Comparison of various instantaneous pulmonary arterial wedge pressure measurements with prognostic validation

Background

Current recommendations on the diagnosis of pulmonary hypertension due to left heart disease (PH-LHD) emphasize the need for standardization of pulmonary arterial wedge pressure (PAWP) measurement. Instead of mean PAWP values instantaneous mid-A wave pressures or, in case of atrial fibrillation (AF), measurement 130–160 ms after the QRS onset is recommended. Recently, PAWP at the QRS onset has also been proposed. Our aim was to compare the various instantaneous PAWP measurements and assess the prognostic value of the derived diastolic pressure gradients (DPG) in heart failure (HF) patients.

Methods and results

PAWP and pulmonary arterial pressure (PAP) tracings of 116 patients with PH-LHD were manually analyzed offline. PAWP was measured in 4 different ways: 1. mean value [PAWPM]; 2.mid-A wave value in sinus, and at 10 ms intervals 130–160 ms following QRS onset in AF [PAWPR]; 3. at the onset of the QRS complex [PAWPQRS]; 4. pre C-wave point value [PAWPC]. The pre C-wave point was chosen as a reference for truly end-diastolic pressures. The corresponding DPGM, DPGR, DPGQRS and DPGC were calculated. The patients were followed for 17 (8–27) months and the prognostic value of the various DPG measurements for predicting all-cause mortality was assessed. The pre C-wave point was identifiable in 35 patients (30%); on average it occurred 171 ms after the QRS-onset whereas the A wave-onset and A-wave peak happened on average 62 and 149 ms after the QRS-onset, respectively. All three instantaneous PAWP measurements gave significantly lower values than PAWPM [19.3 (15.4–25.0)]. PAWPR did not differ from PAWPC [18.1 mmHg (14–22) vs. 19.2 mmHg (13–22.8), p=0.9], whereas PAWPQRS was lower [15.8 mmHg (12.2–19.9), p<0.001]. Accordingly, all instantaneous DPG measurements were higher than DPGM, yielding lower prevalence of negative DPG (29%, 17% and 45%, for DPGR, DPGQRS and DPGM, respectively). In AF (n=30), DPGR values at 130–140–150–160 ms demonstrated increasing scatter and progressively overestimated DPGQRS. For prognostic assessment, in case of both DPGQRS and DPGR, 6 mmHg was identified as a best cut-off value for predicting all-cause mortality, at which both indices provided superior prognostic information than DPGM [DPGR: HR 2.7; CI 1.1–6.9, p=0.029; DPGQRS: HR 2.6; CI 1.1–6.4, p=0.037, high-risk cases 17 for both; DPGM: HR 2.8; CI 1.0–7.6, p=0.045, high-risk cases 10].

Conclusions

PAWP measured at the mid-A wave provides a reliable assessment of the end-diastolic PAWP in sinus rhythm. On the other hand, ECG-gated measurements yield more robust evaluation of PAWP in AF. Finally, both approaches carry significant and similar prognostic information in PH-LHD.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): AIN was supported by the János Bolyai Scholarship of the Hungarian Academy of Sciences

Development of Coagulation Factor XII Antibodies for Inhibiting Vascular Device-Related Thrombosis

Introduction

Vascular devices such as stents, hemodialyzers, and membrane oxygenators can activate blood coagulation and often require the use of systemic anticoagulants to selectively prevent intravascular thrombotic/embolic events or extracorporeal device failure. Coagulation factor (F)XII of the contact activation system has been shown to play an important role in initiating vascular device surface-initiated thrombus formation. As FXII is dispensable for hemostasis, targeting the contact activation system holds promise as a significantly safer strategy than traditional antithrombotics for preventing vascular device-associated thrombosis.

Objective

Generate and characterize anti-FXII monoclonal antibodies that inhibit FXII activation or activity.

Methods

Monoclonal antibodies against FXII were generated in FXII-deficient mice and evaluated for their binding and anticoagulant properties in purified and plasma systems, in whole blood flow-based assays, and in an in vivo non-human primate model of vascular device-initiated thrombus formation.

