Stereoselective Synthesis of Either Exo- or Endo-3-Azabicyclo[3.1.0]hexane-6-carboxylates by Dirhodium(II)-Catalyzed Cyclopropanation with Ethyl Diazoacetate under Low Catalyst Loadings

Although cyclopropanation with donor/acceptor carbenes can be conducted under low catalyst loadings (<0.001 mol %), such low loading has not been generally effective for other classes of carbenes such as acceptor carbenes. In this current study, we demonstrate that ethyl diazoacetate can be effectively used in the cyclopropanation of N-Boc-2,5-dihydropyrrole with dirhodium(II) catalyst loadings of 0.005 mol %. By appropriate choice of catalyst and hydrolysis conditions, either the exo- or endo-3-azabicyclo[3.1.0]hexanes can be formed cleanly with high levels of diastereoselectivity with no chromatographic purification.

Last twenty-years activity of cardiovascular tissue banking in Barcelona

The Barcelona Tissue Bank was established from the merge of two previous multi-tissue banks. Potential donors are screened by Donor Center staff and multi-tissue retrieval is performed by specialized own teams. Tissue processing and preservation is performed in clean room facilities by specialised personnel. After quality control of both donor and all tissues results, the heart valves and vascular segments are stored until medical request. The aim of this report is to present the cardiovascular tissue activity and retrospectively evaluate the outcomes of the changes performed in last 20 years. Cardiovascular tissue from 4088 donors was received, specifically 3115 hearts and 2095 vascular segments were processed and evaluated. A total of 48% of the aortic valves, 68% of the pulmonary valves and 75% of the vascular segments were suitable for transplant. The main reason for discarding tissue was macroscopic morphology followed by microbiological results, for both valves and arteries. Altogether, 4360 tissues were distributed for transplantation: 2032 (47%) vascular segments, 1545 (35%) pulmonary valves and 781 (18%) aortic valves. The most common indication for aortic valve surgery was the treatment of endocarditis, while for pulmonary valves, it was congenital malformation reconstruction. Vascular segments were mainly used for reconstruction after ischemia. During this period, a number of changes were made with the goal of enhancing tissue quality, safety and efficacy. These improvements were achieved through the use of a new antibiotic cocktail, increasing of donor age criteria and changing the microbiological control strategy.

Mancha3D Code: Multipurpose Advanced Nonideal MHD Code for High-Resolution Simulations in Astrophysics

The Mancha3D code is a versatile tool for numerical simulations of magnetohydrodynamic (MHD) processes in solar/stellar atmospheres. The code includes nonideal physics derived from plasma partial ionization, a realistic equation of state and radiative transfer, which allows performing high-quality realistic simulations of magnetoconvection, as well as idealized simulations of particular processes, such as wave propagation, instabilities or energetic events. The paper summarizes the equations and methods used in the Mancha3D (Multifluid (-purpose -physics -dimensional) Advanced Non-ideal MHD Code for High resolution simulations in Astrophysics 3D) code. It also describes its numerical stability and parallel performance and efficiency. The code is based on a finite difference discretization and a memory-saving Runge-Kutta (RK) scheme. It handles nonideal effects through super-time-stepping and Hall diffusion schemes, and takes into account thermal conduction by solving an additional hyperbolic equation for the heat flux. The code is easily configurable to perform different kinds of simulations. Several examples of the code usage are given. It is demonstrated that splitting variables into equilibrium and perturbation parts is essential for simulations of wave propagation in a static background. A perfectly matched layer (PML) boundary condition built into the code greatly facilitates a nonreflective open boundary implementation. Spatial filtering is an important numerical remedy to eliminate grid-size perturbations enhancing the code stability. Parallel performance analysis reveals that the code is strongly memory bound, which is a natural consequence of the numerical techniques used, such as split variables and PML boundary conditions. Both strong and weak scalings show adequate performance up to several thousands of processors (CPUs).

Radiotherapy for Metastatic Spinal Cord Compression with Increased Doses: Final Results of the RAMSES-01 Trial

PURPOSE/OBJECTIVE(S)

To investigate the outcomes of precision-radiotherapy (RT) with 15 × 2.633 Gy (EQD2 = 41.6 Gy for tumor cell kill, α/β = 10 Gy) or 18 × 2.333 Gy (EQD2 = 43.2 Gy) in patients with metastatic spinal cord compression (MSCC) and favorable survival prognoses (>35 points on a validated survival score). In addition, these patients were compared to a historical control group of patients with favorable prognoses treated with 10 × 3 Gy (EQD2 = 32.5 Gy).

