Expert Consensus Criteria Research Articles

Associations between sedentary behaviour and sarcopenia among patients aged 40 and older with chronic obstructive pulmonary disease: a cross-sectional study

BackgroundPatients with chronic obstructive pulmonary disease (COPD) and sarcopenia experience poorer clinical prognosis. Although sedentary behaviour (SB) is common risk factor for COPD, its relationship with sarcopenia in this specific population remains unclear.MethodsThis is a cross-sectional survey of participants aged 40 and above with COPD, involving 27 communities and 2 hospitals’ outpatient departments. The definition of sarcopenia was in accordance with the Asian Expert Consensus Criteria for sarcopenia. SB and physical activity (PA) were evaluated using the short form of the international physical activity questionnaires (IPAQ-SF). SB was categorized into 4 categories: less than 4 h/day, 4 to 6 h/day, 6 to 8 h/day, and 8 h or more per day. PA was classified into light-intensity and moderate-to-vigorous intensity physical activity (LPA and MVPA). Multiple logistic regression and restricted cubic spline (RCS) were performed to investigate the rates of association between sarcopenia and SB. Subgroups was analysed by gender.ResultsA total of 414 COPD patients with complete information were included in this trial. The overall prevalence of sarcopenia was 22.9%. Participants with sarcopenia had longer of SB (P = 0.008) and less MVPA (P < 0.001) compared to those without sarcopenia. After adjustment for confounders, SB showed a significant association with sarcopenia (adjusted β = 1.47, 95% CI = 1.28–1.68). The participants who spent 6 or more hours on SB had a greater odds ratio for sarcopenia (= 6-8 h: adjusted OR = 2.97, 95% CI = 1.14–7.70; > 8 h: OR = 9.14, 95% CI = 3.59–23.22) than the participants who spent less than 4 h. The results of RCS indicated that when SB exceeded 5.7 h/day, a trend towards a significant increasing prevalence of sarcopenia was observed with increased SB. This trend was also observed across genders, differing only in the threshold values (male: SB = 5.7 h; female: SB = 8.0 h).ConclusionSB was an independent determinant of sarcopenia, independent of MVPA, and the prevalence of sarcopenia increases as SB increases within a certain range. This study advocated for the integration of SB in the self-management strategies for patients with COPD. Regardless of their engagement in MVPA, it was crucial to regulate SB.

Sudden sustained monomorphic ventricular tachycardia in a previously healthy adult with many causes for it, but which one is the correct? A case report

Introduction. Sustained monomorphic ventricular tachycardia (VT) ? SMVT is a rare, underdiagnosed pathology with a very poor prognosis. Along with ventricular fibrillation, SMVT is responsible for nearly all of the arrhythmic sudden cardiac deaths (SCD). The most common cause of VT is ischemic heart disease, but there are many other reasons, among which are arrhythmogenic right ventricular cardiomyopathy (ARVD) and myocardial bridging phenomenon. Treatment options include a hybrid approach consisting of antiarrhythmic drugs, catheter ablation, and implantable cardioverter defibrillators (ICD). Case report. We present a case of a 46-year-old man, a military officer, who experienced chest pain, palpitations, and nausea during regular physical activity at home. Due to the symptoms described, he was examined immediately and diagnosed with SMVT. Shortly after the diagnosis, he lost consciousness and was successfully resuscitated. A complete non-invasive and invasive cardiology examination was performed. It revealed that the patient had stable coronary disease and a muscle bridge on the left anterior descending artery. An ARVD was suspected after transthoracic echocardiography and heart magnetic resonance imaging. Genetic testing for ARVD was negative, but according to the Heart Rhythm Society expert consensus criteria, we had enough for a definitive diagnosis. The patient was hospitalized for ten days and treated with drugs without recurring VT or other disorders. We implanted an implantable loop recorder before the discharge and monitored the heart rhythm for one year. During a three-year follow-up, all of his electrocardiographic findings presented sinus rhythm without heart rhythm disorders. Conclusion. Sudden SMVT is the most common cause of SCD. It is of inestimable importance to carry out a detailed examination and determine the immediate cause of the arrhythmia and the right therapy, which, for these patients, is a life-saving form of treatment. Therapy includes medications, electrophysiology or ICD, or a combination of these treatment approaches.

Sequential detection rates of intramural hematoma for diagnosing spontaneous intracranial artery dissection.