Results

A FXII antibody screen identified over 400 candidates, which were evaluated in binding studies and clotting assays. One non-inhibitor and six inhibitor antibodies were selected for characterization in functional assays. The most potent inhibitory antibody, 1B2, was found to prolong clotting times, inhibit fibrin generation on collagen under shear, and inhibit platelet deposition and fibrin formation in an extracorporeal membrane oxygenator deployed in a non-human primate.

Conclusion

Selective contact activation inhibitors hold potential as useful tools for research applications as well as safe and effective inhibitors of vascular device-related thrombosis.

A review of social determinants of health for dashboard development for SDG 3.4 for sub-Sahara Africa

Background

All sustainable developmental goals (SDGs) require implementing sustainable strategies and monitoring to track progress. But what is known of sub-Sahara Africa (SSA)'s efforts in following this stride to reduce by 30% mortality from non-communicable diseases (NCDs) through prevention (SDG 3.4), by considering the effect of social determinants of health (SODHs) on type 2 diabetes increasing prevalence?

Methods

Our search produced 2005 unique articles. Only 10 studies were used in the analysis of this study. These studies include 1 from Botswana, 2 from Ghana, 2 from Kenya, 3 from Nigeria and 2 from South Africa. The findings were evaluated in a greater extent.

Results

All studies (100%) showed non-adherence to exercise and poor glycemic control. 7 studies (70%) on education revealed lack of knowledge or misconceptions, 5 studies (50%) with obesity showed a strong linkage between obesity and type 2 diabetes, and 4 studies (40%) on diet, showed diets high in carbohydrates, saturated fats, and sodium predisposition to type 2 diabetes. All studies (100%) linked urbanization with an increased prevalence of type 2 diabetes.

Conclusions

Changes in SODHs seem to be contributing to the growing prevalence of diabetes in SSA. These changes with other key data should be considered and tailored to policy processes, environment, infrastructures, and norms for prevention strategies and informing dashboard development for SDG 3.4.

Key messages

Social determinants of health must reflect in relevant causal pathways, settings, and sectors for preventive intervention such as in taxation; regulation of food advertising, school, and healthcare. Analysis of the effect of the changing social determinants of health on type 2 diabetes, will assist in establishing indicators for the dashboard development for SDG 3.4 for sub-Sahara Africa.

Evidence-based health security: The nexus of governance and pandemic preparedness

Background

Pandemic preparedness continues to be an important focus of the global health security agenda. Many nations in the sub-Saharan African region remain at high risk for a major pandemic due to limited capacity and endemic co-morbid conditions in their populations. While the literature does suggest that state capacity influences health, no studies to date indicate an association between state capacity and pandemic disease distribution, particularly in the presence of other endemic diseases.

Methods

This mixed methods study will contribute to existing research by examining how economic and sociopolitical attributes of state capacity influence pandemic-prone disease distribution in sub-Saharan Africa. A convergent mixed methods design was used to collect and analyze quantitative state capacity attributes and prevention, and control using correlation in six sub-Saharan countries. Results of the quantitative study were triangulated through the use of an expert panel and results integrated for an overall interpretation and conclusion.

Results

Variables in the study showed statistically significant relationships between proxies of state capacity and the follow areas: control of pandemics and prevention of pandemics. The Expert Panel interviews illustrated convergence between the correlated results.

Conclusions

This study brought forward associations with expert confirmation suggestive of areas for national governments in sub-Saharan Africa to further review and improve. While many internal factors limit state capacity in these nations (e.g. human and fiscal resources), external funders may consider adding information from this study and other metrics to test progress.

Key messages

Evidence is valuable for pandemic preparedness planning. Nation state capacity is a factor in pandemic preparedness.

A comparison between Parkinson's medication errors identified through retrospective case note review versus via an incident reporting system during hospital admission

OBJECTIVE

To compare the frequency and type of inpatient Parkinson's medication errors reported through an incident report system versus those identified through retrospective case note review in a tertiary teaching hospital.

