P5430Long term outcomes of patients receiving Implantable Cardioverter Defibrillators in a contemporary implant population in the Essex region of the UK

Introduction

Implantable cardioverter-defibrillators (ICD) reduce the risk of sudden cardiac death in patients who are at risk and amongst among heart failure (HF) patients with a reduced left ventricular ejection fraction (LVEF).

Objective

The aim of this study was to determine the differences in outcomes amongst patients in a contemporary ICD implant population based on primary or secondary indications and an ischaemic or non-ischaemic aetiology. The primary outcome was death or appropriate device therapy for a ventricular arrhythmia. The secondary outcome was inappropriate shock therapy.

Purpose

The study cohort included consecutive patients who had an ICD or CRT-D implanted at a high-volume regional referral centre in Essex between 2014 and 2015. The censor point for follow up was 31/12/2018. Cumulative incidences were analysed by the method of Kaplan–Meier and compared using the log-rank test. In addition, the relationship between several clinical variables were tested in a multivariate Cox model to predict long-term mortality and this is described with hazard ratios (HR) and 95% CI.

Results

407 patients who received ICD treatment were followed up for a mean of 50±4 months. 63% had an Ischaemic cardiomyopathy and 60% had a primary prevention indication. Majority were men (81.5%), mean LVEF was (31±11) and mean age (71±11). The incidence of appropriate ICD therapy at 1-year post ICD insertion was 6.8% in all patients. This was significantly higher in patients with a secondary prevention indication compared to primary prevention (11.7% v 3.6% p=0.015) but similar in ischaemic compared to non-ischaemic patients (7.8% v 5.2% p=0.46). 1.9% patients had an inappropriate shock at 1 year and between group rate was similar. Overall 8.1% of patients did not survive beyond 1-year post implant with a mean time to death of 5.6±3.6 months. The cumulative incidence of the primary end-point at 1 year was similar in ischaemic and non-Ischaemic patients (7.8% v 8.6%; HR: 1.04, 95% CI 0.7–1.5, p=0.83) but was significantly higher at the end of study period in patients with an ischaemic aetiology (32.4% v 21%; HR: 1.59, 95% CI: 1.1–2.4, p=0.024) (Fig.1). In an adjusted Cox Hazard model, appropriate ICD therapy at 1 year (HR: 0.28, 95% CI: 0.17–0.47, p<0.001) and a secondary indication for ICD treatment (HR: 0.47, 95% CI: 0.31–0.73, p=0.001) were strongly associated with long-term mortality.

Figure 1

Conclusions

Our study highlights outcomes in a long-term follow up of ICD patients and in light of the debate around the DANISH trial, we have shown that at 1 year, the benefit of ICD therapy is comparable in non-ischaemic compared to ischaemic cardiomyopathies. Moreover, patients who had an ICD implanted for secondary prevention had a 3-fold mortality benefit at 1 year and had a higher rate of death. Appropriate ICD therapy and a secondary prevention indication predicted long term mortality.

Quality Improvement at the Laboratory’s Specimen Reception Station

Introduction/Objective

In our 1000-bed acute care tertiary hospital, physicians order laboratory tests via the computerized-provider-order-entry (CPOE) system and print barcode labels (patient demographics/tests ordered) at the computer-on-wheel printer. When tubes with unsuitable barcodes (misaligned, poor quality) are received at the laboratory specimen reception area a fresh barcode is re-printed by our laboratory staff. An incident involving a re- printed barcode label pasted on the wrong blood tube prompted an investigation into the quality of barcodes.

Methods/Case Report

We initiated ‘an opportunity for improvement (OFI) project’ at the laboratory specimen reception station. The OFI team involved Nursing, Information Technology (IT) and Pathology departments aimed to eliminate re-printing of barcode labels by 75% within 6 months. We collated and analyzed reasons for re-printing of barcodes on 3 separate 48-hour periods (27-28 April 2020, 24-25 June 2020, and 13-14 June 2022). A series of interventions and initiatives were implemented.

