COVID-19: a conundrum to decipher

OBJECTIVE

Recent worldwide outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of respiratory coronavirus disease 2019 (COVID-19), is a current, ongoing life-threatening crisis, and international public health emergency. The early diagnosis and management of the disease remains a major challenge. In this review, we aim to summarize the updated epidemiology, causes, clinical manifestation and diagnosis, as well as prevention and control of the novel coronavirus SARS-CoV-2.

MATERIALS AND METHODS

A broad search of the literature was performed in "PubMed" "Medline" "Web of Science", "Google Scholar" and "World Health Organization-WHO" using the keywords "severe acute respiratory syndrome coronavirus", "2019-nCoV", "COVID-19, "SARS", "SARS-CoV-2" "Epidemiology" "Transmission" "Pathogenesis" "Clinical Characteristics". We reviewed and documented the information obtained from literature on epidemiology, pathogenesis and clinical appearances of SARS-CoV-2 infection.

RESULTS

The global cases of COVID-19 as of April 2, 2020, have risen to more than 900,000 and morbidity has reached more than 47,000. The incidence rate for COVID-19 has been predicted to be higher than the previous outbreaks of other coronavirus family members, including those of SARS-CoV and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). The main clinical presentation of SARS-CoV-2 infection ranges from asymptomatic stages to severe lower respiratory infection in the form of pneumonia. Most of the patients also presented with fever, cough, sore throat, headache, fatigue, myalgia and breathlessness. Individuals at higher risk for severe illness include elderly people and patients with a weakened immune system or that are suffering from an underlying chronic medical condition like hypertension, diabetes mellitus, cancer, respiratory illness or cardiovascular diseases.

CONCLUSIONS

SARS-Cov-2 has emerged as a worldwide threat, currently affecting 170 countries and territories across the globe. There is still much to be understood regarding SARS-CoV-2 about its virology, epidemiology and clinical management strategies; this knowledge will be essential to both manage the current pandemic and to conceive comprehensive measures to prevent such outbreaks in the future.

AB0713 PERIODONTAL DISEASES AND ITS ASSOCIATION WITH ANKYLOSING SPONDYLITIS/SPA: A SYSTEMATIC REVIEW

Background:

A close association between periodontal disease and Ankylosing spondylitis (AS) has long been specualted. Both diseases are characterized by dysregulation of the host inflammatory response, leading to further destruction of soft and hard connective tissue with there being evidence of increased levels of TNF-α and various interleukins in both patients of AS and periodontitis.

Objectives:

The aim of this systematic review was to appraise the available literature exploring the relationship between AS and periodontal disease.

Methods:

We searched Medline & Embase databases (from their inception till October 2019) using appropriate combinations of following search items with limits ‘(English, Human)’; Ankylosing spondylitis, spondyloarthritis, spondyloarthropathies, spondyloarthritides, spinal disease, musculoskeletal disease, Rheumatic disease AND periodontitis, periodontal disease, periodontoses, parodontoses, chronic periodontitis, gum disease, gingivitis, oral health, dental health, plaque index, bleeding on probing, probing pocket depth, clinical attachment loss. This search was supplemented by the manual search of bibliographies of articles selected and conferences proceedings of EULAR. Only be reviews, observational study of cross-sectional, cohort or case control type on adult patients with AS were selected. Data was extracted from a predesigned proforma. A close association between periodontal disease and Ankylosing spondylitis (AS) has long been specualted. Both diseases are characterized by dysregulation of the host inflammatory response, leading to further destruction of soft and hard connective tissue with there being evidence of increased levels of TNF-α and various interleukins in both patients of AS and periodontitis.

Results:

A total number of 984 articles were identified and 12 were selcted for detailed appraisal (Figure 1, PRISMA flow chart). They were all case control studies. The prevalence of periodontitis ranged from 38% to 88% in patients with AS whereas in the control group from 26% to 71 % in controls. Out of 12 studies, two showed significant changes in Plaque Index (PI), two studies showed altered Pocket Probing Depth (PPD), three showed significant increased in Clinical Attachment Loss (CAL) and increased Bleeding On Probing (BOP) was seen in 2 studies. In 7 studies, periodontitis was seen in a significant number of patients with AS (P<0.05). All studies reported that the prevalence of periodontal disease in AS patients was higher as compared to non-AS patients.