Spontaneous intracranial artery dissection (IAD) can be definitively diagnosed by detecting intramural hematoma (IMH) on arterial wall imaging. However, evidence of a time-dependent natural history for the development of radiological findings is lacking. Therefore, this study aimed to determine when imaging detects IAD. We obtained data from our cohort databases between March 2011 and August 2018 on consecutive patients who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We assessed IMH on initial and follow-up high-resolution three-dimensional T1-weighted imaging (HR-3D-T1WI). We retrospectively investigated the association between IMH detection and days from symptom onset to initial HR-3D-T1WI and compared the IMH detection rate with other definitive diagnostic arterial dissection findings. We analyzed 106 patients (mean age=51 ± 13 years, 31 women) with at least initial HR-3D-T1WI data. The final diagnoses were definite, probable, and possible IAD in 83, 18, and5 patients, respectively. IMHs were observed in 63 patients (59%, 95% confidence interval [CI] = 49%-69%). Overall IMH detection rate was 55% (95% CI=45%-64%), 20% (95% CI=3%-60%), 40% (95% CI=21%-64%), and 50% (95% CI=37%-63%) on the initial HR-3D-T1WI and Days 3, 7, and 13, respectively. Among 68 patients evaluated with digital subtraction angiography and HR-3D-T1WI, IMH was confirmed more frequently than other definitive diagnostic arterial dissection findings. The overall IMH detection rate on HR-3D-T1WI was >50% and peaked in 1-2 weeks. IMH was a frequently detectable finding for the diagnosis of IAD compared to other radiological findings.

Efficacy of several statistical methods in differentiating TBI and co-occurring conditions: A replication study

Much historical controversy has surrounded TBI criteria especially associated with milder injuries. Lack of sufficient injury documentation underlies problems in the diagnosis of TBI as does variability across multiple expert consensus criteria for diagnosing TBI. The efficacy of diagnostic classification utilizing test data sets with comparison group methodology increases diagnostic accuracy. Five statistical comparisons utilized here improved differential diagnostic accuracy compared with PCS and somatization with neuropsychological testing. Objectives (1) Cross-validation of neuropsychological test data sets of moderate-severe TBI (N = 30) with test data from moderate-severe (N = 74); somatization (N = 24) and PCS (N = 22) cases in a database, (2) Determine if cognitive test data sets alone differentiated TBI from other groups, and (3) Evaluate the efficacy of measures in comparisons: Kullback-Leibler, Correlation, Patterns, Cohen’s d, and MNB. Materials and methods Meyer’s Neuropsychological System; Comparison groups -TBI sample with structural evidence of brain injury (CT/MRI); comparison of 5 statistical measures’ efficacy in test data analysis comparing a community sample of moderate TBI (N=30) with a data base containing moderate-severe TBI (N = 74) + co-occurring groups (PCS N = 22) + Somatization (N = 24). Measures utilized: Correlation, Kullbeck-Leibler divergence, Cohen’s d, MNB code, Configuration. Results Combining the five measures most accurately matched the TBI sample (30/30 cases) with MNB comparison groups of similar TBI severity while differentiating those cases from PCS and Somatoform cognitive testdata. Both Kullback Leibler & Cohens’ d reduced false positive errors in comparison with the other measures.

Expert consensus criteria and practical recommendations for pbc care in the covid-19 era and beyond

Primary biliary cholangitis (PBC) is a chronic autoimmune cholestatic liver disease that can progress to liver fibrosis and cirrhosis, and requires timely diagnosis, optimal treatment, and risk stratification. Several guidelines for the management of PBC have been published, including the American Association for the Study of Liver Disease (AASLD) and European Association for the Study of the Liver (EASL) Clinical Practice Guidelines, which include goals for standards of PBC care. However, recent audits have identified deficiencies in real-world PBC care.

Abstract WMP71: Sequential Detection Rates Of Intramural Hematoma For Diagnosing Spontaneous Intracranial Artery Dissection