Results (if a Case Study enter NA)

Re-printed barcodes were from the Emergency Department (56%), Out-patient clinics (7%) and Wards (57%). Root cause analysis(RCA) using the “5 whys” technique categorized re-print causes into staff-related (misaligned barcodes) and printer-related (faint barcodes lines/truncated un-verifiable patient demographics). The team mass-emailed clinicians an educational “Do-You-Know” guide on proper pasting of barcodes on blood tubes and instructions on how to obtain help for printer rectification. These guide documents were placed in the hospital-wide document-sharing portal - Docupedia. Immediate close follow-up with sites that had poor barcodes was done in real-time. Barcode reprints decreased 83% within 2 months - from 174 (27-28 Apr 2020) to 30 (24-25 Jun 2020). A recent audit showed sustained elimination of barcode re-printing: 25 cases (13-14 Jun 2022).

Conclusion

The OFI project has successfully raised the quality of CPOE labels on specimen tubes contributing to process efficiency and safer patient care. Close communication with all care sites and their representatives on the OFI team are critical success factors.

[Polycystic ovaraian syndrome and hyperinsulinemia]

OBJECTIVE

To identify the relationship between polycystic ovarian syndrome and hyperinsulinemia.

METHODS

Age, body height, body weight, serum estradiol, progesterone, testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), triiodothyronine (T3), tetraiodothyronine (T4), insulin, oral glucose tolerance test (OGTT), and cortisol were measured in 28 patients with polycystic ovarian syndrome (PCOS).

RESULTS

Sxiteen patients (57.1% of total) had hyperinsulinemia. Among them one patient was found diabetic. No difference was noted in age, height, body weight, body mass index, serum estradiol, progesterone, testosterone, FSH, LH, PRL, T3, T4, cortisol, and glucose of OGTT between hyperinsulinemia and non-hyperinsulinemia patients. However the LH/FSH ratio (2.4 +/- 1.5) in hyperinsulinemia patients was significantly higher than 1.2 +/- 0.6 in non-hyperinsulinemia patients (P = 0.0125). In addition, the results showed that the fasting serum insulin, insulin after OGTT, the insulin/glucose ratio at 30, 120 minutes, 180 minutes, the area under curve of and the insulin, insulin resistant index (IRI) were higher in hyperinsulinemia pateints than in non-hyperinsulinemia patients respectively. Furthermore, the fasting insulin level, insulin/glucose ratio were found to be negatively related to insulin sensitivity index and positively related with beta-cell functioning index.

CONCLUSION

Hyperinsulinemia and insulin resistance accompany with some of the PCOS patients in China. Further investigations will be necessary to clarify the relevant mechanisms.

Intraocular pressure measurements in paediatric glaucoma: A narrative review on accuracy, tolerability, and ease of use

INTRODUCTION

Numerous tonometers are available to measure intraocular pressure (IOP) in children with glaucoma. This review aims to discuss IOP measurement techniques and principles and compare the accuracy, tolerability and ease of use of available tonometers in measuring IOP in paediatric glaucoma patients.

MATERIALS AND METHODS

A review of observational studies was conducted to discuss the accuracy, tolerability and ease of use of tonometers in measuring IOP in children with glaucoma.

RESULTS

Goldmann applanation tonometry (GAT) and its portable handheld versions remain the gold standard in measuring IOP. Tono-Pen (Reichert Ophthalmic Instruments, Depew, New York, USA) and rebound tonometer (RBT) both correlate well with GAT. Although both tonometers tend to overestimate IOP, Tono-Pen overestimates more than RBT. Overestimation is more remarkable in higher IOP and corneal pathologies (such as but not limited to scarred cornea and denser corneal opacity). RBT was better tolerated than other tonometers in children and was easier to use in children of all ages.

CONCLUSIONS

RBT is the preferred tonometer for measuring IOP in children with glaucoma, as it is less traumatic, time efficient and does not require fluorescein dye or anaesthesia. However, examiners should use a second tonometer to confirm elevated IOP readings from the RBT.