Conclusion:

Our systematic review found an association between AS and periodontal disease. Patients with AS show higher prevalence of periodontitis and a poor oral hygiene as compared to healthy controls. At practice level, this systematic review underscores the need for a collaboration between dentists and rheumatologist.

Disclosure of Interests:

None declared

1166 Investigating Social Workers’ Sleep Health Knowledge: Opportunities to Promote Sleep Health Among Underserved Populations

Introduction

Social workers are often front-line psychosocial providers working with underserved populations, many of whom struggle with sleep. They are uniquely positioned to promote sleep health among individuals experiencing health inequities. However, U.S. accredited social work programs do not require sleep health training. We used both quantitative and qualitative methodologies to investigate social work students’: a) sleep health knowledge; b) self-reported sleep quality; c) prior sleep health education; and d) client discussions about sleep, in order to inform the development of a sleep health training for social work students.

Methods

Twenty-five social work students were recruited via a listserv email sent at a Florida university. Participants were asked to complete the Sleep Beliefs Scale (SBS) and the Pittsburgh Sleep Quality Index (PSQI) and then to participate in a one-hour long focus group (3 groups with 6-11 students/group) conducted by experienced qualitative researchers.

Results

Mean age was 27.0±11.5 yrs, 92.0% were female, and 48.0% were non-Hispanic white, 28.0% African American, 16.0% Hispanic, 8.0% other. Only 28.0% indicated that they had ever discussed sleep with clients. Knowledge of healthy sleep behaviors (assessed via the SBS) was moderate on a 0-20 scale (13.88, S.D.= 2.7). Participants had an average PSQI score of 8.8 (SD.=4.0), reported sleeping an average of 6.0 hours (SD=1.6), and mean sleep efficiency of 87.0% (SD=12.0). Themes from focus group data highlight students’ lack of exposure to sleep health training and a dearth of sleep discussions in clinical practice.

Conclusion

Though social work students acknowledged the importance of sleep health promotion, they reported feeling ill-equipped to promote healthy sleep practices due to lack of sleep education. Sleep health training could allow social workers to confidently promote healthy sleep practices among their clients, recognize when appropriate to refer clients for evaluation for sleep disorders, and improve social workers’ own sleep health. An online educational program was subsequently created by study investigators to meet these aims.

Support

American Academy of Sleep Medicine Foundation

1168 Preliminary Impact of a Sleep Health Educational Module for Social Work Students

Introduction

Social workers are well-positioned to promote healthy sleep behaviors among underserved populations; however sleep health training is rarely integrated into social work curriculums. To address this gap, our interdisciplinary team developed a 2-hour online sleep health educational module for social work students. The module was grounded in best e-learning pedagogical principles, and based on qualitative formative research. We tested the initial impact and acceptability of the module.

Methods

We recruited 32 social work students at a Florida University via a departmental listserve. Pre- to post-intervention changes in the Sleep Beliefs Scale (SBS) and the Sleep Practices and Attitudes Questionnaire (SPAQ) were assessed using Wilcoxon Signed-Rank tests. We conducted qualitative research to assess intervention acceptability,and to inform future iterations of the program.

Results

Mean age was 29.5±11.6 yrs, 100% were female, and primarily Non-Hispanic White (41.9%), followed by African American/Black (35.5%), and Hispanic/Latino (22.6%). Results showed pre/post intervention improvements in both the Sleep Beliefs Scale (14.7±2.2 vs.16.9±2.6 [p=.002]; higher score=higher knowledge) and SPAQ (2.1±0.6 to 1.5±0.6 [p=.001]; lower score=higher importance of sleep) indicating improvements in knowledge surrounding healthy sleep behaviors and the importance of sleep for overall health (respectively). Qualitative data supports the intervention’s acceptability and utility. When asked what participants liked best about the module, responses included: “I was educated and am better prepared to offer some insight to my clients and staff”; “..they offer resources we can use for ourselves and our clients;” and “easy to navigage, and full of useful information.” Suggestions for improvement included shortening the module’s length.

Conclusion

Assessment of an online sleep health educational module indicates a promising impact on sleep health knowledge. A larger study is planned to more definitively evaluate the module’s impact and acceptability among social work students.

