Benchmarking the CoW with the TopCoW Challenge: Topology-Aware Anatomical Segmentation of the Circle of Willis for CTA and MRA

The Circle of Willis (CoW) is an important network of arteries connecting major circulations of the brain. Its vascular architecture is believed to affect the risk, severity, and clinical outcome of serious neuro-vascular diseases. However, characterizing the highly variable CoW anatomy is still a manual and time-consuming expert task. The CoW is usually imaged by two angiographic imaging modalities, magnetic resonance angiography (MRA) and computed tomography angiography (CTA), but there exist limited public datasets with annotations on CoW anatomy, especially for CTA. Therefore we organized the TopCoW Challenge in 2023 with the release of an annotated CoW dataset. The TopCoW dataset was the first public dataset with voxel-level annotations for thirteen possible CoW vessel components, enabled by virtual-reality (VR) technology. It was also the first large dataset with paired MRA and CTA from the same patients. TopCoW challenge formalized the CoW characterization problem as a multiclass anatomical segmentation task with an emphasis on topological metrics. We invited submissions worldwide for the CoW segmentation task, which attracted over 140 registered participants from four continents. The top performing teams managed to segment many CoW components to Dice scores around 90%, but with lower scores for communicating arteries and rare variants. There were also topological mistakes for predictions with high Dice scores. Additional topological analysis revealed further areas for improvement in detecting certain CoW components and matching CoW variant topology accurately. TopCoW represented a first attempt at benchmarking the CoW anatomical segmentation task for MRA and CTA, both morphologically and topologically.

Patient-Specific Deep Learning Model for Clinical Target Volume Delineation on Daily CBCT of Breast Cancer Patients based on Intentional Deep Overfit Learning (IDOL) Framework

PURPOSE/OBJECTIVE(S)

Increasingly complex target volumes and the use of modern irradiation techniques emphasize the importance of daily image guidance more than ever. Significant progress has been made in adjuvant breast cancer radiotherapy (RT) and the need for optimized image guidance is growing. Furthermore, the position of the breast during RT after breast-conserving surgery is highly variable than expected. In this context, cone beam computed tomography (CBCT) is a very effective tool enabling prompt and accurate adaptive radiation therapy (ART). In this study, we aim to develop a deep learning (DL)-based algorithm to segment clinical target volume (CTV) from daily CBCT scans. Also, we validate the optimization of further learning when applying the Intentional Deep Overfit Learning (IDOL) framework.

MATERIALS/METHODS

A total of 240 different CBCT scans obtained from 100 breast cancer patients were used for this study. CTV was defined as whole breast plus margin in all patients. The workflow consists of two training stages: (1) training a novel 'generalized' DL model (Swin_UNETR) to identify and delineate breast CTV on CBCT scans using 90 breast cancer patient cases (2) applying an 'intentional overfitting' to the 'generalized' DL model to generate a 'patient-specific' model using the remaining 10 breast cancer patients. In this study, for the intentionally overfitting stage, we additionally trained with CBCT scans from the patient's 1st fraction to the 14th fractions cases. The results of the proposed method were compared quantitatively with the expert's contours on 1st-15th fractions CBCT scans using Dice Similarity Coefficient (DSC).

RESULTS

The average DSC between the 'generalized' DL model-based breast CTV contours and reference contours for the patient's 15th fraction was 0.9672. When implementing the IDOL framework with the CBCT scan obtained during the patient's 1st treatment, the average DSC was improved to 0.9809. When additional CBCT scans taken during each of the 1st to 6th fractions were used for training, the average DSC could be most effectively raised to 0.9835. The p-value comparison between the 'generalized' DL model and the 1st fraction was found to be 3.62E-04, while the comparison with the 6th fractions resulted in a p-value of 8.36E-05. The average time required for IDOL training using one CBCT scan and six CBCT scans was 107 seconds and 127 seconds, respectively.

CONCLUSION

In this study, we developed a patient-specific DL-based training algorithm to segment CTV in CBCT scans for breast cancer patients. The performance improvement was relatively significant and was confirmed that using continual DL with additional CBCT scans, which are taken every day, can be more accurate and efficient than drawing breast CTV using a general model. Our novel patient-specific model can be effectively applied to various ARTs by not only reducing labor and time but also increasing accuracy.

National trends in suicide-related behaviors among youths between 2005-2020, including COVID-19: a Korean representative survey of one million adolescents

OBJECTIVE

It is difficult to conclude that COVID-19 is associated with a decrease in the suicide attempts rate by comparing only a short-term period. Therefore, it is necessary to examine attempted suicide rates through a trend analysis over a longer period. This study aimed to investigate an estimated long-term trend regarding the prevalence of suicide-related behaviors among adolescents in South Korea from 2005 to 2020, including COVID-19.

SUBJECTS AND METHODS

We sourced data from a national representative survey (Korea Youth Risk Behavior Survey) and analyzed one million Korean adolescents aged 13 to 18 years (n=1,057,885) from 2005 to 2020. The 16-year trends regarding the prevalence of sadness or despair and suicidal ideation and attempt and the trend changes before and during COVID-19.

RESULTS

Data of 1,057,885 Korean adolescents was analyzed (weighted mean age, 15.03 years; males, 52.5%; females, 47.5%). Although the 16-year trend in the prevalence of sadness or despair and suicide ideation and attempt consistently decreased (prevalence of sadness or despair between 2005-2008, 38.0% with 95% confidence interval [CI], 37.7 to 38.4 vs. prevalence in 2020, 25.0% [24.5 to 25.6]; suicide ideation between 2005-2008, 21.9% [21.6 to 22.1] vs. prevalence in 2020, 10.7% [10.3 to 11.1]; and suicide attempt between 2005-2008, 5.0% [4.9 to 5.2] vs. prevalence in 2020, 1.9% [1.8 to 2.0]), the downward slope decreased during COVID-19 (βdiff in sadness, 0.215 with 95% CI 0.206 to 0.224; βdiff in suicidal ideation, 0.245 [0.234 to 0.256]; and βdiff in suicide attempt, 0.219 [0.201 to 0.237]) compared with pre-pandemic period.

