Homogeneous Group Of Patients Research Articles

Preoperative Counseling in Spinal Cord Stimulation: A Designated Driver in Implantable Pulse Generator–Related Inconveniences?

BackgroundSpinal cord stimulation (SCS) has been reported to cause substantial pain relief and improved quality of life (QoL) in patients with persistent spinal pain syndrome (PSPS). Despite implantable pulse generator (IPG)-related inconveniences such as pain, shame, and discomfort affecting QoL and patient satisfaction, these are often neglected. Hence, the current study aims to determine the associations between patient satisfaction, IPG-related inconveniences, and preoperative counseling in a homogeneous group of patients with PSPS receiving SCS with IPG implantation in the gluteal or abdominal area. Materials and MethodsRetrospective data on sample characteristics were gathered from the EPIC (electronic health record software) digital patient data base. Prospective data on patient satisfaction were obtained with a questionnaire that covered various topics such as shame, pain, disturbances in daily/intense activities, night rest and/or sleep, discomfort caused by clothing, and preoperative counseling. The exact location of the IPG and its scar were determined with photo analysis. Thereafter, the site of IPG placement was classified into separate quadrants within the gluteal and abdominal area. Patient satisfaction was defined as accepting the current location of the IPG without having the wish to undergo revision surgery. ResultsIn total, 81 participants (50.9 ± 10 years) were included in this analysis, with patient satisfaction observed in 61 patients (75.3%). Among satisfied patients, more extensive preoperative counseling concerning IPG pain and discomfort was reported compared with patients who were not satisfied (p < 0.001). When comparing the two groups, significant differences were found in shame (8/81, 9.9%), IPG site pain (21/81, 25.9%), disturbance of activities (42/81, 51.9%), and clothing-related discomfort (42/81, 51.9%). ConclusionsOn the basis of the current results, shared decision-making and comprehensive preoperative provision of information are recommended to optimize patient satisfaction regarding IPG pain, discomfort, and inconveniences. Although many patients experience these disadvantages despite successful SCS for pain related to PSPS, most of them accept this if they have received adequate preoperative information about expectations.

Endotyping in ARDS: one step forward in precision medicine

BackgroundThe Berlin definition of acute respiratory distress syndrome (ARDS) includes only clinical characteristics. Understanding unique patient pathobiology may allow personalized treatment. We aimed to define and describe ARDS phenotypes/endotypes combining clinical and pathophysiologic parameters from a Canadian ARDS cohort.MethodsA cohort of adult ARDS patients from multiple sites in Calgary, Canada, had plasma cytokine levels and clinical parameters measured in the first 24 h of ICU admission. We used a latent class model (LCM) to group the patients into several ARDS subgroups and identified the features differentiating those subgroups. We then discuss the subgroup effect on 30 day mortality.ResultsThe LCM suggested three subgroups (n1 = 64, n2 = 86, and n3 = 30), and 23 out of 69 features made these subgroups distinct. The top five discriminating features were IL-8, IL-6, IL-10, TNF-a, and serum lactate. Mortality distinctively varied between subgroups. Individual clinical characteristics within the subgroup associated with mortality included mean PaO2/FiO2 ratio, pneumonia, platelet count, and bicarbonate negatively associated with mortality, while lactate, creatinine, shock, chronic kidney disease, vasopressor/ionotropic use, low GCS at admission, and sepsis were positively associated. IL-8 and Apache II were individual markers strongly associated with mortality (Area Under the Curve = 0.84).PerspectiveARDS subgrouping using biomarkers and clinical characteristics is useful for categorizing a heterogeneous condition into several homogenous patient groups. This study found three ARDS subgroups using LCM; each subgroup has a different level of mortality. This model may also apply to developing further trial design, prognostication, and treatment selection.

Endophenotypes of Primary Osteoarthritis of the Hip Joint in the Bulgarian Population over 60 Years Old.

