High Probability Group Research Articles

Palpitations across the menopause transition in SWAN: trajectories, characteristics, and associations with subclinical cardiovascular disease.

Our objectives were to identify trajectories of palpitations over the menopause transition, characterize them, and examine associations with subclinical cardiovascular disease (CVD). We analyzed the following data from the multisite, multiethnic SWAN (Study of Women Across the Nation): reported palpitations occurrence over time; baseline sociodemographic, reproductive, medication, and health-related factors; and follow-up visit subclinical CVD (carotid atherosclerosis, vascular stiffness). Trajectories of palpitations (n = 3,276), their characteristics, and their associations with subclinical CVD (n = 1,559) were identified using group-based trajectory modeling and linear and logistic regression models. Three trajectories emerged: high probability of palpitations in perimenopause to early postmenopause diminishing in late postmenopause (15.9% of women), moderate probability of palpitations in perimenopause to early postmenopause diminishing in late postmenopause (34.3%), and sustained low probability of palpitations (49.8%). In the fully adjusted multivariable model, the high probability group had a more adverse reproductive and health-related profile at baseline (higher gravidity, early perimenopause, vasomotor symptoms, poorer overall health, higher depressive symptoms, higher perceived stress, greater sleep problems, higher blood pressure). In fully adjusted multivariable models, palpitation trajectories were not related to atherosclerosis or arterial stiffness. Distinct patterns of palpitations emerged, with a substantial portion of women having palpitations during the perimenopause and early postmenopause. Palpitations were not associated with subclinical CVD. Findings can help identify women at risk of palpitations during the menopause transition who may need symptom relief.

Relationship between standardized uptake value on 18F-FDG PET and PD-L1 expression in clear cell renal cell carcinoma

PurposePartial clear cell renal cell carcinoma (CCRCC) may be sensitive to immune checkpoint inhibitor treatment targeting the programmed cell death 1 (PD-1)/programmed cell death 1 ligand 1 (PD-L1) pathway. Assessing the levels of PD-L1 using non-invasive imaging is useful to select immunotherapy-sensitive patients. Currently, whether PD-L1 levels in CCRCC correlate with 18F fluorodeoxyglucose (18F-FDG) uptake is unknown. This study aimed to assess whether 18F-FDG-positron emission tomography (PET) imaging could be used to infer PD-L1 levels in CCRCC.MethodsImmunohistochemistry (IHC) was used to assess PD-L1 levels in samples of tumors obtained retrospectively from a cohort of 58 patients with CCRCC who also received 18F-FDG PET/CT imaging. The IHC scores for PD-L1 were compared with the 18F-FDG maximum standardized uptake value (SUVmax), and the mean standardized uptake value (SUVmean) value, with the clinical characteristics of CCRCC, and with the IHC scores of enzymes related to glucose metabolism (glucose transporter type 1 (GLUT1), hexokinase 2 (HK2), lactate dehydrogenase A (LDHA)), and Von Hippel-Lindau tumor suppressor (VHL).ResultsIncreased renal venous invasion, lymph node metastasis, tumor size, SUVmean, and SUVmax correlated significantly with higher PD-L1 levels (P < 0.05). The IHC scores of VHL and LDHA correlated positively with those of PD-L1 (P = 0.035, P = 0.011, respectively). Significant correlations between PD-L1 levels and SUVmean and lymph node metastasis were observed upon multivariate analysis. SUVmean combined with lymph node metastasis predicted that 20.59% of the low probability group would express PD-L1, 29.41% of the medium probability group would express PD-L1, and 71.43% of the high probability group would express PD-L1.ConclusionThe status of lymph node metastasis, SUVmax, and SUVmean of the primary lesion correlated with PD-L1 levels in CCRCC. A combination of lymph node metastasis status and SUVmean could be utilized to predict PD-L1 levels, thus allowing monitoring of a tumor’s immunotherapy response.

