Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery

BACKGROUND

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions.

METHODS

Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics.

RESULTS

Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts.

DISCUSSION

Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Displacement of Zygomatic Implant in infratemporal region in a case of COVID-19 associated Mucormycosis

Reconstruction of maxillary defects can be carried out by a variety of treatment modalities. The choice of modality depends on numerous factors including the size and extent of the defect, patient factors and existing comorbidities. One of the various options is reconstruction and rehabilitation using a fixed prosthesis supported over zygomatic implant. In maxillectomy cases, zygomatic implant can be used to improve the retention of the obturator prosthesis as loss of alveolar bone makes it impossible to use conventional endosseous implants. Even though the zygomatic implants are advocated to have high success rates, they are not complication free. We hereby present a rare complication associated with placement of zygomatic implant in an operated patient of COVID - 19 associated mucormycosis. This rare complication has never been reported before. The case report also highlights on the management of complication involving displacement of zygomatic implant in infratemporal region.

The 1.7 Å crystal structure of the C5a peptidase from Streptococcus agalactiae (ScpB) reveals an active site competent for catalysis

A 1.7 Å structure is presented for an active form of the virulence factor ScpB, the C5a peptidase from Streptococcus agalactiae. The previously reported structure of the ScpB active site mutant exhibited a large separation (~20 Å) between the catalytic His and Ser residues. Significant differences are observed in the catalytic domain between the current and mutant ScpB structures resulting with a high RMSDCα (4.6 Å). The fold of the active form of ScpB is nearly identical to ScpA (RMSDCα 0.2 Å), the C5a-peptidase from Streptococcus pyogenes. Both ScpA and ScpB have comparable activity against human C5a, indicating neither enzyme require host proteins for C5a-ase activity. These studies are a first step in resolving reported differences in the specificities of these enzymes.

Multiparametric MRI and T2/FLAIR mismatch complements the World Health Organization 2021 classification for the diagnosis of IDH-mutant 1p/19q non-co-deleted/ATRX-mutant astrocytoma

AIM

To investigate whether T2-weighted imaging-fluid-attenuated inversion recovery (T2/FLAIR) mismatch, T2∗ dynamic susceptibility contrast (DSC) perfusion, and magnetic resonance spectroscopy (MRS) correlated with the histological diagnosis and grading of IDH (isocitrate dehydrogenase)-mutant, 1p/19q non-co-deleted/ATRX (alpha-thalassemia mental retardation X-linked)-mutant astrocytoma.

MATERIALS

Imaging of 101 IDH-mutant diffuse glioma cases of histological grades 2-3 (2019-2021) were analysed retrospectively by two neuroradiologists blinded to the molecular diagnosis. T2/FLAIR mismatch sign is used for radio-phenotyping, and pre-biopsy multiparametric MRI images were assessed for grading purposes. Cut-off values pre-determined for radiologically high-grade lesions were relative cerebral blood volume (rCBV) ≥2, choline/creatine ratio (Cho/Cr) ≥1.5 (30 ms echo time [TE]), Cho/Cr ≥1.8 (135 ms TE).

RESULTS

Sixteen of the 101 cases showed T2/FLAIR mismatch, all of which were histogenetically confirmed IDH-mutant 1p/19q non-co-deleted/ATRX mutant astrocytomas; 50% were grade 3 (8/16) and 50% grade 2 (8/16). None showed contrast enhancement. Nine of the 16 had adequate multiparametric MRI for analysis. Any positive value by combining rCBV ≥2 with Cho/Cr ≥1.5 (30 ms TE) or Cho/Cr ≥1.8 (135 ms TE) predicted grade 3 histology with sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 100%.

CONCLUSION

The T2/FLAIR mismatch sign detected diffuse astrocytomas with 100% specificity. When combined with high Cho/Cr and raised rCBV, this predicted histological grading with high accuracy. The future direction for imaging should explore a similar integrated layered approach of 2021 classification of central nervous system (CNS) tumours combining radio-phenotyping and grading from structural and multiparametric imaging.

ECFS standards of care on CFTR-related disorders: Towards a comprehensive program for affected individuals

After three publications defining an updated guidance on the diagnostic criteria for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorders (pwCFTR-RDs), establishing its relationship to CFTR-dysfunction and describing the individual disorders, this fourth and last paper in the series addresses some critical challenges facing health care providers and pwCFTR-RD. Topics included are: 1) benefits and obstacles to collect data from pwCFTR-RD are discussed, together with the opportunity to integrate them into established CF-registries; 2) the potential of infants designated CRMS/CFSPID to develop a CFTR-RD and how to communicate this information; 3) a description of the challenges in genetic counseling, with particular regard to phenotypic variability, unknown long-term evolution, CFTR testing and pregnancy termination 4) a proposal for the assessment of potential barriers to the implementation and dissemination of the produced documents to health care professionals involved in the care of pwCFTR-RD and a process to monitor the implementation of the CFTR-RD recommendations; 5) clinical trials investigating the efficacy of CFTR modulators in CFTR-RD and how endpoints and outcomes might be adapted to the heterogeneity of these disorders.

Effective interventions for improving routine childhood immunisation in low and middle-income countries: a systematic review of systematic reviews

OBJECTIVE

An umbrella review providing a comprehensive synthesis of the interventions that are effective in providing routine immunisation outcomes for children in low and middle-income countries (L&MICs).

DESIGN

A systematic review of systematic reviews, or an umbrella review.

DATA SOURCES

We comprehensively searched 11 academic databases and 23 grey literature sources. The search was adopted from an evidence gap map on routine child immunisation sector in L&MICs, which was done on 5 May 2020. We updated the search in October 2021.

ELIGIBILITY CRITERIA

We included systematic reviews assessing the effectiveness of any intervention on routine childhood immunisation outcomes in L&MICs.

DATA EXTRACTION AND SYNTHESIS

Search results were screened by two reviewers independently applying predefined inclusion and exclusion criteria. Data were extracted by two researchers independently. The Specialist Unit for Review Evidence checklist was used to assess review quality. A mixed-methods synthesis was employed focusing on meta-analytical and narrative elements to accommodate both the quantitative and qualitative information available from the included reviews.

RESULTS

62 systematic reviews are included in this umbrella review. We find caregiver-oriented interventions have large positive and statistically significant effects, especially those focusing on short-term sensitisation and education campaigns as well as written messages to caregivers. For health system-oriented interventions the evidence base is thin and derived from narrative synthesis suggesting positive effects for home visits, mixed effects for pay-for-performance schemes and inconclusive effects for contracting out services to non-governmental providers. For all other interventions under this category, the evidence is either limited or not available. For community-oriented interventions, a recent high-quality mixed-methods review suggests positive but small effects. Overall, the evidence base is highly heterogenous in terms of scope, intervention types and outcomes.

CONCLUSION

Interventions oriented towards caregivers and communities are effective in improving routine child immunisation outcomes. The evidence base on health system-oriented interventions is scant not allowing us to reach firm conclusions, except for home visits. Large evidence gaps exist and need to be addressed. For example, more high-quality evidence is needed for specific caregiver-oriented interventions (eg, monetary incentives) as well as health system-oriented (eg, health workers and data systems) and community-oriented interventions. We also need to better understand complementarity of different intervention types.

Inhaled mRNA therapy for treatment of cystic fibrosis: Interim results of a randomized, double-blind, placebo-controlled phase 1/2 clinical study

BACKGROUND

MRT5005, a codon-optimized CFTR mRNA, delivered by aerosol in lipid nanoparticles, was designed as a genotype-agnostic treatment for CF lung disease.

