Multichannel laser diode to polymer waveguide array coupling with a double-aspheric lens

An optical system for multichannel coupling of laser arrays to polymer waveguide array probes with a single biconvex lens is developed. The developed cylindrical module with 13 mm and 20 mm in diameter and length, respectively, enables coupling of eight individual optical channels using an aspheric lens. Specific coupling with crosstalk below -13d B for each channel and quasi-uniform coupling over all channels is achieved for a waveguide array with 100 µm lateral facet pitch at the incoupling site. The polymer waveguide technology allows for tapering of the lateral waveguide pitch to 25 µm toward the tip of the flexible waveguide array. SU-8 and PMMA are used as the waveguide core and cladding, respectively. The optical coupling module is designed as a prototype for preclinical evaluation of optical neural stimulators.

Intra-Arterial Thrombolysis is Associated with Delayed Reperfusion of Remaining Vessel Occlusions following Incomplete Thrombectomy

BACKGROUND AND PURPOSE

Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging.

MATERIALS AND METHODS

We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a-2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion.

RESULTS

The median age of the final study population (n = 459) was 74 years (interquartile range, 63-81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics (n = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1-6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1-0.7). No difference was found in the rates of functional independence (90-day mRS, 0-2; adjusted OR = 1.4; 95% CI, 0.4-4.1).

CONCLUSIONS

Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.

A scoring tool to predict mortality and dependency after cerebral venous thrombosis

BACKGROUND

We developed a prognostic score to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials..

METHODS

We used data from the International CVT Consortium. We excluded patients with pre-existent functional dependency. We used logistic regression to predict poor outcome (modified Rankin Scale 3-6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunken using Ridge regression to adjust for optimism in internal validation.

RESULTS

Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, we derived the SI₂ NCAL₂ C score utilizing the following components: absence of female Sex-specific risk factor, Intracerebral hemorrhage, Infection of the central nervous system, Neurologic focal deficits, Coma, Age, lower Level of hemoglobin (g/L), higher Level of glucose (mmol/L) at admission, and Cancer. C-statistics were 0.80 (95%CI 0.75-0.84), 0.84 (95%CI 0.80-0.88) and 0.84 (95%CI 0.80-0.88) for the poor outcome, 30 days and 1 year mortality model, respectively. Calibration plots indicated good model fit between predicted and observed values. The SI₂ NCAL₂ C score calculator is freely available at www.cerebralvenousthrombosis.com.

CONCLUSIONS

The SI₂ NCAL₂ C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.

Applications of machine learning in animal and veterinary public health surveillance

Machine learning (ML) is an approach to artificial intelligence characterised by the use of algorithms that improve their own performance at a given task (e.g. classification or prediction) based on data and without being explicitly and fully instructed on how to achieve this. Surveillance systems for animal and zoonotic diseases depend upon effective completion of a broad range of tasks, some of them amenable to ML algorithms. As in other fields, the use of ML in animal and veterinary public health surveillance has greatly expanded in recent years. Machine learning algorithms are being used to accomplish tasks that have become attainable only with the advent of large data sets, new methods for their analysis and increased computing capacity. Examples include the identification of an underlying structure in large volumes of data from an ongoing stream of abattoir condemnation records, the use of deep learning to identify lesions in digital images obtained during slaughtering, and the mining of free text in electronic health records from veterinary practices for the purpose of sentinel surveillance. However, ML is also being applied to tasks that previously relied on traditional statistical data analysis. Statistical models have been used extensively to infer relationships between predictors and disease to inform risk-based surveillance, and increasingly, ML algorithms are being used for prediction and forecasting of animal diseases in support of more targeted and efficient surveillance. While ML and inferential statistics can accomplish similar tasks, they have different strengths, making one or the other more or less appropriate in a given context.

Population-based investigation of common and deviating patterns of gastric cancer and oesophageal cancer incidence across populations and time

BACKGROUND

The subtypes of gastric cancer (GC) and oesophageal cancer (EC) manifest distinct epidemiological profiles. Here, we aim to examine correlations in their incidence rates and to compare their temporal changes globally, both overall and by subtype.

METHODS

Long-term incidence data were obtained from population-based registries available from the Cancer Incidence in Five Continents series. Variation in the occurrence of EC and GC (overall and by subtype) was assessed using the GC:EC ratio of sex-specific age-standardised rates (ASR) in 2008-2012. Average annual per cent changes were estimated to assess temporal trends during 1998-2012.

RESULTS

ASRs for GC and EC varied remarkably across and within world regions. In the countries evaluated, the GC:EC ratio in men exceeded 10 in several South American countries, Algeria and Republic of Korea, while EC dominated in most sub-Saharan African countries. High rates of both cardia gastric cancer and oesophageal squamous cell carcinoma (ESCC) were observed in several Asian populations. Non-cardia gastric cancer rates correlated positively with ESCC rates (r=0.60) and negatively with EAC (r=-0.79). For the time trends, while GC incidence has been uniformly decreasing by on average 2%-3% annually over 1998-2012 in most countries, trends for EC depend strongly on histology, with several but not all countries experiencing increases in EAC and decreases in ESCC.

CONCLUSIONS

Correlations between GC and EC incidence rates across populations are positive or inverse depending on the GC subsite and EC subtype. Multisite studies that include a combination of populations whose incidence rates follow and deviate from these patterns may be aetiologically informative.

Shifting incidence and survival of epithelial ovarian cancer (1995-2014): A SurvMark-2 study

The aim of the study is to provide a comprehensive assessment of incidence and survival trends of epithelial ovarian cancer (EOC) by histological subtype across seven high income countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the United Kingdom). Data on invasive EOC diagnosed in women aged 15 to 99 years during 1995 to 2014 were obtained from 20 cancer registries. Age standardized incidence rates and average annual percentage change were calculated by subtype for all ages and age groups (15-64 and 65-99 years). Net survival (NS) was estimated by subtype, age group and 5-year period using Pohar-Perme estimator. Our findings showed marked increase in serous carcinoma incidence was observed between 1995 and 2014 among women aged 65 to 99 years with average annual increase ranging between 2.2% and 5.8%. We documented a marked decrease in the incidence of adenocarcinoma "not otherwise specified" with estimates ranging between 4.4% and 7.4% in women aged 15 to 64 years and between 2.0% and 3.7% among the older age group. Improved survival, combining all EOC subtypes, was observed for all ages combined over the 20-year study period in all countries with 5-year NS absolute percent change ranging between 5.0 in Canada and 12.6 in Denmark. Several factors such as changes in guidelines and advancement in diagnostic tools may potentially influence the observed shift in histological subtypes and temporal trends. Progress in clinical management and treatment over the past decades potentially plays a role in the observed improvements in EOC survival.

Prevalence and risk factors of Brachyspira spp. in pig herds with a history of diarrhoea in six European countries

Swine dysentery and porcine intestinal spirochaetosis caused by Brachyspira (B.) hyodysenteriae and B. pilosicoli, respectively, are important diseases in swine production worldwide. The aim of this study was to assess the prevalence of both pathogens in farms with a history of diarrhoea within the last 12 months in Denmark, France, Germany, the Netherlands, Spain, and United Kingdom. In addition, risk factors for their prevalence and correlations between presence of different Brachyspira spp. and Lawsonia intracellularis were investigated. Therefore, faecal samples of 6355 nursery to finishing pigs out of 144 herds were sampled in 2017/2018 during a prevalence study on Lawsonia intracellularis, followed by polymerase chain reaction analysis for Brachyspira spp. detection. Herd prevalence differed significantly between countries, from 4.2% to 45.8% for B. hyodysenteriae and 8.3-87.5% for B. pilosicoli, respectively (p < 0.01). For the within-herd prevalence (in positive herds), these values ranged from 2.2% to 27.0% for B. hyodysenteriae and 3.3-50.8% for B. pilosicoli. Mixed infections occurred in 34.1% and 58.7% of B. hyodysenteriae positive samples with Lawsonia intracellularis or B. pilosicoli, respectively. In 43.2% of B. pilosicoli positive samples, Lawsonia intracellularis was detected simultaneously. Overall, nursery pigs were significantly less often positive for one of the pathogens than growing or finishing pigs (p < 0.001). The absence of gastrointestinal problems like diarrhoea, routine use of antimicrobials and well performed biosecurity measures were some of the factors associated with lower detection rate of Brachyspira spp. Surprisingly, deworming of different age categories also showed associations with the detection of Brachyspira spp. which, however, were not always equally directed, and therefore require further investigations. The only risk factor significant for both Brachyspira spp. was the median number of ≥ 30 nursery pigs per pen after weaning, compared to smaller group sizes. Both pathogens were detected with varying frequency between the six European countries. This should be considered in the probability of disease and in case of transnational transport, to prevent spread of pathogens. In addition, the frequent presence of mixed infections in some countries should be taken into account in diagnostics. The most important protective factors against Brachyspira spp. presence on farm are biosecurity measures, while potential new factors such as deworming still require further investigation.