MM-146 Using Data Science to Characterize Patterns in Cardiovascular Clinical Data: Topological Analysis of Baseline Characteristics in Patients With Relapsed/Refractory Multiple Myeloma Enrolled in Carfilzomib Trials

Oncology clinical trials amass vast amounts of patient data, providing the opportunity to leverage machine learning. Patients with multiple myeloma (MM) often have cardiovascular risk factors and/or established cardiovascular disease. We used topological analysis to identify characteristics at baseline associated with subsequent cardiovascular adverse events (AEs) in patients with relapsed/refractory MM (RRMM). Retrospective data were pooled from the investigational arm (carfilzomib-treatment) of phase 3 trials (ASPIRE, ARROW, FOCUS, ENDEAVOR) for this post-hoc exploratory analysis. Variables included baseline demographics, vital signs, electrocardiogram results, laboratory values, and comorbidities. Topological data analysis (an analytic approach akin to dimensionality reduction, distinct from traditional multivariate modeling) was used to reveal AE occurrence micropatterns. A decision algorithm accounting for both posterior and prior AE probability was used to find risk factors meeting pre-specified clinical criteria. In the pooled population (n=1,484), grade ≥3 cardiovascular AEs analyzed were cardiac failure (5.1%), ischemic heart disease (IHD, 2.2%), and hypertension (9.2%). Using this modeling approach, patient clusters with higher or lower AE posterior probabilities were derived (cardiac failure: 31.1% [higher probability]/68.9% [lower probability]; IHD: 38.5%/61.5%; hypertension: 32.1%/67.9%), with AE rates enriched in the high-probability group (cardiac failure AE rate was 4x higher in the high-probability group than the low-probability group [10.8% vs. 2.4%]). Grade ≥3 cardiac failure clustered in patients with baseline comorbidity of congestive heart failure, moderate-to-severe chronic kidney disease, prolonged mean QRS ≥120 msec, glucose ≥7.9 mmol/L, and/or Asian race. Grade ≥3 IHD clustered in patients with prior myocardial infarction, glucose ≥7.9 mmol/L, activated partial thromboplastin time ≤20 seconds, and/or creatinine clearance ≤60 mL/min. Grade ≥3 hypertension clustered with systolic blood pressure ≥140 mmHg and/or Asian or African race. This novel topological analysis found that cardiovascular AEs in RRMM patients enrolled in carfilzomib trials clustered into groups with known risk factors. Characteristics associated with cardiovascular AEs were detectable by standard clinical assessment or laboratory tests. Study limitations include the lack of comparator arm, small number of Asian patients (n=102), and that this novel methodology has not been validated in clinical settings. These findings suggest that topological analysis may be a useful tool for leveraging machine learning in clinical trials.

Probability scoring system of intravascular large B-cell lymphoma for the application of random skin biopsy: A retrospective cohort study

Intravascular large B-cell lymphoma (IVLBCL) is rare and fatal when diagnosed late in the disease course. Random skin biopsy (RSB) is useful for early diagnosis, but criteria for its application are not well established. To develop an IVLBCL-probability scoring system for stratifying patients and investigate its feasibility and capability for RSB application. A retrospective cohort of 77 consecutive patients with suspected IVLBCL who underwent RSB was included in this study. All patients were classified into 3 IVLBCL-probability groups according to the IVLBCL-probability scoring system comprising the following 4 components: general symptoms, organ-specific symptoms, serum soluble-interleukin-2 receptor levels, and serum lactate-dehydrogenase levels. The high (score 7-10), intermediate (score 4-6) and low (score 1-3) IVLBCL-probability groups contained 32, 30, and 15 patients, respectively. All 5 patients with IVLBCL were stratified into the high IVLBCL probability group. Accuracies in the diagnosis of IVLBCL were 100%, 100%, and 93.8% for the low, intermediate, and high IVLBCL-probability groups. The positive detection rate in the high IVLBCL-probability group increased to 9.4% from 3.9% across all groups. The newly-developed IVLBCL-probability scoring system has good capability for stratification of patients and could allow limiting application of RSB for diagnosis only to high-probability groups.

Physician judgement in predicting obstructive coronary artery disease and adverse events in chest pain patients

ObjectiveTo evaluate informal physician judgement versus pretest probability scores in estimating risk in patients with suspected coronary artery disease (CAD).MethodsWe included 4533 patients from the PROMISE (Prospective Multicenter Imaging Study...

P560 Application of a clinical decision support tool for predicting outcomes with vedolizumab therapy in patients with inflammatory bowel disease: A KASID multicenter study