METHODS

This was a randomized, double-blind, placebo-controlled Phase 1/2 study performed in the US. Adults with 2 severe class I and/or II CFTR mutations and baseline ppFEV1 values between 50 and 90% were randomized 3:1 (MRT5005: placebo). Six dose levels of MRT5005 (4, 8, 12, 16, 20, and 24 mg) or placebo (0.9% Sodium Chloride) were administered by nebulization. The single ascending dose cohort was treated over a range from 8 to 24 mg; the multiple ascending dose cohort received five weekly doses (range 8-20 mg); and the daily dosing cohort received five daily doses (4 mg).

RESULTS

A total of 42 subjects were assigned to MRT5005 [31] or placebo [11]. A total of 14 febrile reactions were observed in 10 MRT5005-treated participants, which were mild [3] or moderate [11] in severity; two subjects discontinued related to these events. Additionally, two MRT5005-treated patients experienced hypersensitivity reactions, which were managed conservatively. The most common treatment emergent adverse events were cough and headache. No consistent effects on FEV1 were noted.

CONCLUSIONS

MRT5005 was generally safe and well tolerated through 28 days of follow-up after the last dose, though febrile and hypersensitivity reactions were noted. The majority of these reactions resolved within 1-2 days with supportive care allowing continued treatment with MRT5005 and careful monitoring. In this small first-in-human study, FEV1 remained stable after treatment, but no beneficial effects on FEV1 were observed.

Operative approach and case volume are associated with negative resection margins for adrenocortical carcinoma

BACKGROUND

Surgical resection with negative margins is the treatment of choice for adrenocortical carcinoma (ACC). This study was undertaken to determine factors associated with negative resection margins.

METHODS

National Cancer Database was queried from 2010 to 2016 to identify patients with AJCC/ENSAT Stage I-III ACC who underwent adrenalectomy. Patient, tumor, facility, and operative characteristics were compared by margin status (positive-PM or negative-NM) and operative approach (open-OA, laparoscopic-LA, or robotic-RA). Multivariable logistic regression was used to identify factors associated with PM.

RESULTS

Eight hundred and eighty-one patients were identified, of which 18.4% had PM and 81.6% had NM. Patients with advanced pathologic T stage and pathologic N1 stage were more likely to have PM (vs. NM) (T3, 49.7% vs. 24.8%, p < 0.01; T4, 26.2% vs. 10.0%, p < 0.01; N1, 6.7% vs. 3.5%, p < 0.01). Patients undergoing OA (vs. LA and RA) were more likely to have advanced clinical T stage (T4, 16.6% vs. 5.7% vs. 7.8%, p < 0.01) and larger tumors (> 6 cm, 84.6% vs. 64.1% vs. 62.3%, p < 0.01). High-volume centers (≥ 5 cases) were more likely to utilize OA. Patients undergoing LA (vs. RA) were more likely to require conversion to open (20.3% vs. 7.8%, p = 0.011). On multivariable analysis, factors associated with higher odds of PM included T3 disease (OR 7.02, 95% CI 2.66-18.55), T4 disease (OR 10.22, 95% CI 3.66-28.53), and LA (OR 1.99, 95% CI 1.28-3.09). High-volume centers were associated with lower odds of PM (OR 0.67, 95% CI 0.45-0.98). There was no significant difference in margin status between OA and RA (OR 1.44, 95% CI 0.71-2.90).

CONCLUSION

Centers with higher ACC case volumes have lower odds of PM and utilize OA more often. LA is associated with higher odds of PM, whereas RA is not. These factors should be considered when planning the operative approach for ACC.

Improving routine childhood immunisation outcomes in low-income and middle-income countries: an evidence gap map

OBJECTIVE

To support evidence-informed decision-making, we created an evidence gap map to characterise the evidence base on the effectiveness of interventions in improving routine childhood immunisation outcomes in low-income and middle-income countries (LMICs).

METHODS

We developed an intervention-outcome matrix with 38 interventions and 43 outcomes. We searched academic databases and grey literature sources for relevant impact evaluations (IEs) and systematic reviews (SRs). Search results were screened on title/abstract. Those included on title/abstract were retrieved for full review. Studies meeting the eligibility criteria were included and data were extracted for each included study. All screening and data extraction was done by two independent reviewers. We analysed these data to identify trends in the geographic distribution of evidence, the concentration of evidence across intervention and outcome categories, and attention to vulnerable populations in the literature.

RESULTS

We identified 309 studies, comprising 226 completed IEs, 58 completed SRs, 24 ongoing IEs and 1 ongoing SR. Evidence from IEs is heavily concentrated in a handful of countries in sub-Saharan Africa and South Asia. Among interventions, the most frequently evaluated are those related to education and material incentives for caregivers or health workers. There are gaps in the study of non-material incentives and outreach to vulnerable populations. Among outcomes, those related to vaccine coverage and health are well covered. However, evidence on intermediate outcomes related to health system capacity or barriers faced by caregivers is much more limited.

CONCLUSIONS

There is valuable evidence available to decision-makers for use in identifying and deploying effective strategies to increase routine immunisation in LMICs. However, additional research is needed to address gaps in the evidence base.

Use of community engagement interventions to improve child immunisation in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To support evidence informed decision-making, we systematically examine the effectiveness and cost-effectiveness of community engagement interventions on routine childhood immunisation outcomes in low-income and middle-income countries (LMICs) and identify contextual, design and implementation features associated with effectiveness.

DESIGN

Mixed-methods systematic review and meta-analysis.

DATA SOURCES

21 databases of academic and grey literature and 12 additional websites were searched in May 2019 and May 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included experimental and quasi-experimental impact evaluations of community engagement interventions considering outcomes related to routine child immunisation in LMICs. No language, publication type, or date restrictions were imposed.

DATA EXTRACTION AND SYNTHESIS

Two independent researchers extracted summary data from published reports and appraised quantitative risk of bias using adapted Cochrane tools. Random effects meta-analysis was used to examine effects on the primary outcome, full immunisation coverage.

RESULTS

Our search identified over 43 000 studies and 61 were eligible for analysis. The average pooled effect of community engagement interventions on full immunisation coverage was standardised mean difference 0.14 (95% CI 0.06 to 0.23, I2=94.46). The most common source of risk to the quality of evidence (risk of bias) was outcome reporting bias: most studies used caregiver-reported measures of vaccinations received by a child in the absence or incompleteness of immunisation cards. Reasons consistently cited for intervention success include appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints. The median intervention cost per treated child per vaccine dose (excluding the cost of vaccines) to increase absolute immunisation coverage by one percent was US$3.68.

CONCLUSION

Community engagement interventions are successful in improving outcomes related to routine child immunisation. The findings are robust to exclusion of studies assessed as high risk of bias.

Designing appropriate, acceptable and feasible community-engagement approaches to improve routine immunisation outcomes in low- and middle-income countries: A synthesis of 3ie-supported formative evaluations

INTRODUCTION

As global child vaccination coverage has plateaued, understanding how to increase routine child vaccination rates further is key to avoiding preventable disease and death. To analyse how community engagement strategies can increase child vaccination, we synthesise the results from formative evaluations of interventions that aimed to increase vaccination coverage in Ethiopia, Myanmar, Nigeria, and Pakistan.

METHODS

This paper uses an inductive qualitative approach to synthesise the results from the six evaluations, gathering lessons for designing context appropriate interventions that are feasible to implement and acceptable to providers, communities, and caregivers.

