Depth of invasion as an independent prognostic factor in early-stage oral cavity squamous cell carcinoma

PURPOSE

To determine the significance of depth of invasion as a predictor of recurrence and mortality in tongue and non-tongue early-stage oral cavity squamous cell carcinoma patients treated with surgery and no postoperative radiotherapy.

MATERIALS AND METHODS

344 patients with oral cavity squamous cell carcinoma from 2005 to 2022 at a tertiary academic medical center were reviewed. Patients were included if they had newly diagnosed, previously untreated T1-T2N0 disease treated with surgery alone that was observed within a follow-up of 5 years. For each patient, anatomic site of oral cavity squamous cell carcinoma was categorized as either tongue or non-tongue. Cox proportional hazards regression analyses were performed to determine the association of depth of invasion with recurrence and mortality, with anatomic site, smoking status, and age at biopsy as covariates. Model assumptions were tested by statistical and graphical evaluation using Schoenfeld residuals.

RESULTS

Of 108 patients with T1-T2N0 disease, 78 (72.2 %) had tongue disease, and 30 (27.8 %) had non-tongue disease. Median follow-up was 18.2 months (range, 0.01-58.2 months). In the Cox proportional hazards models, with adjustment for anatomic site and other covariates, depth of invasion positively predicted recurrence (HR 1.16, 95 % CI: 1.01-1.32, p = 0.034) and death (HR 1.42, 95 % CI: 1.11-1.83, p = 0.006).

CONCLUSIONS

Depth of invasion is an independent predictor of recurrence and death across early-stage tongue and non-tongue squamous cell carcinoma. Therefore, depth of invasion may indicate a need for more aggressive treatment than surgery alone, such as postoperative radiotherapy, even in the absence of other adverse features on pathology within the early-stage population.

Pop-up Langmuir probe diagnostic in the water cooled divertor of Wendelstein 7-X

The design, development, and successful implementation of pop-up Langmuir probes installed in the water-cooled divertor of W7-X are described. The probes are controlled by drive coils (actuators) installed behind the divertor plates. These drive coils make use of the magnetic field in W7-X to move the probe tips into and out of the plasma. The drive coils were installed in the vacuum vessel after extensively testing the durability of the coils and analyzing the criteria for safe operation. The probe design is carefully tailored for each of the 36 probe tips in order to be suitable for the different magnetic field configurations used in W7-X and ensure that the probes do not present leading edges to the magnetic flux tubes. An electronic bridge circuit is used for measurement to compensate for the effects of signal propagation time on the long cable lengths used. The diagnostic is integrated with the segment control of W7-X for automated operation and control of the diagnostic. The evaluation of the results from the plasma operation is presented after accounting for appropriate sheath expansion for negative bias voltage on the probes.

Future Directions and Innovations in Venous Sinus Stenting

This review explores the future role of venous sinus stenting (VSS) in the management of idiopathic intracranial hypertension and pulsatile tinnitus. Despite its favorable safety profile and clinical outcomes compared with traditional treatments, VSS is not yet the standard of care for these conditions, lacking high-level evidence data and guidelines for patient selection and indications. Current and recently completed clinical trials are expected to provide data to support the adoption of VSS as a primary treatment option. Additionally, VSS shows potential in treating other conditions, such as dural arteriovenous fistula and cerebral venous sinus thrombosis, and it is likely that the procedure will continue to see an expansion of its approved indications. The current lack of dedicated venous stenting technology is being addressed with promising advancements, which may improve procedural ease and patient outcomes. VSS also offers potential for expansion into modulation of brain electrophysiology via endovascular routes, offering exciting possibilities for neurodiagnostics and treatment of neurodegenerative disorders.

Foundations of the Diagnosis and Management of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Venous sinus stenosis has garnered increasing academic attention as a potential etiology of idiopathic intracranial hypertension (IIH) and pulsatile tinnitus (PT). The complex anatomy of the cerebral venous sinuses and veins plays a crucial role in the pathophysiology of these conditions. Venous sinus stenosis, often found in the superior sagittal or transverse sinus, can lead to elevated intracranial pressure (ICP) and characteristic IIH symptoms. Stenosis, variations in dural venous anatomy, and flow dominance patterns contribute to aberrant flow and subsequent PT. Accurate imaging plays a vital role in diagnosis, and magnetic resonance (MR) venography is particularly useful for detecting stenosis. Management strategies for IIH and PT focus on treating the underlying disease, weight management, medical interventions, and, in severe cases, surgical or endovascular procedures. Recently, venous sinus stenting has gained interest as a minimally invasive treatment option for IIH and PT. Stenting addresses venous sinus stenosis, breaking the feedback loop between elevated ICP and stenosis, thus reducing ICP and promoting cerebrospinal fluid outflow. The correction and resolution of flow aberrances can also mitigate or resolve PT symptoms. While venous sinus stenting remains an emerging field, initial results are promising. Further research is needed to refine patient selection criteria and evaluate the long-term efficacy of stenting as compared to traditional treatments.