METHODS

A search of inpatient medication-related incident reports identified those pertaining to Parkinson's medication. A discharge diagnoses search identified admissions for patients with Parkinson's disease over the same time period. A retrospective case note and incident report review were performed to describe and quantify medication-related events.

KEY FINDINGS

Substantially, more medication-related problems were identified via case note review (n = 805) versus incident reporting system (n = 19). A significantly different pattern of error types was identified utilising case note review versus incident reporting, with case note review more likely to identify delayed dosing, and incident reports more likely to identify wrong dose or formulation administered errors.

CONCLUSIONS

Retrospective incident report and case note review can be used to characterise medication administration errors encountered in an inpatient setting. Incident report review alone is insufficient in estimating error rates, and dual data collection methods should be used.

Citizens' juries give verdict on whether private practice veterinarians should attend unvaccinated Hendra virus suspect horses

BACKGROUND

Hendra virus (HeV) is endemic in Australian flying foxes, posing a threat to equine and human health. Equine vaccination remains the most effective risk mitigation strategy. Many horses remain unvaccinated - even in higher-risk regions. Debate surrounding the vaccine's use is characterised by conflicting perspectives, misunderstanding and mistrust. Private veterinary practitioners are critical to early identification of public health risk through recognition, sampling and management of suspect-equine-HeV-cases. However, managing such cases can be burdensome, with some veterinarians opting not to attend unvaccinated horses or to abandon equine practice because of risk posed by HeV disease and liability.

OBJECTIVE

Ascertain the perspectives of informed citizens on what obligations (if any) private veterinarians have to attend unvaccinated horses with HeV or HeV-like disease.

METHODS

Three citizens' juries were tasked with considering approaches to managing HeV risk in Australia, including (reported here) roles and obligations of private veterinarians in responding to HeV-suspect-cases.

RESULTS

Jurors acknowledged that HeV management posed an important challenge for private veterinarians. A clear majority (27 of 31 jurors) voted that veterinarians should not be obliged to attend unvaccinated horses. All recognised that greater support for veterinarians should be a priority.

CONCLUSIONS

When informed of HeV risks and strategies for control and management, citizens appreciated the need to support veterinarians performing this critical 'One Health' role for public benefit. The current governance framework within which zoonotic disease recognition and response operates limits the contingency and scope for increasing support and efficacy of these important veterinary public health practices.

Multicenter Postmarket Analysis of the Neuroform Atlas Stent for Stent-Assisted Coil Embolization of Intracranial Aneurysms

BACKGROUND AND PURPOSE

The Neuroform Atlas is a new microstent to assist coil embolization of intracranial aneurysms that recently gained FDA approval. We present a postmarket multicenter analysis of the Neuroform Atlas stent.

MATERIALS AND METHODS

On the basis of retrospective chart review from 11 academic centers, we analyzed patients treated with the Neuroform Atlas after FDA exemption from January 2018 to June 2019. Clinical and radiologic parameters included patient demographics, aneurysm characteristics, stent parameters, complications, and outcomes at discharge and last follow-up.

RESULTS

Overall, 128 aneurysms in 128 patients (median age, 62 years) were treated with 138 stents. Risk factors included smoking (59.4%), multiple aneurysms (27.3%), and family history of aneurysms (16.4%). Most patients were treated electively (93.7%), and 8 (6.3%) underwent treatment within 2 weeks of subarachnoid hemorrhage. Previous aneurysm treatment failure was present in 21% of cases. Wide-neck aneurysms (80.5%), small aneurysm size (<7 mm, 76.6%), and bifurcation aneurysm location (basilar apex, 28.9%; anterior communicating artery, 27.3%; and middle cerebral artery bifurcation, 12.5%) were common. A single stent was used in 92.2% of cases, and a single catheter for both stent placement and coiling was used in 59.4% of cases. Technical complications during stent deployment occurred in 4.7% of cases; symptomatic thromboembolic stroke, in 2.3%; and symptomatic hemorrhage, in 0.8%. Favorable Raymond grades (Raymond-Roy occlusion classification) I and II were achieved in 82.9% at discharge and 89.5% at last follow-up. mRS ≤2 was determined in 96.9% of patients at last follow-up. The immediate Raymond-Roy occlusion classification grade correlated with aneurysm location (P < .0001) and rupture status during treatment (P = .03).