RESULTS

Assessing contextual, caregiver-level and provider-level barriers to vaccination is key to identifying appropriate engagement strategies. Across all contexts, low knowledge about the schedule of vaccines and the importance of timeliness represented a barrier to child immunisation. Despite the variability in how studies measured and reported caregiver attitudes, vaccine hesitancy was not found to represent an important barrier to immunisation. Frontline health workers played a critical role in community engagement approaches to increase vaccination. Interventions successfully obtained community buy-in by centre-staging community members, especially leaders, ensuring their participation in monitoring, and making immunisation an agenda item on community platforms. Interventions were implemented through existing health systems with substantial assistance from research teams. Limited data was available about intervention costs.

CONCLUSIONS

Interventions designed around community engagement strategies can be appropriate, acceptable, and feasible approaches to overcome barriers to vaccination in a variety of low- and middle-income country contexts. However, questions remain about the ability of health systems to implement interventions at scale, both from a cost perspective and a capacity perspective.

Use of community engagement interventions to improve child immunisation in low- and middle-income countries: A systematic review and meta-analysis

Immunisation is one of the most cost-effective interventions to prevent and control life-threatening infectious diseases. Nonetheless, rates of routine vaccination of children in low- and middle-income countries (LMICs) are strikingly low or stagnant. In 2019, an estimated 19.7 million infants did not receive routine immunisations. Community engagement interventions are increasingly being emphasised in international and national policy frameworks as a means to improve immunisation coverage and reach marginalised communities. This systematic review examines the effectiveness and cost-effectiveness of community engagement interventions on outcomes related to childhood immunisation in LMICs and identifies contextual, design and implementation features that may be associated with effectiveness. We identified 61 quantitative and mixed methods impact evaluations and 47 associated qualitative studies related to community engagement interventions for inclusion in the reteview. For cost-effectiveness analysis 14 of the 61 studies had the needed combination of cost and effectiveness data. The 61 included impact evaluations were concentrated in South Asia and Sub-Saharan Africa and spread across 19 LMICs. The review found that community engagement interventions had a small but significant, positive effect on all primary immunisation outcomes related to coverage and their timeliness. The findings are robust to exclusion of studies assessed as high risk of bias. Qualitative evidence indicates appropriate intervention design, including building in community engagement features; addressing common contextual barriers of immunisation and leveraging facilitators; and accounting for existing implementation constraints and practicalities on the ground are consistently cited as reasons for intervention success. Among the studies for which we were able to calculate cost-effectiveness, we find that the median non-vaccine cost per dose of intervention to increase immunisation coverage by 1% was US $3.68. Given the broad scope of the review in terms of interventions and outcomes, there is significant variation in findings. Among the various types of community engagement interventions, those that involve creation of community buy-in or development of new cadres of community-based structures were found to have consistent positive effect on more primary vaccination coverage outcomes than if the engagement is limited to the design or delivery of an intervention or is a combination of the various types. The evidence base for sub-group analysis for female children was sparse (only two studies) and the effect on coverage of both full immunisation and third dose of diphtheria pertussis tetanus for this group was insignificant.

Exosite binding modulates the specificity of the immunomodulatory enzyme ScpA, a C5a inactivating bacterial protease

•

C5a, the human complement protein is implicated in COVID-19 and sepsis.

•

Proteolytic inactivation of C5a by ScpA involves interactions with a novel exosite.

•

High affinity binding of C5a is shown to involve D783 of the ScpA Fn2 domain.

•

Activity and affinity of ScpA is tuned by residues approx 50 Å from the active site.

•

The data supports a complex dynamic process in ScpA substrate recognition.

The C5a peptidase from Streptococcus pyogenes (ScpA) is a highly specific enzyme with potential therapeutic value. ScpA is a good model for studying determinants of specificity in the multidomain immunomodulatory enzymes (IMEs), which comprise a large family of bacterial surface proteases. The surface exposed region of ScpA has 5 main domains which includes 3 C-terminal Fn3-like domains (Fn1, Fn2 and Fn3) (Kagawa et al. 2009). Progressive deletion of the Fn3-like domains from the C-ter resulted in loss of enzyme activity and showed an important role for the Fn2 domain in enzyme function. Functional investigation of specific acidic residues on the Fn2 domain identified 3 residues 30–50 Å from the catalytic site (D783, E864 and D889) which impacted to differing degrees on binding and on catalysis, supporting the presence of an exosite on the Fn2. In particular, residue D783 was observed to impact on both substrate binding affinity and the activity of ScpA. A double mutant cycle analysis showed energetic coupling between the targeted ScpA residues and residues in the core portion (residues 1–67) of the C5a substrate. The data supports the presence of a communication network between the active site and the exosite on Fn2. These findings provide a basis for rational engineering of this important enzyme family to enhance stability, activity and/or specificity.

O-232 Art of fibroid removal in patients with infertility

Aim of myomectomy in infertile patient is to preserve and improve fertility, minimising excessive bleeding and pain. Relation ship of myoma and fertility remains debatable moreover removal of all myomas may not be helpful in improving fertility outcome thus it becomes important to decide which fibroid should be removed and which one shouldn’t be touched. Principle of minimal damage and complication should be kept in mind. Mapping of fibroid is an important step in planning the route of operation.Number and site of myoma decides the approach. A preoperative  meticulous TVS examination supplemented by TAS specially in large and multiple fibroids is extremely helpful in decision making. it is also important to preoperative differentiation of adenomyosis and fibroid to avoid a surprise element and excessive bleeding during removal. Use of colour flow may be helpful in differentiating. Use of 3-D is important specially in borderline sub mucous myoma. Extent of myoma in to uterine cavity is very important to decide the route of operation. various classifications have attempted to simplify the decision making but combining usg and hysteroscopy is the best way to decide. it is also important to diagnose a large intramural myoma touching the junctional zone. Instilling methylene blue before operation to outline the cavity during surgery in case of accidental entry is a good practice. using intraoperative ultrasound while tackling a large intracavitary fibroid having more than 75% extent in intra myometrial region may be helpful in complete removal.

The placement of the optical and secondary ports determines the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the ease of suturing. reducing the bleeding during enucleation, dissection in the right plane, minimal use of cautery and proper suturing and closure avoiding any haematoma formation are key points for a successful myomectomy. Use of diluted vasopressin is very effective in making the surgery blood less. So also the use of bipolar in coagulating the large blood vessels. Using bipolar diathermy, a dissecting grasper, and a suction cannula, meticulous exploration of the dissection field can more efficiently detect and coagulate any actively bleeding vessels. Slow rotation of the bevelled morcellator and good control of the bag could reduce de novo myoma and endometriosis. The surgery outcome and the risk of intraoperative complications are highly dependent on trocar placement, finding of the correct cleavage plane, haemostasis, and suturing technique. Flap technique is an innovative approach for removing small fibroid near junctional zone. Good surgery with respect to minimal destruction and handling of the healthy tissue, avoiding unnecessary organ manipulation, controlled bleeding, minimal coagulation, and reasonable operating time remain the best ways to diminish the risk of adhesion formation.It is very important to preserve the cavity, minimal adhesion formation and perfect suturing avoiding dead spaces and haematoma formation for a successful out come in infertile patient.