CONCLUSIONS

This study found that the observed risk of suicide-related behaviors during the pandemic was higher than expected through long-term trend analysis of the prevalence of sadness/despair and suicidal ideation and attempts among South Korean adolescents. We need a profound epidemiologic study of the change in mental health due to the pandemic's impact and the establishment of prevention strategies for suicide ideation and attempt.

Cerebral venous thrombosis after ChAdOx1 nCoV-19 vaccination: a systematic review

OBJECTIVE

To perform a systematic review of case reports or case series regarding thrombosis with thrombocytopenia syndrome (TTS) and cerebral venous thrombosis (CVT) related to ChAdOx1 nCoV-19 vaccination to address the clinical features, laboratory findings, treatment modalities, and prognosis related with CVT.

SUBJECTS AND METHODS

We included 64 TTS patients from 19 articles, 6 case series and 13 case reports, in which thrombosis occurred after the first dose of ChAdOx1 nCoV-19 vaccination published up to 30 June 2021 in Embase, ePubs, Medline/PubMed, Scopus, and Web of Science databases.

RESULTS

Of the 64 TTS patients, 38 (59.3%) had CVT. Patients with CVT were younger (median 36.5 vs. 52.5 years, p<0.001), had lower fibrinogen levels (130 vs. 245 mg/dL, p=0.008), had more frequent history of intracerebral hemorrhage (ICH), and had higher mortality rate (48.6% vs. 19.2%, p=0.020) than that of patients without CVT. In multivariable analysis, the possibility of presence of CVT was higher in younger age groups [odd ratio (OR): 0.91, 95% confidence interval (CI): (0.86-0.97, p<0.001)] and those with accompanying intracerebral hemorrhage (ICH) (OR: 13.60, 95% CI (1.28-144.12, p=0.045).

CONCLUSIONS

Our study demonstrated that CVT related to ChAdOx1 nCoV-19 vaccination was associated with younger age, low levels of fibrinogen, presence of ICH and more frequent mortality compared to those of non-CVT. If TTS occurs after ChAdOx1 nCoV-19 vaccination, the presence of CVT in patients with young age or ICH should be considered.

The global burden of sudden infant death syndrome from 1990 to 2019: a systematic analysis from the Global Burden of Disease study 2019

BACKGROUND

Sudden infant death syndrome (SIDS) still remains one of the leading causes of infant death worldwide, especially in high-income countries. To date, however, there is no detailed information on the global health burden of SIDS.

AIMS

To characterize the global disease burden of SIDS and its trends from 1990 to 2019 and to compare the burden of SIDS according to the socio-demographic index (SDI).

DESIGN

Systematic analysis based on the Global Burden of Disease (GBD) 2019 data.

METHODS

Epidemiological data of 204 countries from 1990 to 2019 were collected via various methods including civil registration and vital statistics in the original GBD study. Estimates for mortality and disease burden of SIDS were modeled. Crude mortality and mortality rates per 100 000 population were analyzed. Disability-adjusted life years (DALYs) and DALY rates were also assessed.

RESULTS

In 2019, mortality rate of SIDS accounted for 20.98 [95% Uncertainty Interval, 9.15-46.16] globally, which was a 51% decrease from 1990. SIDS was most prevalent in Western sub-Saharan Africa, High-income North America and Oceania in 2019. The burden of SIDS was higher in males than females consistently from 1990 to 2019. Higher SDI and income level was associated with lower burden of SIDS; furthermore, countries with higher SDI and income had greater decreases in SIDS burden from 1990 to 2019.

CONCLUSIONS

The burden of SIDS has decreased drastically from 1990 to 2019. However, the improvements have occurred disproportionately between regions and SDI levels. Focused preventive efforts in under-resourced populations are needed.

Trends in body mass index changes among Korean adolescents between 2005-2020, including the COVID-19 pandemic period: a national representative survey of one million adolescents

OBJECTIVE

The impact of the coronavirus disease 2019 (COVID-19) pandemic on weight gain in children and adolescents remains unknown. We aimed to identify an estimated 15-year trend in mean body mass index (BMI) changes and prevalence of obesity and overweight among Korean adolescents from 2005 to 2020, including the period of the COVID-19 pandemic.

PATIENTS AND METHODS

We analyzed data taken from a nationwide survey (Korea Youth Risk Behavior Survey), between 2005 and 2020. Representative samples of one million Korean adolescents aged 13-18 years (n=1,057,885) were examined. The 15-year trends in mean BMI and proportion of obesity or overweight, and the changes due to the COVID-19 pandemic were analyzed.

RESULTS

The data of 1,057,885 Korean adolescents were analyzed (mean age: 14.98 years; females, 48.4%). The estimated weighted mean BMI was 20.5 kg/m2 [95% confidence interval (CI), 20.4-20.5] from 2005 to 2008 and 21.5 kg/m2 (95% CI, 21.4-21.6) in 2020 (during the COVID-19 pandemic). Although the 15-year trend of mean BMI gradually increased, the change in mean BMI before and during the pandemic significantly lessened (βdiff, -0.027; 95% CI, -0.028 to -0.026). The 15-year (2005-2020) trend changes in the prevalence of obesity and overweight were similar (obesity prevalence from 2005-2008, 3.2%; 95% CI, 3.1-3.3 vs. obesity prevalence in 2020, 8.6%; 95% CI, 8.2-9.0; βdiff, -0.309; 95% CI, -0.330 to -0.288).

CONCLUSIONS

The 15-year trend of overall mean BMI and obesity and overweight prevalence demonstrated a significant increase; however, its slope decreased during the pandemic. These landmark results suggest the need for the development of precise strategies to prevent pediatric obesity and overweight during the COVID-19 pandemic.

COVID-19 susceptibility and clinical outcomes in autoimmune inflammatory rheumatic diseases (AIRDs): a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to assess the susceptibility to and clinical outcomes of COVID-19 in autoimmune inflammatory rheumatic disease (AIRD) and following AIRD drug use.