CONCLUSIONS

This multicenter analysis provides a real-world safety and efficacy profile for the treatment of intracranial aneurysms with the Neuroform Atlas stent.

Chromosome compaction and chromatin stiffness enhance diffusive loop extrusion by slip-link proteins

We use Brownian dynamics simulations to study the formation of chromatin loops through diffusive sliding of slip-link-like proteins, mimicking the behaviour of cohesin molecules. We recently proposed that diffusive sliding is sufficient to explain the extrusion of chromatin loops of hundreds of kilo-base-pairs (kbp), which may then be stabilised by interactions between cohesin and CTCF proteins. Here we show that the flexibility of the chromatin fibre strongly affects this dynamical process, and find that diffusive loop extrusion is more efficient on stiffer chromatin regions. We also show that the dynamics of loop formation are faster in confined and collapsed chromatin conformations but that this enhancement is counteracted by the increased crowding. We provide a simple theoretical argument explaining why stiffness and collapsed conformations favour diffusive extrusion. In light of the heterogeneous physical and conformational properties of eukaryotic chromatin, we suggest that our results are relevant to understand the looping and organisation of interphase chromosomes in vivo.

Continuation of Buprenorphine to Facilitate Postoperative Pain Management for Patients on Buprenorphine Opioid Agonist Therapy

BACKGROUND

Acute pain management in patients on buprenorphine opioid agonist therapy (BOAT) can be challenging. It is unclear whether BOAT should be continued or interrupted for optimization of postoperative pain control.

OBJECTIVES

To determine an evidence-based approach for pain management in patients on BOAT in the perioperative setting, particularly whether BOAT should be continued or interrupted with or without bridging to another mu opioid agonist and to identify benefits and harms of either perioperative strategy.

STUDY DESIGN

Systematic literature review with qualitative data synthesis.

SETTING

Hospital, perioperative.

METHODS

The study protocol was registered on PROSPERO (Registration number 9030276355). Medline via OVID, EMBASE, CINAHL, and the Cochrane CENTRAL register of trials were searched for prospective or retrospective observational or controlled studies, case series, and case reports that described perioperative or acute pain care for patients on BOAT. References of narrative and systematic reviews addressing acute pain management in patients on BOAT and references of included articles were hand-searched to identify additional original articles for inclusion. The full text of publications were reviewed for final inclusion, and data were extracted using a standardized data extraction form. Results were summarized qualitatively. Primary outcomes were postoperative pain intensity and total opioid use and identification of benefits and harms of perioperative strategies.

RESULTS

Eighteen publications presenting data on the perioperative management of patients on BOAT were identified: 10 case reports, 5 case series, and 3 retrospective cohort studies. Eleven articles reported continuation of BOAT, 2 concerned bridging BOAT, and 4 articles described stopping BOAT without planned bridging. In one retrospective cohort study, BOAT was continued in half and interrupted in half of patients. Patients on BOAT may have pain that is more difficult to treat than those who are not on OAT. There is no clear evidence that one particular strategy provides superior postoperative pain control, but interruption of BOAT may result in harm, including failure to return to baseline BOAT doses, continuing non-BOAT opioid use, or relapse of opioid use disorder.

LIMITATIONS

There were a limited number of articles relevant to the study question consisting of case reports and retrospective observational studies. Some omitted relevant details. No prospective studies were found.

CONCLUSIONS

There is no clear benefit to bridging or stopping BOAT but failure to restart it may pose concerns for relapse. We recommend continuing BOAT in the perioperative period when possible and incorporating an interdisciplinary approach with multimodal analgesia.

