Reporting of coronary artery calcification on chest CT studies in patients with interstitial lung disease

AIM

To evaluate the prevalence of coronary artery calcification (CAC) on non-contrast computed tomography (CT) of the thorax in patients with interstitial lung disease (ILD), assess consistency of CAC reporting and assess incidence of subsequent cardiac events.

MATERIALS AND METHODS

Patients with known interstitial lung disease who underwent a CT thorax over a 2-year period were retrospectively reviewed. Presence of CAC was assessed using a visual scale for CAC reporting and graded as mild, moderate, or severe by two cardiothoracic radiologists. CT reports were reviewed to determine if presence of CAC had been described. Electronic medical records were reviewed for any subsequent cardiothoracic events from the date of the CT thorax to present.

RESULTS

254 patients were included in the analysis (54.7% men; mean age 59.9 yo). 43.7% had CAC on their CT thorax; however, in 87.3% of those, reports did not comment on its presence. 8 patients had cardiac events; 7 of them had CAC on CT although only in 1 case this was reported. Global CAC and LAD CAC Patients with cardiac events had a significantly higher global CAC (p=0.016) and LAD CAC (p=0.048) when compared to patients without.

CONCLUSION

We demonstrated a high prevalence of CAC in ILD patients and its significant association with adverse cardiac events. Unfortunately, CAC on CT thorax is still largely unreported. As per recent BSCI/BSCCT and BSTI guidelines, reporting of CAC should become part of routine practice, as may prompt prevention and impact on patients outcome.

COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Global Energy Metabolism Deficit in Alzheimer Disease Brain

BACKGROUND

The understanding of Alzheimer's disease (AD) has been dominated by the amyloid hypothesis. However, therapies targeting beta-amyloid have largely failed, generating interest in other potential pathogenic factors including energy metabolism.

OBJECTIVES

To interrogate canonical energy metabolism pathways from human prefrontal cortical tissue samples obtained from necropsy comparing AD and control.

DESIGN, SETTING, AND PARTICIPANTS

Postmortem pre-frontal cortical tissue from 10 subjects histologically diagnosed with AD and 10 control (CTRL) subjects was subjected to untargeted metabolomics to interrogate energy metabolism pathways. The samples were matched by age, sex, and post-mortem interval. Metabolite Measurements: Untargeted metabolomics analyses were via Metabolon®.

RESULTS

Glucose-derived energy metabolites in the glycolytic and pentose phosphate pathway and the ketone body β-hydroxybutyrate were uniformly decreased in AD brain vs. CTRL brain.

CONCLUSION

This pilot study aimed to identify energy metabolism abnormalities using untargeted brain metabolomics in two independent subject cohorts. Our study revealed a pattern of global energy deficit in AD brain, supporting a growing body of evidence of deficient energy metabolism in AD.

Evaluation of oncology infusion pharmacy practices: A nationwide survey

PURPOSE

Oncology care continues to evolve at a rapid pace including provision of infusion-based care. There is currently a lack of robust metrics around oncology infusion centers and pharmacy practice. The workgroup completed a nationwide survey to learn about oncology-based infusion pharmacy services offered. The objective was to highlight consistent, measureable oncology-based infusion pharmacy metrics that will provide a foundation to describe overall productivity including emphasis on high patient-safety standards.

METHODS

A nationwide survey was developed via a workgroup within the Vizient Pharmacy Cancer Care Group beginning in April 2019 and conducted electronically via the Vizient Pharmacy Network from September to November 2020. The survey was designed to capture a number of key metrics related to oncology-based infusion pharmacy services.

RESULTS

Forty-one sites responded to the survey. Responses highlighted hours of operation (median = 11.5), number of infusion chairs (median = 45). Staffing metrics included 7.1 pharmacist full-time equivalent (FTE) and 7.6 technician FTE per week. 80.5% of sites had cleanrooms and 95.1% reported both hazardous and nonhazardous compounding hoods. 68.3% of sites reported using intravenous (IV) technology, 50.0% measured turnaround time, and 31.4% prepared treatment medications in advance.

CONCLUSION

There was variability among oncology infusion pharmacy practices in regard to survey responses among sites. The survey results highlight the need for standardization of established productivity metrics across oncology infusion pharmacies in order to improve efficiency and contain costs in the changing oncology landscape. The survey provides insight into oncology infusion pharmacy practices nationwide and provides information for pharmacy leaders to help guide their practices.