Support

American Academy of Sleep Medicine Foundation

1069 Posttraumatic Stress Disorder is Associated With Poorer Sleep Specific Quality of Life, but Not With Sleep Apnea

Introduction

The degree that posttraumatic stress disorder (PTSD) contributes to obstructive sleep apnea (OSA) or sleep specific quality of life (QOL) remains uncertain.

Methods

We evaluated consecutive military veterans (n=3,155) with suspected OSA using multivariable regressions to test associations between sleep and QOL measures including the apnea-hypopnea index (AHI), Pittsburgh Sleep Quality Index (PSQI) and Short-Form-12 mental component score (MCS). A mental health expert determined PTSD presence with severity measured utilizing the PTSD Checklist (PCL). Subjects were evaluated with prospectively collected questionnaires, sleep studies, and detailed electronic medical record reviews.

Results

Current-PTSD (n=1,172, 37%) were younger, more likely single, unemployed on disability, report non-white ethnicity or have current alcohol or drug dependence, report past suicide attempt, have current insomnia, restless sleep or nightmares, report lower MCS or higher Epworth Sleepiness, Fatigue Severity, Beck Depression Inventory-II (BDI) and PSQI scores than non-PTSD (n=1,880) or past-PTSD (n=103) veterans. Among current-PTSD, instigating trauma was 75% combat and 13% sexually related. In multivariable regressions, male gender (OR 4.5, p&lt;0.001), age &gt;65 years (OR 2.3, p&lt;0.001), BMI ≥35 kg/m2 (OR 3.5, p&lt;0.001), prior stroke (OR 1.8, p&lt;0.006), current hypertension (OR 1.4, p&lt;0.001), neck circumference &gt;40 cm (OR 1.3, p=0.032), and non-white ethnicity (OR 1.2, p=0.034) were associated with moderate-severe OSA (AHI ≥15/h), however current (OR 0.9, p=0.06) or past-PTSD (OR 1.2, p=0.41) were not. PCL (p=0.937) was not associated with AHI. Factors most associated with lower MCS included current-PTSD (scaled standardized beta[SSB]=0.09, p=0.001), depression (SSB=0.09, p=0.001), age &lt;50 years (SSB=0.09, p&lt;0.001), non-white ethnicity (SSB=0.07, p=0.004), female gender (SSB=0.06, p=0.007) or single/no-partner (SSB=0.05, p=0.03). Likewise, factors most associated with a higher PSQI included depression (SSB=0.19, p&lt;0.001), current-PTSD (SSB=0.15, p&lt;0.001), unemployed on disability (SSB=0.14, p&lt;0.001), non-white ethnicity (SSB=0.13, p&lt;0.001) or age &lt;50 years (SSB=0.10, p=0.001). Among current-PTSD, higher PSQI was associated with BDI ≥20 (SSB=0.31, p&lt;0.001), PCL ≥50 (SSB=0.24, p&lt;0.001) and non-white ethnicity (SSB=0.11, p=0.034), but not with moderate-severe OSA (SSB= -0.09, p=0.095).

Conclusion

In the largest PTSD sleep cohort to date, PTSD is associated with insomnia, restless sleep, poorer sleep specific QOL, and greater daytime sleepiness and fatigue, but is not associated with OSA.

Support

None

1044 Adequate Sleep is Associated with Improved Diabetes Knowledge and HbA1c

Introduction

Although 55 % of the people with T2DM have low quality of sleep that may affect their physical and emotional wellbeing, and present challenges to the management of their condition, many Diabetes Self-Management Education Programs (DSME) that aim to improve knowledge of T2DM, don’t include information on healthy sleep. This study will examine the relationship between adequate sleep on improved T2DM knowledge and diabetes maintenance (HbA1c).

Methods

The Sleep Integrated with Diabetes Education (SLIDE) Trial tests whether including four brief healthy sleep hygiene sessions within an existing traditional Diabetes Self-Management Education Program improves healthy sleep, motivation for change, and biopsychosocial outcomes for 50 patients with DM who are under and uninsured. This study uses descriptive and ANOVAs to examine the relationship between adequate sleep and change in diabetes knowledge (Diabetes Knowledge Test) using self-report. EMR was used to link HbA1c and other biological measures.