Aim. To identify subgroups of patients with primary osteoarthritis of the hip joint (pHOA) with similar imaging and laboratory findings, disease evolution, and response to conventional therapies. Methods. We performed further statistical analyses on patient data from two published, double-blind, randomized, and placebo-controlled studies (DB-RCTs), which examined the effects of intra-articular corticosteroids (ia-CSs), hyaluronic acid (ia-HA)-KИ-109-3-0008/14.01.2014, and intravenous bisphosphonates (iv-BPs) -KИ- 109-3-0009/14.01.2014 compared to the country's standard pHOA therapy. The data span an 8-year follow-up of 700 patients with pHOA, including: 1. Clinical parameters (WOMAC-A, B, C, and T; PtGA). 2. Laboratory markers (serum calcium and phosphate levels; 25-OH-D and PTH, markers for bone sCTX-I and cartilage uCTX-II turnover). 3. Radiological indicators: X-ray stage (Kellgren-Lawrence (K/L) and model (Bombelli/OOARSI), width (mJSW), speed (JSN mm/year), and zone of maximum narrowing of the joint space (max-JSN)-determining the type of femoral head migration (FHM). 4. DXA indicators: bone geometry (HAL; NSA; and MNW); changes in regional and total bone mineral density (TH-BMD, LS-BMD, and TB-BMD). 5. Therapeutic responses (OARSI/MCII; mJSW; JSNmm/yearly) to different drug regimens (iv-BP -zoledronic acid (ZA/-5 mg/yearly for 3 years)); ia-CS 40 mg methylprednisolone acetate, twice every 6 months; and ia-HA with intermediate molecular weight (20 mg/2 mL × 3 weekly applications, two courses every 6 months) were compared to standard of care therapy (Standard of Care/SC/), namely D3-supplementation according to serum levels (20-120 ng/mL; target level of 60 ng/mL), simple analgesics (paracetamol, up to 2.0 g/24 h), and physical exercises. The abovementioned data were integrated into a non-supervised hierarchical agglomerative clustering analysis (NHACA) using Ward's linkage method and the squared Euclidean distance to identify different endophenotypes (EFs). Univariate and multivariate multinomial logistic regression analyses were performed to determine the impact of sex and FHM on clinical and radiographic regression of pHOA. Results. A baseline cluster analysis using incoming (M0) patient data identified three EFs: hypertrophic H-HOA, atrophic A-HOA, and intermediate I-HOA. These EFs had characteristics that were similar to those of patients grouped by radiographic stage and pattern ('H'-RPs, 'I'-RPs, and 'A'-RPs), p < 0.05). The repeated cluster analysis of M36 data identified four EF pHOAs: 1. Hypertrophic (slow progressors, the influence of the type of femoral head migration (FHM) outweighing the influence of sex on progression), progressing to planned total hip replacement (THR) within 5 (K/LIII) to 10 (K/LII) years. 2. Intermediate (sex is more important than the FHM type for progression) with two subgroups: 2#: male-associated (slow progressors), THR within 4 (K/LIII) to 8 years. (K/LII). 2* Female-associated (rapid progressors), THR within 3 (K/LIII) to 5 (K/LII) years. 3. Atrophic (rapid progressors; the influence of FHM type outweighs that of sex), THR within 2 (K/LIII) to 4 (K/LII) years. Each EF, in addition to the patient's individual progression rate, was also associated with a different response to the aforementioned therapies. Conclusions. Clinical endophenotyping provides guidance for a personalized approach in patients with pHOA, simultaneously assisting the creation of homogeneous patient groups necessary for conducting modern genetic and therapeutic scientific studies.

Single procedure tibialis anterior tendon shortening in combination with Achilles tendon lengthening in unilateral cerebral palsy improves swing phase dorsiflexion in gait

Purpose: Tibialis anterior tendon shortening combined with tendon Achilles lengthening showed satisfactory short- and long-term outcomes for pes equinus treatment. This retrospective study aimed to evaluate the effectiveness of a single tibialis anterior tendon shortening-tendon Achilles lengthening procedure for treating pes equinus, in a homogeneous unilateral cerebral palsy patient group. Methods: Gait analysis was conducted on 22 unilateral cerebral palsy patients (mean age at surgery = 13.3 years, standard deviation = 3 years) before and within 2.5 years (standard deviation = 0.61 years) after the tibialis anterior tendon shortening-tendon Achilles lengthening procedure. Primary outcome measures included foot drop occurrence in swing, foot dorsiflexion and the first ankle rocker presence compared to healthy reference data. Movement analysis profile and gait profile score were also calculated for the entire gait cycle. The clinical exam and the A2 peak ankle power were analyzed. Statistical analysis used the paired Wilcoxon’s sign rank test (p &lt; 0.05). Results: Post-operatively, significant improvements were observed in ankle dorsiflexion during swing (p = 0.0006) and reduced foot drop in swing (p = 0.0107). The occurrence of a first ankle rocker did not significantly change (p = 0.1489). Significant improvements in gait profile score and movement analysis profile for all joints and planes indicate overall gait quality improvement. The foot progression changed significantly (p = 0.0285), with a greater external orientation. Nineteen out of 22 patients were able to quit wearing their ankle foot orthoses. Conclusion: Tibialis anterior tendon shortening and tendon Achilles lengthening combination yielded positive outcomes, showing increased foot dorsiflexion, first ankle rocker presence, and overall improved gait quality. These findings support the effectiveness of this surgical approach for treating pes equinus in children with unilateral spastic cerebral palsy.

Extended Long-Term Outcome After Conservative Decompressive Microsurgery and Routine Adjuvant Fractionated Stereotactic Radiotherapy for Symptomatic Cavernous Sinus Meningiomas.