MATERIALS AND METHODS

We included observational and case-controlled studies assessing susceptibility and clinical outcomes of COVID-19 in patients with AIRD as well as the clinical outcomes of COVID-19 with or without use of steroids and conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

RESULTS

Meta-analysis including three studies showed that patients with AIRD are not more susceptible to COVID-19 compared to patients without AIRD or the general population (OR: 1.11, 95% CI: 0.58 to 2.14). Incidence of severe outcomes of COVID-19 (OR: 1.34, 95% CI: 0.76 to 2.35) and COVID-19 related death (OR: 1.21, 95% CI: 0.68 to 2.16) also did not show significant difference. The clinical outcomes of COVID-19 among AIRD patients with and without csDMARD or steroid showed that both use of steroid (OR: 1.69, 95% CI: 0.96 to 2.98) or csDMARD (OR: 1.35, 95% CI: 0.63 to 3.08) had no effect on clinical outcomes of COVID-19.

CONCLUSIONS

AIRD does not increase susceptibility to COVID-19, not affecting the clinical outcome of COVID-19. Similarly, the use of steroids or csDMARDs for AIRD does not worsen the clinical outcome.

Suicide associated with COVID-19 infection: an immunological point of view

OBJECTIVE

Coronavirus disease 2019 (COVID-19) is a pandemic and leading cause of death. Beyond the deaths directly caused by the virus and the suicides related to the psychological response to the dramatic changes as socioeconomic related to the pandemic, there might also be suicides related to the inflammatory responses of the infection. Infection induces inflammation as a cytokine storm, and there is an increasing number of studies that report a relationship between infection and suicide.

MATERIALS AND METHODS

We searched the World Health Organization status report and the PubMed database for keywords (COVID-19, suicide, infection, inflammation, cytokines), and reviewed five cytokine pathways between suicide and inflammation using two meta-analyses and two observational studies starting from November 31, 2020, focusing on the relationship between suicide and inflammation by infection. First, we discussed existing evidence explaining the relationship between suicidal behaviors and inflammation. Second, we summarized the inflammatory features found in COVID-19 patients. Finally, we highlight the potential for these factors to affect the risk of suicide in COVID-19 patients.

RESULTS

Patients infected with COVID-19 have high amounts of IL-1β, IFN-γ, IP10, and MCP1, which may lead to Th1 cell response activation. Also, Th2 cytokines (e.g., IL-4 and IL-10) were increased in COVID-19 infection. In COVID-19 patients, neurological conditions, like headache, dizziness, ataxia, seizures, and others have been observed.

CONCLUSIONS

COVID-19 pandemic can serve as a significant environmental factor contributing directly to increased suicide risk; the role of inflammation by an infection should not be overlooked.

Cytologic Analysis of a Glomus Tumor in the Left Second Toe: Case Report

Introduction/Objective

Glomus bodies reside in the stratum reticularis of the dermis as well as in visceral organs. Their functions involve temperature and blood pressure regulation. The incidence of glomus tumors is approximately 1.5%, occur more frequently in women, and generally manifest during the third to fifth decade of life. A majority of glomus tumors are diagnosed by biopsy and excision. At least 19 case reports exist in the literature where glomus tumors are diagnosed by fine-needle aspiration (FNA). We add to this growing literature by discussing a case report involving the cytologic findings of an FNA-diagnosed glomus tumor.

Methods/Case Report

A 66-year-old female presented with left second toe pain for 41 years but worsening in the past several months. Physical exam revealed 5/5 muscle strength in her toes without loss of sensation. There was no edema, erythema, nor ecchymosis. Pain was notably out of proportion when palpating her second nailbed. Magnetic resonance imaging (MRI) with contrast was performed revealing a 1.1 x 1.0 x 0.9 cm circumscribed, ovoid mass involving the dorsal aspect of the second toe distal phalanx along its dorsal margin (Figure 1). The patient underwent fine needle aspiration and biopsy. Cytologic findings included clusters of uniform cells with round to oval nuclei and scant cytoplasm. There was spindling of cells noted in some of the clusters. Cells were surrounded by thick wisps of magenta colored myxoid material reminiscent of a pleomorphic adenoma (Figure 2). Biopsy showed uniform cells surrounding capillaries. Immunohistochemistry performed on the biopsy showed that lesional cells were positive for alpha-smooth muscle actin (SMA). A diagnosis of glomus tumor was made. Amputation was performed with clear margins.

Results (if a Case Study enter NA)

NA

Conclusion

Glomus tumor is a rare tumor that is usually diagnosed on biopsy; however, it has distinct cytologic features that can aid in its diagnosis on fine needle aspirations.

Type B valvular and supravalvular pulmonic stenosis with aberrant pre-pulmonic right coronary artery diagnosed by non-electrocardiography-gated, multislice computed tomography in a Boston terrier

Pulmonic stenosis (PS) is a common congenital heart disease in dogs. It may be associated with an aberrant coronary artery (CA) in brachycephalic breeds. If present, a CA anomaly must be identified before pulmonic valvuloplasty. A 1.7-year-old Boston terrier was referred for a grade V/VI systolic heart murmur and exercise intolerance. Echocardiography revealed combined type B valvular and supravalvular PS; an aberrant CA was also suspected. Non-electrocardiography (ECG)-gated, 160-multislice computed tomographic angiography (CTA) confirmed severe right ventricular wall hypertrophy, a hypoplastic pulmonic valve annulus, and severe supravalvular PS with a marked main pulmonary artery bulge; a single left coronary ostium with an anomalous pre-pulmonic right CA was also identified. Surgical correction with pulmonic valvuloplasty and pulmonary artery patch angioplasty under cardiopulmonary bypass was planned. The patient died intraoperatively due to profound hypotension after weaning from extracorporeal circulation. However, this is the first case report in which type B valvular and supravalvular PS with an aberrant pre-pulmonic right CA was diagnosed by non-ECG-gated, 160-multislice CTA in a Boston terrier, showing a similar level of image quality to ECG-gated CTA. Thus, in PS cases, high-slice CTA may be helpful to determine if CA anomalies are present and to establish a therapeutic plan.