Introduction: Spontaneous intracranial artery dissection (IAD) can be diagnosed with the detection of intramural hematoma (IMH). We previously reported that high-resolution 3-dimensional T1-weighted magnetic resonance imaging (HR-3D-T1WI) is useful to detect IMH. Limited evidence is available regarding sequential detection rates of IMH and appropriate timing of the detection. Methods: We retrieved data on consecutive patients from our prospective cohort databases from March 2011 to August 2018 who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We detected IMH on initial and follow-up HR-3D-T1WI. We explored the association between detection of IMH and days from symptom onset to initial or follow-up HR-3D-T1WI. Results: A total of 104 patients (mean age 51 ± 13; 30 female; 68 patients, definite IAD; 31 patients; probable IAD, 5 patients; possible IAD) with at least initial HR-3D-T1WI data were included in the analysis. Clinical diagnoses included ischemic stroke (46%), subarachnoid hemorrhage (6%), transient ischemic attack (2%), and head or neck pain alone (46%). Age, Sex, vascular risk factors and modified Rankin Scale at 3 months were comparable between patients with IMH and without. Among them, follow-up HR-3D-T1WI was performed in 54 patients (52%). IMH was observed in 61 patients, 59% of all and 90% of definite IAD. The median days from symptom onset to initial or follow-up HR-3D-T1WI were 11 (interquartile range[IQR] 8–15) and 29 (IQR 19–57) days, respectively. The median days from symptom onset to first IMH detection were 12 (IQR range 8–17). The detection rate of IMH on initial HR-3D-T1WI was 55% overall, reaching 20% on day 3, 40% on day 7, and 50% on day 8–12 ( Figure ). Of the 23 patients who did not have an IMH on the initial HR-3D-T1WI, 4 (17%) had an IMH detected on the follow-up imaging. Conclusion: The detection rate of IMH on HR-3D-T1WI was approximately 60%, which reached the maximum in 1-2 weeks.

Change in out-of-hospital 12-lead ECG diagnostic classification following resuscitation from cardiac arrest

IntroductionWe evaluated the incidence of change in serial 12-lead electrocardiogram (ECG) diagnostic classifications in patients resuscitated from out-of-hospital (OH) cardiac arrest (OHCA) comparing OH to emergency department (ED) ECGs. MethodsThis retrospective case series included: 1) adults (≥ 18 years old), 2) resuscitated from OHCA, 3) ≥ 1 OH and 1 ED ECG/patient, and 4) emergency medical services (EMS) transport to the study hospital. OH and ED ECGs were classified as: 1) STEMI (ST-segment Elevation Myocardial Infarction), 2) Ischemic, and 3) Non-ischemic. Two ED physicians and one cardiologist independently classified all ECGs, then generated a consensus opinion classification for each ECG based on American Heart Association’s 2018 Expert Consensus criteria. The most ischemic OH ECG classification was compared with the last ED ECG classification. ResultsFrom 7/27/12 to 7/18/19, 176 patients were entered with a mean age of 61.2 ± 16.6 years; 102/176 (58%) were male. Overall, 504 OH and ED 12-lead ECGs were acquired (2.9 ECGs/patient). ECG classification inter-rater reliability kappa score was 0.63 ± 0.02 (substantial agreement). Overall, 86/176 (49%) changed ECG classification from the OH to ED setting; 69/86 (80%) of these ECGs changed from more to less ischemic classifications. Of 49 OH STEMI ECG classifications, 33/49 (67%) changed to a less ischemic (non-STEMI) ED ECG classification. ConclusionsChange in 12-lead ECG classification from OH to ED setting in patients resuscitated from OHCA was common (49%). The OH STEMI classification changed to a less ischemic (non-STEMI) ED classification in 67% of cases.

Clusters of community-dwelling individuals empirically derived from stool diaries correspond with clinically meaningful outcomes.

Functional gastrointestinal disorders (FGIDs) are diagnosed according to expert consensus criteria based on recall of symptoms over periods of 3 months or longer. Whether the expert opinion concords with underlying disease process and whether individual recall is accurate are both in doubt. This study aimed to identify naturally occurring clusters of individuals with respect to symptom pattern, evaluate their significance, compare cluster profiles with expert opinion and evaluate their temporal stability. As part of a random population study of FGID-related symptoms, we first explored the use of prospective stool and symptom diaries combined with empirical grouping of individuals into clusters using nonhierarchical cluster analysis. The analysis identified two clusters of individuals, one of which was characterized by elevated scores on all domains of symptoms (26% of the sample) and one that was low to average on all domains (74% of the sample). Cluster membership was found to be stable over a long interval. Clusters were found to differ on most domains of quality-of-life (d = 0.46-0.74), self-rated health (d = -0.42) and depression (d = -0.42) but not anxiety. Prevalence of clinically diagnosed irritable bowel syndrome (IBS) was higher in the more impacted cluster (33%) compared with the healthy cluster (13%; P < 0.0001). A naturalistic classification of individuals challenges consensus criteria in showing that some IBS individuals have a symptom experience not unlike health. The proposed approach has demonstrated temporal stability over time, unlike consensus criteria. A naturalistic disease classification system may have practical advantages over consensus criteria when supported by a decision-analytic system.