Results

Fifty patients with T2DM (mean HbA1c = 8.79 ± 2.42) participating in a DSME Program at a southern urban community nonprofit hospital were randomly assigned to DSME classes or DSME classes + four 15-minute presentations (video and powerpoint) highlighting healthy sleep hygiene practices. The majority of these patients were obese (mean BMI=38.56±8.20). Only 11% reported normal sleep, with 41% reporting short sleep (&lt;6 hours) and 7% long sleep (&gt;8 hours). Patients who reported adequate sleep were more likely to improve diabetes knowledge (81% score vs. 68% score, p&lt;.001) and HbA1c (1.1 vs. -.03, p&lt;.001).

Conclusion

There is a relationship between adequate sleep and improving diabetes knowledge and maintenance for patients with T2DM. Future research could further explore this relationship and determine barriers and facilitators to adequate sleep and what role adequate sleep plays in improving T2DM knowledge and maintenance.

Support

Bon Sequor Foundation

Differential expression of caveolin-1 during pathogenesis of combined pulmonary fibrosis and emphysema: Effect of phosphodiesterase-5 inhibitor

INTRODUCTION

Combined pulmonary fibrosis and emphysema (CPFE) is a relatively new entity within the spectrum of cigarette smoke induced lung disorders. Currently there is no consensus about its treatment. We hypothesized that caveolin-1 critically determines the parenchymal and vascular remodeling leading to the development of CPFE. We assessed the effect of therapeutic targeting of caveolin-1 in mesenchymal and endothelial cells by the phosphodiesterase-5 inhibitor, sildenafil.

METHODS

Male Wistar rats (n = 168) were exposed to; room air (control); bleomycin (7 U/kg), bleomycin+sildenafil (50 mg/kg/day P.O.), cigarette smoke (CS) (4 Gold Flake 69 mm/day), CS + sildenafil, CS + bleomycin, CS + bleomycin+sildenafil. Animals were euthanized at 8, 9, 11, 12 weeks and lung histopathological changes, collagen deposition, ROS, Xanthine oxidase, caveolin-1 determined.

RESULTS

Cigarette smoke causes progressive ROS accumulation, caveolin-1 up-regulation in alveolar epithelial cells, alveolar macrophages, peribronchiolar fibroblasts, endothelial and vascular smooth muscle cells, interstitial inflammation and emphysema. Sildenafil reduces oxidative stress, parenchymal caveolin-1 and attenuates emphysema caused by CS. Bleomycin increases lung ROS and downregulates caveolin-1 leading to fibroblast proliferation and fibrosis. Combined cigarette smoke and bleomycin exposure, results in differential caveolin-1 expression and heterogeneous parenchymal remodeling with alternating areas of emphysema and fibrosis. Increased caveolin-1 induces premature senescence of lung fibroblasts and emphysema. Decreased caveolin-1 is associated with propagation of EMT and fibrosis. Sildenafil attenuates the parenchymal remodeling however it is not effective in reducing VSMC hypertrophy in combined group.

CONCLUSION

CPFE is characterized by heterogenous parenchymal remodeling and differential caveolin-1 expression. Sildenafil therapy attenuates parenchymal pathologies in CPFE. Additional therapy is however needed for attenuating VSMC remodeling.

A129 THE VALUE OF REPEAT MANOMETRIC TESTING

Background

While motility disorders may evolve over time, there is scant guidance around the role of repeat high-resolution esophageal manometry (HRM). Given the invasive nature of HRM and the implications on financial cost and patient discomfort, it is obvious that the emphasis should be on minimizing unnecessary repeat examinations. However, there are no recommendations around indications or timing of repeat HRM.

Aims

We aimed to determine the outcomes in patients who underwent repeat manometry and look for predictors of progression to achalasia or major motility disorder.

Methods

Consecutive reports from HRM studies performed between Aug 2013 – May 2017 were retrospectively analyzed. All patients with ≥ 2 HRM studies were included. Studies without a Chicago classification diagnosis were excluded. Chi-squared analysis was performed to determine if initial HRM diagnosis was associated with change in diagnosis on follow-up HRM. Initial and follow-up manometric parameters were compared with paired T-tests. Binary logistic regression analysis was performed to look for predictors of progression to achalasia or major motility disorder.

