Three-year chronic follow-up from the pilot study of a substernal extravascular implantable cardioverter defibrillator

Funding Acknowledgements

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

Background

The investigational Extravascular Implantable Cardioverter-Defibrillator (EV ICD) uses a substernal lead and delivers defibrillation and pacing therapies, including antitachycardia pacing (ATP).

Objective

To characterize EV ICD system performance through 3 years.

Methods

The prospective, first-in-human EV ICD Pilot study was conducted at 4 sites in Australia and New Zealand. ICD-indicated patients were enrolled July-December of 2018. Defibrillation testing was conducted for all patients at implant, and chronically per physician discretion. Electrical testing was conducted at pre-hospital discharge, 2 weeks, 4-6 weeks and 3 months post-implant, and every 6 months thereafter. Posture effects on pacing and sensing were evaluated through 3 months.

Results

Of 26 patients enrolled, 21 underwent the EV ICD implant procedure. There were no intraprocedural complications. After successful implantation and testing, 17 of 21 patients entered chronic follow-up. 14 patients continue follow up, representing 523 patient-months. Eight elective chronic defibrillation tests converted 7 of 7 patients with ≤ 40 J (maximum energy). Five episodes of spontaneous ventricular tachycardia (VT) were detected in 1 patient and either self-terminated or successfully defibrillated with appropriate shock.

Over the total course of follow-up, 3 patients received an inappropriate shock due to; lead tip displacement with subsequent P-wave oversensing; Electromagnetic interference (EMI) in a ungrounded hot-tub; and EMI while doing plumbing work on unearthed electrical pipes, resulting in an annualized inappropriate shock rate of 6.9%.

Pacing capture thresholds remained stable across time (5.1 ± 2.0 V at implant and 5.5 ± 2.7 V at 3 years); similarly, R-wave amplitudes were stable across time (3.4 ±2.0 mV at implant and 4.2 ± 2.7 mV at 3 years). Pacing thresholds tended to be lowest with the patient lying on the right side and pacing threshold often increased relative to supine position for left-side, prone or bending postures. R-wave amplitude tended to be greater when bending forward.

There were 10 system or procedure-related adverse events in 8 patients through 3 years, including 3 elective system removals for: a single inappropriate shock (1), chronic defibrillation testing showing no safety margin in a patient with arrhythmogenic right ventricular dysplasia (1), intolerance to ATP (1 - high pacing threshold and frequent VT). Other than the lead tip displacement within the first 3 months, no additional clinically significant lead displacements have been observed through 3 years.

Conclusion

The EV ICD is a novel platform for delivering high-voltage therapy. There were no procedure and system related complications observed after the first year post-implant. Lead position and chronic system performance have generally remained stable through 3 years with a low rate of adverse events.

The COV-ED Survey: exploring the impact of learning and teaching from home on parent/carers' and teachers' mental health and wellbeing during COVID-19 lockdown

BACKGROUND

Following the emergence of COVID-19 in the UK, on March 18^th 2020 the majority of schools in England closed and families and teachers were tasked with providing educational support for children and adolescents within the home environment. Little is known, however, regarding the impact of remote teaching and learning on the mental wellbeing of parents/carers and teaching staff.

METHODS

The Coronavirus Education (COV-ED) online survey explored the practicalities of learning and teaching from home for 329 parents/carers and 117 teachers of 11-15 year old adolescents in England, during June/July 2020, and the associated impact on their mental wellbeing. Participants were recruited through schools and via University of Warwick social media channels. Data was analysed using a series of Multiple Linear and Multivariate Regressions.

RESULTS

Despite coping well with the challenges of remote learning, a third of teachers reported below average mental wellbeing on the Warwick-Edinburgh Mental Wellbeing Scale. Multivariate regression revealed that wellbeing was associated with access to resources and confidence to teach from home. Almost half of parents/carers surveyed reported below average wellbeing. Multivariate regression revealed that poor wellbeing was more common in those who were also working from home and who lacked support for their own mental health. Concerns about their child's mental health and lack of access to electronic devices and workspace were also significantly associated with the mental wellbeing of parents/carers.

