Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1 ) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1 ) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1 ) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Bridging gaps in antenatal care: Implementation of the WHO ANC model using a web-based mobile application at different levels of the healthcare system

INTRODUCTION

Antenatal care (ANC) is crucial for ensuring positive maternal and perinatal outcomes. The World Health Organization (WHO) has released comprehensive guidelines on ANC with the aim of providing a "positive pregnancy experience". While mobile health (mHealth) technology shows immense potential in improving healthcare services, evidence of its effectiveness remains limited.

OBJECTIVES

This study aimed to develop a mobile application aligned with the WHO antenatal care model and follow a group of antenatal women using that and compare it to the conventional care provided.

METHODS

A prospective open-label study was carried out at three health centers, where patients with singleton/twin pregnancies and access to smartphones were recruited after obtaining informed consent. The study group was followed using the mobile application, while the control group received conventional care. A recall-based questionnaire was used to assess the content of care, including comprehensive history, examination, and patient counselling. Patient satisfaction and the feasibility of using the application were also evaluated.

RESULTS

A total of 85 patients in the study group and 73 controls were followed until delivery. Baseline demographic details were comparable, while the number of antenatal visits were higher in the intervention group. Patients in the study group had significantly higher mean scores compared to the controls in terms of comprehensive history (8.26 ± 2.26 vs 3.58 ± 2.30; p < 0.001), physical examination (4.26 ± 1.03 vs 3.66 ± 1.09; p = 0.001) and patient counselling (6.09 ± 1.65 vs 4.33 ± 1.69; p < 0.001). Among the recommended investigations, a hemogram (100 % vs 93.2 %; p = 0.02) and ultrasound prior to 24 weeks (89.4 % vs 56.2 %; p < 0.001) were carried out in a larger number of patients in the study group. Patient satisfaction scores, calculated using the PreMAPeQ questionnaire, were higher in the intervention group.

CONCLUSION

This study highlights the effectiveness of an m-health application in enhancing the quality of antenatal care and facilitating standardized ANC visits. Further research is necessary to establish mHealth technology as a cost-effective intervention in this area.

Low-grade extrauterine endometrial stromal sarcoma arising from vaginal endometriosis: a case report and literature review

Extrauterine endometrial stromal sarcoma arising from malignant transformation of the vagina is an extremely rare condition. The diagnosis is often difficult as the symptomatology and pathological features overlap with that of pelvic endometriosis. A 38 years old female presented with complaints of dyspareunia, dysmenorrhea, and painful defecation along with blood-stained vaginal discharge for a year. Examination revealed the presence of multiple brownish irregular nodules in posterior vaginal fornix and fixed tender nodules which on biopsy revealed florid vaginal endometriosis. She improved symptomatically on medical therapy. After 18 months of diagnosis, she presented again with a necrotic growth in posterior fornix, which on repeat biopsy revealed a low-grade endometrial stromal sarcoma. Laparotomy revealed a 7×5 cm mass in the pouch of Douglas, infiltrating the posterior vaginal wall and rectum. A complete cytoreductive surgery with retrograde hysterectomy, excision of posterior vaginal wall and rectosigmoid resection was done. The patient is disease-free at a follow-up of 65 months.

Cervical Cancer Screening Coverage at Tertiary Care Institutes Across India

OBJECTIVES

The 70% screening coverage target proposed in the global cervical cancer elimination strategy is not achieved even at tertiary centres in India. A situational analysis was done to assess the currently existing facilities and barriers in tertiary care institutes.

METHODS

This cross sectional multicentric study was conducted from August to September 2021 in six tertiary care institutes across India. Women aged 30-49 years attending outpatient services (OPD) were invited for cervical screening. Women and health care professionals (HCPs) were administered structured questionnaires to assess knowledge, attitude and practices regarding cervical cancer screening services.

RESULTS

Out of 6709 eligible women who attended OPD, 1666 (24.8%; range:19-57%) received screening. Availability of screening kits was limited to 10-25 Pap/HPV tests per day. Visual inspection with acetic acid (VIA) and HPV testing were offered only at certain centres. Colposcopy and treatment facilities were optimal at all centres. Knowledge, attitude and practices were analysed for 1800 women: 45.7% had heard of cervical cancer, 78.0% did not know that it is preventable, 75.8% never heard about screening. Common symptoms correctly identified included postmenopausal bleeding (4.8%), postcoital bleeding (5.7%), intermenstrual bleeding (5.8%) and vaginal discharge (12.4%). Risk factors were identified by minority: poor menstrual hygiene (6.6%), oral contraceptive pill use (6.4%), multiparity (4.4%), and HPV infection (3.0%). Out of 21, mean total knowledge score (MTKS) was 2.07± 2.67. Out of 317 HCPs, 96.5% knew that cervical cancer is caused by HPV infection, is preceded by premalignant stage, and that it is preventable by screening and treatment (80.1%). Knowledge about screening modalities was present in 87.4% for cytology, 75.1% for VIA, 68.8% for HPV test. MTKS of HCPs was 20.88±6.61 out of 32.

CONCLUSION

Even at tertiary centres, limited availability of HPV tests, reluctance to implement VIA and lack of awareness among women remain the major barriers.

Role of Placental Vascularization Indices and Shear Wave Elastography in Fetal Growth Restriction

Objective

To evaluate the role of placental vascularisation indices using 3D-Power Doppler and placental elasticity using Shear Wave Elastography (SWE) in Fetal Growth Restricted (FGR) pregnancies and to assess their correlation with perinatal outcomes.

Methods

This prospective case-control study was conducted from June 2018-2020. Thirty women with FGR and thirty controls (24-36 weeks) underwent grayscale and Doppler ultrasonography followed by measurement of vascularisation indices and SWE from the central and peripheral parts of fetal and maternal surfaces of the placenta. Participants were followed till delivery and perinatal outcomes were noted.

Results

Vascularisation indices were significantly reduced among FGR vs. controls: Vascularisation Index (VI): 20.90 ± 5.46 vs. 31.49 ± 3.89, Flow Index (FI): 26.29 ± 1.70 vs. 30.85 ± 2.02, Vascularisation- Flow Index (VFI): 7.06 ± 2.42 vs. 12.37 ± 2.43, p < 0.001. The mean placental SWE (17.36 ± 1.50 kPa) in FGR pregnancies was significantly higher as compared to controls (4.14 ± 1.14 kPa), p < 0.001. Neonatal polycythaemia and hyperbilirubinemia were significantly increased in FGR pregnancies with higher SWE value. Receiver operating characteristic curve-based cut-off of VI for intensive care requirement was 23.0 (sensitivity: 75%, specificity: 71%) and for tachypnea was 22.8 (73% sensitivity and specificity). The cut-off of FI for low birth weight was 25.7 (sensitivity: 69.6%, specificity: 71.4%).

Conclusion

This study demonstrates that increased placental stiffness and reduced vascularisation in FGR indicate possible placental pathology. Both modalities help in predicting perinatal complications. Hence, vascularisation indices and SWE reflect the extent of placental insufficiency and can be useful adjuncts in diagnosis.

Synchronous Bilateral Torsion of Nonpathological Ovaries in an Adolescent Girl with Unilateral Recurrence

Synchronous bilateral ovarian torsion is rare that too in nonpathological ovaries. To the best of our knowledge, this is the second case of synchronous bilateral ovarian torsion of nonpathological ovaries in adolescents. A 14-year-old girl presented with pain lower abdomen, vomiting, and constipation for the last 10 days. Ultrasonography (USG) suggested bilateral ovarian torsion without any ovarian pathology. Emergency laparoscopy confirmed bilateral ovarian torsion with necrosed-looking ovaries, and detorsion was done. During follow-up period, she had intermittent mild pain abdomen, and on USG, her left ovary returned to normal size, but her right ovary had been bulky throughout without any cyst. At around 10 months, the patient presented with severe abdomen pain. This time only right ovarian torsion was there. Laparoscopic bilateral ovarian detorsion with bilateral ovarian ligament plication was done. Ovarian torsion can be bilateral, even in nonpathological ovaries. Ovarian fixation should be done in these cases to prevent recurrent torsion.

