US Military Healthcare Professionals' Practice, Knowledge, and Misconceptions About Concussion

OBJECTIVE

To determine the US military healthcare professionals' knowledge and training preferences to improve diagnosis and management of concussion sustained in nondeployed settings.

PARTICIPANTS

US military healthcare professionals (physicians, physician assistants, and nurse practitioners) completed online surveys to investigate practices, knowledge, and attitudes about concussion diagnosis and treatment, as well as preferences on future training. There were 744 responses from active duty US military healthcare providers, all of whom had cared for at least one patient with mild traumatic brain injury (mTBI) in the previous 24 months.

RESULTS

The majority of physicians reported they were confident in their ability to evaluate a patient for a new mTBI (82.1%) and order appropriate imaging for mTBI (78.3%). Accuracy of identifying "red flag" symptoms ranged between 28.2% and 92.6%. A Likert scale from 1 ("not at all confident") to 4 ("very confident") was used to assess providers' confidence in their ability to perform services for patients with mTBI. With respect to barriers to optimal patient care, nurse practitioners consistently reported highest levels of barriers (90.8%).

CONCLUSIONS

Although US military providers regularly care for patients with concussion, many report experiencing barriers to providing care, low confidence in basic skills, and inadequate training to diagnose and manage these patients. Customized provider education based on branch of service and occupation, and broader dissemination and utilization of decision support tools or practice guidelines, and patient information tool kits could help improve concussion care.

A universal tool for stability predictions of biotherapeutics, vaccines and in vitro diagnostic products

It is of particular interest for biopharmaceutical companies developing and distributing fragile biomolecules to warrant the stability and activity of their products during long-term storage and shipment. In accordance with quality by design principles, advanced kinetic modeling (AKM) has been successfully used to predict long-term product shelf-life and relies on data from short-term accelerated stability studies that are used to generate Arrhenius-based kinetic models that can, in turn, be exploited for stability forecasts. The AKM methodology was evaluated through a cross-company perspective on stability modeling for key stability indicating attributes of different types of biotherapeutics, vaccines and biomolecules combined in in vitro diagnostic kits. It is demonstrated that stability predictions up to 3 years for products maintained under recommended storage conditions (2-8 °C) or for products that have experienced temperature excursions outside the cold-chain show excellent agreement with experimental real-time data, thus confirming AKM as a universal and reliable tool for stability predictions for a wide range of product types.

Uncommon Manifestation of Oligometastatic Prostate Cancer: Sister Mary Joseph Nodule

ABSTRACT

A 76-year-old man with a history of prostate cancer diagnosed in 2008 developed biochemical recurrence in 2010 and started intermittent androgen deprivation therapy. In 2021, due to rising prostate-specific antigen, an 18 F-piflufolastat PSMA PET/CT was performed. It showed a radiotracer-avid sclerotic lesion in the right iliac bone and an indeterminate radiotracer-avid nodule in the umbilical region, demonstrating progressive enlargement and increased uptake on subsequent imaging. Pathologic analysis of the umbilical nodule revealed metastatic prostate cancer-a finding eponymically referred to as a Sister Mary Joseph nodule.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Baseline Findings of PreventE4: A Double-Blind Placebo Controlled Clinical Trial Testing High Dose DHA in APOE4 Carriers before the Onset of Dementia

INTRODUCTION

Lower blood levels of the omega-3 polyunsaturated fatty acid docosahexaenoic acid (DHA) are correlated with worse cognitive functions, particularly among APOE ε4 carriers. Whether DHA supplementation in APOE ε4 carriers with limited DHA consumption and dementia risk factors can delay or slow down disease progression when started before the onset of clinical dementia is not known.

METHODS

PreventE4 is a double-blind, single site, randomized, placebo-controlled trial in cognitively unimpaired individuals with limited omega-3 consumption and dementia risk factors (n=368). Its objectives are to determine (1) whether carrying the APOE ε4 allele is associated with lower delivery of DHA to the brain; and (2) whether high dose DHA supplementation affects brain imaging biomarkers of AD and cognitive function.

RESULTS

365 cognitively unimpaired individuals between 55 and 80 (mean age 66) were randomized to 2 grams of DHA per day or identically appearing placebo for a period of 2 years. Half the participants were asked to complete lumbar punctures at baseline and 6-month visits to obtain cerebrospinal fluid (CSF). The primary trial outcome measure is the change in CSF DHA to arachidonic acid ratio after 6 months of the intervention (n=181). Secondary trial outcomes include the change in functional and structural connectivity using resting state functional MRI at 24 months (n=365). Exploratory outcomes include the change in Repeatable Battery of the Assessment of Neuropsychological Status at 24 months (n=365).