Case study of hypertriglyceridemia from COVID-19 Pfizer-BioNTech vaccination in a patient with familial hypercholesteremia

The Pfizer-BioNTech coronavirus disease 2019 (COVID-19) vaccine is the first novel nucleoside-modified messenger ribonucleic acid (modRNA) vaccine to receive Emergency Use Authorization from the Food and Drug Administration in the United States. It is indicated to be used in patients ≥12 years-of-age as of May 25th, 2021, including populations with high atherosclerotic cardiovascular disease (ASCVD) burden. However, little is known about the potential impact this vaccine may have on serum lipoprotein levels in patients with familial hypercholesteremia (FH), who are predisposed to high ASCVD burden due to elevated low-density lipoprotein cholesterol (LDL-C). We present an interesting case where a patient with heterozygous FH (HeFH) and elevated triglycerides (TG)-controlled for years on medication and apheresis-experienced significantly elevated TG, one day after receiving his second Pfizer-BioNTech COVID-19 vaccine dose. It is not known whether this adverse event may be seen in other FH patients and may be worth assessing in such patients to determine the possibility of a rare adverse reaction from a COVID-19 vaccine.

Demonstration of a GaSb/GaAs Quantum Dot Intermediate Band Solar Cell Operating at Maximum Power Point

Intermediate band solar cells (IBSCs) promise high efficiencies while maintaining a low device structural complexity. A high efficiency can be obtained by harvesting below-band-gap photons, thus increasing the current, while at the same time preserving a high voltage. Here, we provide experimental proof that below-band-gap photons can be used to produce nonzero electrical work in an IBSC without compromising the voltage. For this, we manufacture a GaSb/GaAs quantum-dot IBSC. We use light biasing and make our cell operate at the maximum power point at 9 K. We measure the photocurrent response to absorption of photons with an energy of less than 1.15 eV while the cell is operating at 1.15 V. We also show that this result implies the existence of three quasi-Fermi levels linked to the three electronic bands in our device, as demanded by the IBSC theory to preserve the output voltage of the cell.

Correlation of coronary microvascular function and diastolic dysfunction

Background

Coronary microvascular dysfunction (CMD) is an important mechanism for heart failure with preserved ejection fraction (HFpEF) which is closely related with diastolic dysfunction on transthoracic echocardiography (TTE).

Purpose

The aim of this study was to evaluate the association of CMD with echocardiographic parameters of diastolic dysfunction.

Methods

Total 385 patients with chest discomfort in the absence of significant coronary artery obstruction were enrolled to this study and underwent invasive coronary physiologic assessment including index of microcirculatory resistance (IMR), and coronary flow reserve (CFR). Echocardiographic parameters for diastolic dysfunction - left atrial volume index (LAVI) and left ventricular filling pressure (E over e') were compared in patients with true CMD (CFR&lt;2.5 with IMR ≥20), mismatched CMD (CFR≥2.5 with IMR ≥20 or CFR&lt;2.5 with IMR &lt;20), and no CMD (CFR≥2.5 with IMR &lt;20).

Results

Among the study population, 55 patients (14.3%) were true CMD, 162 patients (42.1%) were mismatched CMD and 168 patients (43.6%) were no CMD. Age (62.9±10.5 vs. 61.1±9.9 vs. 61.7±10.5, p=0.522) and left ventricular ejection fraction (63.9±8.1 vs. 63.9±6.2 vs. 63.0±6.7, p=0.414) was not different between groups. Patients with true CMD showed significantly larger left atrial size (LAVI: 34.7±18.2 mL/m2 vs. 26.8±10.7 mL/m2, p=0.005) and trend towards higher LV filling pressure (E/e': 10.8±3.5 vs. 9.9±3.5, p=0.073) compared with no CMD. In subgroup analysis, younger patients showed more pronounced increase of LAVI (Age &lt;65: 39.6±22.6 vs. 26.1±11.6, p=0.003; Age ≥65: 28.0±9.13 vs. 28.8±8.2, p=0.266; p for interaction 0.043) in true CMD compared to no CMD. Non-diabetic patients also showed more pronounced increase of E/e' in true CMD (Non-diabetes: 10.2±2.7 vs. 9.2±2.6, p=0.002; Diabetes: 12.1±4.5 vs. 11.9±5.1, p=0.197; p for interaction 0.015).

Conclusions

Coronary microvascular dysfunction is significantly related with echocardiographic parameters of diastolic dysfunction. The effect of CMD on diastolic dysfunction is more prominent in low-risk patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

A reference high-pressure CH4 adsorption isotherm for zeolite Y: results of an interlaboratory study

This paper reports the results of an international interlaboratory study led by the National Institute of Standards and Technology (NIST) on the measurement of high-pressure surface excess methane adsorption isotherms on NIST Reference Material RM 8850 (Zeolite Y), at 25 °C up to 7.5 MPa. Twenty laboratories participated in the study and contributed over one-hundred adsorption isotherms of methane on Zeolite Y. From these data, an empirical reference equation was determined, along with a 95% uncertainty interval (Uk=2). By requiring participants to replicate a high-pressure reference isotherm for carbon dioxide adsorption on NIST Reference Material RM 8852 (ZSM-5), this interlaboratory study also demonstrated the usefulness of reference isotherms in evaluating the performance of high-pressure adsorption experiments.

Different mother and daughter manifestations due to very high cholesterol-containing lipoproteins

Familial hypercholesterolemia (FH) is an autosomal codominant genetic disorder associated with defective hepatic uptake of circulating low-density lipoproteins (LDL), which can lead to premature atherosclerotic cardiovascular disease (ASCVD). Evidence suggests elevated lipoprotein(a) (Lp(a)) levels in FH patients may also increase their ASCVD risk. We present a case series of 2 FH patients where a daughter has a higher ASCVD burden than her mother due to the daughter having elevated Lp(a). This underscores the importance of including Lp(a) in cascade lipid screening in FH patients and their first-degree relatives.

FRI0516 FACTORS ASSOCIATED WITH DECREASED CERVICAL CANCER SCREENING IN WOMEN WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that carries an increased risk for both viral illnesses and malignancies, including a greater risk for both human papilloma virus (HPV) infection and cervical cancer. Due to this increased risk, the American Society of Colposcopy and Cervical Pathology guidelines for SLE patients recommend more frequent cervical cancer screening. Few studies have examined patient characteristics associated with decreased cervical cancer screening in patients with autoimmune disease, specifically SLE.