Is scolding analogous to positive end-expiratory pressure (PEEP)?

N/A

Clinical and ultrasonographic assessment of airway indices among non-pregnant, normotensive pregnant and pre-eclamptic patients: a prospective observational study

BACKGROUND

Prediction of a difficult airway is of paramount importance for an anaesthesiologist. Various anatomical and physiological factors contribute to a difficult airway in pregnant females, especially those with pre-eclampsia. The aim of the study was to assess airway indices using both routinely used clinical methods and ultrasound.

METHODS

Fifty-five non-pregnant females, 55 normotensive pregnant females and 55 females with pre-eclampsia were included in this prospective study. Clinical airway assessment was the modified Mallampati score, thyromental distance, hyomental distance, hyomental distance ratio, chest circumference, neck circumference and chest-to-neck circumference ratio. Sonographic assessment included tongue width, tongue volume, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, subglottic diameter, ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

RESULTS

Several significant differences were observed between pregnant and non-pregnant females, with additional changes in pre-eclamptic females. These included clinical parameters such as the modified Mallampati score and sonographic measurements of tongue width, tongue volume, subglottic diameter, anterior neck soft tissue thickness at the level of hyoid, epiglottis and vocal cords, and the ratio of pre-epiglottic space to anterior, posterior and midpoint of anterior and posterior vocal folds.

CONCLUSION

Routinely used clinical methods of airway assessment lack sensitivity and specificity. Ultrasound can visualise anatomical structures in the supraglottic and subglottic views and is encouraging as an airway assessment tool.

Abstract 1031: Specific gene alterations of HER2 positive single circulating tumor cell (CTC) compared to autologous leukocytes in metastatic breast cancer (MBC)

Introduction: Monitoring of CTC in MBC showed ability to predict treatment resistance and outcome. HER2 is one of the most important tumor markers which is associated with rapid cell division and the metastasis and prognosis of MBC in the clinic. More recently, we reported single CTC gene mutation is a key point to distinguish metastasis capability in MBC (2022 AACR and 2022 ASCO). Herein, we report specific gene alterations in HER2+ single CTC compared to autologous leukocytes in MBC.

Methods: Whole blood sample (7.5ml/each) was collected from MBC patient before therapy. CTC enumeration was performed in FDA approved CellSearch™ System and then the single HER2+ CTC and leukocytes were isolated by using DEPArrayTM System (Menarini). The single cell DNA was isolated and then the initial library was prepared by using Ampli1™ Whole Genome Amplification, Ampli1™ QC Kit (Menarini) and AMPure XP kit (Beckman Coulter). The exome capture was performed by TruSeq DNA Exome kit (illumine). The sequencing was prepared by NextSeq 500 mid output V2.5 kit and was performed on the NextSeq 500 (Illumina).

Results: We identified 107 CTCs including 55 HER2+ CTCs and 14 CTC-clusters. Autologous single HER2+ CTC (HER2+CK+CD45−, Group 1), HER2+CK−CD45+ leukocyte (Group 2) and HER2−CK−CD45+ leukocyte (Group 3) were isolated and sequenced respectively. The sequencing data was processed following the GATK pipeline and annotated using SnpEff. There were 486,119 counts (56.69%) for intron variants, 175,819 counts (20.51%) for intergenic variants, 70,334 counts (8.20%) for exon variants, 50,370 counts (5.87%) for downstream genes, 45,915 counts (5.36%) for upstream genes and others (3.37%) in HER2+ CTC. Meanwhile, there were 71,848 (8.76%) and 0 counts for exon variants found in Group 2 and Group 3 respectively. There were 79 gene variants ((SNP and Ins-Del) identified to have the highest impact effect (≥20) on HER2+ CTC chromosome, when there were 85 and 0 highest impact gene variants were identified in Group 2 and Group 3 respectively. The specific gene alterations in Group 1 compared to Group 2 includes CCNA2, FOLH1, BRD4, SAMHD1, CYP17A1, IDE, HPGDS and CTNNB1 Among the top 50 high impact gene variants, there were 26 genes alteration sites are same in both Group 1 and Group 2, including FECH, HDAC8, CYP11B2, TTN(6 sites), RAN, CD207, HK1, CASP1(2 sites), BRCA1, PIK3CG (3 sites), APEX1(4 sites), KIF11, SIRT5 (2 sites), XYLB and CHKA.

Conclusion: Genomic characterization of HER2 positive single CTCs elucidated specific gene alterations associated with disease metastasis compared to autologous leukocytes in MBC. The newfound HER2+CK−CD45+ cells with gene alterations maybe a new kind of cancer transformed leukocytes which need further validation. Specific gene alterations will help to develop novel drugs aimed at the eradication of CTCs using molecularly driven therapies for disease metastasis.

Citation Format: Qiang Zhang, Lorenzo Gerratana, Zhe Ji, Xinkun Wang, Paolo D’Amico, Seema Singhal, Youbin Zhang, Andrew A. Davis, Ami N. Shah, William Gradishar. Specific gene alterations of HER2 positive single circulating tumor cell (CTC) compared to autologous leukocytes in metastatic breast cancer (MBC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1031.

Abstract 2220: Dynamic development of ESR1 mutations in circulating tumor DNA (ctDNA) is associated with prognosis of patients with metastatic breast cancer (MBC)

Background: Relapse and endocrine resistance are major clinical challenges in the management of patients with MBC because it is a dynamic phenomenon including development of ESR1 mutations. The monitoring of ctDNA and circulating tumor cells (CTCs) in patients with MBC may predict metastasis and prognosis. We previously reported that ctDNA can be used to evaluate tumor heterogeneity (2022 AACR-#1950 and 2022 ASCO-#1057). Here, we report that dynamic ctDNA ESR1 mutations is a key point associated with a shorter survival, which may help to elucidate prognosis in patients with MBC.

Methods: This study included 406 hormone receptors positive MBC patients who received systemic treatment under an IRB-approved clinical trial (NU16B06) at Northwestern University Robert H Lurie Comprehensive Cancer Center. Plasma samples were collected from each patient at multiple time points: before treatment (Time point 1), and then 3 months (Time point 2), 6 months (Time point 3), 9 months (Time point 4), 12 months (Time point 5) and 24 months (Time point 6) after initiation of systemic treatment respectively. Plasma ctDNA was isolated using a Qiagen circulating nucleic acid kit, and then was analyzed using the Guardant360 Health next-generation sequencing (NGS)-based assay. All statistical analyses were conducted Mann-Whitney U test by IBM SPSS version 23.0.

Results: Of the 406 patients, ESR1 mutations were found in 18 hotspots from 59 patients (ESR1Mut, 14.5%) at either time points. There were 347 patients without any mutation (ESR1WT, 85.5%). Among the 59 patients who have ESR1 mutations, 41 (69.5%) patients have ESR1 mutations at only one time point, 6 patients (10.2%) have ESR1 mutations at 2 time pints, 5 patients (8.5%) have ESR1 mutations at 3 time points, 2 patients (3.3%) have ESR1 mutations at 4 time points, and 5 patents (8.5%) have ESR1 mutations for 5 time points respectively. The median survival times for patients in ESR1WT group is 11.5 years compared to 6.4 years for patients in ESR1Mut group (P=0.0134). This result indicated that patients without ESR1 mutations at any time point have 1.81 times longer median survival time than patients who have ESR1 mutations at any time point. Furthermore, 41 patients who have ESR1 mutation at only one time point have longer survival time (7.1 years) compared to 18 patients who have ESR1 mutation at more than 2 time points (5.1 years) (P&lt;0.01).

