Echocardiographic characteristics of patients admitted with acute heart failure with a previous history of cancer: a single-centre observational study

Funding Acknowledgements

Type of funding sources: None.

Background

Cancer and heart failure frequently co-exist, with cancer and chemotherapy exerting a number of pathological effects on the myocardium. Despite this, our understanding of the clinical impact of previous history of cancer in acute heart failure remains unclear.  We therefore performed a retrospective cohort study to identify the echocardiographic characteristics in patients admitted with acute heart failure with and without a diagnosis of solid organ cancer.

Methods

Consecutive patients with signs and/or symptoms of acute heart failure admitted over a period of 33 weeks (7th January – 28th August 2020) were identified. Discharge summaries, electronic notes and shared care networks were manually searched to determine baseline demographics, admission bloods, comorbidities, cancer diagnoses, imaging and echocardiography. Univariate and multivariate Cox regression analysis was performed to identify clinical and biochemical predictors of mortality.

Results

In total, 478 patients were admitted with acute heart failure over the study period (mean age 80 ± 11 years, 53.6% were male and mean NT pro-BNP was 9106). 386 had echocardiography available for review. Of these, 64 (16.6%) had a past or current history of solid organ cancer.

Patients with a past or current history of solid organ cancer had a significantly higher ejection fraction (48% (±9%) vs 44% (±11%), p = 0.003), higher incidence of heart failure with preserved ejection fraction (57.8% vs 33.5%, p < 0.001) and lower incidence of right ventricular impairment (defined using both visual inspection and TAPSE measurements) (25.0% vs 47.8%, p < 0.001).

There were no significant differences in any valvular pathologies between groups (overall prevalence 71.9% vs 71.7%, p = 0.982) No difference was observed between the rate of prior myocardial infarction (28.1% vs 26.0%, p = 0.727) or lung disease (34.4% vs 37.0%, p = 0.692).

Overall, mortality at six months follow up was significantly higher in the group with a current or previous cancer diagnosis (43.4% vs 32.0%, p = 0.046) compared to the group without.

Conclusion

Patients admitted with acute heart failure and a past or current history of cancer have a significantly higher ejection fraction and lower prevalence of right ventricular impairment. Despite the higher ejection fraction their prognosis is worse. Further work is needed to determine potential mechanisms for this, as well as its clinical implications. Abstract Figure. Six Month Survival Kaplan Meier Graph  Abstract Figure. Echocardiogrpahic Features

233 BISPHOSPHONATES: ANOTHER COMPLEX DRUG TO PRESCRIBE

Background

Bisphosphonates provide effective treatment for osteoporosis. They accumulate a bone reservoir lasting for 3 years and beyond. The 2021 NICE guidelines recommend a medication review and a ‘drug holiday’ after 5 years of oral bisphosphonate therapy for low-fracture risk patients. Continuing treatment for high risk individuals is advised: age=/>75, previous hip or vertebral fracture, one or more fractures during treatment, recent DEXA scan with T score =/<−2.5, and/or current treatment with oral glucocorticoids. This retrospective audit aimed to assess compliance with NICE guidelines in a primary care setting.

Methods

Data were collected using the Health One online medical record system in an urban general practice. Inclusion criteria: all patients =/> 65 years old, prescribed oral bisphosphonate therapy for osteoporosis for >5 years. Exclusion criteria: deceased, did not attend clinic >1 year, patients on bisphosphonate treatment for conditions other than osteoporosis.

Results

137 patients with a history of bisphosphonate therapy were identified. 76 patients were on bisphosphonate treatment for greater than 5 years. Of the 76 patients, 33 were classified as low-fracture risk and appropriately commenced a drug holiday, while 22 correctly remained on bisphosphonates due to a high fracture risk. The remaining 21 patients inappropriately continued therapy without receiving a medication review, repeat DEXA or fracture-risk assessment.

Conclusion

One third of patients on bisphosphonates beyond 5 years were not assessed for a drug holiday. The aim of a bisphosphonate ‘drug holiday’ is to reduce poly-pharmacy and prevent rare but serious long-term adverse events (such as atypical fractures, osteonecrosis of the jaw, gastric cancer and atrial fibrillation). Factors which had an impact on inappropriate prescribing should be assessed. Incorporating computer-based prescribing alerts could support safe prescribing practices.

232 DETECTION OF POST STROKE DEPRESSION IN ACUTE STROKE UNIT AT UNIVERSITY HOSPITAL

Background

Depression is the most common neuropsychiatric manifestation after stroke. It is associated with lower satisfaction and quality of life in stroke survivors and their families. Routine screening for mood disturbance is recommended in stroke patients {Royal College of Physicians, 2016; National Office of Clinical Audit (NOCA) 2019}. The psychological impact of a stroke can present challenges for assessment and diagnosis. We audited the assessment and diagnosis of post stroke depression in a teaching hospital.

Methods

PHQ-9 was prospectively administered to stroke patients (and also to the next of kin with patient consent) within 2 weeks of stroke and repeated at 4–6 weeks after stroke in November 2016. The Patient Health Questionnaire (PHQ—9) is a self-administered, validated screening tool for depression. Chart diagnosis or drug prescribing for depression was retrospectively assessed in the medical and nursing notes.

Results

15 of 34 admitted stroke patients were administered the paper based PHQ-9. 19 patients were excluded due to: severe cognitive impairment; aphasic; death or having been discharged.

No patient had depression diagnosed prior to admission to the hospital. One patient was diagnosed and prescribed an anti-depressant post stroke.

7 patients screened positive for depression on PHQ-9: mild depression n = 4 (27%); moderate n = 2 (13%); and severe depression n = 1 (6%). Repeat questionnaire at 4–6 weeks post stroke revealed an unchanged PHQ-9 score in n = 10 (67%); however n = 2 (11%) had deteriorated and n = 4 (22%) improved.

Conclusion

Depression was a common finding in 47% of patients post stroke and was under-recognized without a formal screening process incorporated in clinical practice. A nuanced screening process, accounting for common co-morbidities such as aphasia and cognitive impairment, was incorporated after this audit. Further guidance is being developed by the National Stroke Programme based on NOCA feedback.

241 IMPLEMENTATION OF AN INTRACEREBRAL CEREBRAL HAEMORRHAGE CARE BUNDLE

Background

Mortality for Intracerebral haemorrhage (ICH) is 31% (Irish National Audit Stroke, 2019). An ICH care bundle focusing on acute anticoagulation reversal, blood pressure lowering, and a neurosurgical care pathway was associated with improved survival. Translating evidence-based medicine into clinical practice is challenging. The aim of this study was to determine feasibility and outcomes of implementation of a care bundle.

Methods

An ICH care bundle was developed using an iterative process involving expert stakeholder review of the evidence-based literature. A pre-and-post quasi-experimental research design was employed to evaluate this intervention. Baseline data were collected before implementation (January 2016-June 2018). Implementation took place in a staged manner in a single university teaching hospital with multiple ‘Plan Do Study Act cycles’ (June 2018 to January 2021). Data on compliance, process measures and outcomes were collected.

Results

Systolic blood pressure (first 24-hours) and anticoagulant reversal were significantly better controlled post-implementation (χ2 (1, N = 91) = 5.34, P = 0.02), (χ2 (1, N = 25) = 5.85, P = 0.016), respectively. DNAR orders were significantly lower in the post-implementation group (χ2 (1, N = 25) = 5.85, P = 0.029). However, ‘Do Not Actively Resuscitate’ status did not significantly differ when accounting for low GCS as a surrogate measure for poor prognosis (χ2 (1, N = 34) = 0.00, P = 0.966). Modified Rankin Scale on discharge did not differ significantly pre-and-post-implementation (z = −0.075, P = 0.94). A greater proportion of patients survived in the post-implementation group; however, this was not statistically significant (χ2 (1, N = 133) = 0.77, P = 0.38). Length of stay significantly increased post implementation.