Objectives:

To estimate cervical cancer screening rates in women with recently diagnosed SLE, and to identify characteristics associated with decreased screening.

Methods:

We identified women with an initial diagnosis of SLE in the United States MarketScan Commercial Claims and Encounter (CCAE, age 18-64) administrative claims database. We included patients with at least three claims with a lupus diagnosis (first and last at least >90 days apart), no lupus claims within the year before initial claim, and who had been on antimalarial drugs for at least 90 days. We excluded all patients with a previous claim for hysterectomy.

Cervical cancer screening was ascertained using diagnosis and procedure codes within 1 year before and 2 years after the first SLE claim. Our covariates included the year of first SLE claim (2001-2014), age at first SLE claim, comorbidity score, insurance type, geographical region, and prescriptions for multiple types of corticosteroids. Control patients included age-matched females without autoimmune disease. Univariate comparison and multivariate logistic regression models were built to evaluate determinants of screening.

Results:

We included 4,316 SLE patients (median age 45) and 86,544 control patients. The screening rate in SLE patients was 73.4% vs 58.5% in the controls (P < 0.001). The screening rate was 71% in 2001, increased to 75% in 2004, then decreased to 70% in 2014 (trend P =0.005). In the multivariate model the following factors were associated with decreased cervical cancer screening: year of first SLE claim 2012-2014 versus 2001-2005 (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.53 – 0.84, P < 0.001); older age 61-64 versus 21-30 (OR 0.27, 95% CI 0.19 – 0.39, P < 0.001); comorbidity score of ≥2 versus <2 (OR 0.71, 95% CI 0.6 – 0.83, P < 0.001); and use of corticosteroids for ≥ 90 days versus <90 days (OR 0.73, 95% CI 0.59 – 0.9, P = 0.003). Insurance type and geographical region were not associated with cervical cancer screening.

Conclusion:

About three quarters of women with SLE underwent cervical cancer screening within 3 years of their first lupus claim, at higher rates than controls. However, there was a concerning downward trend in screening rates in recent years. In addition, higher risk populations for cervical cancer (older age, increased comorbidities, and longer duration of corticosteroids) had lower screening rates. These findings highlight the need to enhance education for healthcare providers to improve utilization of screening in women with SLE at high risk of cervical cancer.

Disclosure of Interests:

Sebastian Bruera: None declared, Richard Zogala: None declared, Xiudong Lei: None declared, Xerxes Pundole: None declared, Hui Zhao: None declared, Sharon Giordano: None declared, Jessica Hwang Grant/research support from: MERCK grant funding unrelated to SLE., Maria Suarez-Almazor: None declared

OP0073 RISK OF DEVELOPING RHEUMATIC DISEASES IN PATIENTS WITH PALINDROMIC RHEUMATISM IN SOUTH KOREA: A NATION-WIDE POPULATION-BASED STUDY

Background:

Palindromic rheumatism (PR) has known to be three patterns of disease course: clinical remission of attacks, persistent attacks, and evolution to chronic arthritis or systemic disease. The spectrum in progression to chronic diseases of PR, however, is quite variable; rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), systemic sclerosis (SSc), Sjögren’s syndrome (SjS), ankylosing spondylitis (AS), relapsing polychondritis (RP), Behçet’s disease (BD), sarcoidosis, and psoriatic spondylitis and arthropathy. Because of the small numbers in case-control studies and too aged investigations, now we needs to shed new light on the fate of PR.

Objectives:

The aim was to investigate the epidemiology of PR and the risk of developing various rheumatic diseases compared with non-PR individuals, employing the National Health Insurance Service (NHIS) medical claims data, which covers all medical institutions of South Korea.

Methods:

The study used 2007-2018 claims data from the Korean Health Insurance Review and Assessment Service (HIRA). The identified 19,724 PR patients from 2010 to 2016 were assessed for the incidence rate (IR) compared with the population in the given year by 100,000 person-year (py). The date of diagnosis was the index date. After matching with non-PR individuals (1:10) for age, sex and the year of index date, we calculated the hazard ratios (HRs) with 95% confidence intervals (CIs). The risk of developing the various rheumatic diseases and adult immunodeficiency syndrome (AIDS) as the outcome diseases in PR cohort was estimated. This risk was compared with that of matched non-PR cohort.

Results:

Of 19,724 PR patients (8,665 males and 11,059 females), the mean age was 50.2 ± 14.9 years (47.7 ± 14.4 years in males and 52.6 ± 14.9 years in females,p< 0.001). The ratio of male to female patients with PR was approximately 1:1.28. The annual IR of PR was 7.02 (6.92-7.12) per 100,000 py (6.22 (6.09-6.35) and 7.80 (7.66-7.95) per 100,000 py in males and females, respectively). The mean duration to develop the outcome diseases was significantly shorter in PR cohort compared that of non-PR cohort (19.4 vs. 35.8 months,p< 0.001). The most common outcome disease was RA (7.34% of PR patients; 80.0% of total outcome diseases), followed by AS, SLE, BD, SjS, MCTD, DM/PM, SSc, RP, psoriatic arthropathy, and AIDS in PR cohort. The patients with PR had an increased risk of RA (HR 46.6, 95% CI [41.1-52.7]), psoriatic arthropathy (44.79 [15.2-132.4]), SLE (24.5 [16.2-37.2]), MCTD (22.0 [7.7-63.3]), BD (21.0 [13.8-32.1]), SjS (12.4 [8.5-17.9]), AS (9.0 [6.7-12.2]), DM/PM (6.1 [2.6-14.8]), and SSc (3.8 [1.5-9.6]) but not of AIDS. The risk of developing RA was greater in male patients (HR 58.9, 95% CI [45.6-76.2] vs. 43.2 [37.4-49.8],pfor interaction = 0.037) while female patients encountered a higher risk of developing AS (15.8 [8.9-28.1] vs. 7.2 [5.0-10.3],pfor interaction = 0.023). The risk of developing RA, SLE, SjS, and BD were significantly more highly affected in younger age (pfor interaction < 0.001, = 0.003, 0.002, and 0.017, at each).