Abstract Background A clinical decision support tool (CDST) has been developed and validated for predicting outcomes of vedolizumab (VDZ) therapy for patients with Crohn’s disease (CD) and ulcerative colitis (UC), respectively. We aimed to validate each CDST for predicting outcomes and need for drug optimisation in patients with inflammatory bowel disease (IBD). Methods We retrospectively analysed 166 patients with IBD (71 with CD, and 95 with UC) treated with VDZ from January 2017 through November 2021 at 6 tertiary referral centres in Korea. We assessed clinical remission (CREM) and response (CRES), corticosteroid-free clinical remission (CfCREM) and response (CfCRES), biochemical response (BioRES), endoscopic healing (EH), and need for drug optimisation by CDST-defined response groups (low vs. intermediate to high probability group with a cut-off of 13 points in CD, Table 1A, and 26 points in UC, Table 2A, respectively). CDST was evaluated by area under the receiver operating characteristics curve (AUC) and test performance. Results Patients were classified as low (27 with CD, and 28 with UC) and intermediate to high probability group (44 with CD, and 67 with UC). Among CD patients, there showed no significant difference in the response rate of any outcomes between CDST-defined groups. Among UC patients, the rates of CREM (41.0 vs. 18.5%, p=0.040) and EH (56.5 vs. 33.3%, p=0.045) at week 14 were higher among intermediate to high probability group. The rate of drug optimisation during maintenance therapy was also higher in low probability group (54.2 vs. 30.2%, p=0.038). At week 26, CDST for CD discriminated CfCREM with an AUC of 0.656 (sensitivity 87.5%, specificity 43.8%) (Table 1B). Meanwhile, CDST for UC identified CREM with an AUC of 0.606 (sensitivity 83.3%, specificity 37.9%) at week 14 (Table 2B). BioRES of FC was identified with an AUC of 0.649 (sensitivity 84.6%, specificity 45.2%) at week 26. BioRES of CRP was identified with an AUC of 0.660 (sensitivity 68.8%, specificity 63.2%) at week 26, and with an AUC of 0.642 (sensitivity 70.0%, specificity 58.3%) at week 54. Drug optimisation during maintenance therapy was identified with an AUC of 0.620 (sensitivity 54.2%, specificity 69.8%). Conclusion Both CDST for CD and UC can be used to help guide VDZ therapy for Korean patients to predict BioRES with a fair discriminant function and moderate sensitivity.

The Added Value of 18F-FDG PET/CT Compared with 68Ga-PSMA PET/CT in Patients with Castration-Resistant Prostate Cancer.

68Ga-prostate-specific membrane antigen (68Ga-PSMA) PET/CT is a commonly used imaging modality in prostate cancers. However, few studies have compared the diagnostic efficiency between 68Ga-PSMA and 18F-FDG PET/CT and evaluated whether a heterogeneous metabolic phenotype (especially 68Ga-PSMA-negative [-], 18F-FDG-positive [+] lesions) exists in patients with castration-resistant prostate cancer (CRPC). We determined the added value of 18F-FDG PET/CT compared with 68Ga-PSMA PET/CT in CRPC patients and identified CRPC patients who may benefit from additional 18F-FDG PET/CT. Methods: The data of 56 patients with CRPC who underwent both 68Ga-PSMA and 18F-FDG PET/CT from May 2018 to February 2021 were retrospectively analyzed. The patients were classified into 2 groups: with or without 68Ga-PSMA-, 18F-FDG+ lesions. The differences in patient characteristics between the 2 groups and predictors of patients who have at least 1 68Ga-PSMA-, 18F-FDG+ lesion were analyzed. Results: Although both the detection rate (75.0% vs. 51.8%, P = 0.004) and the number of positive lesions (135 vs. 95) were higher for 68Ga-PSMA PET/CT than for 18F-FDG PET/CT, there were still 13 of 56 (23.2%) patients with at least 1 68Ga-PSMA-, 18F-FDG+ lesion. Prostate-specific antigen (PSA) and the Gleason score were both higher in patients with 68Ga-PSMA-, 18F-FDG+ lesions than in those without (P = 0.04 and P < 0.001, respectively). Multivariate regression analysis showed that the Gleason score (≥8) and PSA (≥7.9 ng/mL) were associated with the detection rate of patients who had 68Ga-PSMA-, 18F-FDG+ lesions (P = 0.01 and P = 0.04, respectively). The incidences of having 68Ga-PSMA-, 18F-FDG+ lesions in low-probability (Gleason score < 8 and PSA < 7.9 ng/mL), medium-probability (Gleason score ≥ 8 and PSA < 7.9 ng/mL or Gleason score < 8 and PSA ≥ 7.9 ng/mL), and high-probability (Gleason score ≥ 8 and PSA ≥ 7.9 ng/mL) groups were 0%, 21.7%, and 61.5%, respectively (P < 0.001). Conclusion: Gleason score and PSA are significant predictors of 68Ga-PSMA-, 18F-FDG+ lesions, and CRPC patients with a high Gleason score and PSA may benefit from additional 18F-FDG PET/CT.

