Reducing decisional conflict in decisions about prenatal genetic testing: the impact of a dyadic intervention at the start of prenatal care

OBJECTIVES

Decisional conflict and regret about prenatal genetic screening and diagnostic tests may have important consequences in the current pregnancy and for future reproductive decisions. Identifying mechanisms that reduce conflict associated with the decision to use or decline these options is necessary for optimal patient counseling.

METHODS

We conducted a cluster-randomized controlled trial of a shared decision-making tool (NEST) at the beginning of prenatal care. Enrolled patients completed follow-up surveys at the time of testing (QTT) and in the second-third trimester (QFF), including the Decision Conflict Scale (DCS). Total DCS scores were analyzed using a multivariate linear mixed-effect model.

RESULTS

Of the total number of participants (n=502) enrolled, 449 completed the QTT and QFF surveys. The mean age of participants was 31.6±3.8, with most parous at the time of study participation (n=321; 71.7 %). Both the NEST (the intervention) and control groups had lower median total DCS scores at QFF (NEST 13.3 [1.7, 25.0] vs. control 16.7 [1.7, 25.0]; p=0.24) compared to QTT (NEST 20.8 [5.0, 25.0] vs. control 18.3 [3.3, 26.7]; p=0.89). Participants exposed to NEST had lower decisional conflict at QFF compared to control (β -3.889; [CI -7.341, -0.437]; p=0.027).

CONCLUSIONS

Using a shared decision-making tool at the start of prenatal care decreased decisional conflict regarding prenatal genetic testing. Such interventions have the potential to provide an important form of decision-making support for patients facing the unique type of complex and preference-based choices about the use of prenatal genetic tests.

Using Preanesthesia Clinic Visits to Improve Advance Directives Completion: An Interrupted Time Series Analysis

BACKGROUND

Advance directives documentation can increase the likelihood that patient's wishes are respected if they become incapacitated. Unfortunately, completion rates are suboptimal overall, and disparities may exist, especially for vulnerable groups. We assessed whether implementing an initiative to standardize advance directives discussions during preanesthesia visits was associated with changes in rates of advance directives completion over time, and whether the association depends on race, insurance type, or income.

METHODS

We conducted a before-after interrupted time series evaluation between January 1, 2015 and June 30, 2019 in a single-center, outpatient preanesthesia clinic. Participants were adults who visited the preanesthesia clinic at Cleveland Clinic and had >1 comorbidity before a noncardiac surgery of either medium or high risk. The intervention in March of 2017 consisted of training staff to help patients complete and witness advance directives documents during visits. We measured advance directives completion, by race, payor, and income (using the 2019 Federal Poverty Line). We assessed the confounder-adjusted association between intervention (pre versus post) and proportion of patients completing advanced directives over time using segmented regression to compare slopes between periods and assess changes at start of the intervention. We used similar models to assess whether changes depended on race, insurance type, or income level.

RESULTS

We included 26,368 visits from 22,430 patients. We analyzed financial status for 16,788 visits from 14,274 patients who had address data. There were 11,242 (43%) visits preintervention and 15,126 (57%) visits postintervention. Crude completion rates for advance directives increased from 29% to 78%, with odds of completion an estimated 18 times higher than preintervention (odds ratio [95% CI] of 18 [16-21]; P < 0.001). Regarding race, Black patients had lower completion rates preintervention than White patients, although the gap steadily closed after the intervention ( P = .001). Postintervention, both race groups immediately increased, with no difference in amount of increase ( P = .17) or postintervention change in slope difference ( P = .17). Regarding insurance, patients with Medicaid had lower preintervention completion rates than those with private. Intervention was associated with increases in both groups, but the difference in slopes ( P = .43) or proportions ( P = .23) between the groups did not change after intervention. Regarding the Federal Poverty Line, the completion rate gap between those below (<100%) and above (139%-400%) narrowed by approximately half (0.51: 95% CI, 0.27-0.98; P = .04).

CONCLUSIONS

Standardizing advance directives discussions during preanesthesia visits was associated with more patients completing advance directives, particularly in vulnerable patient groups.

Recommendations for the use of pediatric data in artificial intelligence and machine learning ACCEPT-AI

ACCEPT-AI is a framework of recommendations for the safe inclusion of pediatric data in artificial intelligence and machine learning (AI/ML) research. It has been built on fundamental ethical principles of pediatric and AI research and incorporates age, consent, assent, communication, equity, protection of data, and technological considerations. ACCEPT-AI has been designed to guide researchers, clinicians, regulators, and policymakers and can be utilized as an independent tool, or adjunctively to existing AI/ML guidelines.

Use of Direct-to-Consumer Telemedicine to Access Mental Health Services

BACKGROUND

The coronavirus disease 2019 pandemic has contributed to growing demand for mental health services, but patients face significant barriers to accessing care. Direct-to-consumer(DTC) telemedicine has been proposed as one way to increase access, yet little is known about its pre-pandemic use for mental healthcare.

OBJECTIVE

To characterize patients, providers, and their use of a large nationwide DTC telemedicine platform for mental healthcare.

DESIGN

Retrospective cross-sectional study.

SETTING

Mental health encounters conducted on the American Well DTC telemedicine platform from 2016 to 2018.

PARTICIPANTS

Patients and physicians.

MAIN MEASURES

Patient measures included demographics, insurance report, and number of visits. Provider characteristics included specialty, region, and number of encounters. Encounter measures included wait time, visit length and timing, out-of-pocket payment, coupon use, prescription outcome, referral receipt, where care otherwise would have been sought, and patient satisfaction. Factors associated with five-star physician ratings and prescription receipt were assessed using logistic regression.

KEY RESULTS

We analyzed 19,270 mental health encounters between 6708 patients and 1045 providers. Visits were most frequently for anxiety (39.1%) or depression (32.5%), with high satisfaction (4.9/5) across conditions. Patients had a median 2.0 visits for psychiatry (IQR 1.0-3.0) and therapy (IQR 1.0-5.0), compared to 1.0 visit (IQR 1.0-1.0) for urgent care. High satisfaction was positively correlated with prescription receipt (OR 1.89, 95% CI 1.54-2.32) and after-hours timing (aOR 1.18, 95% CI 1.02-1.36). Prescription rates ranged from 79.6% for depression to 32.2% for substance use disorders. Prescription receipt was associated with increased visit frequency (aOR 1.95, 95% CI 1.57-2.42 for ≥ 3 visits).

CONCLUSIONS

As the burden of psychiatric disease grows, DTC telemedicine offers one solution for extending access to mental healthcare. While most encounters were one-off, evidence of some continuity in psychiatry and therapy visits-as well as overall high patient satisfaction-suggests potential for broader DTC telemental health use.