Conclusion:

This nationwide, population-based cohort study demonstrated that patients with PR had an increased risk of developing various rheumatic diseases, not only RA but also psoriatic arthropathy. Therefore, patients with PR needs to be cautiously followed up for their potential of diverse outcome other than RA: RA, SLE, SjS, and BD in younger patients, RA in males, and AS in females, in particular.

Disclosure of Interests:

None declared

Knowledge, attitudes and behaviour towards needlestick injuries among junior doctors

BACKGROUND

Needlestick injuries (NSIs) are common healthcare-related injuries and possible consequences include blood-borne infections. Despite that, a large proportion of NSIs are not reported.

AIMS

To estimate the prevalence of under-reporting of NSIs and to evaluate the knowledge, attitude and behaviour towards NSIs among junior doctors in a tertiary hospital in Singapore.

METHODS

An explanatory sequential mixed-methods design was employed. Quantitative data were collected through questionnaires completed by 99 junior doctors. Descriptive statistics and bivariate analysis were performed to evaluate socio-demographic characteristics, NSI history and NSI reporting practices. Qualitative data were collected through 12 in-depth interviews. Participants were purposively recruited, and semi-structured topic guides were developed. Data were analysed using a thematic approach.

RESULTS

Fifty-two per cent of respondents had history of NSI. Of those with history of NSI, 31% did not report injury. NSI reporters were 1.52 times as likely to be aware of how to report injury (P < 0.05), and 1.63 times as likely to feel that reporting benefits their health (P < 0.01) compared with non-reporters. NSI reporters were 83% more likely to report a clean NSI (P = 0.05). For non-reporters, the main reasons for not reporting were perceived low risk of transmission (41%) and lack of time to report (35%). Themes identified in the qualitative data include perceived benefits, perceived barriers, perceived threats, cues to action and organizational culture.

CONCLUSION

Under-reporting of NSIs may have significant implications for patients and healthcare workers. Addressing identified factors and instituting targeted interventions will help to improve reporting rates.

Abstract ES10-2: Understanding breast cancer using a developmental perspective

Parallels among embryonic development, stem cells, and cancer have long been recognized. We identified, isolated, and characterized stem cells that first become committed to a mammary fate during embryogenesis; we refer to these cells as fetal mammary stem cells (fMaSCs). Lineage tracing, in vitro sphere formation, and in vivo transplantation studies by our group and many others all confirm that cells in the embryo are the bipotent progenitors of the mammary gland. There is debate, however, on whether such bipotent cells persist into the adult, or whether the luminal and basal lineages are maintained by unipotent progenitors. To gain insight into the relationships between fMaSCs and breast cancer, and to investigate their potential persistence in the adult, we have applied bulk and single cell RNA-sequencing (sc-RNA-seq) and single nucleus ATAC-sequencing (snATAC-seq) throughout mammary development. The results to be discussed demonstrate that fMaSC transcriptomes are heterogeneous, but all share co-expression of genes associated with luminal and basal cell fates. This fits a model in which the bipotent state is created by a balance of lineage specifiers. We also find that the fMaSC transcriptome is highly enriched in basal-like human breast cancers and identify potential embryonic pathways that correlate with poor prognosis. We used a variety of computational tools to infer the gene expression programs that ensue when fMaSCs commit to luminal and basal states. The data from scRNA-seq and snATAC-seq demonstrate that the transitions are gradual, not precipitous, and that luminal and basal cells exhibit significant transcriptomic and epigenetic heterogeneity. This challenges the notion that the mammary gland consists of discrete cell types defined by rigid transcriptomic parameters, and reveals a potential for intrinsic phenotypic plasticity of normal mammary cells. Using the combined databases, we identified Sox10 as a significantly differentially expressed cell state regulator. We show that tumors are heterogeneous with regard to Sox10 expression, and that locally invasive cells tend to express high Sox10 levels. Elevated Sox10 correlates with acquisition of a neural-crest like, EMT-related state. Implications for interception of metastasis by targeting neural crest-like cells will be discussed. Finally, we have generated a web resource that is available to the scientific community to enable the transcription and epigenetic characteristics of any gene of interest to be tracked through mammary development (https://wahl-labsalk.shinyapps.io/Mammary_snATAC/).

Citation Format: GM Wahl, Z Ma, C Chung, C Dravis, BT Spike, RR Giraddi, O Balcioglu, C Fan, B Hagos, R Heinz, Herrera-Valdez J, X Hou, J Hwang, R Lasken, G Luna, NE Lytle, EM Mehrabad, M Novotny, CM Perou, O Poirion, S Preissl, B Ren, T Reya, CL Trejo, KT Varley. Understanding breast cancer using a developmental perspective [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr ES10-2.

P5731Optimal blood pressure in diabetic hypertensive patients with overt proteinuria

Background

Evidence for the benefit of intensive blood pressure lowering in diabetic nephropathy is not clear at this time. The objective of this study was to demonstrate whether lower mean blood pressure (BP) in treated hypertensive patients with diabetic nephropathy is associated with better prognosis.

Methods

From the National Health Insurance Service (NHIS) Health Examination Database, diabetic hypertensive subjects with proteinuria between 2009 and 2010 were selected and followed-up until 2015 (N=8,663). Mean of the recorded systolic and diastolic BP during follow-up health examinations were stratified into five categories (SBP: <120, 120 to <130, 130 to <140, 140 to <150, and ≥150 mmHg; DBP: <70, 70 to <80, 80 to <90, 90 to <100, and ≥100 mmHg). All-cause death, myocardial infarction (MI), stroke, and renal outcome (progression to end stage renal disease or doubling of serum creatinine) were examined by Cox proportional hazard models with the propensity scores adjusted method.

