Supportive technology in collaborative research: proposing the STiCR framework

INTRODUCTION

Achieving a standard of clinical research at the pinnacle of the evidence pyramid is historically expensive and logistically challenging. Research collaboratives have delivered high-impact prospective multicentre audits and clinical trials by using trainee networks with a range of enabling technology. This review outlines such use of technology in the UK and provides a framework of recommended technologies for future studies.

METHODS

A review of the literature identified technology used in collaborative projects. Additional technologies were identified through web searches. Technologies were grouped into themes including access (networking and engagement), collaboration and event organisation. The technologies available to support each theme were studied further to outline relative benefits and limitations.

FINDINGS

Thirty-three articles from trainee research collaboratives were identified. The most frequently documented technologies were social media applications, website platforms and research databases. The Supportive Technologies in Collaborative Research framework is proposed, providing a structure for using the technologies available to support multicentre collaboration. Such technologies are often overlooked in the literature by established and start-up collaborative project groups. If used correctly, they might help to overcome the physical, logistical and financial barriers of multicentre clinical trials.

Suboptimal Adherence in Clinical Practice to Guidelines Recommendation to Screen for Lynch Syndrome

BACKGROUND

Identification of Lynch syndrome (LS) followed by annual/biannual surveillance colonoscopy markedly reduces the risk of developing new colorectal cancer (CRC) among those with LS.

AIMS

(1) To determine the current practice of identifying LS in the USA and Canada, and current surveillance and management practices for those diagnosed with LS; (2) to determine whether variances in current practice are physician/region dependent or influenced by ease of access to specialist clinics.

METHODS

An online survey request was sent to practicing gastroenterologists through the Canadian Association of Gastroenterology and the American College of Gastroenterology. Fisher's exact tests were performed to determine the factors associated with screening for LS and separately for follow-up, surveillance, and management.

RESULTS

A total of 249 participants were recruited, of which 237 were gastroenterologists and included in the analysis. Less than one-third of practicing gastroenterologists indicated that their CRC patients were undergoing screening tests to identify LS. While 42% (65/153) of participants from the USA stated that their patients were undergoing universal LS screening (i.e., among all diagnosed with CRC), only 12% (6/49) of participants from Canada reported this practice (p < 0.001). There was no difference in reported practice between the physicians that do and do not have access to hereditary clinics (35% vs. 34% testing; p = 0.54). Appropriate surveillance interval to look for CRC in patients with LS was recommended by most.

CONCLUSION

This survey suggests there is a significant difference in practice between Canada and the USA in regard to identification of LS, with suboptimal practice throughout North America.

Infection after operative fixation of tibia plateau fractures. A risk factor analysis

INTRODUCTION

Surgical fixation of tibial plateau fractures has been shown to improve long-term functional outcomes, but a major complication is that of postoperative infection which can be deleterious to long-term outcomes. This study aims to assess the impact of common comorbidities on the risk of postoperative infection.

METHOD

A retrospective study of 210 consecutive operatively treated patients, treated at two Level 1 Trauma Centres over a 27-month period was performed. Records were analysed to assess the presence of the study factors; smoking, alcohol intake >13 units/week, diabetes, and BMI > 30. The impact of these factors on infection was assessed with univariate and multivariate analyses.

RESULTS

175 patients were included in the study, 56.6% male with a mean age of 46.9 years (± 18.2 years). Excessive alcohol consumption of >13 units/week was the only significant risk factor for postoperative infection (p = 0.05) on multivariate analysis.

CONCLUSION

This study has identified excessive alcohol consumption as the only independent risk factor for postoperative infection in patients with all types of tibial plateau fracture treated with operative fixation. No relationship between smoking, diabetes nor obesity was found for postoperative infection.

Molecular characterization and expression profile of interferon-stimulated gene 15 (ISG15) in the endometrium of goat (Capra hircus)

Interferon-stimulated gene 15 (ISG15), a ubiquitin-like protein, is responsible for uterine receptivity, implantation and conceptus development in different ruminant species, but in goat (Capra hircus) its role is yet to be explicated. In the present study, the ISG15 gene was cloned, characterized and its temporal expression profile was examined in the endometrium of caprine (cp). A fragment of cpISG15 gene, 1033 bp in length, was amplified, cloned and sequenced from genomic DNA covering the coding region. Sequence analysis of cpISG15 gene revealed that it was comprised of two exons of 59 bp and 496 bp encoding a peptide of 157 amino acids. Complementary DNA (cDNA) and deduced amino acid sequences of cpISG15 exhibited 99 and 98, 93 and 88, 94 and 89, 76 and 66, and 73 and 62% identity with that of sheep, cattle, buffalo, human and mice, respectively. Further, relative expression of cpISG15 mRNA and protein was determined by quantitative real-time PCR (qPCR) and Western blot, respectively, in the endometrium of pregnant and cyclic does. Both cpISG15 mRNA and protein were expressed maximally (P < 0.05) in the endometrium during early stage of pregnancy (16-24 d) as compared to cyclic does, but no significant difference was observed in cpISG15 mRNA and protein expression in the endometrium between the later stage of pregnancy (25-40 d) and cyclic does. It is concluded that cpISG15 is almost similar in structure and probably in function also to other species as it has been found significantly upregulated during early pregnancy.