The Impact of Outpatient Prenatal Care Visitor Restrictions on Pregnant Patients and Partners During the COVID-19 Pandemic

Introduction:

Methods:

Results:

Conclusions:

OP0232 HIGH PLASMA C4d/C4 IDENTIFIES LUPUS NEPHRITIS PATIENTS WITH DISEASE MEDIATED BY ACTIVATION OF THE CLASSICAL COMPLEMENT PATHWAY

Background

Proliferative lupus nephritis (LN) involves immune complex deposition in the kidney that can severely impact normal renal clearance mechanisms. Immune complexes can activate C1q and the classical complement cascade, and along with pathogenic anti-C1q antibodies (PACAs), may amplify inflammation and disease progression. Martin et al reported that circulating C4d, a marker of complement activation downstream of the C1 complex, correlated well with C4d immunohistochemistry score in kidney tissue and could be a sensitive and specific biomarker for diagnosing active LN.1

Objectives

To confirm and extend observations by Martin et al, and to extend a link between C4d, C1q activation, and PACA levels to identify patients most likely to have the classical complement pathway as a driving component of disease. Such patients would be potential candidates for anti-C1q therapy, such as ANX009, to dampen disease activity and slow disease progression (NCT04535752).

Methods

Plasma samples were collected from a cohort of 40 LN patients (20 with disease flare and 20 without disease flare) from the California Lupus Epidemiology Study (CLUES), a multi-racial/ethnic cohort of individuals with physician-confirmed systemic lupus erythematosus, and 20 healthy controls (Table 1). A panel of complement factors, including 15 complement protein and relevant complexes, were measured using an enzyme-linked immunosorbent assay. Clinical disease activity was measured using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and proteinuria was evaluated by a random spot urine protein to creatinine ratio (UPCR).

Table 1.

Patient Demographics

CharacteristicsHealthy Control(n=20)LN Flare(n=20)LN Without Flare(n=20)Median age (years)*50 (31-60.8)28.5 (26-34.5)43.5 (33.5-52)Sex, n (%)Female18 (90)17 (85)18 (90)Demographics, n (%)Caucasian8 (40)1 (5)5 (25)Hispanic3 (15)9 (45)4 (20)African American1 (5)3 (15)3 (15)Asian8 (40)7 (35)8 (40)Median UPCR (mg/mg)*N/A1.8 (1.3-6.5)0.4 (0.2-0.6)Median SLEDAI*N/A12 (9-16)2 (2-4)

*Reported as median (IQR).

LN, lupus nephritis; N/A, not applicable; SLEDAI, Systemic Lupus Erythematosus Disease Activity Index; UPCR, urine protein:creatinine ratio.

Results

We observed evidence of coordinated complement activation in LN patients relative to healthy controls. Specifically, levels of C4d and the C4d/C4 ratio were highly increased in LN patients with flare, while levels of C1q, C1s, and C4 were decreased, consistent with activation of the classical complement pathway (increased activation and component consumption). The C4d/C4 ratio also correlated with levels of PACA isotypes 1 and 3 that are known to activate the classical pathway. Improvements in C4 and C4d/C4 ratio were associated with improvements in proteinuria and SLEDAI following treatment for disease flare, indicating their potential value as biomarkers of treatment response.

Conclusion

A subset of LN patients exhibited high C4d/C4 ratio along with specific markers of classical pathway activation, indicating that the classical complement pathway may be a driving component of their disease. Reduction in this ratio appears to correlate with treatment response, but its levels are generally not normalized, suggesting an insufficient resolution of complement-mediated inflammation by currently available treatments. Our data support a clinical hypothesis that a subset of LN patients may benefit from a precision medicine approach targeting the classical complement pathway (Figure 1). This hypothesis will be evaluated in a forthcoming clinical trial testing the subcutaneously administered C1q inhibitor ANX009 in patients with active LN.

References

[1]Martin M, Trattner R, Nilsson SC, et al. Plasma C4d Correlates With C4d Deposition in Kidneys and With Treatment Response in Lupus Nephritis Patients. Front Immunol. 2020;11:582737.

Acknowledgements

Supported by: Annexon Biosciences

Disclosure of Interests

Ann Mongan Employee of: Annexon Biosciences, Poojan Suri Employee of: Annexon Biosciences, Maze Therapeutics, Dean Richard Artis Shareholder of: Annexon Biosciences, Bristol Myer Squibb, Roche, Sanofi, BMS, J&J, Employee of: Annexon Biosciences, Ellen Cahir-McFarland Shareholder of: Annexon Biosciences, Employee of: Annexon Biosciences, Biogen, Henk-André Kroon Shareholder of: Annexon Biosciences, Employee of: Annexon Biosciences, Yaisa Andrews-Zwilling Employee of: Annexon Biosciences, Shawn Rose Employee of: Annexon, Johnson & Johnson, Sanjay Keswani Shareholder of: Annexon Biosciences, Nura Bio, Employee of: Annexon Biosciences, Nura Bio, Maria Dall’Era Consultant of: GSK, AstraZeneca, Biogen, Annexon Biosciences, Pfizer, Aurinia, Grant/research support from: Annexon Biosciences, GSK, Ted Yednock Shareholder of: Annexon Biosciences, Consultant of: Cortexyme, Employee of: Annexon Biosciences

Anthropometry indicators that are most related to metabolic profiles in female college students

Metabolic syndrome is not a disease but is a set of several disorders and causes an increased risk of cardiovascular disease and diabetes mellitus complications. Several studies have shown that non-invasive approaches such as anthropometric measurements can be used for the early detection of metabolic syndrome. This study aimed to analyse the anthropometric indicators related to metabolic syndrome in female college students. The design of this research was cross sectional, with the number of subjects involved were as many as 163 female college students aged 19 to 24 years old. Purposive sampling was used in the sampling of this research. The independent variables in this study were the Waist-to-Height Ratio (WHtR), Waist-Hip Ratio (WHR), Body Mass Index (BMI), Sagittal Abdominal Diameter (SAD), and hip circumference. The dependent variable in this study is the metabolic syndrome component that has been converted into a metabolic syndrome score (cMetS). The analysis results showed that all anthropometric indicators, namely WHtR, BMI, SAD, waist circumference, hip circumference and WHR have a strong positive relationship with the metabolic syndrome score (p<0.001). BMI was the anthropometric indicator that is most associated with the metabolic profiles, such as systolic blood pressure (p<0.001), blood sugar (p<0.05), and HDL (p<0.001). Waist circumference was the anthropometric indicator that is most associated with triglycerides and metabolic syndrome score (p<0.001). Metabolic syndrome in female college students can be identified using anthropometric measurements, one of which is BMI and WHR which are very easy to measure and efficient. BMI and WHR have the strongest relationship and can be used to detect early risk of metabolic syndrome in female college students.