CONCLUSIONS

Findings from PreventE4 will clarify the brain delivery of DHA in individuals carrying the APOE ε4 allele with implications for dementia prevention strategies. Trial was registered as NCT03613844.

2045. IVAC Plus in the Time of COVID-19: An Imperfect Metric?

Background

Prior to the COVID-19 pandemic, the incidence of infection related ventilator associated complications plus possible ventilator associated pneumonias (IVAC+) was decreasing; however, as the number of COVID-19 hospitalizations increased, so did the number of IVAC+. Our goal was to investigate if there was a relationship between these two occurrences.

Methods

This was a retrospective study at the Audie Murphy VA Hospital (ALMVA) from October 2017 to December 2021. ALMVA is a level 1A facility with 232 beds and an active bone marrow transplant program in San Antonio, Texas. This study included acute care COVID-19 hospitalizations per 10,000 bed days of care and IVAC+ per 1000 ventilator days. Monthly acute and intensive care COVID-19 hospitalization rates were correlated with IVAC+ rates using Pearson correlation for the overall study period and in the subgroup of COVID pandemic months (Mar 2020-December 2021).

Results

During the overall study period, COVID-19 hospitalization rates were significantly associated with IVAC+ rates: acute care correlation 0.86 (p&lt; 0.01) and intensive care correlation 0.33 (p=0.04). During the COVID-19 pandemic months, acute care COVID-19 hospitalizations but not intensive care COVID-19 hospitalizations, were correlated with IVAC+ (correlation 0.90, p&lt; 0.01 and correlation 0.21, p=0.53, respectively). There were 0 IVAC+ before the pandemic months and this rose to 14 during (0 per 1000 ventilator days and 3.05 per 1000 ventilator days, respectively). All but 2 cases of IVAC+ had COVID-19.

COVID-19 Hospitalizations and IVAC Plus, October 2017 to December 2021

A sharp increase in COVID-19 hospitalizations correlated with a rise in patients meeting criteria for IVAC Plus.

Conclusion

The natural history of COVID-19 disease has presented challenges for IVAC+ monitoring. COVID-19 can cause persistent fevers and worsening oxygenation, and antibiotic use is common during periods of clinical deterioration. These factors can fulfill criteria for IVAC+. In this study, each IVAC+ case was traced for safety bundle compliance. These bundles were followed, along with conservative fluid management, low tidal volume ventilation, and sedation breaks. Patients met NHSN criteria for IVAC+ despite these measures and most had COVID-19. Given the common occurrence of IVAC+ in COVID-19 patients, futures studies are needed to define if IVAC+ are preventable in this population and whether IVAC+ surveillance has any value among COVID-19 patients.

Disclosures

All Authors: No reported disclosures.

Barriers and Challenges for Career Milestones Among Faculty Mentees

'Critical' career milestones for faculty (e.g., tenure, securing grant funding) relate to career advancement, job satisfaction, service/leadership, scholarship/research, clinical or teaching activities, professionalism, compensation, and work-life balance. However, barriers and challenges to these milestones encountered by junior faculty have been inadequately studied, particularly those affecting underrepresented minorities in science (URM-S). Additionally, little is known about how barriers and challenges to career milestones have changed during the COVID-19 pandemic for URM-S and non-URM faculty mentees in science. In this study, we conducted semi-structured interviews with 31 faculty mentees from four academic institutions (located in New Mexico, Arizona, Idaho, and Hawaii), including 22 URM-S (women or racial/ethnic). Respondents were given examples of 'critical' career milestones and were asked to identify and discuss barriers and challenges that they have encountered or expect to encounter while working toward achieving these milestones. We performed thematic descriptive analysis using NVivo software in an iterative, team-based process. Our preliminary analysis identified five key themes that illustrate barriers and challenges encountered: Job and career development, Discrimination and a lack of workplace diversity; Lack of interpersonal relationships and inadequate social support at the workplace; Personal and family matters; and Unique COVID-19-related issues. COVID-19 barriers and challenges were related to online curriculum creation and administration, interpersonal relationship development, inadequate training/service/conference opportunities, and disruptions in childcare and schooling. Although COVID-19 helped create new barriers and challenges for junior faculty mentees, traditional barriers and challenges for 'critical' career milestones continue to be reported among our respondents. URM-S respondents also identified discrimination and diversity-related barriers and challenges. Subsequent interviews will focus on 12-month and 24-month follow-ups and provide additional insight into the unique challenges and barriers to 'critical' career milestones that URM and non-URM faculty in science have encountered during the unique historical context of the COVID-19 pandemic.