CONCLUSIONS

Whilst young people's mental health and wellbeing has, and continues to be a national priority, the mental health and wellbeing of the families and teachers supporting them has not previously been explored. Our survey population was of predominantly white British heritage, female and living in the West Midlands UK, therefore, findings should be treated with caution. Findings provide a snapshot of factors that may be of significance to families and schools in supporting the mental wellbeing of those tasked with learning from home. They will help i) increase knowledge and awareness with regard to future support of families and teachers during similar crises; ii) enable the design and development of practical solutions in the delivery of remote teaching and learning; and, iii) help address the mental wellbeing needs of those tasked with supporting adolescents.

The effects of exercise training in the cold on cerebral blood flow and cerebrovascular function in young healthy individuals

Exercise elicits acute increases in cerebral blood flow velocity (CBFv) and provokes long-term beneficial effects on CBFv, thereby reducing cerebrovascular risk. Acute exposure to a cold stimulus also increases CBFv. We compared the impact of exercise training in cold and thermoneutral environments on CFBv, cerebrovascular function and peripheral endothelial function. Twenty-one (16 males, 22 ± 5 years) individuals were randomly allocated to either a cold (5 °C) or thermoneutral (15 °C) exercise intervention. Exercise consisted of 50-min cycling at 70% heart rate max, three times per week for eight weeks. Transcranial Doppler was used to determine pre and post intervention CBFv, dynamic cerebral autoregulation (dCA) and cerebrovascular reactivity (CVRCO2). Conduit endothelial function, microvascular function and cardiorespiratory fitness were also assessed. Cardiorespiratory fitness improved (2.91 ml.min.kg-1, 95%CI 0.49, 5.3; P = 0.02), regardless of exercise setting. Neither intervention had an impact on CBFv, CVRCO2, FMD or microvascular function (P > 0.05). There was a significant interaction between time and condition for dCA normalised gain with evidence of a decrease by 0.192%cm.s-1.%mmHg-1 (95%CI -0.318, -0.065) following training in the cold and increase (0.129%cm.s-1.%mmHg-1, 95%CI 0.011, 0.248) following training in the thermoneutral environment (P = 0.001). This was also evident for dCA phase with evidence of an increase by 0.072 rad (95%CI -0.007, 0.152) following training in the cold and decrease by 0.065 (95%CI -0.144, 0.014) radians following training in the thermoneutral environment (P = 0.02). Both training interventions improved fitness but CBFv, CVRCO2 and peripheral endothelial function were unaltered. Exercise training in the cold improved dCA whereas thermoneutral negated dCA.

Designing Experiments for Physiological Phenomics

Phenomics has emerged as the technology of choice for understanding quantitative genetic variation in plant physiology and plant breeding. Phenomics has allowed for unmatched precision in exploring plant life cycles and physiological patterns. As new technologies are developed, it is still vital to follow best practices for designing and planning to be able to fully exploit any experimental results. Here we describe the basic - but sometimes overlooked - considerations of a phenomics experiment to help you maximize the value from the data collected: choosing population and location, accounting for sources of variation, establishing a timeline, and leveraging ground-truth measurements.

1700 Using Intra-Operative Imaging as A Tool to Provide Peer Review, Scoring, Feedback and Education for Hand and Wrist Trauma Cases - A Quality Improvement Project

Aim

To improve the efficiency of intraoperative hand trauma x-ray review, introduce a scoring system for quality of fixation achieved and use this as an education and feedback tool for trainees.

Method

A large QI project in 2019 demonstrated that intra-operative images taken using the mini C-arm were not being reviewed. In March 2020 the first QI cycle introduced an Access database to ensure that as cases were removed from the trauma board, they were added to a review list. Each x-ray was also scored in the trauma meeting (good, acceptable, poor) to assess the radiographic quality of fixation. The second QI cycle identified the named surgeon for each case, allowing surgeon specific feedback. Finally, we trained all qualified users of the mini C-arm to upload their own images after each case, reducing the mean time to upload.

Results

This QI project has improved the review rate of mini C-arm images from 30% to 100% and every x-ray is scored. The mean time to review images has reduced from 4 days to less than 24 hours. All trainees can access their scores for imaged hand and wrist trauma and receive written constructive feedback.

