Evaluation and 1-year follow-up of patients presenting at a Lyme borreliosis expertise centre: a prospective cohort study with validated questionnaires

OBJECTIVES

To describe the course of symptoms reported by patients with symptoms attributed to Lyme borreliosis (LB) without being subsequently diagnosed with LB.

METHODS

We performed a prospective cohort study with patients presenting at the outpatient clinic of two clinical LB centres. The primary outcome was the prevalence of persistent symptoms, which were defined as clinically relevant fatigue (CIS, subscale fatigue), pain (SF-36, subscale bodily pain), and cognitive impairment (CFQ) for ≥ 6 months and onset < 6 months over the first year of follow-up. Outcomes were compared with a longitudinal cohort of confirmed LB patients and a general population cohort. Prevalences were standardised to the distribution of pre-defined confounders in the confirmed LB cohort.

RESULTS

Participants (n = 123) reported mostly fatigue, arthralgia, myalgia, and paraesthesia as symptoms. The primary outcome could be determined for 74.8% (92/123) of participants. The standardised prevalence of persistent symptoms in our participants was 58.6%, which was higher than in patients with confirmed LB at baseline (27.2%, p < 0.0001) and the population cohort (21.2%, p < 0.0001). Participants reported overall improvement of fatigue (p < 0.0001) and pain (p < 0.0001) but not for cognitive impairment (p = 0.062) during the follow-up, though symptom severity at the end of follow-up remained greater compared to confirmed LB patients (various comparisons p < 0.05).

CONCLUSION

Patients with symptoms attributed to LB who present at clinical LB centres without physician-confirmed LB more often report persistent symptoms and report more severe symptoms compared to confirmed LB patients and a population cohort.

Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Neratinib + fulvestrant + trastuzumab for HR-positive, HER2-negative, HER2-mutant metastatic breast cancer: outcomes and biomarker analysis from the SUMMIT trial

BACKGROUND

HER2 mutations are targetable alterations in patients with hormone receptor-positive (HR+) metastatic breast cancer (MBC). In the SUMMIT basket study, patients with HER2-mutant MBC received neratinib monotherapy, neratinib + fulvestrant, or neratinib + fulvestrant + trastuzumab (N + F + T). We report results from 71 patients with HR+, HER2-mutant MBC, including 21 (seven in each arm) from a randomized substudy of fulvestrant versus fulvestrant + trastuzumab (F + T) versus N + F + T.

PATIENTS AND METHODS

Patients with HR+ HER2-negative MBC with activating HER2 mutation(s) and prior cyclin-dependent kinase 4/6 inhibitor (CDK4/6i) therapy received N + F + T (oral neratinib 240 mg/day with loperamide prophylaxis, intramuscular fulvestrant 500 mg on days 1, 15, and 29 of cycle 1 then q4w, intravenous trastuzumab 8 mg/kg then 6 mg/kg q3w) or F + T or fulvestrant alone. Those whose disease progressed on F + T or fulvestrant could cross-over to N + F + T. Efficacy endpoints included investigator-assessed objective response rate (ORR), clinical benefit rate (RECIST v1.1), duration of response, and progression-free survival (PFS). Plasma and/or formalin-fixed paraffin-embedded tissue samples were collected at baseline; plasma was collected during and at end of treatment. Extracted DNA was analyzed by next-generation sequencing.

RESULTS

ORR for 57 N + F + T-treated patients was 39% [95% confidence interval (CI) 26% to 52%); median PFS was 8.3 months (95% CI 6.0-15.1 months). No responses occurred in fulvestrant- or F + T-treated patients; responses in patients crossing over to N + F + T supported the requirement for neratinib in the triplet. Responses were observed in patients with ductal and lobular histology, 1 or ≥1 HER2 mutations, and co-occurring HER3 mutations. Longitudinal circulating tumor DNA sequencing revealed acquisition of additional HER2 alterations, and mutations in genes including PIK3CA, enabling further precision targeting and possible re-response.

CONCLUSIONS

The benefit of N + F + T for HR+ HER2-mutant MBC after progression on CDK4/6is is clinically meaningful and, based on this study, N + F + T has been included in the National Comprehensive Cancer Network treatment guidelines. SUMMIT has improved our understanding of the translational implications of targeting HER2 mutations with neratinib-based therapy.

Impact of Concurrent Targeted Therapy and Immunotherapy on the Incidence of Radiation Necrosis Following Stereotactic Radiosurgery for Brain Metastases

PURPOSE/OBJECTIVE(S)

The management of metastatic disease has evolved with the advent of immunotherapy (IT) and targeted therapies (TT). Yet, there is limited understanding of the toxicity associated with combining these agents with stereotactic radiosurgery (SRS). We retrospectively evaluated the impact of concurrent systemic therapy (ST) on the risk of radiation necrosis (RN) following LINAC-based SRS for brain metastases (BM).

MATERIALS/METHODS

A retrospective study was conducted within an integrated health care system from March 2017 to December 2021 of 313 patients who underwent SRS or fractionated SRS in 3 or 5 treatments to a total of 1,644 intact BM. Post-operative cavity SRS and re-irradiated lesions were excluded. RN was diagnosed using perfusion MRI, contrast clearance MRI, or serial standard MRI and graded using CTCAE (v.5). Concurrent ST was defined as administration within 1 month preceding or following SRS. Overall survival (OS) and risk of RN were estimated by the Kaplan-Meier method. Logistics regression analyses were performed to compare risk of RN in patients who received concurrent systemic therapy to those who did not, adjusted for PTV volume and receipt of whole brain radiotherapy (WBRT).

