Simultaneous Detection of Seven Drugs of Abuse by the TriageTM Panel for Drugs of Abuse

This novel, competitive immunoassay simultaneously detects seven drugs of abuse in urine. A urine sample is placed in contact with lyophilized reagents, the reaction mixture is allowed to come to equilibrium (10 min), and then the whole mixture is applied to a solid phase that contains various immobilized antibodies in discrete drug-class-specific zones. After a washing step, the operator visually examines each zone for the presence of a red bar. The method incorporates present threshold concentrations that are independent for each drug. In the absence of drug or in the presence of drug in quantities less than the threshold concentration, no colored bar is visible. Samples containing drug(s) at or above the threshold concentration cause a red bar to appear for the appropriate drug(s). Positive and negative procedural control zones are incorporated into each determination. The performance of the assay methodology matches that of instrumented immunoassay systems.

Medicolegal Aspects of Craniofacial Trauma

Characterization of complications in facial trauma management is of special interest to practitioners of facial trauma surgery. It is important for facial trauma surgeons to not only understand the standard of care, but also the pitfalls that can expose them to litigation. Litigation within the realm of facial trauma surgery often manifests from issues with poor communication, inadequate informed consent processes, and poor surgical management. In this analysis, we comprehensively examine malpractice litigation in facial trauma surgery, and outline important factors for surgeons to consider in the care of this patient population. It is important for facial trauma surgeons to understand medicolegal issues within their scope of practice. These include principles of informed consent, state regulated statutes of limitation, and Emergency Medical Treatment and Active Labor Act laws. This analysis emphasizes the importance of exercising appropriate patient care, understanding the indications for surgery, and seeking counsel when necessary.

Nasal Fractures: The Role of Primary Reduction and Secondary Revision

The nasal bones are among the most commonly fractured bones in the facial skeleton. Proper management of nasal trauma acutely is important in minimizing secondary deformities and impaired function with nasal airway obstruction. Septal hematoma, if present, should be drained right away. Acutely closed nasal reduction and limited septoplasty can be performed. Unrecognized septal fracture may play a role in the failure of closed nasal reduction of fractured nasal bones. Complex nasoorbitoethmoid fractures are approached openly and treated with rigid fixation. Primary use of open rhinoplasty in an acute setting is debated, and there are no clearly accepted indications for timing, patient selection, and surgical technique. However, open septorhinoplasty is more commonly used in a delayed fashion to provide definitive correction of any residual cosmetic or functional problems. Recent algorithms provide a systematic approach to nasal trauma and may improve secondary deformity rates following closed reduction.

Determination of Total Dietary Fiber (CODEX Definition) by Enzymatic-Gravimetric Method and Liquid Chromatography: Collaborative Study

A method for the determination of total dietary fiber (TDF), as defined by the CODEX Alimentarius, was validated in foods. Based upon the principles of AOAC Official MethodsSM 985.29, 991.43, 2001.03, and 2002.02, the method quantitates high- and low-molecular-weight dietary fiber (HMWDF and LMWDF, respectively). In 2007, McCleary described a method of extended enzymatic digestion at 37C to simulate human intestinal digestion followed by gravimetric isolation and quantitation of HMWDF and the use of LC to quantitate low-molecular-weight soluble dietary fiber (LMWSDF). The method thus quantitates the complete range of dietary fiber components from resistant starch (by utilizing the digestion conditions of AOAC Method 2002.02) to digestion resistant oligosaccharides (by incorporating the deionization and LC procedures of AOAC Method 2001.03). The method was evaluated through an AOAC collaborative study. Eighteen laboratories participated with 16 laboratories returning valid assay data for 16 test portions (eight blind duplicates) consisting of samples with a range of traditional dietary fiber, resistant starch, and nondigestible oligosaccharides. The dietary fiber content of the eight test pairs ranged from 11.57 to 47.83. Digestion of samples under the conditions of AOAC Method 2002.02 followed by the isolation and gravimetric procedures of AOAC Methods 985.29 and 991.43 results in quantitation of HMWDF. The filtrate from the quantitation of HMWDF is concentrated, deionized, concentrated again, and analyzed by LC to determine the LMWSDF, i.e., all nondigestible oligosaccharides of degree of polymerization 3. TDF is calculated as the sum of HMWDF and LMWSDF. Repeatability standard deviations (sr) ranged from 0.41 to 1.43, and reproducibility standard deviations (sR) ranged from 1.18 to 5.44. These results are comparable to other official dietary fiber methods, and the method is recommended for adoption as Official First Action.