Conclusions

This project ensures appropriate and prompt review of all hand and wrist trauma cases allowing early identification of any concerns. All x-rays are scored, and this process acts as an educational prompt in the trauma meeting. A final report can be printed for each trainee which can be uploaded to their portfolio to document their surgical progress.

Utilizing MIKC-type MADS-box protein SOC1 for yield potential enhancement in maize

Overexpression of Zea mays SOC gene promotes flowering, reduces plant height, and leads to no reduction in grain production per plant, suggesting enhanced yield potential, at least, through increasing planting density. MIKC-type MADS-box gene SUPPRESSOR OF OVEREXPRESSION OF CONSTANS 1 (SOC1) is an integrator conserved in the plant flowering pathway. In this study, the maize SOC1 (ZmSOC1) gene was cloned and overexpressed in transgenic maize Hi-II genotype. The T₀ plants were backcrossed with nontransgenic inbred B73 to produce first generation backcross (BC₁) seeds. Phenotyping of both transgenic and null segregant (NT) BC₁ plants was conducted in three independent experiments. The BC₁ transgenic plants showed new attributes such as increased vegetative growth, accelerated flowering time, reduced overall plant height, and increased grain weight. Second generation backcross (BC₂) plants were evaluated in the field using two planting densities. Compared to BC₂ NT plants, BC₂ transgenic plants, were 12-18% shorter, flowered 5 days earlier, and showed no reduction in grain production per plant and an increase in fat, starch, and simple sugars in the grain. Transcriptome comparison in young leaves of 56-day-old BC₁ plants revealed that the overexpressed ZmSOC1 resulted in 107 differentially expressed genes. The upregulated transcription factor DNA BINDING WITH ONE FINGER 5.4 (DOF5.4) was among the genes responsible for the reduced plant height. Modulating expression of SOC1 opens a new and effective approach to promote flowering and reduce plant height, which may have potential to enhance crop yield and improve grain quality.

Mucosal Bacteria Modulate Candida albicans Virulence in Oropharyngeal Candidiasis

Oropharyngeal candidiasis (OPC) is the most prevalent oral infection in immunocompromised patients, primarily associated with Candida albicans. Increasing evidence points to a significant role of mucosal bacteria on the transition of C. albicans from commensal to pathogenic. In this work, we hypothesized that changes in the abundance or composition of the mucosal bacterial microbiota induced by dietary sucrose during the development of OPC can modulate C. albicans virulence. C. albicans burdens and mucosal lesions were evaluated in a mouse cortisone immunosuppression model amended with sucrose. We also analyzed the mucosal bacterial composition using 16S rRNA gene sequencing and culture methods. In immunocompetent mice, sucrose significantly increased total bacterial burdens and reduced alpha diversity, by increasing the relative abundance of mitis group streptococci. In immunocompromised mice, C. albicans infection was associated with a significantly reduced bacterial alpha diversity due to an increase in the relative abundance of enterococci. When exposed to dietary sucrose, these mice had reduced C. albicans burdens and reduced bacterial alpha diversity, associated with an increase in the relative abundance of Lactobacillus. SparCC correlation networks showed a significant negative correlation between Lactobacillus and Enterococcus in all Candida-infected mice. Depletion of lactobacilli with antibiotic treatment partially restored C. albicans burdens in mice receiving sucrose. In coculture in vitro experiments, mouse oral Lactobacillus johnsonii isolates inhibited growth of Enterococcus faecalis isolates and C. albicans. These results support the hypothesis that the sucrose-induced attenuation of C. albicans virulence was a result of changes in the mucosal bacterial microbiome characterized by a reduction in enterococci and an increase in lactobacilli. IMPORTANCE By comparing Candida albicans virulence and the mucosal bacterial composition in a mouse oral infection model, we were able to dissect the effects of the host environment (immunosuppression), infection with C. albicans, and local modulating factors (availability of sucrose as a carbon source) on the mucosal bacterial microbiome and its role on fungal virulence. We showed that changes in endogenous microbial communities in response to sucrose can lead to attenuation of fungal disease. We also showed that Lactobacillus johnsonii may curtail Candida virulence both by inhibiting its growth and by inhibiting the growth of potentially synergistic bacteria such as enterococci. Our results support the concept that Candida pathogenesis should be viewed in the contexts of both a susceptible host and a mucosal bacterial microbiota conducive to virulence.