Conclusions: Dynamic development of ctDNA ESR1 mutations at different time points during the treatment significantly correlated with prognosis and survival of patients with metastatic breast cancer. Longitudinal dynamics of ESR1 mutation for treatment monitoring may offer important message for minimal residual disease and expand the early predictive role of prognosis for clinical decision-making in metastatic breast cancer.

Citation Format: Qiang Zhang, Jianhua Jiao, Lorenzo Gerratana, Paolo D’Amico, Seema Singhal, Youbin Zhang, Andrew A. Davis, Ami N. Shah, William Gradishar. Dynamic development of ESR1 mutations in circulating tumor DNA (ctDNA) is associated with prognosis of patients with metastatic breast cancer (MBC) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2220.

Imaging Recommendations for Diagnosis, Staging, and Management of Uterine Cancer

Uterine cancers are classified into cancers of the corpus uteri (uterine carcinomas and carcinosarcoma) and corpus uteri (sarcomas) by the AJCC staging system (eighth edition). Endometrial carcinoma is the most common amongst these with prolonged estrogen exposure being a well-known risk factor. The FIGO staging system for endometrial carcinoma is primarily surgical and includes total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy. Imaging is useful in the preoperative evaluation of tumor stage, especially assessment of myometrial invasion and cervical stromal extension. Dynamic contrast enhanced MRI with DWI has a high staging accuracy and is the preferred imaging modality for primary evaluation with contrast-enhanced CT abdomen being indicated for recurrent disease. PET/CT is considered superior in evaluation of lymph nodes and extra pelvic metastases.

Continuous Glucose Monitoring System Profile of Women with Gestational Diabetes Mellitus Missed Using Isolated Fasting Plasma Glucose-Based Strategies Alternative to WHO 2013 Criteria: A Cross-Sectional Study

INTRODUCTION

The aim of the study was to evaluate the differences in the continuous glucose monitoring system (CGMS)-based glycemic parameters between women with normoglycemia and early gestational diabetes mellitus (GDM) identified on the basis of mild fasting plasma glucose elevation (FPG, 5.1-5.5 mmol/L) and/or post-load plasma glucose elevation (PLG, 1-h ≥ 10.0 mmol/L or 2-h ≥ 8.5 mmol/L).

METHODS

This cross-sectional study included women with singleton pregnancy (8⁺⁰ to 19⁺⁶ weeks of gestation) and normoglycemia or GDM per World Health Organization (WHO) 2013 criteria. We evaluated the glycemic parameters of clinical interest using blinded CGMS evaluation and reported them per standard methodology proposed by Hernandez et al. RESULTS: A total of 87 women (GDM, n = 38) were enrolled at 28.6 ± 4.5 years. Among women with GDM, 10 (26.3%) had isolated mild FPG elevation (5.1-5.5 mmol/L), 10 (26.3%) had isolated PLG elevation (1-h ≥ 10.0 mmol/L or 2-h ≥ 8.5 mmol/L), and 7 (18.4%) had a combination of both. The remaining 11 (28.9%) had elevated FPG (≥ 5.6 mmol/L) with or without PLG elevation. Thus, when an isolated FPG cutoff ≥ 5.6 mmol/L is used to diagnose GDM, 27 (71.0%) women would be perceived as normoglycemic. Such women had significantly higher CGMS parameters of clinical interest, such as 24-h mean glucose, fasting glucose, 1-h and 2-h postprandial glucose (PPG), 1-h PPG excursion, and peak PPG.

CONCLUSIONS

An isolated FPG threshold, especially the higher cutoff ≥ 5.6 mmol/L, can potentially miss a large proportion of women (nearly three-fourths) diagnosed with GDM per WHO 2013 criteria. Eventually, such women fare significantly differently from normoglycemic women in various CGMS parameters of clinical interest.

Can portable Colposcopes Replace Standard-of-care Colposcopes? A Crossover Trial of Two Portable Colposcopes with a Standard-of-Care Video Colposcope

BACKGROUND

Screen positive women need to be triaged by colposcopy which is a major challenge in low-middle income countries. Portable colposcopes may overcome many challenges, reduce referrals and enable a single visit approach. This study assessed the performance of portable colposcopes and potential to reduce referral.

METHOD

This crossover randomised study enrolled women aged 25 to 65 years with abnormal screening result or cervical symptoms. All women underwent visual inspection with acetic acid (VIA), HPV test, colposcopy with two portable colposcopes (Gynocular®, Gynius, Sweden, and Pocket® transvaginal colposcope, Duke University, NC, USA) and a standard video colposcope, and biopsy. Colposcopic Swede score agreement between portable and video colposcopes, as well as agreement of Swede score with histology were calculated for each device. The potential impact of portable colposcopes in a single visit approach was assessed based on the final diagnosis.

RESULTS

Among 250 subjects, 27(10.80%) had high-grade cervical intraepithelial neoplasia (CIN2+) lesions. Swede scores for Pocket and Gynocular colposcopes were similar to video colposcope in 248 (99.20%) and 247 (98.80%) subjects, respectively (agreement scores 0.9969 and 0.9954, respectively). At a Swede score cut-off of ≥5, all three devices had identical sensitivity, specificity, positive and negative predictive value of 96.30%, 92.30%, 60.50% and 99.50,. Ablative treatment offered at field setting would result in optimal treatment in 52.0% and 85.1% cases when screened with VIA and HPV test respectively; using Pocket colposcope could improve this to 94.0% and 95.9%, respectively. Overtreatment and referral rates reduced from 46.8% and 12.4% to 4.8% and 6.0%, respectively, when VIA test is followed by triage with pocket colposcope. These outcomes were comparable to screening with HPV followed by colposcopy triage.

CONCLUSIONS

Pocket colposcope performed comparably to the video colposcope. Used by healthcare providers in the field setting, they can augment the results of VIA significantly.

Outcome in women undergoing uterine artery embolization for arterio-venous malformation diagnosed post-pregnancy-A retrospective study

Objective:

To analyse the outcome of patients with symptomatic arterio-venous malformation (AVM), formed following pregnancy and managed by uterine artery embolization (UAE).

Materials and Methods:

This retrospective study was conducted after ethical approval and included 15 patients presenting with abnormal uterine bleeding following pregnancy, who were suspected to have an AVM which later was confirmed by angiography and managed with UAE. Presenting symptoms, post- UAE complications and subsequent fertility outcomes were noted. Follow-up period ranged from 6 months to 2.5 years.

Results:

The mean age was 28.4±3.82 years and mean parity was 1.3. Out of 15 cases, 9 (60%) presented after abortion, 4 (26.6%) after normal vaginal delivery and 2 (13.3%) after cesarean delivery; of these 10/15 (66.7%) patients had a history of curettage. The most common presenting symptom was continuous bleeding per-vaginum since the antecedent pregnancy in 9/15 (60%) patients and 6/15 (40%) patients had irregular bleeding. The mean duration of symptoms was 91±85.7 (30-360) days. For UAE, embolic agents used were polyvinyl alcohol (PVA) particles (300-500 μm) in 2 (13.3%), 30% glue injection in 3 (20%), the combination of PVA with glue injection in 4 (26.6%) and PVA with gelfoam in 6 (40%) patients. After UAE, bleeding responded within 3.6±0.97 (3-6) days in all but one patient who required repeat UAE one month later. All women resumed their normal menstrual cycle in 31.3±5.2 (24-42) days. Ten patients desired conception, of whom 5 (50%) conceived within 13.2±5.1 (6-19) months after UAE. Two women carried pregnancy to term, one underwent preterm cesarean for growth restriction with oligohydramnios. One patient had postpartum hemorrhage, which was managed medically. One had spontaneous abortion at 6 weeks gestation and the other is 13 weeks pregnant at present.