62. Accuracy of Polycystic Ovarian Syndrome Diagnosis in the Adolescent Population

<h3>Background</h3> Historically, PCOS diagnosis for adolescents has been based on adult criteria. Since PCOS symptoms commonly overlap with normal pubertal changes, the Pediatric Endocrine Society developed a diagnostic criteria for PCOS in adolescents in December 2015. The purpose of this study is to assess the rate of correct diagnosis of PCOS in the adolescent population (age 10-19) at Lehigh Valley Health Network, based on Pediatric Endocrine Society (PES) expert consensus criteria. <h3>Methods</h3> We conducted a descriptive study which was a retrospective case series, using our institution's electronic medical record system. All female patients between the ages of 10-19 who were given the diagnosis of PCOS between Jan 1, 2012 to March 31, 2020 were included in the study. Patients with existence of non-PCOS causes for hyperandrogenic anovulation were excluded. If diagnosis of PCOS was made at an outside facility or if no initial note for diagnosis was found, these patients were excluded from the study as well. Study charts were reviewed to see if patients met the PES criteria for PCOS at the time the PCOS diagnosis was given. <h3>Results</h3> Out of the 40 patients in the study, 18 (45.0%) patients met the PES criteria for PCOS at the time the diagnosis was given. In the Ob/Gyn department, 7 out of 18 patients (38.9%) met the PES criteria for PCOS. In the adolescent medicine department, 7 out of 13 patients (53.9%) met the PES criteria. In the family medicine department, 1 out of 3 patients (33.3%) met PES criteria. In the pediatric endocrinology department, 3 out of 6 patients (50%) met the PES criteria. Out of the 40 patients in the study, 36 patients (90%) did meet the Rotterdam criteria for PCOS, which is not the standard for diagnosis of PCOS in the adolescent population. <h3>Conclusions</h3> The findings of the study indicate that more than half of the study population was over-diagnosed with PCOS based on adult criteria. The diagnosis of PCOS is often inaccurately given in the adolescent population. Most providers still use the Rotterdam criteria for diagnosis of PCOS in the adolescent population.

A123 DEFINING CROHN’S DISEASE STRICTURES USING INTESTINAL ULTRASOUND COMPARED TO HISTOPATHOLOGY

Abstract Background Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype often leading to surgical resection. Diagnostic imaging is an invaluable tool to diagnose CD strictures. MRE (Magnetic Resonance Enterography) is the most widely used modality for evaluating strictures, but is limited by access and cost. The current definition of strictures is based only on MRE or CT (computed tomography). Strictures are defined as increased bowel wall thickness (BWT), narrowed luminal apposition, and pre-stenotic dilation &amp;gt; 3cm according to CONSTRICT MR/CT expert consensus criteria. However, this definition has not been studied in intestinal US (IUS). IUS is a cost-effective, easily repeatable, and well-tolerated tool shown to have equal accuracy to MRE in diagnosing and monitoring CD. Aims The objective of this study was to assess the utility of identifying strictures with IUS using CONSTRICT definition. Methods In this retrospective pilot study, 30 of 80 CD patients who underwent small bowel resection (gold standard for stricture diagnosis) between 2015–2019 with IUS within 6 months prior to surgery were randomly identified for chart review. IUS was performed in a fasted state without oral contrast. Data extracted included confirmed stricture on resection specimens defined as having fibrosis and prestenotic dilation. Fistulizing disease was excluded. Student’s t-tests, sensitivities, specificities, positive (PNV) and negative predictive values (NPV) were calculated for IUS in detecting strictures. Results Of the 30 CD patients evaluated, 20 patients had fibrostenosis on pathology and IUS reports. Only 40% (8/20) met CONSTRICT criteria for stricture diagnosis on IUS, despite having a stricture on pathology. All patients had elevated BWT and luminal narrowing, but 60% (12/20) did not have prestenotic dilation &amp;gt; 3cm. Mean dilation was 2.9 cm (SD 1.38) and was significantly different from the mean stricture diameter of 1.3cm (SD 0.59 cm, p=0.0001, 95% CI: 0.9–2.2). Mean BWT was 8.7 mm (SD: 2.5, range 5–15) where normal is &amp;lt; 3mm, and mean luminal apposition was 2.3 mm (SD 1.2, range 0.2–5.8mm). IUS has a sensitivity of 95.2% (95% CI: 76.2 - 99.9%), specificity of 66.7% (95% CI: 29.9 - 92.5%), PPV of 87.0% (95% CI: 72.5–94.4), and NPV of 85.7% (95% CI 45.6–97.7%) in detecting strictures when compared to gold standard. Conclusions CONSTRICT criteria for diagnosing fibrostenotic CD on CT/MR may not be applicable to IUS. In this study, only 40% of patients met criteria despite having histologic confirmed strictures. Thus, perhaps additional criteria of stricture diameter &amp;lt; 50% of prestenotic dilation size is most appropriate for IUS. This pilot study provides the initial data to delineate an IUS stricture definition for future validation and to inform both clinical practice and trial design. Funding Agencies None

Increase in the risk of clopidogrel resistance and consequent TIMI flow impairment by DNA hypomethylation of CYP2C19 gene in STEMI patients undergoing primary percutaneous coronary intervention (PPCI).