Anthropometric profile and its correlation to insulin resistance in female students with obesity

The prevalence of obesity in adolescent girls is increasing each year. Several anthropometric measurements can be used to detect the incidence of insulin resistance. This study was aimed to observe the correlation of anthropometric profiles with insulin resistance in adolescent girls with obesity. This was an observational study with a total of 120 female students of Universitas Diponegoro (Undip), aged between 18 and 21 years old, who have waist circumference >80 cm. They were chosen by a simple random sampling technique. Anthropometric profile data taken has consisted of waist circumference, hip circumference, waist-hip circumference ratio (WHR), waist-to-height ratio (WHtR), neck circumference, waist circumference, thigh circumference, and 2D:4D digit ratio. Insulin resistance data was determined using the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR.). Bivariate analysis was completed with the Spearman rank test. There was 83.3% of subjects who experienced insulin resistance. High WHtR was found in 98.3% of total subjects as many as 90.8% of subjects were at risk based on WHR values. Based on 2D:4D ratio digits, neck circumference, wrist circumference <50% of subjects were found as at risk. There was no correlation between waist circumference, WHR, wrist circumference, 2D:4D digit ratio with HOMA-IR (p>0.05). However, there was a positive correlation between WHtR, neck circumference, and thigh circumference with HOMA-IR (p<0.05). Anthropometric profiles such as WHtR, neck circumference, and thigh circumference were correlated with insulin resistance in female adolescents with obesity.

Successes and Challenges of Implementing Telehealth for Diverse Patient Populations: Attending to Prenatal Care during COVID-19

Background

Although telehealth appears to have been accepted among some obstetric populations before the COVID-19 pandemic, patients’ receptivity and experience with the rapid conversion of this mode of health care delivery are unknown.

Objective

In this study, we examine patients' prenatal care needs, preferences, and experiences during the COVID-19 pandemic, with the aim of supporting the development of successful models to serve the needs of pregnant patients, obstetric providers, and health care systems during this time.

Methods

This study involved qualitative methods to explore pregnant patients’ experiences with prenatal health care delivery at the onset of the COVID-19 pandemic. We conducted in-depth interviews with pregnant patients in the first and second trimester of pregnancy who received prenatal care in Cleveland, Ohio, from May to July 2020. An interview guide was used to probe experiences with health care delivery as it rapidly evolved at the onset of the pandemic.

Results

Although advantages of telehealth were noted, there were several concerns noted with the broad implementation of telehealth for prenatal care during the pandemic. This included concerns about monitoring the pregnancy at home; the need for additional reassurance for the pregnancy, given the uncertainties presented by the pandemic; and the ability to have effective patient-provider discussions via a telehealth visit. The need to tailor telehealth to prenatal health care delivery was noted.

Conclusions

Although previous studies have demonstrated that telehealth is a flexible and convenient alternative for some prenatal appointments, our study suggests that there may be specific needs and concerns among the diverse patient groups using this modality during the pandemic. More research is needed to understand patients' experiences with telehealth during the pandemic and develop approaches that are responsive to the needs and preferences of patients.

Automating Quantitative Measures of an Established Conventional MRI Scoring System for Preterm-Born Infants Scanned between 29 and 47 Weeks' Postmenstrual Age

BACKGROUND AND PURPOSE

Conventional MR imaging scoring is a valuable tool for risk stratification and prognostication of outcomes, but manual scoring is time-consuming, operator-dependent, and requires high-level expertise. This study aimed to automate the regional measurements of an established brain MR imaging scoring system for preterm neonates scanned between 29 and 47 weeks' postmenstrual age.

MATERIALS AND METHODS

This study used T2WI from the longitudinal Prediction of PREterm Motor Outcomes cohort study and the developing Human Connectome Project. Measures of biparietal width, interhemispheric distance, callosal thickness, transcerebellar diameter, lateral ventricular diameter, and deep gray matter area were extracted manually (Prediction of PREterm Motor Outcomes study only) and automatically. Scans with poor quality, failure of automated analysis, or severe pathology were excluded. Agreement, reliability, and associations between manual and automated measures were assessed and compared against statistics for manual measures. Associations between measures with postmenstrual age, gestational age at birth, and birth weight were examined (Pearson correlation) in both cohorts.

RESULTS

A total of 652 MRIs (86%) were suitable for analysis. Automated measures showed good-to-excellent agreement and good reliability with manual measures, except for interhemispheric distance at early MR imaging (scanned between 29 and 35 weeks, postmenstrual age; in line with poor manual reliability) and callosal thickness measures. All measures were positively associated with postmenstrual age (r = 0.11-0.94; R² = 0.01-0.89). Negative and positive associations were found with gestational age at birth (r = -0.26-0.71; R² = 0.05-0.52) and birth weight (r = -0.25-0.75; R² = 0.06-0.56). Automated measures were successfully extracted for 80%-99% of suitable scans.

CONCLUSIONS

Measures of brain injury and impaired brain growth can be automatically extracted from neonatal MR imaging, which could assist with clinical reporting.

Patient Experience in Virtual Visits Hinges on Technology and the Patient-Clinician Relationship: A Large Survey Study With Open-ended Questions

BACKGROUND

Patient satisfaction with in-person medical visits includes patient-clinician engagement. However, communication, empathy, and other relationship-centered care measures in virtual visits have not been adequately investigated.

OBJECTIVE

This study aims to comprehensively consider patient experience, including relationship-centered care measures, to assess patient satisfaction during virtual visits.

METHODS

We conducted a large survey study with open-ended questions to comprehensively assess patients' experiences with virtual visits in a diverse patient population. Adults with a virtual visit between June 21, 2017, and July 12, 2017, were invited to complete a survey of 21 Likert-scale items and textboxes for comments following their visit. Factor analysis of the survey items revealed three factors: experience with technology, patient-clinician engagement, and overall satisfaction. Multivariable logistic regression was used to test the associations among the three factors and patient demographics, clinician type, and prior relationship with the clinician. Using qualitative framework analysis, we identified recurrent themes in survey comments, quantitatively coded comments, and computed descriptive statistics of the coded comments.