RESULTS

Median follow-up was 12.2 months. Median age was 64 years (range: 24-92). Primary sites per patient included lung (48.9%), breast (18.2%), melanoma (11.5%), kidney (6.1%), and other (15.3%). Median total lesions treated was 3 (range: 1-44); 65.9% of patients underwent 1 course of SRS, 23.4% underwent 2 courses, 6.2% underwent 3 courses, 4.5% underwent >4 courses. Seventy-six (24.2%) patients received WBRT. Overall, 70.6% of lesions received concurrent ST including chemotherapy (CT) (32.5%), IT (26.8%), and TT (27.6%); 16.4% received a combination of ST. Median OS was 12.9 months (95% CI: 10.4-15.5). RN was observed in 50 (3.0%) lesions in 42 (13.4%) patients. The 1-year risk of RN was 4.0% per lesion and 15.4% per patient. Symptomatic RN (SRN) was observed in 31 (1.9%) lesions in 24 (7.7%) patients. The 1-year risk of SRN was 2.7% per lesion and 10.1% per patient. When compared to lesions treated without concurrent systemic therapy, there was no increased risk of RN observed in lesions treated with concurrent CT (adjusted OR = 0.86 (95% CI: 0.43-1.73) p = 0.68), concurrent IT (adjusted OR = 0.84 (95% CI: 0.41-1.71) p = 0.84), or concurrent TT (adjusted OR = 0.57 (95% CI: 0.25-1.30) p = 0.18). Treatments of SRN included dexamethasone (96.8%), bevacizumab (22.6%), and laser interstitial thermal therapy (6.5%).

CONCLUSION

Concurrent IT and TT appears well-tolerated in patients who undergo SRS for treatment of BM. No increased risk of RN was observed in lesions treated with concurrent IT or TT compared to lesions treated in the absence of concurrent ST. Further prospective and agent-specific evaluation is necessary to confirm these findings.

High-Dose Rate Brachytherapy Alone for Treatment of Unfavorable Intermediate Risk Prostate Cancer: A Propensity-Score Matched Analysis

PURPOSE/OBJECTIVE(S)

To demonstrate the feasibility of high-dose rate brachytherapy (HDR BT) as monotherapy for unfavorable intermediate risk (UIR) prostate cancer by comparing survival outcomes of HDR BT alone against external beam radiation therapy (EBRT) + HDR BT boost, +/- androgen deprivation therapy (ADT) using propensity-score matched (PSM) data.

MATERIALS/METHODS

This retrospective study queried two data registries collecting patient data from 1991 to present. 633 patients with UIR prostate cancer treated with HDR BT alone, HDR BT+EBRT or HDR+EBRT+ADT were included. HDR BT patients received 42-45Gy/6 fractions (fx) or 27 Gy/2 fx. For HDR BT+EBRT, the HDR dose was 20-24 Gy/2 fx, 24 Gy/4 fx, or 15 Gy/1 fx. EBRT patients received 45 Gy/25 fx to the prostate +/- pelvic nodes. GU/GI toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Time-to-event analyses were carried out to evaluate the relationship between treatments and five primary endpoints of interest: freedom from biochemical recurrence (FFBC), freedom from distant metastasis (FFDM), freedom from local failure (FFLF), cancer specific survival (CSS), and overall survival (OS) at 5 years. PSM was performed with one-to-n matching. Logistic regression was used to estimate the respective propensity scores. The five potential confounders identified were T-stage, Gleason score, pre-treatment PSA, age, and percent positive cores. Balance was checked using the standardized mean difference of covariates. Univariate and multivariate analyses were conducted on the matched data. Toxicity analysis was performed via association between a change in pre- and post-treatment GU/GI toxicity status and the treatment group, as well as incidence of post-treatment severe GI/GU toxicity (grade 3 or higher) and the treatment group.

RESULTS

Univariate analysis with Kaplan-Meier method and log rank test comparison between the three cohorts demonstrated no significant difference in all survival outcomes FFBC, FFDM, FFLF, CSS, OS (p = 0.15, 0.19, 0.29, 0.57, 0.28, respectively). Multivariate analysis with Cox proportional hazard regression showed no differences in HR for FFBC and OS (p = 0.95, 0.11) with addition of EBRT, or with EBRT+ADT (p = 0.17, 0.24); no fit was obtainable for FFDM, CSS, FFLF. Toxicities between the three cohorts were not significantly different when comparing post-treatment and baseline GI/GU symptoms (p = 0.53/1). No Grade 2 or 3 GI toxicities were identified, while 8%/1% HDR patients, 10%/1% HDR+EBRT patients, and 12%/2% HDR+EBRT+ADT patients experienced Grade 2/3 GU toxicities. The incidence of grade 3 or higher GU toxicities between the three groups was not significantly different (p = 0.91).

CONCLUSION

This propensity-score matched study demonstrates the feasibility of HDR BT alone for effective treatment of UIR prostate cancer when compared to HDR+EBRT or HDR+EBRT+ADT, while potentially minimizing the added toxicities of EBRT and the undesirable side effect profile of ADT.