POS1057 IMPACT OF RISANKIZUMAB ON ENTHESITIS AND ASSOCIATED PAIN: POOLED RESULTS FROM THE PHASE 3, RANDOMIZED, DOUBLE-BLIND KEEPsAKE 1 AND 2 TRIALS

Background

Controlling or improving musculoskeletal disease activity of psoriatic arthritis (PsA) (eg, enthesitis and associated pain) is a treatment priority for patients, rheumatologists, and dermatologists.1 Enthesitis is the cardinal lesion in PsA and is immunogenetically and experimentally linked to the interleukin-23 (IL-23) pathway.2 Risankizumab (RZB), a humanized immunoglobulin G1 monoclonal antibody that specifically inhibits IL-23 by binding to its p19 subunit, was studied in a phase 3 adult PsA program (KEEPsAKE clinical trials).3,4 Pooled analyses from the program demonstrated the efficacy of RZB to treat enthesitis and pain associated with PsA, and increase the proportion of patients whose enthesitis resolved compared with placebo (PBO) in those patients who had an inadequate response or intolerance to ≥1 conventional synthetic disease-modifying antirheumatic drugs (KEEPsAKE 1 and 2) and/or ≤ 2 biological therapies (KEEPsAKE 2).

Objectives

To investigate whether patients without enthesitis at baseline (BL) (Leeds Enthesitis Index [LEI] = 0 at BL) remained enthesitis-free through week (W) 52, patients with enthesitis at BL (LEI > 0 at BL) had resolution of enthesitis through W52, and if greater pain relief was achieved with RZB 150 mg in patients with enthesitis at BL vs PBO up to W24.

Methods

The study design and primary results of KEEPsAKE 1 (NCT03675308) and KEEPsAKE 2 (NCT03671148) have been previously reported.3,4 Briefly, patients were randomized to receive RZB 150 mg or PBO subcutaneously at weeks 0, 4, and 16 during a 24-week, double-blind treatment period; at W28 all patients received open label RZB 150 mg. For this post hoc analysis, the RZB 150 mg and PBO groups were pooled across the 2 studies. Pain reductions (as measured by change from BL in visual analogue scale [VAS] scores) were assessed at each time point through W24 among patients with enthesitis at BL (LEI > 0 at BL) using mixed-effect model repeated measurement analysis. Additional enthesitis analyses were calculated on the data as observed.

Results

Across the pooled population, over 60% of patients in each treatment group had enthesitis at BL (RZB=444/707 [63%]; PBO=448/700 [64%]). Conversely, 37% (263/707) and 36% (252/700) had no enthesitis (LEI=0) at BL among those randomized to RZB and PBO, respectively. Among enthesitis-free patients at BL (LEI=0 at BL), 84.7% on PBO and 90% on RZB remained free of enthesitis through W24; by W52, approximately 93% of patients in both groups (RZB and PBO to RZB) remained enthesitis free. A numerically higher proportion of patients with enthesitis at BL (LEI > 0 at BL) treated with RZB (52.1%) achieved an enthesitis-free state at W24 vs PBO (41.8%); similar proportions achieved an enthesitis-free state at W36 and W52 during open label treatment (Figure 1). Among patients with enthesitis at BL, a significantly greater improvement in VAS pain scores was observed in patients treated with RZB 150 mg vs PBO, as early as W4 (P < .01) and increased through W24 (Figure 1; P < .001).

Figure 1.

Conclusion

Long-term maintenance of an enthesitis-free state (LEI = 0) was similar between the RZB 150 mg and PBO groups, with approximately 93% of patients remaining free of enthesitis at W52. For LEI > 0 patients, the RZB 150-mg group had numerically more patients whose enthesitis resolved at W24, and similar proportions were observed at W52 after the open label switch. Patients with enthesitis at BL treated with RZB 150 mg had statistically greater improvements in pain compared with patients taking PBO starting at W4 through to W24.

References

[1]Orbai A-M, et al. Ann Rheum Dis. 2017;76:673–680.

[2]Stavre Z, et al. Arthritis Res Ther. 2022;24(1):24.

[3]Kristensen LE, et al. Ann Rheum Dis. 2021;0:1–7.

[4]Östör A, et al. Ann Rheum Dis. 2021;0:1–8.

Acknowledgements

AbbVie Inc. participated in the study design; study research; collection, analysis, and interpretation of data; and writing, reviewing, and approving this abstract for submission. All authors had access to the data; participated in the development, review, and approval of the abstract; and agreed to submit this abstract to EULAR 2022 for consideration as a poster or oral presentation. No honoraria or payments were made for authorship. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. AbbVie funded the research for this study and provided writing support for this abstract. Medical writing assistance, funded by AbbVie, was provided by Kersten Reich, MPH, and Nancy Niguidula, DPH, of JB Ashtin.

Disclosure of Interests

Marina Magrey Consultant of: MM has received consulting fees from UCB, Novartis, Eli Lilly, Pfizer, and Janssen., Grant/research support from: MM received research grants from Amgen, AbbVie, and UCB Pharma, Manish Jain Consultant of: MJ received consulting fees from Amgen, Abbvie, Eli Lilly, Pfizer, and Novartis., Grant/research support from: MJ received research support from Amgen, Abbvie, Eli Lilly, Pfizer, and Novartis., R Ranza Speakers bureau: RR is a member of speaker bureaus for AbbVie, Janssen, Novartis, and Pfizer, Consultant of: RR is a consultant for AbbVie, Janssen, Novartis, and Pfizer, Jayne Stigler Shareholder of: JS may hold AbbVie stock or stock options., Employee of: JS is a full-time employee of AbbVie., Erin McDearmon-Blondell Shareholder of: EMB may hold AbbVie stock or stock options., Employee of: EMB is a full-time employee of AbbVie., Cuiyong Yue Shareholder of: CY may hold AbbVie stock or stock options., Employee of: CY is a full-time employee of AbbVie., Byron Padilla Shareholder of: BP may hold AbbVie stock or stock options., Employee of: BP is a full-time employee of AbbVie., Christian Kaufmann Shareholder of: CK may hold AbbVie stock or stock options., Employee of: CK is a full-time employee of AbbVie., Dennis McGonagle Speakers bureau: DM is a member of speaker bureaus for AbbVie, Janssen, Novartis, and Pfizer., Grant/research support from: DM received research grants from AbbVie, Janssen, Novartis, and Pfizer, UCB, BMS, Celgene.

POS0683 EFFICACY AND SAFETY OF UPADACITINIB IN TNFi-IR PATIENTS WITH RHEUMATOID ARTHRITIS FROM THREE PHASE 3 CLINICAL TRIALS

Background

For patients with RA who are refractory to biologic DMARDs (bDMARDs), such as tumor necrosis factor inhibitors (TNFis), optimal disease control is less likely to be achieved with subsequent therapy.1 In line with recommendations from EULAR and ACR, switching to a treatment with a different mechanism of action is appropriate for these patients.

Objectives

To describe the efficacy and safety of upadacitinib (UPA) 15 mg once daily in patients with RA and an inadequate response or intolerance to TNFis (TNFi-IR).

Methods

A post hoc subgroup analysis was conducted in TNFi-IR patients who were treated with UPA 15 mg once daily in three Phase 3 clinical trials: SELECT-BEYOND,2 -CHOICE,3 and -COMPARE.4 For COMPARE, only patients treated with adalimumab and switched to UPA as rescue therapy were included. ≥20/50/70% improvement in ACR criteria, DAS28(CRP), CDAI, and SDAI, as well as change from baseline in HAQ-DI and other patient-reported outcomes (PROs) were reported through 24 weeks. Non-responder imputation was used for all missing categorical outcomes; as observed (COMPARE) or multiple imputation (CHOICE, BEYOND) were used for missing continuous outcomes. Pooled safety results were presented as exposure-adjusted event rates (EAERs) with a cut-off of June 30, 2021.