Projections of Lung Cancer Incidence by 2035 in 40 Countries Worldwide: Population-Based Study

BACKGROUND

The global burden of lung cancer (LC) is increasing. Quantitative projections of the future LC burden in different world regions could help optimize the allocation of resources and provide a benchmark for evaluating LC prevention and control interventions.

OBJECTIVE

We aimed to predict the future incidence of LC in 40 countries by 2035, with an emphasis on country- and sex-specific disparities.

METHODS

Data on LC incidence from 1978 to 2012 were extracted from 126 cancer registries of 40 countries in Cancer Incidence in Five Continents Volumes V-XI and used for the projection. Age-standardized incidence rates (ASRs) per 100,000 person-years and the number of incident cases were predicted through 2035, using the NORDPRED age-period-cohort model.

RESULTS

Global ASRs of the 40 studied countries were predicted to decrease by 23% (8.2/35.8) among males, from 35.8 per 100,000 person-years in 2010 to 27.6 in 2035, and increase by 2% (0.3/16.8) among females, from 16.8 in 2010 to 17.1 in 2035. The ASRs of LC among females are projected to continue increasing dramatically in most countries by 2035, with peaks after the 2020s in most European, Eastern Asian, and Oceanian countries, whereas the ASRs among males will continue to decline in almost all countries. The ASRs among females are predicted to almost reach those among males in Ireland, Norway, the United Kingdom, the Netherlands, Canada, the United States, and New Zealand in 2025 and in Slovenia in 2035 and even surpass those among males in Denmark in 2020 and in Brazil and Colombia in 2025. In 2035, the highest ASRs are projected to occur among males in Belarus (49.3) and among females in Denmark (36.8). The number of new cases in 40 countries is predicted to increase by 65.32% (858,000/1,314,000), from 1.31 million in 2010 to 2.17 million in 2035. China will have the largest number of new cases.

CONCLUSIONS

LC incidence is expected to continue to increase through 2035 in most countries, making LC a major public health challenge worldwide. The ongoing transition in the epidemiology of LC highlights the need for resource redistribution and improved LC control measures to reduce future LC burden worldwide.

Global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN

OBJECTIVE

Colorectal cancer (CRC) is the third most common cancer worldwide. The geographical and temporal burden of this cancer provides insights into risk factor prevalence and progress in cancer control strategies. We examine the current and future burden of CRC in 185 countries in 2020 and 2040.

METHODS

Data on CRC cases and deaths were extracted from the GLOBOCAN database for the year 2020. Age-standardised incidence and mortality rates were calculated by sex, country, world region and Human Development Index (HDI) for 185 countries. Age-specific rates were also estimated. The predicted number of cases and deaths in 2040 were calculated based on global demographic projections by HDI.

RESULTS

Over 1.9 million new CRC cases and 930 000 deaths were estimated in 2020. Incidence rates were highest in Australia/ New Zealand and European regions (40.6 per 100 000, males) and lowest in several African regions and Southern Asia (4.4 per 100 000, females). Similar patterns were observed for mortality rates, with the highest observed in Eastern Europe (20.2 per 100 000, males) and the lowest in Southern Asia (2.5 per 100 000, females). The burden of CRC is projected to increase to 3.2 million new cases and 1.6 million deaths by 2040 with most cases predicted to occur in high or very high HDI countries.

CONCLUSIONS

CRC is a highly frequent cancer worldwide, and largely preventable through changes in modifiable risk factors, alongside the detection and removal of precancerous lesions. With increasing rates in transitioning countries and younger adults, there is a pressing need to better understand and act on findings to avert future cases and deaths from the disease.

Current and future burden of breast cancer: Global statistics for 2020 and 2040

BACKGROUND

Breast cancer is the most commonly diagnosed cancer worldwide, and its burden has been rising over the past decades. In this article, we examine and describe the global burden of breast cancer in 2020 and predictions for the year 2040.

METHODS

Estimates of new female breast cancer cases and deaths in 2020 were abstracted from the GLOBOCAN database. Age-standardized incidence and mortality rates were calculated per 100,000 females by country, world region, and level of human development. Predicted cases and deaths were computed based on global demographic projections for the year 2040.

RESULTS

Over 2.3 million new cases and 685,000 deaths from breast cancer occurred in 2020. Large geographic variation across countries and world regions exists, with incidence rates ranging from <40 per 100,000 females in some Asian and African countries, to over 80 per 100,000 in Australia/New Zealand, Northern America, and parts of Europe. Smaller geographical variation was observed for mortality; however, transitioning countries continue to carry a disproportionate share of breast cancer deaths relative to transitioned countries. By 2040, the burden from breast cancer is predicted to increase to over 3 million new cases and 1 million deaths every year because of population growth and ageing alone.

CONCLUSION

Breast cancer is the most common cancer worldwide and continues to have a large impact on the global number of cancer deaths. Global efforts are needed to counteract its growing burden, especially in transitioning countries where incidence is rising rapidly, and mortality rates remain high.

Global and national trends in the age-specific sex ratio of esophageal cancer and gastric cancer by subtype

A male predominance was observed in esophageal and gastric cancers, though present limited data has revealed variations by age. We aim to investigate the global age-specific sex differences in esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), gastric cardia cancer (GCC) and gastric noncardia cancer (GNCC). Data on esophageal and gastric cancers incidence by diagnosis year, sex, histology, subsite and age group were extracted from 171 registries in 54 countries included in the last two volumes (X and XI, 2003-2012) of Cancer Incidence in Five Continents, which contributing to over 80% of the global burdens of these cancers. Age-standardized incidence rates (ASIRs) and male-to-female ASIRs ratios were estimated for esophageal and gastric cancers, by histological subtype and subsite, globally and by country. We consistently observed a male predominance in esophageal and gastric cancers across the world from 2003 to 2012, with male-to-female ASIRs ratios of 6.7:1 for EAC, 3.3:1 for ESCC, 4.0:1 for GCC and 2.1:1 for GNCC. The sex differences were consistent across time periods but varied significantly by age across the life span. Across the four cancer types, the male-to-female incidence rate ratios increased from young ages, approaching a peak at ages 60-64, but sharply declined thereafter. Similar "low-high-low" trends of age-specific sex ratio were observed in other digestive cancers including liver, pancreas, colon and rectum with peak ages ranging from 50 to 65. Age-dependent risk factors warrant further investigation to aid our understanding of the underlying etiologies of esophageal and gastric cancers by histological subtype and subsite.

CT analysis of left ventricular function predicts short term survival in patients following transcatheter aortic valve implantation: 1-year outcome data

Introduction

Contrast-enhanced cardiac CT routinely performed prior to transcatheter aortic valve implantation (TAVI), allows assessment of cardiac morphology and function. We assessed left ventricular function in CT as a predictor of survival following TAVI.

Methods

500 consecutive patients referred for CT assessment of aortic root anatomy prior to TAVI were screened for inclusion in this analysis. All CT data sets were acquired using a third-generation dual source system. For assessment of aortic root anatomy, acquisitions were acquired using ECG-gated retrospective spiral acquisition and multiphase reconstructions in 10% increments of the cardiac cycle were rendered (slice thickness 0.75, increment 0.4 mm). left ventricular endocardial contours were automatically traced by a dedicated software (syngo. via, Siemens Healthineers, Forchheim, Germany) throughout the cardiac cycle and manually adjusted if required. Global left ventricular function parameters (end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction) were derived by volumetric assessment.

Results

Out of 500 patients, 439 patients (mean age 80±6 years, 56% males, and Log EuroScore 23±14%) were included in this analysis (61 patients were excluded due to poor CT image quality or missing outcome data). Previous cardiac surgery had been performed in 15% of the patients, 50% had obstructive CAD with previous interventional or surgical revascularisation and 18% had a previous acute coronary syndrome. One-year survival was 83% (366/439 patients). Parameters of left ventricular function were as follows: mean LVEDV 172±56 ml, mean LVESV 78±62 ml, mean LV ejection fraction 59±18%, mean LV stroke volume index 51±22 ml/m2, mean LV cardiac output 6.6±3.3 L/min and LV cardiac index 3.5±1.7 l/min/m2. Cluster analysis of multiple LV-function surrogate parameters identified a group of patients with higher 1-year mortality, with LVEF identified as a predictor of 1-year survival with a cut-0ff of ≥37% associated with an OR 0f 0.52 (95% CI 0.27 to 0.98).