Conclusion:

UAE is an effective treatment modality for the management of symptomatic post-pregnancy AVMs.

CGMS profile of women diagnosed as GDM by IADPSG criteria and labelled as normoglycemic by alternate criteria in early pregnancy

AIMS/INTRODUCTION

We aimed to evaluate and compare CGMS-based glycemic parameters in women in early pregnancy (<20 weeks of gestation) who were classified as: a) GDM by IADPSG but normoglycemia by alternate (UK NICE, CDA and DIPSI) criteria, and b) normoglycemia by both (IADPSG and alternate) criteria.

MATERIAL AND METHODS

In this cross-sectional study, eligible women underwent standard 75-g OGTT, followed by the placement of a CGMS. Glycemia-related parameters were calculated using the standard approach for CGMS data in pregnancy.

RESULTS

We enrolled 96 women at 14.0 ± 3.2 weeks of gestation. Of the women diagnosed as GDM by IADPSG criteria, 34.2%, 26.3% and 44.7% were classified as normoglycemic by UK NICE, CDA and DIPSI criteria, respectively. Mean 1-h postprandial glucose and time above range were significantly higher in women who were GDM by IADPSG, but normoglycemia by CDA criteria, compared to women with normoglycemia using both criteria. Similarly, mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, 1-hr postprandial glucose excursion and time above range were significantly higher in women who were not identified as GDM by UK NICE criteria. Finally, women missed by DIPSI criteria had significantly higher mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, postprandial glucose excursion, 24-h glucose, and time above range parameters.

CONCLUSIONS

More than a quarter of women diagnosed as GDM by IADPSG criteria are not identified by alternate criteria. Such women are significantly different from normoglycemic women in terms of several CGMS-based glycemic parameters of clinical significance.

LB0004 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE, ALLOSTERIC TYK2 INHIBITOR, IN PATIENTS WITH ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS: A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY

Background

Tyrosine kinase 2 (TYK2) mediates signaling of Type I interferons, IL-23, and IL-12, key cytokines involved in lupus pathogenesis. Deucravacitinib (DEUC) is an oral, selective, allosteric TYK2 inhibitor with a unique mechanism of action, distinct from Janus kinase (JAK) 1/2/3 inhibitors, and has shown efficacy in psoriasis and psoriatic arthritis.

Objectives

Assess efficacy and safety of DEUC in patients with active systemic lupus erythematosus (SLE).

Methods

This was a 48-week (wk), randomized, double-blind, placebo (PBO)-controlled, phase 2 trial (NCT03252587). Eligible patients met SLICC criteria, were seropositive (ANA/anti-dsDNA/anti-Sm), and had a SLEDAI-2K score ≥6 and ≥1 BILAG index A or >2 BILAG B manifestations from the musculoskeletal or mucocutaneous domain. Patients on standard background medications were randomized 1:1:1:1 to PBO or DEUC (3 mg BID, 6 mg BID, 12 mg QD). Oral corticosteroid tapering to 7.5 mg/day was required from wks 8-20; further tapering was optional from wks 32-40. The primary endpoint was the proportion of patients achieving SRI(4) at wk 32. Key secondary endpoints at wk 48 included SRI(4), BICLA, LLDAS, CLASI-50, and change from baseline in active (tender and swollen) joint count.

Results

A total of 363 patients were randomized, with baseline demographic and disease characteristics similar across treatment groups. Of randomized patients, 275 (76%) completed 48 wks of treatment. The primary endpoint at wk 32 was met, with significantly greater proportion of patients in DEUC 3 mg BID and 6 mg BID groups vs PBO achieving SRI(4) responses (PBO: 34.4%; DEUC 3 mg BID: 58.2%, P=0.0006; DEUC 6 mg BID: 49.5%, P=0.021; DEUC 12 mg QD: 44.9%, P=0.078). SRI(4) response was sustained across all DEUC groups up to 48 wks (Figure 1). At wk 48, the DEUC 3 mg BID group demonstrated statistical significance in BICLA, LLDAS, CLASI-50, and active joint count, and the two other DEUC groups demonstrated clinically meaningful differences vs PBO (Figure 1). Rates of adverse events (AEs), serious AEs, and AEs of interest were similar between DEUC and PBO groups (Table 1). Most common AEs (≥10%) with DEUC were upper respiratory tract infection, nasopharyngitis, headache, and urinary tract infection. No deaths, major cardiac events, thrombotic events, systemic opportunistic infections, or active tuberculosis occurred. Malignancies were rare with similar rates across all groups. No meaningful abnormalities in mean levels of hematology and chemistry laboratory parameters were observed.

Table 1.

Summary of Adverse Events Through Week 48

AE, na(%)Placebo n = 90DEUC 3 mg BID n = 91DEUC 6 mg BID n = 93DEUC 12 mg QD n = 89AE79 (87.8)85 (93.4)81 (87.1)75 (84.3)SAE11 (12.2)7 (7.7)8 (8.6)7 (7.9)AEs leading to treatment discontinuation3 (3.3)8 (8.8)6 (6.5)11 (12.4)Skin-related AEsb12 (13.3)15 (16.5)32 (34.4)30 (33.7)Overall infections/infestations48 (53.3)60 (65.9)60 (64.5)45 (50.6)Serious infections/infestations1 (1.1)1 (1.1)2 (2.2)1 (1.1)Infections of interest Tuberculosis0000 Herpes zosterc4 (4.4)3 (3.3)3 (3.2)2 (2.2) Influenza1 (1.1)3 (3.3)1 (1.1)3 (3.4) COVID-193 (3.3)3 (3.3)5 (5.4)3 (3.4)Malignancy events1 (1.1)d1 (1.1)e01 (1.1)fMACE0000Thrombotic events0000

an is the number of patients who experienced an event. bIncludes (≤8.6% in any arm) acne, rash, dermatitis acneiform, pruritus, skin lesion, urticaria. cIncludes herpes zoster, herpes ophthalmic, genital herpes zoster. dBasal cell carcinoma. eBreast carcinoma. fVaginal squamous cell carcinoma.

AE, adverse event; COVID-19, coronavirus disease 2019; DEUC, deucravacitinib; MACE, major adverse cardiac events; SAE, serious adverse event.

Conclusion

In patients with active SLE, DEUC showed statistically significant and sustained clinical efficacy in SRI(4), improvement across multiple composite and organ-specific measures up to 48 wks, and was well tolerated. DEUC shows promise as a novel therapy for SLE and warrants further investigation in phase 3 trials.

Acknowledgements

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Julianne Hatfield, PhD at Peloton Advantage, LLC, an OPEN Health company, Parsippany, NJ, USA, and funded by Bristol Myers Squibb. The authors acknowledge Christina Crater, MD, who was employed by Bristol Myers Squibb at the time the study was conducted, for contributions to study conduct.