MATERIALS/METHODS

In a multi-center phase 2 study (RAMSES-01), patients with MSCC and favorable survival prognoses receiving 15 × 2.633 Gy or 18 × 2.333 Gy of precision-RT alone (no upfront surgery) were mainly evaluated for local progression-free survival (LPFS), defined as no deterioration of motor function during RT and no in-field recurrence of MSCC following RT, at 12 months (primary endpoint). Secondary endpoints included improvement of motor and sensory functions, post-RT ambulatory status, relief of pain and distress, toxicity, and survival (OS). The maximum relative doses allowed to the spinal cord were 101.5 % of the prescribed dose for 18 × 2.333 Gy and 101.2% for 15 × 2.633 Gy, respectively (both representing an EQD2 of 46.6 Gy for myelopathy, α/β = 2 Gy). In addition, the RAMSES-cohort was compared to a historical control group (N = 266) irradiated with 10 × 3 Gy (propensity score adjusted Cox regression).

RESULTS

In the RAMSES-cohort, 50 (of 62 planned) patients were evaluable for LPFS and included in the analyses. Since OS was worse than expected, a new survival score was developed, which was more precise in predicting OS than a previous tool. As a consequence, the RAMSES-trial, which was based on the previous score, was terminated. In the 50 patients included so far, 12-month rates of LPFS and OS were 97.6% and 69.9%, respectively. Improvement of motor function occurred in 28 patients (56.0%), and 47 patients (94.0%) were ambulatory following RT. Within 3 months following RT, 12 of 21 patients (57.2%) with pre-RT sensory deficits improved, 38 of 45 patients (84.4%) with pre-RT pain experienced at least partial relief, and 39 of 50 patients (78.0%) reported relief of distress. Ten of 50 patients (20.0%) experienced grade 2 toxicities (mainly esophagitis/dysphagia) and another two patients (4.0%) grade 3 toxicities (1 diarrhea, 1 esophagitis). After propensity score adjustment, the RAMSES-cohort showed significantly better LPFS than the control group (hazard ratio = 0.125, 95% confidence interval = 0.016 - 0.962, p = 0.046) and a strong trend regarding improvement of motor function (hazard ratio = 1.943, 95% confidence interval = 0.981 - 3.850, p = 0.057). Post-RT ambulatory rates (p = 0.56) and OS rates (p = 0.62) were not significantly different.

CONCLUSION

Precision-RT with 15 × 2.633 Gy or 18 × 2.333 Gy was sufficiently well tolerated and resulted in significantly better long-term LPFS than 10 × 3 Gy in patients with MSCC and favorable survival prognoses. Thus, the dose-fractionation regimens of the RAMSES-01 trial appear preferable for these patients.

Blood component requirements in liver transplantation: effect of 2 thromboelastometry-guided strategies for bolus fibrinogen infusion-the TROMBOFIB randomized trial

BACKGROUND

A low plasma fibrinogen level influences blood component transfusion. Thromboelastometry provides clinical guidance for fibrinogen replacement in liver transplantation (LT).

OBJECTIVES

We hypothesized that infusions of fibrinogen concentrate to reach an A10_FibTem value of 11 mm during LT could reduce red blood cell (RBC) and other component and fluid requirements in comparison to standard care.

METHODS

This randomized, blinded, multicenter trial in 3 hospitals enrolled 189 LT-scheduled patients allocated to an intervention target (A10_FibTem, 11 mm) or a standard target (A10_FibTem, 8 mm); 176 patients underwent LT with fibrinogen replacement. Data were analyzed by intention-to-treat (intervention group, 91; control group, 85). Blood was extracted, and fibrinogen kits were prepared to bring each patient's fibrinogen level to the assigned target at the start of LT, after portal vein clamping, and after graft reperfusion. The main outcome was the proportion of patients requiring RBC transfusion during LT or within 24 hours.

RESULTS

The proportion of patients requiring RBCs did not differ between the groups: intervention, 74.7% (95% CI, 65.5%-83.3%); control, 72.9% (95% CI, 62.2%-82.0%); absolute difference, 1.8% (95% CI, -11.1% to 14.78%) (P = .922). Thrombotic events occurred in 4% of the patients in both groups; reoperation and retransplantation rates and mortality did not differ. Nearly 70% of the patients in both groups required fibrinogen concentrate to reach the target. Using an 11-mm A10_FibTem target increased the maximum clot firmness without affecting safety. However, this change provided no clinical benefits.

CONCLUSION

The similar low plasma fibrinogen concentrations could explain the lack of significant between-group outcomes.

Short term Neuropsychiatric and Body Weight Changes in Patients Switching from EVG/Cobi/FTC/TAF to BIC/FTC/TAF (PreEC/RIS69)

BACKGROUND

NP, clinical and laboratory changes have been reported in patients switching from EVG/Cobi/FTC/TAF to BIC/FTC/TAF in clinical practice.