Continuous versus intermittent extended adjuvant letrozole for breast cancer: final results of randomized phase III SOLE (Study of Letrozole Extension) and SOLE Estrogen Substudy

BACKGROUND

Late recurrences in postmenopausal women with hormone receptor-positive breast cancers remain an important challenge. Avoidance or delayed development of resistance represents the main objective in extended endocrine therapy (ET). In animal models, resistance was reversed with restoration of circulating estrogen levels during interruption of letrozole treatment. This phase III, randomized, open-label Study of Letrozole Extension (SOLE) studied the effect of extended intermittent letrozole treatment in comparison with continuous letrozole. In parallel, the SOLE estrogen substudy (SOLE-EST) analyzed the levels of estrogen during the interruption of treatment.

PATIENTS AND METHODS

SOLE enrolled 4884 postmenopausal women with hormone receptor-positive, lymph node-positive, operable breast cancer between December 2007 and October 2012 and among them, 104 patients were enrolled in SOLE-EST. They must have undergone local treatment and have completed 4-6 years of adjuvant ET. Patients were randomized between continuous letrozole (2.5 mg/day orally for 5 years) and intermittent letrozole treatment (2.5 mg/day for 9 months followed by a 3-month interruption in years 1-4 and then 2.5 mg/day during all of year 5).

RESULTS

Intention-to-treat population included 4851 women in SOLE (n = 2425 in the intermittent and n = 2426 in the continuous letrozole groups) and 103 women in SOLE-EST (n = 78 in the intermittent and n = 25 in the continuous letrozole groups). After a median follow-up of 84 months, 7-year disease-free survival (DFS) was 81.4% in the intermittent group and 81.5% in the continuous group (hazard ratio: 1.03, 95% confidence interval: 0.91-1.17). Reported adverse events were similar in both groups. Circulating estrogen recovery was demonstrated within 6 weeks after the stop of letrozole treatment.

CONCLUSIONS

Extended adjuvant ET by intermittent administration of letrozole did not improve DFS compared with continuous use, despite the recovery of circulating estrogen levels. The similar DFS coupled with previously reported quality-of-life advantages suggest intermittent extended treatment is a valid option for patients who require or prefer a treatment interruption.

The importance of dominance and genotype-by-environment interactions on grain yield variation in a large-scale public cooperative maize experiment

High-dimensional and high-throughput genomic, field performance, and environmental data are becoming increasingly available to crop breeding programs, and their integration can facilitate genomic prediction within and across environments and provide insights into the genetic architecture of complex traits and the nature of genotype-by-environment interactions. To partition trait variation into additive and dominance (main effect) genetic and corresponding genetic-by-environment variances, and to identify specific environmental factors that influence genotype-by-environment interactions, we curated and analyzed genotypic and phenotypic data on 1918 maize (Zea mays L.) hybrids and environmental data from 65 testing environments. For grain yield, dominance variance was similar in magnitude to additive variance, and genetic-by-environment variances were more important than genetic main effect variances. Models involving both additive and dominance relationships best fit the data and modeling unique genetic covariances among all environments provided the best characterization of the genotype-by-environment interaction patterns. Similarity of relative hybrid performance among environments was modeled as a function of underlying weather variables, permitting identification of weather covariates driving correlations of genetic effects across environments. The resulting models can be used for genomic prediction of mean hybrid performance across populations of environments tested or for environment-specific predictions. These results can also guide efforts to incorporate high-throughput environmental data into genomic prediction models and predict values in new environments characterized with the same environmental characteristics.

Toxoplasma gondii, Herpesviridae and long-term risk of transition to first-episode psychosis in an ultra high-risk sample

BACKGROUND

Ultra high-risk (UHR) criteria were introduced to identify people at imminent risk of developing psychosis. To improve prognostic accuracy, additional clinical and biological risk factors have been researched. Associations between psychotic disorders and infections with Toxoplasma gondii and Herpesviridae have been found. It is unknown if exposure to those pathogens increases the risk of transition to psychosis in UHR cohorts.

