Clinical Demographics Research Articles

Age Increases the Risk of Mortality by Four-Fold in Patients with Emergent Paralytic Ileus: Hospital Length of Stay, Sex, Frailty, and Time to Operation as Other Risk Factors.

Background: In the United States, ileus accounts for USD 750 million of healthcare expenditures annually and significantly contributes to morbidity and mortality. Despite its significance, the complete picture of mortality risk factors for these patients have yet to be fully elucidated; therefore, the aim of this study is to identify mortality risk factors in patients emergently admitted with paralytic ileus. Methods: Adult and elderly patients emergently admitted with paralytic ileus between 2005–2014 were investigated using the National Inpatient Sample Database. Clinical outcomes, therapeutic management, demographics and comorbidities were collected. Associations between mortality and all other variables were established via univariable and multivariable logistic regression models. Results: A total of 81,674 patients were included, of which 45.2% were adults, 54.8% elderly patients, 45.8% male and 54.2% female. The average adult and elderly ages were 48.3 and 78.8 years, respectively. Elderly patients displayed a significantly (p < 0.01) higher mortality rate (3.0%) than adults (0.7%). The final multivariable logistic regression model showed that for every one-day delay in operation, the odds of mortality for adult and elderly patients increased by 4.1% (p = 0.002) and 3.2% (p = 0.014), respectively. Every additional year of age corresponded to 3.8% and 2.6% increases in mortality for operatively managed adult (p = 0.026) and elderly (p = 0.015) patients. Similarly, non-operatively treated adult and elderly patients displayed associations between mortality and advanced age (p = 0.001). The modified frailty index exhibited associations with mortality in operatively treated adults, conservatively managed adults and conservatively managed elderly patients (p = 0.001). Every additional day of hospitalization increased the odds of mortality in non-operative adult and elderly patients by 7.6% and 5.8%, respectively. Female sex correlated to lower mortality rates in non-operatively managed adult patients (odds ratio = 0.71, p = 0.028). Undergoing invasive diagnostic procedures in non-operatively managed elderly patients related to reduced mortality (odds ratio = 0.78, p = 0.026). Conclusions: Patients emergently admitted for paralytic ileus with increased hospital length of stay, longer time to operation, advanced age or higher modified frailty index displayed higher mortality rates. Female sex and invasive diagnostic procedures were negatively correlated with death in nonoperatively managed patients with paralytic ileus.

Neoadjuvant chemotherapy or upfront surgery in localized pancreatic cancer: a contemporary analysis

Neoadjuvant chemotherapy is considered a new treatment option for potentially resectable pancreatic cancer. However, data are not well established on overall survival and delaying surgery in resectable pancreatic cancer, as well as on those patients that ultimately cannot undergo surgery. We analyzed pancreatic cancer patients treated in a tertiary hospital from January 2016 to December 2020. Patients with resectable stage I and II pancreatic cancer were evaluated regarding surgery, neoadjuvant treatment, and other clinical demographics. The survival function was estimated using the Kaplan–Meier method, and the relationship between the variables of interest and the overall survival (OS) was assessed by adopting the proportional regression Cox models. A total of 216 patients were evaluated. 81 of them with resectable/borderline resectable disease and 135 with unresectable /metastatic disease at diagnosis. Median OS for stage I and II disease were 36 and 28 months, respectively. For resectable pancreatic cancer median OS was 28 months, for borderline resectable pancreatic cancer median OS was 11 months. Median OS for stage III (locally advanced) and stage IV (metastatic) were 10 and 7 months, respectively (p < 0.0001). Median OS of 9 months were obtained for patients with stage I and II that did not undergo surgery compared to 25 months in patients that underwent surgery in any time (p < 0.001). Comparing patients with localized disease, median OS for patients treated with upfront surgery was 28 months, compared to 15 months in patients treated with neoadjuvant approach (p = 0.04). Most patients that did not undergo surgery have decline of performance status or disease progression on neoadjuvant treatment. On multivariable analysis in pancreatic cancer stages I and II, including age, sex, borderline or resectable disease, CA 19–9, positive lymph nodes and neoadjuvant treatment, the surgery was the only factor associated with improved overall survival (p = 0.04). Upfront surgery should still be considered a standard of care approach for resectable pancreatic cancer. Biomarker driven studies and randomized trials with combination therapies are necessary to address neoadjuvant chemotherapy and delaying surgery in purely resectable pancreatic cancer.

The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients.

Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial. We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings. Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs. Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.