Disclosure of Interests

Eric Morand Consultant of: AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Servier, and Novartis , Grant/research support from: AbbVie, Amgen, AstraZeneca, Bristol Myers Squibb, Biogen, Eli Lilly, EMD Serono, Genentech, Janssen, and UCB , Marilyn Pike Consultant of: AstraZeneca, Bristol Myers Squibb, and Pfizer, Joan T. Merrill Consultant of: UCB, GlaxoSmithKline, AbbVie, EMD Serono, Remegen, Celgene/Bristol Myers Squibb, AstraZeneca, Amgen, Janssen, Lilly, Genentech, Aurinia, Astellas, Alexion, Sanofi, Zenas, and Provention , Grant/research support from: GlaxoSmithKline and AstraZeneca , Ronald van Vollenhoven Consultant of: UCB, Pfizer, AbbVie, AstraZeneca, Biogen, Biotest, Celgene, Galapagos, Gilead, Janssen, Servier, Paid instructor for: Roche, Pfizer, Speakers bureau: UCB, Pfizer, AbbVie, Galapagos, Janssen, Grant/research support from: Bristol Myers Squibb, GlaxoSmithKline, Eli Lilly, UCB, , Victoria P. Werth Consultant of: Celgene, Medimmune, Resolve, Genentech, Idera, Janssen, Lilly, Biogen, Bristol Myers Squibb, Gilead, Amgen, Medscape, Nektar, Incyte, EMD Serono, CSL Behring, Principia, Crisalis, Viela Bio, Argenx, Kirin, AstraZeneca, AbbVie, GSK, AstraZeneca, Cugene, UCB, Corcept, Beacon Bioscience , Grant/research support from: Celgene, Janssen, Biogen, Gilead, AstraZeneca, Viela, Amgen, Lupus Research Alliance/BMS , Coburn Hobar Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Nikolay Delev Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Vaishali Shah Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Brian Sharkey Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Thomas Wegman Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Ian Catlett Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

The Impact of the COVID-19 Pandemic on the Psychological Well-being of Healthcare Workers in Obstetrics and Gynaecology: An Observational Study at an Apex Institute

Background and objective

The coronavirus disease 2019 (COVID-19) pandemic has affected the health, social, and economic sectors all over the world. With a view to assessing the impact of COVID-19 on the mental health of healthcare workers (HCWs), we conducted a study to find out the incidence and severity of depression, anxiety, and post-traumatic stress disorder (PTSD) among HCWs.

Material and methods

This was an observational cross-sectional study conducted in the Department of Obstetrics and Gynaecology in collaboration with the Department of Psychiatry at AIIMS, New Delhi from March 2021 to June 2021. One hundred HCWs working in the Department of Obstetrics and Gynaecology were surveyed using a set of semi-structured interview schedules and structured questionnaires distributed via email or manually. The structured questionnaire included the demographic profile; other baseline information; the 42-item Depression, Anxiety, and Stress Scale (DASS-42); and the Impact of Event Scale-Revised (IES-R) instrument. Data analysis was carried out using the statistical package STATA version 14.0 (StataCorp LLC, College Station, TX).

Results

A total of 100 HCWs participated in the study, out of which 39 (39%), 45 (45%), and 16 (16%) were doctors, nursing staff, and supporting staff, respectively. Overall, 92 (92%) of the participants were women, and the mean age of the participants was 29.87 ±4.85 years. Out of the 100 participants, 17 (17%), 25 (25%), 13 (13%), and two (2%) participants had depression, anxiety, stress, and PTSD, respectively. Occupation-wise, among the nursing staff, doctors, and supporting staff, the incidence of depression was 24.4%, 15.4%, 0.0%, respectively; the anxiety rate was 33.3%, 25.6%, and 0.0%, respectively; and the rate of stress was 17.8%, 12.8%, and 0.0%, respectively. The IES-R score was significantly higher among unmarried as compared to married participants (2.70 ±7.935 vs. 1.60 ±3.583, p=0.000). Participants living in joint families had a higher DASS-42 score (DASS-D: 4.00 ±5.299 vs. 3.77 ±7.727, p=0.889; DASS-A: 4.31 ±4.398 vs. 4.12 ±7.496, p=0.905; DASS-S: 4.08 ±4.816 vs. 3.88 ±7.567, p=0.016) and lower IES-R score (1.31 ±4.922 vs. 2.66 ±9.947, p=0.752) as compared to those living in nuclear families. Depression (4.86 ±8.165 vs. 2.00 ±4.388, p=0.054), anxiety (5.31 ±7.538 vs. 2.14 ±4.704, p=0.024), stress (5.20 ±7.651 vs. 1.67 ±4.733, p=0.014) and PTSD (3.61 ±10.900 vs. 1.44 ±2.634, p=0.245) were all higher among HCWs having exposure to COVID-19 more than 10 hours per week compared to participants with an exposure of less than 10 hours per week. The participants having psychiatric illness in the family showed significantly higher mean values for DASS-42 (DASS-D: 20.00 ±26.870 vs. 3.50 ±6.264, p=0.001; DASS-A: 18.50 ±20.506 vs. 3.88 ±6.215, p=0.002; DASS-S: 18.00 ±21.213 vs. 3.64 ±6.346, p=0.003) as compared to those without any psychiatric illness in the family.

Conclusion

Based on our findings, occupational and environmental factors at the workplace play a key role in mental health outcomes, and COVID-19 has had a significant impact on the mental health of HCWs. Furthermore, we have also observed that effective planning can significantly reduce mental stress.

Imaging in Carcinoma Cervix and Revised 2018 FIGO Staging System: Implications in Radiology Reporting

The International Federation of Gynecology and Obstetrics (FIGO) staging system of carcinoma cervix saw a radical change in 2018 with the inclusion of cross-sectional imaging tools for the assessment of disease extent and staging. One of the major revisions is the inclusion of lymph node status, detected either on imaging or pathological evaluation, in the staging system. The changes were based on long-term patient follow-up and survival rates reported in literature. Thus, it becomes imperative for a radiologist to be well versed with the recent staging system, its limitations, and implications on the patient management.

A Cross-Sectional Analysis to Evaluate Knowledge, Attitude And Practices Among Pregnant Women During COVID-19 Pandemic

Objective

To assess knowledge, attitude and practices (KAP) towards COVID-19 among pregnant women at a tertiary care hospital.

Methods

This was a questionnaire-based cross-sectional analysis pertaining to COVID-19 which was conducted at a tertiary care obstetric facility in India among 200 consecutive consenting pregnant women. They were assessed for demographic details and KAP score (knowledge—17 questions, attitude—9 questions and practice—8 questions). Analysis of data was done using Statistical Package for the Social Sciences (SPSS) version 25.0.

Results

The participants had adequate mean knowledge score (± SD) of 22.5 (± 3.5) were following good practices [mean score (± SD) = 15.5 (± 2.6)] and showed positive attitude for preventive measures against COVID-19 [n (%) = 194(96%)]. Low knowledge score (p-value 0.030) was seen in non-health care workers.

Conclusion

This study demonstrated that majority of the pregnant women had satisfactory knowledge, positive attitude and were following practices in right manner regarding COVID-19 but continued efforts for generating awareness were warranted. As India is battling the second COVID-19 wave and in the absence of definitive cure, strengthening of health policies directed at pregnant women should be prioritized with special focus on significant gaps in KAP.

Facility preparedness for an obstetric unit during the Covid-19 pandemic

Covid-19 infection has placed health systems under unprecedented strain and foresight for preparedness is the key factor to avert disaster. Every facility that provides obstetric service needs a certain level of preparedness to be able to handle at least Covid-suspect pregnant women awaiting test reports, who need to be managed as Covid-positive patients till reports are available. Thus, these facilities need to have triage areas and Covid-suspect labour rooms. Healthcare facilities can have designated areas for Covid-positive patients or have referral linkages with designated Covid-positive hospitals. Preparation includes structural reorganization with setting up a Covid-suspect and Covid-positive facility in adequate space, as well as extensive training of staff about infection control practices and rational use of personal protective equipment (PPE). A systematic approach involving five essential steps of making standard operating procedures, infrastructural reorganization for a triage area and a Covid-suspect labour ward, procurement of PPE, managing the personnel and instituting appropriate infection control practices can ensure uninterrupted services to patients without compromising the safety of healthcare providers.