Results

568 TNFi-IR patients were included: 146 from BEYOND, 263 from CHOICE, and 159 from COMPARE. Mean duration since RA diagnosis was longer for BEYOND and CHOICE versus COMPARE; cardiovascular (CV) risk factors were common among this refractory population (Table 1). ACR20/50/70 and disease activity outcomes observed in the TNFi-IR population were generally consistent with the overall BEYOND2 and CHOICE3 bDMARD-IR populations, and consistent across the three studies in the TNFi-IR subgroups (Figure 1). Improvements in PROs including HAQ-DI, fatigue, pain, and morning stiffness over 24 weeks were observed (data not shown). Pooled safety results reporting 1574.8 patient-years (PY) of exposure in the TNFi-IR subgroup showed similar results to the overall BEYOND2 and CHOICE3 bDMARD-IR study populations, with EAERs of 3.1 events/100 PY for herpes zoster and 0.8 events/100 PY for adjudicated major adverse CV events, adjudicated venous thromboembolism (VTE), and malignancy excluding non-melanoma skin cancer. The EAER of any AE leading to death was 1.4 events/100 PY.

Table 1.

Baseline characteristics of TNFi-IR patients treated with UPA 15 mg

n (%), unless specifiedSELECT-BEYOND (n=146)SELECT-CHOICE (n=263)SELECT-COMPARE (ADA → UPA) (n=159)Female122 (83.6)219 (83.3)133 (83.6)Mean (SD) age, years56.6 (11.0)55.5 (11.1)53.9 (10.6)Mean (SD) duration of RA diagnosis, years13.2 (9.5)12.5 (9.4)8.2 (8.5)Concomitant csDMARDs MTX alone100 (70.4)195 (74.1)159 (100.0) MTX and other csDMARDs20 (14.1)25 (9.5)0 csDMARDs other than MTX22 (15.5)38 (14.4)0Concomitant oral steroids73 (50.0)140 (53.2)98 (61.6)1 prior bDMARD68 (46.6)172 (65.4)142 (89.3)2 prior bDMARDs40 (27.4)62 (23.6)17 (10.7)a≥3 prior bDMARDs38 (26.0)29 (11.0)0Failed ≥1 prior TNFi due to lack of efficacyb131 (89.7)223 (84.8)159 (100.0)History of VTE / CV event3 (2.1) / 28 (19.2)6 (2.3) / 20 (7.6)4 (2.5) / 14 (8.8)CV risk factors Hypertension72 (49.3)109 (41.4)68 (42.8) Diabetes mellitus22 (15.1)34 (12.9)17 (10.7) Smoking (current former past)68 (46.6)109 (41.5)55 (34.6) Elevated LDL-C (≥3.36 mmol/L)38 (26.0)52 (20.0)48 (30.2) Low HDL-C (≤1.55 mmol/L)80 (54.8)171 (65.0)88 (55.3)

aThese patients received one bDMARD before entry into SELECT-COMPARE.

bRemaining patients were intolerant to ≥1 prior TNFi.

Conclusion

In this post hoc subgroup analysis, TNFi-IR patients treated with UPA 15 mg achieved clinically meaningful efficacy responses over 24 weeks, with safety consistent with the overall bDMARD-IR patient population in the Phase 3 program.

References

[1]Rendas-Baum R, et al. Arthritis Res Ther 2011;13:R25;

[2]Genovese C, et al. Lancet 2018;391:2513–24;

[3]Rubbert-Roth A, et al. NEJM 2020;383:1511–21;

[4]Fleischmann R, et al. Ann Rheum Dis 2019;78:1454–62.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data; and participated in the writing, review, and approval of the abstract. AbbVie and the authors thank all study investigators for their contributions and the patients who participated in this study. No honoraria or payments were made for authorship. Medical writing support was provided by Amy Wilson, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Roy M. Fleischmann Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Galvani, Gilead, GSK, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Biosplice, Bristol-Myers Squibb, Flexion, Gilead, Horizon, Eli Lilly, Galvani, Janssen, Novartis, Pfizer, Sanofi-Aventis, Selecta, Teva, UCB, Viela, and Vorso, Louis Bessette Speakers bureau: AbbVie, Amgen, Bristol-Meyers Squibb, Celgene, Eli Lilly, Fresenius Kabi, Gilead, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi-Aventis, Teva, and UCB, Consultant of: AbbVie, Amgen, Bristol-Meyers Squibb, Celgene, Eli Lilly, Fresenius Kabi, Gilead, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi-Aventis, Teva, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Meyers Squibb, Celgene, Eli Lilly, Fresenius Kabi, Gilead, Janssen, Merck, Novartis, Pfizer, Roche, Sanofi-Aventis, Teva, and UCB, Jeffrey Sparks Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer, Stephen Hall Consultant of: AbbVie, Amgen, Bristol-Meyers Sqibb, Eli Lilly, Gilead, Janssen, Merck, Novartis, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Meyers Sqibb, Eli Lilly, Gilead, Janssen, Merck, Novartis, and UCB, Manish Jain Consultant of: AbbVie, Amgen, Eli Lilly, Novartis, and Pfizer, Grant/research support from: AbbVie, Amgen, Eli Lilly, Novartis, and Pfizer, Adriana Kakehasi Speakers bureau: AbbVie, Amgen, Eli Lilly, Fresenius Kabi, Janssen, Novartis, Pfizer, Sandoz, and UCB, Consultant of: AbbVie, Amgen, Eli Lilly, Fresenius Kabi, Janssen, Novartis, Pfizer, Sandoz, and UCB, Grant/research support from: AbbVie, Amgen, Eli Lilly, Fresenius Kabi, Janssen, Novartis, Pfizer, Sandoz, and UCB, Yanna Song Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Sebastian Meerwein Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Ryan DeMasi Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Jessica Suboticki Shareholder of: AbbVie (may own stock or options), Employee of: AbbVie, Andrea Rubbert-Roth Consultant of: AbbVie, AbbVie Deutschland, Amgen, Bristol-Myers Squibb, Chugai Pharmaceuticals, Eli Lilly, F. Hoffman-La Roche, Gilead Sciences, Janssen Global Services, Novartis, and Sanofi Pasteur

POS0506 DIFFERENT BIOACTIVE LIPID PROFILES PREDICT RESPONSE TO TNF OR IL6 INHIBITORS IN RHEUMATOID ARTHRITIS: RESULT OF THE CorEvitas CERTAIN COMPARATIVE EFFECTIVENESS STUDY

Background

Circulating bioactive lipids can provide information about the pathogenesis of specific diseases and potentially help predict therapeutic response. Choosing the right biological therapy earlier in the course of rheumatoid arthritis (RA) could help reach the goal of remission.

Objectives

We hypothesized that circulating bioactive lipids at baseline would identify specific metabolic profiles that predict patient response to therapy and define elements of metabolic pathobiology in arthritis.

Methods

Bioactive lipids were measured in plasma from two cohorts of RA patients from the CorEvitas (formerly known as Corrona) CERTAIN registry (1) at baseline prior to treatment with TNF inhibitors (all biologic naïve, N=102) or anti-IL6 (all previously exposed to biologics, N=114). Response to treatment was categorized by minimal clinically important difference (MCID) in Clinical Disease Activity Index (CDAI) (2) at 6 months after treatment initiation. Patients had to have a 6 month follow up visit and plasma available at both the baseline and the f/u time points. Liquid chromatography (LC) system coupled with high resolution QExactive orbitrap mass spectrometer (LC/MS) was used for bioactive lipids profiling. Around 300 spectral features were identified as potential oxylipins by searching against an in-house MS/MS library. Logistic regression analyses adjusted for gender, age and BMI was perfomed using R software.