Quality of life outcomes after transnasal endoscopic pituitary surgery using the Glasgow Benefit Inventory

Purpose This study assesses postoperative quality-of-life outcomes via the Glasgow Benefit Inventory (GBI) in patients undergoing transnasal endoscopic pituitary surgery for pituitary adenoma. Methods This was a retrospective cohort study in a UK tertiary referral centre. 145 patients who had undergone transnasal endoscopic pituitary surgery for pituitary adenoma over a 6-year period at one institution completed the GBI with at least 3 months’ follow up. Patients with prior radiotherapy were excluded. The GBI is a patient-reported outcome measure that assesses post-intervention outcomes in three domains: ‘general’ functioning, ‘social support’ and ‘physical’ functioning. Pre- and post-operative visual loss scores were additionally assessed via a 1–5 Likert scale. GBI scores were assessed alongside these visual loss scores, clinical and surgical parameters and demographics. Results Mean age was 59.5 years (range 20–87 years) and mean follow up was 36 months. A total of 46 of 145 (31.7%) patients had secreting tumours. The most common primary symptom was visual loss. Mean total score for all patients was positive (+8.4); with ‘general’ domain score the most positive (+10.5). All patient groups had overall positive, ‘general’ and ‘social support’ domain scores. Patients with Cushing’s disease reported significantly higher mean total scores (+29.6) than all other groups. Acromegaly (+7.9) and non-functioning adenoma (NFA) groups (+5.2) reported lower mean total scores. ‘Physical’ domain mean scores were negative for acromegaly and NFA groups. There was statistical significance between a pre- to post-operative improvement in visual score and mean total GBI score (p = 0.02) and mean ‘general’ domain GBI score (p = 0.02). Conclusions These findings can aid preoperative counselling of patients undergoing this surgery. Those with NFA and no anticipated improvement to visual loss symptoms may be advised of possible worsened physical outcomes and of the option to delay the surgery until symptoms are present.

Clinical Characteristics of Rapid Eye Movement-Related Obstructive Sleep Apnea: An Experience in a Tertiary Medical Center of Taiwan.

PurposeObstructive sleep apnea (OSA) is characterized by intermittent hypoxemia and sleep fragmentation. While apnea is pronounced with severe desaturation during rapid eye movement (REM) sleep, REM-related OSA is a distinct phenotype of OSA associated with respiratory disturbances predominantly during REM sleep. In this study, we investigated the clinical features of REM-related OSA in Taiwan.Patients and MethodsAll patients diagnosed with OSA in the Taipei Veterans General Hospital from 2015 to 2017 were analyzed retrospectively and classified into REM-related OSA (REM-OSA) group, non-REM related OSA (NREM-OSA) group, and non-stage specific-OSA group. The clinical demographics, OSA-related symptoms, polysomnography results, and medical comorbidities of the three groups were analyzed.ResultsAmong 1331 patients with OSA, 414 (31.1%) were classified as REM-OSA, 808 (60.7%) as NREM-OSA, and 109 (8.2%) as non-stage specific-OSA. After being adjusted for OSA severity, the REM-OSA group was associated with less portion of males, longer desaturation duration, and lower nadir oxygen saturation (SpO2) compared with the NREM-OSA group in mild and moderate OSA. In moderate OSA, the non-stage specific-OSA group featured more OSA severity and more desaturation compared with the other groups. The Epworth Sleepiness Scale scores and the prevalence of comorbidities did not vary among the REM-OSA, NREM-OSA, and non-stage specific-OSA groups. High REM-AHI/NREM-AHI ratio was associated with young age, female gender, high BMI, and low AHI.ConclusionOSA patients with high REM-AHI/NREM-AHI ratio are related to young age, female gender, high BMI, and low AHI. Patients with REM-related OSA presented with longer desaturation duration and lower nadir SpO2 after being adjusted for OSA severity.

The Impact of Frailty on Perioperative Outcomes in Patients Receiving Short-Level Posterior Lumbar Interbody Fusion: A Stepwise Propensity Score Matching Analysis