A case of cutaneous psoriasis vulgaris achieving complete remission post major breast reconstructive surgery

Psoriasis is a debilitating chronic inflammatory systemic condition largely affecting the skin. Major surgery is relatively contraindicated due to the propensity for triggering psoriatic flares and koebnerization of the surgical scars. We detail an interesting case of complete psoriasis remission following a right nipple-sparing mastectomy with sentinel lymph node biopsy with vascular augmented pedicled transverse rectus abdominal myocutaneous (TRAM) flap in a patient with systemic psoriasis vulgaris and arthropathy. Intra-operatively, majority of the psoriatic plaques were excised or de-epithelized and used as part of the ipsilateral TRAM flap. Post-operatively, koebnerization did not occur and her psoriasis was cured completely even after cancer chemotherapy. One of several hypotheses include excision with de-epithelization of most of the psoriatic plaques reduces disease and inflammatory burden leading to complete remission. Perhaps, surgery could one day play a supporting role to existing treatment options to achieve psoriasis remission.

Fixed prosthetic rehabilitation of a patient with Papillon-Lefevre syndrome supported by a Quad Zygoma Approach: A clinical report

Papillon-Lefevere syndrome (PLS) is a rare disorder with severe oral manifestations resulting in premature tooth loss at an early stage of life. As a result, extensive bone resorption pattern in the maxilla negates conventional implant treatment in the majority of cases. This clinical report describes a prosthetic rehabilitation revision of a 26-year-old female diagnosed with PLS using an implant supported fixed complete denture with a quad zygoma approach. A 1 year follow-up is also presented.

Concussion and Psychological Effects: A Review of Recent Literature

ABSTRACT

The aim of this article is to provide an up-to-date review of psychological changes in association with postconcussive athletes. In particular, this article focused on the symptomatology, risk factors, and treatment of psychiatric diagnoses in patients who suffered a sports-related concussion (SRC). After an extensive review of prior and current literature, there is significant evidence that demonstrates an association of changes in mood and behavior, including new or worsening symptoms of anxiety, depression, and difficulty with attention and concentration in those who are recovering from a concussion. The goal of care in these patients is to identify and treat these psychological symptoms early to have more favorable long-term outcomes. Primary treatment should focus on psychotherapy; however, other considerations may be warranted in certain cases, such as selective serotonin reuptake inhibitors for depression and tricyclic antidepressants and gabapentin for short-term cognitive symptom improvement.

A two-ward acute care hospital outbreak of SARS-CoV-2 delta variant including a point-source outbreak associated with the use of a mobile vital signs cart and sub-optimal doffing of personal protective equipment

BACKGROUND

The arrival of the Delta variant of SARS-CoV-2 was associated with increased transmissibility and illness of greater severity. Reports of nosocomial outbreaks of Delta variant COVID-19 in acute care hospitals have been described but control measures varied widely.

AIM

Epidemiological investigation of a linked two-ward COVID-19 Delta variant outbreak was conducted to elucidate its source, risk factors, and control measures.

METHODS

Investigations included epidemiologic analysis, detailed case review serial SARS-CoV-2 reverse transcriptase-polymerase chain reaction (RT-PCR) testing of patients and healthcare workers (HCWs), viral culture, environmental swabbing, HCW-unaware personal protective equipment (PPE) audits, ventilation assessments, and the use of whole genome sequencing (WGS).

FINDINGS

This linked two-ward outbreak resulted in 17 patient and 12 HCW cases, despite an 83% vaccination rate. In this setting, suboptimal adherence and compliance to PPE protocols, suboptimal hand hygiene, multi-bedded rooms, and a contaminated vital signs cart with potential fomite or spread via the hands of HCWs were identified as significant risk factors for nosocomial COVID-19 infection. Sudden onset of symptoms, within 72 h, was observed in 79% of all Ward 2 patients, and 93% of all cases (patients and HCWs) on Ward 2 occurred within one incubation period, consistent with a point-source outbreak. RT-PCR assays showed low cycle threshold (C_T) values, indicating high viral load from environmental swabs including the vital signs cart. WGS results with ≤3 SNP differences between specimens were observed.

CONCLUSION

Outbreaks on both wards settled rapidly, within 3 weeks, using a `back-to-basics' approach without extraordinary measures or changes to standard PPE requirements. Strict adherence to recommended PPE, hand hygiene, education, co-operation from HCWs, including testing and interviews, and additional measures such as limiting movement of patients and staff temporarily were all deemed to have contributed to prompt resolution of the outbreak.

Evaluation of a prescribing pharmacist-led heart failure (HF) up-titration clinic

Background/Introduction

Pharmacotherapy is considered the cornerstone of treatment for patients with heart failure with reduced ejection fraction (HFrEF). Modulation of the renin-angiotensin-aldosterone (RAAS) and sympathetic nervous system have been shown to improve survival, reduce the risk of heart failure (HF) hospitalisations and improve quality of life. Unless contraindicated or not tolerated, these patients should be prescribed angiotensin-converting enzyme inhibitor (ACEi)/angiotensin-receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 (SGLT2) inhibitor and up-titrated to guideline directed dosages.1 Despite the availability of effective treatments, patients are often sub-optimally dosed and experience a prolonged optimisation process. Pharmacist-led clinics can complement existing services and increase uptake of guideline directed medical therapies (GDMT).

Purpose

To evaluate the effectiveness of pharmacist-led heart failure clinics in the Princess of Wales Hospital, supported by the Heart Failure team, in optimisation of patients with HFrEF.