P4356Assessment of global and regional right ventricular systolic function in restrictive pulmonary disease by novel speckle tracking 3D echocardiography comparison with cardiac magnetic resonance imaging

Background

Chronic restrictive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In CRPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging.

Purpose

The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function.

Methods

In a retrospective, cross-sectional study setting, RV volumetric data were studied in 200 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments.

Results

136 patients (68%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.89; RV end-systolic volume, R2=0.82; RV ejection fraction [RVEF], R2=0.68; P<0.003 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −3% and −8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.30, P=0.005). Among segmental 3D strain variables, inlet area strain (r=−0.49, P<0.004) and outflow circumferential strain (r=−0.39, P<0.005) were independent factors associated with CMR-derived RVEF.

Conclusions

Severity of restrictive pulmonary disease influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters. Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements.

P2671The addition of admission lactate to the CREST risk score to determine prognosis in out of hospital cardiac arrest: the C-AREST score

Introduction

There has been an increasing focus on the development of scoring systems for patients admitted following resuscitation from out-of-hospital cardiac arrest (OHCA) to determine both prognosis and short-term management. One such system, the CREST score, has been shown to predict circulatory aetiology death in patients without ST-elevation myocardial infarction, however with an increasing number of OHCAs seen, general scoring systems to predict outcome in OHCA would be helpful.

Aims

We sought to determine whether the addition of an admission lactate ≥8 mmol/l to the existing CREST score was able to better predict in-hospital mortality in patients admitted with OHCA.

Methods and results

We retrospectively analysed the data of 500 patients admitted with an OHCA of presumed cardiac origin to our tertiary cardiac centre between June 2014 and Oct 2018. Mean age was 62.6y (±14.7), 379 (76%) were male and 250 (50%) were Caucasian. 313 (62.6%) were admitted with ST elevation myocardial infarction or equivalent. 48.6% (243/500) of patients died in hospital and of those that survived, 20.2% (52/257) were left with hypoxic brain injury (CPC score 3–4).

When analysed independently, all individual factors other than history of Coronary artery disease (OR 1.47, p=0.084) significantly predicted in-hospital mortality: Admission lactate ≥8 mmol/l (OR 6.78, p<0.0001), non-shockable Rhythm (OR 10.9, p<0.0001), Ejection fraction <30% (OR 5.84, p<0.0001), Shock at presentation (OR 5.49, p<0.0001) and ischaemic Time >25 minutes (OR 12.8, p<0.0001).

When each factor was assigned one point and totalled, both increasing CREST and C-AREST scores were associated with increasing in-hospital mortality: CREST (0–5 points): 4.3%, 30.5%, 41.5%, 85.6%, 95.2%, 100% vs C-AREST (0–6 points): 9.1%, 28.3%, 41.9%, 62.8%, 97.6%, 96.4%, 100%. When analysed with stepwise logistic regression, the addition of admission lactate ≥8 mmol/l to the model improved the prediction of in-hospital mortality: CREST (40.8% of variance explained) vs C-AREST (43.3%), with admission lactate remaining an independently significant predictor (OR 3.67, p=0.002).

Conclusion

We describe a novel modification to the previously described CREST scoring system for OHCA: the C-AREST score. The addition of admission lactate ≥8 mmol/l may have a role in differentiating those in intermediate risk categories (score between 2 and 3) where the predicted in hospital mortality would otherwise vary greatly. Given the relative ease of obtaining admission lactate, this scoring system may further improve stratification of patients who may or may not benefit from invasive management.

P6516The association between prior coronary artery bypass graft surgery and outcome after percutaneous coronary intervention (PCI): an observational study of 123,780 patients

Background

Limited information exists regarding procedural success and clinical outcomes in patients with previous CABG undergoing percutaneous coronary intervention (PCI). We sought to compare outcomes in patients undergoing PCI with or without previous coronary artery bypass grafts (CABG).

Methods

This was an observational cohort study of 123,780 consecutive PCI procedures from the Pan-London (United Kingdom) PCI registry, from January 2005 to December 2015. The primary end-point was all-cause mortality at a median follow-up of 3.0 years (interquartile range 1.2–4.6 years).

Results

12,641 (10.2%) patients had a history of previous CABG, of whom 29.3% (n=3,703) underwent PCI to native vessels and 70.7% (n=8,938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow-up was significantly higher in patients with prior CABG (23.2%) (p=0.0005) compared to patients with no history of prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%, p<0.0001). However, after adjustment for baseline characteristics, there was no significant difference in outcomes seen between the groups when PCI was performed in native vessels in patients with previous CABG (HR 1.02, 95% CI 0.77–1.34; P=0.89) but a significant increase in mortality among patients with PCI to bypass grafts (HR 1.33 95% CI 1.03–1.71, P=0.026). This was seen after multivariate adjustment and propensity matching.

Figure 1. Kaplan-Meier Curves

Conclusion

Patients with prior CABG are older, with a greater comorbid burden and more complex procedural characteristics, but after adjustment for these differences clinical outcomes are similar to patients undergoing PCI without prior CABG. In these patients, native vessel PCI was associated with better outcomes compared to the treatment of vein grafts.