BackgroundThere are many studies on the impact of frailty on postoperative complications; however, there are few studies focusing on stepwise propensity score matching (PSM) to offset the influence of age.MethodsWe gathered data for patients undergoing short-level posterior lumbar interbody fusion from January to December 2021. According to the Fried frailty phenotype, we categorized patients into non-frail, pre-frail, and frail groups, then, stepwise PSM for age, sex, American Society of Anesthesiologists (ASA) and fusion levels were performed to keep comparable clinical data between groups. Univariate and multivariate logistic regressions were used to determine the impact of clinical demographics on postoperative complications.ResultsA total of 559 consecutive patients with complete medical records were enrolled (237 males and 322 females; mean age 72.55 ± 5.86 years). After PSM, we found that pre-frail patients were more vulnerable to develop urinary retention (p = 0.031) and surgical site infections (p = 0.021) than non-frail patients. Longer length of stay (LOS), delayed ambulation and removal of urinary catheter times were observed in pre-frail patients. However, there was a significant difference only in LOS between pre-frail and frail patients. Binary logistic regression revealed that C-reactive protein (CRP) and frail status were independently associated with postoperative complications between non-frail and pre-frail patients, while only CRP was independently correlated with complications between pre-frail and frail patients.ConclusionAfter PSM, we found higher rates of urinary retention and surgical site infections in pre-frail patients than in non-frail patients. CRP was independently related to postoperative complications, while frail status was only independently associated with postoperative complications between pre-frail and non-frail patients. Pre-frail/frail patients tended to have more severe stress responses than non-frail patients.

Effectiveness of empirical angioembolization for non-variceal Upper GI Bleed in comparison to conservative management.

Objective: To share experience and present our data of past 15 years on endoscopy guided empiric embolization of GDA and compare it with the results of conservative management. Study Design: Retrospective study Setting: Agha Khan University Hospital Karachi. Period: January 2001 till October 2017. Material &amp; Methods: 70 patients were selected who presented with upper GI bleed followed by conventional angiography. The data was collected on clinical presentation, patient demographics, embolization procedures, and postembolization outcomes. Results: A total of 101 patients were included in the study. 79 were male and 22 were female. The median age at presentation was 54 years (range 15-96 years). All the patients presented with upper gastrointestinal bleeding. All the patients underwent fluoroscopy guided angiography. In 30 patients the angiography was able to locate the bleeding source. In 44 patients the bleeding source could not be identified however empiric embolization was performed. In 27 patients the angiography was negative and embolization was not performed. The overall clinical success in the empirically embolized group is 77.2 %. 27 patients were conservatively managed after negative angiography. The overall clinical success in the empirically embolized group is 77.2 %.However in the patients who were conservatively managed the clinical success was only 48.1 %. Conclusion: This study concluded that it safe and effective to empirically emobolize the GDA in patients refractory to initial endoscopic treatment for non variceal upper GI bleed.

Retinal and choroidal microvascular alterations in Behcet’s disease without ocular manifestations: A systematic review and meta-analysis

PurposeWe performed a systematic review and meta-analysis to examine the microvascular alterations in non-ocular Behcet’s disease (BD) using optical coherence tomography angiography (OCTA).MethodsA comprehensive search was performed in Pubmed, Embase and Cochrane databases for eligible studies from inception to February 2022. Detailed clinical demographics were extracted from each study by two independent reviewers. The weighted mean difference (WMD) and 95% confidence intervals (CI) were used to compare the OCTA parameters between non-ocular BD and healthy controls. Stata 12.0 was adopted to conduct statistical analyses.ResultsTen cross-sectional studies involving 386 eyes in non-ocular BD and 418 eyes in healthy volunteers were ultimately included in the present analysis. When considering superficial capillary plexus (SCP) and deep capillary plexus (DCP), no significant differences of vessel densities in the whole enface image, fovea and perifovea were evaluated between two groups. Significantly reduced parafoveal vessel density of SCP was observed in non-ocular BD in comparison with healthy group (WMD = −1.33, 95%CI: −1.78, −0.89; I2 = 0.6%), while slightly decreased parafoveal vessel density was assessed in DCP (WMD = −1.47, 95%CI: −3.30, 0.35; I2 = 89.3%). Significantly increasing foveal avascular zone (FAZ) area was observed in non-ocular BD when compared to healthy controls (WMD = 0.11, 95%CI: 0.03, 0.19; I2 = 95.3%). There was no significant difference in flow area of choriocapillaris between non-ocular BD and control group (WMD = 0.06, 95%CI: −0.19, 0.32; I2 = 0%).ConclusionBased on current analysis, our results demonstrated significantly lower parafoveal vessel density of SCP and lager FAZ area in full vasculature in non-ocular BD. The retinal microvascular alterations appear before the emergence of ocular manifestations.Systematic Trial Registration[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42021244856].