Rapid Determination of Total trans Fat Content—An Attenuated Total Reflection Infrared Spectroscopy International Collaborative Study

Interest in trans fat labeling has prompted efforts to develop new, more efficient methods for rapidly and accurately determining trans fat content of foods. A novel and rapid (5 min) attenuated total reflection–Fourier transform infrared (ATR–FTIR) spectroscopic procedure was recently developed and applied to food products. This procedure was voted official method AOCS Cd 14d-99 by the American Oil Chemists' Society in 1999 after testing in a 12 laboratory international collaborative study. The results of the study are described in this paper. Analytical ATR–FTIR results exhibited high accuracy in the range 5–40% trans; results tended to have <2% high bias relative to the gravimetrically determined values. The precision of this internal reflection method was found to be superior to the precision of transmission infrared official methods. It is recommended that the applicability of the ATR–FTIR method be limited to trans levels of >5% (as percent of total fat).

2088. Cross-sectional Analysis of Administrative Structure and Practices for Hospital Antimicrobial Stewardship Programs (ASPs) in a Large Metropolitan City

Background

Methods

Results

Conclusion

Disclosures

Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity

INTRODUCTION

As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.

OBJECTIVE

The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.

STUDY DESIGN

A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.

RESULTS

A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).

DISCUSSION

Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.

CONCLUSIONS

When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.

P5618Coronary flow capacity to identify stenosis associated with coronary flow improvement after coronary revascularization

Background

Coronary flow capacity (CFC) has recently been introduced as a comprehensive assessment of the coronary circulation by combining coronary flow reserve (CFR) and maximal coronary flow velocity to overcome the limitations of using CFR alone, and was reported to provide enhanced risk stratification compared with CFR. However, its potential to identify stenosis that would be associated with clinically relevant flow coronary flow improvement after revascularization has not been investigated.

Aims

The aim of this study is to quantify coronary flow changes after revascularization in relation to CFC and CFR.

Methods and results

Using a combined dataset of DEFINE FLOW and the Amsterdam UMC prospective ComboWire database, a total of 133 patients (135 vessels) with intermediate coronary artery lesions who underwent intracoronary physiologic assessment including intracoronary Doppler flow measurement before and after PCI were analyzed. The median values of fractional flow reserve (FFR) and CFR before PCI were 0.70 (Q1–3: 0.56–0.80) and 1.64 (Q1–3: 1.30–2.06). The number of lesions classified by CFC before PCI were 14 for normal CFC, 40 for mildly reduced CFC, 33 for moderately reduced CFC and 48 for severely reduced CFC. The lesions with larger impairment of CFC showed greater increase in coronary flow, and vice versa (median percent increase in coronary flow by revascularization: 4.2% for normal CFC; 25.9% for mildly reduced; 50.1% for moderately reduced; 145.5% for severely reduced, P<0.0001). Using the same CFR distribution based on CFC criteria showed that only lesions with severely reduced CFR showed a significantly higher coronary flow increase after PCI (−2.6% for CFR in the normal zone; 26.6% for CFR in the mildly reduced zone; 33.3% for CFR in the moderately reduced zone; 81.7% for CFR in the severely reduced zone, P=0.0007). Compared with the established CFR cut-off value of 2.0, moderate to severely reduced CFC showed higher specificity and positive predictive value (PPV) to predict at least 20% increase in coronary flow after PCI (specificity and PPV: 86.4% and 72.5% for ischemic CFC vs. 75.8% and 40% for CFR cut-off value 2.0). Multivariate logistic regression analysis revealed that the lesions with moderately or severely reduced CFC (odd ratio [OR] = 7.606 95%interconfidence interval [CI]: 2.834–20.412, P<0.001) and pre-PCI FFR (OR=0.0002, 95% CI: 0.0002–0.0204, P<0.001) were the independent predictors of coronary flow increase after PCI.