METHODS

We conducted a long-term follow-up of 96 people meeting UHR criteria, previously seen at the Personal Assessment and Crisis Evaluation (PACE) clinic, a specialized service in Melbourne, Australia. Transition to psychosis was assessed using the Comprehensive Assessment of the At-Risk Mental State (CAARMS) and state public mental health records. The relationship between IgG antibodies to Herpesviridae (HSV-1, HSV-2, CMV, EBV, VZV) and Toxoplasma gondii and risk for transition was examined with Cox regression models.

RESULTS

Mean follow-up duration was 6.46 (±3.65) years. Participants who transitioned to psychosis (n = 14) had significantly higher antibody titers for Toxoplasma gondii compared to those who did not develop psychosis (p = 0.03). After adjusting for age, gender and year of baseline assessment, seropositivity for Toxoplasma gondii was associated with a 3.6-fold increase in transition hazard in multivariate Cox regression models (HR = 3.6; p = 0.036). No significant association was found between serostatus for Herpesviridae and risk of transition.

CONCLUSIONS

Exposure to Toxoplasma gondii may contribute to the manifestation of positive psychotic symptoms and increase the risk of transitioning to psychosis in UHR individuals.

Development and implementation of a clinical information system-based protocol to improve nurse satisfaction of end-of-life care in a single intensive care unit

BACKGROUND

Patients treated in Australian intensive care units (ICUs) have an overall mortality rate of 5.05%. This is due to the critical nature of their disease, the increasing proportion of patients with multiple comorbidities, and advanced age. This has made treating patients during the end of life an integral part of intensive care practice and requires a high quality of care. With the increased use of electronic clinical information systems, a standardised protocol encompassing end-of-life care may provide an efficient method for documentation, communication, and timely delivery of comfort care.

OBJECTIVE

The aim of the study was to determine if an electronic clinical information system-based end-of-life care protocol improved nurses' satisfaction with the practice of end-of-life care for patients in the ICU.

DESIGN

This is a prospective single-centre observational study.

SETTING

The study was carried out at a 20-bed cardiothoracic and general ICU between 2015 and 2017.

PARTICIPANTS

The study participants were ICU nurses.

INTERVENTION

Electronic clinical information-based end-of-life care protocol was used in the study.

OUTCOME

The primary outcome was nurse satisfaction obtained by a survey.

RESULTS

The number of respondents for the before survey and after survey was 58 (29%) and 64 (32%), respectively. There was a significant difference between the before survey and the after survey with regard to feeling comfortable in transitioning from curative treatment (median = 2 [interquartile range {IQR} = 2, 3] vs 3 [IQR = 2, 3], p = 0.03), feeling involved in the decision to move from curative treatment to end-of-life care (median = 2 [IQR = 2, 2] vs 2 [IQR 2, 3], p = 0.049), and feeling religious beliefs/rituals should be respected during the end-of-life process (median = 4 [IQR = 3, 4] vs. 4 [IQR = 4, 4], p = 0.02). There were some practices that had a low satisfaction rate on both the before survey and after survey. However, a high proportion of nurses were satisfied with many of the end-of-life care practices.

CONCLUSION

The nurses were highly satisfied with many aspects of end-of-life care practices in this unit. The use of an electronic clinical information system-based protocol improved nurse satisfaction and perception of quality of end-of-life care practices for three survey questions.

Management of acute disturbance: The intravenous route

Introduction

The intravenous (IV) is one of the main parenteral routes for drug administration. Rapid onset of action, precise titration, patient-specific dosing and bypass of liver metabolism are a few of its advantages, while hypersensitivity reactions, adverse effects, infection risk and a higher overall cost some of its most debated downsides. Unlike other areas of Medicine, IV has been significantly under-utilized in Psychiatry.

Objectives

This systematic review analyzed the evidence for effectiveness and safety behind the use of IV medication used for the management of acute disturbance.

Methods

APA PsycINFO, MEDLINE, and EMBASE databases were searched for eligible studies. Studies were included if they used IV medication to treat acute disturbance, in English language, had participants aged >18. The quality of the included studies was assessed using the National Institutes of Health quality checklist.

Results

17 studies were deemed eligible. Data analysis was limited to narrative synthesis since primary outcome measures varied significantly between each study. Findings showed strong evidence for efficacy and safety of dexmedetomidine, droperidol, midazolam, and olanzapine. These medications displayed a short time to sedation, reduction in agitation levels, or large percentage of patients adequately sedated with a low number of adverse events. Results did not provide enough evidence for the use of IV ketamine, haloperidol, diazepam, lorazepam, and promethazine.

