Variations in morphology of cystic artery: systematic review and meta-analysis

Background

Variations in cystic artery anatomy are not unusual in occurrence, hence considerably crucial during hepatobiliary surgical planning and execution. This systematic review and meta-analysis of the anatomical variations of cystic artery (CA) was undertaken to emphasize their significance in surgical practice.

Methods

The PICO model was adopted, both MeSH term and free keywords were utilized for the search strategy. The risk of bias in each study was calculated by the anatomy quality assurance (AQUA) tool.

Result

The search strategy identified 8204 records, extracted 5529 studies, and evaluated 117 abstracts. Out of these 117 studies, 53 met the eligibility criteria. The CA was absent in 2% of instances (95% CI: 0.01-0.04), indicating that 98% of cases had the CA. In 10071 participants from 29 investigations, double cystic arteries were found in 13% (95% CI: 11-16%), with significant heterogeneity (I2 = 91%). In 46 studies with a total of 9928 participants, 89% of the individuals had CA originating from RHA (95% CI: 85%-92%) with significant heterogeneity (I2=94.3%) and a predictive range of 43%-99%.

Conclusion

The cystic artery is primarily derived from the right hepatic artery, followed by aberrant, proper, and left hepatic arteries. It is located anterior to common hepatic ducts and cystic ducts. The mean length and diameter of CA were 20.77 mm and 1.91 mm Short cystic arteries are common (20%) Congenital anomalies like absent and double cystic arteries have low prevalence but must be conside-red during surgery.

Novel case of combination antibiotic therapy for treatment of a complicated polymicrobial urinary tract infection with one organism harboring a metallo-β-lactamase (MBL) in a pregnant patient

Carbapenem resistance due to metallo-beta-lactamases (MBLs) is a global phenomenon and an important challenge for antibiotic therapy (Boyd et al., 2020 [1]). While previous reports have demonstrated both in vitro and in vivo synergy using the combination of ceftazidime-avibactam and aztreonam against Stenotrophomonas maltophilia, an MBL-harboring organism, this treatment strategy has not been reported during pregnancy (Mojic et al., 2017 [2], [3], Mojica et al., 2016 [4], Alexander et al., 2020 [5]). We describe a 33-year-old pregnant female with polymicrobial, bilateral pyelonephritis caused by Stenotrophomonas maltophilia and other gram-negative bacteria. The organisms were eradicated with the combination of ceftazidime-avibactam and aztreonam followed by successful delivery with no observed adverse effects in either mother or child post-partum.

Utility of long-read sequencing for All of Us

The All of Us (AoU) initiative aims to sequence the genomes of over one million Americans from diverse ethnic backgrounds to improve personalized medical care. In a recent technical pilot, we compare the performance of traditional short-read sequencing with long-read sequencing in a small cohort of samples from the HapMap project and two AoU control samples representing eight datasets. Our analysis reveals substantial differences in the ability of these technologies to accurately sequence complex medically relevant genes, particularly in terms of gene coverage and pathogenic variant identification. We also consider the advantages and challenges of using low coverage sequencing to increase sample numbers in large cohort analysis. Our results show that HiFi reads produce the most accurate results for both small and large variants. Further, we present a cloud-based pipeline to optimize SNV, indel and SV calling at scale for long-reads analysis. These results lead to widespread improvements across AoU.

An adjudication algorithm for respiratory-related hospitalisation in idiopathic pulmonary fibrosis

Background

There is no standard definition of respiratory-related hospitalisation, a common end-point in idiopathic pulmonary fibrosis (IPF) clinical trials. As diverse aetiologies and complicating comorbidities can present similarly, external adjudication is sometimes employed to achieve standardisation of these events.

Methods

An algorithm for respiratory-related hospitalisation was developed through a literature review of IPF clinical trials with respiratory-related hospitalisation as an end-point. Experts reviewed the algorithm until a consensus was reached. The algorithm was validated using data from the phase 3 ISABELA trials (clinicaltrials.gov identifiers NCT03711162 and NCT03733444), by assessing concordance between nonadjudicated, investigator-defined, respiratory-related hospitalisations and those defined by the adjudication committee using the algorithm.

Results

The algorithm classifies respiratory-related hospitalisation according to cause: extraparenchymal (worsening respiratory symptoms due to left heart failure, volume overload, pulmonary embolism, pneumothorax or trauma); other (respiratory tract infection, right heart failure or exacerbation of COPD); "definite" acute exacerbation of IPF (AEIPF) (worsening respiratory symptoms within 1 month, with radiological or histological evidence of diffuse alveolar damage); or "suspected" AEIPF (as for "definite" AEIPF, but with no radiological or histological evidence of diffuse alveolar damage). Exacerbations ("definite" or "suspected") with identified triggers (infective, post-procedural or traumatic, drug toxicity- or aspiration-related) are classed as "known AEIPF"; "idiopathic AEIPF" refers to exacerbations with no identified trigger. In the ISABELA programme, there was 94% concordance between investigator- and adjudication committee-determined causes of respiratory-related hospitalisation.