P6293Assessment of testosterone/estradiol ratio, DHEA-S level and correlation with coronary inflammatory markers IL-1 & 6, TNF-1 and hsCRP predict 5 years risk of cardiovascular disease in men

Background

Previous data showed the adrenal sex hormone dehydroepiandrosterone (DHEA) which is present in serum mainly as the sulfate DHEA-S is the most abundant steroid hormone and another hormones like testosterone, estradiol are related to cardiovascular risk in men. Literatures revealed vascular and metabolic actions of DHEA/-S, evidence for an association between DHEA/-S levels and cardiovascular events is controversy.

Objectives

Our aim is to review and clear the contradictory point regarding cardiovascular risk and correlation of testeosterone/ estradiol ratio, DHEA-S level with coronary inflammatory markers in men.

Methods

Large population based cohort study done at multi centre of cardiology from 2013- 2018 in India. We enrolled total 23631 normal healthy male population age between 40 to 60 years and divided into two groups based on testosterone/estradiol ratio (Group A (n=2450) lower value of T/E ratio and Group B (n=21181) normal or higher T/E ratio. We did cohort analysis for 5 years and evaluated DHEA-S level and correlated it with coronary inflammatory markers and cardiovascular risk.

Results

In group A (low T/E ratio) we found low level of DHEA-S (98% of individual) and higher value of interleukins IL-1 (68%),IL-6 (74%) and tumor necrosis factor TNF-1 (71%) and high sensitive C-reactive protein (hsCRP) (73% of individual). Data revealed two fold increase of high blood pressure and LDL cholesterol level as compared to group B (normal or high T/E ratio and normal or high value of DHEA-S). 2.5 fold higher rate of coronary heart disease (CHD) found in group A versus in group B. We did not found as much significant difference in stroke, carotid and peripheral artery disease. T/E ratio and DHEA-S levels were inversely associated with the age-adjusted risk of a CHD event; the hazard ratios and 95% confidence intervals per standard deviation (SD) increase were 0.76 (0.66 to 0.91) and 0.82 (0.72 to 0.93), respectively.

Conclusions

Decrease ratio of testosterone/estradiol levels correlate decreased levels of DHEA-S which may increase the risk of CHD in men. For future aspect, correction of T/E ratio, DHEA-S and increase its awareness should be at mass level for prevention of CHD.

P1463Cardiology, cardiovascular clinical and economical beneficiary outcomes of tele-cardiology, e-audio-visual cardiology and m-cardiology: TEAM study at multi cardiac centre in India

Background

Telemedicine has beneficiary aspect to manage health and reduce the burden of illness. It represent health promotion with support of many ways like tele (distance mode), e (electronic mode), audio visual mode and m (mobile or smart phones) mode etc.

Objectives

To evaluate the cardiovascular land economical outcomes of tele-cardiology, e-cardiology, audio-visual cardiology and m-cardiology in large population and to review with increase awareness and application of telemedicine.

Methods

We enrolled 12872 patients from different cardiac centres in india and registered in TEAM (Tele-cardiology, E-cardiology, Audio-visual cardiology and M-cardiology) registry from 2008 to 2018. We included tele diagnosis, tele assistance, tele monitoring, tele therapy, electronic remot media, audio visual media and mobile apps for management of different category of cardiovascular disease like coronary heart and structural heart disease, hypertension, heart failure and congenital heart disorders. We compared TEAM registry with usual group (n=13229) at the platform of beneficiary outcomes regarding diagnostic, therapeutic significance, economical burden, mortality and rate of hospitalization.

Results

Our data revealed that 34% more correction of the diagnosis of congenital heart diseases, 29% reduction of unnecessary transport of acute coronary syndrome and non cardiac chest pain from primary to higher cardiac centre. 38% patients of ST elevation of myocardial infarction were benefited by facilliated angioplasty and 50% mortality risk reduction in TEAM registry as compare usual group. In heart failure patients, 12 months clinical outcomes revealed that there was a significant reduction in rehospitalizations in the TEAM group compared with the usual-care group (19.6% versus 33.7%,) and also found 29% stroke reduction in TEAM group. Usual group showed 2.5 fold higher economical burden than TEAM registry.

Conclusion

Total approach of telemedicine in cardiology service may diagnose correctly at root level, prevent clinical instability, reduce rehospitalization and lower the cost of managing heart patients.

P2665An observational study assessing the impact of a cardiac arrest centre on patient outcome

Background

Out-of-hospital cardiac arrest (OHCA) is a major cause of death in Europe and the United States. There has been recent literature to suggest that the centralisation of OHCA services may benefit patient outcomes. In 2015, two major tertiary cardiac centres in the UK agglomerated to form a large dedicated tertiary cardiac centre. The previous centre had strict criteria on which OHCA patients could be admitted, with the vast majority of cases being STEMI-related. After the agglomeration, admission criteria were relaxed to include all OHCA cases within geographic range with a suspected cardiac cause.