KEY WORDS

Opioid use disorder, opiate substitution treatment, buprenorphine, buprenorphine-naloxone, buprenorphine opioid agonist therapy, postoperative pain, acute pain, multimodal analgesia.

Determination of Nitrate in Forages by Using Selective Ion Electrode: Collaborative Study

Each of 10 collaborating laboratories analyzed 4 blind duplicate pairs of forage samples for nitrate, by using a potentiometric method. Two forage controls and a 100 000 mg KNO3/L standard were also provided. Nitrate was extracted into an aqueous Al2(SO4)3 solution containing 70 mg KNO3/L and quantitated with a nitrate-selective electrode. Standards were prepared using extracting solution as diluent. Nitrate concentrations in forage samples ranged from &lt;0.50 to 4.35% KNO3. Repeatability coefficients of variation (CV0) ranged from 1.74 to 3.61%, and reproducibility coefficients of variation (CV1) ranged from 6.92 to 7.66%. Mean recovery of a 0.55% KNO3 spike was 94.5%. The method has been adopted official first action.

High-Sensitivity Dry Rehydratable Film Method for Enumeration of Coliforms in Dairy Products: Collaborative Study

A dry-film coliform count plate that is inoculated with 5 mL sample was compared with the Violet Red Bile Agar plate method in a collaborative study by 18 laboratories. Products analyzed were 2% milk, chocolate milk, cream, vanilla ice cream, cottage cheese, and cheese. Collaborators tested blind duplicate uninoculated samples and samples inoculated at low, medium, and high level. Significantly (P&lt; 0.05) higher numbers of coliforms were recovered by the dry-film method from 2% milk samples at the 3 inoculum levels, the chocolate milk at the low- and high-inoculum levels, and the cream at the high-inoculum level. Significantly higher counts were obtained by the agar method for cottage cheese samples at the low-inoculum level. The repeatability standard deviation for the dry-film method was significantly higher for the high-inoculum level chocolate milk sample and the medium-inoculum level cottage cheese. The same statistic was significantly higher for the agar method at all 3 inoculum levels in the 2% milk and the medium-inoculum level cream. The high-sensitivity dry rehydratable film method for enumeration of coliforms in dairy products has been adopted first action by AOAC INTERNATIONAL.

SuperCam Calibration Targets: Design and Development

SuperCam is a highly integrated remote-sensing instrumental suite for NASA's Mars 2020 mission. It consists of a co-aligned combination of Laser-Induced Breakdown Spectroscopy (LIBS), Time-Resolved Raman and Luminescence (TRR/L), Visible and Infrared Spectroscopy (VISIR), together with sound recording (MIC) and high-magnification imaging techniques (RMI). They provide information on the mineralogy, geochemistry and mineral context around the Perseverance Rover. The calibration of this complex suite is a major challenge. Not only does each technique require its own standards or references, their combination also introduces new requirements to obtain optimal scientific output. Elemental composition, molecular vibrational features, fluorescence, morphology and texture provide a full picture of the sample with spectral information that needs to be co-aligned, correlated, and individually calibrated. The resulting hardware includes different kinds of targets, each one covering different needs of the instrument. Standards for imaging calibration, geological samples for mineral identification and chemometric calculations or spectral references to calibrate and evaluate the health of the instrument, are all included in the SuperCam Calibration Target (SCCT). The system also includes a specifically designed assembly in which the samples are mounted. This hardware allows the targets to survive the harsh environmental conditions of the launch, cruise, landing and operation on Mars during the whole mission. Here we summarize the design, development, integration, verification and functional testing of the SCCT. This work includes some key results obtained to verify the scientific outcome of the SuperCam system.