Methods

Patients who attended HF pharmacist led clinic between November 2020 and November 2021 were included in the analysis. Baseline demographics, left ventricular ejection fraction (LVEF), biomarkers, vital signs and medications were documented at baseline and after optimisation of GDMT. Number of clinics appointments and rate of hospitalisation and mortality were captured during the study period.

Results

76 patients were reviewed over a total of 318 consultations (34% virtual), averaging 4 consultations per patient. The mean age was 71 years, 36% of patients were female, mean LVEF was 32% and NT-proBNP 3078ng/L with 15% of patients on “quadruple therapy” at baseline. 93% of patients were referred by cardiologists and the average time from referral to first appointment was 42 days. Post-optimisation, 67% of patients were receiving “quadruple therapy”, with increased uptake of ACEi/ARB/ARNI, beta-blocker, MRA and SGLT2i from baseline (100%, 77%, 93% and 90% respectively). Mean LVEF increased to 42% and mean NT-proBNP reduced to 1695ng/L. No significant changes in creatinine clearance, blood pressure, heart rate or serum potassium (sK+) were recorded. The hospitalisation rate was 11% for heart failure, 6% for other cardiovascular causes and the mortality rate was 7%.

Conclusions

The pharmacist-led HF clinic demonstrated a high uptake of optimally dosed GDMT and improvements in NT-proBNP and LVEF. Pharmacist-led clinics can enhance the provision of existing heart failure services to improve patient outcomes and heart failure care.

Funding Acknowledgement

Type of funding sources: None.

A single-center comparison of our initial experiences in treating penile and urethral cancer with video-endoscopic inguinal lymphadenectomy (VEIL) and later experiences in melanoma cases

Background

Video-endoscopic inguinal lymphadenectomy (VEIL) is a minimally invasive approach that is increasingly indicated in oncological settings, with mounting evidence for its long-term oncological safety.

Objectives

To present our single-center experience of treating penile and urethral cancer with VEIL, as well as its more recent application in melanoma patients.

Methods

We prospectively recorded our experiences with VEIL from September 2010 to July 2018, registering the patient primary indication, surgical details, complications, and follow-up.

Results

Twenty-nine patients were operated in one (24) or both (5) groins; 18 had penile cancer, 1 had urethral cancer, and 10 had melanoma. A mean 8.62 ± 4.45 lymph nodes were removed using VEIL and of these, an average of 1.00 ± 2.87 were metastatic; 16 patients developed lymphocele and 10 presented some degree of lymphedema; there were no skin or other major complications. The median follow-up was 19.35 months; there were 3 penile cancer patient recurrences in the VEIL-operated side. None of the melanoma patients presented a lymphatic inguinal recurrence.

Conclusions

VEIL is a minimally invasive technique which appears to be oncologically safe showing fewer complications than open surgery. However, complications such as lymphorrhea, lymphocele, or lymphedema were not diminished by using VEIL.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Virtual Interview Day: An AEGD's approach and assessment of interviewing during a pandemic

PURPOSE

A novel approach to interviewing for Advanced Education in General Dentistry residency positions became necessary during the COVID-19 pandemic. An efficient, virtual interview schedule, including video faculty introductions and clinic tour, was devised and executed to replace in-person interviews. The purpose of this study was to describe and assess this new way of managing virtual interviews.

METHODS

Forty virtual interviews were conducted via a web-based videoconferencing platform. Interviewers and applicants received surveys to be anonymously completed after interviews. The applicant survey gauged how helpful each component of the interview process was in their program ranking decision. The interviewer survey assessed time and knowledge needed for interviewing, clarity of instructions, and if they felt valued.

RESULTS

The response rate was 79% for applicants and 75% for interviewers. There was a high level of satisfaction from both applicants and interviewers. All interviewers reported that the team worked well together, instructions were clear, there was enough collective knowledge to answer questions, and they felt valued. There was a majority of positive responses for clarity of instructions and time with applicants. All applicants responded positively to correspondence with the Admissions Office, interview day instructions, informational PowerPoint, and sessions with the chief resident and program director. Regarding videos of faculty and clinic tour, there was a majority of positive responses. There were varying responses regarding the interview team being fair and nonthreatening. Lessons learned include reviewing on-camera behavior with interviewers, detailing the interview format in applicants' correspondence, requesting applicants photos in advance, allowing interviewers more time to study applicant material, and hosting a virtual happy hour for applicants and residents before the interview day.

CONCLUSION

Overall, the Virtual Interview Day successfully achieved the goals of applicant and program rank selection. Virtual interviews can be considered an alternative to in-person interviews.

Guidelines for Medical Immobilization/Protective Stabilization for Your Practice

Many patients with special healthcare needs present to medical, dental, and other health visits with behavioral, emotional, postural, and psychological issues. According to the American Academy of Developmental Medicine and Dentistry (AADMD) guidelines from 2017: "Clinical dental treatment is the most exacting and demanding medical procedure that persons with special needs undergo on a regular basis throughout their lifetime." Moreover, dental treatment is basically surgical in nature, usually requiring controlled placement of sharpened instruments in intimate proximity to the face, airway, and highly vascularized and innervated oral tissues. When medically necessary healthcare must be provided and the patient's inability to accept or cooperate will compromise the quality of care the clinician will be able to deliver, interventions may be indicated and implemented.