Results

102 patients (average age 54, standard deviation [SD] 12.6, 82% female [83], average BMI 29.7, SD 6.7, average CDAI 27.1, SD 13.7) starting anti-TNF therapy and 114 patients (average age 57, SD 13, 90% female [102], average BMI 30.5, SD 7.4, average CDAI 28.7, SD 13.8) starting tocilizumab were analyzed. Twenty-five bioactive metabolites discriminated between RA patients classified as anti-TNF responders (R, n = 74) and non-responders (NR, n = 28). Among these, the anti-inflammatory oxylipin maresin 2 was higher in R while the pro-inflammatory oxylipins 15d PGJ2 and 5,6-diHETE were higher in NR. Twenty different metabolites discriminated anti-IL6 R (n=73) and NR (n=41) as shown in Figure 1. The anti-inflammatory oxylipin 14-15EET was higher in R while the pro-inflammatory oxylipins 16-HETE and 5S-HpETE were higher in NR.

Figure 1.

Volcano plots visualizing baseline metabolites associated with responders vs. non responders in a) anti-TNF and b) anti IL-6 therapy groups. Results are derived from multivariate logistic regression analysis of baseline metabolites and response to treatment categorized by MCID. Data plotted as the metabolite against its statistical significance, respectively reported as odds ratio (OR) and -log10(pvalue).

Conclusion

Circulating bioactive lipid analysis using LC/MS provided a rapid analysis of a wide range of metabolites and can be used to describe metabolic signatures that predict response to therapies. These results lay the groundwork for more deliberate investigations novel metabolic-based interventions to predict response to therapy and reduce arthritis morbidity.

References

[1]Pappas DA, Kremer JM, Reed G, Greenberg JD, Curtis JR. Design characteristics of the CORRONA CERTAIN study: a comparative effectiveness study of biologic agents for rheumatoid arthritis patients. BMC Musculoskeletal Disord 2014; 15: 113

[2]Curtis JR, Yang S, Chen L, Pope JE, Keystone EC, Haraoui B, Boire G, Thorne JC, Tin D, Hitchon CA, Bingham CO 3rd, Bykerk VP. Determining the Minimally Important Difference in the Clinical Disease Activity Index for Improvement and Worsening in Early Rheumatoid Arthritis Patients. Arthritis Care Res (Hoboken). 2015 Oct;67(10):1345-53. doi: 10.1002/acr.22606. PMID: 25988705; PMCID: PMC4580563.

Disclosure of Interests

Mona Alotaibi: None declared, Roxana Coras: None declared, Dimitrios A Pappas Speakers bureau: Sanofi, Novartis, Paid instructor for: Novartis, Consultant of: Roche, Sanofi, Joel M Kremer Speakers bureau: Pfizer, Consultant of: BMS, Geoffrey Thiele: None declared, Ted Mikuls Consultant of: Pfizer, Gilead, BMS, Sanofi, Mohit Jain Employee of: Sapient Bio, Monica Guma Grant/research support from: Pfizer, Novartis.

Adrenocortical Carcinoma: The Value of Lymphadenectomy

BACKGROUND

Adrenocortical carcinoma (ACC) staging does not account for the number of positive nodes. The prognostic value of quantitative metastatic nodal burden is unknown.

METHODS

The National Cancer Database was retrospectively queried from 2004-2016 to identify patients with Stage I-III ACC undergoing adrenalectomy. Patients who underwent lymphadenectomy (LAD) were further studied. Demographics, TNM staging, tumor characteristics, and surgical approach were analyzed.

RESULTS

386 LADs were identified. The median number of nodes examined was 2 (IQR 2-6), with no difference by surgical approach '[laparoscopic, 3 (1-3); robotic, 1.5 (1-4.5); open, 2 (1-7), p = 0.493]. In LADs with cN0 disease, positive nodes were seen in 17.5% of patients; an average of 6 (1-12) nodes were examined in patients who upstaged to pN1 disease compared with an average of 2 (1-6) nodes in those who remained pN0. Median survival was incrementally worse for patients with more positive nodes (62.8 vs. 21.9 vs. 13.7 vs. 11.3 vs. 10.7 months for 0, 1, 2, 3, and ≥ 4 positive nodes, respectively, p < 0.01). On multivariate analysis, significant prognostic factors for poor survival included older age, ≥ 2 comorbidities, pT3, and pT4. The strongest prognostic factor for poor survival was the number of positive nodes (1 node, hazards ratio [HR] 2.3, 95% confidence interval [CI] 1.5-3.6; 2 nodes, HR 1.3, 95% CI 0.6-3.0; 3 nodes, HR 3.0, 95% CI 1.1-8.0; ≥ 4 nodes, HR 4.0, 95% CI 2.5-6.2). Lymphadenectomy was associated with improved survival (HR 0.82, 95% CI 0.67-0.99).

CONCLUSIONS

Higher quantitative metastatic nodal burden is a robust prognostic factor for worse survival in ACC.

Predictive Impact of Metastatic Lymph Node Burden on Distant Metastasis Across Papillary Thyroid Cancer Variants

Background: While numerous factors determine prognosis in papillary thyroid carcinoma (PTC), distant metastasis (M1) represents one of the most dire. Escalating nodal burden and aggressive histology may contribute to higher metastatic risk, but this relationship is poorly defined and challenging to anticipate. We evaluate the predictive impact of these histological features on predicting distant metastases at initial presentation. Methods: Univariate and multivariable logistic regression models of conventional and aggressive thyroid cancer variants (well-differentiated papillary thyroid carcinoma [WDPTC], diffuse sclerosing variant [DSV], tall cell variant [TCV], poorly differentiated thyroid cancer [PDTC], and anaplastic thyroid carcinoma [ATC]) identified via U.S. cancer registry data were constructed to determine associations between M1 status and quantitative nodal burden. Associations between metastatic lymph node (LN) number and M1 disease were modeled using univariate and multivariable logistic regression with interaction terms, as well as a linear continuous probability model. Results: Overall, M1 prevalence at disease presentation was 3.6% (n = 1717). When stratified by subtype, M1 prevalence varied significantly by histology (WDPTC [1.0%], DSV [2.3%], TCV [4.1%], PDTC [17.4%], ATC [38.4%] [p < 0.001]). For WDPTC, M1 prevalence escalated with metastatic LN number (0 LN+ [0.5%], 1-5 LN+ [2.0%], 6-10 LN+ [3.4%], >10 LN+ [5.5%] [p < 0.001]) and LN ratio (p < 0.001). A statistically significant interaction was observed between histology and increasing nodal burden for M1 risk. On multivariable analysis, each successive metastatic LN conferred increased M1 risk for WDPTC (odds ratio [OR] 1.06 [1.05-1.08], p < 0.001) and TCVs (OR 1.04 [1.02-1.07], p < 0.001). In contrast, other aggressive variants had a higher baseline M1 risk, but this did not vary based on the number of positive LN (DSV, OR 1.02 [0.95-1.10], p = 0.52; PDTC, OR 1.00 [0.98-1.02], p = 0.66; ATC, 1.00 [0.98-1.02], p = 0.97). Conclusions: Progressive nodal burden independently escalates the risk of distant metastasis in WDPTC and TCVs of PTC. Conversely, aggressive variants such as PDTC and ATC have substantial M1 risk at baseline and appear to be minimally affected by metastatic nodal burden. Consideration of these factors after surgery may help tailor clinical decision-making for treatment and surveillance. Further studies are warranted to calibrate the ideal management approach for these higher risk patient groups.