Conclusion

The algorithm could help to ensure consistency in the reporting of respiratory-related hospitalisation in IPF trials, optimising its utility as an end-point.

Ziritaxestat, a Novel Autotaxin Inhibitor, and Lung Function in Idiopathic Pulmonary Fibrosis: The ISABELA 1 and 2 Randomized Clinical Trials

Importance

There is a major need for effective, well-tolerated treatments for idiopathic pulmonary fibrosis (IPF).

Objective

To assess the efficacy and safety of the autotaxin inhibitor ziritaxestat in patients with IPF.

Design, Setting, and Participants

The 2 identically designed, phase 3, randomized clinical trials, ISABELA 1 and ISABELA 2, were conducted in Africa, Asia-Pacific region, Europe, Latin America, the Middle East, and North America (26 countries). A total of 1306 patients with IPF were randomized (525 patients at 106 sites in ISABELA 1 and 781 patients at 121 sites in ISABELA 2). Enrollment began in November 2018 in both trials and follow-up was completed early due to study termination on April 12, 2021, for ISABELA 1 and on March 30, 2021, for ISABELA 2.

Interventions

Patients were randomized 1:1:1 to receive 600 mg of oral ziritaxestat, 200 mg of ziritaxestat, or placebo once daily in addition to local standard of care (pirfenidone, nintedanib, or neither) for at least 52 weeks.

Main Outcomes and Measures

The primary outcome was the annual rate of decline for forced vital capacity (FVC) at week 52. The key secondary outcomes were disease progression, time to first respiratory-related hospitalization, and change from baseline in St George's Respiratory Questionnaire total score (range, 0 to 100; higher scores indicate poorer health-related quality of life).

Results

At the time of study termination, 525 patients were randomized in ISABELA 1 and 781 patients in ISABELA 2 (mean age: 70.0 [SD, 7.2] years in ISABELA 1 and 69.8 [SD, 7.1] years in ISABELA 2; male: 82.4% and 81.2%, respectively). The trials were terminated early after an independent data and safety monitoring committee concluded that the benefit to risk profile of ziritaxestat no longer supported their continuation. Ziritaxestat did not improve the annual rate of FVC decline vs placebo in either study. In ISABELA 1, the least-squares mean annual rate of FVC decline was -124.6 mL (95% CI, -178.0 to -71.2 mL) with 600 mg of ziritaxestat vs -147.3 mL (95% CI, -199.8 to -94.7 mL) with placebo (between-group difference, 22.7 mL [95% CI, -52.3 to 97.6 mL]), and -173.9 mL (95% CI, -225.7 to -122.2 mL) with 200 mg of ziritaxestat (between-group difference vs placebo, -26.7 mL [95% CI, -100.5 to 47.1 mL]). In ISABELA 2, the least-squares mean annual rate of FVC decline was -173.8 mL (95% CI, -209.2 to -138.4 mL) with 600 mg of ziritaxestat vs -176.6 mL (95% CI, -211.4 to -141.8 mL) with placebo (between-group difference, 2.8 mL [95% CI, -46.9 to 52.4 mL]) and -174.9 mL (95% CI, -209.5 to -140.2 mL) with 200 mg of ziritaxestat (between-group difference vs placebo, 1.7 mL [95% CI, -47.4 to 50.8 mL]). There was no benefit with ziritaxestat vs placebo for the key secondary outcomes. In ISABELA 1, all-cause mortality was 8.0% with 600 mg of ziritaxestat, 4.6% with 200 mg of ziritaxestat, and 6.3% with placebo; in ISABELA 2, it was 9.3% with 600 mg of ziritaxestat, 8.5% with 200 mg of ziritaxestat, and 4.7% with placebo.

Conclusions and Relevance

Ziritaxestat did not improve clinical outcomes compared with placebo in patients with IPF receiving standard of care treatment with pirfenidone or nintedanib or in those not receiving standard of care treatment.

Trial Registration

ClinicalTrials.gov Identifiers: NCT03711162 and NCT03733444.

A 24-Week, Phase IIa, Randomized, Double-blind, Placebo-controlled Study of Ziritaxestat in Early Diffuse Cutaneous Systemic Sclerosis (NOVESA)

OBJECTIVE

NOVESA explored the efficacy, safety, and tolerability of ziritaxestat, a selective autotaxin inhibitor, in patients with early diffuse cutaneous systemic sclerosis (dcSSc).

