Evaluation of the in vivo chemical reactivity of a novel copolymer insulation on cardiac leads in a single-center study

BACKGROUND

Human in vivo data on the chemical stability of different transvenous lead materials, particularly OptimTM leads, are lacking.

OBJECTIVES

The purpose of this study was to determine the chemical reactivity of insulation materials by analyzing the molar mass of extracted pacing and defibrillator leads METHODS: We collected extracted leads at Emory University Hospitals and sent the leads with thermoplastic outer insulation material for molar mass analysis, a material characteristic that informs biostability. Leads were separated based on the chemical identity of the outer insulation material, and the molar mass was measured by an independent party. The extent of chemical reaction was compared across leads having different materials: poly(ether)urethane 55D, poly(ether)urethane 80A, and Optim.

RESULTS

A total of 70 leads were extracted. The subset of extracted leads having outer insulation materials composed of PEU or Optim were analyzed for molar mass, where implant times ranged from 0.12 to 16.26 years. The rate of chemical degradation was compared by plotting the extent of reaction [Mn(t = 0)/Mn(t)] as a function of implant time. The Optim molar mass decreased to 40% of its initial value at 10 years of implant. No change in the molar mass of the PEU insulations could be resolved over the same 10-year implant time.

CONCLUSION

Because the molar mass of a polymer is directly related to its mechanical integrity, the observed decrease in molar mass of Optim likely translates into premature insulation defects and is consistent with the observed increased rate of electrical malfunction/noise in this subset of cardiac leads.

One-year mortality and causes of death after stereotactic radiation therapy for refractory ventricular arrhythmias: A systematic review and pooled analysis

Patients treated with cardiac stereotactic body radiation therapy (radioablation) for refractory ventricular arrhythmias are patients with advanced structural heart disease and significant comorbidities. However, data regarding 1-year mortality after the procedure are scarce. This systematic review and pooled analysis aimed at determining 1-year mortality after cardiac radioablation for refractory ventricular arrhythmias and investigating leading causes of death in this population. MEDLINE/EMBASE databases were searched up to January 2023 for studies including patients undergoing cardiac radioablation for the treatment of refractory ventricular arrhythmias. Quality of included trials was assessed using the NIH Tool for Case Series Studies (PROSPERO CRD42022379713). A total of 1,151 references were retrieved and evaluated for relevance. Data were extracted from 16 studies, with a total of 157 patients undergoing cardiac radioablation for refractory ventricular arrhythmias. Pooled 1-year mortality was 32 % (95 %CI: 23-41), with almost half of the deaths occurring within three months after treatment. Among the 157 patients, 46 died within the year following cardiac radioablation. Worsening heart failure appeared to be the leading cause of death (52 %), although non-cardiac mortality remained substantial (41 %) in this population. Age≥70yo was associated with a significantly higher 12-month all-cause mortality (p<0.022). Neither target volume size nor radiotherapy device appeared to be associated with 1-year mortality (p = 0.465 and p = 0.199, respectively). About one-third of patients undergoing cardiac stereotactic body radiation therapy for refractory ventricular arrhythmias die within the first year after the procedure. Worsening heart failure appears to be the leading cause of death in this population.

Worldwide survey on implantation of and outcomes for conduction system pacing with His bundle and left bundle branch area pacing leads

BACKGROUND

Adoption and outcomes for conduction system pacing (CSP), which includes His bundle pacing (HBP) or left bundle branch area pacing (LBBAP), in real-world settings are incompletely understood. We sought to describe real-world adoption of CSP lead implantation and subsequent outcomes.

METHODS

We performed an online cross-sectional survey on the implantation and outcomes associated with CSP, between November 15, 2020, and February 15, 2021. We described survey responses and reported HBP and LBBAP outcomes for bradycardia pacing and cardiac resynchronization CRT indications, separately.

RESULTS

The analysis cohort included 140 institutions, located on 5 continents, who contributed data to the worldwide survey on CSP. Of these, 127 institutions (90.7%) reported experience implanting CSP leads. CSP and overall device implantation volumes were reported by 84 institutions. In 2019, the median proportion of device implants with CSP, HBP, and/or LBBAP leads attempted were 4.4% (interquartile range [IQR], 1.9-12.5%; range, 0.4-100%), 3.3% (IQR, 1.3-7.1%; range, 0.2-87.0%), and 2.5% (IQR, 0.5-24.0%; range, 0.1-55.6%), respectively. For bradycardia pacing indications, HBP leads, as compared to LBBAP leads, had higher reported implant threshold (median [IQR]: 1.5 V [1.3-2.0 V] vs 0.8 V [0.6-1.0 V], p = 0.0008) and lower ventricular sensing (median [IQR]: 4.0 mV [3.0-5.0 mV] vs. 10.0 mV [7.0-12.0 mV], p < 0.0001).

CONCLUSION

In conclusion, CSP lead implantation has been broadly adopted but has yet to become the default approach at most surveyed institutions. As the indications and data for CSP continue to evolve, strategies to educate and promote CSP lead implantation at institutions without CSP lead implantation experience would be necessary.

Design and characteristics of the prophylactic intra-operative ventricular arrhythmia ablation in high-risk LVAD candidates (PIVATAL) trial

BACKGROUND

The use of a Left Ventricular Assist Device (LVAD) in patients with advanced heart failure refractory to optimal medical management has progressed steadily over the past two decades. Data have demonstrated reduced LVAD efficacy, worse clinical outcome, and higher mortality for patients who experience significant ventricular tachyarrhythmia (VTA). We hypothesize that a novel prophylactic intra-operative VTA ablation protocol at the time of LVAD implantation may reduce the recurrent VTA and adverse events postimplant.

METHODS

We designed a prospective, multicenter, open-label, randomized-controlled clinical trial enrolling 100 patients who are LVAD candidates with a history of VTA in the previous 5 years. Enrolled patients will be randomized in a 1:1 fashion to intra-operative VTA ablation (n = 50) versus conventional medical management (n = 50) with LVAD implant. Arrhythmia outcomes data will be captured by an implantable cardioverter defibrillator (ICD) to monitor VTA events, with a uniform ICD programming protocol. Patients will be followed prospectively over a mean of 18 months (with a minimum of 9 months) after LVAD implantation to evaluate recurrent VTA, adverse events, and procedural outcomes. Secondary endpoints include right heart function/hemodynamics, healthcare utilization, and quality of life.

CONCLUSION

The primary aim of this first-ever randomized trial is to assess the efficacy of intra-operative ablation during LVAD surgery in reducing VTA recurrence and improving clinical outcomes for patients with a history of VTA.

Childhood trauma in patients with epileptic vs nonepileptic seizures

OBJECTIVE

Childhood trauma has been implicated as a risk factor for the etiology of psychogenic nonepileptic seizures (PNES). Relatively little attention has been paid to whether profiles of specific trauma types differ between patients with epilepsy and PNES. Investigating childhood trauma profiles in these patient groups may identify psychological vulnerabilities that predispose to developing PNES, and aid early diagnoses, prevention, and treatment.

METHODS

Data were collected from two cohorts (n_{Retrospective}  = 203; n_Prospective  = 209) admitted to video-electroencephalography (EEG) monitoring units in Melbourne Australia. The differences in Childhood Trauma Questionnaire domain score between patient groups were investigated using standardized effect sizes and general linear mixed-effects models (GLMMs). Receiver-operating characteristic curves were used to investigate classification accuracy.