Purpose

This study aimed to compare the short-term mortality of patients admitted with an OHCA to a tertiary cardiac centre before-and-after a major agglomeration of services had taken place and admission criteria had been relaxed.

Methods

We retrospectively analysed the data of patients admitted before and after agglomeration (2015) with OHCA who were resuscitated via conventional cardiopulmonary resuscitation. Baseline demographic characteristics were recorded, along with factors relating to the cardiac arrest. Primary endpoint was in-hospital mortality.

Results

A total of 650 patients (189 before and 461 after the agglomeration) with an OHCA between 2013 and 2018 were analysed. Patients admitted pre merger were older (67.7 vs 62.4 years, p=0.022), otherwise there were similar baseline demographic characteristics between patients admitted before and after the agglomeration (pre vs post) in terms of gender (74.4% vs 75.9% male, p=0.827), ethnicity (66.7% vs 58.9% Caucasian, p=0.588) and existing coronary artery disease (22.8% vs 22.7%, p=0.432). There were also similar peri-arrest characteristics, with a comparable number of patients having a non-shockable rhythm (15.4% vs 25.4%, p=0.164) and similar total downtimes between the groups (33 vs 32.3 mins, p=0.883). Interestingly there was a decrease in those with cardiogenic shock on arrival (92.3% vs 57.0%, p=0.0001) and fewer patients with an ejection fraction <30% (63.2 vs 38.7%, p=0.0003) post-agglomeration.

There was a greater proportion of non-ACS-related OHCA admission after the agglomeration (16.9% vs 24.1%, p=0.047) and a corresponding decrease in those admitted with a STEMI (81.5% vs 62.3%, p=0.032) and those treated with PCI (77.8% vs 54.0%, p=0.034). Despite this, in-hospital mortality was lower after the agglomeration (69.7% vs 47.1%, p=0.019), which persisted after adjustment for the previously described demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the two groups.

Conclusion

Despite an increase in non-ACS-related-OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit for an out-of-hospital cardiac arrest-centre model of care, supporting a centralised strategy for immediate post-resuscitation care in OHCA patients.

Acknowledgement/Funding

None

P615Role of three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR) and to assess the contribution of regional RV function to

Background

Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging.

Purpose

The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function.

Methods

In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments.

Results

208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF.

Conclusions

Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.

P630Role of Indian yoga with pranayam prevent ventricular remodeling and reduce mortality rate according to LV ejection fraction in post PCI patients of STEMI

Background

Coronary revascularization is fruitful management to relieve angina and reduce mortality as compare to medical management in significant coronary artery stenosis. Although measurement of left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) is a performance measure, little is known about the relationship between EF and post-discharge mortality among MI patients in contemporary clinical practice.

Objectives

To assessment of mortality according to left ventricular ejection fraction and compare between yoga group and non yoga group, so that we can evaluate the importance of yoga and pranayam.

Methods

2,470 patients (25 to 68 years of age) with STEMI were registered and managed with percutaneous coronary intervention at three centres from 2010 to 2012. Method was used to assess the association between left ventricular ejection fraction (LVEF) measured during the index hospitalization and 5-year mortality from date of registry. The relationship was examined with EF as a categorical variable, utilizing four clinically relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%), and also with EF as a continuous variable. We divided two groups, group A was yoga with pranayam (n=1470) and group B was normal group (n=1000).

Results

Among STEMI patients we found a graded inverse association between EF category and mortality. For patients relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%) mortality after 5 years was assessed by 21%, 14.3%, 12.2% and 11% in yoga, pranayam group (p<0.004). For patients relevant categories (EF ≤34%, 35 to 45%, 46 to 54%, and ≥55%) mortality after 5 years was assessed by 25%, 17.5%, 14.4% and 13% in normal group (p<0.004). LVEF was increased in yoga & pranayam group by 11±3% versus 4±1% non yoga group.

Conclusion

Yoga and Pranayam; breathing exercise may help to reduce metabolic stress, reduce oxygen demand and prevent ventricular remodeling. Low LVEF after STEMI remains an important risk factor for post-discharge mortality, even after extensive adjustment for patient and hospital characteristics. Routine yoga and pranayam; breathing exercise may reduce the mortality after myocardial infarction.

P4365Role of 3D speckle-tracking echocardiography system, using comparison with cardiac magnetic resonance imaging and to assess the contribution of regional RV function to global function in COPD patients

Background

Chronic obstructive pulmonary disease may alter right and left ventricular function by changing intrathoracic pressure. Pulmonary hyperinflation may increase right atrial pressure, leading to reduced venous return and subsequent reductions in RV pre-load. In COPD patients, hyperinflation has been directly correlated with reduced atrial chamber size, global RV dysfunction, and reduced LV filling. Accurate assessment of global and regional right ventricular (RV) systolic function is challenging.

Purpose

The aims of this study were to confirm the reliability and feasibility of a three-dimensional (3D) speckle-tracking echocardiography (STE) system, using comparison with cardiac magnetic resonance imaging (CMR), and to assess the contribution of regional RV function to global function.

Methods

In a retrospective, cross-sectional study setting, RV volumetric data were studied in 302 patients who were referred for both CMR and 3D echocardiography within 1 month. Three-dimensional STE-derived area strain, longitudinal strain, and circumferential strain were assessed as global, inlet, outflow, apical, and septal segments.