Suprascapular Neuropathy

Suprascapular neuropathy (SSN) is often missed or neglected. Although the occurrence is rare, it is for this reason that one needs to be aware of the correct clinical skill sets and investigations to nail the diagnosis. SSN pathologies are being diagnosed with increasing frequency in high probability groups like athletes, massive rotator cuff tear with fatty infiltration, labral tear and subsequent cyst formation. With better understanding of the pathology, management of SSN has also improved in recent decades. With the advancement in electrodiagnostic modalities, SSN can be more reliably diagnosed now. The article highlights the aetiology and the points of compression, clinical picture to trigger the need for an EMG and the results of Arthroscopic decompression

A new pre-test probability score for diagnosis of deep vein thrombosis in patients before surgery

BackgroundVenous thromboembolism is a serious perioperative complication. We developed a new pre-test probability score for predicting deep vein thrombosis (DVT) before surgery. MethodsWhole leg ultrasonography was performed on 973 inpatients and outpatients with suspected DVT based on a preoperative D-dimer cut-off value of ≥ 1 μg/ml. We allocated two-thirds (n = 651) of the study participants to a derivation cohort and one-third (n = 322) to a validation cohort. The pre-test probability model was developed from the derivation cohort data. ResultsThe pre-test probability model for DVT assigned 2 points to D-dimer ≥ 1.5 μg/mL and 1 point each to age ≥ 60 years, female sex, ongoing glucocorticoid therapy, prolonged immobility, and cancer with high risk of DVT. The area under the curve of the pre-test probability score was 0.72 and 0.70 in the derivation and validation cohorts, respectively. The rates of DVT according to pre-test probability scores in the derivation and validation cohorts were 7% and 6% in the low (score = 0-2), 23% and 22% in the intermediate (score = 3-4), and 47% and 50% in the high probability group (score ≥ 5), respectively (p < 0.0001). ConclusionsThe pre-test probability score (Kagoshima-DVT score) was helpful in detecting preoperative DVT in both inpatients and outpatients. We identified low probability group to reduce whole-leg ultrasonography and high probability group to detect more DVT before surgery.

Importance of Tricuspid Regurgitation Velocity Threshold in Risk Assessment of Pulmonary Hypertension-Long-Term Outcome of Patients Submitted to Aortic Valve Replacement.

Background: The upper physiological threshold for tricuspid regurgitation velocity (TRV) of 2.8 m/s proposed by the Pulmonary Hypertension (PH) guidelines had been questioned. The aim of this study was to evaluate the prognostic significance of preoperative PH in patients with aortic stenosis, long-term after valve replacement, using two different TRV thresholds (2.55 and 2.8 m/s).Methods: Four hundred and forty four patients were included (mean age 73 ± 9 years; 55% male), with a median follow-up of 5.8 years (98% completed). Patients were divided into three PH probability groups according to guidelines (low, intermediate and high) for both thresholds (TRV ≤ 2.8 m/s and TRV ≤ 2.55 m/s), using right atrial area>18 cm2 and right ventricle/left ventricle ratio>1 as additional echocardiographic variables.Results: In patients with measurable TRV (n = 304), the low group mortality rate was 25% and 30%, respectively for 2.55 and 2.8 m/s TRV thresholds. The intermediate group with TRV > 2.55 m/s was an independent mortality risk factor (HR 2.04; 95% CI: 1.91 to 3.48, p = 0.01), in contrast to the intermediate group with TRV>2.8 m/s (HR 1.44; 95% CI: 0.89 to 2.32, p = 0.14). Both high probability groups were associated with an increased mortality risk, as compared to their respective low groups. When including all patients (with measurable and non-measurable TRV), both intermediate groups remained independently associated with an increased mortality risk: HR 1.62 (95% CI 1.11 to 2.35 p = 0.01) for the new cut-off point; and HR 1.43 (95% CI: 0.96 to 2.13, p = 0.07) for guidelines threshold.Conclusion: A TRV threshold of 2.55 m/s, together with right cavities measures, allowed a better risk assessment of patients with PH secondary to severe aortic stenosis, with or without tricuspid regurgitation.

Pulmonary Vascular Resistance Estimated by Echocardiography in Dogs With Myxomatous Mitral Valve Disease and Pulmonary Hypertension Probability.