Implications of the revised cervical cancer FIGO staging system

The 2018 revised International Federation of Gynaecology and Obstetrics (FIGO) staging of cervical cancer has brought about a paradigm shift by offering the option of adding imaging and pathology to clinical staging. This makes it applicable to all types of resource situations across geographies with implications for all stakeholders, including gynaecologists, gynaecologic oncologists, radiologists, pathologists and radiation and medical oncologists. The new staging classification has more granularity, with three sub-stages of stage IB and a new category of stage IIIC for all cases with lymph node (LN) involvement. The major limitations of clinical staging were inaccurate assessment of tumour size and inability to assess pelvic and para-aortic LNs with the limited investigations permitted by FIGO to change the stage. This resulted in understaging of stages IB-III, and overstaging of stage IIIB, which has been largely overcome by incorporating imaging findings. Although any imaging modality can be used, magnetic resonance imaging appears to be the best imaging modality for early-stage disease owing to its better soft-tissue resolution. However, the use of contrast-enhanced computed tomography or ultrasonography are also feasible options, depending on the availability and resources. But wherever pathological evaluation is possible, it supersedes clinical and radiological findings.

Assessment of Tubal Patency with Selective Chromopertubation at Office Hysteroscopy versus Modified Minilaparoscopy in Infertile Women

OBJECTIVES

Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.

MATERIALS AND METHODS

The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, "Visualizable flow" at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.

RESULTS

All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93-0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.

CONCLUSION

OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.

Predictors of chemotherapy resistance & relapse in gestational trophoblastic neoplasia

Background & objectives:

Gestational trophoblastic neoplasia (GTN) is a chemosensitive malignancy with an excellent cure rate. The primary objective of the present study was to determine the predictors of chemoresistance and disease relapse, and the secondary objective was to appraise the WHO/FIGO risk scoring and course of disease in women with GTN.

Methods:

In this retrospective study, case records of women treated for GTN from January 2011 to June 2019 were reviewed. For the purpose of comparison, sub-stratification of FIGO/WHO low risk group (≤6) into low (0-4) and intermediate (5-6) risk was done. Similarly, WHO high risk (≥7) group was sub-stratified into high (7-12) and ultra-high risk (≥13) groups.

Results:

Case records of 116 patients were included: 51.7 per cent (60/116) were of low risk disease and 48.2 per cent (56/116) were of high risk disease. Chemoresistance developed in 28.4 per cent (33/116) and relapse in 10.3 per cent (12/116) cases. Risk of chemoresistance was higher in low risk (0-6) while risk of relapse was more in high risk (≥7) group. On sub-stratification, chemoresistance was more with intermediate [0-4: 28.5% (10/35), 5-6: 44% (11/25), 7-12: 22.5% (9/40), ≥13: 18.7% (3/16)] and relapse with ultra-high risk score [0-4: 5.7% (2/35), 5-6: 4% (1/25), 7-12:10% (4/40), ≥13: 31.2% (5/16)]. Age, myometrial invasion, serum beta-human chorionic gonadotropin and tumour size were not related to chemoresistance or relapse.

Interpretation & conclusions:

WHO risk score and presence of metastatic disease predict the probability of developing chemotherapy resistance and disease relapse. Risk of chemotherapy resistance was higher in women with intermediate-risk score (5-6), and risk of relapse was more in those with ultra-high risk score (≥13).

Maternal and Perinatal Outcomes of Pregnancy in Women With Autoimmune Disorder

Objective

Pregnancy with an autoimmune disorder is faced with several risks for mother and fetus. The aim of the present study is to analyze the course and outcome of pregnancy in women with autoimmune disorders (AIDs).

Methods

A retrospective cohort study was conducted at a tertiary care teaching hospital. The hospital records of 153 pregnancies with autoimmune disorders and 1095 low-risk pregnant women who served as controls were reviewed. An adverse perinatal outcome was defined as the presence of any obstetric complications, including preeclampsia, eclampsia, abruption, antepartum hemorrhage (APH), prematurity, fetal growth restriction (FGR), intrauterine death (IUD), intrapartum event, mode of delivery, birth weight, neonatal intensive care unit (NICU) stay, or disease-specific neonatal complications. For all statistical tests with two-tailed probability, p<0.05 was considered statistically significant.

Results

A high incidence of adverse perinatal outcomes was observed in all women with AIDs when compared with age-matched controls. The highest incidence of adverse perinatal outcomes was observed in women with Takayasu’s arteritis. The incidence of abortions was more in women with antiphospholipid antibody syndrome (APS) and Grave’s disease (22.2% and 33.3%, respectively). The incidence of prematurity, fetal growth restriction (FGR), and low birth weight were highest in women with systemic lupus erythematosus (SLE). Pregnancy with myasthenia gravis and rheumatoid arthritis did not have any significant adverse impact on pregnancy outcomes.

Conclusion

We found a strong association between autoimmune disorders and obstetric complications. The multidisciplinary team approach and pre-pregnancy optimization of the disease improve maternal and fetal outcomes.

POS0198 EFFICACY AND SAFETY OF DEUCRAVACITINIB, AN ORAL, SELECTIVE TYROSINE KINASE 2 INHIBITOR, IN PATIENTS WITH ACTIVE PSORIATIC ARTHRITIS: RESULTS FROM A PHASE 2, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL

Background:

Tyrosine kinase 2 (TYK2) is an intracellular kinase that mediates signaling by key cytokines involved in psoriatic arthritis (PsA) and plaque psoriasis (PsO) pathogenesis. Deucravacitinib is a novel oral agent that selectively inhibits TYK2 via an allosteric mechanism by binding to the nonconserved regulatory domain of the kinase. A previous Phase 2 trial in PsO had demonstrated that deucravacitinib was efficacious and well tolerated, with no laboratory abnormalities observed.

Objectives:

To evaluate the efficacy and safety of deucravacitinib in active PsA.

Methods:

This is an ongoing, 1-year, randomized, double-blind, placebo (PBO)-controlled (initial 16 weeks), multiregional, Phase 2 trial (NCT03881059). Eligible patients had a PsA diagnosis for ≥6 months, met CASPAR criteria, and had active disease with ≥3 tender and ≥3 swollen joints, C-reactive protein ≥3 mg/L (ULN, 5 mg/L), and ≥1 psoriatic lesion (≥2 cm). Patients had failed or were intolerant to ≥1 nonsteroidal anti-inflammatory drug, corticosteroid, conventional synthetic disease-modifying antirheumatic drug (csDMARD), and/or 1 TNF inhibitor (TNFi; ≤30%). Patients were randomized 1:1:1 to deucravacitinib 6 mg once daily (QD) or 12 mg QD, or PBO. The primary endpoint was achievement of ACR 20 response at Week 16. Additional endpoints included the proportion of patients achieving ACR 50/70 response, Health Assessment Questionnaire-Disability Index (HAQ-DI) response (≥0.35 improvement from baseline), enthesitis resolution (Leeds Index score of 0), minimal disease activity, change from baseline in SF-36 physical component score (SF-36 PCS) and mental component score (SF-36 MCS), Psoriasis Area and Severity Index (PASI) 75 response, adverse events (AEs), and laboratory parameters.