Conclusion

Assessment of left ventricular function using functional CT data sets is feasible and allows risk stratification of patients following TAVI. Among LV functional parameters, CT derived LV-ejection fraction with a cut-off ≥37% identifies patients with better short-term outcome.

Funding Acknowledgement

Type of funding sources: None.

Comorbidity and medication use in patients with angina due to a coronary vasomotion disorder

Background

Microvascular angina and vasospastic angina are disorders of coronary vasomotion. The associations between these conditions, comorbidity and medication use in relatively unselected populations is not well described.

Aim

To describe the proportions of patients with concomitant morbidity and related medication use in an international, contemporary, clinical database.

Methods

TriNetX, a global federated health research network with access to anonymized electronical medical records (EMRs) from participating healthcare organizations including academic medical centres, specialty physician practices, and community hospitals, predominantly in the USA was used. The ICD10 code (I20.1) representing “Angina pectoris with documented spasm” was used as a primary search term. ICD10 codes were also used for cardiorenal and metabolic conditions. Medication use was classified as occurring prior to or on the date of the angina episode. The time-period for defining the analysis population was 01.01.2017–31.12.2019. The population age was ≥18 years.

Results

Data were available on 12,200 individuals (mean (SD) age 63 (13) years; 63% female). The % of individuals with a concomitant diagnosis is described in Table 1. Hypertension occurred in almost two thirds of individuals, an anxiety disorder affected more than one quarter and type 2 diabetes and/or obesity occurred in one fifth. Medication use is described in Table 2. Half of patients received a calcium channel blocker therapy. Nitroglycerin, beta-blockers, and isosorbide mononitrate were less commonly used (45%, 45% and 23%, respectively). Most (58%) patients were prescribed an antacid. Half of patients received statin treatment (50% overall; 36% atorvastatin) and insulin (12%) and metformin (9%) were the most commonly prescribed antidiabetic medications.

Conclusions

Angina associated with coronary spasm associates with female sex and cardio-metabolic risk factors. Contemporary pharmacotherapy for diabetes and statins appear to be under-used.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

Radiation exposure during transcatheter aortic valve implantation (TAVI): comparison of balloon-expandable versus self-expandable prostheses

 

Transcatheter aortoc valve implantation (TAVI) is performed under fluoroscopic control and can be associated with the need for long fluoroscopy times and repeated cine acquisitions in angulated projections. The procedural steps for TAVI with balloon-expandable and self-expanding prostheses differ and may be associated with significant differences in radiation exposure. Published data regarding patient or operator radiation exposure in TAVI are limited to small series. We therefore analyzed the influence of prosthesis type on radiation exposure in a consecutive series of 1185 patients who underwent TAVI between 2016 and 2021.

A cohort of 1185 consecutive patients undergoing TAVI between 2016 and 2021 was analyzed. Radiation exposure was determined by evaluating overall fluoroscopy time, the number of acquired cine sequences, and total dose-area product (DAP). After eliminating patients treated via a non-transfemoral approach, data between patients underging TAVI with self-expanding prostheses and patients undergoing TAVI with balloon-expandable prostheses were compared.

Out of the total patient cohort, 46 patients were excluded due to treatment via a non-transfemoral approach. Of the remaining 1139 patients, 437 (38%) were treated with self-expandable prostheses and 702 (62%) were treated with balloon-expandable prostheses. Median age was 81 years, 45% of patients were female. Body weight was slightly but significantly higher in patients treated by balloon-expandable prostheses (median 73 kg vs. 79 kg, p&lt;0.001). Median fluoroscopy time was 453 s (IQR 365–603 s) for self-expandable prostheses vs. 414 s (IQR 341–540 s) for balloon-expandable prostheses (p=0.002). Also, the number of cine acqusitions was significantly higher (median 12 vs. 7; p&lt;0.001), and total DAP was 6442 mGy cm2 (IQR 4452–9669 mGy cm2) for self-expandable vs. 4798 (IQR 3353–6981 mGy cm2) for balloon-expandable prostheses (p&lt;0.001, see Fig. 1). In multivariable analysis, male sex, higher body weight and use of a self-expandable prosthesis were independently associated with higher total DAP.

Transcatheter aortic valve implantation using balloon-expandable prostheses is associated with significantly lower total dose-area product than treatment with self-expandable prostheses. This may be particularly relevant for operators who perform the procedure frequently.

Funding Acknowledgement

Type of funding sources: None.

The Global Landscape of Esophageal Squamous Cell Carcinoma and Esophageal Adenocarcinoma Incidence and Mortality in 2020 and Projections to 2040: New Estimates From GLOBOCAN 2020

BACKGROUND & AIMS

The aim of this study was to provide an overview of the burden of esophageal cancer in 185 countries in 2020 and projections for the year 2040.

METHODS

Estimates of esophageal cancer cases and deaths were extracted from the GLOBOCAN database for 2020. Age-standardized incidence and mortality rates were calculated overall, by sex, histologic subtype (adenocarcinoma [AC] and squamous cell carcinoma [SCC]), country, and level of human development for 185 countries. The predicted burden of incidence and mortality in 2040 was calculated based on global demographic projections.

RESULTS

Globally, there were an estimated 604,100 new cases of, and 544,100 deaths from, esophageal cancer in 2020, corresponding to age-standardized incidence and mortality rates of 6.3 and 5.6 per 100,000, respectively. Most cases were SCCs (85% [512,500 cases]) and 14% (85,700 cases) were ACs. Incidence and mortality rates were 2- to 3-fold higher in male (9.3 and 8.2, respectively) compared with female (3.6 and 3.2, respectively) individuals. Global variations in incidence and mortality were observed across countries and world regions; the highest rates occurred in Eastern Asia and Southern and Eastern Africa and the lowest occurred in Western Africa and Central America regions. If rates remain stable, 957,000 new cases (141,300 AC cases and 806,000 SCC cases) and 880,000 deaths from esophageal cancer are expected in 2040.

CONCLUSIONS

These updated estimates of the global burden of esophageal cancer represent an important baseline for setting priorities in policy making and developing and accelerating cancer control initiatives to reduce the current and projected burden. Although primary prevention remains key, screening and early detection represent important components of esophageal cancer control in high-risk populations.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Relationship between BMI trajectories and cardiometabolic outcomes in postmenopausal women: a growth mixture modeling approach

PURPOSE

The objective of this manuscript is to identify longitudinal trajectories of change in body mass index (BMI) after menopause and investigate the association of BMI trajectories with risk of diabetes and cardiovascular disease (CVD) among postmenopausal women.

METHODS

Using data from 54,073 participants in the Women's Health Initiative (WHI) clinical trials, we used growth mixture modeling (GMM) to develop BMI trajectories. Cox proportional hazards models were used to examine the relationship between BMI trajectories with incident diabetes and CVD. Further, we stratified by hormone therapy trial arm and time since menopause.

RESULTS

Using GMM, we identified five BMI trajectories. We did not find evidence of substantial change in BMI over time; the trajectories were stable over the study follow-up period in this sample of postmenopausal women. Risk of diabetes and CVD increased by BMI trajectory; risk was greater for women in moderate-high, high, and very high BMI trajectories compared to those in the lowest trajectory group.

CONCLUSIONS

Despite minimal change in BMI over the follow-up period, our results demonstrate a strong association of high BMI with diabetes and CVD. These results highlight the importance of further longitudinal research focused on adverse health effects of BMI in older women.

International variation in oesophageal and gastric cancer survival 2012-2014: differences by histological subtype and stage at diagnosis (an ICBP SURVMARK-2 population-based study)

OBJECTIVE

To provide the first international comparison of oesophageal and gastric cancer survival by stage at diagnosis and histological subtype across high-income countries with similar access to healthcare.

METHODS

As part of the ICBP SURVMARK-2 project, data from 28 923 patients with oesophageal cancer and 25 946 patients with gastric cancer diagnosed during 2012-2014 from 14 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were included. 1-year and 3-year age-standardised net survival were estimated by stage at diagnosis, histological subtype (oesophageal adenocarcinoma (OAC) and oesophageal squamous cell carcinoma (OSCC)) and country.