Results

208 patients (69%) had adequate 3D echocardiographic data. RV measurements derived from 3D STE and CMR were closely related (RV end-diastolic volume, R2=0.88; RV end-systolic volume, R2=0.81; RV ejection fraction [RVEF], R2=0.69; P<0.004 for all). RVEF and RV end-diastolic volume from 3D STE were slightly but significantly smaller than CMR values (mean differences, −2.8% and −7.8 mL for RVEF and RV end-diastolic volume, respectively). Among conventional echocardiographic parameters for RV function (tricuspid annular plane systolic excursion, fractional area change, S' of the tricuspid annulus, RV free wall two-dimensional longitudinal strain), only fractional area change was significantly related to RVEF (r=0.29, P=0.003). Among segmental 3D strain variables, inlet area strain (r=−0.48, P<0.002) and outflow circumferential strain (r=−0.37, P<0.003) were independent factors associated with CMR-derived RVEF.

Conclusions

Regional RV wall motion showed that heterogeneous segmental deformations affect global RV function differently; specifically, inlet area strain and outflow circumferential strain.RV volume and RVEF determined by STE were comparable with CMR measurements. Severity of COPD influences RV systolic dysfunction, which is reflected in speckle tracking 3D echocardiographic parameters.

P1509The novel application of speckle tracking during dobutamine stress echo for assessment of coronary artery diseases

Background

Major cause of death across the world is coronary artery disease. The choice of treatment strategy should be primarily based on the hemodynamic significance of coronary artery stenosis. Two-dimensional speckle tracking provides valuable information for regional wall motion abnormalities. The purpose of this study was to determine the diagnostic value of left ventricular longitudinal strain and torsion to diagnose coronary artery disease during dobutamine stress echocardiography.

Purpose

The purpose of this study was to evaluate the diagnostic value of speckle tracking imaging-derived myocardial deformation parameters at rest and during dobutamine stress to determine the hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of CAD.

Methods

We studied 204 patients (mean age 54.2±9.8 years, 128 male and 76 female) with known or suspected coronary artery disease, excluding those with prior history of transmural infarction. All of them underwent dobutamine stress echo and coronary angiography within one month. Wall-motion score index, left ventricular global longitudinal strain and torsion were measured at rest and peak stress. Optimal cut-offs were derived from receiver operating characteristic curves for strain and torsion values. Additionally, the respective differences between rest and stress were also calculated.

Results

During dobutamine stress echocardiography we revealed mean left ventricular ejection fraction was 53±6.2%. Coronary angiography revealed significant stenotic lesions in 124 patients (60.7%). Values regarding sensitivity, and specificity for wall motion score index difference were 76% and 84% respectively (area under curve 0.84). Global longitudinal strain difference (median 0.6%) illustrated 83% sensitivity and 74% specificity for disease detection (area under curve 0.82, cut-off value ≤0.5%). The respective values for torsion difference (median 5.1°) were 84% and 79% (area under curve 0.80, cut-off value ≤5.9°). Combination of wall motion score index difference and torsion difference for disease detection showed 89% sensitivity and 77% specificity (area under curve 0.84).

Conclusions

Left ventricular strain and strain rate analyses during DSE can be used in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high risk for CAD. The implementation of speckle tracking during dobutamine stress echo could serve as an adjunct method for coronary artery disease assessment, providing quantitative diagnostic information.

Unique Crystal Structure of Ca_{2}RuO_{4} in the Current Stabilized Semimetallic State

The electric-current stabilized semimetallic state in the quasi-two-dimensional Mott insulator Ca_{2}RuO_{4} exhibits an exceptionally strong diamagnetism. Through a comprehensive study using neutron and x-ray diffraction, we show that this nonequilibrium phase assumes a crystal structure distinct from those of equilibrium metallic phases realized in the ruthenates by chemical doping, high pressure, and epitaxial strain, which in turn leads to a distinct electronic band structure. Dynamical mean field theory calculations based on the crystallographically refined atomic coordinates and realistic Coulomb repulsion parameters indicate a semimetallic state with partially gapped Fermi surface. Our neutron diffraction data show that the nonequilibrium behavior is homogeneous, with antiferromagnetic long-range order completely suppressed. These results provide a new basis for theoretical work on the origin of the unusual nonequilibrium diamagnetism in Ca_{2}RuO_{4}.

Study of interleukin-6 and interleukin-8 levels in patients with neurological manifestations of dengue

Context:

Pro-inflammatory markers play a key role in the pathogenesis of various Flavivirus infection.

Aim:

In this study, we evaluated the role of these markers in neurological manifestations of dengue.

Settings and Designs:

Consecutive dengue cases with different neurological manifestations who presented between August 2012 and July 2014 were studied in hospital-based case–control study.

Materials and Methods:

Interleukin (IL-6) and IL-8 level were measured in serum and cerebrospinal fluid (CSF) of dengue cases with different neurological manifestations and also in age- and sex-matched controls. Level was analyzed with various parameters and outcomes.

