Identification of the intermittent nature of trace mitral and/or aortic regurgitation: long-term longitudinal echocardiogram study in children with Dravet syndrome treated with fenfluramine

Background

Previous studies have identified the presence of trace valvular regurgitation; however, these studies are typically cross-sectional assessments at a single point in time and provide no information regarding the natural history of trace aortic or mitral regurgitation (AR, MR). To our knowledge no study has assessed valve function in growing children with longitudinal echocardiogram (ECHO) assessments.

Purpose

To monitor cardiac valve function with regular, standardized ECHOs in patients with Dravet syndrome (DS) treated with fenfluramine for up to 3 years.

Methods

Patients with DS who completed either of two double-blind Phase 3 clinical trials were eligible to enroll in the open label extension (OLE) study. Patients were to be excluded from entry into the double-blind trials if they exhibited any degree of AR or MR, including trace; or pulmonary artery hypertension (PAH). However, trace MR or AR were not exclusion criteria for continuation into the OLE study. All patients had an ECHO prior to initiation of treatment in the double-blind study, after 6 to 8 weeks of treatment, and at the end of that study. In the OLE study, ECHOs were performed at study week 4, 5, or 6, and every 3 months thereafter. Valve morphology was also examined.

Results

As of September 1, 2019 a total of 330 patients had enrolled in the OLE study and received at least one dose of fenfluramine. The average age of patients at enrollment was 9.0±4.6 years, 27.6% were <6 years old, and 54.5% were male. The median duration of treatment with fenfluramine in the OLE study was 631 days (min, max; 7, 1086 days), and a total of 2,691 ECHOs had been performed. The point prevalence of trace MR was 10.6% at OLE study entry and ranged from 2.8% to 12.9% thereafter. All instances of trace MR were transient events that reverted to absent or oscillated between trace and absent at later study visits. Four patients demonstrated trace AR at one or more visits and all had reverted to absent at their most recent examination. No changes in valve morphology were observed.

Conclusions

In this long-term longitudinal ECHO study in DS children treated with fenfluramine, we identified that trace MR and AR were intermittent and not predictive of future valve disease. In all cases trace reverted to absent regurgitation at subsequent ECHOs. No valve morphological changes were seen. The intermittent and transient nature of trace regurgitation observed in this study is consistent with current ECHO guidelines, which consider trace regurgitation to be a normal physiologic phenomenon.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Zogenix, Inc.

Poorly Differentiated Chordoma with Rhabdoid Features

Casestudy: Chordoma is an uncommon primary malignant tumor of the bone showing notochordal differentiation. The current World Health Organization classifies chordoma into three subtypes: conventional, chondroid, and dedifferentiated.

Poorly differentiated chordoma (PDC) is a newly described variant of chordoma, with its own distinct features in terms of age distribution (common in pediatric and young adults), histopathology (lack of physaliphorous cells and chondromyxoid matrix), immunohistochemical and molecular characteristics (loss of SMARCB1/INI1 expression) and clinical outcome (poor prognosis with rapid onset of local recurrence and metastasis).

Herein, we report the case of a 43 year old man with history of fall and injury of tailbone 2 years prior, who presented with pain and swelling at the sacrcoccygeal region and intermittent numbness in the legs. MRI of the pelvis showed a 9.8 cm lobulated mass centered on the sacrum with osseous destruction of S5 through coccyx, with intralesional hemorrhage, and mild heterogeneous enhancement. Biopsy of the sacrococcygeal mass demonstrated a malignant neoplasm composed of lobules of epithelioid cells with abundant eosinophilic cytoplasm showing focal vacuolization, and mild to moderate nuclear pleomorphism with an average 3 mitoses per high power field (400x). Immunohistochemically, the neoplastic cells were positive for pancytokeratin, CAM 5.2, vimentin and brachyury. They had loss of SMARCB1 (INI1) and were negative for S100, CK7, CK20, desmin and actin. The location, imaging studies, morphologic features and immunohistochemical profile were consistent with poorly differentiated chordoma with rhabdoid features. With its specific clinical, morphologic, immunophenotypical, and molecular features, PDC may be recognized as a chordoma subtype in a future WHO classification. According to current knowledge, the diagnosis of PDC should be restricted to cases with brachyury expression (specific for notochord tumors) and INI1 protein loss, especially in tumors of pediatric and young patients, regardless of cellular characteristics.