Interpretability of a Deep Learning-Based Prediction Model for Mandibular Osteoradionecrosis

PURPOSE/OBJECTIVE(S)

The development of radiation-induced toxicities is a multifactorial process. Existing DVH-based prediction models use traditional multivariate analysis to combine all the potential risk factors. Recently, deep learning (DL) has been proposed for predicting mandibular osteoradionecrosis (ORN) directly from 3D dose distribution maps [1]. However, with this approach, incorporating non-imaging data such as potential risk factors presents challenges. We investigate the use of DL-based multimodality fusion for the purpose of radiation-induced ORN toxicity prediction.

MATERIALS/METHODS

This study explores early and late fusion strategies for combining 3D radiation dose distribution maps and clinical and demographic variables in the prediction of mandibular ORN incidence in head and neck cancer patients treated with radiotherapy. The results are compared to single-modality predictions with a random forest (RF) trained only on clinical variables and a 3D DenseNet40 trained on dose maps alone. We investigate two different fusion approaches. In the first, the image features extracted from the radiation dose maps using a 3D DenseNet40 were concatenated with the clinical variables into one single vector using a type II early fusion strategy. The combined feature vector was input into a fully connected layer for classification of ORN vs. controls. A final softmax activation layer was added to obtain the class predicted probabilities. The second approach used a late fusion strategy, in which the outputs from the 3D DenseNet40 and the RF model were combined by averaging the predicted classification probabilities for each of the two classes (ORN and no ORN) to obtain the final class decision on a case-by-case basis.

RESULTS

The AUROC values obtained for the late and early fusion models and the single-modality 3D DenseNet40 and RF models were 0.70, 0.68, 0.69 and 0.60, respectively. The highest AUC ROC was observed with the late fusion approach, which was statistically significantly different to that of the RF single-modality model with a significance level of 0.05. However, after Bonferroni correction (Altman 1999) for multiple comparisons was applied, resulting in a corrected significance level of 0.05/6 = 0.008 for each comparison, no statistically significant difference was observed between any of the models' AUROC values. This is most likely due to the lack of discriminative contribution observed from clinical variables, which on their own resulted in a poorly predictive RF model.

CONCLUSION

To our knowledge, no previous work has been published on the use of multimodal fusion DL methods to combine dose distribution maps and clinical variables in the prediction of mandibular ORN. Although non-conclusive results were obtained, this study demonstrates the potential of DL in the prediction of the multifactorial side effects resulting from radiotherapy treatments. [1] Humbert-Vidan L et al. Prediction of Mandibular ORN Incidence from 3D Radiation Dose Distribution Maps Using DL (2022).

Memory discrimination is promoted by the expression of the transcription repressor WT1 in the dentate gyrus

The hippocampus is critical for the precise formation of contextual memories. Overlapping inputs coming from the entorhinal cortex are processed by the trisynaptic pathway to form distinct memories. Disruption in any step of the circuit flow can lead to a lack of memory precision, and to memory interference. We have identified the transcriptional repressor Wilm's Tumor 1 (WT1) as an important regulator of synaptic plasticity involved in memory discrimination in the hippocampus. In male mice, using viral and transgenic approaches, we showed that WT1 deletion in granule cells of the dentate gyrus (DG) disrupts memory discrimination. With electrophysiological methods, we then identified changes in granule cells' excitability and DG synaptic transmission indicating that WT1 knockdown in DG granule cells disrupts the inhibitory feedforward input from mossy fibers to CA3 by decreasing mIPSCs and shifting the normal excitatory/inhibitory (E/I) balance in the DG → CA3 circuit in favor of excitation. Finally, using a chemogenetic approach, we established a causal link between granule cell hyperexcitability and memory discrimination impairments. Our results suggest that WT1 enables a circuit-level computation that drives pattern discrimination behavior.

Dopaminoceptive D1 and D2 neurons in ventral hippocampus arbitrate approach and avoidance in anxiety

The hippocampus 1-7, as well as dopamine circuits 8-11, coordinate decision-making in anxiety-eliciting situations. Yet, little is known about how dopamine modulates hippocampal representations of emotionally-salient stimuli to inform appropriate resolution of approach versus avoidance conflicts. We here study dopaminoceptive neurons in mouse ventral hippocampus (vHipp), molecularly distinguished by their expression of dopamine D1 or D2 receptors. We show that these neurons are transcriptionally distinct and topographically organized across vHipp subfields and cell types. In the ventral subiculum where they are enriched, both D1 and D2 neurons are recruited during anxiogenic exploration, yet with distinct profiles related to investigation and behavioral selection. In turn, they mediate opposite approach/avoidance responses, and are differentially modulated by dopaminergic transmission in that region. Together, these results suggest that vHipp dopamine dynamics gate exploratory behaviors under contextual uncertainty, implicating dopaminoception in the complex computation engaged in vHipp to govern emotional states.