Post-capillary pulmonary hypertension (PH) is a life-threatening complication in dogs with myxomatous mitral valve disease (MMVD). An increase in pulmonary vascular resistance (PVR) is associated with post-capillary PH progression. In humans, PVR estimated by echocardiography (PVRecho) enables the non-invasive assessment of PVR in patients with PH. This study aimed to evaluate the clinical utility of PVRecho in dogs with MMVD, PH probability, and right-sided congestive heart failure (R-CHF). Dogs with MMVD and detectable tricuspid valve regurgitation were included in the study. Dogs were classified into three PH probability groups (low/intermediate/high) and according to the presence or absence of R-CHF. All dogs underwent echocardiographic measurements for right ventricular (RV) morphology and function. PVRecho was calculated by two methods using tricuspid valve regurgitation velocity and velocity–time integral of the pulmonary artery flow (PVRecho and PVRecho2). RV size indicators were significantly higher with a higher probability of PH. RV strain and velocity–time integral of the pulmonary artery flow in the high probability group were significantly lower than those in the other groups. Tricuspid valve regurgitation velocity, PVRecho, and PVRecho2 were significantly higher with an increase in PH probability. Logistic regression analysis revealed a significant association between the presence of R-CHF and increased PVRecho2 and end-diastolic RV internal dimension normalized by body weight. PVRecho and PVRecho2 showed significant differences among the PH probability groups. These non-invasive variables may be useful for the diagnosis and stratification of PH and the determination of the presence of R-CHF in dogs with MMVD.

Correlation between Non-Alcoholic Fatty Liver Disease (NAFLD) fibrosis score (NFS) with Left Ventricular Mass Index (LVMI) in patients with NAFLD

Background: Cardiovascular-related mortality is a major concern in NAFLD. Advanced fibrosis was known to be associated with cardiovascular diseases. NAFLD Fibrosis Score (NFS) is used to identify the development of liver fibrosis in NAFLD patients. Left ventricular mass index (LVMI) is a sign of subclinical cardiovascular complications in NAFLD. The correlation between NAFLD fibrosis score with LVMI in NAFLD patients is not fully established.Objective: To analyze the correlation between NAFLD fibrosis score with LVMI in NAFLD patients.Methods: A cross-sectional study of NAFLD patients in Kariadi Hospital Indonesia. NFS was done using a formula based on clinical and biochemical parameters. LVMI was measured with echocardiography. Pearson’s, Mann-Whitney, and logistic regression were used for analysis.Results: A total of 64 patients with primary NAFLD were enrolled, 54.7% males and 45.3% females. Mean age was 52,8 ± 10,5 years (30-77 years). Based on NFS criteria, high probability group was the highest (50%), followed by intermediate probability group (34,4%) and low probability group (15,6%). Highest increase in LVMI was obtained in the high probability group (93,8%), followed by intermediate probability (59,1%), and low probability group (10%) respectively. There was significant correlation between NFS and LVMI (P 0,002). Logistic regression showed that NFS has a more significant correlation with LVMI compared to gender (P=0,002).Conclusion: NFS is a non‐invasive liver fibrosis scores which independently corelated with Left ventricular mass index (LVMI), a marker of cardiovascular abnormality.

Liver regeneration after radiotherapy in patients with hepatocellular carcinoma: A simple-to-use model and nomogram.

e16115 Background: In the past clinical practice of radiotherapy for liver cancer, liver regeneration (LR) which is beneficial to the prevention or recovery of radiation-induced liver injury, has not received enough attention. In current study, we aimed to build and validate multivariate model for liver regeneration after radiation therapy for hepatocellular carcinoma (HCC) based on data from 2 prospective studies. Methods: Thirty patients treated with preoperative downstaging radiotherapy were prospectively included in the training cohort, and 21 patients treated with postoperative adjuvant radiotherapy were included in the validation cohort. Liver regeneration was defined as an increase of more than 10% of normal liver volume in the areas of the protected hepatic segment or lobe, without Child-Pugh class decreased and tumor progression compared to pre-radiotherapy. Model and nomogram of liver regeneration after radiotherapy were developed and validated. The cut-off points of each optimal predictors were obtained using receiver-operating characteristic analysis. Risk stratification based on the cut-off point was conducted to compare the proportion of patients with liver regeneration between subgroups. Results: After radiotherapy, 12 (40%) cases in the training cohort and 13 (61.9%) cases in the validation cohort experienced liver regeneration. The model and nomogram of liver regeneration based on SVs20 (standard residual liver volume spared from at least 20 Gy) and alanine aminotransferase (ALT) showed good prediction performance (AUC = 0.759) in training cohort and performed well (AUC = 0.808) in the validation cohort. The risk stratification according to the cutoffs of SVs20 with 303.4 mL and ALT with 43 U/L demonstrated clear differentiation in risk of liver regeneration between the training(P = 0.049) and entire cohort (P = 0.032). The proportion of patients with liver regeneration decrease progressively with 88.9% in high-probability group (ALT＜43 U/L and SVs20＜303.4 mL), 60% in high-intermediate probability group (ALT ≥43 U/L and SVs20＜303.4 mL), 43.75% in low-intermediate probability group (ALT＜43 U/L and SVs20≥303.4 mL) and 33% in low- probability group (ALT≥43 U/L and SVs20≥303.4 mL). Conclusions: SVs20 and ALT are optimal predictors for liver regeneration. This simple-to-use nomogram is beneficial to the constraints of normal liver outside the radiotherapy target area and make prognosis-based decision without complex calculations. Clinical trial information: ChiCTR1800015350. [Table: see text]