Amplification of a terahertz wave via stimulated Raman scattering

Extremely strong terahertz (THz) waves are desperately demanded for investigating nonlinear physics, spectroscopy, and imaging in the THz range. However, traditional crystal-/semiconductor-based THz sources have limitations of reaching extremely high amplitude due to the damage threshold of devices. Here, by introducing Raman amplification to the THz range, we propose a novel, to the best of our knowledge, scheme to amplify THz waves in plasma. A long-pulse CO₂ pump laser transfers its energy to a multicycle, 10-THz seed in a two-step plasma. By one-dimensional simulations, a 0.87-GV/m, 1.2-ps-duration THz seed is amplified to 10 GV/m in a 5.7-mm-long plasma with an amplification efficiency approaching 1%. The method provides a new technology to manipulate the intensity of THz waves.

A perspective from the practice of swaddling by Turkish mothers

AIM

The purpose of this study was to investigate the practice of swaddling by Turkish mothers residing in different areas of the country (rural or urban), and determine to their level of knowledge on its positive and negative effects on children's health.

MATERIAL AND METHODS

A total of 632 mothers with an infant aged 0-3 months who presented to our University Hospital volunteered their participation and 598 mothers were included in the study. The study was based on a questionnaire form given to the mothers.

RESULTS

Two hundred eighty three (283) mothers swaddled their infants (47.3 %), while 315 mothers did not swaddle (52.7%). The mothers that swaddled their baby cited tradition ("That's what I learned from my elders") as the most common reason (38%) for swaddling. The most important reason (32%) for not swaddling was the mothers' belief "that it would prevent normal development".

CONCLUSION

In Turkey, the swaddling tends to decrease with the increase of maternal education level and socio-economic situation.The level of Turkish mother's knowledge about beneficial and adverse effect of swaddling were insufficient.We think that the information about properly swaddling should be given to mothers In order to benefit from it's positive effects and at the same time and avoid its adverse effects.

Diagnostic Performance of High-Resolution Vessel Wall MR Imaging Combined with TOF-MRA in the Follow-up of Intracranial Vertebrobasilar Dissecting Aneurysms after Reconstructive Endovascular Treatment

BACKGROUND AND PURPOSE

Few studies have reported the utility of high-resolution vessel wall MR imaging in the follow-up of endovascularly treated vertebrobasilar dissecting aneurysms. This study aimed to evaluate the diagnostic performance of high-resolution vessel wall MR imaging combined with TOF-MRA in the follow-up of intracranial vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment.

MATERIALS AND METHODS

Patients with intracranial vertebrobasilar dissecting aneurysms with reconstructive endovascular treatment and followed up with TOF-MRA, high-resolution vessel wall MR imaging, and DSA were included. With DSA as the criterion standard, the diagnostic performance of TOF-MRA, high-resolution vessel wall MR imaging, and high-resolution vessel wall MR imaging combined with TOF-MRA in the evaluation of aneurysm occlusion status and parent artery patency was assessed. Visualization of the stented artery on TOF-MRA and high-resolution vessel wall MR imaging was rated on a 5-point scale.

RESULTS

Twenty-seven patients with 29 aneurysms were included. The sensitivity, specificity, positive predictive value, and negative predictive value of TOF-MRA, high-resolution vessel wall MR imaging, and high-resolution vessel wall MR imaging combined with TOF-MRA for diagnosing aneurysm remnants were 80.0%, 100.0%, 100.0%, and 82.4%; 53.3%, 100.0%, 100.0%, and 66.7%; and 93.3%, 100.0%, 100.0%, and 93.3%, respectively. For the visualization of the stented artery, the mean score of high-resolution vessel wall MR imaging was significantly higher than that of TOF-MRA (4.88 [SD, 0.32] versus 2.53 [SD, 1.25], P < .001). In the evaluation of parent artery patency (normal or pathologic), whereas TOF-MRA had a sensitivity, specificity, positive predictive value, and negative predictive value of 100.0%, 8.0%, 14.8%, and 100.0%, respectively, high-resolution vessel wall MR imaging was completely consistent with the DSA.