RESULTS

In the retrospective cohort, patients diagnosed with PNES reported greater childhood emotional abuse, emotional neglect, physical abuse, sexual abuse, and physical neglect relative to patients with epilepsy. These differences were replicated in the prospective cohort, except for physical abuse. GLMMs revealed significant main effects for group in both cohorts, but no evidence for any group by domain interactions. Reported sexual abuse showed the best screening performance of PNES, although no psychometric scores were adequate as isolated measures.

SIGNIFICANCE

Patients with PNES report a greater frequency of childhood trauma than patients with epilepsy. This effect appears to hold across all trauma types, with no strong evidence emerging for a particular trauma type that is more prevalent in PNES. From a practical perspective, inquiry regarding a history of sexual abuse shows the most promise as a screening measure.

Multidimensional psychopathological profile differences between patients with psychogenic nonepileptic seizures and epileptic seizure disorders

OBJECTIVE

Early differential diagnosis of psychogenic nonepileptic seizures (PNES) and epileptic seizures (ES) remains difficult. Self-reported psychopathology is often elevated in patients with PNES, although relatively few studies have examined multiple measures of psychopathology simultaneously. This study aimed to identify differences in multidimensional psychopathology profiles between PNES and ES patient groups.

METHOD

This was a retrospective case-control study involving patients admitted for video-EEG monitoring (VEM) over a two-year period. Clinicodemographic variables and psychometric measures of depression, anxiety, dissociation, childhood trauma, maladaptive personality traits, and cognition were recorded. Diagnosis of PNES or ES was determined by multidisciplinary assessment and consensus opinion. General linear mixed models (GLMMs) were used to investigate profile differences between diagnostic groups across psychometric measures. A general psychopathology factor was then computed using principal components analysis (PCA) and differences between groups in this 'p' factor were investigated.

RESULTS

261 patients (77 % with ES and 23 % with PNES) were included in the study. The PNES group endorsed greater symptomatology with GLMM demonstrating a significant main effect of group (η²_p = 0.05) and group by measure interaction (η²_p = 0.03). Simple effects analysis indicated that the PNES group had particularly elevated scores for childhood trauma (β = 0.78), dissociation (β = 0.70), and depression (β = 0.60). There was a high correlation between psychopathology measures, with a single p factor generated to explain 60 % variance in the psychometric scores. The p factor was elevated in the PNES group (β = 0.61). ROC curve analysis indicated that these psychometric measures had limited usefulness when considered individually (AUC range = 0.63-0.69).

CONCLUSION

Multidimensional psychopathological profile differences exist between patients with PNES and ES. Patients with PNES report more psychopathology overall, with particular elevations in childhood trauma, dissociation, and depression. Although not suitable to be used as a standalone screening tool to differentiate PNES and ES, understanding of these profiles at a construct level might help triage patients and guide further psychiatric examination and enquiry.

O086 Genomic analysis of response to neoadjuvant chemotherapy in oesophageal adenocarcinoma

Introduction

Oesophageal adenocarcinoma (OAC) is the ninth most common cancer worldwide with a mortality of over 500,000 deaths yearly. Neoadjuvant chemotherapy (NAC) followed by surgery is the standard of care (SOC) for locally advanced OAC. Although almost all patients receive chemotherapy as SOC, fewer than 20% obtain a clinically meaningful response and benefit before surgery. The OAC genome is complex and heterogeneous between patients, and it is not yet understood whether specific mutational patterns result in chemotherapy sensitivity or resistance.

Methods

To identify associations between genomic events and response to NAC in OAC, a comparative genomic analysis was performed in 65 patients using whole-genome sequencing. We defined response to NAC using Mandard Tumour Regression Grade TRG), with responders classified as TRG1-2 (n=27) and non-responders classified as TRG4- 5 (n=38).

Results

We report a higher non-synonymous mutation burden in responders (median 2.08/Mb vs 1.70/Mb, P=0.036) and elevated copy number variation (CNV) in non-responders (282 vs 136/patient, P&lt;0.001). We identified CNVs unique to each group, with cell cycle (CDKN2A, CCND1), c-Myc (MYC), RTK/PIK3 (KRAS, EGFR) and gastrointestinal differentiation (GATA6) pathway genes being specifically altered in non-responders. Of particular interest was the identification of the Neuron Navigator-3 (NAV3), a known tumour suppressor downstream of EGFR, which was mutated exclusively in 22% of non-responders.

Conclusion

We characterise genetic features and mutations that are uniquely associated with response to NAC. We envision a treatment pipeline that incorporates driver mutation profiling in OAC, combining response prediction with targeted therapies enhancing response to NAC and improving survival outcomes.

Take-home message

Developing a method of determining an OAC patient's response to neoadjuvant chemotherapy before treatment is administered is desperately needed and will improve patient outcome and quality of life. We identified a number of aberrations in the genome that were unique to non-responders to chemotherapy compared to responders, particularly a known tumour suppressor gene namely Neuron Navigator-3, suggesting that these events may contribute to chemoresistance in these patients. Our work characterises pre-existing genomic alterations that have potential as biomarkers for resistance or sensitivity to NAC.

Psychological safety in elite sport settings: a psychometric study of the Sport Psychological Safety Inventory

Objectives

Effectively supporting the mental health of elite athletes and coaches requires validated tools that assess not only individual-level factors but organisational-level influences. The aim of this study was to develop a bespoke scale assessing perceived psychological safety within high-performance environments.

Methods

337 elite athletes (M=24.12 years) and 238 elite-level coaches and high-performance support staff (HPSS; M=41.9 years) identified via the Australian Institute of Sport provided data across a range of mental health and well-being domains. Exploratory factor analysis (EFA; n=169 athletes) with parallel analysis identified the Sport Psychological Safety Inventory (SPSI) factor structure. Confirmatory factor analysis (CFA) validated the identified structure in separate validation subsamples of athletes (n=168) and coaches/HPSS (n=238).

Results

EFA identified the 11-item, 3-factor SPSI. Factors assessed domains of the Mentally Healthy Environment, Mental Health Literacy and Low Self-Stigma. All scale items loaded strongly on their specific domain. CFA model fit indices validated scale structure for athletes and coaches/HPSS. Internal consistency and convergent and divergent validity were evident. Logistic regression indicated that incrementally higher Mentally Healthy Environment scores reduced the likelihood of athletes scoring in the ‘moderate’ range of general and athlete-specific distress, with a stronger endorsement of the Low Self-Stigma subscale reducing the likelihood of being identified for athlete-specific distress.

Conclusion

Psychometric properties of the SPSI support scale utility among athletes and coaches/HPSS in elite sports settings, though further psychometric efforts are needed. This brief measure may support benchmarking efforts across elite sporting contexts to improve mental health culture and broader well-being among athletes and coaches/HPSS.

Outcomes Of Manifest Right Free Wall Accessory Pathway Ablation: Data From A Single Center

Background

Right free wall (RFW) accessory pathways (AP) typically present anatomical challenges to ablation leading to high rates of procedural failure and recovery of AP conduction.

Methods

Patients with a diagnosis of Wolff-Parkinson-White Syndrome (WPW) and a manifest RFW AP undergoing an electrophysiology study (EPS) or an ablation at our center between 01/01/2008 and 08/01/2019 were identified from our databases using diagnosis codes and manual chart review.