Challenges in the use of Venous Sinus Stenting in the Treatment of Idiopathic Intracranial Hypertension and Pulsatile Tinnitus

Although numerous case series and meta-analyses have shown the efficacy of venous sinus stenting (VSS) in the treatment of idiopathic intracranial hypertension and idiopathic intracranial hypertension-associated pulsatile tinnitus, there remain numerous challenges to be resolved. There is no widespread agreement on candidacy; pressure gradient and failed medical treatment are common indications, but not all clinicians require medical refractoriness as a criterion. Venous manometry, venography, and cerebral angiography are essential tools for patient assessment, but again disagreements exist regarding the best, or most appropriate, diagnostic imaging choice. Challenges with the VSS technique also exist, such as stent choice and deployment. There are considerations regarding postprocedural balloon angioplasty and pharmacologic treatment, but there is insufficient evidence to formalize postoperative decision making. Although complications of VSS are relatively rare, they include in-stent stenosis, hemorrhage, and subdural hematoma, and the learning curve for VSS presents specific challenges in navigating venous anatomy, emphasizing the need for wider availability of high-quality training. Recurrence of symptoms, particularly stent-adjacent stenosis, poses challenges, and although restenting and cerebrospinal fluid-diverting procedures are options, there is a need for clearer criteria for retreatment strategies. Despite these challenges, when comparing VSS with traditional cerebrospinal fluid-diverting procedures, VSS emerges as a favorable option, with strong clinical outcomes, lower complication rates, and cost-effectiveness. Further research is necessary to refine techniques and indications and address specific aspects of VSS to overcome these challenges.

Association of Private Equity Firm Acquisition of Ophthalmology Practices with Medicare Spending and Use of Ophthalmology Services

PURPOSE

Private equity (PE) firms increasingly are acquiring ophthalmology practices; little is known of their influence on care use and spending. We studied changes in use and Medicare spending after PE acquisition.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Seven hundred sixty-two clinicians in 123 practices acquired by PE between 2017 and 2018 and 34 807 clinicians in 20 549 never-acquired practices.

METHODS

We analyzed Medicare fee-for-service claims (2012-2019) combined with a novel national database of PE acquisitions of ophthalmology practices using a difference-in-differences method within an event study framework to compare changes after a practice was acquired with changes in practices that were not acquired.

MAIN OUTCOME MEASURES

Numbers of beneficiaries seen; intravitreal injections and medications used for injections; and spending on ophthalmologist and optometrist services, ancillary services, and intravitreal injections.

RESULTS

Comparing PE-acquired with nonacquired practices showed a 23.92% increase (n = 4.20 beneficiaries; 95% confidence interval [CI], 1.73-6.67) in beneficiaries seen per PE optometrist per quarter and no change for ophthalmologists, while spending per beneficiary increased 5.06% ($9.66; 95% CI, -2.82 to 22.14). Spending on clinician services decreased 1.62% (-$2.37; 95% CI, -5.78 to 1.04), with ophthalmologist services increasing 5.46% ($17.70; 95% CI, -2.73 to 38.15) and optometrists decreasing 4.60% (-$5.76; 95% CI, -9.17 to -2.34) per beneficiary per quarter. Ancillary services decreased 7.56% (-$2.19; 95% CI, 4.19 to -0.22). Intravitreal injection costs increased 25.0% ($20.02; 95% CI, -1.38 to 41.41) with the number increasing 5.10% (1.83; 95% CI, -0.1 to 3.80). There was a 74.09% increase (8.38 injections; 95% CI, 0.01-16.74) in ranibizumab and a 12.91% decrease (-3.40 injections; 95% CI, -6.86 to 0.07) in bevacizumab after acquisition. The event study showed consistent and often statistically significant increases in ranibizumab injections and decreases in bevacizumab injections after acquisition.