Conclusion

CFC showed a higher diagnostic efficiency for identification of lesions which benefit from revascularization compared to CFR with respect to coronary flow improvement. This study provides the physiological rational of revascularization for the lesions with moderately to severely reduced CFC from the perspective of coronary flow increase.

Acknowledgement/Funding

Philips Volcano

P6439Clinical outcomes of acute coronary syndrome with intact-fibrous cap plaque at the culprit lesions in diabetic and non-diabetic patients

Background

Previous studies revealed that the morphological substrates of the culprit lesion assessed by optical coherence tomography (OCT) in acute coronary syndrome (ACS), which includes ruptured plaque (RP) and intact fibrous cap (IFC) plaque, are associated with subsequent clinical outcomes. Nevertheless, the impact of culprit morphology on clinical outcomes has not been evaluated in patients with diabetes mellitus (DM), which is one of the major determinants of clinical prognosis.

Purpose

We sought to investigate the association of the culprit lesion morphology with clinical outcomes in patients with DM and those without DM.

Methods

We retrospectively investigated a total of 508 patients with acute myocardial infarction (AMI) experiencing their first episode of ACS in whom OCT-guided, primary percutaneous coronary intervention (PCI) was performed and a culprit lesion was observed by OCT with sufficient image quality. Patients were divided into two groups according to the culprit lesion morphology into patients with RP (RP group) and those without RP (IFC group). The rate of major adverse cardiac events (MACE) including death, myocardial infarction, target or non-target lesion revascularizations were compared between RP and IFC groups in patients with DM (DM) and those without DM (non-DM), separately.

Results

MACE was captured in 80 patients during the median follow-up of 505 (IQR 274–1300) days. In non-DM, RP group showed significantly worse MACE-free rate than in IFC group (Figure), In DM, there was no significant difference between RP and IFC groups (Figure).

Figure 1

Conclusion

Culprit lesion morphology assessed by OCT was not associated with clinical outcomes in DM patients unlike non-DM patients. Distinct strategy for secondary prevention may be required for DM patients.

P5589Patterns of extended apixaban treatment for unprovoked venous thromboembolism in routine clinical practice

Background

Current CHEST guidelines recommend extended anticoagulation therapy without a scheduled stop in patients with unprovoked VTE and low bleeding risk following initial anticoagulation treatment of 3 months. AMPLIFY-EXT suggests that extended treatment with apixaban beyond 6 months reduces the risk of recurrent VTE without increasing major bleeding rates. This study evaluated patterns of extended apixaban treatment among unprovoked VTE patients.

Methods

Utilizing 4 US commercial claims databases, this retrospective study assessed unprovoked VTE patients (VTE events that were not preceded by a provoked factor or event) who initiated apixaban within 30 days from the VTE event (01SEPT2014–31MAR2018). Patients were required to have ≥6 months continuous apixaban treatment (without a gap of >30 days). Characteristics of patients treated beyond 6 months and those who discontinued at 6 months were evaluated respectively. An additional analysis was conducted to assess proportion with apixaban treatment for ≥3 months.

Results

Among unprovoked VTE patients, 60.8% and 34.6% had apixaban treatment for ≥3 and ≥6 months, respectively. Of those treated for ≥6 months (3,015 after applying additional selection criteria), 75.6% continued treatment beyond 6 months and 24.4% discontinued at 6 months. Younger age and having thrombophilia were associated with a higher likelihood of treatment beyond 6 months (Table). Among patients with treatment beyond 6 months, 7.5% of patients switched from apixaban 5mg to 2.5mg, 36.5% discontinued therapy, and 1.1% switched to another oral anticoagulant (Figure).