Results

134 patients underwent ≥ 2 HRM studies. Initial diagnoses were IEM (45 patients [33.6%], EGJOO (34 [25.4%], absent peristalsis (18 [13.4%], achalasia (11 [8.2%], DES (4 [3.0%]), and JH (3 [2.2%]; 29 (14.2%) of patients had a normal HRM. 109 (81.3%) patients underwent 2 HRM, 18 (13.4%) 3 HRM, 4 (3%) 4 HRM, and 3 (2.2%) 5 HRM.

The final follow-up HRM occurred after a median 496 [80 – 1823] days. 72 (53.7%) of patients had no change from their initial diagnosis. Patients with an initial diagnosis of DES were significantly more likely to have a change in diagnosis on the final follow-up (3 normal:1 IEM) (p = .043). No other classes reached significance. Patients with IEM had a significantly higher mean DCI (395.1 [0 - 3248] vs 790.8 [0 – 10715.0], p = .006) and IRP (4.5 [-10.4 – 14.2] vs [6.6 [-6.2 – 21.0], p = .017) on their follow-up HRM.

4 patients without achalasia (3 EGJOO:1 IEM) on their index HRM had a diagnosis of achalasia on their final HRM. The median IRP in non-achalasia patients with a diagnosis of achalasia on final HRM (22.3 [8.4 – 30.7] was significantly higher than those without a diagnosis of achalasia on final HRM (6.6 [-10.4 – 39.8]) (p = .013); however no manometric criteria or initial HRM diagnoses predicted progression to achalasia or major motility disorder on binary logistic regression analysis.

Conclusions

In most patients, repeat manometry did not change the manometric diagnosis. Patients with DES were significantly likely to have their diagnosis change with repeat HRM, and most of these patients had normalization of their HRM. Manometric parameters in IEM appear to improve over time. This finding could reflect interval therapy, or shed some light on the natural history of this disease.

Funding Agencies

None

Digital tooth reconstruction: An innovative approach in forensic odontology

In mass disasters, accidents and crime investigations, where human remains are decomposed, charred or skeletonized, teeth may dislodge due to post-mortem loss or due to mishandling of evidence during the manipulation of skeletal and dental remains. Thus, the identification process is hampered due to the loss of dental evidence. In these situations, forensic tooth reconstruction may aid in the identification process. Forensic tooth reconstruction (FTR) refers to the process that aims to reconstruct the morphology of the missing tooth from the skeletal remains from the intra-alveolar morphology of the dental socket. The study is an innovative attempt to develop a digital approach to reconstruct three-dimensional (3D) printed tooth models through recording intra-alveolar morphology of empty dental sockets which simulate the teeth which are missing post-mortem. An experimental study was conducted on the human mandible, where using volumetric scanning, 3D scanning and printing techniques the tooth was reconstructed from the intra-alveolar morphology of the socket. Through metric analysis and qualitative congruency testing it was established that there was minimal discrepancy between natural tooth and 3D printed tooth. It was determined that teeth missing post-mortem do not necessarily invalidate the identification process. Digital FTR gives accurate results with minimum error.

Photonic crystal tunnel junction deep ultraviolet light emitting diodes with enhanced light extraction efficiency

We report on the demonstration of top emitting AlGaN tunnel junction deep ultraviolet (UV) light emitting didoes (LEDs) operating at ∼267 nm. We show, both theoretically and experimentally, that the light extraction efficiency can be enhanced by nearly a factor of two with the incorporation of AlGaN nanowire photonic crystal structures. A peak wall-plug efficiency (WPE) ∼3.5% and external quantum efficiency (EQE) ∼5.4% were measured for AlGaN LEDs directly on-wafer without any packaging. This work demonstrates a viable path for achieving high efficiency deep UV LEDs through the integration of AlGaN planar and nanoscale structures.

Ultrahigh Q microring resonators using a single-crystal aluminum-nitride-on-sapphire platform

Aluminum-nitride-on-sapphire has recently emerged as a novel low-loss photonics platform for a variety of on-chip electro-optics as well as linear and nonlinear optics applications. In this Letter, we demonstrate ultrahigh quality factor (Q_int) microring resonators using single-crystal aluminum nitride grown on a sapphire substrate with an optimized design and fabrication process. A record high intrinsic Q_int up to 2.8×10⁶ at the wavelength of 1550 nm is achieved with a fully etched structure, indicating a low propagation loss less than 0.13 dB/cm. Such high Q_int aluminum-nitride-on-sapphire resonators with their wide bandgap and electro-optical and nonlinear optical properties is promising for a wide range of low-power and high-power compact on-chip applications over a broad spectral range.