Cavernous sinus meningiomas (CSM) pose one of the most difficult to treat subgroup of skull base meningiomas. The purpose of this study was to evaluate the efficacy of an interdisciplinary treatment approach for symptomatic CSM which incorporated conservative function preserving microsurgery and routine adjuvant fractionated stereotactic radiotherapy (FSRT). A homogenous group of patients with symptomatic primary CSM with extracavernous extension was treated between 2005 and 2012. All patients were available for a minimum follow-up of 5 years. Clinical follow-up included detailed examination of oculomotor deficits, visual status, and endocrinologic function. Radiologic follow-up was conducted by tumor volumetry. Overall, 23 patients were included in this study (78.3% women; median age 58 years). Diplopia was the most common presenting symptom, followed by headache and visual disturbances. Surgical morbidity was low (3/23; 13%). FSRT was applied after a median of 2 months after surgery. At a median clinical follow-up of 113 months, 70.45% of the presenting symptoms had improved, 25% remained unchanged, and in 2 cases (4.54%), worsening occurred. Overall tumor regression was evident in 19/21 World Health Organization 1 and in 1/2 of World Health Organization 2 CSM, respectively, at a median radiological follow-up of 103 months. Our findings demonstrate the efficacy of an interdisciplinary treatment approach for symptomatic primary CSM with extracavernous extension with decompression of neurovascular elements followed by FSRT. Precise preoperative planning and intraoperative decision making in combination with routine postoperative radiotherapy can achieve excellent tumor control, improve neurologic function, and minimize long-term morbidity.

Phenotypes of patients with systemic sclerosis in the Chinese Han population: a cluster analysis.

Systemic sclerosis (SSc) is a heterogeneous connective tissue disease that is commonly subdivided into limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc) based on the extent of skin involvement. This subclassification may not reflect the full range of clinical phenotypic variation. This study aimed to investigate clinical features and aggregation of patients with SSc in Chinese based on SSc manifestations and organ involvements, in order to achieve precise treatment of SSc early prevention of complications. In total 287 SSc patients were included in this study. A cluster analysis was applied according to 13 clinical and serologic variables to determine subgroups of patients. Survival rates between obtained clusters and risk factors affecting prognosis were also compared. In this study, six clusters were observed: cluster 1 (n = 66) represented the skin type, with all patients showing skin thickening. In cluster 2 (n = 56), most patients had vascular and articular involvement. Cluster 3 (n = 14) individuals mostly had cardiac and pulmonary involvement. In cluster 4 (n = 52), the gastrointestinal type, 50 patients presented with stomach symptoms and 28 patients presented with esophageal symptoms. In cluster 5 (n = 50), patients barely had any major organ involvement. Cluster 6 (n = 49) included 46% of all patients presenting with renal crisis. The results of our cluster analysis study implied that limiting SSc patient subgroups to those based only on skin involvement might not capture the full heterogeneity of the disease. Organ damage and antibody profiles should be considered when identifying homogeneous patient groups with a specific prognosis. Key Points • Provides a new method of categorizing SSc patients. • Can better explain disease progression and guide subsequent treatment.

Single Versus Fractionated Gamma Knife Radiosurgery for Nonfunctioning Pituitary Adenomas Close to the Optic Pathway: A Multicenter Propensity Score Matched Study.

Gamma Knife radiosurgery (GKRS), typically administered in a single session (S-GKRS), is an effective treatment for nonfunctioning pituitary adenoma (NFPA). For lesions close to the optic pathway, the use of hypofractionated radiosurgery is growing. This study seeks to compare the results of S-GKRS vs fractionated-GKRS (F-GKRS) for NFPAs adjacent to the optic pathway. Two cohorts of patients with residual or recurrent NFPAs in contact to the optic pathway were retrospectively included in this study: (1) a group of patients who underwent a 3-day course of F-GKRS in Europe and (2) a group of patients treated with S-GKRS in the United States. A propensity score matching (ratio 1:1) was carried out to obtain and compare 2 homogeneous groups of patients with NFPA. A total of 84 patients were included for analysis (42 in the S-GKRS cohort and 42 in the F-GKRS group). The 2 cohorts did not differ for age, sex, number of previous surgical procedure, tumor volume, and follow-up. The mean follow-up was 60.2 ± 37.0 months and 62.4 ± 37.4 months for F-GKRS and S-GKRS cohort, respectively (P = .38). The overall tumor control at last follow-up was achieved in 95.2% and 92.9% of patients in F-GKRS and S-GKRS, respectively (P = .64). The 1-year, 3-year, 5-year, and 7-year progression-free survival rate after F-GKRS was 100%, 97.1%, 97.1%, and 91%, respectively. In the S-GKRS sample, progression-free survival rates were 100%, 100%, 92.5%, and 92.5% at 1, 3, 5, and 7 years after treatment, respectively. Two patients (4.7%) from the F-GKRS cohort and 2 (4.7%) from the S-GKRS cohort sustained visual worsening after radiosurgery (P = 1.0). In the management of NFPAs adjacent to the optic pathway both F-GKRS and S-GKRS had comparable outcomes and risks at 7 years. Future prospective studies including larger cohorts with longer follow-up are needed to confirm our results.