Statins and renal disease progression, ophthalmic manifestations, and neurological manifestations in veterans with diabetes: A retrospective cohort study

Statins increase insulin resistance, which may increase risk of diabetic microvascular complications. Little is known about the impact of statins on renal, ophthalmologic, and neurologic complications of diabetes in practice. The objective of this study was to examine the association of statins with renal disease progression, ophthalmic manifestations, and neurological manifestations in diabetes. This is a retrospective cohort study, new-user active comparator design, that included a national Veterans Health Administration (VA) patients with diabetes from 2003 to 2015. Patients were age 30 years or older and were regular users of the VA with data encompassing clinical encounters, demographics, vital signs, laboratory tests, and medications. Patients were divided into statin users or nonusers (active comparators). Statin users initiated statins and nonusers initiated H2-blockers or proton pump-inhibitors (H2-PPI) as an active comparator. Study outcomes were: 1) Composite renal disease progression outcome; 2) Incident diabetes with ophthalmic manifestations; and 3) Incident diabetes with neurological manifestations. Out of 705,774 eligible patients, we propensity score matched 81,146 pairs of statin users and active comparators. Over a mean (standard deviation) of follow up duration of 4.8 (3) years, renal disease progression occurred in 9.5% of statin users vs 8.3% of nonusers (odds ratio [OR]: 1.16; 95% confidence interval [95%CI]: 1.12-1.20), incident ophthalmic manifestations in 2.7% of statin users vs 2.0% of nonusers (OR: 1.35, 95%CI:1.27-1.44), and incident neurological manifestations in 6.7% of statin users vs 5.7% of nonusers (OR: 1.19, 95%CI:1.15-1.25). Secondary, sensitivity, and post-hoc analyses were consistent and demonstrated highest risks among the healthier subgroup and those with intensive lowering of LDL-cholesterol. Statin use in patients with diabetes was associated with modestly higher risk of renal disease progression, incident ophthalmic, and neurological manifestations. More research is needed to assess the overall harm/benefit balance for statins in the lower risk populations with diabetes and those who receive intensive statin therapy.

658 Clinical and histopathologic risk factors for early-stage melanoma recurrence

Emerging data suggest that the majority of patients who die from melanoma experience recurrence of disease that is early-stage (Stage I or II) at the time of diagnosis. Therefore, we aim to understand the clinical (demographics, medical history, surgical margins) and histopathologic (synoptic features) characteristics that influence early-stage melanoma recurrence utilizing a multi-institutional database comprising of 1,244 patients with 1,342 early-stage primary cutaneous melanomas from 2000-2020. A multivariable Cox proportional hazards model with clustering adjustment was used to analyze the risk for melanoma recurrence. Harrell C’s concordance index was used to assess the goodness of fit. 331 (24.7%) of melanomas recurred within the study period. Among the recurrent melanomas, 52% of patients progressed to develop metastatic disease and 39.9% were deceased at end of follow-up. In univariate modeling for risk of melanoma recurrence, Breslow depth, AJCC stage, and tumor mitotic rate had the highest Harrell’s C (0.8, 0.77, and 0.77 respectively) and were at significantly higher risk of melanoma recurrence. Multivariate modeling demonstrated that individuals who are older at diagnosis (HR 1.02, p<0.001), in the second quartile of income range of $77,484-$99,677 (HR 1.36, p=0.046), Clark’s level above 4, melanoma stage above 2A, with the presence of tumor-infiltrating lymphocytes (HR 1.51, p=0.02), and presence of mitoses (HR 2.09, p=0.001) were at higher risk of melanoma recurrence. The risk factors identified above, particularly mitotic rate, can guide clinicians in risk stratifying patients with early-stage melanoma for increased surveillance to detect recurrence.

Preoperative Computed Tomography Morphological Features Indicative of Incisional Hernia Formation After Abdominal Surgery.

To investigate key morphometric features identifiable on routine preoperative computed tomography (CT) imaging indicative of incisional hernia (IH) formation following abdominal surgery. IH is a pervasive surgical disease that impacts all surgical disciplines operating in the abdominopelvic region and affecting 13% of patients undergoing abdominal surgery. Despite the significant costs and disability associated with IH, there is an incomplete understanding of the pathophysiology of hernia. A cohort of patients (n=21,501) that underwent colorectal surgery was identified, and clinical data and demographics were extracted, with a primary outcome of IH. Two datasets of case-control matched pairs were created for feature measurement, classification, and testing. Morphometric linear and volumetric measurements were extracted as features from anonymized preoperative abdominopelvic CT scans. Multivariate Pearson testing was performed to assess correlations among features. Each feature's ability to discriminate between classes was evaluated using 2-sided paired t testing. A support vector machine was implemented to determine the predictive accuracy of the features individually and in combination. Two hundred and twelve patients were analyzed (106 matched pairs). Of 117 features measured, 21 features were capable of discriminating between IH and non-IH patients. These features are categorized into three key pathophysiologic domains: 1) structural widening of the rectus complex, 2) increased visceral volume, 3) atrophy of abdominopelvic skeletal muscle. Individual prediction accuracy ranged from 0.69 to 0.78 for the top 3 features among 117. Three morphometric domains identifiable on routine preoperative CT imaging were associated with hernia: widening of the rectus complex, increased visceral volume, and body wall skeletal muscle atrophy. This work highlights an innovative pathophysiologic mechanism for IH formation hallmarked by increased intra-abdominal pressure and compromise of the rectus complex and abdominopelvic skeletal musculature.