Results

Twenty-one patients with manifest RFW AP underwent EPS, all of which were targeted for ablation. Single procedure success rate was 19 / 21 (90.5%). Of the 19 successful cases, 4 (17.4%) patients were found to have recurrent right free wall pathway conduction at follow-up and each underwent a successful 2nd procedure (9.5%). Fluoroscopic and 3D electroanatomic mapping software was used in all cases to guide ablation. A 4 mm or 8 mm non-irrigated radiofrequency (RF) ablation catheter was used in 76% of cases while an 8 mm cryo-catheter was used in one case. More than one type of ablation catheter was used in four cases (16%). A steerable sheath was used in 68% of cases.

Conclusions

In a tertiary center, RFW AP ablation has high acute success (>90%) but approximately 21% of patients with initially successful ablation required a 2nd procedure for recurrence of pathway conduction. A combination of a large tip ablation catheter and a steerable sheath were used in most cases.

O4 Neural network image capture to predict response of oesophageal adenocarcinoma to neoadjuvant therapy

Introduction

Locally advanced oesophageal adenocarcinoma is typically treated with neoadjuvant chemotherapy (NACT) or chemoradiotherapy (NACRT) followed by surgery. Significant benefit to neoadjuvant treatment however is confined to a minority of patients (&lt;25%) and there are no reliable means of establishing prior to treatment in whom this benefit will occur. In this study, we assessed the utility of features extracted from high-resolution digital microscopy of pre-treatment biopsies in predicting response to neoadjuvant therapy in a machine-learning based modelling framework.

Method

A total of 102 cases were included in the study. Pre-treatment clinical information, including TNM staging, was obtained, along with diagnostic biopsies. Diagnostic biopsies were converted into high-resolution whole slide-images and features extracted using a pre-trained convolutional neural network (Xception). Elastic net regression models were then trained and validated with bootstrapping with 1000 resampled datasets. The response was considered according to Mandard tumour regression grade (TRG).

Result

There were 45 (44.1%) responders (TRG1-2) and 57 (57%) non-responders (TRG3-5) in the dataset. 34 patients (33.3%) received NACT and 68 (66.7%) received NACRT. A model trained with RNA-seq data achieved fair performance only in predicting response (AUC 0.598 95% CI 0.593–0.603), which was far exceeded by use of segmented diagnostic biopsy images (AUC 0.872 95% CI 0.869–0.875), which also produced well calibrated predictions of risk.

Conclusion

Despite using a small dataset, impressive performance in classifying response to neoadjuvant treatment can be achieved, particularly using automated image classification. Further study to refine the methodology is required before expansion to clinical settings.

Take-home Message

Response to neoadjuvant treatment for oesophageal cancer can be predicted from diagnostic biopsies

Stellate ganglion blockade for treating refractory electrical storm: a historical cohort study

BACKGROUND

Stellate ganglion blockade (SGB) has been used to treat electrical storm (ES) refractory to antiarrhythmic therapy or to stabilize patients before more definitive intervention. Nevertheless, its efficacy is not well understood, with only a few case reports and retrospective case series in the literature.

METHODS

We conducted a historical cohort study on patients with drug-refractory ES who underwent ultrasound-guided unilateral SGB from 1 January 2010 until 19 July 2019 at two hospital sites. Stellate ganglion blockade was performed with variable combinations of bupivacaine, lidocaine, ropivacaine, and dexamethasone. We collected data on demographic and procedural characteristics, the number of arrhythmias and defibrillation episodes, antiarrhythmic and anticoagulant medication, left ventricular ejection fraction (EF), and respiratory support requirement.

RESULTS

We identified N = 13 patients; their mean (standard deviation [SD]) age was 64 (13) yr, and 10 (77%) were male. The baseline mean (SD) number of overall arrhythmia and defibrillation episodes per day were 9 (6) and 4 (3), respectively; the mean (SD) pre-SGB EF was 23 (7)%. Seven patients (54%) received dexamethasone in addition to local anesthetic for SGB. One patient experienced hypotension after SGB. Arrhythmias and defibrillation episodes significantly decreased at 24, 48, 72, and 96 hr after SGB; at 96 hr, 62% and 92% of patients had no VA and defibrillation episodes, respectively (P < 0.001 for all time points). Ejection fraction and the number of patients receiving antiarrhythmic medications or requiring respiratory support were unchanged.

CONCLUSIONS

Unilateral SGB was associated with a reduction in arrhythmias and defibrillation episodes, but did not affect antiarrhythmic medication, respiratory support, or EF. Randomized controlled trials on larger cohorts are needed to confirm these findings.

Psychiatric and cognitive characteristics of older adults admitted to a Video-EEG monitoring (VEM) unit

OBJECTIVE

To compare the clinical, psychiatric, and cognitive characteristics of older with younger patients presenting to a video-EEG monitoring (VEM) unit.

METHOD

This was a retrospective case-control study involving patients admitted for VEM over a two-year period (from April 2018 to April 2020) at two comprehensive epilepsy units. Patients were categorized into an older (≥60 years) and a younger (<60 years) group. Younger patients were individually matched to older adults to form a matched younger group. Diagnosis was determined by a consensus opinion of epileptologists, neurologists, and neuropsychiatrists. The main diagnostic categories were epilepsy, psychogenic nonepileptic seizures (PNES), and 'other' diagnosis (non-diagnostic and other nonepileptic diagnoses). Clinical psychiatric diagnoses were obtained from neuropsychiatric reports. Objective cognitive function was measured with the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG). Subjective cognitive function was assessed using the Quality of Life in Epilepsy Inventory-89 (QOLIE-89) cognitive subscales.

RESULTS

Five-hundred and thirty three patients (71 older, 462 younger) aged 16-91 years were admitted to the VEM unit during the study period. There was a diagnosis of focal epilepsy in 55% of the older group and 48% of the younger group, generalized epilepsy in 3% of the older group and 10% of the younger group, and 'other' in 32% of the older group and 19% of the younger group. Ten percent (2 males and 5 females) of the older group were diagnosed with PNES compared to 22% of the younger group (p = 0.016). A depressive disorder was diagnosed in 34% of the older group and 24% of the younger group (p = 0.20). An anxiety disorder was diagnosed in 15% of the older group and 25% of the younger group (p = 0.15). Mild neurocognitive disorder was more common in the older group (34%) compared to the matched younger group (34% vs 3%, p < 0.001). The older group had lower mean NUCOG scores compared to the matched younger group (79.49 vs 87.73, p = <0.001). There was no evidence for a relationship between mean NUCOG score and overall subjective cognitive difficulties for the older group (r = 0.03, p = 0.83). Among older adults, those diagnosed with PNES had more experiences of childhood trauma. Measures of dissociation, depression, or general anxiety did not differ between PNES and non-PNES diagnoses in the older group.

CONCLUSION

Psychiatric comorbidities are common among older adults admitted for VEM. The psychological impact of epilepsy and risk factors for PNES seen in younger patients are also applicable in the older group. The older group demonstrated more cognitive impairments than the younger group, although these were usually unrecognized by individuals. Older adults admitted to VEM will benefit from psychiatric and neuropsychological input to ensure a comprehensive care approach to evaluation and management.