Deep Ultraviolet Luminescence Due to Extreme Confinement in Monolayer GaN/Al(Ga)N Nanowire and Planar Heterostructures

We present experimental results confirming extreme quantum confinement in GaN/Al_xGa_1-xN (x = 0.65 and 1.0) nanowire and planar heterostructures, where the GaN layer thickness is of the order of a monolayer. The results were obtained from temperature- and excitation-dependent and time-resolved photoluminescence measurements. In the GaN/AlN nanowire heterostructure array sample, the measured emission peak at 300 K is ∼5.18-5.28 eV. This is in excellent agreement with the calculated optical gap of 5.23 eV and 160-260 meV below the calculated electronic gap of 5.44 eV, suggesting that the observed emission is excitonic in nature with an exciton binding energy of ∼160-260 meV. Similarly, in the monolayer GaN/Al_0.65Ga_0.35N planar heterostructure, the measured emission peak at 300 K is 4.785 eV and in good agreement with the calculated optical gap of 4.68 eV and 95 meV below the calculated electronic gap of 4.88 eV. The estimated exciton binding energy is 95 meV and in close agreement with our theoretical calculations. Excitation-dependent and time-resolved photoluminescence data support the presence of excitonic transitions. Our results indicate that deep-ultraviolet excitonic light sources and microcavity devices can be realized with heterostructures incorporating monolayer-thick GaN.

P635The addition of yoga to aerobic exercise programs reduces global cardiovascular risk

Introduction

Regular physical activity may modulate the inflammatory process and be cardio-protective. Yoga is a form of exercise that may have cardiovascular benefits. The effects of yoga on global cardiovascular risk have not been adequately described. The purpose of this study is to determine whether the addition of yoga to a regular exercise regimen reduces global cardiovascular risk.

Methods

Sixty consecutive individuals with essential hypertension were recruited in a lifestyle intervention program. All individuals with known hypertensive end organ damage, known cardiovascular diseases, as well as those taking medications/supplements that affected blood pressure, blood sugar, cholesterol or vascular inflammation were excluded. Participants were randomized to either a yoga group or similar duration stretching control group. Participants, over the 3-month intervention regimen, performed 15 minutes of either yoga or stretching in addition to 30 minutes of aerobic exercises thrice weekly. Blood pressure, cholesterol levels and hs-CRP were measured, and Reynold's Global Cardiovascular Risk Score was calculated at baseline and at the end of the 3-month intervention program.

Results

At screening, there were no statistically significant differences between the groups in any measured parameters or the 10-year risk of a cardiovascular event as measured by the Reynolds Risk Score. (8.2 vs. 9.0%; yoga vs. control group) After the 3-month intervention period, there was a statistically significantly greater decrease in the Reynold's Risk Score in the yoga vs. the control group. (7.0 vs. 8.4%, p=0.003, relative reduction 13.2 vs. 6.5%, p<0.0001)

Baseline and 3 Month Outcomes

Conclusions

In patients with essential hypertension on no medications and with no known end organ damage, the practice of yoga incorporated into a 3-month exercise intervention program was associated with significant greater improvement in the Reynold's Risk of a 10-year cardiovascular event, when compared to the control stretching group. If these results are validated in more diverse populations over a longer duration of follow up, yoga may represent an important addition to traditional cardiovascular disease prevention programs.

P57262018 ESC/ESH guideline-recommended age categories and intensive blood pressure management in high-risk adults: insights from SPRINT

Background

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for arterial hypertension propose different intensities of blood pressure (BP) lowering in patients <65 years, 65–79 years, and ≥80 years of age. However, it is unclear whether intensive BP management is well-tolerated and modifies risk uniformly across this age spectrum.

Purpose

To assess the relationship between age, treatment response to intensive BP lowering, and cardiovascular (CV) outcomes.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events (SAE). We examined the prognostic implications of age, using Cox proportional-hazards regression models adjusted for demographic, clinical, and laboratory variables. Whether a linear association was present between age and clinical endpoints was evaluated using restricted cubic splines. We further explored the effects of intensive BP lowering across the age spectrum using interaction analyses.