CONCLUSIONS

Although not all results reached statistical significance, this study suggested that PE acquisition of practices showed little or no overall effect on use or total spending, but increased the number of unique patients seen per optometrist and the use of expensive intravitreal injections.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Emission performance evaluation of urban passenger car fleet through field investigation data in a megacity

Continued improvements in living standards and the economic well-being in the megacities have led to a huge surge in vehicular density. The worst environmental outcome of the same has been persistent unsafe urban air quality, thanks to vehicular emission. Further, the existing inspection and maintenance programs, conceived to check such emission remain largely ineffective, particularly in developing countries. This is due to the absence of a thorough assessment of the vehicle's compliance with the in-use emission norms generated through reliable field investigation data. To address this gap, the present comprehensive study collected real-time tailpipe emission data from 2040 cars in Delhi, India. Exhaust emission parameters, namely, CO (carbon monoxide), HC (hydrocarbon), and SE (smoke emission), were recorded from both petrol and diesel-driven cars of private ownership, in collaboration with the emission compliance test centers. The performance of cars was assessed in terms of their compliance with the in-use BS (Bharat Stage) emission norms. The one-of-its-kind study reported the petrol cars to be highly compliant toward the BS IV norm while faring even better toward BS II for both CO and HC emissions (80-90%). The conformance to the HC norm was found to be typically better than that for CO (85-90% versus 75-80%). For the diesel-driven cars, BS III compliance levels were reported relatively better compared to BS IV (90% in the case of the former against 80% in the latter's case). Further, the study puts forward a clear indication that the in-use emission norm and maintenance status of cars have a direct and negative relationship with tailpipe emission parameters. Cars of both overseas and domestic origin have almost equal degrees of compliance with the emission norms (over 80% in any case). The study recommends the incorporation of these two critical vehicular variables, i.e., maintenance status and in-use emission standard in the emission certification policy.

Laser interstitial thermal therapy as a radiation-sparing approach for central nervous system tumors in children with cancer predisposition syndromes: report of a child with Li-Fraumeni syndrome. Illustrative case

BACKGROUND

Ionizing radiation and alkylating chemotherapies increase secondary malignancy risk in patients with cancer predisposition syndromes (CPSs), such as Li-Fraumeni syndrome. Laser interstitial thermal therapy (LITT) is a minimally invasive ablation technique that has not been associated with mutagenic risks. We describe the case of a child with LFS and a history of treated choroid plexus carcinoma (CPC) who developed a second primary glial tumor that was safely treated with magnetic resonance imaging (MRI)-guided LITT.

OBSERVATIONS

A 4-year-old male with left parietal World Health Organization grade III CPC associated with a TP53 germline mutation was evaluated. The patient underwent neoadjuvant platinum-based chemotherapy before near-total resection, followed by 131I-8H9 immunotherapy and 30 fractions of 54-Gy proton radiotherapy. He remained without evidence of disease for 2 years before developing a slow-growing mass adjacent to the left frontal ventricular horn. Stereotactic biopsy revealed a glial neoplasm. Given the nonsuperficial location and focality of the lesion, MRI-guided LITT was performed for ablative therapy. There were no complications, and 2 years of surveillance revealed continued retraction of the ablated tumor focus and no subsequent disease.

LESSONS

Alternatives to mutagenic therapies for brain tumors should be explored for patients with CPS. LITT paired with imaging surveillance is a logical strategy to ensure durable outcomes and mitigate treatment-related secondary neoplasms.

The Endoscopic Lateral Transorbital Approach for the Removal of Select Sphenoid Wing and Middle Fossa Meningiomas. Surgical Technique and Short-Term Outcomes

BACKGROUND AND OBJECTIVE

The endoscopic lateral transorbital approach (eLTOA) is a relatively new approach to the skull base that has only recently been applied in vivo in the management of complex skull base pathology. Most meningiomas removed with this approach have been in the spheno-orbital location. We present a series of select purely sphenoid wing and middle fossa meningiomas removed through eLTOA. The objective here was to describe the selection criteria and results of eLTOA for a subset of sphenoid wing and middle fossa meningiomas.

METHODS

This is a retrospective study based on a prospectively maintained database of consecutive cases of eLTOA operated on at our institution by the lead author. The cohort's clinical and radiographic characteristics and outcome are presented.

RESULTS

Five patients underwent eLTOA to remove 3 sphenoid wing and 2 middle fossa meningiomas. The mean tumor volume was 11.9 cm 3 . Gross total resection was achieved in all cases. There were no intraoperative complications. Postoperatively, there was one case of subretinal hemorrhage, which was corrected by open vitrectomy repair, and one case of cerebrospinal fluid leak, which resolved with lumbar drainage. Three patients presented with visual impairment, 1 improved, 1 remained stable, and 1 worsened, but returned to stable after vitrectomy repair. All patients have been free of disease at a median follow-up of 8.9 months.