O-006 Diagnosis debate – USG vs endoscopy

MULLERIAN ANOMAIES – DEBATE USG OR ENDOSCOPY

Mullerian duct anomalies are a complex spectrum of congenital anomalies resulting from defective fusion or canalization leading to different uterine anomalies. Early detection and proper diagnosis of uterine anomalies are paramount for proper management. Outflow obstruction defects like transvers septal defects or non canalised functional horn present early with complaint of pain while rest of patients present with amenorrhoea , infertility, repeated first-trimester abortion, fetal intrauterine growth restriction, and obstetric complications.The prevalence of uterine malformations is variable depending on the population studied , 0.4% , 4 % respectively in the general population and in infertile women while a high prevalence between 3 and 38% is reported in patients with repeated spontaneous miscarriages.

Imaging plays an important role in diagnosis and treatment planning in mullerian duct anomalies. There are different imaging and endoscopic modalities that can be used for the diagnosis and confirmation of uterine malformations. All modalities are having limitations and one need to select and combine various modalities depending on the clinical presentation of patient and pelvic examination. In younger patients or acute cases, trans abdominal ultrasonography (US) is the preferred method because it is readily available, inexpensive, and rapid and does not use ionizing radiation. However it may not give the complete picture because of poor demarcation especially in fatty patient and owing to complex nature of defects , Field-of-view restrictions with US, patient body habitus, and artefact from bowel gas. Pelvic magnetic resonance imaging (MRI) is an excellent tool in the diagnosis of Mullerian duct anomalies due to high soft tissue resolution. But it is more expensive and less available. 3D ultrasound may be a valid alternative to pelvic MRI as It is less expensive and better tolerated by patients however in doubtful cases of complex nature , hysteroscopy combined with laparoscopy may be considered to confirm the diagnosis. Another advantage of endoscopy is the opportunity to correct the defect in the same sitting in most of the cases.

Hysterosalpingography (HSG) and hysteroscopy are considered good modalities to assess the uterine cavity. Hysteroscopy provide the direct visualisation of the defect and considered as gold standard for cavity evaluation in doubtful cases of septate and bicornuate uterus and for simultaneous correction. However outer contour cannot be visualised so one need to use laparoscopy for complete evaluation which is a major drawback. Three-dimensional transvaginal sonography provides image quality like those provided by MRI and is being extensively used for diagnosis of all sorts of mullerian defects. it has got the advantage of realtime imaging which is helpful in distorted pelvic anatomy , visualisation of outer contour is possible ,which is considered very important to differentiate between bicornuate and septate uterus and unicornuate uterus with rudimentary horn. however it may not be possible in all cases to get a definitive diagnosis inspite of using a high end 3D machine specially in presence of artefacts , distorted contour and retroverted uterus. In such cases both modalities including MRI and endoscopy may be required to reach to a definitive diagnosis.

It can be concluded that primary imaging tool is still 2d ultrasound but 3D TVS should be included in all suspected anomalies along with complete careful pelvic examination to corroborate the findings of USG. In doubt ful or complex cases, MRI should be performed particularly for cervical and vaginal atresia and septum. endoscopy should be reserved for all doubtful cases for confirmation and for acute cases where a corrective surgery can also be planned to relieve the distress.

Factors Associated With Non-Operative Management of Resectable Adrenocortical Carcinoma

INTRODUCTION

Surgery is the initial treatment of choice for patients with resectable adrenocortical carcinoma (ACC). We sought to determine factors associated with non-operative management of resectable ACC.

METHODS

2004-2016 National Cancer Database (NCDB) was queried to identify patients with AJCC/ENSAT Stage I-III ACC. Patients who underwent surgery (S) were compared to those who did not undergo surgery (NS). Multivariate logistic regression was used to identify factors associated with NS. Kaplan-Meier estimates used to assess survival.

RESULTS

Two thousand-seventy patients with Stage I-III ACC were identified, of which 17.5% were NS. 85.9% of NS patients were not offered surgery; 69.9% of NS patients did not receive chemotherapy or radiation therapy. NS were older and less likely to receive care at an Academic center or high volume center (≥5 cases during the study period). NS patients were more likely to have advanced T stage and N1 disease. On multivariate regression, factors associated with lower odds of surgery include older age (OR 1.03, 95% CI 1.02-1.06), T4 disease (OR 3.34, 95% CI 1.05-10.68), and treatment at a community center (OR 2.92, 95% CI 1.58-5.40). Overall median survival was significantly poorer for NS patients (50.4 versus 78.4 months, P < 0.01).

CONCLUSION

Patients with locally advanced ACC are less likely to undergo an operation, while those treated at centers with more operative experience or Academic facilities are more likely to undergo an operation. As the surgery-first approach is the current standard of care for resectable ACC, these patients may be best served at high volume Academic facilities.

Enzyme kinetic and binding studies identify determinants of specificity for the immunomodulatory enzyme ScpA, a C5a inactivating bacterial protease

•

The human complement protein C5a is implicated in immunomodulatory diseases.

•

ScpA, a C5a inactivating protease, represents a novel enzymatic approach to therapy.

•

High-affinity ScpA specificity for C5a is driven by C5a core-exosite interactions.

•

3 Arginines in the C5a core, and electrostatic interactions contribute to binding.

•

These studies are first steps in the development of novel immunomodulatory therapies.

The Streptococcal C5a peptidase (ScpA) specifically inactivates the human complement factor hC5a, a potent anaphylatoxin recently identified as a therapeutic target for treatment of COVID-19 infections. Biologics used to modulate hC5a are predominantly monoclonal antibodies. Here we present data to support an alternative therapeutic approach based on the specific inactivation of hC5a by ScpA in studies using recombinant hC5a (rhC5a). Initial characterization of ScpA confirmed activity in human serum and against rhC5a desArg (rhC5a_dR), the predominant hC5a form in blood. A new FRET based enzyme assay showed that ScpA cleaved rhC5a at near physiological concentrations (K_m 185 nM). Surface Plasmon Resonance (SPR) and Isothermal Titration Calorimetry (ITC) studies established a high affinity ScpA-rhC5a interaction (K_D 34 nM, KDITC 30.8 nM). SPR analyses also showed that substrate binding is dominated (88% of ΔG°_bind) by interactions with the bulky N-ter cleavage product (P_N, ’core’ residues 1–67) with interactions involving the C-ter R74 contributing most of the remaining ΔG°_bind. Furthermore, reduced binding affinity following mutation of a subset of positively charged Arginine residues of P_N and in the presence of higher salt concentrations, highlighted the importance of electrostatic interactions. These data provide the first in-depth study of the ScpA-C5a interaction and indicate that ScpA’s ability to efficiently cleave physiological concentrations of C5a is driven by electrostatic interactions between an exosite on the enzyme and the ‘core’ of C5a. The results and methods described herein will facilitate engineering of ScpA to enhance its potential as a therapeutic for excessive immune response to infectious disease.