Conclusions

This review supports dexmedetomidine, droperidol, midazolam, and olanzapine as safe and efficacious options for managing acute disturbance via the intravenous route, particularly in special clinical settings where trained staff, optimal monitoring, resuscitation equipment and ventilators are all at hand.

Tonsillitis, tonsillectomy, and deep neck space infections in England: the case for a new guideline for surgical and non-surgical management

INTRODUCTION

Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits.

MATERIALS AND METHODS

A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance.

RESULTS

Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period.

DISCUSSION

The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.

Factors Associated with Self-Reported Dysphagia in Older Adults Receiving Meal Support

OBJECTIVES

Dysphagia is common in older adults. However, there are no current estimates of dysphagia in community-dwelling older adults those receiving meal support. It is unknown whether dysphagia is associated with other measures of physical function (activities of daily living [ADL] ability or nutrition status). The study purposes were to determine the prevalence of self-reported dysphagia and to identify factors associated with self-reported dysphagia in community-dwelling older adults receiving meal support.

DESIGN

A cross-sectional study.

SETTING AND PARTICIPANTS

476 community-dwelling older adults (78.5±0.51 years) across five Elder Nutrition Program meal services in Wisconsin participated in the study.

MEASUREMENTS

Data were collected through administration of validated ADL and nutrition questionnaires (nutritional status, functional status with ADLs, chewing ability, dental conditions, and prior diagnoses of dysphagia, pneumonia, and dementia). For self-reported dysphagia, the validated 10-item eating assessment tool (EAT-10) was used.

RESULTS

The prevalence of self-reported dysphagia (EAT-10 score of ≥ 3) was 20.4%. Multivariate logistic regression results indicated that poor nutritional status (OR=3.1, p=0.04), difficulty chewing (OR=2.2, p=0.03), prior dysphagia diagnosis (OR=34.8, p<0.001), prior pneumonia diagnosis (OR=2.1, p=0.04), and meal service site (OR=2.68, p=0.02) were associated with self-reported dysphagia.

CONCLUSION

Approximately one in five community-dwelling older adults receiving meal support had self-reported dysphagia. Increased risk for poor nutrition, reduced chewing ability, prior dysphagia and pneumonia diagnosis, and meal service site were identified as factors associated with dysphagia on the EAT-10. Results highlight the need for further studies across more sites to identify dysphagia risk indicators in community-dwelling older adults receiving meal support state-wide.

Cochlear nerve anomalies in paediatric single-sided deafness - prevalence and implications for cochlear implantation strategies

OBJECTIVE

To determine the prevalence of cochlear nerve anomalies on magnetic resonance imaging in patients with unilateral or bilateral sensorineural hearing loss.

METHODS

A retrospective case series was conducted at a tertiary referral centre. The inclusion criteria were paediatric patients with bilateral or unilateral sensorineural hearing loss, investigated with magnetic resonance imaging. The primary outcome measure was the rate of cochlear nerve hypoplasia or aplasia.

RESULTS

Of the 72 patients with unilateral sensorineural hearing loss, 39 per cent (28 cases) had absent or hypoplastic cochlear nerves on the affected side. Fifteen per cent (11 cases) had other abnormal findings on magnetic resonance imaging. Eighty-four patients had bilateral sensorineural hearing loss, of which cochlear nerve hypoplasia or aplasia was identified only in 5 per cent (four cases). Other abnormal findings were identified in 14 per cent (12 cases).

CONCLUSION

Paediatric patients with unilateral sensorineural hearing loss are more likely to have cochlear nerve anomalies than those patients with bilateral sensorineural hearing loss. This has important implications regarding cochlear implantation for patients with single-sided deafness.

Multimorbidity, polypharmacy, and drug-drug-gene interactions following a non-ST elevation acute coronary syndrome: analysis of a multicentre observational study

BACKGROUND

The number of patients living with co-existing diseases is growing. This study aimed to assess the extent of multimorbidity, medication use, and drug- and gene-based interactions in patients following a non-ST elevation acute coronary syndrome (NSTE-ACS).