V-018 PREOPERATIVE OPTIMIZATION AND POSTERIOR COMPONENT SEPARATION WITH INTRAOPERATIVE MONITORING OF RECTUS MUSCLE INERVATION FOR LOSS OF DOMAIN INCISIONAL HERNIA

Aim

The importance of an appropriate patient optimization (botulin toxin and pneumoperitoneum) and adequate surgical technique is highlighted.The possibility of intraoperative monitoring of the nerves that may be injured during posterior component separation is explained

Material and methods

We present a 74 years old man, past smoker, with history of hypertension, steatohepatitis and chronic bronchopathy

Results

This is a disastrous but unfortunately not so uncommon story of a failed repair of a simple umbilical hernia with 3 previous unsuccessful attempts of repair with and without mesh. After the last surgery the patient developed a giant incisional hernia with loss of domain. Optimization consisted of improving nutritional status, respiratory physiotherapy, botulin toxin and pneumoperitoneum. The surgery was made using previous skin scar. After dissecting the retrorectus space, a posterior component separation was made with the aid of monitoring the nerves that come to innervate the rectus abdominis. An overextended overlapped was obtained. A patch of absorbable mesh was used to completely close the peritoneum. A combination of absorbable and permanent synthetic mesh was used as giant reinforcement of the visceral sac. The only points of fixation were the Cooper Ligaments. The patient had a satisfactory recovery without complications and was discharged on the 8th postoperative day.

Conclusions

Loss of domain incisional hernias is a real surgical challenge. The combination of a good preoperative strategy (preoperative neumoperitoneum) and surgical technique (TAR and pannniculectomy) gives a great opportunity to solve very complex cases of incisional hernia.

V-007 LESSONS LEARNED DURING THE ABDOMINAL WALL RECONSUTRCTION FOR A MULTIRECURRENT LUMBAR HERNIA AFTER BONE GRAFT HARVESTING

The best approach for lateral incisional hernia is not known. Among these difficult hernias, those arising from iliac crest harvesting can be particularly challenging. The objective of this video is to illustrate the surgical approach of a multirecurrent case with the need of adding a posterior component separation

A 70 years old woman with 2 previous attempts of repair was referred to our center. With the patient in a 45 degrees lateral decubitus, a posterior lumbar approach was initiated through the previous scar. The retromuscular preperitoneal plane was accessed with difficulty due to previous meshes in the subdiaphragmatic, iliac and posterior areas. A big tear on the medial peritoneum changed our plan to add a posterior component separation. As we did not want to enlarge the lumbar incision to denervate more the lateral abdominal wall, we decided to make an accessory midline incision. Probably, an ETEP approach could have been better even before making the posterior incision. Once the retromuscular plane was dissected, the hole in the peritoneum could be closed. The reconstructive phase consisted in making a taco configuration using the combination of a permanent and absorbable mesh.

We have learned from this case, that an eTEP dissection of the retromuscular plane could have helped to avoid the accessory midline incision. It is also important to consider the potential iatrogenic denervation we could add in case of enlargement of the incision.

Severe smallness as predictor of adverse perinatal outcome in suspected late small-for-gestational-age fetuses: systematic review and meta-analysis

OBJECTIVE

To investigate the performance of severe smallness in the prediction of adverse perinatal outcome among fetuses with suspected late-onset small-for-gestational age (SGA).

METHODS

A systematic search was performed to identify relevant studies in PubMed, Web of Science and Scopus. Late-onset SGA was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 10^th percentile diagnosed at or after 32 weeks' gestation, while severe SGA was defined as EFW or AC < 3^rd percentile or < 2 SD. Random-effects modeling was used to generate hierarchical summary receiver-operating-characteristics (HSROC) curves. The performance of severe SGA (as a presumptive diagnosis) in predicting adverse perinatal outcome among singleton pregnancies with suspected late-onset SGA was expressed as area under the HSROC curve (AUC), sensitivity, specificity and positive/negative likelihood ratios. The association between suspected severe SGA and adverse perinatal outcome was also assessed by random-effects modeling using the Mantel-Haenszel method and presented as odds ratio (OR). The non-exposed group was defined as non-severe SGA (EFW ≥ 3^rd centile).