Clopidogrel resistance is an important risk factor of ischemic event recurrence after optimal antiplatelet therapy. This study aims to investigate the role of CYP2C19 gene DNA methylation as one of the epigenetic factors for the risk of clopidogrel resistance in STEMI patients undergoing PPCI. ST‐segment elevation myocardial infarction (STEMI) patients undergoing PPCI were pretreated with clopidogrel, and their platelet function was measured using VerifyNow™ assay. The criteria for high on‐treatment platelet reactivity (HPR) were defined according to the expert consensus criteria (PRU >208). DNA methylation of the CYP2C19 gene was performed using bisulfite genomic sequencing technology. Furthermore, clinical, laboratory, and angiographic data including TIMI flow were collected. Among 122 patients, clopidogrel resistance was found in 22%. DNA methylation level percentage was lower in the clopidogrel resistance group (76.7 vs. 88.8, p‐value .038). But, the <50% methylation group was associated with increased risk of clopidogrel resistance (OR =4.5, 95%CI =2.1–9.3, p‐value = .018). This group was also found to have suboptimal post‐PCI TIMI flow (OR =3.4 95%CI =1.3–8.7, p‐value =.045). The lower DNA methylation level of the CYP2C19 gene increases the risk of clopidogrel resistance and subsequent poorer clinical outcome.

A community-based validation of the International Alliance for the Control of Scabies Consensus Criteria by expert and non-expert examiners in Liberia.

BackgroundThe International Alliance for the Control of Scabies (IACS) recently published expert consensus criteria for scabies diagnosis. Formal validation of these criteria is needed to guide implementation. We conducted a study to provide detailed description of the morphology and distribution of scabies lesions as assessed by dermatologists and validate the IACS criteria for diagnosis by both expert and non-expert examiners.MethodsParticipants from a community in Monrovia, Liberia, were independently assessed by two dermatologists and six non-expert examiners. Lesion morphology and distribution were documented based on the dermatologist examination. Diagnoses were classified by IACS criteria and the sensitivity and specificity of non-expert examiner assessments calculated.ResultsPapules were the most common lesions (97.8%). Burrows were found in just under half (46.7%) and dermatoscopy was positive in a minority (13.3%). Scabies lesions were found in all body regions but more than 90% of patients could have been diagnosed by an examination of only the limbs. Severity of itch was associated with lesion number (p = 0.003). The sensitivity of non-expert examiners to detect typical scabies ranged between 69–83% and specificity 70–96%. The sensitivity of non-expert examiners was higher in more extensive disease (78–94%).ConclusionsThe IACS criteria proved a valid tool for scabies diagnosis. For the purposes of implementation papules and burrows represent truly ‘typical’ scabies lesions.Non-expert examiners are able to diagnose scabies with a high degree of accuracy, demonstrating they could form a key component in population-level control strategies.

Group Cognitive-Behavior Therapy or Group Metacognitive Therapy for Obsessive-Compulsive Disorder? Benchmarking and Comparative Effectiveness in a Routine Clinical Service.

Cognitive-behavior therapy (CBT), delivered in an individual or group format, is the recommended treatment of choice for Obsessive-Compulsive Disorder (OCD), but no studies have benchmarked the outcomes for group CBT in real-world clinical settings. The first aim of this evaluation was to benchmark the outcomes for group CBT in a sample of 125 patients who attended a routine clinical service for OCD. The results showed that the outcomes for the group CBT were comparable to those reported in previous treatment studies. However, consistent with the CBT for OCD literature, 28% of patients receiving CBT reported minimal improvement. The second aim of this evaluation was to carry out a benchmarking analysis for group metacognitive therapy (MCT) to determine if this could provide any advantages in a sample of 95 patients who also attended this clinical service over a subsequent period. The clinically significant results obtained for group MCT improved upon or equaled those obtained for group CBT and those typically found in treatment studies. The group MCT cohort improved significantly more than the group CBT cohort even after controlling for important pre-treatment variables including age, gender, number of diagnoses, symptoms of depression, and psychotropic medication. MCT had significantly higher clinical response rates. Based on international expert consensus criteria, 86.3% of patients in the MCT cohort responded compared with 64% in CBT. The implications of these findings are discussed.