Can Patient Triaging with Clinical Scoring Systems Reduce CT Use in Adolescents and Young Adults Suspected of Having Appendicitis?

Background There are ongoing efforts to reduce CT radiation exposure for the diagnosis of appendicitis. Recent guidelines recommend using clinical scoring systems to triage patients who need imaging examinations. Purpose To determine whether patient triaging with scoring systems can reduce CT use without a loss of diagnostic accuracy in adolescents and young adults suspected of having appendicitis. Materials and Methods This retrospective study used data from a previous multicenter randomized controlled trial conducted between December 2013 and August 2016. Five scoring systems (adult appendicitis, appendicitis inflammatory response, modified Alvarado, Broek, and Christian scores) were used to categorize patients into low-, intermediate-, or high-probability groups. CT use was simulated for only the intermediate-probability group. The primary outcomes were CT reduction rate, sensitivity, and specificity. The CT reduction rate was defined as the proportion of patients in low- and high-probability groups who would not have to undergo CT among all patients. Sensitivity and specificity were calculated in the overall diagnostic pathway using each scoring system and subsequent CT. As a secondary analysis, to maintain the diagnostic accuracy to a level of when CT was used for all patients with suspected appendicitis, new cutoff values for probability group stratification targeting 97.6% sensitivity and 94.9% specificity were applied for each of the scoring systems. Results A total of 2888 patients (mean age ± standard deviation, 28 years ± 9; 1580 women and 1308 men) with suspected appendicitis were evaluated, of whom 1088 had and 1800 did not have appendicitis. The CT reduction rates of the five scoring systems ranged from 55.6% (1606 of 2888 patients) to 71.1% (2053 of 2888), but at the cost of sensitivity (range, 48.7% [530 of 1088] to 81.2% [883 of 1088]) and specificity (range, 79.0% [1422 of 1800] to 97.8% [1761 of 1800]). Targeting 97.6% sensitivity and 94.9% specificity, the CT reduction rates of all five scoring systems were 0% (0 of 2888). Conclusion Using clinical scoring systems in triaging patients for selective CT use led to a considerable loss of diagnostic accuracy. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Mellnick in this issue.

P006 The potential of colour Doppler ultrasound in reducing temporal artery biopsies in suspected giant cell arteritis

Abstract Background/Aims Giant cell arteritis (GCA) is an emergency. The initial treatment with high dose glucocorticoids (GC) is often started on clinical suspicion without waiting for temporal artery biopsy (TAB) results. Colour Doppler ultrasound (CDUS) is a simple, non-invasive test which is readily available. However, like any other ultrasound, it is operator dependent. Non-compressible ‘halo sign’ is the most specific abnormality on CDUS. British society for Rheumatology (BSR) guidelines advises to avoid TAB in patients with low clinical probability and negative CDUS as well as in high clinical probability and positive CDUS. Methods We adopted the quality improvement methodology for assessment. Retrospective data of suspected GCA patients was collected over the last two years. CDUS was introduced to investigative plan midway, after eleven months. Two rheumatology consultants were trained in CDUS. Results were compared before and after the introduction of ultrasound as a diagnostic tool. In collecting the data, our main focus for documentation was based on clinical symptoms, CDUS and TAB results. Patient were divided into high, medium and low probability groups based on clinical assessment by a rheumatologist. Final diagnosis was decided on the basis of clinical assessment at 6 months. Results It was a retrospective review from January 2018 to November 2019, 101 patients were referred with suspected GCA. Median age was 72 years (50 - 91 years) with male to female ratio of 1:3. Thirty five patients were referred in the first 11 months and 28.6% were diagnosed with GCA. CDUS and TAB was done in 20% and 49% of patients respectively. Sixty six patients were referred in the next 12 months after CDUS was introduced and 21.2% were diagnosed as GCA. CDUS and TAB were done in 82% and 38% of the patients respectively. We reviewed all TABs in the second phase of QIP (38%). As per current BSR guideline, 8 TABs could have been avoided in patients with positive CDUS and high probability of GCA or negative CDUS and low probability of GCA. Even if we deduct these 8 TABs from total of 25, 26% of our suspected GCA referrals would still require TAB for diagnostic workup. Conclusion After the routine introduction of CDUS, the percentage of patients requiring TAB has declined. Approximately one fourth patients would still require TAB as per BSR guidelines. To improve the clinical relevance of biopsies further we recommended; the routine use of GCA probability score, improve CDUS skills and arrange availability of urgent slots in clinic for CDUS. We also noticed that the number of patients referred has almost doubled. This might be due to better education and awareness at the primary and secondary care level which was done as part of the project. Disclosure A.A. Sidhu: None. A. Nandagudi: None. A. Bharadwaj: None.