Results

Compared to SBP of 130 to <140 mmHg, SBP of 120 to <130 mmHg was associated with lower risk of all-cause death (HR=0.78; 95% CI, 0.64–0.95), stroke (HR: 0.65; 95% CI, 0.45–0.94), and renal outcome (HR: 0.81; 95% CI, 0.68–0.97). SBP of <120 mmHg was associated with benefit for renal outcomes (HR: 0.69; 95% CI 0.55–0.88) but not with elevated risk of other outcomes. Compared to DBP of 80 to <90 mmHg, DBP of 70 to <80 mmHg were associated with lower risk of all-cause death (HR: 0.75; 95% CI, 0.64–0.88) but with higher risk of MI (HR: 1.52; 95% CI, 1.05–2.21). DBP of <70 mmHg was associated with reduced risk of all-cause death (HR: 0.79; 95% CI, 0.64–0.98).

Conclusion

In diabetic hypertensive subjects with overt proteinuria, deterioration of renal function decreased with decreasing SBP and the lowest risk of all-cause death and stroke were observed in SBP <130 mmHg. Low DBP was associated with low risk of all-cause death but there was a J curve phenomenon for MI in DBP of 70 to <80 mmHg.

P10.01 Anti-migration and anti-invasion effects of curcumin via suppression of fascin expression in glioblastoma cells

BACKGROUND

The natural compound Curcumin was known to inhibit migration and invasion of glioblastoma (GBM) cells. Fascin, a kind of actin-binding proteins, is correlated with migration and invasion of GBM cells. The purpose of this study was to investigate anti-migration and anti-invasion effects of Curcumin via suppression of fascin expression in GBM cells.

MATERIAL AND METHODS

U87 cell line was used as an experimental model of GBM. Fascin was quantified by Western blot analysis. And, the signal transducer and activator of transcription 3 (STAT3), known to play an important role in migration and invasion of tumor cells, were analyzed by sandwich-ELISA. Migration and invasion capacities were assessed by attachment, migration and invasion assays. Cellular morphology was demonstrated by immunofluorescence.

RESULTS

At various concentrations of curcumin and exposure times, fascin expression decreased. After temporarily exposure to 10μM/L Curcumin during 6 hours as less invasive concentration and time, fascin expression temporarily decreased at 12 hours (18.4%, p=0.024), and since then recovered. And, the change of phosphrylated STAT3 level also reflected the temporarily decreased pattern of fascin expression at 12 hours (19.7%, p=0.010). Attachment, migration, and invasion capacities consistently decreased at 6, 12, and 24 hours. And, immunofluorescence showed the change of shape and the reduction of filopodia formation in cells.

CONCLUSION

Curcumin is likely to suppress the fascin expression in GBM cells, and this might be a possible mechanism for anti-migration and anti-invasion effects of Curcumin via inhibition of STAT3 phosphorylation.

P14.27 The significance of multicentric noncontrast-enhancing lesions distant from surgically resected glioblastoma: Case series of 3 patients

BACKGROUND

Glioblastoma is the most malignant primary brain tumor. The tumor location and multiplicity plays an important role in surgical and further treatment. The incidence of multiple lesions at the time of diagnosis was known as 1–20%, which showed a poor prognostic factor. Most researches has focused on multiple contrast-enhancing lesions, however, multicentric non-enhancing lesions distant from glioblastoma has been rarely evaluated. The authors reported the case series of the patient who showed multicentric non contrast-enhancing lesions without connection to histologically-proven glioblastoma.

MATERIAL AND METHODS

Multicentric non contrast-enhancing lesions were defined as areas of FLAIR hyperintensity and mass effect without post-contrast enhancement, separated from the histologically-proven glioblastoma in a newly diagnosed disease. Three patients who showed distant non-enhancing lesions with appearance of a multicentric low-grade glioma were included in this study. The typical enhancing lesions were surgically resected and standard chemo-radiotherapy was followed in all patients.

RESULTS

All patients were male and their age was 38, 60 and 65 years old respectively. Multicentric tumor location was as follows: Case 1, left frontal lobe with non-enhancing lesion in left parahippocampal gyrus; Case 2, left parietal with non-enhancing lesion in left anteromedial temporal lobe; Case 3, left thalamus with non-enhancing lesions in both basal frontal and right temporal lobe. Pathologically, the resected enhancing tumor revealed glioblastoma in 2 patients and diffuse midline glioma in 1. All tumors were IDH-wild type. The resected enhanced lesion showed no progression but all non-enhancing lesions developed contrast-enhancing tumors at 3, 13 and 17 months after initial treatment, with high tracer uptake on 18FDG-PET or 18FDOPA-PET. Despite multidisciplinary treatment, two patients died from disease progression at 30 and 32 months after diagnosis and one patient is still alive with overall survival of 15 months.

CONCLUSION

The appearance of multicentric non-enhancing lesions distant from a typically enhancing tumor showed an uncommon finding in glioblastoma and poor prognostic features. These lesions progress faster than expected for a low-grade glioma. These lesions should be distinguished from typical low-grade glioma and should be considered more advanced lesions than their appearances suggest.

Serum Vitamin D and Age-Related Muscle Loss in Afro-Caribbean Men: The Importance of Age and Diabetic Status

BACKGROUND

Prospective studies examining the potential association of vitamin D with age-related muscle loss have shown inconsistent results.

OBJECTIVE

To examine the association between baseline serum 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)2D), and prospective change in lean mass with aging in African ancestry population. We also determined if associations were modulated by age and diabetes mellitus (DM).

DESIGN

Prospective observational cohort study.

SETTING

Data were collected from a random sub-sample of 574 men, participants of the Tobago Bone Health Study (TBHS).

PARTICIPANTS

574 Afro-Caribbean men, aged 43+ years (mean age: 59.1 ± 10.5), who were randomly selected as the participants in both the baseline and the follow-up visits.

MEASUREMENTS

Baseline fasting serum 25(OH)D was measured using liquid chromatography mass spectrometry (LC-MS/MS), and and 1,25(OH)2D was measured using radioimmunosassay (RIA). Changes in dual-energy X-ray absorptiometry (DXA)-measured appendicular lean mass (ALM), and total body lean mass (TBLM) were measured over an average of 6.0 ± 0.5 years. The associations of 25(OH)D and 1,25(OH)2D with ALM and TBLM were assessed by multiple linear regression model after adjusting for potential confounders.

