Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial

BACKGROUND AND AIMS

Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pretransplant NGF on pre-liver transplant and post-liver transplant outcomes.

APPROACH AND RESULTS

This single-center, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared a standard high-energy high-protein diet to diet plus supplemental nocturnal NGF while awaiting transplant. The primary outcome was a change in HGS. The median age was 58.5 years (IQR: 51.1-64), median MELD was 24 (20-28.5), and 32 (58%) patients were male. The median duration of NGF was 63.0 days (34.5-127), following which time the median between-group difference in HGS was 3.6 kg (95% CI: 1.7-5.2, p <0.001), an increase of 20% from baseline. Mid-upper-arm circumference, triceps skinfold, and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285 kcal (95% CI: 860-1677) and protein intake by 51 g (95% CI: 32-71) (both p <0.001). All NGF patients met >100% of their measured nutritional requirements. Posttransplant clinical outcomes were similar between groups.

CONCLUSIONS

Targeted enteral feeding before liver transplant improves HGS, anthropometry, and immune function in severely malnourished patients with cirrhosis. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pretransplant and posttransplant mortality.

Transitioning patients from intravenous to subcutaneous infliximab and vedolizumab for inflammatory bowel disease: what is the opportunity cost of improving access to healthcare?

BACKGROUND

Biologic drugs are highly effective for inflammatory bowel disease (IBD) management but are key drivers of costs of care especially when administered intravenously (i.v.). Availability of subcutaneous (SC) formulations has increased convenience for patients and improved access to care, but at the cost of revenue to health services.

AIMS

To evaluate the economic impact of transitioning a tertiary centre IBD cohort from i.v. to SC biologic administration and assess the implications for key stakeholders.

METHODS

A retrospective analysis of all patients who received i.v. infliximab or vedolizumab in the outpatient infusion centre of a tertiary IBD centre between July 2019 and June 2021 was undertaken. Data were collated from electronic medical records, pharmacy dispensing systems and the hospital business intelligence unit. An economic analysis and theoretical financial/capacity impact analysis of a transition to an SC model were estimated under two scenarios using a random 10% and 30% of the patient cohort.

RESULTS

Transitioning our IBD cohort from i.v. to SC administration would result in a loss to our health service of AU$2 732 123.75, composed of AU$1 463 003.75 in Weighted Inlier Equivalent Separation (WIES) and AU$1 269 120 in drug procurement revenue. However, it would ease capacity in the infusion centre by up to 5256 h.

CONCLUSIONS

Transitioning patients to SC administration results in improved access to infusion centres and substantial savings to state governments; however, switching results in a loss of i.v. biologic-generated WIES to health services. Alternative funding models are required to achieve sustainability in IBD care and reduce reliance on i.v. biologic-generated income.

Effects of transcranial direct current stimulation and transcranial random noise stimulation on working memory and task-related EEG in major depressive disorder

OBJECTIVE

To compare effects of transcranial direct current stimulation (tDCS) and transcranial random noise stimulation with a direct-current offset (tRNS + DC-offset) on working memory (WM) performance and task-related electroencephalography (EEG) in individuals with Major Depressive Disorder (MDD).

METHODS

Using a sham-controlled, parallel-groups design, 49 participants with MDD received either anodal tDCS (N = 16), high-frequency tRNS + DC-offset (N = 16), or sham stimulation (N = 17) to the left dorsolateral prefrontal cortex (DLPFC) for 20-minutes. The Sternberg WM task was completed with concurrent EEG recording before and at 5- and 25-minutes post-stimulation. Event-related synchronisation/desynchronisation (ERS/ERD) was calculated for theta, upper alpha, and gamma oscillations during WM encoding and maintenance.

RESULTS

tDCS significantly increased parieto-occipital upper alpha ERS/ERD during WM maintenance, observed on EEG recorded 5- and 25-minutes post-stimulation. tRNS + DC-offset did not significantly alter WM-related oscillatory activity when compared to sham stimulation. Neither tDCS nor tRNS + DC-offset improved WM performance to a significantly greater degree than sham stimulation.

CONCLUSIONS

Although tDCS induced persistent effects on WM-related oscillatory activity, neither tDCS nor tRNS + DC-offset enhanced WM performance in MDD.

SIGNIFICANCE

This reflects the first sham-controlled comparison of tDCS and tRNS + DC-offset in MDD. These findings directly contrast with evidence of tRNS-induced enhancements in WM in healthy individuals.

Redefining Nutritional Requirements in End-Stage Liver Disease: Towards a Personalized Approach

Malnutrition is ubiquitous in cirrhotic patients presenting for liver transplant (LT). Providing an appropriate energy prescription is fundamental to effective nutrition therapy. We aimed to compare measured energy expenditure (mEE) with predicted energy expenditure (pEE) in patients awaiting LT and determine clinical factors associated with mEE. In this prospective observational study, energy expenditure was measured by indirect calorimetry in 110 adult patients referred for LT and predicted by commonly utilized equations (Harris-Benedict, Schofield, and EASL guidelines). Nutritional status, anthropometry, muscle function, biochemical and clinical data were also collected. The median model for end-stage liver disease (MELD) was 19 (IQR 13, 25), and the majority were Child-Pugh B (51%) or C (37%). Malnutrition was evident in 85%. Median mEE by calorimetry was 1756 (1531, 2104) kcal/d and significantly higher than pEE as per Harris-Benedict 1480 (1322, 1722) kcal/d and Schofield 1474 (1349, 1723) kcal/d (both p < 0.001), but lower than EASL guidelines (35 kcal/kg) when an activity factor was applied to mEE; 2283 (1990, 2735) kcal/d versus 2590 (2178, 3010) kcal/d (p < 0.001). Hypermetabolism (mEE:pEE > 1.2) was evident in 48% of the cohort. Multivariate analysis found MELD, Child-Pugh class, diuretic use, and severe malnutrition to be independent predictors of hypermetabolism. A new liver-specific predictive model has been developed, showing superior agreement with mEE than common predictive equations. In conclusion, there is a poor correlation between mEE and pEE in patients awaiting LTs, and hypermetabolism is common. Relying on historical predictive equations in this patient population may result in significant under or over-feeding. A tailored energy prescription based on indirect calorimetry or a liver-specific predictive model is recommended for LT candidates.

Cochlear implantation in advanced otosclerosis: utility of pre-operative radiological assessment in predicting intra-operative difficulty and final electrode position

OBJECTIVE

This study aimed to determine if pre-operative radiological scoring can reliably predict intra-operative difficulty and final cochlear electrode position in patients with advanced otosclerosis.

METHOD

A retrospective cohort study of advanced otosclerosis patients who underwent cochlear implantation (n = 48, 52 ears) was compared with a larger cohort of post-lingually deaf adult patients (n = 1414) with bilateral hearing loss and normal cochlear anatomy. Pre-operative imaging for advanced otosclerosis patients and final electrode position were scored and correlated with intra-operative difficulty and speech outcomes.