The added value of 18F-FDG PET/CT compared to 68Ga-PSMA PET/CT in patients with castration-resistant prostate cancer.

Purpose: The 68Ga-PSMA PET/CT is a commonly used imaging modality in prostate cancers. However, few studies have compared the diagnostic efficiency between 68Ga-PSMA and 18F-FDG PET/CT and evaluated whether a heterogeneous metabolic phenotype (especially PSMA-FDG+ lesions) exists in patients with castration-resistant prostate cancer (CRPC). We determined the added value of 18F-FDG PET/CT compared to 68Ga-PSMA PET/CT in CRPC patients and identified CRPC patients who may benefit from additional 18F-FDG PET/CT. Methods: Data of 56 patients with CRPC who underwent both 68Ga-PSMA and 18F-FDG PET/CT from May 2018 to February 2021 were retrospectively analysed. Patients were classified into two groups with or without PSMA-FDG+ lesions. The differences in patient characteristics between the two groups and predictors of patients who having at least one PSMA-FDG+ lesion were analysed. Results: Although both the detection rate (75.0% vs. 51.8%, P = 0.004) and positive lesion number (135 vs. 95) of 68Ga-PSMA PET/CT were higher than 18F-FDG PET/CT, there were still 13/56 (23.2%) patients with at least one PSMA-FDG+ lesion. The prostate-specific antigen (PSA) and Gleason score were both higher in the patients with PSMA-FDG+ lesions than in those without PSMA-FDG+ lesions (P = 0.04 and P<0.001, respectively). Multivariate regression analysis showed that the Gleason score (≥8) and PSA (≥7.9 ng/mL) were associated with the detection rate of patients who had PSMA-FDG+ lesions (P = 0.01 and P = 0.04, respectively). The incidences of having PSMA-FDG+ lesions in low-probability (Gleason score<8 and PSA<7.9 ng/mL), medium-probability (Gleason score≥8 and PSA<7.9 ng/mL or Gleason score<8 and PSA≥7.9 ng/mL), and high-probability (Gleason score≥8 and PSA≥7.9 ng/mL) groups were 0%, 21.7%, and 61.5%, respectively (P<0.001). Conclusion: Gleason score and PSA are significant predictors for PSMA-FDG+ lesions, and CRPC patients with high Gleason score and PSA may benefit from additional 18F-FDG PET/CT.

Does Employing a Flowchart Improve the Diagnostic Performance of Cardiac Magnetic Resonance Imaging in Left Ventricular Noncompaction?

To test the hypothesis that making a diagnosis of left ventricular noncompaction (LVNC) on cardiac magnetic resonance imaging (CMRI) using a noncompacted-to-compacted (NC/C) myocardium ratio > 2.3 would yield significant errors, and also to test a diagnostic flowchart in patients who undergo CMRI and have clinical and echocardiographic findings suggesting LVNC could improve the diagnosis of LVNC. A total of 84 patients with LVNC and 162 controls consisting of patients with other diseases and healthy participants who had CMRI and echocardiograms were selected. The diagnostic flowchart of the study involved the use of CMRI with all available sequences for patients with a high pre-test probability of LVNC. Two blinded independent cardiologists evaluated echocardiograms, and patients with suggestive echocardiographic and clinical findings for LVNC were enrolled in the high pre-test probability of LVNC group. Two independent blinded radiologists established the diagnosis of LVNC based on NC/C ratio > 2.3 on CMRI, and they were allowed to re-assess the patients following the diagnostic flowchart. An NC/C ratio > 2.3 identified 83 of 84 LVNC patients, yet incorrectly classified 48 of the 162 controls as having LVNC. Radiologists changed their decision in 23 of 48 patients with incorrect diagnoses, resulted in improved specificity (70.4% to 84.6%). The use of the CMRI diagnostic flowchart in the high pre-test probability group yielded a high specificity (97.2%) and accuracy (95.9%). LVNC diagnosed by CMRI based on the NC/C criterion can lead to overdiagnosis, whereas only using CMRI in patients with a high pre-test probability of LVNC with all available sequences may improve the diagnostic performance.