Results:

Of 203 patients randomized, 180 (89%) completed 16 weeks of treatment (deucravacitinib 6 mg QD, 63/70 [90%]; deucravacitinib 12 mg QD, 59/67 [88%]; PBO, 58/66 [88%]). Demographic and baseline disease characteristics were similar across groups. Mean age was 49.8 years, 51% of patients were female, median PsA duration was 4.5 years, 66% of patients used csDMARDs at baseline and throughout the study, and 15% had used a TNFi. This study met its primary endpoint, with deucravacitinib 6 mg and 12 mg QD demonstrating significantly higher ACR 20 responses versus PBO at Week 16 (Figure 1). Additional endpoints were also met with deucravacitinib versus PBO (Figure 1). Adjusted mean changes from baseline in SF-36 PCS and SF-36 MCS at Week 16, respectively, were significantly higher in the deucravacitinib 6 mg QD group (5.6 vs 2.3, P=0.0062; 3.6 vs 0.7, P=0.0211) and 12 mg QD group (5.8 vs 2.3, P=0.0042; 3.5 vs 0.7, P=0.0263) compared with PBO. PASI 75 responses were also significantly higher in the deucravacitinib groups (P≤0.0136 vs PBO). The most common AEs in the deucravacitinib 6 mg/12 mg/PBO groups, respectively, during the 16-week treatment period were nasopharyngitis (5.7%/17.9%/7.6%), sinusitis (0%/7.5%/0%), headache (7.1%/1.5%/4.5%), and rash (4.3%/6.0%/0%). No serious AEs, herpes zoster infections, opportunistic infections, or thrombotic events were reported in deucravacitinib-treated patients during this period. Additionally, no significant changes from baseline in hematologic parameters (lymphocytes, neutrophils, platelets, and hemoglobin) or serum lipids were observed with deucravacitinib treatment.

Conclusion:

Deucravacitinib was efficacious versus PBO over 16 weeks in patients with active PsA. Treatment was generally well tolerated and the safety and laboratory parameter profile of deucravacitinib was consistent with that observed in an earlier Phase 2 PsO trial.

Acknowledgements:

This study was sponsored by Bristol Myers Squibb. Professional medical writing assistance was provided by Peloton Advantage, LLC, an OPEN Health company, and funded by Bristol Myers Squibb.

Disclosure of Interests:

Philip J Mease Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN Pharma, UCB, Grant/research support from: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer, SUN Pharma, UCB, Atul Deodhar Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Frank Behrens Consultant of: Pfizer, AbbVie, Sanofi, Lilly, Novartis, Genzyme, Boehringer, Janssen, MSD, Celgene, Roche, Chugai, Bristol Myers Squibb, UCB Pharma, Grant/research support from: Pfizer, Janssen, Chugai, Celgene, Roche, Alan Kivitz Shareholder of: Pfizer, Sanofi, GlaxoSmithKline, Gilead Sciences, Inc., Novartis, Paid Consultant: AbbVie, Boehringer Ingelheim, Flexion, Janssen, Pfizer, Sanofi, Regeneron, SUN Pharma Advanced Research, Gilead Sciences, Inc., Speakers bureau: Celgene, Merck, Lilly, Novartis, Pfizer, Sanofi, Genzyme, Flexion, AbbVie, Jonghyeon Kim Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Shalabh Singhal Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Miroslawa Nowak Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Subhashis Banerjee Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

A descriptive audit of healthcare workers exposed to COVID-19 at a tertiary care center in India

Objective

To provide a descriptive audit of healthcare workers (HCWs) exposed to COVID‐19, and their contacts, to understand the dynamics of transmission among HCWs.

Methods

Retrospective analysis of contact tracing data of infected HCWs was done from March 1, 2020 to July 31, 2020 at a tertiary care center in New Delhi, India. Contacts were categorized according to the nature of contact and followed for 14 days.

Results

Qualitative RT‐PCR testing was performed on 106 HCWs (from a total of 257) owing to exposure or development of symptoms. Positive results were found in 16 HCWs (6.2%) who were exposed to 120 other HCWs, generating 197 exposure incidents. Of these, 30 (15.2%) exposure incidents were high risk with multiple exposures in 48 (40.0%) HCWs. Exposure to infected HCWs was noted in 3 (18.8%) of 16 positive cases. Of the 197 exposure incidents, 54 (27.4%) were deemed avoidable exposures. Infection prevention and control policies were periodically reviewed, and the department implemented mitigating steps to minimize the risk to healthcare providers.

Conclusion

Instituting appropriate infection prevention and control policies and use of adequate precautions by HCWs is vital to minimize high‐risk exposure to COVID‐19.

COVID‐19 infection among healthcare workers can be avoided using appropriate on‐duty precautions to help provide sustained patient care during the current pandemic and beyond.

Optimisation of modification parameters for amaranth starch for the development of pudding and study of the quality traits of developed pudding

Amaranth is considered to be a part of “superfood”, however, due to multiple restricting properties, its functionality in the food industry is still not explored to its fullest. The present study investigated the effect of almond gum concentration (3–10 g), temperature (50–90 °C), and quantity of water (30–70 mL) on the functional properties of amaranth starch. A central composite rotatable design (CCRD) showed that the 6.9 g of almond gum, 64.43 mL of water, and temperature maintained at 90 °C, were the optimised conditions to attain 16.77 g g−1 of swelling power, 12.97% of solubility index, and 20.13% freeze-thaw stability. Moreover, the modified amaranth starch was further employed to develop pudding as a value-added product. The findings concluded that the developed pudding using modified amaranth starch exhibited enhanced sensorial attributes due to an increase in cohesiveness, chewiness, and resilience of starch gel.

A Prospective Randomized Comparative Clinical trial of Hysteroscopic Septal Resection Using Conventional Resectoscope Versus Mini-resectoscope

CONTEXT

Hysteroscopic metroplasty (HM) is the gold standard treatment for women with septate uterus with recurrent pregnancy loss. Miniresectoscope requires less cervical dilatation as compared to conventional resectoscope. Very few studies are available in the literature on use of miniresectoscope for operative purpose.

AIM OF THE STUDY

This study aimed to compare operative and postoperative outcome parameters using conventional versus mini resectoscope (MR) for hysteroscopic septal resection (HSR).

STUDY SETTINGS AND DESIGN

This was a prospective randomized controlled trial conducted in the Department of Obstetrics and Gynaecology from July 2017 to May 2019.

MATERIALS AND METHODS

Forty patients fulfilling the inclusion criteria were recruited and randomized into two groups. In Group A (20 patients), HSR was done using conventional resectoscope (CR) and in Group B (20 patients), MR was used. The various parameters recorded were cervical dilatation time, operating time, intraoperative complications, postoperative pain, and hospital stay and reproductive outcome post surgery in both groups.

RESULTS

Data analysis was carried out using SPSS IBM software version 20.0. The mean operating time was comparable but cervical dilatation time was significantly more in Group A. The duration of hospital stay was significantly less in Group B. There were no differences in adequacy of vision in both the groups but area of field was less in MR group. Four out of nine patients with infertility conceived after surgery. 65% in Group A and 70% in Group B conceived during follow up.

CONCLUSION

Our study showed that hysteroscopic metroplasty with MR, has comparable efficacy to CR in terms of good vision and septal resectability with added advantages of shorter cervical dilatation time, ease of entry of resectoscope, shorter operative time and significantly reduced postoperative morbidity in terms of less pain. However, the field of vision is less and resection time is more, hence more expertise is required. Further larger randomized trials are required.

Retrospective analysis of surgically treated cases of squamous cell carcinoma vulva

Context

Vulvar carcinoma accounts for 3%-5% of gynecologic malignancies. The past three decades has observed changes in the trends of clinical characteristics and treatment modalities used in managing this disease.

Aims

The aim of the present study is to analyze the clinic-pathological characteristics and survival of women with squamous cell carcinoma vulva who underwent primary surgical management.

Settings and Design

This was a retrospective observational study.

Subjects and Methods

Case records of 30 consecutive patients with squamous cell carcinoma of vulva during the period of 2010-2016 were retrospectively reviewed and their clinical profile, treatment details, complications, and survival were analyzed.