RESULTS

Advanced otosclerosis patients benefit significantly from cochlear implantation. Mean duration of deafness was longer in the advanced otosclerosis group (19.5 vs 14.3 years; p < 0.05).

CONCLUSION

Anatomical changes in advanced otosclerosis can result in increased difficulty of surgery. Evidence of pre-operative cochlear luminal changes was associated with intra-operative difficult insertion and final non-scala tympani position. Nearly all electrodes implanted in the advanced otosclerosis cohort were peri-modiolar. No reports of facial nerve stimulation were observed.

Pancreatic Adenocarcinoma: Real World Evidence of Care Delivery in AccessHope Data

BACKGROUND

Pancreatic adenocarcinoma is an aggressive disease and the delivery of comprehensive care to individuals with this cancer is critical to achieve appropriate outcomes. The identification of gaps in care delivery facilitates the design of interventions to optimize care delivery and improve outcomes in this population.

METHODS

AccessHope™ is a growing organization that connects oncology subspecialists with treating providers through contracts with self-insured employers. Data from 94 pancreatic adenocarcinoma cases (August 2019-December 2022) in the AccessHope dataset were used to describe gaps in care delivery.

RESULTS

In all but 6% of cases, the subspecialist provided guideline-concordant recommendations anticipated to improve outcomes. Gaps in care were more pronounced in patients with non-metastatic pancreatic cancer. There was a significant deficiency in germline testing regardless of the stage, with only 59% of cases having completed testing. Only 20% of cases were receiving palliative care or other allied support services. There was no difference in observed care gaps between patients receiving care in the community setting vs. those receiving care in the academic setting.

CONCLUSIONS

There are significant gaps in the care delivered to patients with pancreatic adenocarcinoma. A concurrent subspecialist review has the opportunity to identify and address these gaps in a timely manner.

Transjugular intrahepatic portosystemic shunt insertion improves muscle mass but not muscle function or frailty measures

INTRODUCTION

Sarcopenia in cirrhosis is associated with poor outcomes. While transjugular intrahepatic portosystemic shunt (TIPS) insertion improves radiological measures of muscle mass, its impact on muscle function, performance and frailty has not been evaluated.

METHODS

Patients with cirrhosis referred for TIPS were prospectively recruited and followed for 6 months. L3 CT scans were used to calculate skeletal muscle and adipose tissue parameters. Handgrip strength, Liver Frailty Index and short physical performance battery were serially monitored. Dietary intake, insulin resistance, insulin-like growth factor (IGF)-1, and immune function using QuantiFERON Monitor (QFM) were measured.

RESULTS

Twelve patients completed the study with a mean age of 58 ± 9 years and model for end-stage liver disease score of 16 ± 5. At 6 months post-TIPS, skeletal muscle area increased from 139.33 cm 2  ± 22.72 to 154.64 ± 27.42 ( P  = 0.012). Significant increases were observed in the subcutaneous fat area ( P  = 0.0076) and intermuscular adipose tissue ( P  = 0.041), but not muscle attenuation or visceral fat. Despite marked changes in muscle mass, no improvements were observed in handgrip strength, frailty, or physical performance. At 6 months post-TIPS, IGF-1 ( P  = 0.0076) and QFM ( P  = 0.006) increased compared to baseline. Nutritional intake, hepatic encephalopathy measures, insulin resistance and liver biochemistry were not significantly impacted.

CONCLUSION

Muscle mass increased following TIPS insertion as did IGF-1, a known driver of muscle anabolism. The lack of improvement in muscle function was unexpected and may relate to impairment in muscle quality and the effects of hyperammonaemia on muscle contractile function. Improvements in QFM, a marker of immune function, may suggest a reduction in infection susceptibility in this at-risk population and requires further evaluation.

Outcomes of patients with hepatorenal syndrome undergoing liver transplantation in the era of terlipressin

BACKGROUND

The efficacy of terlipressin in improving pre-liver transplant renal function in hepatorenal syndrome (HRS) has been well documented, however, its impact on post-transplant renal function remains poorly described. This study aims to describe the impact of HRS and terlipressin on post-liver transplant renal function and survival.

METHODS

A single-centre, retrospective, observational study was conducted to identify post-transplant outcomes of patients diagnosed with HRS undergoing liver transplant (HRS cohort) and those undergoing transplant for non-HRS, non-hepatocellular carcinoma cirrhotic indications (comparator cohort) between January 1997 and March 2020. The primary outcome was serum creatinine at 180 days post-liver transplant. Other renal outcomes and overall survival were secondary outcomes.

RESULTS

109 patients with HRS and 502 comparator patients underwent liver transplant. The comparator cohort was younger than the HRS cohort (53 vs. 57 years, P < 0.001). The median creatinine at day 180 post-transplant was higher in the HRS transplant group (119 µmol/L vs. 103 µmol/L, P < 0.001), however, this association lost significance following multivariate analysis. Seven patients (7%) in the HRS cohort received a combined liver-kidney transplant. There was no significant difference in the 12-month post-transplant survival between the two groups (94% vs. 94%, P = 0.5).

CONCLUSION

Patients with HRS treated with terlipressin who subsequently undergo liver transplantation have post-transplant renal and survival outcomes comparable to patients transplanted for cirrhosis without HRS. This study supports the practice of liver-only transplant in this cohort and the reservation of renal allografts for those who have primary renal disease.

Testosterone is lower in men with non-alcoholic fatty liver disease and alcohol-related cirrhosis and is associated with adverse clinical outcomes

BACKGROUND/AIMS

Low serum testosterone is common in cirrhotic men, but the impact of disease aetiology remains uncertain. This study compares serum total testosterone (TT) levels by disease aetiology and assesses its prognostic value.

METHODS

Single-centre retrospective study of cirrhotic men who had TT levels measured between 2002 and 2020. A cut-off of 12 nmol/L was used to define low TT and 230 pmol/L for calculated free testosterone (cFT). Linear and logistic regression used to adjust for variables known to affect testosterone levels and assess for an association between levels and outcomes.

RESULTS

Of 766 cirrhotic men, 33.3% had alcohol-related liver disease (ALD) and 11.9% had non-alcoholic fatty liver disease (NAFLD). The median age was 56 years (interquartile range (IQR) 50-61), and the model for end-stage liver disease (MELD) score 14 (IQR 9-20). TT levels were low in 53.3% of patients, (median 11.0 nmol/L; IQR 3.7-19.8) and cFT low in 79.6% (median 122 pmol/L; IQR 48.6-212). Median TT was lower in men with ALD (7.6 nmol/L; IQR 2.1-16.2) and NAFLD (9.8 nmol/L; IQR 2.75-15.6) compared to other aetiologies (11.0 nmol/L; IQR 3.73-19.8) (p < 0.001 for all), which remained true after adjustment for age and MELD score. TT was inversely associated with 12-month mortality or transplant (381 events, p = 0.02) and liver decompensation (345 events, p = 0.004).