RESULTS

Twelve cohort studies were included in this systematic review and meta-analysis. The studies included a total of 3639 fetuses with suspected late-onset SGA, of which 1246 had suspected severe SGA. Significant associations were found between suspected severe SGA and composite adverse perinatal outcome (OR, 1.97 (95% CI, 1.33-2.92)), neonatal intensive care unit admission (OR, 2.87 (95% CI, 1.84-4.47)) and perinatal death (OR, 4.26 (95% CI, 1.07-16.93)). However, summary ROC curves showed limited performance of suspected severe SGA in predicting perinatal outcomes, with AUCs of 60.9%, 66.9%, 53.6%, 57.2%, 54.6% and 64.9% for composite adverse perinatal outcome, neonatal intensive care unit admission, neonatal acidosis, Cesarean section for intrapartum fetal compromise, low Apgar score and perinatal death, respectively.

CONCLUSION

Although suspected severe SGA was associated with a higher risk of perinatal complications, it performed poorly as a standalone parameter in predicting adverse perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome

Despite its increasing recognition and extensive research, there is no unifying hypothesis on the pathophysiology of the postural tachycardia syndrome. In this cross-sectional study, we examined the role of fear conditioning and its association with tachycardia and cerebral hypoperfusion upon standing in 28 patients with postural tachycardia syndrome (31 ± 12 years old, 25 women) and 21 matched controls. We found that patients had higher somatic vigilance (p = 0.0167) and more anxiety (p < 0.0001). They also had a more pronounced anticipatory tachycardia right before assuming the upright position in a tilt-table test (p = 0.015), a physiologic indicator of fear conditioning to orthostasis. While standing, patients had faster heart rate (p < 0.001), higher plasma catecholamine levels (p = 0.020), lower end-tidal CO2 (p = 0.005), and reduced middle cerebral artery blood flow velocity (p = 0.002). Multi-linear logistic regression modeling showed that both epinephrine secretion and excessive somatic vigilance predicted the magnitude of the tachycardia and the hyperventilation. These findings suggest that the postural tachycardia syndrome is a functional psychogenic disorder in which standing may acquire a frightful quality, so that even when experienced alone, it elicits a fearful conditioned response. Heightened somatic anxiety is associated with and may predispose to a fear-conditioned hyperadrenergic state when standing. Our results have therapeutic implications.

Repurposed major urinary protein pheromones and adult sensory neurons: roles in neuron plasticity and experimental diabetes

Major urinary proteins (MUPs), members of the broader lipocalin protein family, are classified as pheromones that are excreted in male rodent urine to define conspecific territoriality. In screening for differentially regulated mRNA transcripts in a mouse model of type 1 experimental diabetes mellitus (DM), we identified an unexpected upregulation of several closely related MUP transcripts within diabetic sensory dorsal root ganglia (DRG). Both sexes expressed overall MUP protein content as identified by an antibody widely targeting these upregulated family members, and immunohistochemistry identified expression within neurons, satellite glial cells, and Schwann cells. In dissociated adult sensory neurons, knockdown by an siRNA targeting upregulated MUP mRNAs, enhanced neurite outgrowth, indicating a growth-suppressive role, an impact that was synergistic with subnanomolar insulin neuronal signaling. While MUP knockdown did not generate rises in insulin signaling transcripts, the protein did bind to several mitochondrial and glial targets in DRG lysates. Analysis of a protein closely related to MUPs but that is expressed in humans, lipocalin-2, also suppressed growth, but its impact was unrelated to insulin. In a model of chronic type 1 DM, MUP siRNA knockdown improved electrophysiological and behavioral abnormalities of experimental neuropathy. MUPs have actions beyond pheromone signaling in rodents that involve suppression of growth plasticity of sensory neurons. Its hitherto unanticipated actions overlap with those of lipocalin-2 and may identify a common and widely mediated impact on neuron growth properties by members of the lipocalin family. Knockdown of MUP supports the trophic actions of insulin as a strategy that may improve features of type 1 experimental diabetic neuropathy.NEW & NOTEWORTHY New molecular mechanisms are important to unravel and understand diabetic polyneuropathy, a disorder prevalent in over half of persons with diabetes mellitus (DM). MUPs, members of the lipocalin family of molecules, have an unexpected impact on the plasticity of sensory neurons that are targeted in type 1 experimental diabetic neuropathy. This work explores this potential target in neuropathy in the context of the lipocalin family of molecules.