Immunoglobulin G Is Increased in the Injured Spinal Cord in a Sex- and Age-Dependent Manner

There are limited studies examining age and sex as biological variables in the pathophysiology of spinal cord injury (SCI). The use of older animals and sex-balanced groups in SCI models is increasingly prioritized to better match clinical demographics. Including older animals in SCI studies is technically challenging, and outcomes are unpredictable with respect to biological and treatment responses. Incidental discoveries that are unrelated to the question under investigation often emerge while including age and sex as biological variables. When probing tissue homogenates on Western blots of 4- and 14-month-old (MO) mice, we identified a sex- and age-dependent increase in immunoglobulin G (IgG) within the spinal cords of older, 14-MO mice acutely after SCI, with females having more IgG compared with males. We further probed to determine whether differences in hemorrhage exist between sexes or ages by evaluating hemoglobin within spinal homogenates. Differences in hemoglobin between sexes and ages were not consistently observed. Because IgG was elevated in an age- and sex-dependent manner without of evidence of differences in hemorrhage, our findings point to potential pre-existing differences in IgG within mouse plasma in an age- and sex-dependent manner. This report has identified age- and sex-dependent differences in infiltrating IgG into the injured spinal cord environment that may affect injury and recovery processes. Our findings highlight that systemic contributions to SCI can be sex- and age-dependent and illustrate the value of reporting incidental discoveries.

Preoperative dysphagia risk in community-dwelling adults aged ≥50 years: Prevalence and risk factors.

Preoperative dysphagia screening is rare. The purpose of this study was to assess the prevalence and potential risk factors of preoperative dysphagia risk in adults preparing for surgery. The Eating Assessment Tool (EAT-10), Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF), and Sarcopenia Screening Tool (SARC-F) were self-administered in adults preparing for surgery to identify dysphagia, malnutrition, and sarcopenia risk, respectively. Other variables collected include clinical demographics, fall risk, and surgical history associated with increased dysphagia risk. Descriptive summary statistics, univariate analysis, and logistic regression were performed as appropriate. The median age was 69 years and preoperative dysphagia risk was 9.6%. Among 357 patients completing both EAT-10 and PG-SGA SF or SARC-F, 7.3% had preoperative dysphagia and malnutrition risk and 7.2% had preoperative dysphagia and sarcopenia risk. Preoperative dysphagia risk was 2.7 times greater in those with prior surgical history associated with increased risk of dysphagia, 2.2 times higher in women, and almost twice as high in Black patients and patients with fall risk. Logistic regression revealed significant odds ratios (ORs) for prior surgical history associated with increased risk of dysphagia (OR, 2.95; 95% CI, 1.62-5.40) and male sex (OR, 0.52; 95% CI, 0.29-0.94), and a significant relationship between preoperative dysphagia and malnutrition risk (OR, 4.56; 95% CI, 2.02-10.28) when controlling for clinical variables. The high prevalence of dysphagia risk alone and in combination with malnutrition and sarcopenia risk in community-dwelling adults underscores the need for standardized preoperative screening and optimization prior to surgery.