CONCLUSIONS

Low serum testosterone is common in cirrhotic men and is associated with adverse clinical outcomes. TT levels are significantly lower in ALD and NAFLD compared to other disease aetiologies. Further large-scale studies are required to assess the potential benefits of testosterone therapy.

Evaluating treatment response following locoregional therapy for hepatocellular carcinoma: A review of the available serological and radiological tools for assessment

Hepatocellular carcinoma (HCC) is an aggressive primary malignancy of the liver and is the third most common cause of cancer-related global mortality. There has been a steady increase in treatment options for HCC in recent years, including innovations in both curative and non-curative therapies. These advances have brought new challenges and necessary improvements in strategies of disease monitoring, to allow early detection of HCC recurrence. Current serological and radiological strategies for post-treatment monitoring and prognostication and their limitations will be discussed and evaluated in this review.

Hepatitis B virus haplotype number at baseline is a predictive marker of functional cure during antiviral therapy for patients with genotypes A and D HBeAg-positive chronic hepatitis B

BACKGROUNDS AND AIMS

We investigated associations between hepatitis B virus (HBV) genome-length haplotype number (HN) at baseline in subjects with HBeAg-positive chronic hepatitis B (CHB), and the likelihood of achieving functional cure during direct-acting antiviral therapy METHOD: We analysed 86 HBeAg-positive baseline samples from patients with HBV genotypes A and D who were enrolled in a Phase II trial of tenofovir disoproxil fumarate (TDF) to determine if HN was a biomarker of HBsAg loss during therapy. Findings were validated using baseline samples from 181 patients with HBV genotypes A and D from an independent clinical trial utilising TDF or tenofovir alafenamide therapy in HBeAg-positive CHB.

RESULTS

In the HBeAg-positive test cohort, patients with genotypes A or D and ≤2 haplotypes had a minimum of 21-fold higher likelihood of achieving HBsAg loss on TDF. Baseline HN (p < 0.0001) was a stronger predictor of HBsAg loss on therapy than HBsAg titre (p = 0.03), HBeAg titre (p = 0.0002), or the presence of HBV basal core promoter (A1762T, p = 0.0379 and G1764A, p = 0.0176) or G1896A precore mutations (p = 0.0218). This finding was validated in the independent validation cohort. HN was statistically higher in patients with HBV genotypes B or C infection compared to genotypes A and D.

CONCLUSION

Baseline HN ≤2 predicts which patients with HBV genotypes A or D will more likely progress to functional cure on current direct-acting antiviral therapy, with greater accuracy than current biomarkers including baseline HBsAg and HBeAg titre.

Relationship between in feed drugs, antibiotics and organic enrichment in marine sediments at Canadian Atlantic salmon aquaculture sites

The presence of in-feed anti-sea lice drugs and their relationship with organic enrichment is poorly understood in sediment surrounding salmon farms. Using data from an aquaculture monitoring program (2018-2020), we describe this relationship at ten sites in four Canadian provinces. Three anti-sea lice pesticides (lufenuron, teflubenzuron, emamectin benzoate and metabolite desmethyl emamectin benzoate), and one antibiotic (oxytetracycline) were detected. Concentrations were often below limits of quantification. Values are also lower than those reported in other aquaculture salmon-producing countries. Highest concentrations, along with organic enrichment, were observed ~200 m of cages with lower concentrations detected up to 1.5 km away. Most samples had at least two drugs present: 75.2 % (British Columbia), 91.4 % (Newfoundland), and 54.8 % (New Brunswick/Nova Scotia) highlighting the potential for cumulative effects. Emamectin benzoate and oxytetracycline were detected four and three years respectively after last known treatments, demonstrating the need for research on overall persistence of compounds.

External validation of a surgical mortality risk prediction model for inpatient noncardiac surgery in an Australian private health insurance dataset

BACKGROUND

We previously conducted a systematic review to identify surgical mortality risk prediction tools suitable for adapting in the Australian context and identified the Surgical Outcome Risk Tool (SORT) as an ideal model. The primary aim was to investigate the external validity of SORT for predicting in-hospital mortality in a large Australian private health insurance dataset.

METHODS

A cohort study using a prospectively collected Australian private health insurance dataset containing over 2 million deidentified records. External validation was conducted by applying the predictive equation for SORT to the complete case analysis dataset. Model re-estimation (recalibration) was performed by logistic regression.

RESULTS

The complete case analysis dataset contained 161 277 records. In-hospital mortality was 0.2% (308/161277). The mean estimated risk given by SORT was 0.2% and the median (IQR) was 0.01% (0.003%-0.08%). Discrimination was high (c-statistic 0.96) and calibration was accurate over the range 0%-10%, beyond which mortality was over-predicted but confidence intervals included or closely approached the perfect prediction line. Re-estimation of the equation did not improve over-prediction. Model diagnostics suggested the presence of outliers or highly influential values.

CONCLUSION

The low perioperative mortality rate suggests the dataset was not representative of the overall Australian surgical population, primarily due to selection bias and classification bias. Our results suggest SORT may significantly under-predict 30-day mortality in this dataset. Given potential differences in perioperative mortality, private health insurance status and hospital setting should be considered as covariables when a locally validated national surgical mortality risk prediction model is developed.

Characteristics of community-acquired carbapenem-resistant Enterobacterales

BACKGROUND

Community-acquired carbapenem-resistant Enterobacterales (CA-CRE) are an important threat.

METHODS

In CRACKLE-2, we defined patients with CA-CRE as admitted from home, without pre-existing conditions, and a positive culture within 48 h of admission. Healthcare-associated CRE (HA-CRE) were those with the lowest likelihood of community acquisition, not admitted from home and cultured >48 h after admission. Specific genetic markers in carbapenemase-producing Klebsiella pneumoniae were evaluated through random forest modelling.

RESULTS

CA-CRE and HA-CRE were detected in 83 (10%) and 208 (26%) of 807 patients. No significant differences were observed in bacterial species or strain type distribution. K. pneumoniae (204/291, 70%) was the most common CRE species, of these 184/204 (90%) were carbapenemase producers (CPKP). The top three genetic markers in random forest models were kpi_SA15, fimE, and kpfC. Of these, kpi_SA15 (which encodes a chaperone/usher system) was positively associated (OR 3.14, 95% CI 1.13-8.87, P = 0.026), and kpfC negatively associated (OR 0.21, 95% CI 0.05-0.72, P = 0.015) with CA-CPKP.

CONCLUSIONS

Ten percent of CDC-defined CRE were CA. The true proportion of CA-CRE in hospitalized patients is likely lower as patients may have had unrecorded prior healthcare exposure. The kpi_SA15 operon was associated with the CA phenotype.

073 Fenfluramine exhibits disease-modifying effects in a mouse model of Dravet syndrome

Rationale

Fenfluramine (FFA) provides clinically significant reductions in convulsive seizure frequency and improved executive function in patients with Dravet syndrome (DS). FFA also reduces sudden unexpected death in epilepsy (SUDEP) in mouse models of DS. We investigated FFA effects upon survival, myelination, and neuroinflammation in a mouse model of DS.