METHODS

In 1456 patients discharged from hospital for a NSTE-ACS, comorbidities and multimorbidity (≥ 2 chronic conditions) were assessed. Of these, 698 had complete drug use recorded at discharge, and 652 (the 'interaction' cohort) had drug use and actionable genotypes available for CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP3A5, DPYD, F5, SLCO1B1, TPMT, UGT1A1, and VKORC1. The following drug interactions were investigated: pharmacokinetic drug-drug (DDIs) involving CYPs (CYPs above, plus CYP1A2, CYP2C8, CYP3A4), SLCO1B1, and P-glycoprotein; drug-gene (DGIs); drug-drug-gene (DDGIs); and drug-gene-gene (DGGIs). Interactions predicted to be 'substantial' were defined as follows: DDIs due to strong inhibitors/inducers, DGIs due to variant homozygous/compound heterozygous genotypes, and DDGIs/DGGIs where the constituent DDI/DGI(s) both influenced the victim drug in the same direction.

RESULTS

In the whole cohort, 727 (49.9%) patients had multimorbidity. Non-linear relationships between age and increasing comorbidities and decreasing coronary intervention were observed. There were 98.1% and 39.8% patients on ≥ 5 and ≥ 10 drugs, respectively (from n = 698); women received more non-cardiovascular drugs than men (median (IQR) 3 (1-5) vs 2 (1-4), p = 0.014). Overall, 98.7% patients had at least one actionable genotype. Within the interaction cohort, 882 interactions were identified in 503 patients (77.1%), of which 346 in 252 patients (38.7%) were substantial: 59.2%, 11.6%, 26.3%, and 2.9% substantial interactions were DDIs, DGIs, DDGIs, and DGGIs, respectively. CYP2C19 (49.5% of all interactions) and SLCO1B1 (18.4%) were involved in the largest number of interactions. Multimorbidity (p = 0.019) and number of drugs (p = 9.8 × 10-10) were both associated with patients having ≥ 1 substantial interaction. Multimorbidity (HR 1.76, 95% CI 1.10-2.82, p = 0.019), number of drugs (HR 1.10, 95% CI 1.04-1.16, p = 1.2 × 10-3), and age (HR 1.05, 95% CI 1.03-1.07, p = 8.9 × 10-7), but not drug interactions, were associated with increased subsequent major adverse cardiovascular events.

CONCLUSIONS

Multimorbidity, polypharmacy, and drug interactions are common after a NSTE-ACS. Replication of results is required; however, the high prevalence of DDGIs suggests integrating co-medications with genetic data will improve medicines optimisation.

Facial action units, activity and time spent with dam are effective measures of pain in response to mulesing of Merino lambs

Repeatable measures of pain in ruminants following husbandry procedures are required to validate responses to pain relief. This study tested the hypotheses that facial action units, activity and time spent with dam can be used to assess the efficacy of pain relief in lambs following mulesing. Merino lambs (n = 120) were allocated to one of six treatments implemented at mulesing: (1) lambs that were not mulesed or lambs that were mulesed and administered (2) no pain relief, (3) meloxicam 15 min before mulesing, (4) Tri-Solfen®, (5) a combination of meloxicam 15 min before mulesing and Tri-Solfen after mulesing and (6) meloxicam at mulesing. Facial action units detected a difference in pain between mulesed and non-mulesed lambs at 1 and 5 h post-mulesing (P = 0.005 and <0.001) but not at 26 h post-mulesing. Lambs that were not mulesed were more active and spent more time with their dams than mulesed lambs (P < 0.001). No differences were observed between lambs that were mulesed with or without pain relief. Therefore, facial action units, activity of the lamb and time spent with dam can detect pain in response to mulesing in Merino lambs but cannot detect any changes associated with pain relief.

Patient comfort factors associated with the chronically implanted extravascular ICD (EV ICD): retrospective analysis of the first-in-human EV ICD trial

Background

The extravascular ICD (EV ICD) utilizes a lead positioned within the substernal space and a device placed along the left midaxillary line to provide pacing and defibrillation therapies. Since substernal implantation positions the lead close to the heart, a lower energy for defibrillation is needed for the EV ICD relative to an ICD with subcutaneous lead placement. With lower energy requirements, the EV ICD system requires only a 33 cubic centimeter (cc) device, whereas the commercially available subcutaneous ICD utilizes a ∼60 cc device. The smaller form factor for EV ICD may require a smaller device incision site with smaller pocket, potentially resulting in less post-operative pain. Figure 1 illustrates the comparative sizes of the EV ICD and a subcutaneous device. While issues related to patient comfort have been published for the subcutaneous ICD, patient comfort factors associated with the EV ICD system have not been described previously.