Conclusion

An ICH care bundle was developed based on expert stakeholder feedback. The feasibility of implementing this bundle of care was demonstrated in a real-world clinical practice setting. A cluster-randomized trial or a large registry study is the next step to evaluate the overall impact of this care bundle on patient outcomes.

235 THROMBOLYSIS DOSING AND WEIGHT ESTIMATION IN ACUTE STROKE: A SINGLE CENTRE AUDIT

Background

Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors.

Methods

This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital.

Results

107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (> ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (>10%).

Conclusion

A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

236 PREDICTORS OF ADVERSE OUTCOMES IN OLDER PATIENTS DISCHARGED DIRECTLY FROM THE EMERGENCY DEPARTMENT

Background

Over 40% of older patients are discharged directly from the Emergency Department (ED) and this cohort is at increased risk of adverse outcomes.

The purpose of this study was to explore the factors that predict future adverse outcomes in this cohort to inform practice, resource planning and policy.

Methods

A secondary analysis of the OPTIMEND, a single-centre, randomized-controlled trial was completed. OPTIMEND examined the effectiveness of an intervention by a team of Health and Social Care Professionals along with usual care and compared this to standard ED care alone (Dec 2018-May 2019). The inclusion criteria were adults aged 65 years and over presenting to the ED at a University Teaching Hospital with medical complaints and a Manchester Triage System category 2–5.

Results

220 patients were included (median age 79 years; 62% female). Median length of stay in ED was 5.5 hrs. 70 patients re-attended the ED within 6 months with 43 re-hospitalised within 6 months. 9 patients died within six months of discharge.

Multivariant logistic regression was completed. Age was the only independent predictor of mortality within six months of discharge {Odds Ratio (OR) 1.15, p = 0.044}. Past hospitalisation (<6 months) was associated with a lower likelihood of ED re-attendance, and rehospitalization within six months of discharge (OR: 0.452 p = 0.022; OR:0.442, p = 0.046; respectively). Clinical Frailty Score was associated with a significantly higher likelihood of rehospitalization (OR:1.48, p = 0.031) but not with ED revisits (OR: 1.235, p = 0.165).

Conclusion

Older people have a high ED re-attendance rate of 33% after an index visit with 20% hospitalized subsequently. Frailty is a significant predictor of rehospitalisation. Rapid and targeted intervention for frail patients who reattend the ED should be a priority for the integrated care program to enhance admission avoidance.

234 THE IMPACT OF OLDER AGE ON CLINICAL OUTCOMES DURING THE FIRST WAVE OF THE COVID-19 PANDEMIC

Background

Severe acute respiratory coronavirus 2 (SARS-CoV-2) was first recorded in Ireland in February 2020. Several studies have explored the association between age and SARS-CoV-2, showing that there were poorer outcomes in older people. Our objective was to evaluate the impact of age on outcomes such as hospital length of stay, mortality, and re-hospitalisation.

Methods

We performed a single-centre, retrospective observational cohort study, using an electronic microbiology database of recorded index admissions of SARS-CoV-2 positive patients aged 65 years and older during SARS-CoV-2 wave one (March 1^st to May 31^st 2020). PCR testing of nasopharyngeal and/or sputum samples was used to confirm positivity. Our clinical outcomes measured included hospital length of stay, mortality and re-admission rate within 6 months.

Results

153 patients 65 years and above were admitted. The male to female ratio was 1.3 with 90% admitted medically. 79 patients were aged between 65–79 years; 84 patients ≥80 years; and 12 patients ≥90 years. Mortality was 25%, 31% and 42%, respectively. Median length of stay remained 14 days for ages 65–89 rising to 17.5 days for those ≥90 years. Re-hospitalisation rates at 6 months were similar for ages 65–79 and 89–89 years at 42% and 40%, respectively. One patient (14%) over 90 years was re-hospitalised.

Conclusion

SARS-CoV-2 has disproportionately impacted on general medical services treating older hospitalised people. In our centre, mortality for patients ≥65 years was 28.1% which compared favourably with 35.6% internationally as outlined by Victor et al. (2020) based on Spanish data. Treatment of SARS-CoV-2 is not futile in older patients with 58% of nonagenarians and 69% of octogenarians surviving, however re-hospitalisation rates are high at 40%. A targeted approach to discharge support via integrated care may ameliorate this.

182 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams

Introduction

A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients.

Method

Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated.

Results

In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges.

Conclusions

By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.

Corrigendum to: Canadian Paediatric Society 92nd Annual Conference: Abstracts-79: Withholding Feeds During Blood Transfusion and Risk of Transfusion Associated Necrotizing Enterocolitis (TANEC)

[This corrects the article DOI: 10.1093/pch/20.5.e62a.].

Observation of Forward Neutron Multiplicity Dependence of Dimuon Acoplanarity in Ultraperipheral Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The first measurement of the dependence of γγ→μ^{+}μ^{-} production on the multiplicity of neutrons emitted very close to the beam direction in ultraperipheral heavy ion collisions is reported. Data for lead-lead interactions at sqrt[s_{NN}]=5.02  TeV, with an integrated luminosity of approximately 1.5  nb^{-1}, are collected using the CMS detector at the LHC. The azimuthal correlations between the two muons in the invariant mass region 8<m_{μμ}<60  GeV are extracted for events including 0, 1, or at least 2 neutrons detected in the forward pseudorapidity range |η|>8.3. The back-to-back correlation structure from leading-order photon-photon scattering is found to be significantly broader for events with a larger number of emitted neutrons from each nucleus, corresponding to interactions with a smaller impact parameter. This observation provides a data-driven demonstration that the average transverse momentum of photons emitted from relativistic heavy ions has an impact parameter dependence. These results provide new constraints on models of photon-induced interactions in ultraperipheral collisions. They also provide a baseline to search for possible final-state effects on lepton pairs caused by traversing a quark-gluon plasma produced in hadronic heavy ion collisions.

Constraints on the Initial State of Pb-Pb Collisions via Measurements of Z-Boson Yields and Azimuthal Anisotropy at sqrt[s_{NN}]=5.02 TeV

The CMS experiment at the LHC has measured the differential cross sections of Z bosons decaying to pairs of leptons, as functions of transverse momentum and rapidity, in lead-lead collisions at a nucleon-nucleon center-of-mass energy of 5.02  TeV. The measured Z boson elliptic azimuthal anisotropy coefficient is compatible with zero, showing that Z bosons do not experience significant final-state interactions in the medium produced in the collision. Yields of Z bosons are compared to Glauber model predictions and are found to deviate from these expectations in peripheral collisions, indicating the presence of initial collision geometry and centrality selection effects. The precision of the measurement allows, for the first time, for a data-driven determination of the nucleon-nucleon integrated luminosity as a function of lead-lead centrality, thereby eliminating the need for its estimation based on a Glauber model.

Role of Left Ventricular Speckle Tracking Imaging in Detection of Coronary Artery Disease in Non-Diabetic Patients

This study aimed to determine the role of global longitudinalstrain (GLS) in early diagnosis and detection of severity of coronaryartery disease (CAD) in non-diabetic patients with preservedleft ventricular ejection fraction (EF) without regionalwall motion abnormalities presented with chronic coronary syndrome,and to identify the role of territorial longitudinal strain(TLS) in detection of the affected coronary artery. We enrolled60 non-diabetic patients with suspected CAD who underwentresting echocardiography and speckle tracking imaging andsubsequently coronary angiography then results were correlatedtogether. Patients with family history of CAD (68.3%), hypertension(68.3%), smokers (43.3%), and dyslipidemia (81.6%). Allparticipants had normal left ventricular systolic function withmean EF of 64.02±6.15% and no regional wall motion abnormalitiesat rest. Patients were classified angiographically accordingto the number of the diseased vessels into: 3 vessels disease(43.3%), 1-2 vessels disease (35%), and normal coronaryangiography (21.7%) with GLS mean values of -13.69±1.94%,-15.4±1.74%, and -18.80±2.14%, respectively. There was a negativesignificant correlation between GLS values and the numberof diseased vessels (P=0.001). The values of TLS were significantlylower in myocardial regions supplied by stenotic arteries thanthose supplied by non-stenotic arteries. Mean TLS values forstenotic left anterior descending, left circumflex, and right coronaryarteries were -15.51±3.19, -13.06±2.90, -13.27±2.60 withP=0.011, 0.001, and 0.001, respectively. Speckle tracking derivedGLS is an effective non-invasive method in predicting presenceand severity of CAD and in locating the affected vessels basedon the distribution of segments affected in TLS.