Mucormycosis in COVID-19 Patients

Introduction: Zygomycetes consisting of Mucorales order is a group of fungal infections. These species cause life threatening opportunistic fungal infections mucormycosis. This infection is highly prevalent in immunocompromised. During the 2nd wave of Covid 19 pandemic corticosteroid treatment was used which has been linked to development of Mucormycosis. In our tertiary care teaching hospital we saw that patients suffering from Covid-19 infections developed mucormycosis. We present these cases in our study. To study the clinical, demographical, and Laboratory parameters in Covid-19 patients with Mucormycosis. Material and Methods: Retrospective Study. All biopsy proven cases of Mucormycosis (which developed after Covid-19 infection) were included. Relevant Clinical Demographics and Laboratory data was retrieved from the available case sheets. The data was tabulated in Excel sheet and further reviewed. Results: A total of 22 patients were diagnosed as suffering from mucormycosis majority were unvaccinated. 11 patients out of 22 (50%) started manifesting mucormycosis within one week of COVID infection. All the patients who had only single comorbidity (22.72%) suffered from mild disease and patient who had more than one comorbidity suffered from moderate (27.27%) to severe (50%) COVID infection. Conclusion: It is suggested that patients with Covid-19 infection are at risk for development of opportunistic fungal infections like Mucormycosis. Hence the physicians who are involved in treating such patients must be mindful of the fact that mucormycosis can develop in them. Histopathology helps in establishing a concrete diagnosis of Mucormycosis.

Identification of Cancerous Cell from Noisy Images

Abstract: Over the last decades, the incidence of skin cancer, melanoma and non-melanoma,has increased at a continuous rate. In particular for melanoma, the deadliest type of skin cancer, early detection is important to increase patient prognosis. Recently, deep neural networks (DNNs) have become viable to deal with skin cancer detection. In this work, we present a smartphone-based application to assist on skin cancer detection. This application is based on a Convolutional Neural Network (CNN) trained on clinical images and patients demographics, both collected from smartphones. Also, as skin cancer datasets are imbalanced, we present an approach, based on the mutation operator of Differential Evolution (DE) algorithm,to balance data. In this sense, beyond provides a flexible tool to assist doctors on skin cancer screening phase, the method obtains promising results with a balancedaccuracy of 85% and a recall of 96%. Index Terms—skin cancer detection, smartphone application, deep learning, convolutional neural network

P-271 Challenges with comparing different commercially available Artificial Intelligence (AI) systems on the same data set of time-lapse selected euploid blastocysts

Abstract Study question To identify challenges in choosing a robust AI following comparative validation with data already pre-selected with established embryos selection tools: blastulation, morphology, time-lapse, PGTA. Summary answer Challenges included: bias; assessment against outcomes AI models were not trained on; performance metrics prioritisation; statistical methodology; continuous data cutoffs for binary clinical decision making. What is known already AI is commercially available to be incorporated into routine practice to support embryo selection decision-making. Different clinical practices and demographics are used to train AI models, potentially impacting the prediction efficacy of the same model when used in different clinics. Fertility professionals require robust methods of validation to responsibly implement AI-based tools. Unbiased and robust frameworks for comparing AI systems in the same dataset are needed. Validating AI in a dataset of time-lapse selected euploid blastocysts using all the current methods of embryo selection currently available is the toughest assessment possible and has not previously been performed. Study design, size, duration This study uses a retrospectively timelapse dataset collected from 2018-2021 at a single private fertility clinic. The dataset included 915 blastocysts which underwent PGTA (913 results: 381 euploids, 528 aneuploids, 4 mosaics) and 46 euploids transferred with known bhcg and ongoing clinical outcome (of which 40 resulted to live birth). Following a prospective, comparative, observational, cohort study design, blastocysts were blindly scored using the CHLOE(FAIRTILITY) and another commercially available AI system, referred to as ‘AI-2’. Participants/materials, setting, methods Patients aged 24-47years (average 35.4). Blastocysts selected for biopsy and transfer based on morphology and KIDScore(Vitrolife). Both AI systems were tested in the data set blindly, without any training. Correlation Regression analysis assessed correlation with KIDSCORE and relative to each AI system. Efficacy of prediction (using metrics AUC, Accuracy, Sensitivity, Specificity and Informedness) of outcomes (ploidy, biochemical and clinical pregnancy) were assessed for both AI models (CHLOEvsAI-2) by two independent statisticians to establish significance. Main results and the role of chance Regression analysis demonstrated no correlation between KIDSCORE and AI-2(r2=0.3%,p=0.5) or between CHLOE(FAIRTILITY) and AI-2(r2=0.03%,p=0.9). CHLOE(FAIRTILITY) correlated with KIDSCORE(r2=29%,p&amp;lt;0.001). AI-2 was not predictive of ploidy (Euploids vs Aneuploids+mosaic: AUC=0.5,p=0.6). CHLOE(Fairtility) was predictive of ploidy(AUC=0.66, p&amp;lt;0.001). Neither AI-2 or CHLOE(Fairtility) predicted which embryo the human embryologist prioritised for transfer (AI-2 vs CHLOE:accuracy:0.31vs0.49, p&amp;lt;0.00001). Neither AI-2 nor CHLOE(Fairtility) predicted which embryo the human embryologist prioritised for transfer (AI-2 vs CHLOE:accuracy: 0.31vs0.49, p&amp;lt;0.00001). There was no difference detected in efficacy of prediction of biochemical (accuracy:0.52vs0.67,NS) and ongoing clinical pregnancy (accuracy:0.53 vs 0.78,NS) by AI-2 or CHLOE. This is partly due to the low number of euploid transfers assessed (n = 46), and partly due to the fact that neither of these algorithms are trained specifically on predicting outcome of euploid transfers. CHLOE(Fairtility) was more specific than AI-2 for predicting selection for transfer(0.44/0.80vs0.17/0.93,p&amp;lt;0.05/NS) and ploidy(0.54/0.77vs0.23/0.87,p&amp;lt;0.05/NS), and they were equally as sensitive. CHLOE(Fairtility) was more sensitive, and less specific than AI-2 for predicting biochemical pregnancy(0.36/0.81vs0.86/0.38,p&amp;lt;0.05) and more sensitive but equally as specific for predicting clinical pregnancy(0.33/0.88vs0.83/0.46,NS/p&amp;lt;0.05). Informedness was positive for both CHLOE(Fairtility) and AI-2 in predicting all outcomes assessed. Informedness was greater for AI-2 for predicting morphology(AI-2vsCHLOE:0.16vs0.31,p&amp;lt;0.05), transfer(0.11vs0.24,p&amp;lt;0.05), ploidy(0.10vs0.31,p&amp;lt;0.05) and equivalent for predicting biochemical (0.23vs0.17,NS) and clinical pregnancy(0.29vs0.22,NS). Limitations, reasons for caution In this single clinic study, both algorithms were assessed against outcomes (live birth following transfer of time-lapse cultured euploid blastocysts) for which they were not trained on: AI-2(designed for ploidy prediction) and CHLOE(FAIRTILITY, implantation prediction of non-PGTA embryos) and no clinic data was used for training. Wider implications of the findings The only way to decide which AI model is more useful is by a direct comparison of two or more models on the same dataset with same outcomes and metrics, as recommended by TRIPOD. To date, this is the first publication comparing multiple commercial AI models on the same dataset. Trial registration number NA