POS0230 THE miR-320 FAMILY IS UPREGULATED IN FAST-PROGRESSING RADIOGRAPHIC KNEE OSTEOARTHRITIS: DATA FROM THE OSTEOARTHRITIS INITIATIVE

Background

There is an outstanding need for prognostic biomarkers to reliably detect fast-progressing knee osteoarthritis (OA) such that preventative interventions can be targeted to this patient population. MicroRNA-sequencing is an unbiased approach for comprehensive profiling of circulating microRNAs in liquid biopsies to discover novel biomarkers of disease. As negative regulators of gene expression, microRNAs hold potential not only as biomarkers, but also as mechanistic drivers of knee OA.

Objectives

To apply microRNA-sequencing to identify unique circulating microRNAs as potential biomarkers that distinguish fast-progressing radiographic knee OA from both slow- and non-progressing radiographic knee OA.

Methods

Leveraging the Osteoarthritis Initiative (OAI) longitudinal cohort, we applied our customized microRNA-sequencing pipeline [1] to blood plasma samples collected at both baseline and 4-year follow-up from 106 participants. The disease trajectory for each participant was constructed by plotting their Kellgren-Lawrence (KL) grades over an 8-year follow-up period. Based on these trajectories, we defined fast-progression as an increase from KL 0/1 at baseline to KL 3/4 by 4-year follow-up, slow-progression as an increase from KL 0/1 at baseline to KL 2/3/4 by 8-year follow-up, and non-progression as no increase from KL0/1 at baseline throughout the 8-year follow-up. Following differential expression analysis, we assessed predictive performance and identified putative gene targets for prioritized microRNAs.

Results

Comparing fast-progressors to both slow-progressors and non-progressors, we identified differentially expressed microRNAs within timepoints (i.e., 48 microRNAs at baseline and 2 microRNAs at 4-year follow-up) and across timepoints. Among these microRNAs were four members of the miR-320 family, with miR-320d showing an increase in fast-progressors at both timepoints, compared to both slow- and non-progressors. The predictive models we constructed included miR-320 members and had good accuracy (area under the receiver operating characteristic curves ranging from 82.6 to 91.9) in distinguishing fast-progressors. Putative gene targets of the miR-320 family included members of the 14-3-3 gene family (Table 1), including YWHAE, whose downregulation in OA cartilage was reported to promote deterioration [2].

Table 1.

Predicted gene targets of the miR-320 family include members of the 14-3-3 gene family.

14-3-3 gene family memberhsa-miR-320bhsa-miR-320chsa-miR-320dhsa-miR-320eSFNMMMLYWHABMMMMYWHAEVVVHYWHAGVVVMYWHAHVVVMYWHAQVVVMYWHAZVVVM

All mirDIP results with bold text indicating the prediction was among the top 1% for that microRNA/gene target pair. Letters denote the mirDIP score class with V=very high, H=high, M=medium, and L=low.

Conclusion

This microRNA-sequencing study is the first of its kind, profiling circulating microRNAs at two timepoints in 106 participants with data-driven construction of knee OA trajectories. We identify the miR-320 family of microRNAs to be associated with fast-progressing radiographic knee OA over time. While our data suggest this microRNA family could have applications as prognostic biomarkers for knee OA, and could be regulating gene targets to impact OA severity, validation of these findings in independent longitudinal cohorts is required.

References

[1]Potla P, Ali SA, Kapoor M. A bioinformatics approach to microRNA-sequencing analysis. Osteoarthritis and Cartilage Open. 2021;3(1):100131. doi: https://doi.org/10.1016/j.ocarto.2020.100131.

[2]Fu W, Hettinghouse A, Chen Y, Hu W, Ding X, Chen M, Ding Y, Mundra J, Song W, Liu R, Yi YS, Attur M, Samuels J, Strauss E, Leucht P, Schwarzkopf R, Liu CJ. 14-3-3 epsilon is an intracellular component of TNFR2 receptor complex and its activation protects against osteoarthritis. Ann Rheum Dis. 2021 Dec;80(12):1615-1627. doi: 10.1136/annrheumdis-2021-220000.

Disclosure of Interests

None declared

The impact of the first wave of COVID-19 on stroke admissions across three tertiary hospitals in Brisbane

Background

COVID‐19 has caused a global shift in healthcare‐seeking behaviour; however, presentation rates with serious conditions, such as stroke in low COVID‐19‐prevalence cities, has received less attention.

Aims

To determine if there was a significant reduction in stroke admissions, delivery of acute reperfusion therapies, or increased delays to presentation during the first wave of the COVID‐19 pandemic.

Methods

A multicentre, retrospective, observational cohort study was performed across three tertiary hospitals in Brisbane, Australia. Cases were identified using ICD‐10 codes and then individually reviewed for eligibility using prespecified inclusion and exclusion criteria. All metrics were compared over 3 months from 1 March to 31 May 2020 with two corresponding 3‐month periods in 2018 and 2019.

Results

There was a mean of 2.15 (95% CI 1.87–2.48) stroke admissions per day in the examined pandemic months compared with 2.13 (95% CI 1.85–2.45) and 2.26 (95% CI 1.97–2.59) in March to May 2018 and 2019 respectively, with no significant difference found (P = 0.81). There was also no difference in rates of intravenous thrombolysis (P = 0.82), endovascular thrombectomy (P = 0.93) and time from last known well to presentation (P = 0.54). Conversely, daily emergency department presentations (including non‐stroke presentations) significantly reduced (P < 0.0001).