Unravelling racial differences in hypertensive heart disease by multiparametric cardiovascular magnetic resonance: a phenotype-wide association study

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Dr Georgiopoulos was supported by the Onassis Foundation under the special grant & support program for scholars" association members

Introduction – Black Afro-Caribbean hypertensives (BAHs) are exposed to a higher risk of heart failure (HF) than white hypertensives (WHs). Arterial afterload is higher in BAHs due to increased arterial stiffness and vascular volume; BAHs develop more often left ventricular (LV) hypertrophy, dilatation and systolic dysfunction than WHs. However, it is unclear whether other racial differences concur to the more pronounced LV remodelling in BAHs.

Methods – This cross-sectional study included hypertensive patients undergoing cardiovascular magnetic resonance for their clinical work-up (1.5T Aera Siemens-Healthcare). Clinical history and haemodynamic parameters were collected in all participants; a subset of patients had complete bio-humoral assay of the renin-angiotensin-aldosterone system (RAAs). Arm cuff pressure was measured during CMR. The CMR protocol included: i) Arterial afterload / LV arterial-coupling - pulse-wave-velocity (PWV), aortic (Ea) and LV elastance (Ees) by aorta anatomic and phase-contrast velocity-encoding imaging; ii) ventricular remodelling and function - LV and right ventricular (RV) volumes, mass, EF, LV peak-filling rate by short-axis cine images; global circumferential and longitudinal strains by cine feature tracking; iii) left atrial (LA) remodelling volumes and reservoir, conduit and booster functions by long-axis cine images; iv) tissue characterisation: T2 and pre/post-contrast T1 relaxation times, extracellular volume (ECV) by single mid-ventricular short-axis T1/T2-mapping.

Results – 34 BAHs and 35 WHs (52 ± 12 vs 45 ± 14 years, P &lt; 0.05; 61% vs 65% males P = NS) were included in the study. Baseline features are summarised in the Table. LV systolic dysfunction was more prevalent in BAH than WHs (P = 0.038). Of note, BAHs tended to have greater LV volumes and significantly higher LV mass and septal thickness than WHs. In BAHs, but not in WHs, PWV was associated with increased septal thickness after correction for blood pressure and age (β-value: 0.447, P = 0.02). Normalised RV mass was greater in BHA than WHs; RV mass suits for the identification of racial or circulating factors predisposing to hypertrophy being largely unaffected by systemic afterload. In our study LV diastolic function and LA volumes were similar between BAHs and WHs, and none of the subjects had conditions associated with pre-capillary pulmonary hypertension. Hence, higher RV-mass in BAHs pinpoints a racial susceptibility to myocardial hypertrophy. Finally, in a subset of patients with RAAs assays (n = 43), the aldosterone/renin ratio was higher in BAHs than WHs (67.04 [IQR: 19.37-209.73] vs 13.77 [IQR: 7.47-40.43], P = 0.01).

Conclusion – BAHs have heightened LV remodelling than WHs because of racial predisposition to develop hypertrophy which also encompasses derangements in RAAs. Altogether, these findings may account for the greater risk for HF in BAHs than WHs.

Effects of increasing aerobic capacity on improving psychological problems seen in patients with COVID-19: a review

OBJECTIVE

In response to the COVID-19 disaster, people have developed several psychological problems mainly stress, anxiety, and depression. These psychological problems have been seen in either normal people during the lockdown (who are waiting to get infected with COVID-19) and patients with COVID-19 (who are waiting for death). These psychological problems adversely affect immune functions causing more increase in the severity of COVID-19 associated disorders and death rates. Increasing the aerobic capacity is one of the effective methods that could be used to decrease stress, anxiety, and depression. Besides, increasing the aerobic capacity increases immune functions through autonomic regulation. Thus, this review was developed to summarize the effect of increasing the aerobic capacity on psycho-immune hormones commonly disturbed in people during the lockdown or patients with COVID-19 infection.

MATERIALS AND METHODS

This review was carried out by searching through Web of Science, Scopus, EBSCO, Medline databases. The search was conducted over clinical trials, literature reviews, and systematic reviews. The search included the possible effects of increasing the aerobic capacity on the functions of psycho-immune hormones.

RESULTS

This review found that increasing the aerobic capacity can decrease psychological problems commonly seen in people with COVID-19 and increase immune functions by modulating the levels of glucocorticoid, oxytocin, insulin, thyroid hormones.

CONCLUSIONS

This review demonstrated that increasing the aerobic capacity is a recommended treatment for decreasing the psychological problems commonly seen in people with COVID-19 because it has the potential for decreasing psychological problems and improving immune functions which would help counter COVID-19.

248 Improving Handovers from A Neurosurgical High Dependency Unit to Ward Teams

Introduction

A good handover is fundamental in providing continuity of care within a multidisciplinary team, allowing for safe and effective management of patients.

Method

Handovers between the neurosurgical high dependency unit and the ward team were prospectively evaluated as patients were stepped down over a 6-week period. The handover rate and consequences of poor handovers (missed investigations, referrals, or delayed discharges) were documented. After 6-weeks, handover proforma was introduced and the rates were recalculated.

Results

In the initial 6-week period, 36 patients were transferred, with only 2(5.6%) appropriately handed-over. Consequently, 9(26%) patients had delayed scans, 5(15%) missed referrals, and 24(71%) delayed discharges. In the 6-week period following the introduction of the proforma, a total of 28 patients were transferred, with 19(67.8%) documented handovers. Consequently, 1(3.5%) patient had a scan delay, 0 missed referrals and only 2(7%) patients had delayed discharges.

Conclusions

By raising awareness of handovers and introducing a proforma, we improved documented handovers by 62.3% whilst reducing the rate of missed investigations, referrals, and delayed discharges by over 90%. This project highlights how small, simple, and easy to enforce changes can lead to significant improvements in the quality of care provided to patients.

388 Detection of Cytomegalovirus Infection in Infants with Biliary Atresia: A Meta-analysis

Introduction

Biliary atresia (BA) is the most common indication of liver transplantation in children. Several reports attributed BA to both prenatal and perinatal aetiologies, including a viral infection-induced auto-immune response that targets the bile ducts. Cytomegalovirus (CMV) remains the most common virus being linked to BA. This meta-analysis estimates to what extent CMV infection is detected in patients with BA.

Method

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The databases of MEDLINE/PubMed, WHO-Virtual Health Library (VHL), ScienceDirect, and Google Scholar were used for the systematic search. Random effects model was used to estimate the pooled prevalence estimate with the corresponding 95% confidence interval (CI) using StatsDirect statistical software.

Results

A total of 13 studies (covering 419 patients) that fulfilled the eligibility criteria were included in the meta-analysis. The pooled overall prevalence of CMV infection in patients with BA was 24.5% (95% CI 11.9 %– 33.9%).

Conclusions

The available data demonstrate that the detection of CMV infection is common in infants with BA. There is still a need for large studies with appropriate controls to examine various aspects of the association between CMV infection and BA.