Institutional experience on the impact of glucagon-like peptide-1 agonists (GLP-1) on glycemic control and weight loss in patients with type 2 diabetes at the Dubai Diabetes Center, United Arab Emirates

AimsTo describe the effect of three classes of GLP1 analogues on HbA1c and weight over one year in a homogenous group of patients at the Dubai Diabetes Center in Dubai, United Arab Emirates. The specific objectives are to study the extent of change in HbA1c and weight loss on these medications as well as the sustainability of change over one year. MethodsA retrospective audit of patients diagnosed Type 2 diabetes receiving one of the three following GLP-1 agonists (Exenatide LA 2 mg weekly, liraglutide 1.8 mg once daily, Dulaglutide 1.5 mg) over one year and documenting changes in HbA1c and weight at 3-, 6-, 9-, and 12-months intervals. ResultsThe study shows that while there was significant reduction in HbA1c and weight in the first 3 months, this change was not clinically significant. Also, the change was not maintained at the end of the year. By the final quarter, the effect of the medication diminishes, accompanied by a partial regain of weight. ConclusionGLP1 agonists favorable initial effect on HbA1c and weight may not be sustainable beyond a certain period. The exact reason and factors contributing to this need further exploration.

DNAR-10. HETEROGENEOUS MGMT PROMOTER METHYLATION IN A MULTIFOCAL GLIOBLASTOMA: A CASE REPORT

Abstract MGMT promoter methylation status is an important predictive biomarker for treatment response in glioblastoma. MGMT unmethylated glioblastoma has elevated levels of MGMT which ultimately leads to chemoresistance. Clinicians consider the MGMT methylation status when treatment recommendations are given, and clinical trials use this marker for the selection of a homogenous group of glioblastoma patients based on prognosis. Here, we present a case of multifocal glioblastoma with heterogeneous MGMT methylation status. A 56-year-old male presented with left leg weakness for 2 months and left arm weakness for 1 month. Imaging revealed a calcified, rim enhancing right temporoparietal cystic lesion and a heterogeneously enhancing right parietal mass. Perilesional edema surrounded and connected the two lesions. The patient underwent gross total resection of the parietal mass and pathology revealed a WHO grade 4 glioblastoma, IDH wildtype, unmethylated tumor. Postoperatively, the patient was neurologically intact. He completed a 6-week long course of concomitant chemoradiation without any significant side effects. Two weeks later the patient developed rapidly worsening headaches, nausea, vomiting, dizziness, and left side weakness. Imaging revealed significant enlargement of the previously unresected temporoparietal cystic lesion with marked increase in surrounding edema and a 2-3 mm right to left midline shift. Patient underwent craniotomy with cyst drainage and tumor resection of the right cystic temporoparietal lesion, demonstrating a WHO grade 4 glioblastoma, IDH wildtype, methylated tumor. Post-operatively the patient was again neurologically intact and started adjuvant temozolomide. MGMT methylation status of glioblastoma can alter recommendations for chemotherapy with temozolomide. MGMT methylation status might vary in distinct parts of the tumor as molecular heterogeneity is a hallmark of glioblastoma. This heterogeneity should be considered by clinicians when treatments are recommended and by clinical trials for glioblastoma patients, especially when multifocal lesions have a distinct radiographic appearance.

Biventricular unloading with Impella on top of veno-arterial membrane oxygenation improves short- and long-term survival in refractory post-cardiac arrest cardiogenic shock

Abstract Background Patients with refractory post-cardiac arrest (CA) cardiogenic shock (RCS) may present with LV-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical circulatory support (MCS) with Impella or veno-arterial membrane oxygenation (vaECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge these patients in definite therapies. However, the selection of the appropriate MCS device should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Especially vaECMO patients may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery. Nowadays there is no data concerning the role of biventricular unloading with an Impella on top of a vaECMO in the homogenous group of post-CA RCS. Purpose To report our experience from the combined use of Impella (2.5 and CP) on top of a vaECMO in the homogenous group of patients with post-CA RCS. Methods Single center study of consecutive patients with biventricular unloading with Impella after initial vaECMO support over a 6-year period suffering from post-CA RCS. Propensity scoring matching analysis was used to account for the differences in baseline data between the two groups. Results A total of 91 patients underwent vaECMO support for RCS, whereas in another 32 patients initial vaECMO support was escalated with an Impella (75% CP) (BiVent group). Mean age was 60.88 ± 9.8 and 98 (80%) patients were male. Survival rates were similar in both groups (hospital survival: BiVent 40.6% and vaECMO 33%, p=0.52; 12-month survival BiVent 37.5% and vaECMO 31.9%, p=0.67). After adjustment for baseline difference with propensity scoring matching analysis, survival rates were significantly better in the BiVent group (hospital and 12-month survival: BiVent 50% and vaECMO 17%, p=0.03 (Figure 1). Vasopressor doses and lactate levels decreased significantly more firmly in the BiVent group within 72 h on biventricular support compared to vaECMO (p&amp;lt;0.05). Moreover, the patients in the BiVent group demonstrated a greater functional recovery of the LV at 96 hours after admission compared to vaECMO patients (Figure 2). Conclusions Impella on top of vaECMO improves short- and long-term survival in patients with post-cardiac arrest refractory cardiogenic shock leading to a better restoration of the left ventricle and end organ function.