METHODS

NOVESA was a 24-week, Phase IIa, double-blind, placebo-controlled study. Adults with dcSSc were randomized to oral ziritaxestat 600 mg once daily or matching placebo. The primary efficacy endpoint was change from baseline in modified Rodnan skin score (mRSS) at Week 24. Secondary endpoints assessed safety and tolerability; other endpoints included assessment of skin and blood biomarkers. Patients in NOVESA could enter a 104-week open-label extension (OLE).

RESULTS

Patients were randomized to ziritaxestat (n = 21) or placebo (n = 12). Reduction in mRSS was significantly greater in the ziritaxestat versus placebo group (-8.9 vs. -6.0 units; P = 0.0411). Placebo patients switching to ziritaxestat in the OLE showed similar reductions in mRSS to those observed for ziritaxestat patients in the parent study. Ziritaxestat was well tolerated; the most frequent treatment-related treatment-emergent adverse events were headache and diarrhea. Circulating lysophosphatidic acid (LPA) C18:2 was significantly reduced, demonstrating ziritaxestat target engagement; levels of fibrosis biomarkers were reduced in the blood. No differentially expressed genes were identified in skin biopsies. Significant changes in 109 genes were identified in blood samples.

CONCLUSION

Ziritaxestat resulted in significantly greater reductions in mRSS at Week 24 than placebo; no new safety signals emerged. Biomarker analysis suggests ziritaxestat may reduce fibrosis. Modulation of the autotaxin/LPA pathway could improve skin involvement in patients with dcSSc. A plain language summary is available in the Supplement.

Lipoprotein(a) in progressive coronary artery disease: beyond classical cardiovascular risk parameters

Introduction

Classical primary preventive cardiovascular disease (CVD) risk algorithms, such as the Framingham risk score and the widely used QRISK score in the UK, predate large-scale deep-phenotyped biomedical research resources. There is therefore the opportunity to identify novel predictors. In addition, whilst CVD risk profiling is well studied in the context of primary prevention, there is a paucity of data examining risk in regard to secondary prevention.

Purpose

To identify independent predictors of repeat coronary artery revascularisation, following index coronary angioplasty.

Methods

The UK Biobank is a large prospective multicentre study which recruited over 500,000 participants in the UK aged 37–73 years at entry between 2006–2010. Data are derived from an array of physical measurements, self-reported measures and biological samples, together with longitudinal linkage to hospital inpatient records and death registries. Procedural codes were used to identify patients who had undergone first coronary angioplasty from 2006 onwards. Repeat revascularisation (RR) was defined as angioplasty or bypass grafting occurring at least 9 months after the index angioplasty, in order to preclude instances of staged revascularisation and in-stent restenosis. Data were censored at January 2021 or date of death as appropriate.

Results

A total of 12,853 participants underwent a first coronary angioplasty during the study period, with 1,394 (10.8%) requiring RR over a median follow-up of 6.5 years. The average age was 64 years in the RR cohort and 1117 (80%) were male. Univariate analyses confirmed a number of established associations with RR, including for example diabetes mellitus and hypertension. Median lipoprotein(a) concentrations were 27.6 vs. 30.3nmol/L in the RR group, p=0.066. Cox regression analyses (n=7,216) incorporating 21 biometric and clinical parameters demonstrated that lipoprotein(a) >80nmol/L was one of six independent predictors of time to RR (HR 1.24, p=0.006), independent of other lipids. The strength and significance of this association persisted when the number of covariates was reduced to include only other lipids and classical cardiovascular risk parameters. LDL, HDL, and triglyceride levels were not significant predictors in this model.

Conclusions

Lipoprotein(a) is identified as a major independent driver of RR. However current European Society of Cardiology guidance does not recommend measurement of Lipoprotein(a) in the context of progressive coronary artery disease. Furthermore, it is known that strategies such as lifestyle advice and statins – recommended in all patients with established coronary artery disease - do no reduce lipoprotein(a), whilst niacin and PCSK9 inhibitors do have a significant effect. Indications for lipoprotein(a) measurement must therefore be broadened, so that specific treatments to lower it can be instituted in order to reduce the burden of progressive coronary artery disease.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Herefordshire Heart Fund

Early versus late acute graft pyelonephritis: A retrospective analysis of graft and patient outcomes

BACKGROUND

Acute graft pyelonephritis (AGPN) is thought to affect graft and patient survival among renal transplant recipients. The objective was to compare outcomes among early AGPN (<6 months from transplant) versus late AGPN (>6 months from transplant).

METHODS

This retrospective study analysed 150 patients with AGPN dividing them into early and late AGPN from 2008 to 2016. Predictors of graft loss and mortality were compared using logistic regression analysis. Graft survival and patient survival were analysed using Kaplan-Meyer survival plots.