Monomethylation of Lysine 27 at Histone 3 Confers Lifelong Susceptibility to Stress

Histone post-translational modifications are critical for mediating persistent alterations in gene expression. By combining unbiased proteomics profiling, and genome-wide approaches, we uncovered a role for mono-methylation of lysine 27 at histone H3 (H3K27me1) in the enduring effects of stress. Specifically, mice exposed to early life stress (ELS) or to chronic social defeat stress (CSDS) in adulthood displayed increased enrichment of H3K27me1, and transient decreases in H3K27me2, in the nucleus accumbens (NAc), a key brain-reward region. Stress induction of H3K27me1 was mediated by the VEFS domain of SUZ12, a core subunit of the polycomb repressive complex-2, which is induced by chronic stress and controls H3K27 methylation patterns. Overexpression of the VEFS domain led to social, emotional, and cognitive abnormalities, and altered excitability of NAc D1 mediums spiny neurons. Together, we describe a novel function of H3K27me1 in brain and demonstrate its role as a "chromatin scar" that mediates lifelong stress susceptibility.

A282 RISK FACTORS ASSOCIATED WITH UNSUCCESSFUL HIGH-RESOLUTION MANOMETRY: FAILURE IS COMMON BUT WHAT CAN WE CHANGE

Background

High-resolution manometry (HRM) is a diagnostic tool used to evaluate esophageal motor function and diagnose motility disorders. A standardized protocol is used to make an accurate diagnosis based on the Chicago Classification. Some existing literature suggests that incomplete or imperfect manometry tests are common, however; there remains a paucity of data to evaluate risk factors for failure to help clinicians determine when a study may be difficult to perform.

Purpose

Our goal was to quantify how often failed tests occurred and determine specific factors that may be associated with failed HRM.

Method

We retrospectively evaluated records for HRM tests performed over 1 year at our academic centre. Based on clinical experience, we identified several factors that may be associated with the success of HRM testing including the following: indications and symptoms leading to testing, patient’s age and biological sex, previous esophageal manometry history, previous esophageal/gastric surgery, previous septal repair/deviated septum, history of significant nausea/vomiting, history of anxiety/depression, history of irritable bowel syndrome, and medication use (opioids, proton pump inhibitors, calcium channel blockers, nitrates). We then compared patients with successful HRM vs. unsuccessful HRM with regard to our pre-specified risk factors.

Result(s)

29 HRM tests were unsuccessful from a total of 152 that were performed (19% failure rate). Reasons for failure included the inability to pass the probe through LES (55%) and the inability to tolerate the manometry probe for a minimum of 10 saline swallows (45%). After separating the failed cases from successful tests, both groups had a similar distribution of age and sex. Specific symptoms and indications did not have a significant association with unsuccessful tests. A previous history of failed manometry was associated with unsuccessful HRM (OR: 15, 95% CI 1.88 to 183.8, p=0.0156). Conversely, PPI usage was associated with fewer failed HRM tests (OR: 0.37, 95% CI 0.16 to 0.90, p=0.0343). Other medical history or medication use was not found to be associated with testing failure in our study.

Conclusion(s)

HRM is useful for diagnosing esophageal motility disorders, but incomplete tests are common. Although this study did not identify any factors in a patient’s medical history that could be used to predict failure in patients who have never had testing, further investigations may identify if PPI therapy can make HRM testing more tolerable. Additionally, the association between previous failed HRM and repeat failures suggests that endoscopic probe placement techniques should be considered instead of retrying conventional probe placement.

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Disclosure of Interest

None Declared

Edge-Enhancing Gradient-Echo MP2RAGE for Clinical Epilepsy Imaging at 7T

The 3D edge-enhancing gradient-echo (EDGE) MR imaging sequence offers superior contrast-to-noise ratio in the detection of focal cortical dysplasia. EDGE could benefit from 7T MR imaging but also faces challenges such as image inhomogeneity and low acquisition efficiency. We propose an EDGE-MP2RAGE sequence that can provide both EDGE and T1-weighted contrast, simultaneously, improving data-acquisition efficiency. We demonstrate that with sequence optimization, EDGE images with sufficient uniformity and T1-weighted images with high gray-to-white matter contrast can be achieved.