Baseline characteristics Variables Discontinued at 6 months Continued treatment beyond 6 months P-value N=735 N=2,280 Age, Mean (SD) 63.0 (15.2) 61.7 (14.3) 0.037 Gender – Female, n (%) 307 (41.8%) 892 (39.1%) 0.203 Setting of Unprovoked VTE Event – Ambulatory, n (%) 592 (80.5%) 1,834 (80.4%) 0.950 VTE Diagnosis – DVT Only, n (%) 494 (67.2%) 1,498 (65.7%) 0.452 Deyo-Charlson Comorbidity Index, Mean (SD) 1.3 (1.9) 1.3 (1.8) 0.305 Thrombophilia, n (%) 54 (7.3%) 296 (13.0%) <0.001 Coagulation Defects, n (%) 38 (5.2%) 153 (6.7%) 0.136 Baseline Bleed, n (%) 77 (10.5%) 210 (9.2%) 0.309

KM curve after 6 months of apixaban use

Conclusion

Among unprovoked VTE patients treated with apixaban, a large proportion did not receive ≥3 months of treatment. Although AMPLIFY-EXT showed beneficial effects of extended treatment, the percentage of patients with ≥6 months of treatment was low. Thrombophilia was the only meaningful predictor of treatment beyond 6 months.

Acknowledgement/Funding

This study was funded by Bristol-Myers Squibb and Pfizer Inc

6111Optical coherence tomography derived predictors of restenosis after non-stenting coronary intervention with drug-coated balloon

Background

One of the limitations of metallic stents including contemporary drug eluting stents lies in the permanent existence of metallic materials within the coronary arteries, which may lead to neoatherosclerosis and a long-term use of dual antiplatelet therapy. Some reports have recently suggested the efficacy and safety of non-stent strategy with drug-coated balloon (DCB) angioplasty in combination with debulking devices for de novo lesions. However, little is known about the potential risk of restenosis after percutaneous coronary intervention (PCI) with DCB.

Purpose

We sought to assess the predictive factors of restenosis by optical coherence tomography (OCT) after PCI with DCB instead of metallic stents.

Methods

We retrospectively investigated 49 de novo lesions in 38 patients treated by DCB without stent implantation in whom OCT was performed immediately after PCI and follow-up angiography was performed at median of 5.6 (3.7–6.9) months. OCT findings after PCI and the incidence of restenosis at follow-up angiography were evaluated. By means of OCT images, medial coronary dissection was defined as a dissection which reached the medial layer of the vessel, and major dissection was defined as a dissection with more than 60 degrees of the circumference of the vessel or more than 3mm in length. Restenosis was defined as more than 50% diameter stenosis evaluated by Quantitative Coronary Angiography.

Results

Restenosis was observed in 13 of 49 lesions (27%). In univariate logistic regression analysis, major dissection and medial dissection at the final OCT were associated with restenosis (Odds ratio [OR] 10.0; 95% confidence interval [CI] 2.5–52.6; p<0.01 and OR 5.8; 95% CI 1.5–25.1; p=0.01, respectively). Lesion preparation prior to DCB were performed with rotational atherectomy (n=9), orbital atherectomy (n=2), directional atherectomy (n=4), excimer laser angioplasty (n=17), scoring balloon angioplasty (n=13), or balloon angioplasty (n=4). OCT-defined major dissection remained a significant predictor for restenosis independent of debulking devices used for the preparation (OR 8.1; 95% CI 1.2–70.2; p=0.03).

Conclusions

Major dissection was associated with restenosis after non-stenting PCI with DCB. Stent implantation should be considered in cases of OCT-defined major dissection.

Acknowledgement/Funding

None

P5622Clinical significance of late-acquired malapposition observed by serial optical coherence tomography after second-generation drug eluting stents

Background

Previous studies have demonstrated that the presence of late-acquired stent malapposition after stent implantation may be a risk of late and very late stent thrombosis and myocardial infarction, which is however still controversial.

Purpose

We sought to investigate the incidence and prognosis of late acquired stent malapposion after second-generation drug eluting stents (2G-DES) implantation.