Statistical Analysis:

Statistical analysis was done using SPSS version 16.0 by applying appropriate statistical methods. P < 0.05 considered statistically significant.

Results:

Out of the 40 enrolled cases of dengue with neurological manifestations, 29 had central nervous system and 11 had peripheral nervous system (CNS/PNS) manifestations. In CNS group, both IL-6 and IL-8 (CSF and serum) were significantly elevated (P < 0.001), whereas CSF IL-6 (P = 0.008), serum IL-6 (P = 0.001), and serum IL-8 (P = 0.005) were significantly elevated in PNS group. CSF IL-6, serum IL-6, and IL-8 were significantly elevated in poor outcome patients in CNS group (P < 0.05). CSF IL-6 and IL-8 were significantly elevated in CSF dengue positive cases as compared to CSF negative patients (P < 0.05). Cytokine level was not significantly correlated with neuroimaging abnormality in CNS group. Nine patients died and the remainder recovered.

Conclusion:

Elevated level of IL-6 and IL-8 is associated with different neurological manifestations and poor outcome, but whether they are contributing to neuropathogenesis or simply a correlate of severe disease remains to be determined.

Advances in Tumor Targeted Liposomes

Cancer remains a deadly disease for effective treatment. Although anomalous tumor microenvironment is now widely exploited for targeted chemotherapy, safe and efficacious drug delivery to tumor cells is not still warranted. Liposomes are promising biodegradable and biocompatible nanocarriers having potential amenability for surface and internal modifications, and extraordinary capability to carry both hydrophilic as well as hydrophobhic drugs. Meticulous fabrication of liposomes with tumor selective ligand(s) and PEGylation reduces immunogenicity and increase target-specificity. This review focuses on critical developmental aspects of liposomes to target cancer cells exploiting Enhanced Permeability and Retention (EPR) effect and tumor-selective ligands such as folate, transferrin, peptides etc. Moreover, stimuli-responsive smart liposomes (triggers: pH, temperature, enzymes, magnetic field, ultrasound, and redox potential etc.) are also investigated for enhancement of drug delivery to tumors. This review summarizes advances in tumor-targeted liposomes via various means of targeting. This knowledgeable assemblage of advances in liposomal approaches will render new insights to formulators and budding scientists to design cancer targeted liposomes.

Vitamins for Cancer Prevention and Treatment: An Insight

Over a few decades a strong interlink between oxidative damage and cancer has been investigated by various scientists across the world on the basis of epidemiological observations of the effects of fruits and vegetables used in the diet for cancer patients. Primarily, Vitamin C, Vitamin D and Vitamin E are reported to be involved in the amelioration of side effects which occur in chemotherapy and radiation therapy of lungs, stomach, prostate, colorectal, gastric head and neck cancers. The vitamins acting as antioxidant adjuvants are found to have apoptotic and antiangiogenesis potential as well as inhibitory effects against metastasis in cancer cells. This chapter explicitly discusses the key aspects concerned with the vitamins in relation to cancer prevention and treatment. It describes vitamins and their natural resources, role of vitamins in the body, and vitamins as prime ingredients in the diet and their effects on cancer biology with reference to recent research reports. Moreover, this paper also includes the emerging potential of pharmaceutical advances to enhance bioavailability of the vitamins to cancer patients with improved safety and efficacy. Clinicians and researchers must mull over the nutritional requirements of individual cancer patient so as to treat cancer and increase life expectancy.

Measurement of the Electrical Properties of a Thundercloud Through Muon Imaging by the GRAPES-3 Experiment

The GRAPES-3 muon telescope located in Ooty, India records rapid (∼10  min) variations in the muon intensity during major thunderstorms. Out of a total of 184 thunderstorms recorded during the interval of April 2011-December 2014, the one on December 1, 2014 produced a massive potential of 1.3 GV. The electric field measured by four well-separated (up to 6 km) monitors on the ground was used to help estimate some of the properties of this thundercloud, including its altitude and area that were found to be 11.4 km above mean sea level and ≥380  km^{2}, respectively. A charging time of 6 min to reach 1.3 GV implied the delivery of a power of ≥2  GW by this thundercloud that was moving at a speed of ∼60  km h^{-1}. This work possibly provides the first direct evidence for the generation of gigavolt potentials in thunderclouds that could also possibly explain the production of highest-energy (100 MeV) gamma rays in the terrestrial gamma-ray flashes.

Abstract P5-11-10: Biomarkers associated with resistance or response to CDK4/6 treatment in patients with metastatic hormone-receptive positive breast cancer

Background:

CDK4/6 inhibitor (CDKi) drugs are the current standard of care for treatment of first and second-line hormone-receptor positive/HER2 negative (HR+/HER2-) metastatic breast cancers. Numerous research efforts have commenced to understand biomarkers of response and resistance. To date, no biomarker of response has been identified. Treatment induced RB1 mutations were noted as mechanism of resistance to palbociclib and fulvestrant in about 5% of patients treated on PALOMA3 trials, whereas PI3K and ESR1 mutations emerged as potential resistance to the anti-hormonal backbone1. Additionally, FGFR1 amplification has been suggested as a resistance pathway to fulvestrant and ribociclib2. A better understanding of the molecular landscape of CDK4/6 treatment is needed. Utilizing next-gen sequencing (NGS), chromogenic in situ hybridization (CISH) and immunohistochemistry (IHC) data from HR+/HER2- patients treated at the University of Tennessee West Cancer Center, we attempted to retrospectively identify a molecular signature of resistance or response as measured by PFS.