Conclusions

During the early months of the COVID‐19 pandemic there was no significant reduction in stroke presentations, use of acute reperfusion therapies or delays to presentation, despite a reduction in ED presentations for any cause. Our results differ from the global experience, with possible explanations, including differences in public health messaging and healthcare infrastructure.

Interdisciplinary Oral Health for Those with Special Health Care Needs

In order for us to understand our current situation of the oral health condition of those with special needs, we need to review the history of how education was presented and what has been done. The American Dental Association, Commission on Dental Accreditation (CODA) is recognized by the US Department of Education. CODA is responsible for the accreditation of predoctoral dental education programs (leading to the DDS or DMD degree), advanced dental education programs, and allied dental education programs that are fully operational or have attained "Initial Accreditation" status, including programs offered via distance education.

From Restraint to Medical Immobilization/Protective Stabilization

Clinical dental treatment is the most exacting and demanding medical procedure that persons with special needs undergo on a regular basis throughout their lifetime. Dental treatment is surgical in nature, usually requiring controlled placement of sharpened instrumentation in intimate proximity to the face, airway, and highly vascularized and inner aged oral tissues. Although approximately 90% of patients with special needs can and should be mainstreamed through any general dental practice, without significant behavioral guidance, techniques, or medical immobilization/protective stabilization, there has been a drastic shift toward pharmacologic management of these patients using various forms of sedation and general anesthesia.

Human Bone Marrow Stromal Cell Exosomes Ameliorate Periodontitis

Human bone marrow stromal cell (hBMSC)-derived exosomes are promising therapeutics for inflammatory diseases due to their unique microRNA (miRNA) and protein cargos. Periodontal diseases often present with chronicity and corresponding exuberant inflammation, which leads to loss of tooth support. In this study, we explored whether hBMSC exosomes can affect periodontitis progression. hBMSC exosomes were isolated from cell culture medium through sequential ultracentrifugation. miRNAs and proteins that were enriched in hBMSC exosomes were characterized by RNA sequencing and protein array, respectively. hBMSC exosomes significantly suppressed periodontal keystone pathogen Porphyromonas gingivalis-triggered inflammatory response in macrophages in vitro. Transcriptomic analysis suggested that exosomes exerted their effects through regulating cell metabolism, differentiation, and inflammation resolution. In vivo, weekly exosome injection into the gingival tissues reduced the tissue destruction and immune cell infiltration in rat ligature-induced periodontitis model. Collectively, these findings suggest that hBMSC-derived exosomes can potentially be used as a host modulation agent in the management of periodontitis.

410 Acute Pancreatitis Annual Review in Cumberland Infirmary

Aim

To document the incidence and presentation of acute pancreatitis, and to audit the process and outcome of management of patients against the UK guidelines in Cumberland Infirmary.

Results

Out of the 206 patients who had acute pancreatitis and admitted to the Cumberland infirmary 116 were male and 90 were female.

Causes

The alcohol consumption and the biliary pathology were the commonest cause, were 56 and 96 patients, respectively. The pancreatic lesions were the cause in 6 patients. The other causes: two patients the cause of the inflammation were drugs (azathioprine and steroids), while the ERCP was the cause in 8 patient and mumps for the one patient. Out of the 9 patients of pancreatic necrosis one patient died. 10/206 Patients with diagnosis of pancreatitis have been referred to the Remote surveillance Programme for N. Pancreatitis to the Freeman Hospital. 6 patients of them have been diagnosed with pancreatic necrosis. The number of the patients died in Cumberland infirmary in 2020 with the diagnosis of acute pancreatitis are 10 patients 04.87%. (The national mortality rate is 4–10%).

Conclusions

To follow NICE Guidelines for management of acute pancreatitis: Pancreatitis, published Sep 2018. To continue a close teamwork in terms of referrals as well as HPB MDT. To report patients with pancreatic necrosis to the FRH surveillance.

A217 TREATMENT ADHERENCE OF CHRONIC HEPATITIS B PATIENTS WITH HEPATOCELLULAR CARCINOMA FROM THE CANHEPB NETWORK

Background

Chronic hepatitis B (CHB) is the most common cause of hepatocellular carcinoma (HCC) worldwide.

Aims

The primary aim of this study is to explore the degree of treatment adherence to the American Association For The Study of Liver Disease (AASLD) HCC treatment guidelines for patients with CHB-HCC.

Methods

This is a retrospective, cross-sectional study of available data (2005–2020) in patients mono-infected with CHB collected from the Canadian HBV Network; a national consortium across 8 Canadian provinces. We analyzed data using descriptive statistics along with parametric and nonparametric statistical methods with a significance level of p < 0.05.

Results

Of the 6500 patients, 132 (2.0%) patients met inclusion criteria. The median age was 64 (IQR: 53.5- 71.5) with 101 (76%) being male. The median ALT was 40 (IQR: 26–59.5) and the median tumor number was 1(IQR: 1- 2) with a median tumor size of 2.6 cm (IQR: 1.9- 4.5). 98 (74.5%) patients were HBeAg negative with a median viral load of 3.8 logs (IQR 1.9 – 5.8). 58 (43%) patients had cirrhosis at diagnosis. 36% of patients were diagnosed with HCC on their first screening imaging whereas 39% were found to have HCC on repeated surveillance imaging. 116 (87.9%) were on treatment at the time of diagnosis or after (70 (60.3%) NA and 46 (39%) Combination therapy with double NA or NA plus interferon). Out of the 132 patients, BCLC stage 0, A, B, and C represented 30 (23%), 42 (32%), 17 (13%), and 5 (4%) patients, respectively, with 38 (28%) patients with unknown BCLC stage. The overall adherence to AASLD guidelines was 61%. The HCC treatment adherence rate for patients with BCLC stage 0, A, B were 63%, 97.5%, and 23.5%, respectively. BCLC stages C and D did not have a sufficient sample size for analysis. The adherence rate ranged from 53% (Eastern Canada) to 71% (Western Canada) across Canada.