M, Kveton A, Tomsa J, Ayala E, Carrera Jarrin E, Abdalla H, Assran Y, Mohamed A, Mahmoud MA, Mohammed Y, Bhowmik S, Carvalho Antunes De Oliveira A, Dewanjee RK, Ehataht K, Kadastik M, Raidal M, Veelken C, Eerola P, Forthomme L, Kirschenmann H, Osterberg K, Voutilainen M, Brücken E, Garcia F, Havukainen J, Karimäki V, Kim MS, Kinnunen R, Lampén T, Lassila-Perini K, Laurila S, Lehti S, Lindén T, Siikonen H, Tuominen E, Tuominiemi J, Luukka P, Tuuva T, Amendola C, Besancon M, Couderc F, Dejardin M, Denegri D, Faure JL, Ferri F, Ganjour S, Givernaud A, Gras P, Hamel de Monchenault G, Jarry P, Lenzi B, Locci E, Malcles J, Rander J, Rosowsky A, Sahin MÖ, Savoy-Navarro A, Titov M, Yu GB, Ahuja S, Beaudette F, Bonanomi M, Buchot Perraguin A, Busson P, Charlot C, Davignon O, Diab B, Falmagne G, Granier de Cassagnac R, Hakimi A, Kucher I, Lobanov A, Martin Perez C, Nguyen M, Ochando C, Paganini P, Rembser J, Salerno R, Sauvan JB, Sirois Y, Zabi A, Zghiche A, Agram JL, Andrea J, Bloch D, Bourgatte G, Brom JM, Chabert EC, Collard C, Fontaine JC, Gelé D, Goerlach U, Grimault C, Le Bihan AC, Van Hove P, Asilar E, Beauceron S, Bernet C, Boudoul G, Camen C, Carle A, Chanon N, Contardo D, Depasse P, El Mamouni H, Fay J, Gascon S, Gouzevitch M, Ille B, Jain S, Laktineh IB, Lattaud H, Lesauvage A, Lethuillier M, Mirabito L, Torterotot L, Touquet G, Vander Donckt M, Viret S, Toriashvili T, Tsamalaidze Z, Feld L, Klein K, Lipinski M, Meuser D, Pauls A, Preuten M, Rauch MP, Schulz J, Teroerde M, Eliseev D, Erdmann M, Fackeldey P, Fischer B, Ghosh S, Hebbeker T, Hoepfner K, Keller H, Mastrolorenzo L, Merschmeyer M, Meyer A, Millet P, Mocellin G, Mondal S, Mukherjee S, Noll D, Novak A, Pook T, Pozdnyakov A, Quast T, Radziej M, Rath Y, Reithler H, Roemer J, Schmidt A, Schuler SC, Sharma A, Wiedenbeck S, Zaleski S, Dziwok C, Flügge G, Haj Ahmad W, Hlushchenko O, Kress T, Nowack A, Pistone C, Pooth O, Roy D, Sert H, Stahl A, Ziemons T, Aarup Petersen H, Aldaya Martin M, Asmuss P, Babounikau I, Baxter S, Behnke O, Bermúdez Martínez A, Bin Anuar AA, Borras K, Botta V, Brunner D, Campbell A, Cardini A, Connor P, Consuegra Rodríguez S, Danilov V, De Wit A, Defranchis MM, Didukh L, Domínguez Damiani D, Eckerlin G, Eckstein D, Eichhorn T, Elwood A, Estevez Banos LI, Gallo E, Geiser A, Giraldi A, Grohsjean A, Guthoff M, Harb A, Jafari A, Jomhari NZ, Jung H, Kasem A, Kasemann M, Kaveh H, Kleinwort C, Knolle J, Krücker D, Lange W, Lenz T, Lidrych J, Lipka K, Lohmann W, Mankel R, Melzer-Pellmann IA, Metwally J, Meyer AB, Meyer M, Missiroli M, Mnich J, Mussgiller A, Myronenko V, Otarid Y, Pérez Adán D, Pflitsch SK, Pitzl D, Raspereza A, Saggio A, Saibel A, Savitskyi M, Scheurer V, Schütze P, Schwanenberger C, Shevchenko R, Singh A, Sosa Ricardo RE, Tholen H, Tonon N, Turkot O, Vagnerini A, Van De Klundert M, Walsh R, Walter D, Wen Y, Wichmann K, Wissing C, Wuchterl S, Zenaiev O, Zlebcik R, Aggleton R, Bein S, Benato L, Benecke A, De Leo K, Dreyer T, Ebrahimi A, Eich M, Feindt F, Fröhlich A, Garbers C, Garutti E, Gunnellini P, Haller J, Hinzmann A, Karavdina A, Kasieczka G, Klanner R, Kogler R, Kutzner V, Lange J, Lange T, Malara A, Multhaup J, Niemeyer CEN, Nigamova A, Pena Rodriguez KJ, Rieger O, Schleper P, Schumann S, Schwandt J, Schwarz D, Sonneveld J, Stadie H, Steinbrück G, Vormwald B, Zoi I, Baselga M, Baur S, Bechtel J, Berger T, Butz E, Caspart R, Chwalek T, De Boer W, Dierlamm A, Droll A, El Morabit K, Faltermann N, Flöh K, Giffels M, Gottmann A, Hartmann F, Heidecker C, Husemann U, Iqbal MA, Katkov I, Keicher P, Koppenhöfer R, Maier S, Metzler M, Mitra S, Mozer MU, Müller D, Müller T, Musich M, Quast G, Rabbertz K, Rauser J, Savoiu D, Schäfer D, Schnepf M, Schröder M, Seith D, Shvetsov I, Simonis HJ, Ulrich R, Wassmer M, Weber M, Wöhrmann C, Wolf R, Wozniewski S, Anagnostou G, Asenov P, Daskalakis G, Geralis T, Kyriakis A, Loukas D, Paspalaki G, Stakia A, Diamantopoulou M, Karasavvas D, Karathanasis G, Kontaxakis P, Koraka CK, Manousakis-katsikakis A, Panagiotou A, Papavergou I, Saoulidou N, Theofilatos K, Vellidis K, Vourliotis E, Bakas G, Kousouris K, Papakrivopoulos I, Tsipolitis G, Zacharopoulou A, Evangelou I, Foudas C, Gianneios P, Katsoulis P, Kokkas P, Mallios S, Manitara K, Manthos N, Papadopoulos I, Strologas J, Bartók M, Chudasama R, Csanad M, Gadallah MMA, Lökös S, Major P, Mandal K, Mehta A, Pasztor G, Surányi O, Veres GI, Bencze G, Hajdu C, Horvath D, Sikler F, Veszpremi V, Vesztergombi G, Czellar S, Karancsi J, Molnar J, Szillasi Z, Teyssier D, Raics P, Trocsanyi ZL, Ujvari B, Csorgo T, Nemes F, Novak T, Choudhury S, Komaragiri JR, Kumar D, Panwar L, Tiwari PC, Bahinipati S, Dash D, Kar C, Mal P, Mishra T, Muraleedharan Nair Bindhu VK, Nayak A, Sahoo DK, Sur N, Swain SK, Bansal S, Beri SB, Bhatnagar V, Chauhan S, Dhingra N, Gupta R, Kaur A, Kaur S, Kumari P, Lohan M, Meena M, Sandeep K, Sharma S, Singh JB, Virdi AK, Ahmed A, Bhardwaj A, Choudhary BC, Garg RB, Gola M, Keshri S, Kumar A, Naimuddin M, Priyanka P, Ranjan K, Shah A, Bharti M, Bhattacharya R, Bhattacharya S, Bhowmik D, Dutta S, Ghosh S, Gomber B, Maity M, Nandan S, Palit P, Purohit A, Rout PK, Saha G, Sarkar S, Sharan M, Singh B, Thakur S, Behera PK, Behera SC, Kalbhor P, Muhammad A, Pradhan R, Pujahari PR, Sharma A, Sikdar AK, Dutta D, Jha V, Kumar V, Mishra DK, Naskar K, Netrakanti PK, Pant LM, Shukla P, Aziz T, Bhat MA, Dugad S, Kumar Verma R, Sarkar U, Banerjee S, Bhattacharya S, Chatterjee S, Das P, Guchait M, Karmakar S, Kumar S, Majumder G, Mazumdar K, Mukherjee S, Roy D, Sahoo N, Dube S, Kansal B, Kapoor A, Kothekar K, Pandey S, Rane A, Rastogi A, Sharma S, Bakhshiansohi H, Chenarani S, Etesami SM, Khakzad M, Mohammadi Najafabadi M, Felcini M, Grunewald M, Abbrescia M, Aly R, Aruta C, Colaleo A, Creanza D, De Filippis N, De Palma M, Di Florio A, Di Pilato A, Elmetenawee W, Fiore L, Gelmi A, Gul M, Iaselli G, Ince M, Lezki S, Maggi G, Maggi M, Margjeka I, Merlin JA, My S, Nuzzo S, Pompili A, Pugliese G, Ranieri A, Selvaggi G, Silvestris