699. Relationship Between Klebsiella pneumoniae Antimicrobial Resistance and Biofilm Formation

Background Klebsiella pneumoniae is a frequently multidrug-resistant organism with a high propensity to form biofilm. K. pneumoniae is the most common carbapenem-resistant Enterobacteriaceae (CRE), and labeled an urgent threat by the CDC. The relationship between K. pneumoniae biofilm formation and specific antimicrobial resistance patterns has not been well defined.Methods K. pneumoniae isolates (n = 139) were evaluated for antimicrobial resistance and biofilm formation (CDC, Providence VA Med. Ctr., Rhode Island Hosp., BEI, and ATCC). Susceptibility was based predominantly on 2017 CLSI (Clinical and Laboratory Standards Institute) breakpoints. Isolates were categorized as multidrug-resistant (MDR: resistant to ≥ 1 antimicrobial in ≥ 3 out of 16 antimicrobial categories) or extensively drug-resistant (XDR: resistant to ≥ 1 antimicrobial in all but ≤ 2 out of 16 antimicrobial categories) based on expert consensus criteria for Enterobacteriaceae (European CDC (ECDC)/CDC, 2012). We collapsed antimicrobial categories described by the ECDC/CDC consensus group into nine categories: penicillins, cephalosporins, monobactam, carbapenems, protein synthesis inhibitors, fluoroquinolones, folate pathway inhibitors, fosfomycin, and colistin. Biofilm formation was assessed using a modified crystal violet method (OD570) and defined by tertile cut-points. Antimicrobial resistance was compared for weak (n = 47) vs. strong (n = 46) biofilm formation by chi-square or Fisher’s exact test. Predictors of strong biofilm formation were identified using logistic regression.ResultsMDR isolates were more common among weak (n = 46/47, 97.9%) vs. strong biofilm formers (n = 35/46, 76.1%; P = 0.002), whereas XDR was similar between groups (n = 12/47, 25.5% vs. n = 13/46, 28.3% P = 0.77). Resistance to penicillins, cephalosporins, monobactams, carbapenems, protein synthesis, or fluoroquinolones was more common among weak biofilm formers (P < 0.05). Carbapenem resistance was inversely associated with strong biofilm formation (odds ratio 0.09; 95% confidence interval 0.02–0.33).ConclusionCarbapenem-resistant K. pneumoniae was 91% less likely to form strong biofilm. Potential trade-off mechanisms between antimicrobial resistance and biofilm formation require further exploration.Disclosures A. Caffrey, Merck: Grant Investigator, Research grant. The Medicine’s Company: Grant Investigator, Research grant. Pfizer: Grant Investigator, Research grant. K. LaPlante, Merck: Grant Investigator, Research grant. Pfizer Pharmaceuticals: Grant Investigator, Research grant. Allergan: Scientific Advisor, Honorarium. Ocean Spray Cranberries, Inc.: Grant Investigator and Scientific Advisor, Honorarium and Research grant. Achaogen, Inc.: Scientific Advisor, Honorarium. Zavante Therapeutics, Inc.: Scientific Advisor, Honorarium.

Management and outcomes of cardiac sarcoidosis: a 20-year experience in two tertiary care centres.

Cardiac sarcoidosis (CS) often presents with ventricular arrhythmias, heart block, and cardiomyopathy. The prognosis of CS with contemporary management is uncertain. We estimated the impact of baseline and treatment variables on left ventricular ejection fraction (LVEF), ventricular assist device placement, heart transplant, and death. We identified patients with CS seen from 1994-2014 at two large academic medical centres. All met the 2014 Heart Rhythm Society expert consensus criteria for diagnosis. From the 574 patients identified, 91 met inclusion criteria. Twenty-two (24.2%) were diagnosed by endomyocardial biopsy. Cardiomyopathy was the primary presentation in 47 patients (51.6%). Within 90 days of diagnosis, 41 patients (45.0%) received prednisone alone, 29 (31.9%) received alternative immunosuppression with or without prednisone, and 21 (23.1%) received no immunosuppression. During follow-up, 31 of 47 cardiomyopathy patients experienced improvement in LVEF, while 23 experienced decline in LVEF or clinical exacerbation, and 15 of 22 patients presenting with ventricular arrhythmia had recurrence. These results did not differ by treatment group. During a median follow-up of 44 months for our cohort, 14 patients reached the composite endpoint of ventricular assist device placement, heart transplant, or death. Survival without the composite outcome did not differ by treatment group, but was worse among patients presenting with cardiomyopathy (log-rank = 0.005). In a large series of CS subjects, rates of ventricular arrhythmia and heart failure events remain high with no treatment regimen clearly associated with better outcome. Patients with cardiomyopathy at diagnosis were more likely to reach the composite endpoint.