RESULTS

A total of 65.7% (426/648) of the patients completed the survey; 64.1% (273/426) of the respondents were women, and the average age was 46 (range 18-86) years. The sample was geographically diverse: 70.2% (299/426) from Ohio, 6.8% (29/426) from Florida, 4.2% (18/426) from Pennsylvania, and 18.7% (80/426) from other states. With regard to insurance coverage, 57.5% (245/426) were undetermined, 23.7% (101/426) had the hospital's employee health insurance, and 18.7% (80/426) had other private insurance. Types of virtual visits and clinicians varied. Overall, 58.4% (249/426) of patients had an on-demand visit, whereas 41.5% (177/426) had a scheduled visit. A total of 41.8% (178/426) of patients had a virtual visit with a family physician, 20.9% (89/426) with an advanced practice provider, and the rest had a visit with a specialist. Most patients (393/423, 92.9%) agreed that their virtual visit clinician was interested in them as a person, and their virtual visit made it easy to get the care they needed (383/421, 90.9%). A total of 81.9% (344/420) of respondents agreed or strongly agreed that their virtual visit was as good as an in-person visit by a clinician. Having a prior relationship with their virtual visit clinician was associated with less comfort and ease with virtual technology among patients (odds ratio 0.58, 95% CI 0.35-0.98). In terms of technology, patients found the interface easy to use (392/423, 92.7%) and felt comfortable using it (401/423, 94.8%). Technical difficulties were associated with lower odds of overall satisfaction (odds ratio 0.46, 95% CI 0.28-0.76).

CONCLUSIONS

Patient-clinician engagement in virtual visits was comparable with in-person visits. This study supports the value and acceptance of virtual visits. Evaluations of virtual visits should include assessments of technology and patient-clinician engagement, as both are likely to influence patient satisfaction.

ENHANCERS OF LIVER REGENERATION IN ONCOLOGICAL SURGERY

INTRODUCTION

Chemotherapy hinders liver function and probably its regenerating capacity, forcing to delay it after surgery. Our objective has been to verify this effect in an experimental model and to see if a hepatotrophic agent can prevent it.

MATERIAL AND METHODS

Four groups of 6 WAG/RijHsd rats (males, 3-4 months) were submitted to ligation of the portal branch to the left lateral and left paramedian lobes. They were sacrificed 36 h later to quantify the percentage of liver corresponding to the ligated lobes (weight), the number of hepatocyte’s nuclei (nº/100 µm2) and their mean size (µm2). One group received no treatment (control); another folic acid (2.5 mg/kg ip, during surgery); other 5-Fluorouracil (5-FU 50 mg/kg ip 48 h before); and the fourth received folic&5-FU.

RESULTS

The animals treated with folic acid showed a greater number of hepatocyte’s nuclei (24.4 ± 2.77 vs 15.2 ± 1.51) and their mean size was also greater (121 ± 2.34 vs 111 ± 1.8). However, the reduction in weight of the ligated parenchyma was less than in control group (33.4 ± 1.08 vs 29.5 ± 1.08). 5-FU did not modify the number of nuclei (15.6 ± 18.4), although they were smaller in size (104 ± 1.7). The addition of folic acid to 5-FU increased the number of nuclei (21.7 ± 2.8) and normalized their size (111 ± 3.2).

CONCLUSIONS

5-FU exerts a depressant effect on livers regeneration, and folic acid overcomes it. Thus, folic acid could allow early application of chemotherapy without affecting liver regeneration.

Performance Evaluation of UAVSAR and Simulated NISAR Data for Crop/Noncrop Classification Over Stoneville, MS

Synthetic Aperture Radar (SAR) data are well-suited for change detection over agricultural fields, owing to high spatiotemporal resolution and sensitivity to soil and vegetation. The goal of this work is to evaluate the science algorithm for the NASA ISRO SAR (NISAR) Cropland Area product using data collected by NASA's airborne Uninhabited Aerial Vehicle SAR (UAVSAR) platform and the simulated NISAR data derived from it. This study uses mode 129, which is to be used for global-scale mapping. The mode consists of an upper (129A) and lower band (129B), respectively having bandwidths of 20 and 5 MHz. This work uses 129A data because it has a four times finer range resolution compared to 129B. The NISAR algorithm uses the coefficient of variation (CV) to perform crop/noncrop classification at 100 m. We evaluate classifications using three accuracy metrics (overall accuracy, J-statistic, Cohen's Kappa) and spatial resolutions (10, 30, and 100 m) for crop/noncrop delineating CV thresholds (CVthr) ranging from 0 to 1 in 0.01 increments. All but the 10 m 129A product exceeded NISAR's mission accuracy requirement of 80%. The UAVSAR 10 m data performed best, achieving maximum overall accuracy, J-statistic, and Kappa values of 85%, 0.62, and 0.60. The same metrics for the 129A product respectively are: 77%, 0.40, 0.36 at 10 m; 81%, 0.55, 0.49 at 30 m; 80%, 0.58, 0.50 at 100 m. We found that using a literature recommended CVthr value of 0.5 yielded suboptimal accuracy (65%) at this site and that optimal CVthr values monotonically decreased with decreasing spatial resolution.

The influence of collecting patient-reported outcome measures on visit satisfaction in rheumatology clinics

Objectives

Patient-reported outcome measures (PROMs) can direct patient-centred care and increase patient satisfaction with the visit. The objective of this study was to assess the relationship between the collection of PROMs and visit satisfaction, as measured by the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey.

Methods

An electronic platform for collection of patient-reported information was implemented in rheumatology clinics between August and September 2016. Adult patients were included in the study if they completed CG-CAHPS after an ambulatory visit. The pre-implementation cohort consisted of patients seen between January and June 2016; the post-implementation cohort consisted of patients seen between January and June 2017. The CG-CAHPS scores were compared between cohorts. Mixed effect models were constructed to identify predictors of visit satisfaction.

Results

Characteristics were similar between the 2117 pre- and 2380 post-implementation patients. Visit satisfaction was high in both cohorts but did not differ [odds ratio = 0.97 (95% CI: 0.79, 1.19)]. Predictors of improved satisfaction included being an established patient, being male, older age and reporting higher quality of life. However, sensitivity analyses in the post-implementation cohort suggested that implementing PROMs might convey benefits for new patients, in particular.

Conclusion

Collection of PROMs had no effect on visit satisfaction in rheumatology clinics, although there might be benefits for new patients. These largely null findings might be attributable to high satisfaction levels in our cohorts or to lack of provider review of PROM data with patients. Further research is indicated to determine the impact of provider communication of PROM results to patients on different domains of visit satisfaction.

Obtaining Patient Priorities in a Multiple Sclerosis Comprehensive Care Center: Beyond Patient-Reported Outcomes

Background:

In order to provide patient center care, our multiple sclerosis (MS) clinic assesses patient concerns before clinical encounters, first by asking the optional qualitative question “What is the most important thing you what your health-care provider to know today” (most important concern of the patient [MIPC]) and then completing quantitative patient-reported outcome measures (PROMs) including Quality of Life in Neurological Disorders (Neuro-QoL). Both sets of questions are designed to facilitate encounters that address patients’ values and preferences.