Newly updated activity results of alrizomadlin (APG-115), a novel MDM2/p53 inhibitor, plus pembrolizumab: Phase 2 study in adults and children with various solid tumors

9517

Background: Alrizomadlin restores TP53 function, activating p53-mediated apoptosis in tumor cells with wild-type TP53 and/or MDM2 amplification. Alrizomadlin also functions as a host immunomodulator and may restore antitumor activity in pts with cancers that progressed on PD-1/PD-L1 inhibitors. Methods: This US/Australian multicenter trial evaluated alrizomadlin, an investigational MDM2-selective, small-molecule inhibitor, combined with pembrolizumab, in pts with unresectable/metastatic melanoma that progressed on I-O drugs; pts with malignant peripheral nerve sheath tumor (MPNST), well-differentiated/dedifferentiated liposarcoma, non-small cell lung cancer (NSCLC), or solid tumors with ATM mutations that progressed on available standard therapy; or pts for whom therapy was unavailable. Eligible pts had ECOG performance status of 0-2 and, if present, stable brain metastases. Alrizomadlin 150 mg PO was administered QOD for 2 consecutive weeks, with 1 week off, and pembrolizumab 200 mg IV over 30 minutes on Day 1 of a 21-day cycle. Results: As of November 3, 2021, preliminary and interim results are reported for 130 pts in 6 cohorts: melanoma (n = 44), NSCLC (n = 26), ATM mutation (n = 18), liposarcoma (n = 17), urothelial (n = 13), and MPNST (n = 12). In the melanoma cohort, confirmed ORR by RECIST, (PR + CR) was 13% (2 CRs + 3 PRs/38 efficacy evaluable [EE] pts). In cutaneous and uveal melanoma subcohorts, confirmed ORR was 24% (2 CRs + 2 PRs/17 EE pts) and 9% (1 PR/11 EE pts), respectively. In the MPNST cohort, the clinical benefit rate, defined by confirmed ORR + SD of > 4 cycles, was 40% (4 SDs/10 EE pts). Additional confirmed PRs were reported in NSCLC, urothelial, and liposarcoma cohorts (1 each). Common treatment (alrizomadlin or pembrolizumab)-related adverse events (TRAEs; ≥ 10%) were nausea (62%), thrombocytopenia (39%), vomiting (38%), fatigue (38%), decreased appetite (29%), diarrhea (25%), neutropenia (15%), and anemia (12%). Grade 3+ TRAEs (≥ 5%) included thrombocytopenia (23%), neutropenia (10%), and anemia (7%). A total of 16 pts discontinued treatment due to AEs; 6 were treatment related, including grade 4 thrombocytopenia (n = 3), grade 2 vomiting (n = 1), grade 2 fatigue (n = 1), and grade 2 posterior reversible encephalopathy syndrome (PRES; n = 1). A total of 10 pts reported treatment-related SAEs: 1 each of abdominal pain, asthenia, colitis, febrile neutropenia, hypophysitis, peripheral edema, overdose, PRES, pulmonary embolism, pyrexia, and thrombocytopenia. Conclusions: Alrizomadlin, combined with pembrolizumab, is well tolerated and demonstrates preliminary antitumor activity in multiple tumor types and may restore antitumor effects in pts with cancer resistant or intolerant to I-O drugs. Internal study identifiers: APG-115-US-002; Keynote MK-3475-B66. Clinical trial information: NCT03611868.

Creating a Digital Psychoeducation Programme for bipolar disorder in the COVID-19 pandemic

Introduction

The Covid-19 pandemic profoundly affected delivery and accessibility of mental health care services at a time when most needed. The OPTIMA Mood Disorder Service, a specialist bipolar disorder service, adapted group psychoeducation programme for delivery on-line.

Objectives

We report the feasibility of creating a digital psychoeducation programme.

Methods

The OPTIMA ten session group psychoeducation programme was converted into a ‘Digital’ intervention using video-conferencing. Sessions offered a range of key topics, derived from the initial Barcelona Group Psychoeducation Programme. At the time of writing, OPTIMA had fully completed two 10 session digital courses.

Results

A total of 12 people (6 in each group) consented to be part of a service evaluation of the digital groups. Just over half of the participants were women (7/12; 58.3%) and one identified as being non-binary (8.3); remaining participants were men. Age of participants ranged from 25 years to 65 years (Mean=42.3; SD=13.1). Data showed a high level of engagement (77%) All participants reported some improvement with a mean Bipolar Self-Efficacy scale (BPSES) post-group score of 105.6 (SD=14.8). At group level, this change was not statistically significant (F (1, 15) = 0.71, p=0.41). At an individual level, two out of five showed a reliable change index >1.96.