RESULTS

Oesophageal cancer survival was highest in Ireland and lowest in Canada at 1 (50.3% vs 41.3%, respectively) and 3 years (27.0% vs 19.2%) postdiagnosis. Survival from gastric cancer was highest in Australia and lowest in the UK, for both 1-year (55.2% vs 44.8%, respectively) and 3-year survival (33.7% vs 22.3%). Most patients with oesophageal and gastric cancer had regional or distant disease, with proportions ranging between 56% and 90% across countries. Stage-specific analyses showed that variation between countries was greatest for localised disease, where survival ranged between 66.6% in Australia and 83.2% in the UK for oesophageal cancer and between 75.5% in Australia and 94.3% in New Zealand for gastric cancer at 1-year postdiagnosis. While survival for OAC was generally higher than that for OSCC, disparities across countries were similar for both histological subtypes.

CONCLUSION

Survival from oesophageal and gastric cancer varies across high-income countries including within stage groups, particularly for localised disease. Disparities can partly be explained by earlier diagnosis resulting in more favourable stage distributions, and distributions of histological subtypes of oesophageal cancer across countries. Yet, differences in treatment, and also in cancer registration practice and the use of different staging methods and systems, across countries may have impacted the comparisons. While primary prevention remains key, advancements in early detection research are promising and will likely allow for additional risk stratification and survival improvements in the future.

POS0429 ACTIVATED RHEUMATOID ARTHRITIS SYNOVIAL FIBROBLASTS ALTER OSTEOCLAST DIFFERENTIATION AND ACTIVITY

Background

In rheumatoid arthritis (RA), osteoclasts are one of the most important mediators of bone erosion. In addition, RA synovial fibroblasts (RASF) have a major influence on joint erosion in RA. They affect osteoclast differentiation e.g. by increased RANKL production or secretion of other pro-osteoclastogenic factors such as IL-6. In addition to the pro-osteoclastogenic effect of soluble factors such as RANKL and IL-1, visfatin inhibits osteoclast differentiation. Furthermore, visfatin increases the secretion of pro-inflammatory factors by RASF, such as IL-6 or matrix degrading enzymes.

Objectives

In this study, the effect of RASF with/without activation by visfatin and IL-1 on osteoclastogenesis was evaluated.

Methods

Blood from healthy donors and RA patients was used for PBMC isolation. RANKL, TGF-β and hM-CSF were added to induce osteoclast differentiation. RASF-conditioned media (CM) were prepared from confluent RASF cultured for 48h. Differentiating PBMCs in monoculture were compared to PBMC cultured with CM from RASF (CM: 10%, 20%, 30%) as well as in direct co-culture with RASF with/without stimulation with IL-1 (0.05ng/ml), visfatin (25ng/ml). After two weeks in culture, cells were stained using TRAP staining. 3-5 images per well were used for quantification dependent on the variability of the wells. IL-6 was measured by ELISA in supernatants collected at day 14.

Results

IL-6 production increased by IL-1 (e.g. co-culture: 2,8-fold) and visfatin (CM-visfatin: 10%=4,3-fold, 20%=5,4-fold, 30%=4,2-fold; co-culture: 9,5-fold) compared to unstimulated control in all settings. In addition, IL-6 was increased with the addition of CM compared to unstimulated controls (healthy donors CM 30%: unstimulated p=0.0342, IL-1 p=0.0133, visfatin p=0,0133; RA: unstimulated p=0.0133, IL-1 p=0.0342, visfatin p=0.0133, n=3 each). Of note, baseline IL-6 concentrations were higher in PBMC from RA patients compared to healthy donors. Co-culture showed an additional increase in IL-6 levels in all settings (e.g. monoculture: IL-1 4.71±5.75pg/ml, visfatin 141.09±182.79pg/ml; co-culture: IL-1 7241±10398pg/ml, visfatin 24535±16994pg/ml;). During osteoclast differentiation, addition of CM showed similar osteoclastogenesis with similar proportion of osteoclasts with 2 and 3-5 vs. higher numbers of nuclei per cell compared to control. In coculture with RASF osteoclasts showed a stronger TRAP signal compared to monoculture especially for unstimulated and IL-1 stimulated co-cultures.

Conclusion

Both, in monoculture with CM and in coculture, IL-6 levels were increased compared to control, whereas in RA patients the IL-6 levels were higher compared to healthy donors. The CM containing secreted factors of RASF did not have a prominent influence on osteoclastogenesis. However, the presence of RASF increased the TRAP signal showing an increased activity of differentiated osteoclasts especially in unstimulated and IL-1 stimulated co-cultures but not with addition of visfatin.

References

None.

Disclosure of Interests

None declared.

Diagnostic Accuracy of High-Resolution 3D T2-SPACE in Detecting Cerebral Venous Sinus Thrombosis

BACKGROUND AND PURPOSE

Assessment of cerebral venous sinus thrombosis on MR imaging can be challenging. The aim of this study was to evaluate the diagnostic accuracy of high-resolution 3D T2 sampling perfection with application-optimized contrasts by using different flip angle evolution (SPACE) in patients with cerebral venous sinus thrombosis and to compare its performance with contrast-enhanced 3D T1-MPRAGE.

MATERIALS AND METHODS

We performed a blinded retrospective analysis of T2-SPACE and contrast-enhanced MPRAGE sequences from patients with cerebral venous sinus thrombosis and a control group. The results were compared with a reference standard, which was based on all available sequences and clinical history. Subanalyses were performed according to the venous segment involved and the clinical stage of the thrombus.

RESULTS

Sixty-three MR imaging examinations from 35 patients with cerebral venous sinus thrombosis and 51 examinations from 40 control subjects were included. The accuracy, sensitivity, and specificity calculated from the initial MR imaging examination for each patient were 100% each for T2-SPACE and 95%, 91%, and 98%, respectively, for contrast-enhanced MPRAGE. The interrater reliability was high for both sequences. In the subanalysis, the accuracy for each venous segment involved and if subdivided according to the clinical stage of thrombus was ≥95% and ≥85% for T2-SPACE and contrast-enhanced MPRAGE, respectively.

CONCLUSIONS

Both T2-SPACE and contrast-enhanced MPRAGE offer high accuracy for the detection and exclusion of cerebral venous sinus thrombosis; however, T2-SPACE showed a better overall performance and thus could be a useful tool if included in a multiparametric MR imaging protocol for the diagnosis of cerebral venous sinus thrombosis, especially in scenarios where gadolinium administration is contraindicated.

Pancreatic cancer survival by stage and age in seven high-income countries (ICBP SURVMARK-2): a population-based study

BACKGROUND

The global burden of pancreatic cancer has steadily increased, while the prognosis after pancreatic cancer diagnosis remains poor. This study aims to compare the stage- and age-specific pancreatic cancer net survival (NS) for seven high-income countries: Australia, Canada, Denmark, Ireland, New Zealand, Norway, and United Kingdom.

METHODS

The study included over 35,000 pancreatic cancer cases diagnosed during 2012-2014, followed through 31 December 2015. The stage- and age-specific NS were calculated using the Pohar-Perme estimator.

RESULTS

Pancreatic cancer survival estimates were low across all 7 countries, with 1-year NS ranging from 21.1% in New Zealand to 30.9% in Australia, and 3-year NS from 6.6% in the UK to 10.9% in Australia. Most pancreatic cancers were diagnosed with distant stage, ranging from 53.9% in Ireland to 83.3% in New Zealand. While survival differences were evident between countries across all stage categories at one year after diagnosis, this survival advantage diminished, particularly in cases with distant stage.

CONCLUSION

This study demonstrated the importance of stage and age at diagnosis in pancreatic cancer survival. Although progress has been made in improving pancreatic cancer prognosis, the disease is highly fatal and will remain so without major breakthroughs in the early diagnosis and management.

Real-world experience on implantation and atrial signal detection of a SC ICD with atrial sensing capability: The MATRIX study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany

Introduction

A single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (the DX ICD system) can potentially give additive information concerning atrial diagnostics in patients requiring only a single-chamber ICD. We therefore report the real-world experience from large DX registry on implantation, atrial signal quality and detection and the long-term stability of the atrial signal.

Methods

The prospective, single-arm MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems, NCT01774357) registry study effectively enrolled 2041 patients at 119 sites in 24 countries. All patients had a DX system implanted for a single-chamber ICD indication for primary or secondary prevention of sudden cardiac death. Patients were followed for 24 months including remote monitoring. Implantation and follow-up data are reported for the whole patient set. For the analyses on atrial sensing amplitude values, remotely transmitted device measurements of patients without history of long-standing persistent or permanent AF at baseline were used.