Athlete Experiences of Shame and Guilt: Initial Psychometric Properties of the Athletic Perceptions of Performance Scale Within Junior Elite Cricketers

Guilt and shame are self-conscious emotions with implications for mental health, social and occupational functioning, and the effectiveness of sports practice. To date, the assessment and role of athlete-specific guilt and shame has been under-researched. Reporting data from 174 junior elite cricketers (M = 17.34 years; females n = 85), the present study utilized exploratory factor analysis in validating the Athletic Perceptions of Performance Scale (APPS), assessing three distinct and statistically reliable factors: athletic shame-proneness, guilt-proneness, and no-concern. Conditional process analysis indicated that APPS shame-proneness mediated the relationship between general and athlete-specific distress (p < 0.01), with this pathway non-contingent on sex or past 12-month help-seeking for mental health concerns (p's > 0.05). While APPS domains of guilt-proneness and no-concern were not significant mediators, they exhibited correlations in the expected direction with indices of psychological distress and well-being. The APPS may assist coaches and support staff identify players who may benefit from targeted interventions to reduce the likelihood of experiencing shame-prone states.

O29: PREDICTING RESPONSE TO NEOADJUVANT THERAPY IN OESOPHAGEAL ADENOCARCINOMA PRE-TREATMENT BIOPSIES

Aims

We currently cannot predict which patients with locally advanced oesophageal adenocarcinoma will be amongst the 15-20% to gain a clinically important response to neoadjuvant therapy (NAT). This pilot study aimed to identify differentially expressed genes from oesophageal adenocarcinoma pre-treatment biopsies between responders and non-responders to NAT and develop methodology for predicting response.

Method

Response to NAT was assessed pathologically using Tumour Regression Grading (TRG). Pre-treatment formalin-fixed paraffin embedded samples were analysed with two nuclease protection assays (EdgeSeq, HTG = Oncology Biomarker Panel (OBP) and Precision Immuno-Oncology Panel (PIP)). Sequencing was performed on the NextSeq500 (Illumina).

Result

Whilst there was no difference in pre-treatment characteristics, responders (TRG1-2, n=26) had significantly better post-treatment pathology and overall survival than non-responders (TRG4-5, n=30). Genes up-regulated in responders were involved in regulating cell cycling, whereas genes up-regulated in non-responders were involved in cytokine signalling and the immune response. Neuronal artificial network models could predict response to NAT with overall accuracy of 73% and 68% for the OBP and PIP, respectively, which is promising considering the small sample size. As no model will be 100% accurate, we developed a model that could take patient's views into consideration with an adjustable probability threshold for classification.

Conclusion

This pilot study informs a biologically sound hypothesis for the basis of response to NAT and suggests prediction from pre-treatment biopsies may be possible using EdgeSeq. We now aim to validate these results in a larger study to inform a bespoke classifier of response to enable delivery of precision therapy.

Take-home message

In oesophageal adenocarcinoma, responders and non-responders to neoadjuvant therapy have different expression profiles. Through using EdgeSeq in larger studies, we may be able to predict which patients will respond to treatment, allowing for delivery of precision therapy.

O7: APPARENT PATHOLOGICAL COMPLETE RESPONSE TO NEOADJUVANT THERAPY LEADS TO SELECTION OF TREATMENT RESISTANT CANCER STEM CELLS IN OESOPHAGEAL ADENOCARCINOMA

Introduction

In oesophageal adenocarcinoma with an apparent pathological complete response (pCR) to neoadjuvant therapy (NAT) there remains debate as to whether oesophagectomy is required. Single Cell RNA sequencing (scRNAseq) enables identification and characterisation of cell populations at higher resolution than diagnostic techniques.

Method

ScRNAseq was used to determine transcriptomic profiles of cell populations in 24 OAC tumours and 13 matched normal samples. Five were also analysed using bulk RNA sequencing and high-precision mass spectrometry proteomics. Immunohistochemistry (IHC) was used to validate pCR. Paired scRNAseq analysis of pre-and post-treatment specimens from three further patients was used to compare transcriptomic profiles before and after NAT. Cancer cells (CCs) were assigned a cancer stem cell (CSC) score curated from published gene sets.

Result

We analysed a total of 22,738 single cells forming 29 different cell phenotypes. In two samples with apparent pCR, IHC staining, bulk RNA sequencing and proteomics of post-treatment samples failed to identify CCs. ScRNAseq, conversely, revealed persistent CCs (12/978 and 45/774). Transcriptomic analysis identified upregulation of stem cell markers and high CSC scores in these cells.

Conclusion

We have shown that CCs persist beneath the lower detection limit of standard approaches in apparent pCR. These cells express marker genes and expression programs consistent with CSCs. CSCs are a critical subpopulation that drive tumour initiation, growth, invasion, metastasis and resistance to therapy. These gene expression programs are not enriched in non-responders and straight to surgery samples. Oesophagus sparing treatment algorithms in pCR may subject patients to unnecessary risk of progression.

Take-home message

Cancer cells remain within tumours after apparent complete pathological response. These cells express stem cell markers associated with resistance to therapy and cancer progression.

A mixed-methods evaluation of the impact of a pharmacist-led feedback pilot intervention on insulin prescribing in a hospital setting

AIMS

To explore the impact of a prescribing feedback intervention on insulin prescribing.

METHODS

This was a mixed-methods study in a hospital setting. An insulin prescribing feedback intervention was delivered verbally and in writing to twelve doctors. Insulin prescribing error frequency was compared to ten doctors who had not received the feedback intervention. Insulin prescribing was audited over four weeks at the start and end of the intervention period. Semi-structured interviews were conducted with participating doctors who had received feedback, and qualitative data analysed thematically to explore the impact of the intervention on their prescribing practice.

RESULTS

Prescribing data were collected on 370 insulin prescriptions with 241 errors identified. A significant reduction (χ2 = 22.6, p=<0.05) in insulin prescribing error frequency was observed in the intervention group, with a non-significant increase reported in the control group. Feedback was received positively and considered valuable by doctors, supporting development of their knowledge and skills and encouraging reflection on their prescribing performance. Doctors described enhanced confidence in insulin prescribing and a desire to improve as a prescriber and avoid harm, with feedback raising awareness of their development needs. Prescribers also described enhanced team work, with greater information and feedback seeking behavior to inform future prescribing decisions.

CONCLUSIONS

Feedback has potential to improve insulin prescribing and is a valued and acceptable process intervention for doctors. The impact on insulin prescribing practice is varied and complex influencing the capability, opportunity and motivation of prescribers to adapt and evolve their behavior in response to ongoing feedback.

Clinical predictors of discordance between screening tests and psychiatric assessment for depressive and anxiety disorders among patients being evaluated for seizure disorders

OBJECTIVE

This study was undertaken to identify factors that predict discordance between the screening instruments Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) and Generalized Anxiety Disorder scale (GAD-7), and diagnoses made by qualified psychiatrists among patients with seizure disorders. Importantly, this is not a validation study; rather, it investigates clinicodemographic predictors of discordance between screening tests and psychiatric assessment.

METHODS

Adult patients admitted for inpatient video-electroencephalographic monitoring completed eight psychometric instruments, including the NDDI-E and GAD-7, and psychiatric assessment. Patients were grouped according to agreement between the screening instrument and psychiatrists' diagnoses. Screening was "discordant" if the outcome differed from the psychiatrist's diagnosis, including both false positive and false negative results. Bayesian statistical analyses were used to identify factors associated with discordance.