Conclusions

Delivering a ‘digital’ group psychoeducation programme was possible due to careful planning and programme development. There was good uptake from service users suggesting it is a feasible approach with preliminary evidence of clinical benefit.

Disclosure

No significant relationships.

Transdiagnostic Role of Glutamate and White Matter Damage in Neuropsychiatric Disorders: A Systematic Review

Introduction

Neuropsychiatric disorders including Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder (MDD), Bipolar Disorder (BD), and Schizophrenia (SZ) have been considered distinct categories of diseases despite their overlapping characteristics and symptomatology.

Objectives

We aimed to provide an in-depth review elucidating the role of glutamate/Glx and white matter (WM) abnormalities from a transdiagnostic perspective.

Methods

The PubMed online database was searched for studies published between 2010 and 2021. After careful screening, 399 studies were included.

Results

The findings point to decreased levels of glutamate in the Anterior Cingulate Cortex in both SZ and BD, whereas Glx is elevated in the Hippocampus in SZ and MDD. With regard to WM abnormalities, the Corpus Callosum and superior Longitudinal Fascicle were the most consistently identified brain regions showing decreased fractional anisotropy (FA) across all the reviewed disorders, except GAD. Additionally, the Uncinate Fasciculus was found to be affected in all the reviewed disorders, except OCD. Decreased FA was also found in the inferior Longitudinal Fasciculus, inferior Fronto-Occipital Fasciculus, Thalamic Radiation, and Corona Radiata in SZ, BD, and MDD. Decreased FA in the Fornix and Corticospinal Tract were found in BD and SZ patients. The Cingulum and Anterior Limb of Internal Capsule exhibited decreased FA in MDD and SZ patients.

Conclusions

The results suggest a gradual increase in severity from GAD to SZ defined by the number of brain regions with WM abnormality which may be partially caused by abnormal glutamate levels. WM damage could thus be considered a potential marker of some of the main neuropsychiatric disorders.

Disclosure

No significant relationships.

Three-dimensional control of layer by layer thin films via laser modification

A novel modification to the traditional layer by layer process that adds three-dimensional control to the technique is introduced. In this modification to the process, the substrate is irradiated with laser light during the polycation and/or polyanion dipping cycles. An array of PAH/PCBS polymer thin films were fabricated using the laser modified approach with varied bilayer numbers, laser powers, and laser irradiation times. The modification was conducted with a semiconductor laser with powers from 1.1 to 5.5 W at 450 nm. Surface profilometry results show a change in height of more than 500 nm for a 55 bilayer PAH/PCBS thin film. For 25 bilayer films, the addition of laser modification during the PAH cycle leads to a reduction in absorbance of up to 54% compared to the areas not being irradiated. The absorbance at 365 nm associated with PCBS shows a nonlinear relationship with bilayer number, in contrast to the usual linear relationship between absorbance and bilayer without laser irradiation. By adjusting irradiation time, irradiation power, number of bilayers, and the location of irradiation, a variety of structures with controlled thicknesses can be fabricated.

MO610: A Graphene-Based Bioactive Compound Reduces Adipogenesis and Increases Lipolysis Via Integrin-Beta1 Interaction: A New Therapeutical Approach Against Obesity

BACKGROUND AND AIMS

Type 2 diabetes and obesity are metabolic disorders related to kidney risk and associated with white adipose tissue (WAT) hypertrophy, which is based in a pro-adipogenic transdifferentiation of the adipocytes and their precursors’ stem cells present in WAT. Several transcription factors are key regulators during this transdifferentiation. The consequence is that adipocytes’ size increases due to the excessive storage of triglycerides (TG) inside the cells. Therapeutic strategies for reducing WAT size may be based in the capacity of increasing lipolysis and reducing adipogenesis. We have previously demonstrated the implication of the extracellular matrix (ECM) mediator integrin beta 1 (INTB1) and intracellular mediation of actin cytoskeleton during obesity (Hatem-Vaquero. J Endocrinol 2017; Cell Physiol Biochem 2020). Here, we demonstrate for the first time the antiobesogenic properties of a new highly biocompatible and bioactive graphene-based product named BioGraph (Llorens-Gámez M. Int J Biol Macromol 2020; Salesa B. Biomedicines 2021), which physicochemical interaction with INTB1 give a great potential as a diagnostic and bioactive therapeutic tool.