The Anti-Narcolepsy Drug Modafinil Reverses Hypoglycemia Unawareness and Normalizes Glucose Sensing of Orexin Neurons in Male Mice

Perifornical hypothalamus (PFH) orexin glucose-inhibited (GI) neurons that facilitate arousal have been implicated in hypoglycemia awareness. Mice lacking orexin exhibit narcolepsy and orexin mediates the effect of the anti-narcolepsy drug, modafinil. Thus, hypoglycemia awareness may require a certain level of arousal for awareness of the sympathetic symptoms of hypoglycemia (e.g., tremors, anxiety). Recurrent hypoglycemia (RH) causes hypoglycemia unawareness. We hypothesize that RH impairs the glucose sensitivity of PFH orexin-GI neurons and that modafinil normalizes glucose sensitivity of these neurons and restores hypoglycemia awareness after RH. Using patch clamp recording, we found that RH enhanced glucose inhibition of PFH orexin-GI neurons from male mice, thereby blunting activation of these neurons in low glucose. We then used a modified conditioned place preference (CPP) behavioral test to demonstrate that modafinil reversed hypoglycemia unawareness in male mice after RH. Similarly, modafinil restored normal glucose sensitivity to PFH orexin-GI neurons. We conclude that impaired glucose sensitivity of PFH orexin-GI neurons plays a role in hypoglycemia unawareness and that normalizing their glucose sensitivity after RH is associated with restoration of hypoglycemia awareness. This suggests that the glucose sensitivity of PFH orexin-GI neurons is a therapeutic target for preventing hypoglycemia unawareness.

Highly Effective, Easy, & Simple Model for the Day-to-Day Monitoring of Blood Bank Inventory Leading to Successful Operations to Provide Blood Products in the Times of Blood Product Shortage Nationally Due to COVID-19 Pandemic

Introduction/Objective

Providing blood products in a timely manner is very important and is an integral part of the health care system to provide best patient care. Transfusion medicine services should be well prepared to respond to blood product demands in a timely manner. Due to the COVID-19 pandemic, all the transfusion medicine services nationally have been facing blood product shortages. A model was created in Pathology & Laboratory services (P&LMS) at the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMC VAMC) to communicate effectively to the patient care team to keep up with ongoing clinical care demands despite the national blood shortage.

Methods/Case Report

Transfusion medicine team at CMC VAMC communicated to patient care team about the national shortage of blood products. All blood requests were evaluated for appropriate usage of blood. Also, PACS (Peri Operative cells Savers) services was considered for Operating room for patient with major blood loss. Daily blood inventory was evaluated, closely monitored, and communicated to patient care team to meet the demands from Jan 16th, 2022, to April 11th, 2022. Importantly, P&LMS created a simple model where each blood product in reduction was recorded every morning and evening. This simple method of 24/7 real time monitoring of the supply of blood products helped tremendously in decision making for procedure prioritization based on clinical indications and contributed to the continued successful clinical operation.

Results (if a Case Study enter NA)

Procedures were successfully prioritized according to the blood supply. Simultaneously, there was no delay in issuing blood products as clinically needed. A significant amount of reduced inventory noted from Jan 16th, 2022, to April 11th, 2022; the average reduction was O+ 53% reduced and A+ 44% reduced.

Conclusion

By monitoring the day-to-day blood bank inventory effectively, P&LMS at CMC VAMC was able to support all the critical clinical needs by providing blood products in a timely manner. P&LMS services was able to reduce the wastage and was able to provide all the critical blood product without any significant delays by monitoring in Realtime. The value of collaborating and communicating to the patient care team cannot be understated as it is both simple and highly cost effective.

A Holistic Approach for an Efficient Day to Day Operation for Blood Bank Market Withdrawals and Recalls Using Departmental Electronic Occurrence System: A CMCVAMC Experience

Introduction/Objective

Donor centers and reagent manufacturers may issue recalls or market withdrawals. Donor center withdrawals of blood components involve units that have a reason that may present a risk to the patient, that subsequently require discarding the product if not transfused or appropriate clinical notification and follow-up if already transfused prior to the notification. Reagent recalls involve problems with reagents that require appropriate corrective action as per the circumstances. Patient safety event reporting systems are universal in hospitals and are a backbone of efforts to detect patient safety events and quality problems. Pathology and Laboratory Medicine (P&LMS) at the Corporal Michael J. Crescenz Veteran Affairs Medical Center (CMC VAMC) has established an electronic occurrence reporting (EOR) program to track and respond to these in the blood bank. The authors explored the usefulness of the holistic approach of this initiative.

Methods/Case Report

EOR is available to all the employees of Blood Bank in P&LMS, who regularly report all received recalls and market withdrawals into the system. These are reviewed by the supervisor and blood bank medical director and co-director to ensure appropriate steps are taken. Information on all market recalls and withdrawals affecting blood bank were compiled from January 1st, 2021, to June 1st, 2022, for quality assurance review.

Results (if a Case Study enter NA)

The EOR plays a significant role in organizing the data from all the recalls and market withdrawals to guide improvement in patient care. There were seven market withdrawals during the study period, all from the donor center for blood product component withdrawals. All seven cases were recorded efficiently with review by the blood bank supervisor and blood bank medical director and co-director. Appropriate follow-up action was performed and recorded for all seven cases in the EOR.