RESULTS

A total of 411 patients met inclusion criteria; mean age was 39.6 years, and 55.5% (n = 228) were female. Depression screening was discordant in 33% of cases (n = 136/411), driven by false positives (n = 76/136, 56%) rather than false negatives (n = 60/136, 44%). Likewise, anxiety screening was discordant in one third of cases (n = 121/411, 29%) due to false positives (n = 60/121, 50%) and false negatives (n = 61/121, 50%). Seven clinical factors were predictive of discordant screening for both depression and anxiety: greater dissociative symptoms, greater patient-reported adverse events, subjective cognitive impairment, negative affect, detachment, disinhibition, and psychoticism. When the analyses were restricted to only patients with psychogenic nonepileptic seizures (PNES) or epilepsy, the rate of discordant depression screening was higher in the PNES group (n = 29, 47%) compared to the epilepsy group (n = 70, 30%, Bayes factor for the alternative hypothesis = 4.65).

SIGNIFICANCE

Patients with seizure disorders who self-report a variety of psychiatric and other symptoms should be evaluated more thoroughly for depression and anxiety, regardless of screening test results, especially if they have PNES and not epilepsy. Clinical assessment by a qualified psychiatrist remains essential in diagnosing depressive and anxiety disorders among such patients.

Adverse events related to antiepileptic drugs

OBJECTIVE

Adverse events (AEs) related to antiepileptic drugs (AEDs) may interfere with adequate dosing and patient adherence, leading to suboptimal seizure control, and relatedly, increased injuries, hospitalizations, and mortality. This study investigated the clinicodemographic factors associated with AEs related to AEDs as reported by the Liverpool Adverse Events Profile (LAEP), and explored the ability of LAEP to discriminate between epilepsy and psychogenic nonepileptic seizures (PNES). We hypothesized that female sex, mood disorders, AED-polytherapy, duration, and severity of epilepsy are associated with increased endorsement of AEs related to AEDs, and that endorsement of AEs related to AEDs would significantly differ between epilepsy and PNES patients.

METHODS

We prospectively enrolled adult patients admitted to two inpatient video-electroencephalogram monitoring units. Clinicodemographic variables and psychometric measures of depression, anxiety, and cognitive function were recorded. Patient-reported AE endorsement was obtained using the LAEP, which was reduced to four latent domains using exploratory structural equation modeling. General linear models identified variables associated with each domain. Logistic regression determined the ability of LAEP scores to differentiate between epilepsy and PNES.

RESULTS

311 patients met inclusion criteria. Mean age was 38 years and 56% of patients were female. Network analysis demonstrated strong relationships between depression and anxiety with physical, sleep, psychiatric, and dermatological AE endorsement. Depression, female sex, and AED polytherapy were associated with greater AE endorsement. Epilepsy, compared to PNES, was associated with lower AE endorsement. Fewer prescribed AEDs and greater reported physical AE endorsement were associated with PNES diagnosis.

SIGNIFICANCE

There is a strong relationship between patient-reported AEs and psychiatric symptomatology. Those with PNES paradoxically endorse greater physical AEs despite receiving fewer AEDs. Patients who endorse AEs in clinical practice should be screened for comorbid depression or anxiety and treated accordingly.

Evaluating the impact of a pharmacist-led prescribing feedback intervention on prescribing errors in a hospital setting

BACKGROUND

Prescribing errors are prevalent in hospital settings with provision of feedback recommended to support prescribing of doctors. Feedback on prescribing has been described as feasible and valued but limited by doctors, with pharmacists described as credible facilitators of prescribing feedback. Evidence supporting prescribing feedback has been limited to date. A formalised programme of pharmacist-led prescribing error feedback was designed and implemented to support prescribers.

OBJECTIVE

To evaluate the impact of a prescribing feedback intervention on prescribing error rates and frequency of prescribing error severity and type.

METHOD

Prospective prescribing audits were undertaken across sixteen hospital wards in a UK teaching hospital over a five day period with 36 prescribers in the intervention group and 41 in the control group. The intervention group received pharmacist-led, individualised constructive feedback on their prescribing, whilst the control group continued with existing practice. Prescribing was re-audited after three months. Prescribing errors were classified by type and severity and data were analysed using relevant statistical tests.

RESULTS

A total of 5191 prescribed medications were audited at baseline and 5122 post-intervention. There was a mean prescribing error rate of 25.0% (SD 16.8, 95% CI 19.3 to 30.7) at baseline and 6.7% (SD 9.0, 95% CI 3.7 to 9.8) post-intervention for the intervention group, and 19.7% (SD 14.5, 95% CI 15.2 to 24.3) at baseline and 25.1% (SD 17.0, 95% CI 19.8 to 30.6) post-intervention for the control group with a significant overall change in prescribing error rates between groups of 23.7% (SD 3.5, 95% CI, -30.6 to -16.8), t(75) = -6.9, p < 0.05. The frequency of each error type and severity rating was reduced in the intervention group, whilst the error frequency of some error types and severity increased in the control group.

CONCLUSION

Pharmacist-led prescribing feedback has the potential to reduce prescribing errors and improve prescribing outcomes and patient safety.

Development and validation of a screening questionnaire for psychogenic nonepileptic seizures

OBJECTIVE

Epilepsy and psychogenic nonepileptic seizures (PNES) are serious conditions, associated with substantial morbidity and mortality. Although prompt diagnosis is essential, these conditions are frequently misdiagnosed, delaying appropriate treatment. We developed and validated the Anxiety, Abuse, and Somatization Questionnaire (AASQ), a quick and clinically practical tool to differentiate PNES from epilepsy.

METHOD

We retrospectively identified psychological variables that differentiated epilepsy from PNES in a discovery cohort of patients admitted to a video-electroencephalography monitoring (VEM) unit from 2002 to 2017. From these findings, we developed the AASQ and prospectively validated it in an independent cohort of patients with gold-standard VEM diagnosis.

RESULTS

One thousand two hundred ninety-one patients were included in the retrospective study; mean age was 39.5 years (range: 18-99), 58% were female, 67% had epilepsy, and 33% had PNES. Psychometric data for 192 instrument items were reviewed, receiver operating characteristic curves were computed, and a 20-item AASQ was created. Prospective validation in 74 patients showed that a one-point increase in the AASQ score was associated with 11 times increase in the odds of having PNES compared with epilepsy. Low scores on the AASQ were associated with a low probability of PNES with a negative predictive value of 95%.

SIGNIFICANCE

The AASQ is quick, inexpensive, and clinically useful for workup of seizure disorders. The AASQ excludes PNES with a high degree of confidence and can predict PNES with significance when combined with basic clinicodemographic variables. Future research will investigate diagnostic performance of the AASQ in relevant clinical subgroups, such as patients with comorbid epilepsy and PNES.

Experience using multielectrode cardiac catheters for detection of electrophysiologic activity of the human urinary bladder

AIM

To determine the feasibility of commercially available multielectrode cardiac electrophysiology catheters to detect electrical activity in the human bladder.