Results

The mean follow-up period was 677±173 days. Implantation took place at 15±22 days before enrollment. Baseline and implantation data are shown in the table. Implantation procedure and lead insertion were rated as "easy" or "very easy" in 91.0% and 96.3% of assessments, respectively. At implantation, the investigators rated the quality of the atrial sensing amplitude as "sufficient" in 97% of the assessed cases. At enrollment (12-month/24-month follow-up), the atrial signal quality and detection were rated as "good" or "excellent" in 92.3% (89.8%/89.9%) and 92.4% (90.1%/91.3%) of assessments, respectively. For 1841 patients (90.2%), remotely transmitted device information was received. The median (mean ± SD, IQR) transmission rate was 92.5% (85.4±18.2%, 81.4-97.3%). 1746 patients (85.5%) matched the inclusion criteria for the quantitative analyses on atrial sensing. 95.6% of available RA sensing amplitude values were ≥1 mV. Based on each patient’s overall median value, the median (mean ± SD, IQR) RA sensing amplitude was 4.6 mV (4.4±2.0 mV, 2.8-6.2 mV). The time course of patient median values stratified by month is shown in the figure.

Conclusion

The study followed 2041 patients implanted with the DX ICD system for two years. In the vast majority of cases, investigators rated implantation as (very) easy and the atrial signal over 24 months as good/excellent. According to daily, automatic Home Monitoring data, the overall mean P-wave amplitude remained stable throughout the whole follow-up. The MATRIX study demonstrated functionality and clinical utility of the DX concept in an unselected, real-life setting.

Capability of guideline-conform remote atrial high rate episode monitoring with a single-chamber implantable defibrillator with atrial sensing

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany

Introduction

Device-detected atrial high-rate episodes (AHRE) and their burden progression are associated with an increased risk for thromboembolic events in correlation with CHA2DS2-VASc score and AHRE burden. To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend the monitoring of AHRE progression along pre-specified strata (6min…&lt;1h, 1h…&lt;24, ≥24h). We sought to assess the capability of a single-lead implantable cardioverter defibrillator (ICD), that is equipped with an atrial dipole for atrial sensing, to remotely detect and monitor AHRE burden progression in patients with standard indication to single-chamber ICD.

Methods

From the MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems) registry, we analyzed remotely transmitted, and electrogram (IEGM) AHREs in a subset of patients with remote transmissions and without history of long-standing AF at baseline. For each patient, we selected the first occurring episode per duration stratum and the first subsequent occurrence when progressing to a stratum of any longer duration. After episode adjudication by an independent electrophysiologist, we assessed the classification performance of the device (positive predictive value [PPV]) and analyzed AHRE onset and progression pathways.

Results

Of the MATRIX cohort, 1,746 patients matched the inclusions criteria (see table for patient characteristics) and 1,451 had no AF history. Of the 258 patients with AHREs (14.8%), 450 out of 465 evaluated episodes were correctly classified as AHRE. Reasons for misclassification were artifact (13) and R-wave oversensing (2). PPV was 96.8% (95% confidence interval 94.7%-98.2%). Grouped by stratum, PPV was 93.9%, 99.5% and 100% for 6min…&lt;1h, 1h…&lt;24 and ≥24h, respectively. Ninety six of 240 patients (40.0%) with a first episode according to the pre-specified strata were progressing to a stratum of longer duration and 9 patients (3.8%) had further progression (see Figure). In 119 out of 1,451 patients without AF history (8.2%), the device detected AHRE and 81 of them (4.6% of analysis set) had a mid to high risk for stroke and were not on anticoagulation therapy. In 121 out of 295 patients with known history of paroxysmal and persistent AF (41.0%), the arrhythmia was confirmed by the device.

Discussion and Conclusion: The single-chamber ICD with atrial sensing capabilities correctly classified ≈97% of all adjudicated AHREs ≥6min. About 7% of patients had device-detected AHRE onset and/or progression and a mid to high stroke risk. These patients would potentially benefit the most from a guideline-conform AF monitoring strategy to timely initiate anticoagulation medication for stroke prevention.

Impact of cumulative body mass index and cardiometabolic diseases on survival among patients with colorectal and breast cancer: a multi-centre cohort study

BACKGROUND

Body mass index (BMI) and cardiometabolic comorbidities such as cardiovascular disease and type 2 diabetes have been studied as negative prognostic factors in cancer survival, but possible dependencies in the mechanisms underlying these associations remain largely unexplored. We analysed these associations in colorectal and breast cancer patients.

METHODS

Based on repeated BMI assessments of cancer-free participants from four European countries in the European Prospective Investigation into Cancer and nutrition (EPIC) study, individual BMI-trajectories reflecting predicted mean BMI between ages 20 to 50 years were estimated using a growth curve model. Participants with incident colorectal or breast cancer after the age of 50 years were included in the survival analysis to study the prognostic effect of mean BMI and cardiometabolic diseases (CMD) prior to cancer. CMD were defined as one or more chronic conditions among stroke, myocardial infarction, and type 2 diabetes. Hazard ratios (HRs) and confidence intervals (CIs) of mean BMI and CMD were derived using multivariable-adjusted Cox proportional hazard regression for mean BMI and CMD separately and both exposures combined, in subgroups of localised and advanced disease.

RESULTS

In the total cohort of 159,045 participants, there were 1,045 and 1,620 eligible patients of colorectal and breast cancer. In colorectal cancer patients, a higher BMI (by 1 kg/m2) was associated with a 6% increase in risk of death (95% CI of HR: 1.02-1.10). The HR for CMD was 1.25 (95% CI: 0.97-1.61). The associations for both exposures were stronger in patients with localised colorectal cancer. In breast cancer patients, a higher BMI was associated with a 4% increase in risk of death (95% CI: 1.00-1.08). CMDs were associated with a 46% increase in risk of death (95% CI: 1.01-2.09). The estimates and CIs for BMI remained similar after adjustment for CMD and vice versa.

CONCLUSIONS

Our results suggest that cumulative exposure to higher BMI during early to mid-adulthood was associated with poorer survival in patients with breast and colorectal cancer, independent of CMD prior to cancer diagnosis. The association between a CMD diagnosis prior to cancer and survival in patients with breast and colorectal cancer was independent of BMI.

Five ways to improve international comparisons of cancer survival: lessons learned from ICBP SURVMARK-2

BACKGROUND

Comparisons of population-based cancer survival between countries are important to benchmark the overall effectiveness of cancer management. The International Cancer Benchmarking Partnership (ICBP) Survmark-2 study aims to compare survival in seven high-income countries across eight cancer sites and explore reasons for the observed differences. A critical aspect in ensuring comparability in the reported survival estimates are similarities in practice across cancer registries. While ICBP Survmark-2 has shown these differences are unlikely to explain the observed differences in cancer-specific survival between countries, it is important to keep in mind potential biases linked to registry practice and understand their likely impact.

METHODS

Based on experiences gained within ICBP Survmark-2, we have developed a set of recommendations that seek to optimally harmonise cancer registry datasets to improve future benchmarking exercises.

RESULTS

Our recommendations stem from considering the impact on cancer survival estimates in five key areas: (1) the completeness of the registry and the availability of registration sources; (2) the inclusion of death certification as a source of identifying cases; (3) the specification of the date of incidence; (4) the approach to handling multiple primary tumours and (5) the quality of linkage of cases to the deaths register.

CONCLUSION

These recommendations seek to improve comparability whilst maintaining the opportunity to understand and act upon international variations in outcomes among cancer patients.

Age at Diagnosis for Lung, Colon, Breast, and Prostate Cancers: An International Comparative Study

PURPOSE

Differences in the age at diagnosis for lung, colon, breast, and prostate cancers have been reported between low- and middle-income countries (LMICs) and high-income countries (HICs). However, this may be influenced by differences in the population age distributions across countries. We aimed to compare the median age at diagnosis for these cancers after adjusting for population age differences.

METHODS

We analyzed data from the Cancer Incidence in 5 Continents (CI5) Volume XI database. It includes information on cancer diagnoses during 2008 to 2012 from cancer registries in 66 countries. We calculated crude median ages at diagnosis for each cancer in each country, and then performed indirect standardization using the age-specific UN world population estimate to remove the influence of population age structure.

RESULTS

Overall, the adjustment for population age structure tended to increase the median ages at diagnosis in LMICs which have younger populations, and decrease them in HICs which have older populations. After standardization, differences between the youngest and oldest median ages of diagnosis across cancer sites were: 11 years for lung cancer (youngest median age observed was 61 in Bulgaria v 71 in Bahrain), 10 years for colon cancer (59 in Iran v 69 New Zealand), 10 years for breast (49 in Algeria v 59 Iceland), and 8 years for prostate cancer (65 in USA v 73 in the Philippines). LMICs had younger ages at diagnosis for colon cancer but older ages at diagnosis for prostate cancer as compared with HICs. Countries with higher smoking prevalence had younger ages at lung cancer diagnosis ( P value Pearson correlation = 0.0025).