Conclusion

The EOR for withdrawals recalls in Blood Bank is highly effective, successful program in terms of electronic organized monitoring. This monitoring is part of ensuring quality care in real time, and plays an important role as part of Veteran Affairs position as a High reliability Organization (HRO).

Continuing Profound Impact of Continued Education Sessions on Blood Bank Specimen Labeling Years Later at the Veteran Affairs Medical Center

Introduction/Objective

Proper patient identification is a critical safety element for transfusion medicine, particularly for the prevention of acute hemolytic transfusion reactions (AHTR). Mislabeled specimens have been documented to carry an increased risk of patient misidentification. Therefore, the submission of a mislabeled specimen to the blood bank generally results in a specimen rejection with a redraw. At the Philadelphia Veteran Affairs Medical Center, an identification bracelet with alphanumeric code is used to help improve transfusion safety but also has additional patient labeling requirements. The redrawing of blood bank specimens poses risks in phlebotomy, and a quality improvement initiative was previously undertaken to educate staff on proper blood specimen and band labeling and usage to prevent labeling errors, improve safety in patient care, and reduce intended redraws.

Methods/Case Report

Colorful laminated posters delineating the labeling requirements and process for blood bank specimens collected using the blood bank system were made and distributed at the time of in-service training by the blood bank in 2017 to the areas of the hospital whereby errors had been noted to occur in the past. The dedicated in-service training was repeated prior to the change in the identification blood band from the Hollister Ident-ATM Blood Recipient Band (Precision Diagnostics Corporation, Valencia CA) to the Typenex Blood Bands (Typenex Medical, Chicago IL) on 11/12/2019. As part of the quality metrics of the blood bank, blood bank specimen labeling errors was tracked from 2017 to track the persistence of the effect of the initial training.

Results (if a Case Study enter NA)

The percentage of properly labeled specimens as a percentage of total specimens increased after the in-service training; specifically, an increase from a low of 97% (December 2017) to a high of 99% (August 2018). The percentage of properly labeled specimens remains at the increased level of 99% and above even at the 4.5-year mark in mid-2022.

Conclusion

The continued availability of laminated educational posters on blood specimen labeling for the clinical service areas combined with initial in-service education can have lasting effects to improve the quality of care even years after the initial in-service education sessions.

National epidemiologic trends (2008-2018) in the United States for the incidence and expenditures associated with incisional hernia in relation to abdominal surgery

PURPOSE

It is unknown whether the trend of rising incisional hernia (IH) repair (IHR) incidence and costs until 2011 currently persists. We aimed to evaluate how the IHR procedure incidence, cost and patient risk-profile have changed over the last decade relative to all abdominal surgeries (AS).

METHODS

Repeated cross-sectional analysis of 38,512,737 patients undergoing inpatient 4AS including IHR within the 2008-2018 National Inpatient Sample. Yearly incidence (procedures/1,000,000 people [PMP]), hospital costs, surgical and patient characteristics were compared between IHR and AS using generalized linear and multinomial regression.

RESULTS

Between 2008-2018, 3.1% of AS were IHR (1,200,568/38,512,737). There was a steeper decrease in the incidence of AS (356.5 PMP/year) compared to IHR procedures (12.0 PMP/year) which resulted in the IHR burden relative to AS (2008-2018: 12,576.3 to 9,113.4 PMP; trend difference P < 0.01). National costs averaged $47.9 and 1.7 billion/year for AS and IHR, respectively. From 2008-2018, procedure costs increased significantly for AS (68.2%) and IHR (74.6%; trends P < 0.01). Open IHR downtrended (42.2%), whereas laparoscopic (511.1%) and robotic (19,301%) uptrended significantly (trends P < 0.01). For both AS and IHR, the proportion of older (65-85y), Black and Hispanic, publicly-insured, and low-income patients, with higher comorbidity burden, undergoing elective procedures at small- and medium-sized hospitals uptrended significantly (all P < 0.01).

CONCLUSION

IH persists as a healthcare burden as demonstrated by the increased proportion of IHR relative to all AS, disproportionate presence of high-risk patients that undergo these procedures, and increased costs. Targeted efforts for IH prevention have the potential of decreasing $17 M/year in costs for every 1% reduction.