L, Simone FM, Venditti R, Verwilligen P, Abbiendi G, Battilana C, Bonacorsi D, Borgonovi L, Braibant-Giacomelli S, Brigliadori L, Campanini R, Capiluppi P, Castro A, Cavallo FR, Cuffiani M, Dallavalle GM, Diotalevi T, Fabbri F, Fanfani A, Fontanesi E, Giacomelli P, Giommi L, Grandi C, Guiducci L, Iemmi F, Lo Meo S, Marcellini S, Masetti G, Navarria FL, Perrotta A, Primavera F, Rovelli T, Siroli GP, Tosi N, Albergo S, Costa S, Di Mattia A, Potenza R, Tricomi A, Tuve C, Barbagli G, Cassese A, Ceccarelli R, Ciulli V, Civinini C, D’Alessandro R, Fiori F, Focardi E, Latino G, Lenzi P, Lizzo M, Meschini M, Paoletti S, Seidita R, Sguazzoni G, Viliani L, Benussi L, Bianco S, Piccolo D, Bozzo M, Ferro F, Mulargia R, Robutti E, Tosi S, Benaglia A, Beschi A, Brivio F, Cetorelli F, Ciriolo V, De Guio F, Dinardo ME, Dini P, Gennai S, Ghezzi A, Govoni P, Guzzi L, Malberti M, Malvezzi S, Menasce D, Monti F, Moroni L, Paganoni M, Pedrini D, Ragazzi S, Tabarelli de Fatis T, Valsecchi D, Zuolo D, Buontempo S, Cavallo N, De Iorio A, Fabozzi F, Fienga F, Iorio AOM, Layer L, Lista L, Meola S, Paolucci P, Rossi B, Sciacca C, Voevodina E, Azzi P, Bacchetta N, Bisello D, Boletti A, Bragagnolo A, Carlin R, Checchia P, De Castro Manzano P, Dorigo T, Gasparini F, Gasparini U, Hoh SY, Margoni M, Meneguzzo AT, Presilla M, Ronchese P, Rossin R, Simonetto F, Strong G, Tiko A, Tosi M, Yarar H, Zanetti M, Zotto P, Zucchetta A, Braghieri A, Calzaferri S, Fiorina D, Montagna P, Ratti SP, Re V, Ressegotti M, Riccardi C, Salvini P, Vai I, Vitulo P, Biasini M, Bilei GM, Ciangottini D, Fanò L, Lariccia P, Mantovani G, Mariani V, Menichelli M, Moscatelli F, Rossi A, Santocchia A, Spiga D, Tedeschi T, Androsov K, Azzurri P, Bagliesi G, Bertacchi V, Bianchini L, Boccali T, Castaldi R, Ciocci MA, Dell’Orso R, Domenico MRD, Donato S, Giannini L, Giassi A, Grippo MT, Ligabue F, Manca E, Mandorli G, Messineo A, Palla F, Ramirez-Sanchez G, Rizzi A, Rolandi G, Roy Chowdhury S, Scribano A, Shafiei N, Spagnolo P, Tenchini R, Tonelli G, Turini N, Venturi A, Verdini PG, Cavallari F, Cipriani M, Del Re D, Di Marco E, Diemoz M, Longo E, Meridiani P, Organtini G, Pandolfi F, Paramatti R, Quaranta C, Rahatlou S, Rovelli C, Santanastasio F, Soffi L, Tramontano R, Amapane N, Arcidiacono R, Argiro S, Arneodo M, Bartosik N, Bellan R, Bellora A, Biino C, Cappati A, Cartiglia N, Cometti S, Costa M, Covarelli R, Demaria N, Kiani B, Legger F, Mariotti C, Maselli S, Migliore E, Monaco V, Monteil E, Monteno M, Obertino MM, Ortona G, Pacher L, Pastrone N, Pelliccioni M, Pinna Angioni GL, Ruspa M, Salvatico R, Siviero F, Sola V, Solano A, Soldi D, Staiano A, Trocino D, Belforte S, Candelise V, Casarsa M, Cossutti F, Da Rold A, Ricca GD, Vazzoler F, Dogra S, Huh C, Kim B, Kim DH, Kim GN, Lee J, Lee SW, Moon CS, Oh YD, Pak SI, Radburn-Smith BC, Sekmen S, Yang YC, Kim H, Moon DH, Francois B, Kim TJ, Park J, Cho S, Choi S, Go Y, Ha S, Hong B, Lee K, Lee KS, Lim J, Park J, Park SK, Yoo J, Goh J, Gurtu A, Kim HS, Kim Y, Almond J, Bhyun JH, Choi J, Jeon S, Kim J, Kim JS, Ko S, Kwon H, Lee H, Lee K, Lee S, Nam K, Oh BH, Oh M, Oh SB, Seo H, Yang UK, Yoon I, Jeon D, Kim JH, Ko B, Lee JSH, Park IC, Roh Y, Song D, Watson IJ, Yoo HD, Choi Y, Hwang C, Jeong Y, Lee H, Lee Y, Yu I, Maghrbi Y, Veckalns V, Juodagalvis A, Rinkevicius A, Tamulaitis G, Wan Abdullah WAT, Yusli MN, Zolkapli Z, Benitez JF, Castaneda Hernandez A, Murillo Quijada JA, Valencia Palomo L, Castilla-Valdez H, De La Cruz-Burelo E, La Cruz IHD, Lopez-Fernandez R, Sanchez-Hernandez A, Carrillo Moreno S, Oropeza Barrera C, Ramirez-Garcia M, Vazquez Valencia F, Eysermans J, Pedraza I, Salazar Ibarguen HA, Uribe Estrada C, Morelos Pineda A, Mijuskovic J, Raicevic N, Krofcheck D, Bheesette S, Butler PH, Ahmad A, Asghar MI, Awan MIM, Hassan Q, Hoorani HR, Khan WA, Shah MA, Shoaib M, Waqas M, Avati V, Grzanka L, Malawski M, Bialkowska H, Bluj M, Boimska B, Frueboes T, Górski M, Kazana M, Szleper M, Traczyk P, Zalewski P, Bunkowski K, Byszuk A, Doroba K, Kalinowski A, Konecki M, Krolikowski J, Olszewski M, Walczak M, Araujo M, Bargassa P, Bastos D, Faccioli P, Gallinaro M, Hollar J, Leonardo N, Niknejad T, Seixas J, Shchelina K, Toldaiev O, Varela J, Afanasiev S, Alexakhin V, Bunin P, Gavrilenko M, Golutvin I, Gorbunov I, Karjavine V, Lanev A, Malakhov A, Matveev V, Mitsyn VV, Moisenz P, Palichik V, Perelygin V, Savina M, Shmatov S, Shulha S, Smirnov V, Teryaev O, Trofimov V, Voytishin N, Yuldashev BS, Zarubin A, Gavrilov G, Golovtcov V, Ivanov Y, Kim V, Kuznetsova E, Murzin V, Oreshkin V, Smirnov I, Sosnov D, Sulimov V, Uvarov L, Volkov S, Vorobyev A, Andreev Y, Dermenev A, Gninenko S, Golubev N, Karneyeu A, Kirsanov M, Krasnikov N, Pashenkov A, Pivovarov G, Tlisov D, Toropin A, Epshteyn V, Gavrilov V, Lychkovskaya N, Nikitenko A, Popov V, Pozdnyakov I, Safronov G, Spiridonov A, Stepennov A, Toms M, Vlasov E, Zhokin A, Aushev T, Chadeeva M, Oskin A, Parygin P, Polikarpov S, Zhemchugov E, Andreev V, Azarkin M, Dremin I, Kirakosyan M, Terkulov A, Belyaev A, Boos E, Bunichev V, Dubinin M, Dudko L, Klyukhin V, Kodolova O, Lokhtin I, Obraztsov S, Perfilov M, Petrushanko S, Savrin V, Snigirev A, Blinov V, Dimova T, Kardapoltsev L, Ovtin I, Skovpen Y, Azhgirey I, Bayshev I, Kachanov V, Kalinin A, Konstantinov D, Petrov V, Ryutin R, Sobol A, Troshin S, Tyurin N, Uzunian A, Volkov A, Babaev A, Iuzhakov A, Okhotnikov V, Sukhikh L, Borchsh V, Ivanchenko V, Tcherniaev E, Adzic P, Cirkovic P, Dordevic M, Milenovic P, Milosevic J, Aguilar-Benitez M, Alcaraz Maestre J, Álvarez Fernández A, Bachiller I, Barrio Luna M, Bedoya CF, Brochero Cifuentes JA, Carrillo Montoya CA, Cepeda M, Cerrada M, Colino N, De La Cruz B, Delgado Peris A, Fernández Ramos JP, Flix J, Fouz MC, García Alonso A, Gonzalez Lopez O, Goy Lopez S, Hernandez JM, Josa MI, León Holgado J, Moran D, Navarro Tobar Á, Pérez-Calero Yzquierdo A, Puerta Pelayo J, Redondo I, Romero L, Sánchez Navas S, Soares MS, Triossi A, Urda Gómez L, Willmott C, Albajar C, de Trocóniz