Statistical Analysis Used

Kaplan-Meier survival analysis, followed by logrank test, was used for survival outcome, and Cox proportional hazard model was used to assess significant risk factors.

Results

The mean age of patients was 58 ± 12.9 years. The most common symptom was growth over vulva (73.3%), itching (63.3%), and nonhealing vulval ulcer (26.6%). The most common site for disease was labia majora. The surgical treatments ranged from wide local excision to radical vulvectomy. Postoperative adjuvant therapy was required for 16 patients. The median (95% confidence interval [CI]) overall survival was 27 (21.7-32.2) months. Five-year survival probability for early-stage disease (I + II) was 49% (95% CI: 12.9, 78.4) and for advanced disease (III + IV) was 24.8% (95% CI: 4.8, 42.6). Lymph node-positive status was found to have a significant impact on survival (hazard ratio of 4.9 [95% CI: 1.15-21.02, P = 0.02]).

Conclusions

Despite advances in detection and management modalities, the survival for vulval malignancies has not improved.

Uterine tumor resembling ovarian sex cord tumor: A series of six cases displaying varied histopathological patterns and clinical profiles

Introduction

Uterine tumors resembling ovarian sex cord tumor (UTROSCT) are a unique group of neoplasms with diverse morphology and immunophenotypic characteristics, coexpressing sex cord, epithelial, and smooth-muscle markers. To date, less than 100 cases have been reported and there is paucity of data concerning their clinical behavior.

Materials and Methods

All cases of uterine body tumors diagnosed over a period of two and a half years (2016-2018) were retrieved. Histopathological features were reviewed and extended panel of immunohistochemistry was performed to identify cases of UTROSCTs.

Results

Six cases of UTROSCTs were identified with a median age of 46.5 years. Four of them presented with menorrhagia, while two with postmenopausal bleeding including one with a history of carcinoma breast. Three of these cases were initially misdiagnosed as endometrial stromal sarcoma and adenocarcinomas. They all underwent hysterectomy with bilateral salpingo-oophorectomy.

Conclusion

It is considered a tumor with low malignant potential; however, one out of six cases (16.7%) in our study showed metastasis, within 1 year of diagnosis. It is important to recognize this entity as it mimics a wide range of both benign and malignant tumors. Molecular pathogenesis and exact management protocols remain elusive due to rarity,hence, multi-institutional studies are warranted.

Glycemic profile of women with normoglycemia and gestational diabetes mellitus during early pregnancy using continuous glucose monitoring system

AIM

We studied women between 8 and 20 weeks of gestation with the aim of evaluating and comparing those having normoglycemia and GDM according to WHO 2013 criteria.

METHODS

In this cross-sectional study (2017-2019), eligible pregnant women underwent a 75-g OGTT, followed by placement of a CGMS.

RESULTS

Women (n = 96, 58 with normoglycemia and 38 with GDM) were enrolled at 14.0 ± 3.2 weeks of gestation. Mean preprandial, 1-h and 2-h postprandial and peak glucose values were significantly higher in women with GDM. Peak glucose value was achieved 60.0 ± 12.3 and 64.3 ± 11.6 min after meal in the normoglycemia and GDM group, respectively. 24-h mean glucose (5.8 ± 0.6 vs. 5.3 ± 0.4 mmol/L), mean daytime glucose (6.0 ± 0.6 vs. 5.5 ± 0.4 mmol/L) and mean nocturnal glucose (5.4 ± 0.7 vs. 5.0 0 ± 0.5 mmol/L) were significantly higher in women with GDM. Total time spent in range was significantly lower in the GDM group compared to the normoglycemia group (92.1 vs. 98.2%).

CONCLUSIONS

This study highlights differences in glycemic patterns between women with normoglycemia and GDM in the context of a South Asian population where burden of GDM is high but good quality data in early pregnancy are limited.

A clinicopathological study of granulosa cell tumors of the ovary: Can morphology predict prognosis?

Objective

Granulosa cell tumors (GCT) are low-grade malignant sex cord-stromal tumors (SCST) with late metastasis/recurrences and long disease-free periods. We performed a clinicopathological evaluation of GCT to ascertain features having prognostic impact.

Materials and Methods

All cases of GCT of ovary from January 2006 to December 2018 were assessed for architectural patterns, nuclear grooves, and Call-Exner bodies. Each feature was graded on frequency of occurrence: not present (0)-very frequent (3). Anisonucleosis, necrosis, and inflammation were noted. Cases were grouped on mitotic count; <10 mitosis/10 High power field (HPF) or >=11 mitoses/10 HPF and Ki-67 index; <10% Ki-67 and >=11% Ki-67.

Results

GCT formed 60.1% of SCST. Sixty cases' ages were in the range of 15-78 years (median 45). Clinical details were available in 37. Commonest presentation was abnormal uterine bleeding. Serum CA125 was raised in 16.1% and Inhibin in 58.8%. Seventy percent were in stage I. Disease recurrence was associated with higher stage (P = 0.007). The most frequent pattern was diffuse sheets (47%). Call-Exner bodies were absent in 22.2%. Grooves with score 1, 2, and 3 were seen in 35.8%, 23.5%, and 13.6%, respectively. Anisonucleosis was present in 26.7%, necrosis in 11.1%, and lympho-plasmacytic infiltrate in 43%. Out of total, 93.3% had <10 mitosis/10 HPF and 43.2% had recurrence, most with high Ki-67 (P = 0.064).

Conclusion

Our study outlines histomorphological spectrum of GCT and emphasizes its frequent occurrence in lower stages with late recurrences. The presence of grooves may indicate granulosa-cell origin. Call-Exner bodies are not a necessity. Histomorphological features are not prognostically important. However, prognostic value of Ki-67 cannot be excluded. Limitation of the study was a small number of cases with follow-up.

Consensus Guidelines on Opening Up of Aesthetic Practices in India During the COVID-19 Era

INTRODUCTION

The COVID-19 is a pandemic which has affected most people directly or indirectly. It being a communicable disease, the best way to control the disease is to prevent its spread. Lockdown in India has resulted in aesthetic practices all over the country being shut down indefinitely. As things return to normal, most aesthetic practitioners are looking forward to opening practices. Hence, there was a definite need for a consensus on how to safely open up practices in India and at the same time reassure patients coming into these clinics that their safety is paramount.

METHODS

This consensus guidelines use the PICO model in its structure. Five critical areas for opening up clinical establishments were identified and approached independently. A questionnaire was prepared using the modified Likert scale, and all the stakeholders were asked to answer the same. Any differences were then resolved with discussion among the stakeholders. The entire study was divided into five subgroups which were then analyzed in detail.

RESULTS

Key recommendations and consensus guidelines were made after detailed analysis. Handy flow diagram reviews of these key areas have been provided. A thorough review of literature was also done on each of the critical areas and recommendations incorporated wherever feasible.

CONCLUSION

These recommendations have considered the difficulties and cultural issues faced by aesthetic practices in India. They are user friendly, easy to understand and implement. These guidelines would help in reassuring practices to open up safely and continue serving patients with utmost care.

LEVEL OF EVIDENCE

Level V, Consensus guidelines.

NCCN Guidelines Insights: Multiple Myeloma, Version 1.2020

The NCCN Guidelines for Multiple Myeloma provide recommendations for diagnosis, workup, treatment, follow-up, and supportive care for patients with monoclonal gammopathy of renal significance, solitary plasmacytoma, smoldering myeloma, and multiple myeloma. These NCCN Guidelines Insights highlight some of the important updates and changes in the 1.2020 version of the NCCN Guidelines for Multiple Myeloma.