Conclusions

In this retrospective nationwide cohort study of patients with CHB-related HCC, the overall treatment adherence rate to AASLD guidelines was low with notable regional differences. Further analysis will determine the cause of regional differences.

Funding Agencies

None

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with renal cell carcinoma

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma was published in 2019 with an update planned for 2021. It was therefore decided by both the ESMO and the Singapore Society of Oncology (SSO) to convene a special, virtual guidelines meeting in May 2021 to adapt the ESMO 2019 guidelines to take into account the ethnic differences associated with the treatment of renal cell carcinomas in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with renal cell carcinoma representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate.

Multicentre study of hospitalised patients with sports- and recreational cycling-related traumatic brain injury in Hong Kong

INTRODUCTION

Cycling is associated with a greater risk of traumatic brain injury (TBI) than other recreational activities. This study aimed to investigate the epidemiology of sports-related TBI in Hong Kong and to examine predictors for recreational cycling-induced intracranial haemorrhage.

METHODS

This retrospective multicentre study included patients diagnosed with sports-related TBI in public hospitals in Hong Kong from 2015 to 2019. Computed tomography scans were reviewed by an independent assessor. The primary endpoint was traumatic intracranial haemorrhage. The secondary endpoint was an unfavourable Glasgow Outcome Scale (GOS) score at discharge from hospital.

RESULTS

In total, 720 patients were hospitalised with sports-related TBI. The most common sport was cycling (59.2%). The crude incidence of cycling-related TBI was 1.1 per 100 000 population. Cyclists were more likely to exhibit intracranial haemorrhage and an unfavourable GOS score, compared with patients who had TBI because of other sports. Although 47% of cyclists had intracranial haemorrhage, only 15% wore a helmet. In multivariate analysis, significant predictors for intracranial haemorrhage were age ≥60 years, antiplatelet medication, moderate or severe TBI, and skull fracture. Among 426 cyclists, 375 (88%) had mild TBI, and helmet wearing was protective against intracranial haemorrhage, regardless of age, antiplatelet medication intake, and mechanism of injury. Of 426 cyclists, 31 (7.3%) had unfavourable outcomes on discharge from hospital.

CONCLUSIONS

The incidence of sports-related TBI is low in Hong Kong. Although cycling-related head injuries carried greater risks of intracranial haemorrhage and unfavourable outcomes compared with other sports, most cyclists experienced good recovery. Helmet wearing among recreational cyclists with mild TBI was protective against intracranial haemorrhage and skull fracture.

The Largest Minority Population With Unmet Oral Health Needs? Individuals With Disabilities

People with disabilities develop the same health problems that affect the general population. Some may be more susceptible to developing chronic conditions because of the influence of behavioral risk factors such as increased physical inactivity. In addition, people with disabilities are more likely to be overweight or obese and to smoke. People with disabilities are at a greater risk of being a victim of violence than those without disabilities. The oral health of many people with disabilities is poor, and access to dental care is limited.

Low dose antibiotic ingestion potentiates systemic and microbiome changes induced by silver nanoparticles

Changes in the mammalian gut microbiome are linked to the impairment of immunological function and numerous other pathologies. Antimicrobial silver nanoparticles (AgNPs) are incorporated into numerous consumer products (e.g., clothing, cosmetics, food packaging), which may directly impact the gut microbiome through ingestion. The human health impact of chronic AgNP ingestion is still uncertain, but evidence from exposure to other antimicrobials provides a strong rationale to assess AgNP effects on organ function, immunity, metabolism, and gut-associated microbiota. To investigate this, mice were gavaged daily for 5 weeks with saline, AgNPs, antibiotics (ciprofloxacin and metronidazole), or AgNPs combined with antibiotics. Animals were weighed daily, assessed for glucose tolerance, organ function, tissue and blood cytokine and leukocyte levels. At the end of the study, we used 16S rDNA amplicon and whole-metagenome shotgun sequencing to assess changes in the gut microbiome. In mice exposed to both AgNPs and antibiotics, silver was found in the stomach, and small and large intestines, but negligible amounts were present in other organs examined. Mice exposed to AgNPs alone showed minimal tissue silver levels. Antibiotics, but not AgNPs, altered glucose metabolism. Mice given AgNPs and antibiotics together demonstrated slower weight gain, reduced peripheral lymphocytes, and elevated splenic, but not circulatory markers of inflammation. 16S rDNA profiling of cecum and feces and metagenomic sequencing of fecal DNA demonstrated that combined AgNP-antibiotic treatment also significantly altered the structure and function of the gut microbiota, including depletion of the indicator species Akkermansia muciniphila. This study provides evidence for possible biological effects from repeated ingestion of AgNP-containing consumer products when antibiotics are also being used and raises concern that an impaired gut microbiome (e.g., through antibiotic use) can potentiate the harm from chemical exposures such as AgNPs.