Methodsscn1a+/-mice (DS mice) were treated subcutaneously with FFA. FFPE sagittal brain sections were immunostained with D-MBP antibody for degenerated myelin and CD11b antibody for inflamma- tory microglia.

Results

In animals receiving FFA, the mortality rate was reduced to 24% (P< 0.01; Figure 1). Degenerated myelin was enriched in DS mouse cortex and hippocampus compared to wild-type controls. FFA treatment reduced degenerated myelin.

Conclusion

This is the first report of increased survival and reductions in myelin degeneration and neuro- inflammation in DS mice treated with FFA. Improved survival and reduced myelin damage and neuroin- flammation demonstrates the claim that FFA exhibits disease-modifying effects in animal models of DS.

Hospital costs and factors associated with days alive and at home after surgery (DAH30 )

OBJECTIVE

To assess the relationships of patient and surgical factors and hospital costs with the number of days alive and at home during the 30 days following surgery (DAH₃₀ ).

DESIGN

Retrospective cohort study; analysis of Medibank Private health insurance hospital claims data, Australia, 1 January 2016 - 31 December 2017.

SETTING, PARTICIPANTS

Admissions of adults (18 years or older) to hospitals for elective or emergency inpatient surgery with anaesthesia covered by private health insurance, Australia, 1 January 2016 - 31 December 2017.

MAIN OUTCOME MEASURES

Associations between DAH₃₀ and total hospital costs, and between DAH₃₀ and surgery risk factors.

RESULTS

Complete data were available for 126 788 of 181 281 eligible patients (69.9%); their median age was 62 years (IQR, 47-73 years), 72 872 were women (57%), and 115 117 had undergone elective surgery (91%). The median DAH₃₀ was 27.1 days (IQR, 24.2-28.8 days), the median hospital cost per patient was $10 358 (IQR, $6624-20 174). The association between DAH₃₀ and total hospital costs was moderate (Spearman ρ = -0.60; P < 0.001). Median DAH₃₀ declined with age, comorbidity score, ASA physical status score, and surgical severity and duration, and was also lower for women.

CONCLUSIONS

DAH₃₀ is a validated, patient-centred outcome measure of post-surgical outcomes; higher values reflect shorter hospital stays and fewer serious complications, re-admissions, and deaths. DAH₃₀ can be used to benchmark quality of surgical care and to monitor quality improvement programs for reducing the costs of surgical and other peri-operative care.

Patient-reported Outcomes: the ICHOM Standard Set for Inflammatory Bowel Disease in Real-life Practice Helps Quantify Deficits in Current Care

BACKGROUND

Patient-reported outcome measures [PROMs] are key to documenting outcomes that matter most to patients and are increasingly important to commissioners of health care seeking value. We report the first series of the ICHOM Standard Set for Inflammatory Bowel Disease [IBD].

METHODS

Patients treated for ulcerative colitis [UC] or Crohn's disease [CD] in our centre were offered enrolment into the web-based TrueColours-IBD programme. Through this programme, e-mail prompts linking to validated questionnaires were sent for symptoms, quality of life, and ICHOM IBD outcomes.

RESULTS

The first 1299 consecutive patients enrolled [779 UC, 520 CD] were studied with median 270 days of follow-up (interquartile range [IQR] 116, 504). 671 [52%] were female, mean age 42 years (standard deviation [sd] 16), mean body mass index [BMI] 26 [sd 5.3]. At registration, 483 [37%] were using advanced therapies. Median adherence to fortnightly quality of life reporting and quarterly outcomes was 100% [IQR 48, 100%] and 100% [IQR 75, 100%], respectively. In the previous 12 months, prednisolone use was reported by 229 [29%] patients with UC vs 81 [16%] with CD, p <0.001; 202 [16%] for <3 months; and 108 [8%] for >3 months. An IBD-related intervention was reported by 174 [13%] patients, and 80 [6%] reported an unplanned hospital admission. There were high rates of fatigue [50%] and mood disturbance [23%].

CONCLUSIONS

Outcomes reported by patients illustrate the scale of the therapeutic deficit in current care. Proof of principle is demonstrated that PROM data can be collected continuously with little burden on health care professionals. This may become a metric for quality improvement programmes or to compare outcomes.

Different factors limit early- and late-season windows of opportunity for monarch development

Seasonal windows of opportunity are intervals within a year that provide improved prospects for growth, survival, or reproduction. However, few studies have sufficient temporal resolution to examine how multiple factors combine to constrain the seasonal timing and extent of developmental opportunities. Here, we document seasonal changes in milkweed (Asclepias fascicularis)-monarch (Danaus plexippus) interactions with high resolution throughout the last three breeding seasons prior to a precipitous single-year decline in the western monarch population. Our results show early- and late-season windows of opportunity for monarch recruitment that were constrained by different combinations of factors. Early-season windows of opportunity were characterized by high egg densities and low survival on a select subset of host plants, consistent with the hypothesis that early-spring migrant female monarchs select earlier-emerging plants to balance a seasonal trade-off between increasing host plant quantity and decreasing host plant quality. Late-season windows of opportunity were coincident with the initiation of host plant senescence, and caterpillar success was negatively correlated with heatwave exposure, consistent with the hypothesis that late-season windows were constrained by plant defense traits and thermal stress. Throughout this study, climatic and microclimatic variations played a foundational role in the timing and success of monarch developmental windows by affecting bottom-up, top-down, and abiotic limitations. More exposed microclimates were associated with higher developmental success during cooler conditions, and more shaded microclimates were associated with higher developmental success during warmer conditions, suggesting that habitat heterogeneity could buffer the effects of climatic variation. Together, these findings show an important dimension of seasonal change in milkweed-monarch interactions and illustrate how different biotic and abiotic factors can limit the developmental success of monarchs across the breeding season. These results also suggest the potential for seasonal sequences of favorable or unfavorable conditions across the breeding range to strongly affect monarch population dynamics.

Testosterone therapy reduces hepatic steatosis in men with type 2 diabetes and low serum testosterone concentrations

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in people with diabetes with no available treatment.

AIM

To explore the effect of testosterone treatment on liver. Testosterone therapy improves insulin resistance and reduces total body fat, but its impact on the liver remains poorly studied.

METHODS

This secondary analysis of a 40 wk, randomised, double-blinded, placebo-controlled trial of intramuscular testosterone undecanoate in men with type 2 diabetes and lowered serum testosterone concentrations evaluated the change in hepatic steatosis as measured by liver fat fraction on magnetic resonance imaging (MRI).