CONCLUSION

For lung, colon, breast, and prostate cancers, the differences across countries in the median age at diagnosis range from 8 to 11 years after adjusting for population age distribution. These differences likely reflect population-level variation in risk factors and screening.

Global Burden of Cutaneous Melanoma in 2020 and Projections to 2040

Importance

Despite many cases being preventable, cutaneous melanoma remains the most serious skin cancer worldwide. Understanding the scale and profile of the disease is vital to concentrate and reinforce global prevention efforts.

Objective

To examine global patterns of cutaneous melanoma in 2020 and to provide projected estimates of cases and deaths by 2040.

Design, Setting, and Participants

This population-based study used the GLOBOCAN 2020 database for global epidemiological assessment of new cases and deaths due to invasive melanoma.

Main Outcomes and Measures

Age-standardized incidence and mortality rates were calculated per 100 000 person-years by country, world region, and 4-tier level of human development. Estimated numbers of cases and deaths were calculated for the year 2040.

Results

A worldwide total of 325 000 new melanoma cases (174 000 males, 151 000 females) and 57 000 deaths (32 000 males, 25 000 females) was estimated for 2020. Large geographic variations existed across countries and world regions, with the highest incidence rates among males (42 per 100 000 person-years) and females (31 per 100 000 person-years) observed in Australia/New Zealand, followed by Western Europe (19 per 100 000 person-years for males and females), North America (18 per 100 000 person-years for males, 14 per 100 000 person-years for females), and Northern Europe (17 per 100 000 person-years for males, 18 per 100 000 person-years for females). Melanoma continued to be rare in most African and Asian countries, with incidence rates commonly less than 1 per 100 000 person-years. Mortality rates peaked at 5 per 100 000 person-years in New Zealand, and geographic variations were less pronounced than for incidence. Melanoma was more frequent among males than females in most world regions. If 2020 rates continue, the burden from melanoma is estimated to increase to 510 000 new cases (a roughly 50% increase) and to 96 000 deaths (a 68% increase) by 2040.

Conclusions and Relevance

This epidemiological assessment suggests that melanoma remains an important challenge to cancer control and public health globally, especially in fair-skinned populations of European descent.

The current and future incidence and mortality of gastric cancer in 185 countries, 2020-40: A population-based modelling study

Background

To examine global patterns of gastric cancer in 2020 and the projected burden in 2040.

Methods

Data on primary gastric cancer were extracted from the GLOBOCAN database for the year 2020. Age-standardized incidence and mortality rates were calculated by sex, country, world region and level of human development index (HDI) for 185 countries. The predicted burden of incidence and mortality in 2040 was calculated based on demographic projections.

Findings

In total, ∼1.1 million new cases and 770,000 deaths of gastric cancer were estimated in 2020. Incidence rates were on average 2-fold higher in males than females (15.8 and 7.0 per 100,000, respectively) with variation across countries. Highest incidence rates were observed in Eastern Asia for both males and females (32.5 and 13.2, respectively); males residing in Japan (48.1), Mongolia (47.2) and Korea (39.7) had the highest rates in the world. Incidence was lowest in Africa with incidence rates < 5 per 100,000. Highest mortality rates were observed in Eastern Asia for both males (21.1) and females (8.8). A lower share of deaths was observed in very high HDI countries compared to medium and low HDI countries. The annual burden of gastric cancer is predicted to increase to ∼1.8 million new cases and ∼1.3 million deaths by 2040.

Interpretation

These estimates of the global burden of gastric cancer pinpoint countries and regions of high incidence and mortality in need of cancer control initiatives. Primary prevention through eradication of H. pylori and behavioural changes such as reducing salt intake, smoking, obesity, and alcohol, remains key in stomach cancer control.

Funding

No direct funding was received. All authors had access to the included study data and all authors agreed with the final decision to submit for publication.

International differences in lung cancer survival by sex, histological type and stage at diagnosis: an ICBP SURVMARK-2 Study

INTRODUCTION

Lung cancer has a poor prognosis that varies internationally when assessed by the two major histological subgroups (non-small cell (NSCLC) and small cell (SCLC)).

METHOD

236 114 NSCLC and 43 167 SCLC cases diagnosed during 2010-2014 in Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK were included in the analyses. One-year and 3-year age-standardised net survival (NS) was estimated by sex, histological type, stage and country.

RESULTS

One-year and 3-year NS was consistently higher for Canada and Norway, and lower for the UK, New Zealand and Ireland, irrespective of stage at diagnosis. Three-year NS for NSCLC ranged from 19.7% for the UK to 27.1% for Canada for men and was consistently higher for women (25.3% in the UK; 35.0% in Canada) partly because men were diagnosed at more advanced stages. International differences in survival for NSCLC were largest for regional stage and smallest at the advanced stage. For SCLC, 3-year NS also showed a clear female advantage with the highest being for Canada (13.8% for women; 9.1% for men) and Norway (12.8% for women; 9.7% for men).

CONCLUSION

Distribution of stage at diagnosis among lung cancer cases differed by sex, histological subtype and country, which may partly explain observed survival differences. Yet, survival differences were also observed within stages, suggesting that quality of treatment, healthcare system factors and prevalence of comorbid conditions may also influence survival. Other possible explanations include differences in data collection practice, as well as differences in histological verification, staging and coding across jurisdictions.

Excess Body Fatness during Early to Mid-Adulthood and Survival from Colorectal and Breast Cancer: A Pooled Analysis of Five International Cohort Studies

BACKGROUND

Here, we explore the association between excess weight during early to mid-adulthood and survival in patients diagnosed with breast and colorectal cancer, using a pooled analysis of five cohort studies and study participants from 11 countries.

METHODS

Participant-level body mass index (BMI) trajectories were estimated by fitting a growth curve model using over 2 million repeated BMI measurements from close to 600,000 cohort participants. Cumulative measures of excess weight were derived. Data from over 23,000 patients with breast and colorectal cancer were subsequently analyzed using time-to-event models for death with the date of diagnosis as start of follow-up. Study-specific results were combined through a random effect meta-analysis.

RESULTS

We found a significant dose-response relationship (P trend = 0.013) between the average BMI during early and mid-adulthood and death from breast cancer, with a pooled HR of 1.31 (1.07-1.60) and the time to death shortened by 16% for average BMI above 25 kg/m2 compared with average BMI less than or equal to 22.5 kg/m2, respectively. Similar results were found for categories of cumulative time spent with excess weight. There was no association between excess body fatness during early to mid-adulthood and death in patients with colorectal cancer.

CONCLUSIONS

Excess body fatness during early to mid-adulthood is associated not only with an increased risk of developing cancer, but also with a lower survival in patients with breast cancer.

IMPACT

Our results emphasize the importance of public health policies aimed at reducing overweight during adulthood and inform future studies on the relationship between excess weight and cancer outcomes.

A way to explore the existence of "immortals" in cancer registry data - An illustration using data from ICBP SURVMARK-2

BACKGROUND

Accurately recorded vital status of individuals is essential when estimating cancer patient survival. When deaths are ascertained by linkage with vital statistics registers, some may be missed, and such individuals will wrongly appear to be long-term survivors, and survival will be overestimated. Interval-specific relative survival that levels off above one indicates that the survival among the cancer patients is better than expected, which could be due to the presence of immortals.

METHODS

We included colon cancer cases diagnosed in 1995-1999 within the 19 jurisdictions in seven countries participating in ICBP SURVMARK-2, with follow-up information available until end-2015. Interval-specific relative survival was estimated for each year following diagnosis, by country and age group at diagnosis.

RESULTS

The interval-specific relative survival levels off at 1 for all countries and age groups, with two exceptions: for the age group diagnosed at age 75 years and above in Ireland, and, to a lesser extent, in New Zealand.

CONCLUSION

Overall, a subset of immortals are not apparent in the early years within the ICBP SURVMARK-2 study, except for possibly in Ireland. We suggest this approach as one strategy of exploring the existence of immortals, and to be part of routine checks of cancer registry data.

Outcomes after reperfusion therapies in patients with ACA stroke: A multicenter cohort study from the EVATRISP collaboration

BACKGROUND

Patients with stroke secondary to occlusions of the anterior cerebral artery (ACA) often have poor outcomes. The optimal acute therapeutic intervention for these patients remains unknown.

METHODS

Patients with isolated ACA-stroke were identified from 10 centers participating in the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) prospective registry. Patients treated with endovascular thrombectomy (EVT) were compared to those treated with intravenous thrombolysis (IVT). Odds ratios with 95% confidence intervals (OR; 95%CI) were calculated using multivariate regression analysis.