Use of ColonFlag score for prioritisation of endoscopy in colorectal cancer

OBJECTIVE

Colorectal cancer (CRC) is the fourth most common cancer in UK. Symptomatic patients are referred via an urgent pathway and although most are investigated with colonoscopy <4% are diagnosed with cancer. There is therefore a need for a suitable triage tool to prioritise investigations. This study retrospectively examined performance of various triage tools in patients awaiting investigation on the urgent lower gastrointestinal cancer pathway DESIGN: All patients over 40 years of age on the urgent pathway awaiting investigation for suspected CRC on 1 May were included. After 6 months, outcomes were evaluated and the performance of the faecal immunochemical test (FIT), faecal haemoglobin concentration, age and sex test (FAST) and the artificial intelligence algorithm ColonFlag were examined.

RESULTS

532 completed investigations and received a diagnosis; 15 had CRC. 388 had a valid FIT result, of whom 11 had CRC; FAST Score ≥4.5 had sensitivity of 72.7%, specificity of 80.6% and would have failed to detect three tumours. Faecal haemoglobin (f-Hb) at cut-off of 10 µg/g and ColonFlag had equal sensitivity of 81.82%, ColonFlag had greater specificity 73.47%, compared with 64.99%. Both tests would have failed to detect two tumours but not in the same patients; when used in combination, sensitivity and specificity were 100% and 49.4%. When ColonFlag was applied to the cohort of 532, an additional four tumours would have been detected in patients without a valid FIT.

CONCLUSION

This study showed ColonFlag to have equal sensitivity and greater specificity than f-Hb at a cut-off of 10 µg/g as a triage tool for CRC.

Towards computer-aided severity assessment via deep neural networks for geographic and opacity extent scoring of SARS-CoV-2 chest X-rays

A critical step in effective care and treatment planning for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause for the coronavirus disease 2019 (COVID-19) pandemic, is the assessment of the severity of disease progression. Chest x-rays (CXRs) are often used to assess SARS-CoV-2 severity, with two important assessment metrics being extent of lung involvement and degree of opacity. In this proof-of-concept study, we assess the feasibility of computer-aided scoring of CXRs of SARS-CoV-2 lung disease severity using a deep learning system. Data consisted of 396 CXRs from SARS-CoV-2 positive patient cases. Geographic extent and opacity extent were scored by two board-certified expert chest radiologists (with 20+ years of experience) and a 2nd-year radiology resident. The deep neural networks used in this study, which we name COVID-Net S, are based on a COVID-Net network architecture. 100 versions of the network were independently learned (50 to perform geographic extent scoring and 50 to perform opacity extent scoring) using random subsets of CXRs from the study, and we evaluated the networks using stratified Monte Carlo cross-validation experiments. The COVID-Net S deep neural networks yielded R[Formula: see text] of [Formula: see text] and [Formula: see text] between predicted scores and radiologist scores for geographic extent and opacity extent, respectively, in stratified Monte Carlo cross-validation experiments. The best performing COVID-Net S networks achieved R[Formula: see text] of 0.739 and 0.741 between predicted scores and radiologist scores for geographic extent and opacity extent, respectively. The results are promising and suggest that the use of deep neural networks on CXRs could be an effective tool for computer-aided assessment of SARS-CoV-2 lung disease severity, although additional studies are needed before adoption for routine clinical use.

Cabazitaxel versus abiraterone or enzalutamide in poor prognosis metastatic castration-resistant prostate cancer: a multicentre, randomised, open-label, phase II trial

BACKGROUND

Treatment of poor prognosis metastatic castration-resistant prostate cancer (mCRPC) includes taxane chemotherapy and androgen receptor pathway inhibitors (ARPI). We sought to determine optimal treatment in this setting.

PATIENTS AND METHODS

This multicentre, randomised, open-label, phase II trial recruited patients with ARPI-naive mCRPC and poor prognosis features (presence of liver metastases, progression to mCRPC after <12 months of androgen deprivation therapy, or ≥4 of 6 clinical criteria). Patients were randomly assigned 1 : 1 to receive cabazitaxel plus prednisone (group A) or physician's choice of enzalutamide or abiraterone plus prednisone (group B) at standard doses. Patients could cross over at progression. The primary endpoint was clinical benefit rate for first-line treatment (defined as prostate-specific antigen response ≥50%, radiographic response, or stable disease ≥12 weeks).

RESULTS

Ninety-five patients were accrued (median follow-up 21.9 months). First-line clinical benefit rate was greater in group A versus group B (80% versus 62%, P = 0.039). Overall survival was not different between groups A and B (median 37.0 versus 15.5 months, hazard ratio (HR) = 0.58, P = 0.073) nor was time to progression (median 5.3 versus 2.8 months, HR = 0.87, P = 0.52). The most common first-line treatment-related grade ≥3 adverse events were neutropenia (cabazitaxel 32% versus ARPI 0%), diarrhoea (9% versus 0%), infection (9% versus 0%), and fatigue (7% versus 5%). Baseline circulating tumour DNA (ctDNA) fraction above the cohort median and on-treatment ctDNA increase were associated with shorter time to progression (HR = 2.38, P < 0.001; HR = 4.03, P < 0.001). Patients with >30% ctDNA fraction at baseline had markedly shorter overall survival than those with undetectable ctDNA (HR = 38.22, P < 0.001).

CONCLUSIONS

Cabazitaxel was associated with a higher clinical benefit rate in patients with ARPI-naive poor prognosis mCRPC. ctDNA abundance was prognostic independent of clinical features, and holds promise as a stratification biomarker.