METHODS

Ten subjects requiring cystoscopy for the evaluation of lower urinary tract pathology were eligible for participation in our study. After routine rigid cystoscopy with a 70° cystoscope, various multielectrode cardiac electrophysiology catheters were introduced into the bladder. One of three catheters with different electrode configurations was used per subject. Electroanatomical images of the bladder were created and spontaneous electrical activity was recorded. Subjective response to electrical stimuli delivered across the electrodes (20 mA at 5 ms pulse width, rate 100 ms) was also recorded. The responses were qualitatively compared with that from a prior study.

RESULTS

Electrical activity recorded at the dome of the bladder was less than 0.5 mV and low frequency. Myopotentials resembling smooth muscle were detected at electrodes near or within the trigone. A sensory response was reported with the use of pacing stimuli, with the sensation in the trigone being reported more often than the dome of the bladder. Stimulation in the trigone triggered sensory urgency and voiding in a patient with a history of overactive bladder.

CONCLUSIONS

The use of multielectrode catheters to measure human bladder electrophysiologic activity is feasible. Issues with noise reduction still exist, though to a lesser extent with the multielectrode basket design than simple quadripolar one. Sensory responses to pacing stimuli may be useful for diagnostic and therapeutic purposes in the future.

Abstract 447: Myristoylation of Protein Kinase C Beta II Peptide Inhibitor Facilitates Rapid Attenuation of Phorbol 12-myristate 13-acetate in Activated Superoxide Release in Isolated Rat Polymorphonuclear Leukocytes

Protein kinase C beta II (PKCβII) activates polymorphonuclear leukocyte (PMN) superoxide (SO) production via NADPH oxidase (NOX-2) phosphorylation to exacerbate myocardial ischemia/reperfusion (I/R) injury. In prior studies, myristoylation (myr) of PKCβII peptide inhibitor (N-myr-SLNPEWNET; myr-PKCβII-), which disrupts PKCβII translocation/phosphorylation of NOX-2, was shown to dose-dependently attenuate PMN SO release induced by phorbol 12-myristate 13-acetate (PMA), a broad-spectrum PKC agonist. However, the role of myr on the inhibitory effects of myr-PKCβII- has yet to be elucidated. We hypothesized that myr-PKCβII peptide activator (N-myr-SVEIWD; myr-PKCβII+) would augment, myr-PKCβII- would attenuate, and scrambled myr-PKCβII- (N-myr-WNPESLNTE; myr-PKCβII-scram), a control for myr, would not affect PMA-induced PMN SO release compared to unconjugated peptides and nontreated controls. Rat PMNs (5х10 6 ) were incubated for 15 min at 37 o C in the presence/absence of SO dismutase (SOD; 10 μg/mL), unconjugated PKCβII+/-, myr-PKCβII+/-, or myr-PKCβII-scram (all 20 μM). SO release was measured by the change in absorbance at 550 nm via ferricytochrome c reduction after PMA (100 nM) stimulation for 390 sec. Data were analyzed by ANOVA using Student-Newman-Keuls post hoc analysis. Myr-PKCβII- significantly attenuated SO release (0.30±0.02; n=27; p<0.05) compared to nontreated controls (0.46±0.01; n=73), myr-PKCβII+ (0.46±0.03; n=25), unconjugated PKCβII+ (0.43±0.04; n=15), PKCβII- (0.43±0.02; n=22) and myr-PKCβII-scram (0.65±0.04; n=22). SOD (n=8), which rapidly converts SO to H 2 O 2 , significantly reduced absorbance by 94±7%, indicating that absorbance increased mainly due to PMA stimulation. Cell viability (trypan blue exclusion) was similar in all groups (94±2%). Unexpectedly, myr-PKCβII-scram significantly stimulated the highest increase in absorbance compared to all groups (p<0.01). Future studies will determine whether myr-PKCβII-scram augments absorbance by a different mechanism. Results suggest that myr improves myr-PKCβII- delivery compared to unconjugated PKCβII- but does not affect inhibition of PMA-induced PMN SO release. Myr-PKCβII- may thus effectively limit inflammation-induced I/R injury.

Abstract 449: Myristic Acid Conjugated Protein Kinase C Beta II Peptide Inhibitor Elicits Robust Cardioprotective Effects in Rat Myocardial Ischemia-Reperfusion Injury

Reactive oxygen species (ROS) induced ischemia-reperfusion (I/R) injury is a phenomenon causing paradoxical myocardial damage after cardio-angioplasty, coronary bypass and organ transplantation. Previous studies show that a cell-permeable myristic acid (myr-) conjugated PKCβII peptide inhibitor given at reperfusion prevents PKCβII translocation (N - myr-SLNPEWNET; myr-PKCβII-) and significantly attenuates ROS mediated I/R injury. We included a scrambled myr-PKCβII- (N-myr-WNPESLNTE; myr-PKCβII-scram) to examine the effects of myr separately. We hypothesize that myr-PKCβII- will improve and myr-PKCβII activator peptide (N-myr-SVEIWD; myr-PKCβII+) will exacerbate infarct size and post-reperfused cardiac function compared to myr-PKCβII-scram and untreated controls. Hearts isolated from male Sprague-Dawley rats (~300g) were perfused with Krebs’ buffer at a constant pressure of 80mmHg and subjected to 30 min of global ischemia and 50 min reperfusion. Myr-PKCβII-, myr-PKCβII+, myr-PKCβII-scram (all 20μM), or untreated control were given during the first five minutes of reperfusion. Left ventricular (LV) dP/dt max and dP/dt min (mmHg/s) were measured using a pressure transducer, and infarct size was determined using 1% triphenyltetrazolium chloride staining comparing infarcted tissue vs. total tissue weight. Data were evaluated using ANOVA with Student-Newman-Keuls post-hoc analysis. Myr-PKCβII- (n=17) significantly improved LV dP/dt max and dP/dt min to 1535±107 and 1063±83 at 50 min post-reperfusion compared to untreated control (815±107 and 722±89; n=15); myr-PKCβII-scram (513±78 and 433±66; n=12), and myr-PKCβII+ (860±118 and 694±81; n=14) (all p<0.05). Myr-PKCβII- significantly reduced infarct size (%) to 13±2 compared to untreated control (24±4); myr-PKCβII-scram (22±2), and myr-PKCβII+ (21±3) (all p<0.05). Unexpectedly, myr-PKCβII-scram significantly depressed post-reperfused LV dP/dt max and LV dP/dt min compared to untreated control and other treated groups (p<0.05). Results suggest that myr-PKCβII- exerted significant cardioprotective effects compared to untreated controls, myr- PKCβII+ and myr-PKCβII-scram and would improve clinical outcomes after cardio-angioplasty or organ transplantation.

Ablation of manifest septal accessory pathways: a single-center experience

BACKGROUND

Ablation of septal accessory pathways (SAPs) is associated with an increased risk of heart block. Data on outcomes of SAP ablation in adults are limited.

OBJECTIVES

To describe outcomes of SAP ablation in our center.

METHODS

Patients with Wolff-Parkinson-White syndrome (WPW) undergoing an EP study at our center between January 2008 and August 2019 were identified from our institutional database. Location of the pathway was noted as anteroseptal (AS), midseptal (MS), or posteroseptal (PS). Outcomes of the ablation including success, complication rates, and recurrences were also recorded.