Comorbidity patterns and health-related outcomes in older adults with atrial fibrillation: nationwide population-based findings from swedish national patient register

Abstract Background Older individuals with atrial fibrillation (AF) often present with multiple comorbidities that might challenge their clinical management and worsen the prognosis. Identifying homogenous groups of individuals within similar patterns of comorbidities and health trajectories could potentially facilitate a better integrated care targeting patient-centred needs in AF management. Purpose To characterize the comorbidity patterns and to explore their prognostic value in health outcomes among older adults with AF. Methods We used population-wide registry data from the Swedish National Patient Register and identified individuals ≥65 years old by 1 January 2017 with AF diagnosis during the period 1 January 2012 - 1 January 2017. Chronic diseases were grouped into 60 clinically relevant disease categories coded by the International Classification of Diseases 10th revision. We performed latent class analysis (LCA) to identify homogeneous groups of AF patients with similar underlying comorbidity patterns. Two measures, disease exclusivity ≥25% and an observed/expected ratio ≥2, were applied to determine the overexpressed diseases in each class. Cox regression models (adjusted by age, sex, education, income, civil status, polypharmacy, vitamin K antagonists, direct oral anticoagulants, antiplatelets, and antiarrhythmics) were fitted to investigate the association between comorbidity patterns and clinical outcomes including two-year risk of all-cause and cardiovascular (CV) mortality, stroke, major bleedings, all-cause and CV hospitalization. Results A total of 203,042 AF individuals (mean age 79.6 [7.9] years, 45% female) were included. Seven classes were identified based on the optimal output of LCA (Figure 1), i.e., unspecific pattern (39.3%), metabolic disease (12.3%), complex comorbidity (11.7%), neuropsychiatric disease (11.0%), CV disease (10.6%), musculoskeletal disease (9.0%) and eye disease (6.2%). Compared with patients showing an unspecific comorbidity pattern, patients with complex comorbidity had the highest increased risk of all-cause mortality (hazard ratio, HR 2.02, 95% confidence, 95%CI 1.96-2.08), CV mortality (HR 2.31, 95%CI 2.20-2.41), all-cause hospitalization (HR 2.45, 95%CI 2.40-2.50), CV hospitalization (HR 2.68, 95%CI 2.60-2.77), and bleedings (HR 1.55, 95%CI 1.40-1.72); patients within the neuropsychiatric disease pattern had the highest increased risk of stroke (HR 1.44, 95%CI 1.30-1.59); and patients within the musculoskeletal disease pattern had reduced risk of all-cause and CV mortality (HR 0.70, 95%CI 0.66-0.74; HR 0.67, 95%CI 0.62-0.74, respectively) and increased risk of all-cause and CV hospitalization (HR 1.37, 95%CI 1.34-1.41; HR 1.19, 95%CI 1.14-1.25, respectively). Conclusions The characterization of comorbidity patterns may help to improve clinical outcomes by targeting patient-centred needs among multimorbid older patients with AF.

Abstract 190: Patient Selection for Intracranial Stenting: Impact on Clinical Outcomes and Procedural Success Rates

Introduction Intracranial atherosclerosis (ICAS) is a leading global cause of stroke. The role of intracranial stenting in ICAS remains uncertain. In the SAMMPRIS trial, patients who had experienced recent TIA/CVA secondary to 70‐99% ICAS demonstrated an increased risk of recurrent stroke when treated with angioplasty and stenting compared to medical therapy alone [1]. The VISSIT trial found an increased 12‐month risk of TIA/CVA in the same territory, as well as an increased 30‐day risk of any TIA/CVA, when a stenting was used in patients with ICAS [2]. Additionally, the recent CASSISS trial demonstrated that adding percutaneous transluminal angioplasty and stenting (PTAS) to medical therapy did not significantly affect the risk of stroke or death within 30 days or stroke beyond 30 days through 1 year in patients TIA/CVA secondary to symptomatic ICAS [3]. However, the WEAVE trial demonstrated that using the Wingspan stent for ICAS resulted in a low periprocedural complication rate and excellent safety profile [4]. Subsequently, the WOVEN study provided a 1‐year follow‐up to WEAVE. It presented a more homogeneous patient group than in prior studies, and demonstrated a relatively low 8.5% 1‐year rate of stroke and death in stented patients [5]. Currently underway, the Angioplasty and Stenting for Patients With Symptomatic Intracranial Atherosclerosis Clinical trial (NCT02689037) aims to determine whether PTAS combined with medical treatment is superior to medical treatment alone in preventing stroke and death events in patients with symptomatic ICAS [6]. The purpose of this case series is to provide an overview of the procedural and clinical outcomes of patients who underwent stenting for symptomatic ICAS. Methods We reviewed a database of all interventional procedures conducted at our institution to identify patients who underwent intracranial stenting from 2013 and 2022 for symptomatic ICAS. Electronic medical records were assessed, and data on patient demographics, comorbidities, lesion characteristics, and clinical outcomes were extracted. The outcomes of interest included successful stent placement, restoration of blood flow, procedural complications, symptomatic improvement, change in NIHSS, and mortality and stroke within one year. Descriptive statistics were used, summarizing continuous variables as means and standard deviations, and categorical variables as frequencies and ranges. Results Between 2013 and 2022, 35 patients underwent intracranial stenting for symptomatic ICAS. Procedurally, all patients had successful stent placement and restoration of blood flow. Six patients (17.1%) experienced perioperative complications including stent occlusion, bradycardia, and hematoma. Regarding clinical outcomes, 25 patients (71.4%) showed improvement in their TIA/CVA symptoms, including dizziness, weakness, and speech difficulties. Furthermore, 21 patients (60%) had improved NIHSS scores by discharge, 9 patients (25.7%) remained stable, and 4 patients (11.4%) deteriorated. One unrelated mortality was recorded at 1‐year post‐procedure. Conclusion This case series demonstrates the successful and effective restoration of distal blood flow through intracranial stenting for symptomatic ICAS. The low rates of perioperative complications and potential improvements in patients' clinical outcomes suggest the need for further investigation into the patient selection, safety, and effectiveness of intracranial stenting for managing symptomatic ICAS.