A cross-sectional study of socio-demographic and clinical profile of HIV patients at ART plus centre, Sawai Man Singh Hospital, Jaipur, India

Background: This study aimed to understand the regional variation in the socio-demographic and clinical profile of human immunodeficiency virus (HIV) infected patients at antiretroviral therapy plus centre of Sawai Man Singh (SMS) hospital, Jaipur, India.  Methods: A descriptive cross-sectional study was conducted on HIV patients from January to December 2019. The HIV-positive patients of all age groups and all categories were included in the study. The socio-economic status was assessed by BG Prasad classification-based consumer price index. However, the clinical staging was done according to the World Health Organization (WHO) classification of HIV/AIDS. Data were expressed as mean ± standard deviation. Results: Among 525 HIV patients 59.16% were males, 40.26% females and 0.57% intersex. About half (51.0%) in the reproductive age group with mean age 36 ±13 years. The commonest mode of HIV transmission was heterosexual (89.77%). Maximum belonged to social class I (57.84%) and class II (26.05 %) of BG Prasad's socioeconomic status. Each of the non-agricultural laborers and semi-skilled workers constitutes 18.0%, and the housewives were 23.6%. At the time of presentation, baseline CD4+Tcell count was <350 /mm3 in 55.0% of HIV patients. Pulmonary tuberculosis and skin involvement were the most predominant secondary opportunistic infections accounting for 24.8% and 7.8%, respectively. More than half (52.09%) of patients were in WHO clinical stage I of HIV disease. Conclusion: Socio-demographic and clinical profile of study participants reflect an impact of early case detection and timely institution of highly active antiretroviral therapy.

Twelve-week secukinumab treatment is consistently efficacious for moderate-to-severe psoriasis regardless of prior biologic and non-biologic systemic treatment: Post hoc analysis of six randomised trials

Background

The efficacy of biologic therapies is greater among biologic‐naïve vs. biologic‐experienced psoriasis patients. However, little is known as to whether prior use of other systemic therapies impacts secukinumab efficacy in patients with moderate‐to‐severe psoriasis.

Objective

To investigate the impact of prior exposure to systemic therapies upon the efficacy and safety of secukinumab 300 mg for moderate‐to‐severe psoriasis.

Methods

Post hoc analysis of six randomised controlled trials (RCTs) comparing secukinumab with placebo, ustekinumab or etanercept at 12 weeks of treatment. Data comparing secukinumab with placebo and ustekinumab were meta‐analysed, while comparisons between secukinumab and etanercept were from a single RCT. Four subgroups of patients were assessed: (i) naïve to non‐biologic systemics (NBS) and biologics; (ii) exposed to NBS but naïve to biologics; (iii) naïve to NBS but exposed to biologics; and (iv) exposed to NBS and biologics. Outcomes of interest included the following: investigator’s global assessment (IGA) score, absolute psoriasis area and severity index (PASI) response, PASI 75, PASI 90 and PASI 100 responses, and dermatology life quality index (DLQI). Safety was also assessed.

Results

One thousand three hundred and eighty‐three patients were included in the secukinumab vs. placebo meta‐analysis: 1776 in the secukinumab vs. ustekinumab meta‐analysis and 653 in the within‐trial analyses of secukinumab vs. etanercept. For all subgroups, secukinumab was significantly more efficacious than placebo for all outcomes measured. Secukinumab generated greater responses in biologic‐naïve patients, while prior NBS had a negligible impact on treatment response. Furthermore, secukinumab was more efficacious than both ustekinumab and etanercept on many outcomes, with an even greater difference for biologic‐naïve than biologic‐exposed patients. Safety results were consistent with individual clinical trial results.

Conclusions

Twelve‐week treatment with secukinumab 300 mg is consistently more efficacious than placebo, etanercept and ustekinumab in patients with moderate‐to‐severe psoriasis, regardless of prior exposure to biologics or NBS. Secukinumab had a comparable safety profile to both etanercept and ustekinumab.

Incidental parathyroidectomy in thyroidectomy and central neck dissection

BACKGROUND

Although higher thyroidectomy volume has been linked with lower complication rates, its association with incidental parathyroidectomy remains less studied. The volume relationship is even less clear for central neck dissection, where individual parathyroid glands are at greater risk.

METHODS

Patients undergoing thyroidectomy with or without central neck dissection were evaluated for incidental parathyroidectomy, hypoparathyroidism, and hypocalcemia. Univariate and multivariable analyses were performed using binary logistic regression.

RESULTS

Overall, 1,114 thyroidectomies and 396 concurrent central neck dissections were performed across 7 surgeons. Incidental parathyroidectomy occurred in 22.4% of surgeries (range, 16.9%-43.6%), affecting 7.1% of parathyroids at risk (range, 5.8%-14.5%). When stratified by surgeon, lower incidental parathyroidectomy rates were associated with higher thyroidectomy volumes (R² = 0.77, P = .008) and higher central neck dissection volumes (R² = 0.93, P < .001). On multivariable analysis, low-volume surgeon (odds ratio 2.94, 95% confidence interval 2.06-4.19, P < .001), extrathyroidal extension (odds ratio 3.13, 95% confidence interval 1.24-7.87, P = .016), prophylactic central neck dissection (odds ratio 2.68, 95% confidence interval 1.65-4.35, P <.001), and therapeutic central neck dissection (odds ratio 4.44, 95% confidence interval 1.98-9.96, P < .001) were the most significant factors associated with incidental parathyroidectomy. In addition, incidental parathyroidectomy was associated with a higher likelihood of temporary hypoparathyroidism (odds ratio 2.79, 95% confidence interval 1.45-5.38, P = .002) and permanent hypoparathyroidism (odds ratio 4.62, 95% confidence interval 1.41-5.96, P = .025), but not permanent hypocalcemia (odds ratio 1.27, 95% confidence interval 0.48-3.35, P = .63). Higher lymph node yield in central neck dissection was not associated with higher incidental parathyroidectomy rates (odds ratio 1.13, 95% confidence interval 0.85-8.81, P = .82).

CONCLUSION

Higher surgical volume conferred a lower rate of incidental parathyroidectomy. Nonetheless, greater lymph node yield in central neck dissections did not result in greater parathyroid-related morbidity. Such findings support the value of leveraging surgical volume to both optimize oncologic resection and minimize complication rates.

Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy

Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.

Team based learning in pathology: Lessons learned from a pilot study

Background: Team based learning (TBL) is an approach where students are organised in groups where they learn from each other. TBL is a student centric approach, which ensures active participation of each member and also promotes teamwork and learning ability. Looking at the teacher centric approach of the conventional teaching learning methods in medical education, where the students are mere passive learners and the sessions can be monotonous, TBL seems to be extremely relevant today as a more student centric teaching learning method. Aim of this study was to compare TBL with conventional teaching learning method (CTL). Methods: This randomised crossover study was conducted in the Department of Pathology, SMS Medical College, on 224 third semester medical students, wherein they were exposed to TBL session and their learning outcome and perception was compared to CTL. The data was analysed using Primer version 6 software. Results: In this study, there was a statistically significant improvement (p < 0.001) in the score of students after exposure to TBL. Also, there was a significant difference in the learning outcome of students of TBL (mean assessment score 7.21) as compared to CTL (mean assessment score 6.09). The student perception trends revealed a positive tilt towards TBL, wherein 70.98 % students agreed that TBL was a better learning strategy as compared to lectures. Conclusion: This pilot study concluded that TBL can be used as a supplement to the conventional lectures for improving the learning as well as team work and leadership skills of students.

Review of therapeutic options for spinal muscular atrophy

Spinal Muscular Atrophy (SMA) is uncommon genetic (autosomal recessive) disease that deteriorates neuromuscular function of the affected person's body by causing lower motor neuron damage, progress in muscle atrophy and in advanced cases leads to paralysis of muscles. Mainly skeletal and respiratory muscles are involved. SMA is present due to lack of SMA proteins, which are encoded by survival motor neuron-1 (SMN-1) genes. In mutation of SMN-1 genes, deficiency of SMN proteins occurs. SMA affects all age groups, but mainly and most severely children younger than 6 months of age. At present, risdiplam is a treatment option and the drug has been approved by the US Food Drug and Administration on 7 August 2020. The availability of the drug has led to increased financial, ethical and medical problems. SMA affected populations are regularly challenged to these issues.