CONCLUSIONS

High-resolution vessel wall MR imaging combined with TOF-MRA at 3T showed good diagnostic performance in the follow-up of intracranial vertebrobasilar dissecting aneurysms after reconstructive endovascular treatment.

Involvement of PD-1+CD4+ T cells in the development of traumatic tracheal stenosis by regulating the IL-17/STAT3 pathway

Studies have highlighted an upregulation of PD-1 expression in CD4+ T cells, which accelerates lung fibrosis by activating the IL-17/STAT3 pathway, leading to IL-17A and TGF-β1 secretion. However, the relation with traumatic tracheal stenosis (TS) remains unexplored. Our analysis found significant increases in PD-1+CD4+ T cells, IL-17A, and TGF-β1 in the TS patients (n = 10). The cellular model used CD4+ T cells co-cultured with bronchial fibroblasts while the animal model used a nylon brush to scrape the damaged tracheal mucosa. Interventions with PD-1 and STAT3 inhibitors both in vitro (n = 5) and in vivo (n = 6) showed decreased expression of TGF-β1 and IL-17A in CD4+ T cells, decreased collagen I synthesis in vitro, and reduced tractal fibrosis in vivo. Furthermore, PD-1's modulation of the STAT3 was evident. This research unveils PD-1+CD4+ T cells' role in TS, thus suggesting a novel immunotherapeutic strategy to counteract tracheal fibrosis.

Features and efficacy of triple-targeted therapy for patients with EGFR-mutant non-small-cell lung cancer with acquired BRAF alterations who are resistant to epidermal growth factor receptor tyrosine kinase inhibitors

BACKGROUND

The recommended first-line treatment for advanced epidermal growth factor receptor (EGFR)-mutant non-small-cell lung cancer (NSCLC) patients is EGFR-tyrosine kinase inhibitors (EGFR-TKIs). BRAF alterations have been identified as resistance mechanisms. We aimed to identify features of and subsequent treatment strategies for such patients.

PATIENTS AND METHODS

We conducted a systematic literature review of NSCLC patients harboring acquired BRAF alterations. Additionally, BRAF-altered NSCLC patients who progressed from EGFR-TKIs at West China Hospital of Sichuan University were screened. Patient characteristics, treatment options, and outcomes were analyzed.

RESULTS

A total of 104 patients were included, 2 of whom came from our center. Seventy-five patients (72.1%) harbored BRAF mutations (57 class I mutations, 7 class II mutations, 9 class III mutations, and 2 non-class I-III mutations), and 29 (27.9%) harbored BRAF fusions. Eighteen patients received triple-targeted therapy, including prior EGFR-TKIs plus dabrafenib and trametinib, and 23 patients received other treatments. The median progression-free survival was significantly longer in patients receiving triple-targeted therapy than in those receiving other treatments (8.0 versus 2.5 months, P < 0.001). Similar findings were observed in patients with BRAF mutations (9.0 versus 2.8 months, P = 0.004), particularly in those with BRAF class I mutations (9.0 versus 2.5 months, P < 0.001). A potential benefit was also observed among patients with BRAF fusions (5.0 versus 2.0 months, P = 0.230). Twenty patients (48.8%) experienced adverse events. Dose reduction of RAF or MEK inhibitor was required in five patients (12.2%). Five patients (12.2%) permanently discontinued treatment (three on triple-targeted therapy; one on prior EGFR-TKI plus vemurafenib; one on prior EGFR-TKI plus trametinib).

CONCLUSIONS

BRAF alterations, specifically BRAF mutations and BRAF fusions, facilitate resistance to EGFR-TKIs. Triple-targeted therapy is effective and safe for patients with EGFR-mutant NSCLC with acquired BRAF alterations, mainly among patients with BRAF class I mutations and potentially in patients with BRAF fusions.