Objective:

Determine whether the qualitative MIPC responses provided unique information not included in PROMs or clinical assessments.

Methods:

We randomly selected 400 first-time MIPC responders and 400 first-time MIPC nonresponders from 2788 participants in our database. We categorized MIPC responses by content and number of unique concerns and appended them to the Neuro-QoL framework. Nonresponders were compared to those who provided 1 and 2 or more responses.

Results:

Several MIPCs MS symptoms categories were added to the Neuro-QoL Physical domain. Most important concern of the patients work and cost-of-care categories were added to the Social Domain. Domains regarding treatment satisfaction and disease management were added. Two hundred thirty (58%) MIPC respondents reported 1 concern, 140 (35%) expressed 2 to 6 concerns, and 30 (7%) reported MS-unrelated concerns and not analyzed. Physical symptoms were the most common MIPC (69.9%). Respondents with more concerns were more likely African American, lacked private insurance, and worse disability.

Conclusions:

Importantly, MIPC responders described idiosyncratic symptoms, disease management, and social concerns not included in the PROMS, suggesting the MIPC question offered patients a unique opportunity to share specific concerns with their providers.

Female In-Class Participation and Performance Increase with More Female Peers and/or a Female Instructor in Life Sciences Courses

As we strive to make science education more inclusive, more research is needed to fully understand gender gaps in academic performance and in-class participation in the life sciences. Studies suggest that male voices dominate introductory biology courses, but no studies have been done on upper-level courses. Results on achievement gender gaps in biology vary and often conflict, and no studies have been done on the correlation between participation and academic performance gaps. We observed 34 life sciences courses at all levels at a large private university. Overall, males were more likely to participate than their female peers, but these gender gaps varied from class to class. Females participated more in classes in which the instructor called on most hands that were raised or in classes with more females in attendance. Performance gender gaps also varied by classroom, but female final course grades were as much as 0.2 SD higher in classes with a female instructor and/or a female student majority. Gender gaps in participation and final course grades were positively correlated, but this could be solely because female students are more likely to both participate more and earn higher grades in classes with many females in attendance.

Comparison of Burnout and Empathy Among Millennial and Generation X Residents and Fellows: Associations with Training Level and Race but Not Generation Affiliation

OBJECTIVE

The authors examine the associations of generational affiliation on empathy and burnout in a sample of millennial (born between 1982 and 2000) and Generation X (born between 1965 and 1981) residents and fellows.

METHODS

At a single large institution during the 2013-2014 academic year, residents and fellows were asked to complete the Jefferson Scale of Physician Empathy and Maslach Burnout Inventory (MBI). Responses were combined with GME database content. Multivariable regression analysis included generation affiliation, race, gender, and post-graduate year (PGY) as covariates.

RESULTS

The study sample included 388 millennial (mean age = 29.3) and 200 Generation X trainees (mean age = 34.6), with the response rate being 96.5%. Groups were statistically different by gender (p < 0.001) and PGY level (p < 0.001). After adjustment for gender, race, and PGY level, no statistically significant differences were found between millennial and Generation X groups in mean scores of empathy or burnout. Empathy was associated with PGY level (p = 0.0008) and race (p < 0.0001), with decreased empathy in advanced training levels and increased empathy in Hispanic/Latino race. Burnout rate was associated with PGY level (p = 0.001) but not generational affiliation (p = 0.6). The MBI depersonalization subscale was associated with PGY level (p < 0.001) and race (p = 0.0034), with decreased depersonalization in advanced training levels and Hispanic/Latino race. The emotional exhaustion and personal accomplishment MBI subscales did not demonstrate any significant associations in the multivariable regression model.

CONCLUSIONS

In a compared sample of millennial and Generation X residents and fellows, PGY level and Hispanic/Latino race (though not generation affiliation) were significantly associated with both empathy and MBI depersonalization subscale scores, while only PGY level was significantly associated with burnout rate. This study presents further evidence of de-escalating burnout and declining empathy over the course of medical residency.

OP0161 ASSOCIATION OF BASELINE CYTOTOXIC GENE EXPRESSION WITH USTEKINUMAB RESPONSE IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Systemic Lupus Erythematous (SLE) is a clinically and biologically diverse disease, for which only one new therapy has been approved in the past 60 years. In a phase 2 trial on patients with mild-to-moderate SLE, ustekinumab (UST) improved clinical and laboratory measures of disease activity compared with placebo (PBO).1

Objectives:

We previously reported an association of IFN-γ reduction with response to UST,2suggesting an impact on the IL12/Th1 axis. To extend these findings, we performed unbiased transcriptomic analysis from baseline whole blood samples to identify genes that discriminate UST responders (UST-R) from non-responders (UST-NR) using the primary endpoint of Systemic Lupus Erythematosus Responder Index (SRI)-4 at week 24 to define response.

Methods:

UST was studied in a Ph2 PBO-controlled study of 102 patients with seropositive SLE and active disease despite standard therapy. Patients were randomized 3:2 to receive IV UST 6 mg/kg or placebo followed by subcutaneous injections of UST 90 mg or PBO every 8 weeks. Whole blood gene expression at baseline was measured via microarray using RNA samples from 100 patients, as samples from 2 patients failed quality control. An unbiased approach was used to identify gene signatures present at baseline that associate with UST response. Recombinant IL-12 or IL-23 was incubatedin vitrowith whole blood from 6 healthy donors for 24h and RNA-Seq was performed to determine the effect of these treatments on representative genes comprising the UST response signature.

Results:

A non-biased machine learning algorithm identified a 9-gene whole blood signature composed primarily of cytotoxic cell-associated transcripts (PRF1, KLRD1, GZMH, NKG7, GNLY, FGFBP2, TRGC2, TARP, TRGV2) that was enriched at baseline in UST-R vs UST-NR. By Gene Set Variation Analysis, the cytotoxic signature enrichment in UST-NR was less at baseline than both UST-R and a healthy control cohort (P=0.0087, P=0.056, respectively), whereas UST-R cytotoxic gene enrichment was similar to healthy controls (P=0.31). No significant difference in cytotoxic signature enrichment was observed at baseline between PBO responders and PBO non-responders or healthy controls (Figure). Enrichment levels of the cytotoxic gene signature remained stable over time in PBO and UST-NR groups while a trend of decreased cytotoxic signature was observed in UST-R, although never reaching levels seen in UST-NR. To begin to understand the relationship between IL-12 and IL-23, the targets of UST, and the cytotoxic signature, whole blood was stimulated with these cytokinesin vitro. Recombinant IL-12, but not IL-23, resulted in increased expression of representative members of this cytotoxic gene signature.