RESULTS

Of 88 patients enrolled in the index study, 39 had liver MRIs of whom 20 received testosterone therapy and 19 received placebo. All patients had > 5% hepatic steatosis at baseline and 38 of 39 patients met diagnostic criteria for NAFLD. Median liver fat at baseline was 15.0% (IQR 11.5%-21.1%) in the testosterone and 18.4% (15.0%-28.9%) in the placebo group. Median ALT was 34units/L (26-38) in the testosterone and 32units/L (25-52) in the placebo group. At week 40, patients receiving testosterone had a median reduction in absolute liver fat of 3.5% (IQR 2.9%-6.4%) compared with an increase of 1.2% in the placebo arm (between-group difference 4.7% P < 0.001). After controlling for baseline liver fat, testosterone therapy was associated with a relative reduction in liver fat of 38.3% (95% confidence interval 25.4%-49.0%, P < 0.001).

CONCLUSION

Testosterone therapy was associated with a reduction in hepatic steatosis in men with diabetes and low serum testosterone. Future randomised studies of testosterone therapy in men with NAFLD focusing on liver-related endpoints are therefore justified.

Carbapenem-Resistant Acinetobacter baumannii in U.S. Hospitals: Diversification of Circulating Lineages and Antimicrobial Resistance

Carbapenem-resistant Acinetobacter baumannii (CRAb) is a major cause of health care-associated infections. CRAb is typically multidrug resistant, and infection is difficult to treat. Despite the urgent threat that CRAb poses, few systematic studies of CRAb clinical and molecular epidemiology have been conducted. The Study Network of Acinetobacter as a Carbapenem-Resistant Pathogen (SNAP) is designed to investigate the clinical characteristics and contemporary population structure of CRAb circulating in U.S. hospital systems using whole-genome sequencing (WGS). Analysis of the initial 120 SNAP patients from four U.S. centers revealed that CRAb remains a significant threat to hospitalized patients, affecting the most vulnerable patients and resulting in 24% all-cause 30-day mortality. The majority of currently circulating isolates belonged to ST2Pas, a part of clonal complex 2 (CC2), which is the dominant drug-resistant lineage in the United States and Europe. We identified three distinct sublineages within CC2, which differed in their antibiotic resistance phenotypes and geographic distribution. Most concerning, colistin resistance (38%) and cefiderocol resistance (10%) were common within CC2 sublineage C (CC2C), where the majority of isolates belonged to ST2Pas/ST281Ox. Additionally, we identified ST499Pas as the most common non-CC2 lineage in our study. Our findings suggest a shift within the CRAb population in the United States during the past 10 years and emphasize the importance of real-time surveillance and molecular epidemiology in studying CRAb dissemination and clinical impact. IMPORTANCE Carbapenem-resistant Acinetobacter baumannii (CRAb) constitutes a major threat to public health. To elucidate the molecular and clinical epidemiology of CRAb in the United States, clinical CRAb isolates were collected along with data on patient characteristics and outcomes, and bacterial isolates underwent whole-genome sequencing and antibiotic susceptibility phenotyping. Key findings included emergence of new sublineages within the globally predominant clonal complex 2 (CC2), increased colistin and cefiderocol resistance within one of the CC2 sublineages, and emergence of ST499Pas as the dominant non-CC2 CRAb lineage in U.S. hospitals.

Surgical treatment of pelvic organ prolapse in women aged ≥75 years in Hong Kong: a multicentre retrospective study

INTRODUCTION

Pelvic organ prolapse (POP) is common among older women. With the increasing lifespan and emphasis on quality of life worldwide, older women increasingly prefer surgical treatment for POP. We reviewed the surgical treatment of POP in older women to characterise its safety, effectiveness, and the type most often selected.

METHODS

This multicentre, retrospective study was conducted at four hospitals between 2013 and 2018. Included patients were aged ≥75 years and had undergone POP surgery. We compared patient demographic characteristics, POP severity, and surgical outcomes between reconstructive and obliterative surgeries; these comparisons were also made among vaginal hysterectomy plus pelvic floor repair (VHPFR), transvaginal mesh surgery (TVM), vaginal hysterectomy (VH) plus colpocleisis, and colpocleisis alone.

RESULTS

In total, 343 patients were included; 84.3% and 15.7% underwent reconstructive and obliterative surgeries, respectively. Overall, 246 (71.7%), 43 (12.5%), 20 (5.8%), and 34 (9.9%) patients underwent VHPFR, TVM, VH plus colpocleisis, and colpocleisis alone, respectively. Patients who were older (81.9 vs 79.6 y; P=0.001), had vault prolapse (38.9% vs 3.5%; P<0.001), and had medical co-morbidities (37% vs 4.8%; P<0.001) chose obliterative surgery more frequently than reconstructive surgery. Obliterative surgeries had shorter operative time (73.5 min vs 107 min; P<0.001) and fewer surgical complications (9.3% vs 28.0%; P=0.003). Vaginal hysterectomy plus pelvic floor repair had the highest rate of surgical complications (most were minor), while colpocleisis alone had the lowest rate (30.1% vs 8.8%; P=0.01).

CONCLUSIONS

Pelvic organ prolapse surgeries were safe and effective for older women. Colpocleisis may be appropriate as primary surgery for fragile older women.

The incidence and outcomes of healthcare-associated respiratory tract infections in non-ventilated neurocritical care patients: Results of a 10-year cohort study

The incidence of healthcare-associated respiratory tract infections in non-ventilated patients (NVA-HARTI) in neurosurgical intensive care units (ICUs) is unknown. The impact of NVA-HARTI on patient outcomes and differences between NVA-HARTI and ventilator-associated healthcare-associated respiratory tract infections (VA-HARTI) are poorly understood. Our objectives were to report the incidence, hospital length of stay (LOS), ICU LOS, and mortality in NVA-HARTI patients and compare these characteristics to VA-HARTI in neurocritical care patients. This cohort study was conducted in a neurosurgical ICU in Moscow. From 2011 to 2020, all patients with an ICU LOS > 48 h were included. A competing risk model was used for survival and risk analysis. A total of 3,937 ICU admissions were analyzed. NVA-HARTI vs VA-HARTI results were as follows: cumulative incidence 7.2 (95%CI: 6.4-8.0) vs 15.4 (95%CI: 14.2-16.5) per 100 ICU admissions; incidence rate 4.2 ± 2.0 vs 9.5 ± 3.0 per 1000 patient-days in the ICU; median LOS 32 [Q1Q3: 21, 48.5] vs 46 [Q1Q3: 28, 76.5] days; median ICU LOS 15 [Q1Q3: 10, 28.75] vs 26 [Q1Q3: 17, 43] days; mortality 12.3% (95%CI: 7.9-16.8) vs 16.7% (95%CI: 13.6-19.7). The incidence of VA-HARTI decreased over ten years while NVA-HARTI incidence did not change. VA-HARTI was an independent risk factor of death, OR 1.54 (1.11-2.14), while NVA-HARTI was not. Our findings suggest that NVA-HARTI in neurocritical care patients represents a significant healthcare burden with relatively high incidence and associated poor outcomes. Unlike VA-HARTI, the incidence of NVA-HARTI remained constant despite preventive measures. This suggests that extrapolating VA-HARTI research findings to NVA-HARTI should be avoided.