Detection of SARS-CoV-2 Genome in Stool and Plasma Samples of Laboratory Confirmed Iranian COVID-19 Patients.

Coronavirus disease 2019 (COVID19), caused by the severe acute respiratory syndrome coronavirus 2 (SARSCoV2), was first discovered in China in late 2019 and quickly spread worldwide. Although nasopharyngeal swab sampling is still the most popular approach identify SARS-CoV-2 carriers, other body samples may reveal the virus genome, indicating the potential for virus transmission via non-respiratory samples. In this study, researchers looked at the presence and degree of SARS-CoV-2 genome in stool and plasma samples from 191 Iranian COVID-19 patients, and looked for a link between these results and the severity of their disease. SARS-CoV-2 RNA shedding in feces and plasma of COVID-19 patients was assessed by reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Medical data were collected and evaluated, including Clinical features, demographics, radiological, and laboratory findings of the patients. Plasma samples from 117 confirmed laboratory patients were evaluated and 24 out of 117 patients (20.51%) tested positive for SARS-COV-2 RNA. Besides, 20 out of 74 patients (27.03%) tested positive for SARS-COV-2 RNA in stool samples. There seems to be no relationship between the presence of SARS-CoV-2 genome in fecal and plasma samples of Covid-19 patients and the severity of illness. We provide evidence of the SARS-CoV-2 genome presence in stool and plasma samples of Iranian COVID-19 patients.

A genomic meta-analysis of clinical variables and their association with intrinsic molecular subsets in systemic sclerosis.