The Abrams geriatric self‐neglect scale: introduction, validation and psychometric properties

Self-neglect is an imprecisely defined entity with multiple clinical expressions and adverse health consequences, especially in the elderly. However, research has been limited by the absence of a measurement instrument that is both inclusive and specific. Our goal was to establish the psychometric properties of a quantitative instrument, the Abrams Geriatric Self-Neglect Scale (AGSS). We analyzed data from a 2007 case-control study of 71 cognitively intact community-dwelling older self-neglectors that had used the AGSS. The AGSS was validated against two "gold standards": a categorical definition of self-neglect developed by expert consensus; and the clinical judgment of a geriatric psychiatrist using chart review. Frequencies were examined for the six scale domains by source (Subject, Observer, and Overall Impression). Internal consistency was estimated for each source, and associations among the sources were evaluated. Internal consistency estimates for the AGSS were rated as "good," with the Subject responses having the lowest alpha and omega (0.681 and 0.692) and the Observer responses the highest (0.758 and 0.765). Subject and Observer scores had the lowest association (0.578, p<0.001). Using expert consensus criteria as the primary "gold standard," the Observer and Overall Impression subscales were "good" at classifying self-neglect, while the Subject subscale was "fair." The AGSS correctly classified and quantified self-neglect against two "gold standards." Sufficient correlations among multiple sources of information allow investigators and clinicians to choose flexibly from Subject, Observer, or Overall Impression. The lower internal consistency estimates for Subject responses are consistent with self-neglectors' propensity to disavow symptoms. Copyright © 2017 John Wiley & Sons, Ltd.

202. Agreement Between Knowledgeable Clinicians and Expert Consensus Criteria in Diagnosing Neuroleptic Malignant Syndrome

202. Agreement Between Knowledgeable Clinicians and Expert Consensus Criteria in Diagnosing Neuroleptic Malignant Syndrome

Multicenter Experience With Mycophenolate Mofetil in Cardiac Sarcoidosis

SESSION TITLE: Sarcoidosis SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, October 26, 2016 at 07:30 AM - 08:30 AM PURPOSE: Cardiac sarcoidosis (CS) is a potentially life-threatening cardiomyopathy, although limited data exist to guide pharmacotherapy. Corticosteroids presently constitute the mainstay of treatment, but are associated with significant toxicities. Mycophenolate mofetil (MMF) is a corticosteroid-sparing agent that may have a role in management of CS. METHODS: Detailed retrospective chart review was performed to identify patients from two academic medical centers meeting 2014 Heart Rhythm Society Expert Consensus criteria for the diagnosis of CS, from 1994-2014. Patients receiving MMF for CS were included in this analysis. Data regarding demographics, disease characteristics, concurrent therapies, and composite endpoint of ventricular assist device (VAD), heart transplant, or death, were abstracted. Kaplan-Meier analyses were used to evaluate time-dependent variables. RESULTS: A total of 33 patients were treated with MMF for a median of 22.0 months (IQR13.0-104.0). Median age at diagnosis was 51.0 years (IQR 47.0-58.0), 24 (73%) patients were male, and 26 (79%) were Caucasian. Cardiomyopathy with left ventricular ejection fraction (LVEF) <40% was the most common presenting manifestation, affecting 17 (52%) patients, followed by 12 (36%) with atrioventricular block, and 11 (33%) with ventricular arrhythmia; 6 (18%) had more than one of these at presentation. Only 3 (9%) patients had isolated cardiac involvement by sarcoidosis, while 28 (85%) also had pulmonary involvement. All but one patient (97%) initially received concurrent prednisone, 2 (6%) received concurrent anti-tumor necrosis factor-alpha therapy, and 1 (3%) received concurrent cyclosporine. Twenty (of 32, 63%) patients were tapered off prednisone, with median prednisone duration after MMF initiation of 15.0 months (IQR 7.1-33.5). Median time to worsening cardiomyopathy (clinical and/or 10% decrease in LVEF) was 28.0 months, while time to recurrent ventricular arrhythmia was 11.5 months. Six (18%) patients received a VAD, and 5 (15%) underwent transplantation (4 with preceding VAD). After MMF initiation, median time to the composite endpoint of VAD, heart transplant, or death, was 79.0 months. Three (9%) patients not receiving VAD or transplant changed therapy for apparent disease progression. Four (12%) patients stopped MMF due to adverse effects, including cytopenias (3), rash (1), and tremor (1). CONCLUSIONS: In this multicenter analysis, MMF allowed a majority of patients with CS to be weaned off prednisone. Median survival without the composite endpoint of VAD, transplant, or death, was more than 6.5 years, suggesting a benefit of immunosuppression. Discontinuation of MMF for toxicity was uncommon. CLINICAL IMPLICATIONS: Prospective studies are needed to better define the role of MMF in CS therapy. DISCLOSURE: The following authors have nothing to disclose: Lynn Fussner, Erin Karlstedt, Nowell Fine, Sanjay Kalra, Eva Carmona, James Utz, Debra Isaac, Leslie Cooper No Product/Research Disclosure Information