METHOD

Pluripotent c3h10t1/2 cells were differentiated into adipocytes using a specific culture medium. After 7 days of differentiation, the adipocytes were treated for 24 h with a suspension of the graphene derivative BioGraph, developed, registered and patented by Graphenano Medical Care S.L. To determine viability and toxicity on adipocytes, trypan blue and MTT labeling techniques were used. The levels of intracellular TG contained in the lipid droplets were determined by fluorescent labeling with AdipoRed. PPARgamma, CEBP and INTB1 mRNA levels were determined by RT-qPCR. Actin polymerization in the cytoskeleton was quantified by fluorescent phalloidin staining. Active INTB1 quantification (phosphorylated isoform at thr788/9) and total and active lipase HSL (phosphorylated isoform at ser660) were performed by western blot.

RESULTS

BioGraph is safe and non-toxic on adipocytes in a two-order concentration range. The TG content is reduced in a dose-dependent manner. Adipogenesis markers PPARgamma and CEBP and actin polymerization were reduced after treatment with an intermediate dose. The expression of INTB1 was not modified, but its phosphorylation was increased rapidly after treatment. Lipolysis-main enzyme HSL expression and activity were increased 24 h after treatment.

CONCLUSION

BioGraph is biocompatible and bioactive on adipocytes. A rapid modulation of INTB1 produces the depolymerization of the cytoskeleton, the reduction of intracellular TG content and the expression of adipogenesis markers, while HSL-mediated lipolysis is increased. We demonstrate for the first time the mechanism followed by a graphene-based material modulating the adipocyte phenotype and behavior. BioGraph may be considered a new anti-obesogenic agent.

mTOR Inhibition with Sirolimus in Multiple System Atrophy: A Randomized, Double-Blind, Placebo-Controlled Futility Trial and 1-Year Biomarker Longitudinal Analysis

BACKGROUND

Multiple system atrophy (MSA) is a fatal neurodegenerative disease characterized by the aggregation of α-synuclein in glia and neurons. Sirolimus (rapamycin) is an mTOR inhibitor that promotes α-synuclein autophagy and reduces its associated neurotoxicity in preclinical models.

OBJECTIVE

To investigate the efficacy and safety of sirolimus in patients with MSA using a futility design. We also analyzed 1-year biomarker trajectories in the trial participants.

METHODS

Randomized, double-blind, parallel group, placebo-controlled clinical trial at the New York University of patients with probable MSA randomly assigned (3:1) to sirolimus (2-6 mg daily) for 48 weeks or placebo. Primary endpoint was change in the Unified MSA Rating Scale (UMSARS) total score from baseline to 48 weeks. (ClinicalTrials.gov NCT03589976).

RESULTS

The trial was stopped after a pre-planned interim analysis met futility criteria. Between August 15, 2018 and November 15, 2020, 54 participants were screened, and 47 enrolled and randomly assigned (35 sirolimus, 12 placebo). Of those randomized, 34 were included in the intention-to-treat analysis. There was no difference in change from baseline to week 48 between the sirolimus and placebo in UMSARS total score (mean difference, 2.66; 95% CI, -7.35-6.91; P = 0.648). There was no difference in UMSARS-1 and UMSARS-2 scores either. UMSARS scores changes were similar to those reported in natural history studies. Neuroimaging and blood biomarker results were similar in the sirolimus and placebo groups. Adverse events were more frequent with sirolimus. Analysis of 1-year biomarker trajectories in all participants showed that increases in blood neurofilament light chain (NfL) and reductions in whole brain volume correlated best with UMSARS progression.

CONCLUSIONS

Sirolimus for 48 weeks was futile to slow the progression of MSA and had no effect on biomarkers compared to placebo. One-year change in blood NfL and whole brain atrophy are promising biomarkers of disease progression for future clinical trials. © 2022 International Parkinson and Movement Disorder Society.

A blood atlas of COVID-19 defines hallmarks of disease severity and specificity

Treatment of severe COVID-19 is currently limited by clinical heterogeneity and incomplete description of specific immune biomarkers. We present here a comprehensive multi-omic blood atlas for patients with varying COVID-19 severity in an integrated comparison with influenza and sepsis patients versus healthy volunteers. We identify immune signatures and correlates of host response. Hallmarks of disease severity involved cells, their inflammatory mediators and networks, including progenitor cells and specific myeloid and lymphocyte subsets, features of the immune repertoire, acute phase response, metabolism, and coagulation. Persisting immune activation involving AP-1/p38MAPK was a specific feature of COVID-19. The plasma proteome enabled sub-phenotyping into patient clusters, predictive of severity and outcome. Systems-based integrative analyses including tensor and matrix decomposition of all modalities revealed feature groupings linked with severity and specificity compared to influenza and sepsis. Our approach and blood atlas will support future drug development, clinical trial design, and personalized medicine approaches for COVID-19.