Role of anti-HBs in functional cure of HBeAg+ chronic hepatitis B patients infected with HBV genotype A

BACKGROUND & AIMS

HBsAg-specific antibody responses are difficult to detect during chronic hepatitis B infection (CHB) and are often overlooked. The aim of this study was to examine whether anti-HBs may be involved in functional cure (FC) by profiling anti-HBs responses in patients with CHB using a panel of specific assays.

METHODS

Longitudinal serum samples were obtained from 25 patients with CHB who were infected with HBV genotype A and were undergoing nucleos(t)ide analogue (NA) treatment: 14 achieved FC while 11 remained infected (non-FC). Anti-HBs immune complexes (HBsAg-IC), FcγRIIIa dimer binding, epitope specificity and neutralisation efficacy were measured.

RESULTS

HBsAg-IC peaks were detected prior to HBsAg loss in 10/14 FC patients. These HBsAg-IC peaks overlapped with either an alanine aminotransferase (ALT) flare (8/10 patients), or a rise in ALT (2/10 patients). HBsAg-IC peaks were detected in 7/11 non-FC patients, but were not associated with an ALT flare. FCγRIIIa binding was detected in 9/14 FC patients, independent from detection of overlapping HBsAg-IC/ALT peaks. FC patients had stable HBsAg epitope occupancy across the study, whereas non-FC patients had a reduction in HBsAg epitope occupancy within the first 12-24 weeks of NA treatment. Convalescent sera from FC patients recognised more HBsAg epitopes and neutralised HBV infection more potently than anti-HBs derived from vaccinees. Neutralisation potency appeared to increase post-HBsAg loss in 4/5 FC patients examined.

CONCLUSIONS

Using these assays, we confirm that anti-HBs responses are present and fluctuate over time in this cohort of patients with HBeAg+ CHB, who were infected with HBV genotype A and treated with NAs. Key anti-HBs profiles associated with either FC or failure to achieve FC were also identified, suggesting a role for anti-HBs responses in FC.

LAY SUMMARY

Using a panel of assays to characterise hepatitis B surface antibody (anti-HBs) responses in a group of patients with chronic hepatitis B, we identified anti-HBs profiles associated with either functional cure, or failure to achieve functional cure. Functional cure was associated with immune complex peaks which overlapped with alanine aminotransferase flares. Conversely, in those who did not achieve functional cure, immune complex peaks were present, but were not associated with alanine aminotransferase flares, and a decline in anti-HBs diversity was observed early during treatment.

Flexor Tenosynovitis Caused by Mycobacterium heraklionense

Mycobacterium heraklionense is a rare etiology of serious hand infection with only 2 cases having been reported in literature to date to our knowledge. We describe the case of a 58-year-old woman with persistent swelling and stiffness in her right index finger. Advanced imaging studies in addition to serial surgical debridement with tissue cultures helped to confirm the diagnosis of flexor tenosynovitis caused by M. heraklionense. In this case report, we highlight the clinical evaluation, operative treatment, and antimicrobial therapy leading to the successful care of this disease presentation. Due to its rarity and potential to cause substantial hand infection, M. heraklionense should be included in the differential diagnosis as the cause for chronic flexor tenosynovitis to appropriately minimize morbidity.

Hepatocellular carcinoma surveillance and quantile regression for determinants of underutilisation in at-risk Australian patients

BACKGROUND

While clinical guidelines recommend hepatocellular carcinoma (HCC) surveillance for at-risk individuals, reported surveillance rates in the United States and Europe remain disappointingly low.

AIM

To quantify HCC surveillance in an Australian cohort, and assess for factors associated with surveillance underutilisation.

METHODS

All patients undergoing HCC surveillance liver ultrasounds between January 1, 2018 to June 30, 2018 at a tertiary hospital in Melbourne, Australia, were followed until July 31, 2020, or when surveillance was no longer required. The primary outcome was the percentage of time up-to-date with HCC surveillance (PTUDS). Quantile regression was performed to determine the impact of factors associated with HCC surveillance underutilisation.

RESULTS

Among 775 at-risk patients followed up for a median of 27.5 months, the median PTUDS was 84.2% (IQR: 66.3%-96.3%). 85.0% of patients were followed up by specialist gastroenterologists. Amongst those receiving specialist care, quantile regression demonstrated differential associations at various quantile levels of PTUDS for several factors. Older age at the 25^th quantile (estimate 0.002 per percent, P = 0.03), and cirrhotic status at the 75^th quantile (estimate 0.021, P = 0.017), were significantly associated with greater percentage of time up-to-date. African ethnicity (estimate -0.089, P = 0.048) and a culturally and linguistically diverse (CALD) background (estimate -0.063, P = 0.01) were significantly associated with lower PTUDS at the 50^th quantile, and again for CALD at the 75^th quantile (estimate -0.026, P = 0.045).

CONCLUSION

While median PTUDS in this Australian cohort study was 84.2%, awareness of the impact of specific factors across PTUDS quantiles can aid targeted interventions towards improved HCC surveillance.

Spectroscopy of the frustrated quantum antiferromagnet Cs2CuCl4

We investigate the electronic structure of Cs₂CuCl₄, a material discussed in the framework of a frustrated quantum antiferromagnet, by means of resonant inelastic x-ray scattering (RIXS) and density functional theory (DFT). From the non-dispersive highly localizedddexcitations, we resolve the crystal field splitting of the Cu²⁺ions in a strongly distorted tetrahedral coordination. This allows us to model the RIXS spectrum within the crystal field theory (CFT), assign theddorbital excitations and retrieve experimentally the values of the crystal field splitting parametersD_q,D_sandD_τ. The electronic structure obtainedab-initioagrees with the RIXS spectrum and modelled by CFT, highlighting the potential of combined spectroscopic, cluster and DFT calculations to determine the electronic ground state of complex materials.

Assessing trace-elements as indicators of marine finfish aquaculture across three distinct Canadian coastal regions

Several trace-elements have been identified as indicators of finfish aquaculture organic enrichment. In this study, sediment sampling at finfish farms was completed as part of an Aquaculture Monitoring Program in three distinct Canadian regions. Despite diverse datasets, multivariate analyses show a consistent clustering of known direct (Cu and Zn) and indirect (Cd, Mo and U) tracers of aquaculture activities with sediment organic matter (OM) and/or total dissolved sulfides concentrations. OM content was also a predictor of Cu, Zn, Mo and U concentrations according to decision tree analyses. Distance from cages did not emerge as a strong driver of differences among sampling points; however, a tendency towards negative associations is clear especially for Zn. Enriched stations as determined after geochemical normalization were mostly localized within 150 m of net-pens. Selected trace-elements (in particular Zn) can be useful indicators of aquaculture organic enrichment in different ecosystems and valuable tools for monitoring programs.