RESULTS

55.3% (n = 83) had early AGPN and 44.7% (n = 67) had late AGPN. In an early AGPN group, 13.3% had CMV disease on the follow-up, compared to only 3% in the late AGPN group (p > 0.05). Furthermore, 38.6% had prolonged DJ stent in-situ (> 2 weeks) following transplant surgery in the early AGPN compared to only 19.4% in the late AGPN group (p < 0.05). Recurrent GPN was more common in the late AGPN group - (35.8% versus 18.1%). The presence of renal abscess was predictive of graft loss in Univariate analysis (HR-6.12, p < 0.004). There was decreased death-censored graft survival in the early AGPN group (p = 0.035), without a significant difference in the patient survival among the two groups.

CONCLUSION

The occurrence of early AGPN had a significant impact on long-term graft survival in renal transplant recipients, with no significant effect on patient survival. This study underlines the paramount importance of the prevention of urinary tract infection (UTI) in renal transplant recipients.

Psycho-social health and quality of life among kidney donors following transplantation

INTRODUCTION

Living kidney donation is a complex psychological experience for donors. The present study examined the psychosocial impact of kidney donation on donors.

METHODS

The retrospective study included 506 donors who donated a kidney between 2010 and 2018 at a transplant centre in India. These donors responded via a donor insight questionnaire about their hospital anxiety, and their possible level of depression. The information included socio-demographic form with multiple information. The health survey was used periodically evaluate the psychosocial impact among donors following donation, including the transplant outcomes.

RESULTS

The majority of donors were females (79.4%). There was a significant improvement in the quality of life among donors (SF-36) following the donation of a kidney, especially among those donors who maintained good graft functions themselves as well as those who were informed about good kidney function in transplanted recipients. These donors showed a lesser degree of depressive and anxiety scores (HAD score 3.5 and BDI II 4.8) than donors who had problems themselves and/or whose donated kidneys did not function well. Most living donors (89.1%) felt that the act of donation had a positive impact on their lives and those donors would encourage others to donate a kidney. Overall, the graft outcomes impacted the donor's state of mind.

CONCLUSION

The study showed a very positive impact of the acknowledgment of the donor by the recipient, especially those donors whose kidney transplants were well functioning. The state of depression, anxiety, and psycho-social outcomes correlated with the graft outcomes. Donors showed positive insight towards donation, with inner conscience still conclusively willing to donate and encourage others.

LoRaWan Sensitivity Analysis and Prevention Strategies Against Wireless DoS Attacks

New wireless IoT technology provides smart pseudo intelligent solutions that will have a big impact on the infrastructures and the society in the future to come. In the last decade, many new low power longrange wireless technologies have emerged to support these wireless IoT based solutions. One of the most promising and commonly accepted technologies is LoRaWAN. Unfortunately, the introduction and deployment of a new wireless technology provides new risks and new security challenges. Some of these challenges can be categorized as "critical", which means that if they fail, this will have major consequences for the society's critical infrastructure and the society as a hole. In this paper one of these critical challenges is analyzed in terms of wireless jamming attacks that cause fatale denial-of-services on the LoRaWAN wireless infrastructure and connectivity. This analysis is based on a mathematical simulation model which is described and elaborated. By using this model on a selected societal critical service example, a sensitivity analysis in terms of jamming and DoS attacks is performed, provided, and elaborated. Finally, some selected prevention strategies to avoid and counter-fight these attacks are presented, discussed, and elaborated.

A prospective validation of a deep learning-based automated workflow for the interpretation of the echocardiogram

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Us2.ai

Background. Deep learning can automate the interpretation of medical imaging tests. This study aimed to prospectively assess the interchangeability of deep learning algorithms with expert human measurements for interpreting echocardiographic studies, the primary method for assessing cardiac structure and function.

Methods. We compared a deep learning interpretation of 23 echocardiographic parameters—including cardiac volumes, ejection fraction, and Doppler measurements—with three repeated measurements by core lab human experts in a prospective study for submission to the United States Food and Drug Administration (FDA). The primary outcome metric was the individual equivalence coefficient (IEC), which compares the disagreement between deep learning and human readers relative to the disagreement among human readers. The pre-determined non-inferiority criterion was 0.25 for the upper bound of the 95% confidence interval (CI). Secondary outcomes included measures of agreement, including the mean absolute deviation.

Results. We included 602 studies from 600 participants (421 with heart failure, 179 controls, 69% women) with a mean age of 57 ± 16 years. The point estimates of IEC were all &lt;0, indicating that the disagreement between the deep learning and human measures were lower than the disagreement among three core lab readers, and the upper bound of the 95% CI of IECs fell below the prespecified success criterion of 0.25. Secondary endpoints showed good agreement of automated with human expert measurements (Figure), with comparable or lower mean absolute deviations between automated and human experts relative to the mean absolute deviation among human experts.

Conclusion. This prospective validation study demonstrated excellent agreement between deep learning and expert human interpretation for a wide range of echocardiographic measurements. These results highlight the potential of deep learning algorithms to improve efficiency and reduce costs of echocardiography. Abstract Figure.