METHODS

A group of subjects switching from EVG/Cobi/FTC/TAF to BIC/F/TAF was prospectively followed. A validated sleep quality questionnaire (Pittsburgh Sleep Quality Index), as well as the Hospital Anxiety and Depression Scale (HADS), were administered after 4 weeks from treatment switch. Adverse events, side effects and discontinuation, were recorded at week 4 and 24. Pre-treatment switch and week 24 body weight and laboratory data were compared.

RESULTS

A total of 96 virologically suppressed patients (86% male) were included. All patients received EVG/Cobi/FTC/TAF at least 1 year before the treatment switch. Median (IQR) nadir CD4 was 367 (263). The most common comorbidities were dyslipidemia, HTA and diabetes, 26%; 14% and 7%, respectively. Depression was reported by 8%. Five patients discontinued BIC/FTC/TAF before week 4 due to intolerance (2 insomnia, 1 headache and 2 GI symptoms). No changes in sleep quality, anxiety and depression outcomes were observed at week 4 (p=0.1, p=0.1 and p=0.3, respectively). After 6 months, median body weight change was statistically significant (0.6 kg, p=0.003). All patients maintained HIV suppression.

CONCLUSIONS

Except in few cases, sleep quality, anxiety and depression symptoms remain stable in HIV virologically suppressed patients on EVG/Cobi/FTC/TAF who switch to BIC/F/TAF. NPAEs are mild and tend to occur in those with previous neuropsychiatric symptoms. Weight gain tends to be small but statistically significant. Long-term follow-up in "real life" cohorts would be needed to confirm these findings.

Changes of CD3+CD56+ γδ T cell number and apoptosis during hospital admission are related to mortality in septic patients

Immunoparalysis and apoptosis of T cells are serious problems for the evolution of septic patients. We aimed to relate changes in the number of αβ and γδ T cells during hospital stay to the poor evolution of sepsis. In this prospective study, we recruited a total of 92 septic patients from the Emergency and Intensive Care Departments of two Hospitals, according to the latest criteria for the definition and management of sepsis. According to the severity of the septic process, there was a progressive decrease in T cells, being much more intense in γδ T cells. This decrease recovered in surviving patients, but CD3+CD56+ γδ T cells continued to decreased during hospital stay in non-surviving patients. Apoptosis increased in sepsis. Cell death of CD3+CD56+ γδ T cells progressively increased according to the severity of sepsis, especially in non-surviving patients.

Evaluation of adverse outcomes in patients with Troponinemia without significant coronary artery disease; a proposal application of the ACTION-ICU Score

Purpose

Elevated troponin in absence of significant coronary artery disease is a frequent situation that is associated with increased mortality. Criteria to estimate complications in these patients are not defined. The aim of this study was to evaluate the predictive capacity of the ACTION-ICU score, a scale designed to predict likelihood of complication requiring ICU care for patients with NSTEMI, to define risk of complications in patients with elevated troponin without significant coronary artery disease.

Methods

A retrospective study of patients with elevated troponin and no significant coronary artery disease were selected to apply the ACTION-ICU Score to predict likelihood of complications. Complications were defined as cardiac arrest development, shock, high-grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. ROC Curves were created to determine the predictive power.

Results

1221 patients were screened, of them 181 presented elevated troponin without significant coronary artery disease; age median 65 year (IQR 56–75 years), female 48,1%. Of 181 patients, 73.5% were admitted to ICU based on physician criteria. Only 13.3% of patients presented a complication. A score greater than 5 was present in 33.7% of the patients, of which 5,5% presented a complication. ROC to predict complications was 0,75 (95% CI: 0,65–0,86). Best cut off point was &gt;6 points, sensitivity 70.83%, specificity 72.08%, LR+ 2.54, LR− 0.4.

Conclusions

In patients with elevated troponin and no significant coronary artery disease, the ACTION-ICU Score was a predictive scale for the development of complications with adequate accuracy. The best cut-off point for this classification in patients with elevated troponin in absence of significant coronary artery disease was &gt;6.

Funding Acknowledgement

Type of funding sources: None. ROC Curve of ACTION-ICU score &gt;6 points

Histological and molecular characterization of human aortic stenosis: a matter of sex

Introduction

Aortic stenosis (AS) is the most common heart valve disease and it is strongly prevalent with elderly. AS is a progressive, degenerative disease associated with fibrosis and calcification of the valve leaflets. Surgical valve replacement is the only treatment available. Molecular, cellular and interstitial events activate multifactorial and complex cues with a significant contribution by valve interstitial cells (VICs). Despite male sex is a risk factor for developing AS, there is scant information on sex-specific differences in aortic valve (AV) biology or pathology.

Purpose

The aim of our study was to analyse sex-specific differences in aortic valves from AS patients.