RESULTS

Included were 92 patients with ACA-stroke. Of the 92 ACA patients, 55 (60%) were treated with IVT only and 37 (40%) with EVT (±bridging IVT). ACA patients treated with EVT had more often wake-up stroke (24% vs. 6%, p = 0.044) and proximal ACA occlusions (43% vs. 24%, p = 0.047) and tended to have higher stroke severity on admission [NIHSS: 10.0 vs 7.0, p = 0.054). However, odds for favorable outcome, mortality or symptomatic intracranial hemorrhage did not differ significantly between both groups. Exploration of the effect of clot location inside the ACA showed that in patients with A1 or A2/A3 ACA occlusions the chances of favorable outcome were not influenced by treatment allocation to IVT or EVT.

DISCUSSION

Treatment with either IVT or EVT could be safe with similar effect in patients with ACA-strokes and these effects may be independent of clot location within the occluded ACA.

Comparison of liver cancer incidence and survival by subtypes across seven high-income countries

International comparison of liver cancer survival has been hampered due to varying standards and degrees for morphological verification and differences in coding practices. This article aims to compare liver cancer survival across the International Cancer Benchmarking Partnership's (ICBP) jurisdictions whilst trying to ensure that the estimates are comparable through a range of sensitivity analyses. Liver cancer incidence data from 21 jurisdictions in 7 countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the United Kingdom) were obtained from population-based registries for 1995-2014. Cases were categorised based on histological classification, age-groups, basis of diagnosis and calendar period. Age-standardised incidence rate (ASR) per 100 000 and net survival at 1 and 3 years after diagnosis were estimated. Liver cancer incidence rates increased over time across all ICBP jurisdictions, particularly for hepatocellular carcinoma (HCC) with the largest relative increase in the United Kingdom, increasing from 1.3 to 4.4 per 100 000 person-years between 1995 and 2014. Australia had the highest age-standardised 1-year and 3-year net survival for all liver cancers combined (48.7% and 28.1%, respectively) in the most recent calendar period, which was still true for morphologically verified tumours when making restrictions to ensure consistent coding and classification. Survival from liver cancers is poor in all countries. The incidence of HCC is increasing alongside the proportion of nonmicroscopically verified cases over time. Survival estimates for all liver tumours combined should be interpreted in this context. Care is needed to ensure that international comparisons are performed on appropriately comparable patients, with careful consideration of coding practice variations.

Risks of Undersizing Stent Retriever Length Relative to Thrombus Length in Patients with Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Results regarding the association of thrombus length, stent retriever length, and recanalization success in patients with acute ischemic stroke are inconsistent. We hypothesized that the ratio of thrombus length to stent retriever length may be of particular relevance.

MATERIALS AND METHODS

Patients with acute ischemic stroke undergoing stent retriever thrombectomy at our institution between January 2010 and December 2018 were reviewed retrospectively. Thrombus length was assessed by measuring the susceptibility vessel sign on SWI using a 1.5T or 3T MR imaging scanner. Multivariable logistic regression models were used to determine the association between thrombus length, stent retriever length, and thrombus length/stent retriever length ratio with first-pass recanalization, overall recanalization, and embolization in new territories. Results are shown as adjusted ORs with 95% CIs. Additional mediation analyses were performed to test for indirect effects on first-pass recanalization and overall recanalization success.

RESULTS

The main analysis included 418 patients (mean age, 74.9 years). Increasing stent retriever length was associated with first-pass recanalization. Decreasing thrombus length and lower thrombus length/stent retriever length ratios were associated with first-pass recanalization and overall recanalization. Thrombus length and stent retriever length showed no association with first-pass recanalization or overall recanalization once thrombus length/stent retriever length ratio was factored in, while thrombus length/stent retriever length ratio remained a significant factor in both models (adjusted OR, 0.316 [95% CI, 0.112-0.892]; P = .030 and adjusted OR, = 0.366 [95% CI, 0.194-0.689]; P = .002). Mediation analyses showed that decreasing thrombus length and increasing stent retriever length had a significant indirect effect on first-pass recanalization mediated through thrombus length/stent retriever length ratio. The only parameter associated with embolization in new territories was an increasing thrombus length/stent retriever length ratio (adjusted OR, 5.079 [95% CI, 1.332-19.362]; P = .017).

CONCLUSIONS

Information about thrombus and stent length is more valuable when combined. High thrombus length/stent retriever length ratios, which may raise the risk of unsuccessful recanalization and embolization in new territories, should be avoided by adapting stent retriever selection to thrombus length whenever possible.

High-degree atrioventricular block after valve-in-valve transcatheter aortic valve implantation: incidence and predictors

Background

High-degree atrioventricular (AV) block and permanent pacemaker (PPM) implantation represent major complications after transcatheter aortic valve implantation (TAVI). Data on the incidence of AV block for patients undergoing valve-in-valve (ViV) TAVI are scarce. We examined the incidence and predictors of periinterventional AV conduction disturbances in a cohort of subjects undergoing ViV TAVI compared to subjects undergoing TAVI of native aortic valves.

Methods

In 50 consecutive patients who underwent ViV TAVI, clinical characteristics, incidence and predictors for AV conduction disturbances as well as intrahospital outcome were assessed. Applying a matched pair approach for age, gender, type and size of transcatheter valve, these subjects were compared to 50 patients undergoing TAVI of native tricuspid aortic valves.

Results

Mean age in both groups was 80±6 years and 50% of subjects were male. In the ViV group, 22 patients (44%) had a stented bioprosthesis, 10 patients (20%) a stentless bioprosthesis and 18 patients (36%) a previous TAVI prosthesis (balloon-expandable: n=15, self-expandable n=3). The majority of subjects (92% in each group) were treated using balloon-expandable valves (ViV group: Sapien XT, n=20 or Sapien 3, n=26, control group: Sapien XT, n=19 or Sapien 3, n=27).

Periinterventional, non-reversible 3rd degree AV-block occurred in 6 patients within each group (12%), and all of the affected patients underwent PPM implantation. Among the 32 patients who underwent ViV-TAVI of a surgically placed bioprosthesis, only 2 (6%) developed a high-degree AV block (1/22 with a stented bioprosthesis and 1/10 with a stentless bioprosthesis). In contrast, high-degree AV block occurred in 4/18 patients (22%) who underwent ViV TAVI of a prior TAVI prosthesis. There was a significant difference in the occurrence of total high-degree AV blocks requiring postinterventional PPM implantation (p=0.033) between subjects who received TAVI of stented bioprostheses and those who received re-TAVI.

In logistic regression analysis, pre-existing RBBB represented a significant predictor for periinterventional 3rd degree AV block across the whole cohort (p=0.001, Exp(B)=10.667), both in ViV subjects (p=0.016, Exp(B)=12.0) and in the control group (p=0.018, Exp(B)=10.0).

Conclusion

Periinterventional AV block occurs infrequently in subjects undergoing ViV TAVI for treatment of degenerated surgical bioprostheses. However, patients undergoing ViV TAVI for degenerated transcatheter prostheses as well as subjects with pre-existing RBBB are at substantial risk for the occurence of AV block and require close peri-interventional monitoring.

Funding Acknowledgement

Type of funding sources: None.

Localization of the femoral artery bifurcation: hips don't lie – in at least 97% of cases

Background

The most common vascular access for structural cardiac interventions such as transcatheter aortic valve implantation (TAVI) is the common femoral artery (CFA). Depending on the procedure CFA puncture has to be performed not only unilaterally, but also bilaterally. Since incorrect localization of femoral access can lead to severe vascular complications, specific knowledge about the exact position of the CFA bifuraction is helpful. Such information might be systematically obtained from pre-TAVI CT scans.

Methods

We performed a retroperspective analysis of consecutive contrast-enhanced pre-TAVI CT angiography data sets (n=1000) to determine the CFA bifurcation localization relative to the femoral head and the correlation to contralateral CFA bifurcation location.

Results

The site of the CFA bifurcation was in 67.2% below the femoral head (−−), in 24.3% within the lower third of the femoral head (−), in 7.4% in the mid (0) and in 1.2% within the upper third (+) of the femoral head. Bifurcations above (++) the femoral head were not detected. CFA bifurcations below the femoral head showed the highest prevalence within men and women in all age groups (50–59, 60–69, 70–79, 80–89, 90–99 years). Bilateral agreement of CFA bifurcations was observed in only 69.3% and was independent of one-sided hip replacement (agreement 72.7%) or two-sided hip replacement (agreement 78.7%). A congruent contralateral left CFA bifurcation below the femoral head could be predicted in 80.6%, whereas CFA bifurcations within the lower and upper margins of the femoral head were congruent in only 65.7% (of these, 49.2% for the lower third, 29.7% for the mid and 36.4% for the upper third).