The Evolving Landscape: Exploring the Future of Myelodysplastic Syndrome Treatment with Dr. Rami Komrokji.

This perspective delves into the evolving landscape of Myelodysplastic Syndrome (MDS) treatment. MDS presents a significant clinical challenge, often progressing to acute myeloid leukemia. For low-risk MDS, the emphasis is on personalized care through comprehensive risk assessment, clinical monitoring, and tailored interventions, including promising agents like erythropoiesis-stimulating agents, lenalidomide, and luspatercept, with the anticipation of an expanding therapeutic arsenal and early intervention for improved outcomes. In contrast, high-risk MDS treatment is evolving towards upfront doublet or triplet therapies with a focus on minimal residual disease (MRD) monitoring. A holistic approach integrates various modalities, including stem cell transplant and post-transplant maintenance, all guided by individual patient circumstances. Risk-adapted strategies are crucial for enhancing patient outcomes. Precision medicine for MDS treatment is budding, largely driven by Next Generation Sequencing (NGS). NGS aids in early diagnosis, prognostication, and the targeting of specific mutations, with molecular data increasingly informing treatment responses and allowing for tailored interventions. Clinical trials within homogeneous patient groups with similar molecular profiles are becoming more common, enhancing treatment precision. In conclusion, the future of MDS treatment is moving towards personalized medicine, leveraging advanced technologies like NGS and molecular insights to improve outcomes in the realm of hematological malignancies.

New ACR/EULAR 2022 classification criteria for ANCA-associated vasculitis

The new 2022 classification criteria for antineutrophil cytoplasmic antibodies associated vasculitis (AAV), proposed by the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR), was an important stage in the development of the doctrine of systemic vasculitis. Based on the analysis of large international cohorts, the criteria for granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis were revised, and classification criteria for microscopic polyangiitis were proposed for the first time. The creation’s history of the AAV classification criteria is discussed over the past three decades, and their limitations are considered. It should be noted, the ACR/EULAR 2022 criteria were developed for creating homogeneous groups of patients for scientific studies and cannot be widely used in clinical practice for the various AAV nosological forms diagnosis, primarily at early stage of the disease or mono organ damage (for example, kidneys). As before, decisive importance in AVV diagnostic belong to a detailed clinical analysis and a complete examination of patients to identify pathognomonic symptoms, including asymptomatic ones.

The Effect of Neoadjuvant Therapy on Esophagectomy for cT2N0M0 Esophageal Adenocarcinoma.

For cT2N0M0 esophageal adenocarcinomas, the effects of neoadjuvant chemoradiotherapy (NT) on surgical outcomes and the oncological benefits to the patients are debatable. In this study, we investigated the optimal management for cT2N0M0 adenocarcinoma (1) assessing the perioperative impact of NT on esophagectomy and (2) evaluating the oncologic effect of NT in a homogeneous group of patients with clinical stage IIA. We hypothesized that NT does not negatively affect perioperative outcomes and provides an oncologic benefit to selected patients with cT2N0M0 disease. The National Cancer Database was queried (2010-2019) for patients with cT2N0M0 esophageal adenocarcinoma undergoing esophagectomy. After propensity-matching to adjust for differences in patient and tumor characteristics, we compared postoperative outcomes (logistic regression) and survival (Kaplan-Meier and Cox regression) among those who underwent NT vs upfront surgery (S). This study included 3413 patients, of whom 2359 (69%) received NT, and 1054 (31%) S. In contrast to those who underwent S, in the matched cohort, patients treated with NT had comparable conversion rates (8% vs11.1%, p = 0.06), length of stay (9 vs 10 days, p = 0.078), unplanned readmission (5.4% vs 8.8%, p = 0.109), and 30- (3.9% vs 3.7%, p = 0.90) and 90-day mortality (5.7% vs 4.7%, p = 0.599). In addition, NT associated with improved survival in patients with cT2N0M0 tumors > 5 cm (HR 0.30, 95% CI 0.17-0.36). NT does not appear to increase technical complexity or to adversely affect postoperative outcomes after esophagectomy. Furthermore, minimally invasive esophagectomy is feasible following NT, with comparable conversion rates to those who had upfront surgery. Lastly, NT was selectively associated with improved survival in patients with cT2N0M0 esophageal cancer.