Managing patients with suspected postpartum retained products of conception using a novel sonographic classification.

Suspicion of retained products of conception (RPOC) often arises after delivery and still poses a diagnostic and management challenge. To prospectively evaluate a sonographic classification for the management of patients with suspected RPOC after delivery. Based on grayscale and Doppler ultrasound parameters, patients were classified into high, moderate, or low probability of RPOC. For the low and moderate probability groups, an ultrasound follow-up at the end of the puerperium was recommended. For the high probability group, a follow-up examination was conducted 10-14 days after the first ultrasound, and patients with persistent high probability findings were referred for surgical intervention. The sample was composed of 215 patients at risk of RPOC. Of these, 100, 93, and 22 patients were classified as having a low, moderate, or high probability of RPOC, respectively. Rates of RPOC were 55%, 2%, and 2% in the high, moderate, and low probability categories, respectively. When the categorization was based on the most recent ultrasound obtained during the puerperium, the adjusted RPOC prevalence rates were 71% in the high, 6% in the moderate, and 0% in the low probability groups. This study confirms the effectiveness of our sonographic classification for managing patients with suspected RPOC after delivery. In all three categories, it is recommended to adhere to a conservative management protocol in clinically stable women until the end of the puerperium. This approach provides good predictability for RPOC and can reduce unnecessary surgical interventions.

Stratification of Hepatocellular Carcinoma Risk Following HCV Eradication or HBV Control.

Hepatocellular carcinoma (HCC) incidence has dramatically decreased in patients infected with HCV and HBV due to the widespread use of highly effective antiviral agents. Nevertheless, a substantial proportion of patients with advanced fibrosis or cirrhosis following HCV clearance of in case of HBV control whatever the stage of fibrosis remains at risk of liver cancer development. Cancer predictors in these virus-free patients include routine parameters estimating coexisting comorbidities, persisting liver inflammation or function impairment, and results of non-invasive tests which can be easily combined into HCC risk scoring systems. The latter enables stratification according to various liver cancer incidences and allocation of patients into low, intermediate or high HCC risk probability groups. All international guidelines endorse lifelong surveillance of these patients using semi-annual ultrasound, with known sensibility issues. Refining HCC prediction in this growing population ultimately will trigger personalized management using more effective surveillance tools such as contrast-enhanced imaging techniques or circulating biomarkers while taking into account cost-effectiveness parameters.

Development and validation of a multivariable predictive model for EGFR gene mutation status in patients with lung adenocarcinoma.

Detection of epidermal growth factor receptor (EGFR) is one real dilemma owing to the non-sufficient tissue for testing EGFR mutations in lung adenocarcinoma. A model for predicting EGFR mutations would be helpful for clinical decisions in those patients. A retrospective cohort of 1,196 patients diagnosed with lung adenocarcinoma was investigated between December 1, 2017, and December 31, 2019, in Renji Hospital, Shanghai, China. All patients were tested for EGFR mutations (amplification refractory mutation system, n=1,144; next-generation sequencing, n=52). Of 1,196 patients with lung adenocarcinoma, 944 met the inclusion criteria. A nomogram model was developed based on 567 patients and validated in 377 patients. Variables associated with EGFR mutations were age, sex, smoking history, lepidic predominant subtype, solid predominant subtype, mucinous adenocarcinoma, Ki67 expression, lobulation, solid texture in radiology, and pleural retraction. The nomogram based on the model performed well in the development group (c-index 0.789, 95% CI: 0.751-0.827), and the validation group (c-index 0.809, 95% CI: 0.771-0.847). At the probability cut-point of 0.7, the diagnostic efficiency was 82.7% in patients with NGS liquid biopsy. Decision curve analysis further confirmed the clinical usefulness of the nomogram, which showed that predicting the EGFR mutations probability applying this nomogram would be better than having all patients or none patients use this nomogram. A high probability group (>0.7) by nomogram model may suggest a high possibility of EGFR mutation, if tissue is limited, NGS-based ctDNA with liquid biopsy could be implemented effectively.