RESULTS

Thirty-three patients with SAP underwent 35 EP studies: AS (n = 13), MS (n = 5), and PS (n = 15). Thirty pathways were targeted for ablation, two of which required a 2nd procedure resulting in 32 attempts at ablation in 30 patients. In the remaining 3 patients, SAP did not have malignant features and were not targeted for ablation. Single-procedure success rate was 28/30 (93.33%): 9/10 AS, 5/5 MS, and 14/15 PS ablations. One AS pathway was successfully ablated during a 2nd procedure. Two complications were observed: 1 pericardial effusion in a patient who underwent epicardial mapping and ablation of both PS and right free wall APs. Additionally, transient 2:1 AV block occurred during an MS pathway ablation that recovered during follow-up and did not require permanent pacing procedure.

CONCLUSION

In this single-center experience, ablation of manifest SAP was associated with high success rates and low complication rates. No instances of permanent heart block requiring pacing occurred.

AB0891 BARE TO THE BONE - AN AUDIT OF RENAL BONE DISEASE AGAINST KDIGO GUIDELINES

Background:

Chronic kidney disease-mineral and bone disorder (CKD-MBD) is complex and management can be difficult. We aimed to compare management of our CKD patients to 2018 KDIGO guidelines. The guidelines suggest checking calcium and phosphate (Ca/PO4) within 12 mths in CKD 3a and 3b, within 6 mths for CKD 4, and within 3 mths for CKD 5. Parathyroid hormone (PTH) should be checked at baseline in CKD 3a-b, within 12 mths in CKD 4 and within 6mths in CKD 5. Alkaline phosphatase (ALP) should be measured within 12 mths in CKD 4 and 5. 25-(OH)D levels ‘might’ be measured at baseline in CKD 3a to 5D. BMD scanning is suggested if the result will impact treatment decisions. Lateral abdominal X ray is recommended as an alternative to CT for detection of vascular calcification. Calcitriol and vitamin D analogues are no longer routinely advised in CKD 3a-5; 25-(OH)D insufficiency should be corrected as in the normal population.

Objectives:

To compare management of our CKD patients to 2018 KDIGO guidelines

Methods:

We randomly selected 70 patients in whom data was available from renal clinics between May and September 2019.

Results:

Mean age was 67.3 yrs. 41 male, 29 female. 33 patients had CKD 3a-b; 31 had CKD 4; 6 had CKD 5. Mean duration of CKD was 10.6 yrs. 10 patients were taking activated vitamin D analogues; 13 were taking 25-(OH)D analogues. 25-(OH)D levels ranged from 24-158 nmol/L (mean 65nmol/L). PTH levels ranged from 2- 69pmol/L (mean 23pmol/L). 3 patients were taking bisphosphonates. 44 had previous lumbar spinal imaging; vertebral fractures were evident in 4 (9%). 12 patients had had DXA scans; lowest T score was -2.5. Table 1 - tests within suggested time frames:

CKD 3a-3bCKD 4CKD 5Ca/ PO433 (100%)29 (93%)6 (100%)ALP33 (100%)31 (100%)6 (100%)PTH14 (42%) (ever)8 (26%)3 (50%)25-(OH)D8 (24%) (ever)8 (26%) (ever)1 (14%)(ever)

Conclusion:

Optimum PTH levels in CKD patients are not known, and therapeutic options in CKD-MBD often limited. Nevertheless, our results suggest that bone biochemistry could be checked more consistently in CKD patients. Although detection of vascular calcification may not alter renal management, abdominal imaging provides an opportunity to screen for vertebral fracture, present in a significant number of our patients. The KDIGO guidelines offer a framework to work with our renal colleagues, as many patients will be jointly managed.

References:

[1]Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney

[2]Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease:

[3]Improving Global Outcomes 2017 Clinical Practice Guideline Update. Ann Int Med 2018

Disclosure of Interests:

NATALIA CERNOVSCHI: None declared, SHABEENA ZEB: None declared, TRACEY SALTER: None declared, MARK LLOYD Speakers bureau: £700 into department fund

THU0589 ‘KU FEVER’: A CASE REPORT

Background:

Anti-Ku antibodies have been associated with various connective tissue diseases, including myositis, arthritis, interstitial lung disease and glomerulonephritis1.

Objectives:

We present a case of a woman initially diagnosed with biopsy proven Kikuchi-Fujimoto disease who later developed a rapidly progressive myositis in association with anti-Ku antibodies.

Methods:

A 47 year-old woman, originally from Myanmar, presented with lymphadenopathy, myalgia, fatigue, livedo reticularis and low-grade fever for the previous 6 months. This was initially diagnosed as a viral infection. Her myalgia progressed with proximal muscle weakness in both legs and associated rise in creatine kinase levels to 349U/L (normal range 25-200). She also developed dyspnoea, an erythematous rash, mouth ulcers and unintentional weight loss.

Blood tests show a lymphopenia and progressively rising CK, with a maximum level of 516 U/L. MRI whole body confirmed a widespread diffuse myositis in her upper and lower limbs, with an unusual ‘speckled’ pattern. High resolution CT Chest was normal. C3 0.40 g/l (normal range 0.75-1.65) and C4 0.12 g/l (0.14-0.54) were low, with a positive ANA (1:160) and Ro-60 antibody. dsDNA, antiphospholipid screen and virology screens were all negative. Extended myositis panel revealed positive anti-Ku antibodies. Axillary lymph node biopsy confirmed necrotising lymphadenitis, consistent with Kikuchi-Fujimoto disease.

Results:

She was initially treated with low dose Prednisolone and Hydroxychloroquine, with a limited response. Due to progressive myositis, pulsed IV Methylprednisolone 1g was provided over 3 days and mycophenolate mofetil (MMF) was started.

An inpatient stay was needed after developing an axillary node abscess and a chest infection. This was treated with intravenous antibiotics and repeated aspirations. Due to progressive myositis on a background of sepsis, intravenous immunoglobulin (IVIG) was administered over 5 days. Our patient made a good recovery, with normalization of CK levels and resolution of the myositis noted on repeat MRI scan. She remains on MMF as maintenance therapy.

Conclusion:

Anti Ku antibodies appear to be associated with 2 spectrums of disease – elevated CK levels with interstitial lung disease and renal disease associated with anti-dsDNA antibodies1To our knowledge this is the first report in association with Kikuchi-Fujimoto disease. The combination of MMF and IVIG appears to have been effective treatment and her renal function remains stable, although we are monitoring the patient carefully for the possible development of interstitial lung disease.

References:

[1]Spielmann L, Nespola B, Séverac F, et al. Anti-Ku syndrome with elevated CK and anti-Ku syndrome with anti-dsDNA are two distinct entities with different outcomes. Annals of the Rheumatic Diseases 2019;78:1101-1106.

Disclosure of Interests:

None declared

THU0291 IS GIANT CELL ARTERITIS REALLY GIANT CELL ARTERITIS? A HISTOLOGICAL REVIEW OF TEMPORAL ARTERY BIOPSIES FROM A UK DISTRICT GENERAL HOSPITAL

Background:

Despite the advent of newer imaging techniques, temporal artery biopsy (TAB) retains a key role in the diagnosis of giant cell arteritis (GCA). The classical histological description of GCA is that of granulomatous lesions characterized by a transmural inflammatory infiltrate1. Giant cells are typically noted in the internal elastic lamina. Vascular remodeling and structural changes are also frequently described, with intimal hyperplasia or fragmentation, fibrosis and calcifications1.