A review of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap for wound coverage during ray amputations of the toes

INTRODUCTION

Exposure of the adjacent Metatarsal-Phalangeal Joint (MTPJ) commonly occurs after application of Topical Negative Pressure Wound Therapy (TNPWT) for a ray amputation wound. This is due to mechanical soft tissue erosion or trauma to the adjacent digital artery from direct pressure effect. This results in toe gangrene requiring a ray amputation and ultimately a larger wound bed. We describe the use of the Turned-down Onto Pericapsular-tissue Hemisectioned Amputated Toe (TOPHAT) flap - a filleted toe flap to protect the adjacent MTPJ capsule combined with a novel Negative Pressure Wound Therapy with instillation and dwell-time (NPWTi-d) dressing technique. The flap protects the adjacent joint capsule and reduces the wound burden whilst allowing the wound to benefit from TNPWT, thereby accelerating wound healing.

MATERIAL AND METHODS

A retrospective review was conducted of patients with toe gangrene requiring ray amputation that underwent the TOPHAT flap on in our institution from 2019 and 2020. Complications such as wound dehiscence, hematoma, flap necrosis and secondary infection were recorded. Other outcomes recorded were time taken to final skin grafting and time taken for complete wound epithelialization.

RESULTS

9 patients underwent treatment with the TOPHAT flap. 2 patients had flap necrosis. 7 patients progressed to definitive skin coverage with skin grafting. One patient subsequently had progressive arterial disease despite successful skin grafting and required above knee amputation. The mean time to final skin grafting and complete wound epithelialization was 49.5 days and 107.5 days respectively. All patients were satisfied with the outcomes and were able to return to their pre-morbid function.

CONCLUSIONS

The TOPHAT flap has a consistent vascular supply that provides durable soft tissue coverage. It is a robust and easily reproducible technique to accelerate wound healing after ray amputations even in patients with peripheral vascular disease.

POS1256 SINGLE DOSE TOCILIZUMAB PHARMACOKINETICS IN GLUCOCORTICOID PRE-TREATED COVID-19 PATIENTS DURING CYTOKINE STORM SYNDROME HYPERINFLAMMATORY EPISODE: LESS IS MORE

Background:

The cytokine storm syndrome (CSS) associated with COVID-19 pneumonia occurs in up to 20% of the admitted patients causing high morbidity and mortality [1]. In the COVID High-intensity Immunosuppression in Cytokine storm syndrome (CHIC) study [1] we reported that CSS patients, who despite high-dose methylprednisolone (MP) treatment still showed severe respiratory deterioration, received subsequent single dose tocilizumab (TCZ) treatment. Our clinical experience with TCZ, every 4 weeks in RA, where a pre-dose serum concentration of > 1 µg/ml is sufficient to block all interleukin (IL)-6 receptors and thereby induce and maintain clinical remission, prompted further investigation of TCZ pharmacokinetics in patients with COVID-19 CSS [1,2].

Objectives:

In this pharmacokinetic study we investigated the clinical-pharmacokinetic rationale for a single TCZ dose in a subset of COVID19 induced CSS patients.

Methods:

Patients with COVID-19-associated CSS, defined as rapid respiratory deterioration plus at least two biomarker elevations (C-reactive protein (CRP) >100 mg/L; ferritin >900 μg/L; D-dimers >1500 μg/L), received per protocol high-dose intravenous MP for 5 consecutive days. If the respiratory condition had not improved sufficiently, TCZ (8 mg/kg, max. 800 mg) single infusion was added on or after day 2[1]. TCZ serum samples were drawn at TCZ day 1, 3 and 10 to assess TCZ serum concentrations with a validated ELISA-method. A nonlinear-mixed effects model was developed based on all concentration time data to characterise TCZ pharmacokinetics (NONMEM). Subsequently individual pharmacokinetic parameters (AUC0-inf, Cmax, time above 1 µg/ml) were estimated and TCZ concentration-time observations were plotted against the individual predicted concentrations to visualize the complete TCZ concentration-time curve.

Results:

In total, 34 patients with COVID19 induced CSS still showing clinical deterioration upon MP treatment received TCZ per protocol [mean (SD) age: 62 (12) years, 22% female, baseline mean (SD) bodyweight: 87 (17) kg, CRP: 108 (833) mmol/L, ferritin: 1653 (911) µg/L, D-dimers 4462 (7272) µg/L]. TCZ clearance was described by a homogeneous population-kinetics model yielding 87 serum samples. TCZ serum concentrations followed a biphasic course [Distribution volume 5.0 L (3.3-7.3), Area Under the Curve0-∞1st dose (682 (397-913) mg/L*days), Cmax 137 mg/L (88 – 199), half-life (linear) 3.5 days (2.3-4.1)]. In all patients, TCZ serum concentrations remained above the theoretical maximum IL-6 receptor occupancy concentration of 1 µg/ml for at least 12 days, depicted in Figure 1.

Figure 1.

Predicted concentration-time profiles after single dose tocilizumab in 34 methylpred-nisolone pretreated patients with COVID-19 induced cytokine storm syndrome. Dashed line: maximum IL-6 receptor occupancy concentration 1 µg/ml

Conclusion:

Based on our study results on the pharmacokinetics of TCZ in patients with severe COVID-19 induced CSS we conclude that the clearance of TCZ is faster compared to RA-patients at steady state. However, our observations indicate that a single dose of tocilizumab in CSS-patients is enough to cover IL-6 mediated hyperinflammation. Restricting TCZ to a single dosage can prevent overtreatment, drug shortage and saves costs, while still maintaining efficacy, as most patients will have overcome their hyperinflammatory period of the CSS after 10-14 days.

References:

[1]Ramiro S. Mostard R.L.M. et al. Historically controlled comparison of glucocorticoids with or without tocilizumab versus supportive care only in patients with COVID-19-associated cytokine storm syndrome: results of the CHIC study. Ann Rheum Dis 2020;79(9):1143-1151.

[2]Nishimoto N, Terao K et al. Mechanisms and pathologic significances in increase in serum interleukin-6 (IL-6) and soluble IL-6 receptor after administration of an anti IL-6 receptor antibody, tocilizumab, in patients with rheumatoid arthritis and Castleman disease. Blood. 2008;112:3959-3964.

Acknowledgements:

The authors are grateful to all patients, nurses and physicians who participated in this study.

Disclosure of Interests:

None declared

All That Coughs Is Not COVID-19: A Delayed Diagnosis of Disseminated Coccidioidomycosis Following Severe Acute Respiratory Syndrome Coronavirus 2 Infection

Coccidioides immitis (and Coccidioides posadasii) are endemic fungi of the southwestern United States and northern Mexico. Uncomplicated, symptomatic Coccidioides infection most commonly causes a self-limited pneumonia; however, immunocompromised patients can manifest severe pneumonia with an additional risk of dissemination to bone, joints, soft tissues, and in the most severe cases, the central nervous system. In 2020, clinicians were challenged with a previously unseen volume of acute respiratory complaints as a result of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. We present a patient with respiratory failure secondary to SARS-CoV-2 who experienced prolonged hypoxia and neurologic deterioration, eventually leading to a diagnosis of occult disseminated coccidiomycosis involving meningitis, miliary-pattern pneumonia, and cutaneous lesions.