Methods:

We analyzed 115 breast cancer patients who received CDKi treatment and 30 matched controls not exposed to CDKi and underwent comprehensive molecular profiling (Caris Life Sciences, Phoenix, AZ). A Cox proportional hazards model was built using genetic test as predictors and progression free survival (PFS) time as response. Only alterations with known pathogenic potential were considered aberrant. The R package glmnet was used to perform regularized lasso regression for feature selection on the entire data set. Important features were then used to construct Kaplan-Meier curves and perform a log-rank test for difference in PFS times.

Results:

Here we report the analysis for 2 known pathogenic biomarkers, ESR1 and TP53 based on PFS for patients who test positive versus negative. The median PFS for all patients was 234 days. Patients who harbored ESR1 mutations had reduced PFS of 180 days compared to 237 days. Patients who had P53 mutations had shorter PFS of 201 days compared to 240 days. When both groups with positive mutations were combined, the median PFS was 191 days compared to 276 days for patients without either ESR1 or P53 mutation with a p-value of 0.011. Further analysis using 4 way Kaplan Meier Curves for controls versus treated, altered versus non-altered genes, or PDL-1 expression is ongoing and will be presented at the conference.

Conclusion:

This data further support, in a real world model, the poor predictive value of ESR1 and P53 mutations on clinical outcome. Because no testing data was used, additional validation will be necessary to confirm the findings from this analysis.

References:

1. Nicholas C. Turner, Ben O'Leary, Ros Cutts, Massimo Cristofanilliet al, Genetic landscape of resistance to CDK4/6 inhibition in circulating tumor DNA (ctDNA) analysis of the PALOMA3 trial of palbociclib and fulvestrant versus placebo and fulvestrant. J Clin Oncol 36, 2018 (suppl; abstr 1001).

2. Luigi Formisano, Yao Lu, Carlos Arteaga et al. Gain of function kinase library identifies FGFR1 amplification as a mechanism of resistance to antiestrogen and CDK4/6 inhibitor in ER+ breast cancer. SABCS 2017 abstract GS6-05.

Citation Format: Mullins JN, Chaudhry A, Ryder J, Valasareddy P, Jain A, Ranganath H, Hare F, Vidal GA. Biomarkers associated with resistance or response to CDK4/6 treatment in patients with metastatic hormone-receptive positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-11-10.

A Randomized Controlled Trial to Study the Effect of Intravenous Clonidine and Intravenous Fentanyl on Perioperative Hemodynamics during Laparoscopic Cholecyctetomy

Peritoneal insufflation and laryngoscopy & intubation cause alteration of hemodynamics to a certain extent. The aim of this double blind, randomized controlled trial was to know and compare the effect of I.V. clonidine and I.V. fentanyl on hemodynamics during laparoscopic cholecystectomy in the department of Anaesthesia, Lady Hardinge Medical College, Delhi University, Delhi, India from November 2011 to April 2013. Eighty (80) patients (ASA I or II) posted for elective laparoscopic cholecystectomy were randomly allocated to two groups. Group C received I.V. Clonidine (2mcg/kg) and Group F received I.V. Fentanyl (2mcg/kg). Heart rate and Mean Blood Pressure were recorded as baseline (before study drug), after study drug, after I.V. induction, at intubation 0, 1, 3, 5 and 10 minutes after intubation, at start of pneumoperitoneum and thereafter every 15 minutes till the end of surgery. I.V. fentanyl and I.V. clonidine both were able to attenuate the perioperative hemodynamics response during laryngoscopy and intubation and also during pneumoperitoneum. In Group F there was insignificant rise and in Group C there was insignificant fall in MBP. The requirement of thiopentone and sevoflurane were significantly less, whereas duration of post operative analgesia was significantly prolonged in clonidine group as compared to fentanyl group. Post operatively, patients were well sedated and side effects like nausea, vomiting and shivering were less in clonidine group. I.V. fentanyl can be used to attenuate the hemodynamic response in normotensive patients whereas clonidine will be a better choice in hypertensive patients.

Mapping complex polarization states of light on a solid

Polarization states of light, represented by different points on a Poincaré sphere, can be readily analyzed for a Gaussian beam by a combination of wave plates and polarizers. However, this method cannot be extended to higher-order Poincaré spheres and complex polarization patterns produced by coherent superpositions of vector vortex (VV) beams. We demonstrate the visualization of complex polarization patterns by imprinting them onto a solid surface in the form of periodic nano-gratings oriented parallel to the local structure of the electric field of light. We design unconventional surface structures by controlling the superposition of VV beams. Our method is of potential interest to the production of sub-wavelength nano-structures.

Synovial sarcoma of the ethmoid sinus

INTRODUCTION

Synovial sarcoma is a malignant mesenchymal tumour typically occurring in the extremities. Its occurrence in the head and neck region, particularly in the paranasal sinuses is extremely rare.