Diagnosis of Pulmonary Tuberculosis in Children: Assessment of the 2012 National Institutes of Health Expert Consensus Criteria.

The 2012 National Institutes of Health (NIH) consensus criteria for standardized diagnostic categories of pulmonary tuberculosis in children have not been validated. We aimed to assess the NIH diagnostic criteria in children with culture-confirmed pulmonary tuberculosis and those in whom tuberculosis has been excluded. We performed a retrospective analysis of consecutive children hospitalized with suspected pulmonary tuberculosis in Cape Town, South Africa, who were enrolled in a diagnostic study. Children were categorized as definite tuberculosis (culture positive), probable tuberculosis (chest radiograph consistent), possible tuberculosis (chest radiograph inconsistent), or not tuberculosis (improved without tuberculosis treatment). We applied the NIH diagnostic categories to the cohort and evaluated their performance specifically in children with definite tuberculosis and not tuberculosis. Four hundred sixty-four children (median age, 25.1 months [interquartile range, 13.5-61.5 months]) were included; 96 (20.7%) were HIV infected. Of these, 165 (35.6%) were definite tuberculosis, and 299 (64.4%) were not tuberculosis. If strict NIH symptom criteria were applied, 100 (21.6%) were unclassifiable including 21 (21.0%) with definite pulmonary tuberculosis, as they did not meet the NIH criteria due to short duration of symptoms; 71 (71%) had cough <14 days, 48 (48%) had recent weight loss, and 39 (39%) had fever <7 days. Of 364 classifiable children, there was moderate agreement (κ = 0.48) with 100% agreement for definite tuberculosis and moderate agreement for not tuberculosis (220 [60.4%] vs 89 [24.5%]). Entry criteria for diagnostic studies should not be restrictive. Data from this analysis have informed revision of the NIH definitions.

Clinical features and outcomes of carotid artery stenting by clinical expert consensus criteria: A report from the CARE registry

In 2007, a multispecialty society task force published a clinical expert consensus document (CECD) on carotid stenting (CAS), containing recommendations for appropriate patient selection and quality of care. The CECD also inspired creation of a large, national registry of carotid revascularization, the Carotid Artery Revascularization and Endarterectomy (CARE) registry. Our goal here was to investigate whether initial CAS procedures submitted to CARE conformed to CECD recommendations, and examine their clinical outcomes. We analyzed CAS procedures for the period January 1, 2005 through December 31, 2008. These were grouped into those that conformed to CECD recommendations [CECD(+), n = 4,636, 79.8%] and those that did not [CECD(-), n = 1,168, 20.2%]. The CECD(+) patients were older than CECD(-) patients (71.5 +/- 10.3 vs. 67.6 +/- 10.3 years, P = 0.001, respectively), and more frequently had chronic kidney disease (46.9% vs. 17.8%, P = 0.001), chronic lung disease (33.0% vs. 12.4%, P = 0.001), ejection fraction <or= 0.30 (13.5% vs. 5.5%, P = 0.001) and contralateral carotid artery occlusion (12.7% vs. 4.6%, P = 0.001). Clinical outcomes at 30 days were similar, including death (1.24% vs. 0.76%, P = 0.184), stroke (5.32% vs. 5.34%, P = 0.954), and death, stroke, or MI (7.04% vs. 6.95%, P = 0.944). Most CAS procedures submitted to CARE conformed to CECD recommendations for patient selection. For reported data, clinical outcomes at 30 days were similar for procedures meeting and those not meeting recommendations, and were similar to outcomes reported by other large registries. These findings suggest that acceptable patient selection criteria for CAS are employed as it expands beyond investigators into more widespread clinical practice.