Bortezomib for treatment-refractory autoimmune haemolytic anaemia following multivisceral transplantation

A 25-year-old man who received alemtuzumab as induction therapy for a multivisceral transplant experienced delayed onset of warm autoimmune haemolytic anaemia and neutropaenia. Serological testing and bone marrow biopsy excluded alternative causes. Haemolysis was refractory to standard therapies including corticosteroids, intravenous immunoglobulin and rituximab. The patient was successfully treated with bortezomib, a proteasome inhibitor, and has remained well as an outpatient without evidence of ongoing haemolysis.

Analysis of Hepatitis B Virus Haplotype Diversity Detects Striking Sequence Conservation Across Genotypes and Chronic Disease Phase

BACKGROUND AND AIMS

We conducted haplotype analysis of complete hepatitis B virus (HBV) genomes following deep sequencing from 368 patients across multiple phases of chronic hepatitis B (CHB) infection from four major genotypes (A-D), analyzing 4,110 haplotypes to identify viral variants associated with treatment outcome and disease progression.

APPROACH AND RESULTS

Between 18.2% and 41.8% of nucleotides and between 5.9% and 34.3% of amino acids were 100% conserved in all genotypes and phases examined, depending on the region analyzed. Hepatitis B e antigen (HBeAg) loss by week 192 was associated with different haplotype populations at baseline. Haplotype populations differed across the HBV genome and CHB history, this being most pronounced in the precore/core gene. Mean number of haplotypes (frequency) per patient was higher in immune-active, HBeAg-positive chronic hepatitis phase 2 (11.8) and HBeAg-negative chronic hepatitis phase 4 (16.2) compared to subjects in the "immune-tolerant," HBeAg-positive chronic infection phase 1 (4.3, P< 0.0001). Haplotype frequency was lowest in genotype B (6.2, P< 0.0001) compared to the other genotypes (A = 11.8, C = 11.8, D = 13.6). Haplotype genetic diversity increased over the course of CHB history, being lowest in phase 1, increasing in phase 2, and highest in phase 4 in all genotypes except genotype C. HBeAg loss by week 192 of tenofovir therapy was associated with different haplotype populations at baseline.

CONCLUSIONS

Despite a degree of HBV haplotype diversity and heterogeneity across the phases of CHB natural history, highly conserved sequences in key genes and regulatory regions were identified in multiple HBV genotypes that should be further investigated as targets for antiviral therapies and predictors of treatment response.

Using item response theory (IRT) to improve the efficiency of the Simple Clinical Colitis Activity Index (SCCAI) for patients with ulcerative colitis

BACKGROUND

The SCCAI was designed to facilitate assessment of disease activity in ulcerative colitis (UC). We aimed to interrogate the metric properties of individual items of the SCCAI using item response theory (IRT) analysis, to simplify and improve its performance.

METHODS

The original 9-item SCCAI was collected through TrueColours, a real-time software platform which allows remote entry and monitoring of patients with UC. Data were securely uploaded onto Dementias Platform UK Data Portal, where they were analysed in Stata 16.1 SE. A 2-parameter (2-PL) logistic IRT model was estimated to evaluate each item of the SCCAI for its informativeness (discrimination). A revised scale was generated and re-assessed following systematic removal of items.

RESULTS

SCCAI data for 516 UC patients (41 years, SD = 15) treated in Oxford were examined. After initial item deletion (Erythema nodosum, Pyoderma gangrenosum), a 7-item scale was estimated. Discrimination values (information) ranged from 0.41 to 2.52 indicating selected item inefficiency with three items < 1.70 which is a suggested discriminatory value for optimal efficiency. Systematic item deletions found that a 4-item scale (bowel frequency day; bowel frequency nocturnal; urgency to defaecation; rectal bleeding) was more informative and discriminatory of trait severity (discrimination values of 1.50 to 2.78). The 4-item scale possesses higher scalability and unidimensionality, suggesting that the responses to items are either direct endorsement (patient selection by symptom) or non-endorsement of the trait (disease activity).

CONCLUSION

Reduction of the SCCAI from the original 9-item scale to a 4-item scale provides optimum trait information that will minimise response burden. This new 4-item scale needs validation against other measures of disease activity such as faecal calprotectin, endoscopy and histopathology.

A228 WHEN ASCITES & VARICEAL BLEEDING ARE NOT FROM CIRRHOSIS: A CASE OF MUTIPLE ARTERIOPORTAL FISTULAE CAUSING PORTAL HYPERTENSION

Background

Portal hypertension is usually due to increased resistance from cirrhosis. However, pressures can also be elevated due to increased flow.

Aims

To describe a peculiar case of non-cirrhotic portal hypertension.

Methods

A case report and literature review was performed.

Results

A 47-year-old previously well man presented with a 6 month history of rapidly progressive weight loss, ascites and variceal bleed. Workup ruled out common causes of primary liver disease. Initial imaging demonstrated a heterogenous liver, splenomegaly, ascites, patent hepatic/portal veins and multiple poorly defined low-density hepatic lesions with the largest measuring 2.1 cm. Transient elastography was 7.3 kPa (F1-mild fibrosis). At transjugular liver biopsy, hepatic venogram ruled out Budd-Chiari and hepatic vein pressure gradient was normal at 3–4 mmHg. Histology unfortunately showed hemangioma. A percutaneous liver biopsy suggested nodular regenerative hyperplasia, minimal fibrosis and mild cholestasis. Given worsening ascites, hyponatremia and 7 months of rapidly progressive decline, transjugular intrahepatic portosystemic shunt (TIPSS) was inserted. Intra-procedure, portal vein pressure was noted to be 51 mmHg, with a portosystemic gradient of 42 mmHg. Although numerous abdominal CT and MRI did not show AV shunting, ultrasound post-TIPSS showed hepatic pseudoaneurysms & arterioportal fistulae (APF). Direct angiogram showed numerous hepatic pseudoaneurysms and intrahepatic fistulae making embolization impossible. CT showed no evidence of pseudoaneurysms or fistulae outside of the liver. Workup for autoimmune rheumatological diseases and congenital telangiectatic syndromes were negative. Given the high pressures being directed through the new TIPSS, right heart failure is an ongoing concern.

APF are rarely encountered causes of presinusoidal portal hypertension, with communications most commonly arising from the hepatic (65%) & splenic arteries (11%) & the portal vein. Causes include traumatic (28%), iatrogenic (16%), vascular/telangiectatic malformations (15%), tumors (15%), aneurysms (14%) & congenital disease. Endovascular embolization can be used to treat single lesions. In complex cases with mulitple APF, surgery and/or liver transplantation may be required.

Conclusions

We report a rare case of non-cirrhotic portal hypertension due to increased flow rather than increased resistance secondary to APF.

Funding Agencies

None