Continuously updated forecasting of SARS-CoV-2 in a regional health system

OBJECTIVES

To build a model of local hospital utilization resulting from SARS-CoV-2 and to continuously update it with new data.

STUDY DESIGN

Retrospective analysis of real performance resulting from a model deployed in a major regional health system.

METHODS

Using hospitalization data from the Kaiser Permanente Mid-Atlantic States integrated care system during the period from March 10, 2020, through December 31, 2020, and a custom-developed genetic particle filtering algorithm, we modeled the SARS-CoV-2 outbreak in the mid-Atlantic region. This model produced weekly forecasts of COVID-19-related hospital admissions, which we then compared with actual hospital admissions over the same period.

RESULTS

We found that the model was able to accurately capture the data-generating process (weekly mean absolute percentage error, 10.0%-48.8%; Anderson-Darling P value of .97 when comparing percentiles of observed admissions with the uniform distribution) once the effects of social distancing could be accurately measured in mid-April. We also found that our estimates of key parameters, including the reproductive rate, were consistent with consensus literature estimates.

CONCLUSIONS

The genetic particle filtering algorithm that we have proposed is effective at modeling hospitalizations due to SARS-CoV-2. The methods used by our model can be reproduced by any major health care system for the purposes of resource planning, staffing, and population care management to create an effective forecasting regimen at scale.

Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014-2017

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) has reported downward trends in life expectancy and racial/ethnic differences between 2014 and 2017.

OBJECTIVE

To determine the life expectancy of the Kaiser Permanente Mid-Atlantic States (KPMAS) insured population as compared to the CDC National Vital Statistics data from 2014 to 2017. We also aimed to highlight the utilization of membership data to inform population statistical estimates such as life expectancy. We examine whether national trends in life expectancy are reflected in an insured population with relatively uniform access to care.

METHODS

This retrospective, data only study examined life expectancy between 2014 and 2017. Data from electronic medical records and the National Death Index were combined to construct complete life tables by race and sex for the KPMAS population, which was compared to the CDC National Vital Statistics data.

RESULTS

From 2014 to 2017, the overall KPMAS population life expectancy at birth varied between 84.6 and 85.2 years compared to the CDC reported national average of 78.6-78.9 years (p < 0.001). While the CDC dataset reported a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and non-Hispanic Black populations, in the KPMAS population, this gap was significantly smaller (0.0-0.9 years). The gap in life expectancy between males and females was consistent across KPMAS and the CDC data; however, overall KPMAS male and female patient life expectancy was extended in comparison.

CONCLUSION

Among members who disclosed their race/ethnicity, KPMAS Hispanic, non-Hispanic Black, and non-Hispanic White members had significantly higher life expectancies than the CDC dataset in all years reported.

A comparison of attentional neural network architectures for modeling with electronic medical records

Objective

Attention networks learn an intelligent weighted averaging mechanism over a series of entities, providing increases to both performance and interpretability. In this article, we propose a novel time-aware transformer-based network and compare it to another leading model with similar characteristics. We also decompose model performance along several critical axes and examine which features contribute most to our model's performance.

Materials and methods

Using data sets representing patient records obtained between 2017 and 2019 by the Kaiser Permanente Mid-Atlantic States medical system, we construct four attentional models with varying levels of complexity on two targets (patient mortality and hospitalization). We examine how incorporating transfer learning and demographic features contribute to model success. We also test the performance of a model proposed in recent medical modeling literature. We compare these models with out-of-sample data using the area under the receiver-operator characteristic (AUROC) curve and average precision as measures of performance. We also analyze the attentional weights assigned by these models to patient diagnoses.

Results

We found that our model significantly outperformed the alternative on a mortality prediction task (91.96% AUROC against 73.82% AUROC). Our model also outperformed on the hospitalization task, although the models were significantly more competitive in that space (82.41% AUROC against 80.33% AUROC). Furthermore, we found that demographic features and transfer learning features which are frequently omitted from new models proposed in the EMR modeling space contributed significantly to the success of our model.

Discussion

We proposed an original construction of deep learning electronic medical record models which achieved very strong performance. We found that our unique model construction outperformed on several tasks in comparison to a leading literature alternative, even when input data was held constant between them. We obtained further improvements by incorporating several methods that are frequently overlooked in new model proposals, suggesting that it will be useful to explore these options further in the future.