Lateral habenula glutamatergic neurons projecting to the dorsal raphe nucleus promote aggressive arousal in mice

The dorsal raphe nucleus (DRN) is known to control aggressive behavior in mice. Here, we found that glutamatergic projections from the lateral habenula (LHb) to the DRN were activated in male mice that experienced pre-exposure to a rival male mouse ("social instigation") resulting in heightened intermale aggression. Both chemogenetic and optogenetic suppression of the LHb-DRN projection blocked heightened aggression after social instigation in male mice. In contrast, inhibition of this pathway did not affect basal levels of aggressive behavior, suggesting that the activity of the LHb-DRN projection is not necessary for the expression of species-typical aggressive behavior, but required for the increase of aggressive behavior resulting from social instigation. Anatomical analysis showed that LHb neurons synapse on non-serotonergic DRN neurons that project to the ventral tegmental area (VTA), and optogenetic activation of the DRN-VTA projection increased aggressive behaviors. Our results demonstrate that the LHb glutamatergic inputs to the DRN promote aggressive arousal induced by social instigation, which contributes to aggressive behavior by activating VTA-projecting non-serotonergic DRN neurons as one of its potential targets.

The Abdominal Hernia-Q: a critical analysis of the components that impact quality-of-life

PURPOSE

Ventral hernias (VH) are a common surgical problem associated with significant morbidity. While assessment tools have examined quality-of-life (QoL), the relative change in specific domains of hernia-related QoL measures from pre- to post-operative period has yet to be comprehensively examined. Using the Abdominal Hernia-Q (AHQ), this study aims to assess the impact of ventral hernia repair (VHR) on key components of QoL.

METHODS

A retrospective chart review was conducted of patients undergoing VHR between September 2017 and September 2019 who had completed at least one pre- and post-operative AHQ. Post-operative intervals were created to capture AHQ responses around standard follow-up visits (< 1.5 months, 1.5-4.5 months, 4.5-11 months, and 11 + months) and scores were statistically analyzed.

RESULTS

A total of 136 patients were included, with an average age of 54.8 years at the time of VHR. Compared to the pre-operative period, the appearance score increased significantly (p < 0.05). The physical domain score increased from < 1.5 month to the 1.5-4.5 month period (p = 0.03) and remained significantly higher in later time period. The appearance score decreased from the 1.5-4.5 month to 4.5-11 month period (p = 0.05).

CONCLUSIONS

VHR leads to a sustained multi-dimensional increase in hernia-specific QoL measures during the post-operative course driven by early positive changes in appearance and sustained physical functioning. The initial increase in QoL is mainly driven by an improvement in appearance, while the sustained increase may be due to restored physical function.

POS0343 TREATMENT PERSISTENCE AND ADHERENCE AMONG PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS RECEIVING ABATACEPT OR TNF INHIBITORS USING US CLAIMS DATA

Background

Juvenile idiopathic arthritis (JIA) is the most common rheumatic condition among children and teens1 and contributes to a diminished quality of life.2 Previous data underscore the potential for abatacept to improve health-related outcomes in patients with JIA after demonstrating poor responses to other DMARDs.3 Patients with RA show greater persistence on abatacept vs TNF inhibitors (TNFi), and this should also be confirmed in patients with JIA.4

Objectives

To evaluate treatment persistence and adherence at 12- and 18-month follow-up in patients with JIA newly initiating either abatacept or a TNFi.

Methods

This analysis used data from the IQVIA PharMetrics Plus claims database from Jan 2008–Apr 2021. We identified patients with ≥ 1 claim of JIA diagnosis after Jan 2008, who were < 18 years old at initial diagnosis, had ≥ 1 claim of abatacept or TNFi treatment (adalimumab, etanercept, golimumab) following diagnosis, had continuous enrollment in medical and pharmacy benefits for ≥ 12 months before index date (first prescription of abatacept or TNFi), and had 12 or 18 months’ continuous medical and pharmacy enrollment after index date. Patients receiving abatacept or TNFi treatment ≤ 12 months prior to index date and patients initiating combined abatacept + TNFi treatment on the index date were excluded. Specific outcomes included: discontinuation (absence of a new prescription for index treatment within the gap of 5× treatment half-life), persistence rate (proportion of patients continuing index medication without any gaps exceeding 5× treatment half-life), and treatment adherence (defined as medication possession ratio [MPR, proportion of follow-up period where medication supply is available] and proportion of days covered [PDC, proportion of follow-up period where a patient is covered by a given drug]). All outcomes were reported at 12 and 18 months. All statistical analyses are descriptive with the intent for hypothesis generation.