Characterising diabetes in Kazakhstan: a cluster analysis

Abstract Background Diabetes is a global pandemic, affecting 537 million adults worldwide in 2021. Diabetes is much more complex than the classification into type 1 diabetes and type 2 diabetes suggests. We aimed to identify homogeneous groups of patients with diabetes based on routinely collected measurements using unsupervised, data-driven cluster analysis. Methods We analyzed the data from Electronic Medical Records of 558 patients with newly diagnosed diabetes from 4 outpatient clinics in Astana. We performed a k-means cluster analysis of 9 routinely measured variables using the KMeans function (iterations=3 million) from the Scikit-Learn Python library. Results Cluster 1, consisting of 176 (31,5%) patients, was defined by late-onset diabetes, relatively low blood pressure (BP) and body mass index (BMI), moderate metabolic derangements, and comparably low glomerular filtration rate (GFR). The 83 (14,9%) patients in cluster 2 were characterized by a late manifestation of diabetes, high BP and BMI, relatively poor glycemic control, moderate dyslipidemia, and comparably low GFR. Cluster 3, including 98 (17,6%) patients, was represented by a low age at onset, comparably low BP and BMI, moderately poor glycemic and lipid controls, and high GFR. The 110 (19,7%) patients in cluster 4 had late-onset diabetes, high BP and BMI, subcompensated diabetes, poor lipid control, and relatively low GFR. Cluster 5, which involved 91 (16,3%) patients, was characterized by comparably low BP and BMI, poor glycemic control, modest dyslipidemia, and high GFR. Conclusions We intend to continue the project for further conducting a prospective study with dynamic monitoring of study participants, tracking specific patterns in the development of diabetic complications in each cluster. The results of this work will contribute to the development of a model for identifying patients with an initially predictable course of diabetes and a high risk of its complications at the time of diagnosis. Key messages • We identified five clusters of patients with diabetes with clinically significant characteristics in each cluster. • Identification of subgroups of patients with an initially predictable course can be useful for recognizing those at highest risk of complications and applying personalized treatment strategies.

Identification of shared disease marker genes and underlying mechanisms between major depression and rheumatoid arthritis

Both depression and rheumatoid arthritis (RA) have a very high comorbidity rate. A bilateral association is estimated to increase the mutual risk and the common denominator is inflammation being observed in both diseases. Previous studies have mainly focused on assessing peripheral blood's inflammatory and pro-inflammatory cytokines levels.We aimed to extend insights into the molecular mechanisms of depression based on hub RA genes. To do so, we prioritized RA-related genes using in-silico tools. We then investigated whether RA-related genes undergo altered expression in patients with unipolar and bipolar depression without a concurrent RA diagnosis and any exponents of active inflammation. In addition, we selected a homogeneous group of patients treated with lithium (Li), which has immunomodulatory properties.The study was performed on patients with bipolar depression (BD, n = 45; Li, n = 20), unipolar depression (UD, n = 27), and healthy controls (HC, n = 22) of both sexes. To identify DEGs in peripheral blood mononuclear cells (PBMCs), we used the SurePrint G3 Microarray and GeneSpring software.We selected a list of 180 hub genes whose altered expression we analyzed using the expression microarray results. In the entire study group, we identified altered expression of 93 of the 180 genes, including 35 down-regulated (OPRM1 gene with highest FC > 3) and 58 up-regulated (TLR4 gene with highest FC > 3). In UD patients, we observed maximally up-regulated expression of the TEK gene (FC > 3), and in BD of the CXCL8 gene (FC > 5). On the other hand, in lithium-treated patients, the gene with the most reduced expression was the TRPV1 gene.The study proved that depression and RA are produced by a partially shared “inflammatory interactome” in which the opioid and angiogenesis pathways are important.

Relationship of End Expiratory Lung Volume, Compliance, and Plateau Pressure in Acute Respiratory Distress Syndrome.