CASE REPORT

Here, we report a case of primary synovial sarcoma of the ethmoid sinus in a 36-year-old female and review the literature of synovial sarcomas arising from the ethmoid sinus. Histopathology was essential in confirming the diagnosis. The patient underwent endoscopic excision of the tumour followed by postoperative radiotherapy.

DISCUSSION

As per our knowledge, only 2 cases of ethmoid sinus synovial sarcoma have been reported in the English literature till date. Although synovial sarcomas rarely involve the paranasal sinuses, they should be included in the differential diagnosis of paranasal sinus tumours. The accepted treatment modality is wide local excision followed by post operative radiotherapy.

Immediate weight bearing after plate fixation of fractures of the tibial plateau

BACKGROUND

Proximal articular fractures of the tibia are commonly stabilised with internal fixation using plates and screws. There is a lack of evidence and conflicting guidelines as to the most suitable post-operative rehabilitation regime including weight bearing status. There are numerous physiological and socioeconomic benefits of early weight bearing after orthopaedic surgery, but concerns remain around loss of fracture reduction. Therefore, the aim of this study is to investigate whether the weight bearing status after tibial plateau plate fixation is associated with any loss of reduction or articular collapse.

METHODS

We retrospectively analysed data from our prospectively collected major trauma centre database. All tibial plateau fractures that required open reduction and internal fixation with plate and screws were included. The immediate post-operative weight bearing status of these patients was recorded. Group I consisted of those patients that were either non-weight bearing or touch weight bearing for the first six post-operative weeks. Group II consisted of patients who were instructed to weight bear fully (as tolerated) immediately after the operation. Radiographs were taken on day one post-operation, at six weeks and at three months and analysed for fracture displacement and joint depression or loss of fixation.

RESULTS

A total of 90 patients were included in the study. Group I (non-weight bearing or touch weight bearing) consisted of 60 patients (67%). Group II (full weight bearing as tolerated) consisted of 30 patients (33%). The follow up radiographs demonstrated no failure of fixation in either study group. One patient from the weight bearing group had >1 mm joint depression (4 mm) identified at the first follow up, which did not progress.

CONCLUSIONS

This study shows immediate post-operative full weight bearing does not affect the fixation or cause articular collapse up to three months after surgery and thus we propose that patients should be allowed to weight bear immediately after surgical stabilisation of tibial plateau fractures. This will enable patients to benefit from the positive effects on fracture healing of early weight bearing post-surgery and avoid the complications of non-weight bearing without loss of fixation or articular collapse.

A Study of Thyroid Dysfunction in Cirrhosis of Liver and Correlation with Severity of Liver Disease

INTRODUCTION

Liver plays an important role in the metabolism of thyroid hormones, as it is the most important organ in the peripheral conversion of tetraiodothyronine (T4) to triiodothyronine (T3) by Type 1 deiodinase.

MATERIALS AND METHODS

This case-control study included 100 decompensated liver cirrhosis patients (71 males and 29 females) and 100 apparently healthy controls (71 male and 29 female). Serum FT3, FT4, and thyroid-stimulating hormone (TSH) levels were measured using electrochemiluminescence immunoassay and analyses between cases versus healthy controls (Group 1) and further analyses in subgroups, cirrhosis with hepatic encephalopathy (HE) cases (n = 38) versus cirrhosis without HE cases (Subgroup 1), cirrhosis survivors (n = 84) versus cirrhosis nonsurvivors (Subgroup 2), HE survivors (n = 23) versus HE nonsurvivors (Subgroup 3). Results were also analyzed for severity of liver disease according to Child-Turcotte-Pugh (CTP) (Class A, B, and C), model for end-stage liver disease (MELD) score, and HE grades.

RESULTS

Most common etiology was alcohol (46%) and presentation was gross ascites (74%). Cirrhosis patients had statistically significant lower level of FT3 (P < 0.0001) and FT4 (P < 0.0001) but had higher level of TSH (P < 0.0001) compared with the controls. Cirrhosis with HE (n = 38) had significantly lower lever of FT3 (P < 0.0001) compared with cirrhosis without HE (n = 62), whereas there was no statistically significant difference in FT4 (P < 0.09) and TSH (P < 0.60) levels. FT3 level significantly low in HE Grade 4 patients compared with HE Grade 1 patients (P = 0.0001). In all cirrhotic patients, FT3 and FT4 were negatively correlated, but TSH level was positively correlated with total leukocyte counts, serum total bilirubin, aspartate transaminase, alanine transaminase, globulin, prothrombin time (PT), blood urea, serum creatinine, CTP, and MELD score. Overall, the most common abnormality seen was low T3 (low FT3) syndrome 41% (41 out of 100) in cases, 50% (19 out of 38) in cirrhosis with HE, and 32% (5 out of 16) in Non-survivors cases.

CONCLUSION

The mean FT3 and FT4 levels were significantly decrease and mean TSH levels were significantly increase in liver cirrhosis patients compared to healthy controls. Level of FT3, FT4, and TSH also correlate with the severity of liver disease, level of FT3 can be used as prognostic marker for liver cirrhosis patients.