Conclusion:

We identified a novel cytotoxic signature in baseline blood samples that associated with UST response in SLE. The observation that IL-12 can increase this signaturein vitroand that IL-12 is a robust inducer of cytotoxic cell activity3as well as IFN-γ3suggests an important role of IL-12 blockade in the mechanism of action of UST in SLE.

References:

[1]van Vollenhoven RF. Lancet. 2018;392:1330-39

[2]Jordan. ACR 2018 Abstract # 2951

[3]G. Trinchieri. Nat Rev Immunol. 2003;3:133-46

Figure.

Disclosure of Interests:

Loqmane Seridi Employee of: Janssen Research & Development, LLC, Matteo Cesaroni Employee of: Janssen Research & Development, LLC, Matthew J Loza Employee of: Janssen Research & Development, LLC, Jessica Schreiter Employee of: Janssen Research & Development, LLC, Kristen Sweet Employee of: Janssen Research & Development, LLC, Yevgeniya Orlovsky Employee of: Janssen Research & Development, LLC, Spring House, PA, United States of America, Isabelle Baribaud Employee of: Janssen Research & Development, LLC, Ashley Orillion Employee of: Janssen Research & Development, LLC, Peter Lipsky Consultant of: Horizon Therapeutics, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Bevra H. Hahn Grant/research support from: Janssen Research & Development, LLC, George Tsokos Grant/research support from: Janssen Research & Development, LLC, Marc Chevrier Employee of: Janssen Research & Development, LLC, Shawn Rose Employee of: Janssen Research & Development, LLC, Frederic Baribaud Shareholder of: Janssen Research & Development, LLC, Employee of: Janssen Research & Development, LLC, Jarrat Jordan Employee of: Janssen Research & Development, LLC

AB0850 CUTANEOUS LUPUS ERYTHEMATOSUS DISEASE AREA & SEVERITY INDEX (CLASI) DEMONSTRATES THRESHOLDS FOR DETECTION OF TREATMENT RESPONSE IN A PHASE 2, PLACEBO-CONTROLLED TRIAL OF USTEKINUMAB IN SLE

Background:

In a Phase 2 study, Ustekinumab (UST) showed improvement at week (wk) 24 in the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) response (≥4-point improvement from baseline [BL]) vs placebo (PBO).1Post hoc analysis revealed that more patients (pts) on UST vs PBO achieved ≥50% improvement in total CLASI activity score.

Objectives:

To examine the relationships of CLASI activity responses to SLEDAI-2K (S2K) mucocutaneous disease responses.

Methods:

Adults with SLE (S2K ≥6, ≥1 BILAG A and/or ≥2 BILAG B scores) despite standard of care (SOC) therapy were enrolled. Pts (n=102) were randomized (3:2) to UST ~6 mg/kg IV or PBO at wk 0, followed by UST 90 mg SC or PBO every 8 wks beginning at wk 8 + SOC. S2K index measures complete improvement from BL; S2K Responder Index-50 (S2K RI-50) evaluates partial improvement (≥50%) in S2K rash. CLASI rash: sum of erythema and scale/hypertrophy score. In post hoc analysis, improvement in CLASI activity score at wk 24 was calculated using increasing thresholds of BL disease activity and various cut points of improvement to define treatment response.

Results:

Complete improvement from BL in rash was concordant between CLASI and S2K (correlation coefficients [r] ≥0.997, Table 1). There was less agreement between CLASI and S2K RI-50 for assessing partial improvement in rash. Treatment difference (UST vs PBO) in % pts achieving partial improvement in rash was observed for CLASI (60% vs 38.5%), but not S2K RI-50 (51.1% vs 50%). Complete improvement from BL in mucosal ulceration was congruent between CLASI and S2K (r=1). Both instruments demonstrated greater proportions of responders to UST vs PBO. Treatment differences between UST and PBO in achieving ≥20%, ≥35%, and ≥50% improvement from BL in total CLASI activity score were noteworthy at various thresholds of disease activity (Table 2).

Table 1.

CLASI Activity Scores vs SLEDAI-2K Activity

24-Week ImprovementTreatmentActivity Measure% (n/N*)r**CLASI RashSLEDAI-2K Rash100%PBO30.8 (8/26)30.8 (8/26)1.0000UST28.9 (13/45)31.1 (14/45)0.9997≥50%PBO38.5 (10/26)50.0 (13/26)0.9996UST60.0 (27/45)51.1 (23/45)0.8693CLASIMucosal UlcerSLEDAI-2KMucosal Ulcer100%PBO66.7 (8/12)69.2 (9/13)1.0000UST89.5 (17/19)89.5 (17/19)1.0000

*N=Evaluated pts with BL SLEDAI rash present, total CLASI activity score >0, and CLASI rash or mucosal ulcer activity scores >0 in analyses of subcomponents; **Calculated using tetrachoric correlation.

Table 2.

Differences in Partial Improvement in Total CLASI Activity Score at Various BL Disease Activity Thresholds

CLASI Total Activity ScoreImprovementThreshold (%)PBO% (n/N*)UST% (n/N*)Difference % (UST vs PBO)BL >0≥2054.8 (17/31)74.5 (38/51)19.7≥3541.9 (13/31)60.8 (31/51)18.9≥5041.9 (13/31)54.9 (28/51)13.0BL ≥4≥2058.8 (10/17)71.9 (23/32)13.1≥3535.3 (6/17)62.5 (20/32)27.2≥5035.3 (6/17)53.1 (17/32)17.8BL ≥6≥2053.8 (7/13)72.0 (18/25)18.2≥3530.8 (4/13)60.0 (15/25)29.2≥5030.8 (4/13)52.0 (13/25)21.2BL ≥8≥2058.3 (7/12)70.6 (12/17)12.3≥3533.3 (4/12)58.8 (10/17)25.5≥5033.3 (4/12)47.1 (8/17)13.8

*N=Evaluated pts with BL total CLASI activity score >0, ≥4, ≥6, ≥8 based on post hoc analyses

Conclusion:

CLASI demonstrated partial improvement in active mucocutaneous disease that was not captured by S2K RI-50. Treatment effect favoring UST vs PBO was observed across range of thresholds of BL CLASI activity and cut points used to define improvement, which have previously been shown to be clinically meaningful.2Findings are based on a limited sample size and treatment duration; results will be confirmed in an ongoing Phase 3 UST trial (NCT03517722).