Purpose

To characterize post-operative factors related to patient comfort associated with the EV ICD system.

Methods

The EV ICD first-in-human study was conducted at four sites in Australia and New Zealand. Data from chronically implanted patients were retrospectively analyzed for changes in analgesics in the post-operative window between implant and the two-week follow-up. Adverse events were collected between implant and six months related to patient-reported pain/discomfort, need for system revision based on discomfort, impaired wound healing and seroma formation.

Results

In total, 21 patients underwent implantation of the EV ICD system. Three patients had initiated pain control medications prior to enrollment, including one patient with fractured ribs. Overall, 12 patients (57.1%) received no anesthetic or analgesic medications besides acetaminophen beyond the day of implant. For the remainder of patients, post-operative medications included fentanyl (1), discontinued after two days; morphine (4), discontinued the day of implant (1) or after ≤2 days (3); or oxycodone (10), discontinued after ≤1 day (7) or ≤1 week (3).

There were no intraprocedural complications. There were four non-serious, early-onset (≤1 week post-implant) adverse events identified, which included swelling (1), impaired healing at the xiphoid incision site (1), and two instances of inspiratory pain ≤1 day post-implant, all of which resolved without sequelae. There were no system revisions or removals associated with incision sites or pocket discomfort, and there were no reports of seroma formation through six months of follow-up.

Conclusions

Analysis of factors related to patient comfort indicate that the EV ICD system has generally been well tolerated across patients. A larger data set is needed to more fully characterize whether the smaller device size of the EV ICD relative to the subcutaneous defibrillator results in improved patient comfort.

Sizes of extravascular devices

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic plc

Chronic follow-up from the pilot study of a novel substernal extravascular implantable cardioverter-defibrillator

Background

The investigational Extravascular Implantable Cardioverter Defibrillator (EV ICD) is an implantable defibrillator with defibrillation and pacing therapies, including the potential for antitachycardia pacing (ATP).

Purpose

To characterize chronic EV ICD system performance through 12 months of follow-up.

Methods

The first-in-human EV ICD Pilot study was prospectively conducted at four centers in Australia and New Zealand. Patients with Class I or IIa indications for ICD were enrolled between July and December of 2018. A defibrillation lead was inserted into the substernal space under radiologic guidance and a device was positioned close to the left midaxillary line. Figure 1 illustrates the implanted EV ICD. Defibrillation testing was conducted at implant and chronically in 5 patients. Follow-ups were conducted at pre-hospital discharge, 2 weeks, 4–6 weeks and 3 months post-implant, and every 6 months thereafter.

Results

A total of 26 patients were enrolled and 21 underwent the EV ICD implant procedure with no intraprocedural complications. Median energy for defibrillation at implant was 15 J; mean R-wave amplitude was 3.4±2.0 mV; mean pacing capture threshold was 5.1±2.0 volts. Seventeen of 21 implanted patients entered into chronic follow-up after successful system placement and implant testing, and 14 patients continue to be followed, representing &gt;180 patient-months of total follow-up.

Multiple episodes of spontaneous ventricular tachycardia (VT) were detected in one patient and either self-terminated or successfully cardioverted following unsuccessful ATP. One patient received an inappropriate shock secondary to lead tip displacement with subsequent P-wave oversensing. Elective chronic defibrillation testing was performed at physician discretion and converted 5 of 5 patients with ≤40 J (maximum energy of device). Three patients had the system electively removed due to 1) inappropriate shock after lead displacement, 2) recurrent VT without ATP termination, and 3) inadequate chronic safety margin for defibrillation.

Conclusions

The EV ICD is a novel platform for delivering high voltage therapy. Chronic system performance has generally remained stable during 12 months of follow-up and the device has demonstrated the ability to detect and treat VT.

Fluoro images of implanted system

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic plc