JF, Reyes-Almanza R, Alvarez Gonzalez B, Cuevas J, Erice C, Fernandez Menendez J, Folgueras S, Gonzalez Caballero I, Palencia Cortezon E, Ramón Álvarez C, Ripoll Sau J, Rodríguez Bouza V, Sanchez Cruz S, Trapote A, Cabrillo IJ, Calderon A, Chazin Quero B, Duarte Campderros J, Fernandez M, Fernández Manteca PJ, Gomez G, Martinez Rivero C, Martinez Ruiz del Arbol P, Matorras F, Piedra Gomez J, Prieels C, Ricci-Tam F, Rodrigo T, Ruiz-Jimeno A, Russo L, Scodellaro L, Vila I, Vizan Garcia JM, Jayananda MK, Kailasapathy B, Sonnadara DUJ, Wickramarathna DDC, Dharmaratna WGD, Liyanage K, Perera N, Wickramage N, Aarrestad TK, Abbaneo D, Akgun B, Auffray E, Auzinger G, Baechler J, Baillon P, Ball AH, Barney D, Bendavid J, Beni N, Bianco M, Bocci A, Bortignon P, Bossini E, Brondolin E, Camporesi T, Cerminara G, Cristella L, d’Enterria D, Dabrowski A, Daci N, Daponte V, David A, De Roeck A, Deile M, Di Maria R, Dobson M, Dünser M, Dupont N, Elliott-Peisert A, Emriskova N, Fallavollita F, Fasanella D, Fiorendi S, Franzoni G, Fulcher J, Funk W, Giani S, Gigi D, Gill K, Glege F, Gouskos L, Guilbaud M, Gulhan D, Haranko M, Hegeman J, Iiyama Y, Innocente V, James T, Janot P, Kaspar J, Kieseler J, Komm M, Kratochwil N, Lange C, Lecoq P, Long K, Lourenço C, Malgeri L, Mannelli M, Massironi A, Meijers F, Mersi S, Meschi E, Moortgat F, Mulders M, Ngadiuba J, Niedziela J, Orfanelli S, Orsini L, Pantaleo F, Pape L, Perez E, Peruzzi M, Petrilli A, Petrucciani G, Pfeiffer A, Pierini M, Rabady D, Racz A, Rieger M, Rovere M, Sakulin H, Salfeld-Nebgen J, Scarfi S, Schäfer C, Schwick C, Selvaggi M, Sharma A, Silva P, Snoeys W, Sphicas P, Steggemann J, Summers S, Tavolaro VR, Treille D, Tsirou A, Van Onsem GP, Vartak A, Verzetti M, Wozniak KA, Zeuner WD, Caminada L, Erdmann W, Horisberger R, Ingram Q, Kaestli HC, Kotlinski D, Langenegger U, Rohe T, Backhaus M, Berger P, Calandri A, Chernyavskaya N, Dissertori G, Dittmar M, Donegà M, Dorfer C, Gadek T, Gómez Espinosa TA, Grab C, Hits D, Lustermann W, Lyon AM, Manzoni RA, Meinhard MT, Micheli F, Nessi-Tedaldi F, Pauss F, Perovic V, Perrin G, Perrozzi L, Pigazzini S, Ratti MG, Reichmann M, Reissel C, Reitenspiess T, Ristic B, Ruini D, Sanz Becerra DA, Schönenberger M, Shchutska L, Stampf V, Vesterbacka Olsson ML, Wallny R, Zhu DH, Amsler C, Botta C, Brzhechko D, Canelli MF, De Cosa A, Burgo RD, Heikkilä JK, Huwiler M, Jofrehei A, Kilminster B, Leontsinis S, Macchiolo A, Meiring P, Mikuni VM, Molinatti U, Neutelings I, Rauco G, Reimers A, Robmann P, Schweiger K, Takahashi Y, Wertz S, Adloff C, Kuo CM, Lin W, Roy A, Sarkar T, Yu SS, Ceard L, Chang P, Chao Y, Chen KF, Chen PH, Hou WS, Li YY, Lu RS, Paganis E, Psallidas A, Steen A, Yazgan E, Asavapibhop B, Asawatangtrakuldee C, Srimanobhas N, Boran F, Damarseckin S, Demiroglu ZS, Dolek F, Dozen C, Dumanoglu I, Eskut E, Gokbulut G, Guler Y, Gurpinar Guler E, Hos I, Isik C, Kangal EE, Kara O, Kayis Topaksu A, Kiminsu U, Onengut G, Ozdemir K, Polatoz A, Simsek AE, Tali B, Tok UG, Turkcapar S, Zorbakir IS, Zorbilmez C, Isildak B, Karapinar G, Ocalan K, Yalvac M, Atakisi IO, Gülmez E, Kaya M, Kaya O, Özçelik Ö, Tekten S, Yetkin EA, Cakir A, Cankocak K, Komurcu Y, Sen S, Aydogmus Sen F, Cerci S, Kaynak B, Ozkorucuklu S, Sunar Cerci D, Grynyov B, Levchuk L, Bhal E, Bologna S, Brooke JJ, Clement E, Cussans D, Flacher H, Goldstein J, Heath GP, Heath HF, Kreczko L, Krikler B, Paramesvaran S, Sakuma T, Seif El Nasr-Storey S, Smith VJ, Taylor J, Titterton A, Bell KW, Belyaev A, Brew C, Brown RM, Cockerill DJA, Ellis KV, Harder K, Harper S, Linacre J, Manolopoulos K, Newbold DM, Olaiya E, Petyt D, Reis T, Schuh T, Shepherd-Themistocleous CH, Thea A, Tomalin IR, Williams T, Bainbridge R, Bloch P, Bonomally S, Borg J, Breeze S, Buchmuller O, Bundock A, Cepaitis V, Chahal GS, Colling D, Dauncey P, Davies G, Della Negra M, Everaerts P, Fedi G, Hall G, Iles G, Langford J, Lyons L, Magnan AM, Malik S, Martelli A, Milosevic V, Nash J, Palladino V, Pesaresi M, Raymond DM, Richards A, Rose A, Scott E, Seez C, Shtipliyski A, Stoye M, Tapper A, Uchida K, Virdee T, Wardle N, Webb SN, Winterbottom D, Zecchinelli AG, Zenz SC, Cole JE, Hobson PR, Khan A, Kyberd P, Mackay CK, Reid ID, Teodorescu L, Zahid S, Brinkerhoff A, Call K, Caraway B, Dittmann J, Hatakeyama K, Kanuganti AR, Madrid C, McMaster B, Pastika N, Sawant S, Smith C, Bartek R, Dominguez A, Uniyal R, Vargas Hernandez AM, Buccilli A, Charaf O, Cooper SI, Gleyzer SV, Henderson C, Rumerio P, West C, Akpinar A, Albert A, Arcaro D, Cosby C, Demiragli Z, Gastler D, Richardson C, Rohlf J, Salyer K, Sperka D, Spitzbart D, Suarez I, Yuan S, Zou D, Benelli G, Burkle B, Coubez X, Cutts D, Duh YT, Hadley M, Heintz U, Hogan JM, Kwok KHM, Laird E, Landsberg G, Lau KT, Lee J, Narain M, Sagir S, Syarif R, Usai E, Wong WY, Yu D, Zhang W, Band R, Brainerd C, Breedon R, Calderon De La Barca Sanchez M, Chertok M, Conway J, Conway R, Cox PT, Erbacher R, Flores C, Funk G, Jensen F, Ko W, Kukral O, Lander R, Mulhearn M, Pellett D, Pilot J, Shi M, Taylor D, Tos K, Tripathi M, Yao Y, Zhang F, Bachtis M, Cousins R, Dasgupta A, Florent A, Hamilton D, Hauser J, Ignatenko M, Lam T, Mccoll N, Nash WA, Regnard S, Saltzberg D, Schnaible C, Stone B, Valuev V, Burt K, Chen Y, Clare R, Gary JW, Ghiasi Shirazi SMA, Hanson G, Karapostoli G, Long OR, Manganelli N, Olmedo Negrete M, Paneva MI, Si W, Wimpenny S, Zhang Y, Branson JG, Chang P, Cittolin S, Cooperstein S, Deelen N, Derdzinski M, Duarte J, Gerosa R, Gilbert D, Hashemi B, Klein D, Krutelyov V, Letts J, Masciovecchio M, May S, Padhi S, Pieri M, Sharma V, Tadel M, Würthwein F, Yagil A, Amin N, Campagnari C, Citron M, Dorsett A, Dutta V, Incandela J, Marsh B, Mei H, Ovcharova A, Qu H, Quinnan M, Richman J, Sarica U, Stuart D, Wang S, Anderson D, Bornheim A, Cerri O, Dutta I, Lawhorn JM, Lu N, Mao J, Newman HB, Nguyen TQ, Pata J, Spiropulu M, Vlimant JR, Xie S, Zhang Z, Zhu RY, Alison J, Andrews MB, Ferguson T, Mudholkar T, Paulini M, Sun M, Vorobiev I, Cumalat JP, Ford WT, MacDonald