COVID-19 ARDS (acute respiratory distress syndrome), caused by SARS-CoV-2,involves a decrease in the end expiratory lung volume (EELV), compliance, and hypoxemia. The authors retrospectively analysed the relationship between the EELV, Plateau pressure (Pplat), and compliance of the respiratory system in a group of 21 mechanically ventilated COVID ARDS patients with moderate to severe hypoxia who were subjected to a recruitment manoeuvre. Further, these parameters were studied after dividing them into two groups as Group 1 of clinically non-recruitable and Group 2 of clinically recruitable patients.There was relationship between EELV, compliance, and Pplat among those patients who were clinically recruited versus those who were not in a homogeneous group of COVID ARDS patients. In Group 1, the statistical value of EELV and compliance were r = 0.395, p>0.05, EELV and Pplat were r = 0.021, p>0.05, and compliance and Pplat were r = -0.848, p<0.001. In Group 2, the statistical values of EELV and compliance were (r = 0.605, p<0.001), EELV and Pplat were r = -0.391, p<0.05, compliance and Pplat were r = -0.848, p<0.001. The additional information gained after understanding this relationship can help to optimise ventilator settings. Key Words: COVID, ARDS, End expiratory lung volume, Plateau pressure, Compliance, Recruitment, Ventilation.

Metalloproteinase-2 in failed back surgery syndrome caused by epidural fibrosis: can it play a role in persistent pain?

Failed Back Surgery Syndrome (FBSS) occurs in 10-40% of patients treated surgically due to disk herniation (DH). There are several factors that can cause a predisposition to FBSS, but the exact pathomechanism has not been elucidated. The aim of this study was to investigate Metalloproteinase-2 (MMP-2) and Tissue Inhibitor of Metalloproteinase-2 (TIMP-2) activities in a homogeneous group of FBSS patients with epidural fibrosis in comparison to its activity in patients with surgically treated DH. DH, FBSS, and control (CG) groups consisted of 30 subjects. The patients were assessed clinically by the Numerical Rating Scale (NRS), McGill Pain Questionnaire (SF -MPQ), Oswestry Disability Index (ODI), and Beck Depression Inventory (BDI). Serum concentrations of MMP-2 and TIMP-2 were measured by using the immunoenzymatic method. There was a significantly higher MMP-2 expression (medians: 4797.49 vs. 2656.65; p < 0.0001) and TIMP-2 concentration (medians: 166.40 vs. 109.60; p < 0.0001) in the DH compared to the CG. Significantly higher MMP-2 expression (4219.95 vs. 2656.65; p < 0.0001) and TIMP-2 concentration (medians: 150.17 vs. 109.60; p = 0.0003) were also found in the FBSS compared to the CG. The activity of MMP-2, measured as MMP-2/TIMP-2, did not significantly change between the DH, FBSS, and CG. MMP2 expression (p < 0.0001) and TIMP-2 concentration (p < 0.0001) were significantly higher in the DH than FBSS. Results indicate the presence of a contribution of MMP-2 and TIMP-2 in DH and FBSS. Unchanged activity of MMP-2 can indicate an insufficiency in the MMP-2 repair system in both diseases. Lower MMP-2 expression and TIMP-2 concentration in the FBSS group can reflect the chronicity of the process.

P21.06.A TIME IN ONCOLOGY. GLIOBLASTOMA REAL-WORLD DATA

Abstract BACKGROUND Time is a crucial component in all diagnostic and therapeutic processes of cancer. Retard in the treatment can have adverse consequences on outcomes. Total treatment delays could be due to patient interval (from the first perceived symptom to the first medical consultation) and system interval (from the first medical consultation to end of treatment). To minimize delays, it is essential to know the time intervals elapsed between each of the steps in the diagnostic and the treatment phase.The purpose of this pilot study is to holistically analyze the total treatment interval of cancer patients as a part of process-oriented total quality management with the ultimate intention of having more useful information for benchmarking and making decisions to improve time in oncology. MATERIAL AND METHODS During 2019 in a context of public health-care system all relevant clinical pathway time data from the patient’s perceived first symptom until the end of oncological treatment were collected in a prospective cohort of newly diagnosed glioblastoma patients. Clinical pathway is defined as a description of the current practice in an homogeneous patient group treated by a multidisciplinary team and an inventory of actions defining a diagnostic and therapeutic sequence. This cohort was compared with a serie of glioblastoma patients treated in 2020 (COVID-19-year). We analyzed the mean, median and quartile data of 16-time intervals represented on a time scale RESULTS From January 1 to December 31, 2019, we collected data from 59 patients diagnosed and treated for a glioblastoma. There were 24 women and 35 men with a mean age of 60,9 years. We collected 1062 time-points. This group was compared with a COVID-19-year cohort of 49 patients (14 women and 35 men with a mean age of 61,7 years and 630 time-points). The median patient interval time and the system interval time were 6 days (0-210) vs 5 (0-150) and 240 days (81-363) vs 255 (120-482) respectively. Median time from surgery to the start of adjuvancy was 34 days (19-56) vs 34 (17-108). No differences were found in any of the intervals analyzed, in the overall treatment time of radiotherapy or in the dose intensity of chemotherapy. CONCLUSION The routine measurement of the intervals between the different diagnostic and therapeutic actions is essential to monitor the time of clinical processes in terms of quality and benchmarking. It is also essential to standardize in a holistic way the distressing temporality in oncology.