Results

There were 2847 patients (abatacept, n = 111; TNFi, n = 2736) at 12-month follow-up; fewer completed the 18-month follow-up (2403 patients: abatacept, n = 94; TNFi, n = 2309). At index date, treatment groups were similar for sex, geographic location, and comorbidities (Table 1). Numerically higher persistence was observed in patients prescribed abatacept compared with TNFi overall at both time points. Abatacept persistence was higher than etanercept but similar to adalimumab (Figure 1). At 12 months, the percent of patients with PDC ≥ 0.8 was 57% for abatacept, 51% for adalimumab, and 38% for etanercept, while MPR ≥ 0.8 was 63% for abatacept, 55% for adalimumab, and 42% for etanercept. Patients prescribed abatacept had numerically greater proportions of PDC ≥ 0.8 (abatacept, 48%; adalimumab, 40%; etanercept, 29%) and MPR ≥ 0.8 (abatacept, 53%; adalimumab, 44%; etanercept, 33%) at 18 months.

Table 1.

Baseline characteristics of patients with 12-month follow-up data

CharacteristicAbatacept (n = 111)TNFi (n = 2736)Age, years, mean (SD)14.4 (3.8)12.6 (4.6)Female sex89 (80.2)1930 (70.5)Geographic region South43 (38.7)865 (31.6) Midwest40 (36.0)818 (29.9) West9 (8.1)408 (14.9) East19 (17.1)540 (19.7) Unknown0 (0)105 (3.8)Comorbidities Asthma9 (8.1)275 (10.1) COPD11 (9.9)323 (11.8) Cardiovascular disease14 (12.6)222 (8.1) Uveitis14 (12.6)321 (11.7) Iridocyclitisa12 (10.8)216 (7.9)CCI score, mean (SD)0.58 (0.73)0.46 (0.68)

Data are shown as n (%) unless otherwise specified.

aSubgroup disease under uveitis.

CCI, Charlson Comorbidity Index; COPD, chronic obstructive pulmonary disease.

Conclusion

The present findings suggest that patients with JIA initiating abatacept treatment display numerically higher persistence and adherence compared with patients treated with TNFis at both 12- and 18-months’ follow-up.

References

[1]Prakken B, et al. Lancet 2011;377:2138–49.

[2]Lovell DJ, et al. Arthritis Rheumatol 2015;67:2759–70.

[3]Ruperto N, et al. Lancet 2008;372:383–91.

[4]Han X, et al. J Health Econ Outcomes Res 2021;8:71–8.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Medical writing and editorial assistance were provided by Ryan Miller, of Caudex, and were funded by Bristol Myers Squibb. Project analysis was provided by Akshay Vinod (Mu Sigma).

Disclosure of Interests

Ching-An Wang Consultant of: Novartis (used to work there as an external contractor from Jan 2016 to Apr 2021), Employee of: Bristol Myers Squibb, Robert Wong Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Tzuyung Douglas Kou Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Hanke Zheng Employee of: Bristol Myers Squibb, Keith Wittstock Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vadim Khaychuk Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vardhaman PATEL Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

IL-1 Signal Inhibition In Alcoholic Hepatitis (ISAIAH): a study protocol for a multicentre, randomised, placebo-controlled trial to explore the potential benefits of canakinumab in the treatment of alcoholic hepatitis

BACKGROUND

Alcohol consumption causes a spectrum of liver abnormalities and leads to over 3 million deaths per year. Alcoholic hepatitis (AH) is a florid presentation of alcoholic liver disease characterized by liver failure in the context of recent and heavy alcohol consumption. The aim of this study is to explore the potential benefits of the IL-1β antibody, canakinumab, in the treatment of AH.

METHODS

This is a multicentre, double-blind, randomised placebo-controlled trial. Participants will be diagnosed with AH using clinical criteria. Liver biopsy will then confirm that all histological features of AH are present. Up to 58 participants will be recruited into two groups from 15 centres in the UK. Patients will receive an infusion of Canakinumab or matched placebo by random 1:1 allocation. The primary outcome is the difference between groups in the proportion of patients demonstrating histological improvement and will compare histological appearances at baseline with appearances at 28 days to assign a category of "improved" or "not improved". Patients with evidence of ongoing disease activity will receive a second infusion of canakinumab or placebo. Participants will be followed up for 90 days. Secondary outcomes include mortality and change in MELD score at 90 days.

DISCUSSION

This phase II study will explore the benefits of the IL-1β antibody, canakinumab, in the treatment of AH to provide proof of concept that inhibition of IL-1β signalling may improve histology and survival for patients with AH.

TRIAL REGISTRATION

EudraCT 2017-003724-79 . Prospectively registered on 13 April 2018.