RESULTS

When stratifying all men into two groups by age, greater baseline 25(OH)D and 1,25(OH)2D levels were associated with smaller losses of ALM and TBLM in older (age 60+ years) but not in younger (age 43 - 59 years) men. When stratifying by DM status, the associations of 25(OH)D and 1,25(OH)2D with declines in ALM and TBLM were statistically significant only in prediabetic, but not among normal glycemic or diabetic men.

CONCLUSION

Higher endogenous vitamin D concentrations are associated with less lean mass loss with aging among older and prediabetic Afro-Caribbean men independent of potential confounders. Our findings raise a possibility that maintaining high serum vitamin D level might be important for musculoskeletal health in elderly and prediabetic African ancestry men.

Effect of different doses of ketamine with low-dose rocuronium on intubation conditions in children: prospective randomized double blind trial

OBJECTIVE

The effect of ketamine on intubation condition, when used as an induction agent with low-dose rocuronium, is unknown. This study aimed to compare the effects of three doses of ketamine used with 0.3 mg/kg rocuronium and 1 µg/kg fentanyl on intubation conditions in children undergoing short elective surgery.

PATIENTS AND METHODS

The study was performed as a prospective, randomized double-blind clinical trial. A total of 60 children aged 2 to 12 years, who were scheduled for inguinal herniorrhaphy under general anesthesia, were randomly allocated into three groups on the basis of ketamine dose: 1 mg/kg (Group K1, n = 20), 1.5 mg/kg (Group K1.5, n = 20), and 2 mg/kg (Group K2, n = 20). The primary outcome was the intubation condition. Other assessments included hemodynamic data, recovery profile, adverse events in the postanesthetic care unit (PACU) and use of fentanyl as a rescue analgesic in the PACU were also assessed.

RESULTS

The occurrence of a clinically acceptable intubation condition increased with the use of an increased dose (≥ 1.5 mg/kg) (K1/K1.5/K2: 30%/65%/65%; p=0.038, for trends p=0.028). Hemodynamic data, recovery profile and adverse events in PACU showed no difference among groups. Fentanyl dose used in the PACU was higher in K1 than K2 and the number of patients requiring rescue analgesics in the PACU decreased in accordance with the dose of ketamine (K1/K1.5/K2: 30%/15%/0%; p=.031, for trends p=0.013).

CONCLUSIONS

Different intubation conditions were observed on the basis of ketamine dose used in conjunction with 0.3 mg/kg rocuronium and fentanyl 1 µg/kg. Ketamine dose ≥ 1.5 mg/kg with low-dose rocuronium should be used to improve intubation conditions in pediatrics.

Abstract OT3-04-04: A randomized phase II study of pembrolizumab in combination with carboplatin versus carboplatin alone in breast cancer patients with chest wall disease, with immunologic and genomic correlative studies

Background: Thirty percent of patients with breast cancer may experience chest wall recurrence, which is associated with a higher risk of developing distant metastases and a poor prognosis. Cancer cells may evade immune rejection through the programmed cell death 1 (PD-1) pathway. Pembrolizumab, an anti-PD-1 antibody, binds PD-1 and inhibits its interaction with the programmed death ligand 1 (PD-L1) to facilitate tumor immune rejection. We hypothesize that pembrolizumab may be an effective therapy in chest wall recurrence, given the inflammatory nature, and the high expression of PD-1 in tumors with lymphovascular invasion. Platinum agents may enhance anti-tumor immunity in a synergistic manner, and the combination of pembrolizumab and carboplatin has demonstrated efficacy in advanced lung cancer. In this study, the combination of pembrolizumab and carboplatin is being evaluated in breast cancer patients with chest wall disease.

Methods: This is a randomized phase II study of breast cancer patients with advanced, unresectable breast cancer involving the chest wall, being conducted through the Translational Breast Cancer Research Consortium (TBCRC). Patients may have hormone resistant disease (at least 2 prior lines of hormone therapy), triple negative breast cancer, or refractory HER2+ disease for enrollment. They may have other sites of distant metastases, have received any number of prior lines of therapy, have had prior surgery, but prior chest wall radiation is not necessary. Eighty-four patients at 7 TBCRC sites will be randomized 2:1 to treatment with pembrolizumab 200 mg IV and carboplatin AUC 5 IV every 3 weeks followed by pembrolizumab 200 mg IV alone every 3 weeks (Arm A, n=56) or carboplatin AUC 5 IV every 3 weeks (Arm B, n=28), with an option for patients in Arm B to cross-over to single agent pembrolizumab 200 mg IV every 3 weeks (arm Bx) on progression. Patients will undergo imaging with CT chest, abdomen, and pelvis at baseline and every 2 cycles of treatment for response evaluation. The primary endpoint is the disease control rate in the chest wall and distant sites at 18 weeks of treatment, and this study is powered to determine a 20% difference in disease control rates between arms A and B (hazard ratio of 0.52, α= 0.10, β= 0.20). After 18 patients are enrolled into Arm B, an interim analysis for futility will be conducted to enable early closure of that arm for lack of efficacy. Secondary endpoints in the study are toxicity, progression free survival, and response based on PD-L1 expression and irRECIST. Exploratory endpoints, which will be studied using peripheral blood testing and chest wall tumor biopsies at baseline and after 2 cycles of treatment, include determining associations of response with changes in tumor and peripheral blood immune composition, soluble PD-L1 expression, circulating tumor cells, cell free DNA, and tumor PD-L1 and MYC genomic expression. Ultimately this study promises to improve our understanding of checkpoint inhibition and chemotherapy for chest wall disease, and the underlying mechanism of action. This study is open for enrollment and 2 patients are currently enrolled. (NCT03095352).

Citation Format: Vidula N, Goga A, Hwang J, Liu MC, Park BH, Nanda R, Pohlmann PR, Storniolo AM, Brufsky A, Abramson V, Rugo HS. A randomized phase II study of pembrolizumab in combination with carboplatin versus carboplatin alone in breast cancer patients with chest wall disease, with immunologic and genomic correlative studies [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT3-04-04.