially in primary care settings.

Key messages

The study showed an opportunity to apply the diagnostic strategy of brief intervention in this population in primary care. It showed an impact on the change in behavior of these patients, in view of greater adherence to treatment and improvement in quality of life.

Visual processing disorders in patients with Huntington's disease and asymptomatic carriers

Deficits in visual processing are early cognitive abnormalities in patients with Huntington's disease (HD) and may be found in presymptomatic gene carriers. We investigated the nature and evolution of deficits in visual processing in HD, and whether subtle deficits could be recognized by formal testing in asymptomatic carriers. We studied 35 patients with HD in stages 1-3 of functional disability, and 26 symptom-free relatives at 50% risk for the disease. We administered the Mini Mental State Examination to assess overall cognitive function and tests to assess visuospatial skills such as visual attention and ocular scanning (Cancellation Task and Line Bisection Test), visuoconstructive abilities (Copy of Rey's Complex Figure), and visuoperception (Hooper Visual Organization Test). The group at risk comprised 15 asymptomatic carriers (AC) and 11 non-carriers (NC) and was assessed by investigators blinded to gene status. HD patients were impaired in most of the tasks compared with AC and NC, and the scores declined steadily from stage 1 to 3. However, the difference between patients in stage 1 of HD and AC and NC in most of the tasks was not significant. Only the Hooper Test, which requires complex visual integration, was highly discriminative of early symptomatic from asymptomatic carriers (P < 0.05). There were no significant differences between AC and NC in any of the tasks. We conclude deficits in visual processing develop with other manifestations of the disease and are not significant on formal testing at presymptomatic stages; also, early visual deficits in HD seem to be related to disorders in complex visual processing.