Methods

A total of 199 lesions in 139 patients who underwent optical coherence tomography (OCT) at both immediately after implantation (Baseline) and 6–12 months after 2G-DES implantation (follow-up) were investigated. We excluded lesions with stent failure before follow-up examination. We evaluated presence or absence of malapposed strut at 1mm interval of OCT images and stents with one or more cross-sections with >30% malapposed strut was defined as stents with malapposition (MP), otherwise well-apposed (WA). We divided the lesions into 4 groups according to the presence of malapposition at baseline and follow-up; WA and WA, persistent well-apposed; MP and WA, resoloved malapposition; WA and MP, late acquired malapposition (LAMP); and MP and MP, persistent malapposition. We compared the target lesion failure (TLF) rate after follow-up examination among 4 groups with Kaplan–Meier analysis.

Results

Median follow-up period was 469 (IQR 71–1416) days. follow-up OCT examination was performed at median 9 months (IQR 7.6–10.5). There were no significant differences in patient's and procedural characteristics among the 4 groups. TLF rate in LAMP group was 12.0% and Kaplan–Meier analysis showed no significant differences among the 4 groups in TLF rate.

TLF-free suvival curves (Kaplan-Meier)

Conclusion

LAMP was observed by OCT at 6–12 months in 12.0% of lesions after 2G-DES implantation, which was not associated with TLF at 5 years.

Regulation of histone methylation by automethylation of PRC2

In this study, Wang et al. set out to identify the methylation site on the EZH2 subunit of the core PRC2 complex and its physiological importance. Using mass spectrometry analysis of recombinant human PRC2, they identified a conserved methylation loop in EZH2 that serves an autoregulatory role and allows PRC2 to modulate its histone methyltransferase activity by sensing histone H3 tails, SAM concentration, and potentially other effectors.

Polycomb-repressive complex 2 (PRC2) is a histone methyltransferase that is critical for regulating transcriptional repression in mammals. Its catalytic subunit, EZH2, is responsible for the trimethylation of H3K27 and also undergoes automethylation. Using mass spectrometry analysis of recombinant human PRC2, we identified three methylated lysine residues (K510, K514, and K515) on a disordered but highly conserved loop of EZH2. Methylation of these lysines increases PRC2 histone methyltransferase activity, whereas their mutation decreases activity in vitro. De novo histone methylation in an EZH2 knockout cell line is greatly impeded by mutation of the automethylation lysines. EZH2 automethylation occurs intramolecularly (in cis) by methylation of a pseudosubstrate sequence on a flexible loop. This posttranslational modification and cis regulation of PRC2 are analogous to the activation of many protein kinases by autophosphorylation. We propose that EZH2 automethylation allows PRC2 to modulate its histone methyltransferase activity by sensing histone H3 tails, SAM concentration, and perhaps other effectors.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Congenital anomalies following antenatal exposure to dolutegravir: a Canadian surveillance study

OBJECTIVE

Dolutegravir is recommended worldwide as a first-line antiretroviral therapy (ART) for individuals living with HIV. A recent study reported increased rates of neural tube defects in infants of dolutegravir-treated women. This study examined rates of congenital anomalies in infants born to women living with HIV (WLWH) in Canada.

DESIGN

The Canadian Perinatal HIV Surveillance Programme captures surveillance data on pregnant WLWH and their babies and was analysed to examine the incidence of congenital anomalies.

SETTING

Paediatric HIV clinics.

POPULATION

Live-born infants born in Canada to WLWH between 2007 and 2017.

METHODS

Data on mother-infant pairs, including maternal ART use at conception and during pregnancy, are collected by participating sites.

MAIN OUTCOME MEASURES

Congenital anomalies.

RESULTS

Of the 2423 WLWH, 85 (3.5%, 95% CI 2.85-4.36%) had non-chromosomal congenital anomalies. There was no evidence of a significant difference in rates of congenital anomalies between women who were on ART in their first trimester (3.9%, CI 1.7-7.6%) or later in the pregnancy (3.9%, 95% CI 2.6-5.6%). Four of the 80 (5.0%, 95% CI 1.4-12.3%) neonates born to WLWH on dolutegravir during the first trimester had congenital anomalies, none were neural tube defects (95% CI 0.00-3.10%).

CONCLUSION

Despite recent evidence raising a safety concern, this analysis found no signal for increased congenital anomalies.

TWEETABLE ABSTRACT

Five percent of the infants of Canadian women living with HIV on dolutegravir at conception had congenital anomalies; none had neural tube defects.