Antagonistic postsynaptic and presynaptic actions of cyclohexanol on neuromuscular synaptic transmission and function

Intentional ingestion of agricultural organophosphorus insecticides is a significant public health issue in rural Asia, causing thousands of deaths annually. Some survivors develop a severe, acute or delayed myasthenic syndrome. In animal models, similar myasthenia has been associated with increasing plasma concentration of one insecticide solvent metabolite, cyclohexanol. We investigated possible mechanisms using voltage and current recordings from mouse neuromuscular junctions (NMJs) and transfected human cell lines. Cyclohexanol (10-25 mM) reduced endplate potential (EPP) amplitudes by 10-40% and enhanced depression during repetitive (2-20 Hz) stimulation by up to 60%. EPP decay was prolonged more than twofold. Miniature EPPs were attenuated by more than 50%. Cyclohexanol inhibited whole-cell currents recorded from CN21 cells expressing human postjunctional acetylcholine receptors (hnAChR) with an IC₅₀ of 3.74 mM. Cyclohexanol (10-20 mM) also caused prolonged episodes of reduced-current, multi-channel bursting in outside-out patch recordings from hnAChRs expressed in transfected HEK293T cells, reducing charge transfer by more than 50%. Molecular modelling indicated cyclohexanol binding (-6 kcal/mol) to a previously identified alcohol binding site on nicotinic AChR α-subunits. Cyclohexanol also increased quantal content of evoked transmitter release by ∼50%. In perineurial recordings, cyclohexanol selectively inhibited presynaptic K⁺ currents. Modelling indicated cyclohexanol binding (-3.8 kcal/mol) to voltage-sensitive K⁺ channels at the same site as tetraethylammonium (TEA). TEA (10 mM) blocked K⁺ channels more effectively than cyclohexanol but EPPs were more prolonged in 20 mM cyclohexanol. The results explain the pattern of neuromuscular dysfunction following ingestion of organophosphorus insecticides containing cyclohexanol precursors and suggest that cyclohexanol may facilitate investigation of mechanisms regulating synaptic strength at NMJs. KEY POINTS: Intentional ingestion of agricultural organophosphorus insecticides is a significant public health issue in rural Asia, causing thousands of deaths annually. Survivors may develop a severe myasthenic syndrome or paralysis, associated with increased plasma levels of cyclohexanol, an insecticide solvent metabolite. Analysis of synaptic transmission at neuromuscular junctions in isolated mouse skeletal muscle, using isometric tension recording and microelectrode recording of endplate voltages and currents, showed that cyclohexanol reduced postsynaptic sensitivity to acetylcholine neurotransmitter (reduced quantal size) while simultaneously enhancing evoked transmitter release (increased quantal content). Patch recording from transfected cell lines, together with molecular modelling, indicated that cyclohexanol causes selective, allosteric antagonism of postsynaptic nicotinic acetylcholine receptors and block of presynaptic K⁺ -channel function. The data provide insight into the cellular and molecular mechanisms of neuromuscular weakness following intentional ingestion of agricultural organophosphorus insecticides. Our findings also extend understanding of the effects of alcohols on synaptic transmission and homeostatic synaptic function.

P34 The value of combined ophthalmology and rheumatology review- an unmet need

Case report - Introduction

Rheumatic diseases manifest in different specialties including ophthalmology. Presentation with eye symptoms may be a sight-threatening emergency such as GCA. Other inflammatory symptoms such as uveitis present to the Eye Casualty frequently, which need prompt rheumatologist input for a holistic management.

Case report - Case description

We present an interesting case with multiple learning points for both rheumatologists as well as ophthalmologists.

We present a case of a 73-year-old Caucasian lady who initially presented to the Eye Department. She was diagnosed as having bilateral uveitis by the ophthalmologist with an interest in uveitis. She had various investigations which showed positive HLA-B27 status, ENA, ANA, serum ACE level were normal; however, she was found to have raised immunoglobulins and plasma viscosity. She was treated with steroid eye drops and intravitreal dexamethasone implant in both eyes. She is a steroid responder and unfortunately developed glaucoma which needed two surgical procedures. She developed chronic cystoid macular oedema in Left eye.

She did not have any symptoms of psoriasis or gut symptoms suggestive of inflammatory bowel disease. She did report symptoms of inflammatory bowel disease. She had an MRI of axial spine as per AS protocol, which confirmed inflammatory spondyloarthropathy. She was diagnosed to have non-radiographic spondyloarthropathy which is managed by simple anti-inflammatories. Her BASDAI is less than 3 and does not qualify for biologic treatment for her axial spondyloarthropathy. Her main symptoms were ocular, which is very active and she is not able to escalate to biologic therapy.

Case report - Discussion

This is a patient presenting with late-onset inflammatory back pain without any articular or extra-articular activity. Her main manifestation is spectrum of spondyloarthropathy with uveitis; however, we could not escalate her to biologics. She has been on topical, intraocular and oral steroids which has led on to complications. The combined clinic between rheumatologists and ophthalmologists is key in managing such patients.

Case report - Key learning points