E, Mulholland T, Patel R, Perloff A, Stenson K, Ulmer KA, Wagner SR, Alexander J, Cheng Y, Chu J, Cranshaw DJ, Datta A, Frankenthal A, Mcdermott K, Monroy J, Patterson JR, Quach D, Ryd A, Sun W, Tan SM, Tao Z, Thom J, Wittich P, Zientek M, Abdullin S, Albrow M, Alyari M, Apollinari G, Apresyan A, Apyan A, Banerjee S, Bauerdick LAT, Beretvas A, Berry D, Berryhill J, Bhat PC, Burkett K, Butler JN, Canepa A, Cerati GB, Cheung HWK, Chlebana F, Cremonesi M, Elvira VD, Freeman J, Gecse Z, Gottschalk E, Gray L, Green D, Grünendahl S, Gutsche O, Harris RM, Hasegawa S, Heller R, Herwig TC, Hirschauer J, Jayatilaka B, Jindariani S, Johnson M, Joshi U, Klabbers P, Klijnsma T, Klima B, Kortelainen MJ, Lammel S, Lincoln D, Lipton R, Liu M, Liu T, Lykken J, Maeshima K, Mason D, McBride P, Merkel P, Mrenna S, Nahn S, O’Dell V, Papadimitriou V, Pedro K, Pena C, Prokofyev O, Ravera F, Reinsvold Hall A, Ristori L, Schneider B, Sexton-Kennedy E, Smith N, Soha A, Spalding WJ, Spiegel L, Stoynev S, Strait J, Taylor L, Tkaczyk S, Tran NV, Uplegger L, Vaandering EW, Weber HA, Woodard A, Acosta D, Avery P, Bourilkov D, Cadamuro L, Cherepanov V, Errico F, Field RD, Guerrero D, Joshi BM, Kim M, Konigsberg J, Korytov A, Lo KH, Matchev K, Menendez N, Mitselmakher G, Rosenzweig D, Shi K, Wang J, Wang S, Zuo X, Adams T, Askew A, Diaz D, Habibullah R, Hagopian S, Hagopian V, Johnson KF, Khurana R, Kolberg T, Martinez G, Prosper H, Schiber C, Yohay R, Zhang J, Baarmand MM, Butalla S, Elkafrawy T, Hohlmann M, Noonan D, Rahmani M, Saunders M, Yumiceva F, Adams MR, Apanasevich L, Becerril Gonzalez H, Cavanaugh R, Chen X, Dittmer S, Evdokimov O, Gerber CE, Hangal DA, Hofman DJ, Mills C, Oh G, Roy T, Tonjes MB, Varelas N, Viinikainen J, Wang X, Wu Z, Alhusseini M, Dilsiz K, Durgut S, Gandrajula RP, Haytmyradov M, Khristenko V, Köseyan OK, Merlo JP, Mestvirishvili A, Moeller A, Nachtman J, Ogul H, Onel Y, Ozok F, Penzo A, Snyder C, Tiras E, Wetzel J, Yi K, Amram O, Blumenfeld B, Corcodilos L, Eminizer M, Gritsan AV, Kyriacou S, Maksimovic P, Mantilla C, Roskes J, Swartz M, Vámi TÁ, Baldenegro Barrera C, Baringer P, Bean A, Bylinkin A, Isidori T, Khalil S, King J, Krintiras G, Kropivnitskaya A, Lindsey C, Minafra N, Murray M, Rogan C, Royon C, Sanders S, Schmitz E, Takaki JDT, Wang Q, Williams J, Wilson G, Duric S, Ivanov A, Kaadze K, Kim D, Maravin Y, Mitchell T, Modak A, Mohammadi A, Rebassoo F, Wright D, Adams E, Baden A, Baron O, Belloni A, Eno SC, Feng Y, Hadley NJ, Jabeen S, Jeng GY, Kellogg RG, Koeth T, Mignerey AC, Nabili S, Seidel M, Skuja A, Tonwar SC, Wang L, Wong K, Abercrombie D, Allen B, Bi R, Brandt S, Busza W, Cali IA, Chen Y, D’Alfonso M, Gomez Ceballos G, Goncharov M, Harris P, Hsu D, Hu M, Klute M, Kovalskyi D, Krupa J, Lee YJ, Luckey PD, Maier B, Marini AC, Mcginn C, Mironov C, Narayanan S, Niu X, Paus C, Rankin D, Roland C, Roland G, Shi Z, Stephans GSF, Sumorok K, Tatar K, Velicanu D, Wang J, Wang TW, Wang Z, Wyslouch B, Chatterjee RM, Evans A, Guts S, Hansen P, Hiltbrand J, Jain S, Krohn M, Kubota Y, Lesko Z, Mans J, Revering M, Rusack R, Saradhy R, Schroeder N, Strobbe N, Wadud MA, Acosta JG, Oliveros S, Bloom K, Chauhan S, Claes DR, Fangmeier C, Finco L, Golf F, González Fernández JR, Kravchenko I, Siado JE, Snow GR, Stieger B, Tabb W, Yan F, Agarwal G, Harrington C, Hay L, Iashvili I, Kharchilava A, McLean C, Nguyen D, Parker A, Pekkanen J, Rappoccio S, Roozbahani B, Alverson G, Barberis E, Freer C, Haddad Y, Hortiangtham A, Madigan G, Marzocchi B, Morse DM, Nguyen V, Orimoto T, Skinnari L, Tishelman-Charny A, Wamorkar T, Wang B, Wisecarver A, Wood D, Bhattacharya S, Bueghly J, Chen Z, Gilbert A, Gunter T, Hahn KA, Odell N, Schmitt MH, Sung K, Velasco M, Bucci R, Dev N, Goldouzian R, Hildreth M, Hurtado Anampa K, Jessop C, Karmgard DJ, Lannon K, Li W, Loukas N, Marinelli N, Mcalister I, Meng F, Mohrman K, Musienko Y, Ruchti R, Siddireddy P, Taroni S, Wayne M, Wightman A, Wolf M, Zygala L, Alimena J, Bylsma B, Cardwell B, Durkin LS, Francis B, Hill C, Lefeld A, Winer BL, Yates BR, Dezoort G, Elmer P, Greenberg B, Haubrich N, Higginbotham S, Kalogeropoulos A, Kopp G, Kwan S, Lange D, Lucchini MT, Luo J, Marlow D, Mei K, Ojalvo I, Olsen J, Palmer C, Piroué P, Stickland D, Tully C, Malik S, Norberg S, Barnes VE, Chawla R, Das S, Gutay L, Jones M, Jung AW, Mahakud B, Negro G, Neumeister N, Peng CC, Piperov S, Qiu H, Schulte JF, Trevisani N, Wang F, Xiao R, Xie W, Cheng T, Dolen J, Parashar N, Stojanovic M, Baty A, Dildick S, Ecklund KM, Freed S, Geurts FJM, Kilpatrick M, Kumar A, Li W, Padley BP, Redjimi R, Roberts J, Rorie J, Shi W, Stahl Leiton AG, Zhang A, Bodek A, de Barbaro P, Demina R, Dulemba JL, Fallon C, Ferbel T, Galanti M, Garcia-Bellido A, Hindrichs O, Khukhunaishvili A, Ranken E, Taus R, Chiarito B, Chou JP, Gandrakota A, Gershtein Y, Halkiadakis E, Hart A, Heindl M, Hughes E, Kaplan S, Karacheban O, Laflotte I, Lath A, Montalvo R, Nash K, Osherson M, Salur S, Schnetzer S, Somalwar S, Stone R, Thayil SA, Thomas S, Wang H, Acharya H, Delannoy AG, Spanier S, Bouhali O, Dalchenko M, Delgado A, Eusebi R, Gilmore J, Huang T, Kamon T, Kim H, Luo S, Malhotra S, Mueller R, Overton D, Perniè L, Rathjens D, Safonov A, Sturdy J, Akchurin N, Damgov J, Hegde V, Kunori S, Lamichhane K, Lee SW, Mengke T, Muthumuni S, Peltola T, Undleeb S, Volobouev I, Wang Z, Whitbeck A, Appelt E, Greene S, Gurrola A, Janjam R, Johns W, Maguire C, Melo A, Ni H, Padeken K, Romeo F, Sheldon P, Tuo S, Velkovska J, Verweij M, Ang L, Arenton MW, Cox B, Cummings G, Hakala J, Hirosky R, Joyce M, Ledovskoy A, Neu C, Tannenwald B, Wang Y, Wolfe E, Xia F, Karchin PE, Poudyal N, Thapa P, Black K, Bose T, Buchanan J, Caillol C, Dasu S, De Bruyn I, Galloni C, He H, Herndon M, Hervé A, Hussain U, Lanaro A, Loeliger A, Loveless R, Madhusudanan Sreekala J, Mallampalli A, Pinna D, Ruggles T, Savin A, Shang V, Sharma V, Smith WH, Teague D, Trembath-reichert S, Vetens W. Development and validation of HERWIG 7 tunes from CMS underlying-event measurements