Cytology-Histology Correlation of Hydatid Cyst: A Case Study and Literature Review

Casestudy: Hydatid cyst results when humans get infected by ingesting the eggs of Echinococcus Granulosus. Upon release, the six-hooked oncospheres penetrate the intestinal wall and migrate via circulation to various organs, mostly liver and lung. Here, they develop into hydatid cyst. The cyst enlarges gradually and is filled with daughter cysts and protoscolices.

We report the case of a 69-year old female, native of Uzbekistan, who presented with right upper quadrant pain. Imaging showed a 20 cm liver cyst and multiple pelvic cysts with a stage of CE2 implying that they were most likely functional. Serum Echinococcal antibody was positive. After 2 months of Albendazole treatment, there was no radiological change. The patient underwent laparoscopic puncture aspiration and injection with 20% saline (PAIR) and pericystectomy of the pelvic cysts. The aspirate revealed scattered scolices, inflammatory cells and abundant amorphous debris consistent with hydatid cyst. Bilateral 5-cm pelvic cysts had pale yellow, soft to firm walled, multiple cavities. Microscopy revealed a fibrofatty outermost layer with chronic inflammation and a two-layered cyst wall including a thin germinal epithelium covered by a thick acellular outer membrane. Multiple parasites, some degenerate (dense eosinophilic) were present, confirming the cytologic diagnosis of cystic echinococcosis. Following further treatment with Albendazole, she underwent a robotic assisted PAIR and partial peri-cystectomy of the liver cyst with repair of the duct to cyst communication. The liver cyst contained daughter cysts of Echinococcus and brood capsule with protoscolices. After 2 months more of Albendazole her Elisa was intermediate.

A prior study reported cytopathologic diagnosis of hydatid cyst in 17 patients evaluated for various masses. Our case highlights the role of cytology sampling in confirming the diagnosis of hydatid disease. Potentially fatal in untreated patients, this entity has to be considered in the differential diagnosis of cystic lesions.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H₂O (7.97-11.70 mm H₂O) vs 9.85 mm H₂O (8.33-11.44 mm H₂O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m² resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m². Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m²) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m² or greater, and confirm appropriate mask fit following decontamination.

Recurrent costs in primary health care in Ethiopia: facility and disease specific unit costs and their components in government primary hospitals and health centers

Background

Continued investment, especially from domestic financing, is needed for Ethiopia to achieve universal health coverage and a sustainable health system over time. Understanding costs of providing health services will assist the government to mobilize adequate resources for health, and to understand future costs of changes in quality of care, service provision scope, and potential decline in external resources. This study assessed costs per unit of service output, “unit costs”, for government primary hospitals and health centers, and disease-specific services within each facility.

Methods

Quantitative and qualitative data were collected from 25 primary hospitals and 47 health centers across eight of the eleven regions of Ethiopia for 2013/14, and 2014/15 and 2015/16 but only for primary hospitals, and supplemented by other related health and financial institutions records. A top-down costing approach was used to estimate unit costs for each facility by department – inpatient, outpatient, maternal and child health, and delivery. A mixed-method approach was used for the disease-specific unit costs exempt from fees.

Results

Health center median unit cost was 146 Ethiopian birr (ETB) (17 PPP$, 2012), the Delivery department had the highest median unit cost (647 ETB; 76 PPP$, 2012) and Outpatient department (OPD) had the lowest (124 ETB; 14 PPP$, 2012). Primary hospital median unit cost was 339 ETB (40 PPP$, 2012), with Inpatient department having the highest median unit cost (1288 ETB; 151 PPP$, 2012), while OPD was the lowest (252 ETB; 29 PPP$, 2012). Drugs and pharmaceutical supplies accounted for most of the costs for both facilities. Among the exempted services offered, tuberculosis and antiretroviral treatment are the costliest with median unit costs from 1091 to 1536 ETB (128–180 PPP$, 2012), with drugs and supplies accounting for almost 90% of the costs.