Methods

185 patients with severe AS undergoing surgical valve replacement were recruited. 149 AVs (66 women; 83 men) were used for ex vivo analyses. Human VICs were isolated from 36 AVs (12 women; 24 men) for in vitro experiments. AVs structure were evaluated by haematoxylin-eosin, Movat, Alizarin Red, Congo red and Alcian blue/Sirius Red staining and immunohistochemistry. Western blot, ELISA and zymography were used for molecular biology studies.

Results

AVs from men presented increased inflammatory infiltrates (CD68 and CD45 positive cells) as compared to women. Complementarily, AVs from men exhibited higher levels of the inflammatory molecules interleukin (IL)-6 and IL-1b and RANTES. In line with these results, oxidative stress markers (eNOS, myeloperoxidase, malondialdehyde and nitrotyrosine) were upregulated in male AVs. Concerning, fibrosis, increased levels of collagen type I, fibronectin and syndecan-1 were found in AVs from men. Extracellular matrix (ECM) remodelling was characterized by reduced metalloproteinase-1 expression and increased tissue inhibitor of metalloproteinase-2 expression in male AVs. Importantly, calcification and osteogenic markers (bone morphogenetic protein-9, periostin, osteocalcin and Sox-9) was greatly enhanced in men AVs as compared to women. These findings were confirmed in isolated VICs. At baseline, male VICs presented higher myofibroblast-like phenotype than female VICs. In line with our ex vivo results, male VICs exhibited increased inflammatory, oxidative stress, fibrotic and osteogenic differentiation markers.

Conclusions

Our results suggest that the mechanisms driving the AV pathogenesis could be different in men and women patients with the same AS severity. Male AVs and isolated VICs presented more inflammation, oxidative stress, fibrosis and ECM remodelling including extensive calcification as compared to female. A better knowledge of the pathophysiological pathways in AVs and VICs will allow developing sex-specific options for AS treatment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III

Soares S. P–787 Impact of delaying ART to promote weight loss: a large multicentre study accounting for the combined effect of female/male age and body mass index (BMI)

Study question

Is postponing the start of ART (to promote a reduction in female BMI) beneficial for cumulative live birth rates (CLBR) when accounting for the female/male ageing this delay will cause?

Summary answer

Postponing ART treatment in one year to promote female weight loss could be detrimental in women of advanced maternal age (AMA, &gt;35 years-old).

What is known already

Overweight/obese couples are frequently encouraged to lose weight prior to infertility treatment to enhance ART outcomes. However, a meaningful weight loss is often difficult to achieve for these couples, frequently taking at least one year to accomplish. Given that both female and male ageing are also important for ART success, we were interested in understanding the combined impact on CLBR of BMI reduction and ageing following a one-year delay.

Study design, size, duration

A retrospective study including patients performing their first ART cycle using autologous gametes between 2013–2018 in one of 39 participating ART centres. Only GnRH antagonist cycles were included (n = 14260). CLBR was the primary outcome. Secondary outcomes included time-to-pregnancy, birthweight and gestational age.

Participants/materials, setting, methods

Patients were subdivided according to female BMI (Kg/m2) in either underweight (&lt;18.5), normal-weight (18.5–24.9), overweight (BMI 25.0–29.9 kg/m2) and obese (≥30 kg/m2). Meaningful and extreme weight loss were defined as a reduction from obesity to either overweight or normal-weight, respectively. We performed multivariable regression analysis to account for potential confounding.

Main results and the role of chance

Overweight (36.8%) and obese (33.0%) women had significantly lower CLBR when compared to the underweight (42.6%) and normal-weight (41.4%). When assessing the confounder-adjusted net-effect of male/female age and BMI, the predicted benefit of promoting a meaningful BMI reduction was lower than the estimated hindrance due to male/female ageing as soon as women reached AMA (n = 8365, 58.6%). This absence of benefit was especially important in women &gt;38 years-old, in which even extreme weight-loss did not compensate for the age-related reduction in CLBR caused by the one-year delay. Moreover, male weight-loss failed to provide any additional benefit when accounted for in the regression models. Finally, obesity was also associated with a modest but statistically significant one-month delay in time-to-pregnancy and a 96.1 g (95% confidence interval: 39.9–152.4) increase in birth weight. The diagram of predicted outcomes presented in this study may serve as a useful tool to counsel patients before treatment, namely when recommending treatment postponement to promote short-term (i.e. 3–6 months) or long-term (i.e. 1 year) weight loss.

Limitations, reasons for caution

Caution is recommended when extrapolating these results into everyday practice owing to the retrospective nature of the study and the fact that only GnRH antagonist cycles were included.

Wider implications of the findings: Patients are frequently confronted with the dilemma to either postpone treatment (and promote weight loss) or start treatment immediately (to avoid further ageing). Our results seem to show that women in AMA may have hindered CLBR if recommended to delay treatment even if the desired weight loss is ultimately achieved.

Trial registration number

Not applicable