Four intrinsic molecular subsets (inflammatory, fibroproliferative, limited, normal-like) have previously been identified in SSc and are characterized by unique gene expression signatures and pathways. The intrinsic subsets have been linked to improvement with specific therapies. Here, we investigated associations between baseline demographics and intrinsic molecular subsets in a meta-analysis of published datasets. Publicly available gene expression data from skin biopsies of 311 SSc patients measured by DNA microarray were classified into the intrinsic molecular subsets. RNA-sequencing data from 84 participants from the ASSET trial were used as a validation cohort. Baseline clinical demographics and intrinsic molecular subsets were tested for statistically significant associations. Males were more likely to be classified in the fibroproliferative subset (P = 0.0046). SSc patients who identified as African American/Black were 2.5 times more likely to be classified as fibroproliferative compared with White/Caucasian patients (P = 0.0378). ASSET participants sera positive for anti-RNA pol I and RNA pol III autoantibodies were enriched in the inflammatory subset (P = 5.8 × 10-5, P = 9.3 × 10-5, respectively), while anti-Scl-70 was enriched in the fibroproliferative subset. Mean modified Rodnan Skin Score (mRSS) was statistically higher in the inflammatory and fibroproliferative subsets compared with normal-like (P = 0.0027). The average disease duration for inflammatory subset was less than fibroproliferative and normal-like intrinsic subsets (P = 8.8 × 10-4). We identified multiple statistically significant differences in baseline demographics between the intrinsic subsets that may represent underlying features of disease pathogenesis (e.g. chronological stages of fibrosis) and have implications for treatments that are more likely to work in certain SSc populations.

Association of sleep duration and quality with immunological response after vaccination against severe acute respiratory syndrome coronavirus-2 infection.

SummaryGrowing evidence suggests that sleep could affect the immunological response after vaccination. The aim of this prospective study was to investigate possible associations between regular sleep disruption and immunity response after vaccination against coronavirus disease 2019 (COVID‐19). In total, 592 healthcare workers, with no previous history of COVID‐19, from eight major Greek hospitals were enrolled in this study. All subjects underwent two Pfizer–BioNTech messenger ribonucleic acid (mRNA) COVID‐19 vaccine BNT162b2 inoculations with an interval of 21 days between the doses. Furthermore, a questionnaire was completed 2 days after each vaccination and clinical characteristics, demographics, sleep duration, and habits were recorded. Blood samples were collected and anti‐spike immunoglobulin G antibodies were measured at 20 ± 1 days after the first dose and 21 ± 2 days after the second dose. A total of 544 subjects (30% males), with median (interquartile range [IQR]) age of 46 (38–54) years and body mass index of 24·84 (22.6–28.51) kg/m2 were eligible for the study. The median (IQR) habitual duration of sleep was 6 (6–7) h/night. In all, 283 participants (52%) had a short daytime nap. In 214 (39.3%) participants the Pittsburgh Sleep Quality Index score was >5, with a higher percentage in women (74·3%, p < 0.05). Antibody levels were associated with age (r = −0.178, p < 0.001), poor sleep quality (r = −0.094, p < 0.05), insomnia (r = −0.098, p < 0.05), and nap frequency per week (r = −0.098, p < 0.05), but after adjusting for confounders, only insomnia, gender, and age were independent determinants of antibody levels. It is important to emphasise that insomnia is associated with lower antibody levels against COVID‐19 after vaccination.

Anastomotic Suturing Techniques and Their Association With Post-Lung Transplantation Complications.

Currently, standard practice is to use the continuous suturing technique on the bronchial anastomosis during lung transplantation. This study used a large cohort to investigate and contrast continuous and interrupted suturing techniques, comparing survival outcomes and occurrence of postoperative bronchial complications to examine if utilization of interrupted suturing has merit. Survival outcomes of 740 single-center lung transplant recipients over 8y (February 2012-March 2020) were compared by suturing techniques: either continuous or interrupted at the bronchial anastomosis. Clinical parameters and demographics were compared between two suturing groups, with P values<0.05 considered significant. The groups were compared for postoperative morbidity, including need for bronchial interventions. Survival was compared using Kaplan-Meier curves and log-rank tests. Cox regression analysis was run with statistically significant variables to study association with survival. Of the 740 patients, 462 received the continuous suturing technique and 278 received the interrupted suturing technique. Most demographic and clinical data were not statistically significant between the two groups, and those that were significant were not associated with worse survival outcomes, with the exception of the variable diagnosis. Bronchial complications were comparable between the continuous and interrupted groups (12.6% versus 10.4%, P=0.382). Extracorporeal membrane oxygenation (ECMO) use did not differ significantly between the two groups (P=0.12). The Kaplan-Meier curve showed comparable survival between groups (P=0.98), and Cox regression analysis showed that only diagnosis, bronchial complications, and ECMO utilization were associated with different survival outcomes. Chronic obstructive pulmonary disorder was shown to be associated with more favorable survival outcomes as opposed to idiopathic pulmonary fibrosis and the category "other". The need for ECMO and the occurrence of a bronchial complication were also associated with worse survival outcomes. Both techniques showed reasonable post-transplant outcomes, as our study demonstrated similar survival outcomes and bronchial complication rates.