Conclusion

In conclusion, punctures within the upper third of the femoral head will provide an ideal puncture site in at least 97% of cases, independent of age, sex, or previous hip replacement.

Funding Acknowledgement

Type of funding sources: None.

Impact of COVID-19 lockdown on the procedural and intra-hospital outcome of STEMI patients

Background

While during the COVID-19 pandemic the number of patients presenting with ST-segment elevation myocardial infarction (STEMI) decreased, no change in patient or system delay could be shown due to local lockdown (LD) policy. Not much is known about the influence of LD on procedural details and intrahospital outcome of these patients.

Methods

Data was obtained from 511 patients treated for acute STEMI (24hours from symptom onset) from January 2019 to March 8th 2021 at two primary PCI (pPCI) centers in Germany. Patients presenting as intra-hospital STEMI, patients showing no culprit lesion and patients undergoing direct CABG were excluded. Overall, 456 patients (74% male, mean age 64±12) were included. These patients were divided into two groups: complete lockdown (LD; n=58; March 21st–April 20th 2020 and December 16th 2020–March 7th 2021) and no complete lockdown (No-LD; n=398)).

Results

There were no differences in pre-hospital care between the groups: Telemedicine (LD 23.5% vs. No-LD 34.9%; p=0.11), pre-alarm of the cath-lab staff (LD 59.6% vs. 66.6%, p=0.32) and direct admission to the cath-lab (LD 44.8% vs. No-LD 49.8%, p=0.58) were performed as often as in No-LD times. Neither the pain to first medical contact (LD 188±272 Min vs. No-LD 236±317 Min, p=0.29) nor the door to balloon time (55±54 Min vs. No-LD 49±58 Min, p=0.470) as well as other periods showed any difference.

All over cardio-pulmonary resuscitation (CPR; LD 19.0% vs. No-LD 14.3%, p=0.35) or presentation with cardiogenic shock (25.9% vs 23.9%, p=0.74) was equally presented in both groups. However, left ventricular assist devices were implanted more often during LD (6.9% vs. No-LD 1.8%; p=0.017).

Primary radial access was performed in the majority of the cases (LD 60.3% vs. No-LD 58.8%, p=0.82). During LD the culprit lesion was RCA in most cases (46.6% vs. No-LD LAD 46.7%, p=0.341). Stent thrombosis was not more common in out-of-hospital STEMI patients during LD (6.9% vs. 8.0%, p=0.76). Thrombus aspiration was performed in 10.3% during lockdown (vs. No-LD 4.5%, p=0.06), GP-IIb-IIIa inhibitors were not administered more often (LD 19.0% vs. No-LD 19.4%, p=0.92) and no reflow phenomenon was not seen more frequent (LD 20.7% vs. No-LD 21.3% p=0.91). TIMI III flow could be established in the majority of the cases (LD 86.0% vs. No-LD 91.5%, p=0.20).

During further hospital stay, neither the frequency of ventilator (LD 17.2% vs. No-LD 17.0%, p=0.98) nor vasopressor use (LD 20.7% vs. No-LD 20.1% p=0.925) differed. Left ventricular function (47±13% vs. No-LD 45±12%; p=0.34) and maximum creatinkinase (LD 1827±1687 U/l vs. No-LD: 2292±4100 U/l, p=0.40) showed no difference between the groups as did intrahospital death (LD 10.3% vs. No-LD 11.6%, p=0.79).

Conclusion

Despite the known decline in STEMI patients during LD periods, patient care, procedural details and inta-hospital outcome of the ones presenting to a pPCI hospital do not change during LD periods.

Funding Acknowledgement

Type of funding sources: None.

SWI Susceptibility Vessel Sign in Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The frequency and clinical significance of the susceptibility vessel sign in patients with acute ischemic stroke remains unclear. We aimed to assess its prevalence in patients with acute ischemic stroke undergoing mechanical thrombectomy and to analyze its association with interventional and clinical outcome parameters in that group.

MATERIALS AND METHODS

Six hundred seventy-six patients with acute ischemic stroke and admission MR imaging were reviewed retrospectively. Of those, 577 met the eligibility criteria for further analysis. Imaging was performed using a 1.5T or 3T MR imaging scanner. Associations between baseline variables, interventional and clinical outcome parameters, and susceptibility vessel sign were determined with multivariable logistic regression models. Results are shown as adjusted ORs with 95% CIs.

RESULTS

The susceptibility vessel sign was present in 87.5% (n = 505) of patients and associated with tandem occlusion (adjusted OR, 3.3; 95% CI, 1.1-10.0; P = .032) as well as successful reperfusion, defined as an expanded TICI score of ≥2b (adjusted OR, 2.4; 95% CI, 1.28-4.6; P = .007). The susceptibility vessel sign was independently associated with functional independence (mRS ≤ 2: adjusted OR, 2.1; 95% CI, 1.1-4.0; P = .028) and lower mortality (adjusted OR, 0.4; 95% CI, 0.2-0.7; P = .003) at 90 days, even after adjusting for successful reperfusion. The susceptibility vessel sign did not influence the number of passes performed during mechanical thrombectomy, the first-pass reperfusion, or the risk of peri- or postinterventional complications.

CONCLUSIONS

The susceptibility vessel sign is an MR imaging phenomenon frequently observed in patients with acute ischemic stroke and is associated with successful reperfusion after mechanical thrombectomy. However, superior clinical functional outcome and lower mortality noted in patients showing the susceptibility vessel sign could not be entirely attributed to higher reperfusion rates.

Population-based cancer staging for oesophageal, gastric, and pancreatic cancer 2012-2014: International Cancer Benchmarking Partnership SurvMark-2

Cancer stage at diagnosis is important information for management and treatment of individual patients as well as in epidemiological studies to evaluate effectiveness of health care system in managing cancer patients. Population-based studies to examine international disparities on cancer survival by stage, however, has been challenging due to the lack of international standardization on recording stage information and variation in stage completeness across regions and countries. The International Cancer Benchmarking Partnership (ICBP) previously assessed the availability and comparability of staging information for colorectal, lung, female breast and ovarian cancers. Stage conversion algorithms were developed to aggregate and map all stage information into a single staging system to allow international comparison by stage at diagnosis. In this article, we developed stage conversion algorithms for three additional cancers, namely oesophageal, gastric and pancreatic cancers. We examined all stage information available, evaluated stage completeness, applied each stage conversion algorithm, and assessed the magnitude of misclassification using data from six Canadian cancer registries (Alberta, Manitoba, Newfoundland, Nova Scotia, Prince Edward Island and Saskatchewan). In addition, we discussed five recommendations for registries to improve international cancer survival comparison by stage: (a) improve collection and completeness of staging data; (b) promote a comparable definition for stage at diagnosis; (c) promote the use of a common stage classification system; (d) record versions of staging classifications and (e) use multiple data sources for valid staging data.

The impact of reclassifying cancers of unspecified histology on international differences in survival for small cell and non-small cell lung cancer (ICBP SurvMark-2 project)

Survival from lung cancer remains low, yet is the most common cancer diagnosed worldwide. With survival contrasting between the main histological groupings, small-cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), it is important to assess the extent that geographical differences could be from varying proportions of cancers with unspecified histology across countries. Lung cancer cases diagnosed 2010-2014, followed until 31 December 2015 were provided by cancer registries from seven countries for the ICBP SURVMARK-2 project. Multiple imputation was used to reassign cases with unspecified histology into SCLC, NSCLC and other. One-year and three-year age-standardised net survival were estimated by histology, sex, age group and country. In all, 404 617 lung cancer cases were included, of which 47 533 (11.7%) and 262 040 (64.8%) were SCLC and NSCLC. The proportion of unspecified cases varied, from 11.2% (Denmark) to 29.0% (The United Kingdom). After imputation with unspecified histology, survival variations remained: 1-year SCLC survival ranged from 28.0% (New Zealand) to 35.6% (Australia) NSCLC survival from 39.4% (The United Kingdom) to 49.5% (Australia). The largest survival change after imputation was for 1-year NSCLC (4.9 percentage point decrease). Similar variations were observed for 3-year survival. The oldest age group had lowest survival and largest decline after imputation. International variations in SCLC and NSCLC survival are only partially attributable to differences in the distribution of unspecified histology. While it is important that registries and clinicians aim to improve completeness in classifying cancers, it is likely that other factors play a larger role, including underlying risk factors, stage, comorbidity and care management which warrants investigation.