References:

[1]Van Vollenhoven R.Lancet. 2018;392:1330

[2]Chakka S.JID.2019;139: S101 (#587)

Disclosure of Interests:

Victoria Werth Grant/research support from: Biogen, Celgene, Gilead, Janssen, Viela, Consultant of: Biogen, Gilead, Janssen, Abbvie, GSK, Resolve, AstraZeneca, Amgen, Eli Lilly, EMD Serono, BMS, Viela, Kyowa Kirin, Bevra H. Hahn Grant/research support from: Janssen Research & Development, LLC, George Tsokos Grant/research support from: Janssen Research & Development, LLC, Shawn Rose Employee of: Janssen Research & Development, LLC, Kaiyin Fei Employee of: Janssen Research & Development, LLC, Y Irene Gregan Employee of: Janssen Research & Development, LLC, Robert Gordon Employee of: Janssen Research & Development, LLC, Kim Hung Lo Employee of: Janssen Research & Development, LLC, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex

Association Between Patient Experience With Patient-Reported Outcome Measurements and Overall Satisfaction With Care in Neurology

BACKGROUND

There has been increasing focus on both patient-reported outcome measurement (PROM) collection and patient satisfaction ratings; nevertheless, little is known about their relationship.

OBJECTIVES

To determine the association between patient experience with PROM collection and visit satisfaction and to identify characteristics of better ratings for each.

METHODS

This cross-sectional observational study included all patients seen in 15 neurological clinics who completed PROMs as well as 6 questions on the patient experience with PROMs at least once from October 1, 2015 to December 31, 2016. Visit satisfaction was evaluated using a composite measure of physician communication, overall physician rating, and the likelihood of recommending that physician as indicated on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. Predictors of PROM experience and satisfaction were identified using proportional odds and logistic regression models, respectively.

RESULTS

There were 6454 patients (average age 58 ± 15 years, 59% women) who completed PROMs and responded to the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey. There were significant positive associations between each PROM experience question and visit satisfaction (r = 0.11-0.19; P<.010), although factors predicting visit satisfaction differed from those predicting PROM experience. A differential effect of PROMs on visit satisfaction was identified for patients who were nonwhite, had lower income, and had more comorbidities.

CONCLUSIONS

Although there was a significant association between better PROM experience and higher visit satisfaction, relationships with clinical characteristics differed, providing insights into how PROMs may be associated with patients' visit satisfaction. Further research is necessary to confirm whether PROMs can be used to improve visit satisfaction, particularly in patients who historically have reported lower quality of care.

Application of TruGraf v1: A Novel Molecular Biomarker for Managing Kidney Transplant Recipients With Stable Renal Function

TruGraf v1 is a laboratory-developed DNA microarray-based gene expression blood test to enable proactive noninvasive serial assessment of kidney transplant recipients with stable renal function. It has been previously validated in patients identified as Transplant eXcellence (TX: stable serum creatinine, normal biopsy results, indicative of immune quiescence), and not-TX (renal dysfunction and/or rejection on biopsy results). TruGraf v1 is intended for use in subjects with stable renal function to measure the immune status as an alternative to invasive, expensive, and risky surveillance biopsies.

MATERIALS AND METHODS

In this study, simultaneous blood tests and clinical assessments were performed in 192 patients from 7 transplant centers to evaluate TruGraf v1. The molecular testing laboratory was blinded to renal function and biopsy results.

RESULTS

Overall, TruGraf v1 accuracy (concordance between TruGraf v1 result and clinical and/or histologic assessment) was 74% (142/192), and a result of TX was accurate in 116 of 125 (93%). The negative predictive value for TruGraf v1 was 90%, with a sensitivity 74% and specificity of 73%. Results did not significantly differ in patients with a biopsy-confirmed diagnosis vs those without a biopsy.

CONCLUSIONS

TruGraf v1 can potentially support a clinical decision enabling unnecessary surveillance biopsies with high confidence, making it an invaluable addition to the transplant physician's tool kit for managing patients. TruGraf v1 testing can potentially avoid painful and risky invasive biopsies, reduce health care costs, and enable frequent assessment of patients with stable renal function to confirm the presence of immune quiescence in the peripheral blood.

Investigator Assessment of the Utility of the TruGraf Molecular Diagnostic Test in Clinical Practice

BACKGROUND

TruGraf v1 is a well-validated DNA microarray-based test that analyzes blood gene expression profiles as an indicator of immune status in kidney transplant recipients with stable renal function.

METHODS

In this study, investigators assessed clinical utility of the TruGraf test in patient management. In a retrospective study, simultaneous blood tests and clinical assessments were performed in 192 patients at 7 transplant centers, and in a prospective observational study they were performed in 45 subjects at 5 transplant centers.

RESULTS

When queried regarding whether or not the TruGraf test result impacted their decision regarding patient management, in 168 of 192 (87.5%) cases the investigator responded affirmatively. The prospective study indicated that TruGraf results supported physicians' decisions on patient management 87% (39/45) of the time, and in 93% of cases physicians indicated that they would use serial TruGraf testing in future patient management. A total of 21 of 39 (54%) reported results confirmed their decision that no intervention was needed, and 17 of 39 (44%) reported that results specifically informed them that a decision not to perform a surveillance biopsy was correct.

CONCLUSIONS

TruGraf is the first and only noninvasive test to be evaluated for clinical utility in determining rejection status of patients with stable renal function and shows promise of providing support for clinical decisions to avoid unnecessary surveillance biopsies with a high degree of confidence. TruGraf is an invaluable addition to the transplant physician's tool kit for managing patient health by avoiding painful and invasive biopsies, reducing health care costs, and enabling frequent assessment of patients with stable renal function to confirm immune quiescence.

Patterns of Use and Correlates of Patient Satisfaction with a Large Nationwide Direct to Consumer Telemedicine Service

BACKGROUND

Despite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.

OBJECTIVE

To characterize telemedicine patients and physicians and correlates of patient satisfaction DESIGN: Cross-sectional study PARTICIPANTS: Patients and physicians of a large nationwide DTC telemedicine service MAIN MEASURES: Patient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.

KEY RESULTS

The analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor's office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74-3.23) and coupon use (OR 1.47; 95%CI 1.33-1.62).

CONCLUSIONS

Patients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

Learning Gains from a Recurring "Teach and Question" Homework Assignment in a General Biology Course: Using Reciprocal Peer Tutoring Outside Class

Providing students with one-on-one interaction with instructors is a big challenge in large courses. One solution is to have students interact with their peers during class. Reciprocal peer tutoring (RPT) is a more involved interaction that requires peers to alternate the roles of "teacher" and "student." Theoretically, advantages for peer tutoring include the verbalization and questioning of information and the scaffolded exploration of material through social and cognitive interaction. Studies on RPT vary in their execution, but most require elaborate planning and take up valuable class time. We tested the effectiveness of a "teach and question" (TQ) assignment that required student pairs to engage in RPT regularly outside class. A quasi-experimental design was implemented: one section of a general biology course completed TQ assignments, while another section completed a substitute assignment requiring individuals to review course material. The TQ section outperformed the other section by ∼6% on exams. Session recordings were coded to investigate correlation between TQ quality and student performance. Asking more questions was the characteristic that best predicted exam performance, and this was more predictive than most aspects of the course. We propose the TQ as an easy assignment to implement with large performance gains.