Conclusions

High unit costs of service provision could be indicative of underutilization of the primary health care system, coupled with inefficiencies associated with organization and delivery of health services. Data from this study are being used to assess efficiency and productivity among primary care facilities, facilitate premium setting for health insurance, and improve budgeting and allocating health resources for a more sustainable and effective primary health care system.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Intracranial vessel wall imaging: applications, interpretation, and pitfalls

Vessel wall imaging (VWI) is being increasingly used as a non-invasive diagnostic method to evaluate the intra- and extracranial vascular bed. Whereas conventional vascular imaging primarily assesses the vessel lumen, VWI changes the focus of analysis toward the vessel wall. As the technical challenges of high spatial resolution, signal-to-noise ratio, and contrast-to-noise ratio and long scans times are addressed, interest in the clinical applications of this technique has steadily increased over the years. In this review, the authors will discuss the various applications of VWI as well as principles of interpretation and common imaging findings, focusing on intracranial atherosclerosis, vascular dissection, vasculitides (such as primary angiitis of the central nervous system (PACNS) and neurosarcoidosis), vasculopathies (such as reversible cerebral vasoconstriction syndrome (RCVS), cocaine-induced vasculopathy, moyamoya disease, and radiation-induced arteriopathy), aneurysms, and post-thrombectomy changes. The authors will also discuss the potential pitfalls of VWI and helpful cues to avoid being tricked.

Indirect costs of adult pneumococcal disease and the productivity-based rate of return to the 13-valent pneumococcal conjugate vaccine for adults in Turkey

Productivity benefits of health technologies are ignored in typical economic evaluations from a health payer’s perspective, risking undervaluation. We conduct a productivity-based cost-benefit analysis from a societal perspective and estimate indirect costs of adult pneumococcal disease, vaccination benefits from the adult 13-valent pneumococcal conjugate vaccine (PCV13 Adult), and rates of return to PCV13 Adult for a range of hypothetical vaccination costs. Our context is Turkey’s funding PCV13 for the elderly and for non-elderly adults with select comorbidities within the Ministry of Health’s National Immunization Program. We use a Markov model with one-year cycles. Indirect costs from death or disability equal the expected present discounted value of lifetime losses in the infected individual’s paid and unpaid work and in caregivers’ paid work. Vaccination benefits comprise averted indirect costs. Rates of return equal vaccination benefits divided by vaccination costs, minus one. Input parameters are from public data sources. We model comorbidities’ effects by scalar multiplication of the parameters of the general population. Indirect costs per treatment episode of inpatient community-acquired pneumonia (CAP), bacteremia, and meningitis – but not for outpatient CAP – approach or exceed Turkish per capita gross domestic product. Vaccination benefits equal $207.02 per vaccination in 2017 US dollars. The rate of return is positive for all hypothetical costs below this. Results are sensitive to herd effects from pediatric vaccination and vaccine efficacy rates. For a wide range of hypothetical vaccination costs, the rate of return compares favorably with those of other global development interventions with well-established strong investment cases.

Microwave-induced electric discharges on metal particles for the synthesis of inorganic nanomaterials under solvent-free conditions

Microwave irradiation of metals generates electric discharges (arcs). These arcs are used to generate nanoparticles of Cu and Ni and one-dimensional nanorods of CuS, ZnF₂, and NiF₂ protected with fluorinated amorphous carbon. We have also synthesized reduced graphene oxide and partially rolled graphene by this method.

Silver nanoparticles (AgNPs) induced impairment of in vitro pollen performance of Peltophorum pterocarpum (DC.) K. Heyne

Increasing use of silver nanoparticles (AgNPs) in myriad applications including electronics, medicines and agriculture has led to serious concerns regarding its release to plant ecosystems. Over the years, numerous studies have demonstrated the toxic impact of AgNPs in a variety of cell and tissue systems involved in vegetative growth across a wide range of plant species. However, assessing their impact on haploid phase of plant life cycle was restricted only to a study with Kiwifruit. In this study, in vitro pollen performance of Peltophorum pterocarpum at two endpoints i.e., germination and tube growth was assessed to evaluate the impact of nanoparticulate or ionic form of silver. Increasing concentrations of AgNO₃/AgNPs significantly reduced the pollen germination and retarded the tube growth. The EC 50 values indicated a more potent toxic effect of AgNPs than AgNO₃ on pollen germination as well as tube growth. Impairment of pollen performance was more pronounced at the stage of emergence of pollen tube. Extensive alterations in the muri and lumen of exine as revealed through SEM analysis and subsequent blockage of germpore might disrupt the emergence of pollen tube. The dynamics of pollen tube growth was analyzed with polynomial models of different degrees. A high degree of polynomial, the quintic model was able to approximate the real data points with highest coefficient of determination and smallest RMSE, compared to other models. An oscillating pattern of tube growth was portrayed with the passage of time in all the treatments that fits well with the established mechanistic oscillatory model of tube growth. It appears that exposure to AgNO₃/AgNPs inhibited pollen germination and retarded tube growth without affecting the oscillatory behavior of tip-growth.