One Health and Zoonotic Uncertainty in Singapore and Australia: Examining Different Regimes of Precaution in Outbreak Decision-Making

A One Health approach holds great promise for attenuating the risk and burdens of emerging infectious diseases (EIDs) in both human and animal populations. Because the course and costs of EID outbreaks are difficult to predict, One Health policies must deal with scientific uncertainty, whilst addressing the political, economic and ethical dimensions of communication and intervention strategies. Drawing on the outcomes of parallel Delphi surveys conducted with policymakers in Singapore and Australia, we explore the normative dimensions of two different precautionary approaches to EID decision-making—which we call regimes of risk management and organizing uncertainty, respectively. The imperative to act cautiously can be seen as either an epistemic rule or as a decision rule, which has implications for how EID uncertainty is managed. The normative features of each regime, and their implications for One Health approaches to infectious disease risks and outbreaks, are described. As One Health attempts to move upstream to prevent rather than react to emergence of EIDs in humans, we show how the approaches to uncertainty, taken by experts and decision-makers, and their choices about the content and quality of evidence, have implications for who pays the price of precaution, and, thereby, social and global justice.

Apoptotic and Proteolytic Attributes and Metabolomic Changes in Postmortem Muscles from Pigs Subjected to Post-Weaning Transport at Different Seasons

ObjectivesPost-weaning transport of pigs was commonly practiced in the swine industry, however, adversely impact animal growth and well-being due to concurrent stress from weaning and transport. Further, our recent study found that post-weaning transport may have long-term effects on final pork quality attributes in terms of inferior texture and water-holding capacity. Heat shock proteins (HSPs) are anti-apoptotic chaperone proteins, protecting against apoptosis under a variety of cell death stimuli including postmortem muscle conversion process. While a potential role of apoptosis in meat tenderization has been proposed, how early life stress influences apoptotic/proteolytic process and metabolism of postmortem muscles is largely unknown. Thus, the study objective was to evaluate apoptotic and proteolytic attributes and metabolomic changes in postmortem muscles of market weight pigs exposed to early life transport/weaning stress at two seasons.Materials and MethodsTwo repetitions of newly weaned pigs (N = 480) were transported for 12 h in a trailer truck during July 2016 (SUMMER) and April 2017 (SPRING) in north-central Indiana. Upon reaching market weight, 10 animals were randomly chosen from each season and slaughtered in January 2017 and September 2017, respectively. Pairs of longissimus dorsi and psoas major muscles from each carcass were separated at 1d and 7d postmortem. Proteolytic and apoptotic factors including desmin, troponin T, calpain 1, HSP27, and aβ-crystallin were quantified using Western-blot assays, and mitochondria membrane permeability (MMP) was evaluated. Metabolome profiles of 1d samples were analyzed using the GC-TOF-MS/MS platform. Multivariate analyses PCA and PLS-DA were used to determine changes of metabolites. Data were analyzed using PROC MIXED of SAS to compare the traits across season, muscle, and aging effects.ResultsPreviously, SUMMER pigs were reported showing decreased body weight, muscling, and fat deposition, as well as increased shear force and water loss during aging. In the present study, SPRING muscles exhibited increases in calpain 1 autolysis and structural protein degradation, coincided with accelerated apoptosis shown as higher MMP compared to the SUMMER counterparts (P < 0.05). Moreover, PCA and PLS-DA clustering indicated distinct metabolome profiles affected by season and muscle. Seasonal effect mainly altered lipid, glucose, and nitrogen metabolism. A group of 16C to 18C fatty acids were increased in SPRING, probably due to increased lipid anabolism during warm growing/finishing season. Changes of urea, ornithine, aspartic acid, and 5’methylthioadenosine suggested increased amino acid catabolism in SUMMER, corroborating the decreased lean and fat accretion. Seasonal changes of key metabolites related to stress response, including histidine, GABA, and ascorbic acid, suggested increased stress defense in SUMMER pigs, which implied the suppression of apoptotic and proteolytic activities.ConclusionTaken together, SUMMER pigs showed suppressed onset of apoptosis with compromised growth and meat quality, possibly due to alternations in seasonal metabolic response. This may in turn affect the proteolytic potential of early postmortem muscles. Further studies elucidating the involvement of apoptotic process in proteolytic activities in postmortem muscles should be warranted.