Results

Age was noted for all individuals, and 3,805 (41%), 4,390 (47%), and 1,166 (12%) were <65 years, 65–79 years, and ≥80 years, respectively. Mean age was similar between the two study groups (intensive group 67.9 years vs. standard group 67.9 years; P=0.94). Median follow-up was 3.3 years (range 0–4.8), with 562 primary efficacy events (6%) and 3,529 primary safety events (38%) recorded during the study period. Age was linearly associated with the risk of stroke (test for overall trend, P<0.001) and non-linearly associated with the risk of primary efficacy events, death from CV causes, death from any cause, heart failure, and SAE (test for non-linearity, P<0.05; test for overall trend, P<0.001). Age remained significantly associated with all tested endpoints after multivariable adjustment (P<0.001). Furthermore, the risk of primary events increased over guideline-recommended age-categories (65–79 years vs. <65 years; adj. HR 1.65, 95% CI 1.34–2.04; P<0.001 and ≥80 years vs. 65–79 years; adj. HR 1.92, 95% CI 1.54–2.40; P<0.001), as did the risk of SAE (P<0.001). The safety and efficacy of intensive BP lowering was not modified by age whether tested continuously or categorically (P>0.05). The Figure shows similar treatment effects (hazard ratios) across the spectrum of age. P-values are for the interaction between age and treatment effect for each endpoint.

Figure 1

Conclusions

In SPRINT, higher age was associated with a greater risk of both CV events and SAE. However, intensive BP lowering appeared to be associated with similar risks and benefits across the age spectrum.

Breast deformation during the course of radiotherapy: The need for an additional outer margin

PURPOSE

The aim of this retrospective study was to investigate and quantify the extent of breast deformation during the course of breast cancer (BC) radiotherapy (RT). The magnitude of breast deformation determines the additional outer margin needed for treatment planning to deliver a full dose to the target volume. This is especially important when using inverse planning techniques.

METHODS

A total of 93 BC patients treated with RT and with daily CBCT image guidance were selected for this study. Patients underwent either only breast-conserving surgery (BCS) (n = 5), BCS with sentinel node biopsy (n = 57) or BCS with radical axillary node dissection (n = 31). The treatment area included the whole breast and chest wall (54%) or also the axillary lymph nodes (46%). 3D-registration was conducted between 1731 CBCT images and the respective planning CT images to assess the difference in breast surface.

RESULTS

The largest maximum breast surface expansion (MBSE) was 15 mm; the average was 2.4 ± 2.1 mm. In 294 fractions (17%), the MBSE was ≥5 mm. An outer margin of 8 mm would have been required to cover the whole breast in 95% of the treated fractions. There was a statistically significant correlation between the MBSE and body mass index (r = 0.38, p = 0.001).

CONCLUSIONS

Significant changes in the breast surface occur during the course of BC RT which should be considered in treatment planning. An additional margin outside the breast surface of at least 8 mm is required to take into account the anatomical changes occurring during BC RT.

Quantification of atomic hydrogen anion density in a permanent magnet based helicon ion source (HELEN) by using pulsed ring down spectroscopy

In the present work, a permanent magnet-based helicon plasma source (HELEN) is characterized as a negative ion source. A noninvasive diagnostic technique based on cavity ring down spectroscopy (CRDS) is developed to measure the line-integrated negative hydrogen ion (H^-) density in HELEN. This paper discusses the experimental results in which negative hydrogen ion density is measured for different magnetic field, pressure, and RF (13.56 MHz) power configurations. It is observed that in high power range (800-850 W), the source is operating in helicon wave heating mode with a background plasma density of ∼10¹⁸ m^-3 and electron temperature of ∼2 eV. Negative hydrogen ion density is measured by CRDS method and also by optical emission spectroscopic technique. The measured negative ion density is in the range of ∼10¹⁶ m^-3 under volume mode operational condition even without any use of standard magnetic filter or cesium seeding in the downstream region. The influence of pressure variation (pressure range from 4 × 10^-3 mbar to 4 × 10^-2 mbar) on negative ion density production is not significant, except for a particular axial magnetic field configuration (55 G) and at 8 × 10^-3 mbar pressure, where ∼34% hike is observed.