Orthogonal Comparison of Molecular Signatures of Kidney Transplants With Subclinical and Clinical Acute Rejection: Equivalent Performance Is Agnostic to Both Technology and Platform

We performed orthogonal technology comparisons of concurrent peripheral blood and biopsy tissue samples from 69 kidney transplant recipients who underwent comprehensive algorithm-driven clinical phenotyping. The sample cohort included patients with normal protocol biopsies and stable transplant (sTx) function (n = 25), subclinical acute rejection (subAR, n = 23), and clinical acute rejection (cAR, n = 21). Comparisons between microarray and RNA sequencing (RNA-seq) signatures were performed and demonstrated a strong correlation between the blood and tissue compartments for both technology platforms. A number of shared differentially expressed genes and pathways between subAR and cAR in both platforms strongly suggest that these two clinical phenotypes form a continuum of alloimmune activation. SubAR is associated with fewer or less expressed genes than cAR in blood, whereas in biopsy tissues, this clinical phenotype demonstrates a more robust molecular signature for both platforms. The discovery work done in this study confirms a clear ability to detect gene expression profiles for sTx, subAR, and cAR in both blood and biopsy tissue, yielding equivalent predictive performance that is agnostic to both technology and platform. Our data also provide strong biological insights into the molecular mechanisms underlying these signatures, underscoring their logistical potential as molecular diagnostics to improve clinical outcomes following kidney transplantation.

Genotype-phenotype dilemma in a case of sudden cardiac death with the E1053K mutation and a deletion in the SCN5A gene

Mutations in the cardiac sodium channel gene SCN5A may result in various arrhythmia syndromes such as long QT syndrome type 3 (LQTS), Brugada syndrome (BrS), sick sinus syndrome (SSS), cardiac conduction diseases (CCD) and possibly dilated cardiomyopathy (DCM). In most of these inherited cardiac arrhythmia syndromes the phenotypical expression may range from asymptomatic phenotypes to sudden cardiac death (SCD). A 16-year-old female died during sleep. Autopsy did not reveal any explanation for her death and a genetic analysis was performed. A variant in the SCN5A gene (E1053K) that was previously described as disease causing was detected. Family members are carriers of the same E1053K variant, some even in a homozygous state, but surprisingly did not exhibit any pathological cardiac phenotype. Due to the lack of genotype-phenotype correlation further genetic studies were performed. A novel deletion in the promoter region of SCN5A was identified in the sudden death victim but was absent in other family members. These findings demonstrate the difficulties in interpreting the results of a family-based genetic screening and underline the phenotypic variability of SCN5A mutations.

Thyroid dysfunction in children with autism spectrum disorder is associated with folate receptor α autoimmune disorder

Folate receptor α (FRα) autoantibodies (FRAAs) are prevalent in autism spectrum disorder (ASD). FRAAs disrupt folate transport across the blood-brain barrier by binding to the FRα. Thyroid dysfunction is frequently found in children with ASD. We measured blocking and binding FRAAs and thyroid-stimulating hormone (TSH), free thyroxine (T4) (FT4), total triiodothyronine (T3) (TT3), reverse T3 (rT3), thyroid-releasing hormone (TRH) and other metabolites in 87 children with ASD, 84 of whom also underwent behaviour and cognition testing and in 42 of whom FRAAs, TSH and FT4 were measured at two time points. To better understand the significance of the FRα in relation to thyroid development, we examined FRα expression on prenatal and postnatal thyroid. TSH, TT3 and rT3 were above the normal range in 7%, 33% and 51% of the participants and TRH was below the normal range in 13% of the participants. FT4 was rarely outside the normal range. TSH concentration was positively and the FT4/TSH, TT3/TSH and rT3/TSH ratios were inversely related to blocking FRAA titres. On repeated measurements, changes in TSH and FT4/TSH ratio were found to correspond to changes in blocking FRAA titres. TSH and the FT4/TSH, TT3/TSH and rT3/TSH ratios were related to irritability on the Aberrant Behavior Checklist and several scales of the Social Responsiveness Scale (SRS), whereas TT3 was associated with SRS subscales and TRH was related to Vineland Adaptive Behavior Scale subscales. The thyroid showed significant FRα expression during the early prenatal period, although expression decreased significantly in later gestation and postnatal thyroid tissue. The results of the present study suggest that thyroid dysfunction in ASD may be related to blocking FRAA. The high expression of FRα in the early foetal thyroid suggests that foetal and neonatal exposure to maternal FRAAs could affect the development of the thyroid and may contribute to the pathology in ASD.

Network over-connectivity differentiates autism spectrum disorder from other developmental disorders in toddlers: A diffusion MRI study

Advanced connectivity studies in toddlers with Autism Spectrum Disorder (ASD) are increasing and consistently reporting a disruption of brain connectivity. However, most of these studies compare ASD and typically developing subjects, thus providing little information on the specificity of the abnormalities detected in comparison with other developmental disorders (other-DD). We recruited subjects aged below 36 months who received a clinical diagnosis of Neurodevelopmental Disorder (32 ASD and 16 other-DD including intellectual disability and language disorder) according to DSM-IV TR. Structural and diffusion MRI were acquired to perform whole brain probabilistic and anatomically constrained tractography. Network connectivity matrices were built encoding the number of streamlines (D_NUM ) and the tract-averaged fractional anisotropy (D_FA ) values connecting each pair of cortical and subcortical regions. Network Based Statistics (NBS) was finally applied on the connectivity matrices to evaluate the network differences between the ASD and other-DD groups. The network differences resulted in an over-connectivity pattern (i.e., higher D_NUM and D_FA values) in the ASD group with a significance of P < 0.05. No contra-comparison results were found. The over-connectivity pattern in ASD occurred in networks primarily involving the fronto-temporal nodes, known to be crucial for social-skill development and basal ganglia, related to restricted and repetitive behaviours in ASD. To our knowledge, this is the first network-based diffusion study comparing toddlers with ASD and those with other-DD. Results indicate the detection of different connectivity patterns in ASD and other-DD at an age when clinical differential diagnosis is often challenging. Hum Brain Mapp 38:2333-2344, 2017. © 2017 Wiley Periodicals, Inc.

Cognitive-behaviour therapy for post-traumatic stress in schizophrenia. A randomized controlled trial

BACKGROUND

There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia.

METHOD

A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive-behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale.

RESULTS

Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes.

CONCLUSIONS

The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.