This paper presents new sets of parameters ("tunes") for the underlying-event model of the H E R W I G 7 event generator. These parameters control the description of multiple-parton interactions (MPI) and colour reconnection in H E R W I G 7 , and are obtained from a fit to minimum-bias data collected by the CMS experiment at s = 0.9 , 7, and 13 Te . The tunes are based on the NNPDF 3.1 next-to-next-to-leading-order parton distribution function (PDF) set for the parton shower, and either a leading-order or next-to-next-to-leading-order PDF set for the simulation of MPI and the beam remnants. Predictions utilizing the tunes are produced for event shape observables in electron-positron collisions, and for minimum-bias, inclusive jet, top quark pair, and Z and W boson events in proton-proton collisions, and are compared with data. Each of the new tunes describes the data at a reasonable level, and the tunes using a leading-order PDF for the simulation of MPI provide the best description of the data.

Measurements of p p → Z Z production cross sections and constraints on anomalous triple gauge couplings at s = 13 TeV

The production of Z boson pairs in proton-proton ( p p ) collisions, p p → ( Z / γ ∗ ) ( Z / γ ∗ ) → 2 ℓ 2 ℓ ' , where ℓ , ℓ ' = e or μ , is studied at a center-of-mass energy of 13TeV with the CMS detector at the CERN LHC. The data sample corresponds to an integrated luminosity of 137fb - 1 , collected during 2016-2018. The Z Z production cross section,σ tot ( p p → Z Z ) = 17.4 ± 0.3 (stat) ± 0.5 (syst) ± 0.4 (theo) ± 0.3 (lumi) pb , measured for events with two pairs of opposite-sign, same-flavor leptons produced in the mass region 60 < m ℓ + ℓ - < 120 GeV is consistent with standard model predictions. Differential cross sections are also measured and agree with theoretical predictions. The invariant mass distribution of the four-lepton system is used to set limits on anomalous Z Z Z and Z Z γ couplings.

Search for dark matter produced in association with a leptonically decaying Z boson in proton-proton collisions at s = 13 Te

A search for dark matter particles is performed using events with a Z boson candidate and large missing transverse momentum. The analysis is based on proton-proton collision data at a center-of-mass energy of 13Te , collected by the CMS experiment at the LHC in 2016-2018, corresponding to an integrated luminosity of 137fb - 1 . The search uses the decay channels Z → e e and Z → μ μ . No significant excess of events is observed over the background expected from the standard model. Limits are set on dark matter particle production in the context of simplified models with vector, axial-vector, scalar, and pseudoscalar mediators, as well as on a two-Higgs-doublet model with an additional pseudoscalar mediator. In addition, limits are provided for spin-dependent and spin-independent scattering cross sections and are compared to those from direct-detection experiments. The results are also interpreted in the context of models of invisible Higgs boson decays, unparticles, and large extra dimensions.