Objectives:

To identify the type and location of the inflammatory lesions in TAB-positive cases of GCA.

Methods:

We conducted a retrospective analysis of all TABs undertaken at our unit between 2011- 2018 with clinical record review. TABs were performed by vascular, ophthalmology and ENT teams.

Results:

379 TABs were reviewed of which 68 (17.9%) were reported as positive and 10 (2.6%) were equivocal (presence of fragmentation and intimal thickening). Of the TAB-positive cases, 43 (63.2%) were greater than 1cm in keeping with the British Society for Rheumatology guidance and 65 (95.6%) were biopsies in patients on corticosteroids at the time of procedure. The following tables demonstrate the frequency of the type and location of the inflammatory lesions detected in TAB-positive cases of GCA.

Type of inflammatory lesionFrequencyChronic inflammatory infiltrate (lymphocytes, macrophages, plasma cells)66Giant cells41Intimal thickening22Intimal fragmentation33Location of inflammatory infiltrateFrequencyFull thickness32Intima only7Intima and Media only3Media only7Media and Adventitia only8Adventitia only4Intima and Adventitia only3Not recorded4

Conclusion:

Only 60% of our TAB-positive biopsies had giant cells present. Although perhaps surprisingly low, this finding is similar to other studies1,2. It emphasises the need to review the body of a report as well the conclusion. Other non-giant cell features present in positive reported biopsies may suggest a less certain diagnosis and prompt clinical review. There was considerable variablity in the style of reporting. With no standardised scoring system in place, the variable spectrum of inflammation and differences in reporting, there is the potential for inconsistencies amongst pathologists in interpreting and recording TAB results. Consistent reporting templates and close collaboration between rheumatologists and pathologists is needed to help correlate clinical, laboratory and imaging findings.

References:

[1]Cavazza A, Muratore F, Boiardi L, Restuccia G, Pipitone N, Pazzola G, et al. Inflamed temporal artery: histologic findings in 354 biopsies, with clinical correlations. Am J Surg Pathol. 2014;38(10):1360-70.

[2]Hernandez-Rodriguez J, Murgia G, Villar I, Campo E, Mackie SL, Chakrabarty A, et al. Description and Validation of Histological Patterns and Proposal of a Dynamic Model of Inflammatory Infiltration in Giant-cell Arteritis. Medicine (Baltimore). 2016;95(8):e2368.

Disclosure of Interests:

Soha Khaled Amar: None declared, Dimitrios Christidis: None declared, George Kousparos: None declared, MARK LLOYD Speakers bureau: £700 into department fund

Illinois Dental Anesthesia and Sedation Survey for 2016

A statewide decennial survey was sent to practicing dentists holding sedation or general anesthesia permits to identify office sedation/general anesthesia trends and practices over the last 10 years. This survey constitutes the third such survey, spanning a total of 20 years. Of the 234 respondents in the 2016 survey, 34% held an Illinois moderate sedation permit and 64% held a general anesthesia permit. Oral and maxillofacial surgeons represented the majority of respondents (143/234; 61%). The remainder of responses were from general dentists (39; 17%) pediatric dentists (32; 14%), periodontists (16; 7%), dentist anesthesiologists (3; 1.3%) and 1 periodontist/dentist anesthesiologist. Surveys over the 20 years revealed the following significant trends: an increase in practitioners current in advanced cardiac life support certification, an increase in the number of non-oral maxillofacial surgeons with a sedation permit, an increase in providers of moderate sedation, and an increase in offices equipped with end-tidal CO₂ and electrocardiogram monitoring. However, a number of providers were identified as not compliant with certain state mandates. For example, many respondents failed to meet minimum office team staffing requirements during sedation, hold semiannual office emergency drills, and establish written emergency management protocols.

A review of specialized and automated features in implantable cardiac devices

Automated features available in cardiac implantable electronic devices continue to increase in number and complexity. These features are frequently confused with device malfunction and often result in unnecessary clinical attention. This review will serve as an update to some of the more commonly-encountered features discussed in terms of the behavior they exhibit.

Spider-specific probe set for ultraconserved elements offers new perspectives on the evolutionary history of spiders (Arachnida, Araneae)

Phylogenomic methods have proven useful for resolving deep nodes and recalcitrant groups in the spider tree of life. Across arachnids, transcriptomic approaches may generate thousands of loci, and target-capture methods, using the previously designed arachnid-specific probe set, can target a maximum of about 1,000 loci. Here, we develop a specialized target-capture probe set for spiders that contains over 2,000 ultraconserved elements (UCEs) and then demonstrate the utility of this probe set through sequencing and phylogenetic analysis. We designed the 'spider-specific' probe set using three spider genomes (Loxosceles, Parasteatoda and Stegodyphus) and ensured that the newly designed probe set includes UCEs from the previously designed Arachnida probe set. The new 'spider-specific' probes were used to sequence UCE loci in 51 specimens. The remaining samples included five spider genomes and taxa that were enriched using Arachnida probe set. The 'spider-specific' probes were also used to gather loci from a total of 84 representative taxa across Araneae. On mapping these 84 taxa to the Arachnida probe set, we captured at most 710 UCE loci, while the spider-specific probe set captured up to 1,547 UCE loci from the same taxon sample. Phylogenetic analyses using maximum likelihood and coalescent methods corroborate most nodes resolved by recent transcriptomic analyses, but not all (e.g. UCE data suggest monophyly of 'symphytognathoids'). Our preferred hypothesis based on topology tests, suggests monophyly of the 'symphytognathoids' (the miniature orb weavers), which in previous studies has only been supported by a combination of morphological and behavioural characters.

Life's Simple 7 Approach to Atrial Fibrillation Prevention

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice. It constitutes a major public health problem, with total related annual expenses estimated at $6.65 billion. The American Heart Association developed Life's Simple 7 (LS7) to define and monitor ideal cardiovascular health (CVH). In this review, we examine the role of individual components of LS7 to provide further insight regarding potential influence of achieving AHA's strategic goal on AF prevention. While significant advances have been made in the secondary prevention of AF, little progress has been made to prevent the first occurrence of this arrhythmia in at-risk patients. Improvement of overall cardiovascular health as defined by LS7 may substantially reduce AF risk.

Asthma prevalence and control levels among Special Olympics athletes, and asthma-related knowledge of their coaches

BACKGROUND

The prevalence of asthma among athletes with intellectual disabilities, and the asthma knowledge levels of their coaches, is unknown.

METHODS

Special Olympics Canada athletes completed a demographic questionnaire (n = 208). Athletes who identified as having ever or current asthma completed the Asthma Control Questionnaire and the Mini Asthma Quality of Life Questionnaire and were measured for height, weight and lung function (n = 73). National level coaches (n = 27) completed a questionnaire pertaining to asthma knowledge.

RESULTS

The prevalence of ever and current asthma were 35.5% (n = 73) and 21.1% (n = 44), respectively. Athletes with asthma reported that they had inadequately controlled asthma, but good quality of life. Coaches correctly answered 43% true/false questions on the survey, indicating suboptimal asthma knowledge.

CONCLUSIONS

Athletes with intellectual disabilities appear to have a greater prevalence of asthma than the general population; however, coaches of these athletes appear to have limited knowledge pertaining to asthma and exercise-induced asthma.