CONCLUSION

eLTOA provides a direct minimal access corridor to certain well-selected sphenoid wing and middle fossa meningiomas. eLTOA minimizes brain retraction and provides a high rate of gross total resection. Meningiomas appropriately selected based on size, type, and location of dural attachment, and the eLTOA is a safe, rapid, and highly effective procedure with acceptable morbidity.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Endonasal, supraorbital, and transorbital approaches: minimal access endoscope-assisted surgical approaches for meningiomas in the anterior and middle cranial fossae

OBJECTIVE

Minimally invasive endoscope-assisted approaches to the anterior skull base offer an alternative to traditional open craniotomies. Given the restrictive operative corridor, appropriate case selection is critical for success. In this paper, the authors present the results of three different minimal access approaches to meningiomas of the anterior and middle fossae and examine the differences in the target areas considered appropriate for each approach, as well as the outcomes, to determine whether the surgical goals were achieved.

METHODS

A consecutive series of the endoscopic endonasal approach (EEA), supraorbital approach (SOA), or transorbital approach (TOA) for newly diagnosed meningiomas of the anterior and middle fossa skull base between 2007 and 2022 were examined. Probabilistic heat maps were created to display the distribution of tumor volumes for each approach. Gross-total resection (GTR), extent of resection, visual and olfactory outcomes, and postoperative complications were assessed.

RESULTS

Of 525 patients who had meningioma resection, 88 (16.7%) were included in this study. EEA was performed for planum sphenoidale and tuberculum sellae meningiomas (n = 44), SOA for olfactory groove and anterior clinoid meningiomas (n = 36), and TOA for spheno-orbital and middle fossa meningiomas (n = 8). The largest tumors were treated using SOA (mean volume 28 ± 29 cm3), followed by TOA (mean volume 10 ± 10 cm3) and EEA (mean volume 9 ± 8 cm3) (p = 0.024). Most cases (91%) were WHO grade I. GTR was achieved in 84% of patients (n = 74), which was similar to the rates for EEA (84%) and SOA (92%), but lower than that for TOA (50%) (p = 0.002), the latter attributable to spheno-orbital (GTR: 33%) not middle fossa (GTR: 100%) tumors. There were 7 (8%) CSF leaks: 5 (11%) from EEA, 1 (3%) from SOA, and 1 (13%) from TOA (p = 0.326). All resolved with lumbar drainage except for 1 EEA leak that required a reoperation.

CONCLUSIONS

Minimally invasive approaches for anterior and middle fossa skull base meningiomas require careful case selection. GTR rates are equally high for all approaches except for spheno-orbital meningiomas, where alleviation of proptosis and not GTR is the primary goal of surgery. New anosmia was most common after EEA.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Clinical-genomic determinants of immune checkpoint blockade response in head and neck squamous cell carcinoma

BACKGROUNDRecurrent and/or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) is generally an incurable disease, with patients experiencing median survival of under 10 months and significant morbidity. While immune checkpoint blockade (ICB) drugs are effective in approximately 20% of patients, the remaining experience limited clinical benefit and are exposed to potential adverse effects and financial costs. Clinically approved biomarkers, such as tumor mutational burden (TMB), have a modest predictive value in HNSCC.METHODSWe analyzed clinical and genomic features, generated using whole-exome sequencing, in 133 ICB-treated patients with R/M HNSCC, of whom 69 had virus-associated and 64 had non-virus-associated tumors.RESULTSHierarchical clustering of genomic data revealed 6 molecular subtypes characterized by a wide range of objective response rates and survival after ICB therapy. The prognostic importance of these 6 subtypes was validated in an external cohort. A random forest-based predictive model, using several clinical and genomic features, predicted progression-free survival (PFS), overall survival (OS), and response with greater accuracy than did a model based on TMB alone. Recursive partitioning analysis identified 3 features (systemic inflammatory response index, TMB, and smoking signature) that classified patients into risk groups with accurate discrimination of PFS and OS.CONCLUSIONThese findings shed light on the immunogenomic characteristics of HNSCC tumors that drive differential responses to ICB and identify a clinical-genomic classifier that outperformed the current clinically approved biomarker of TMB. This validated predictive tool may help with clinical risk stratification in patients with R/M HNSCC for whom ICB is being considered.FUNDINGFundación Alfonso Martín Escudero, NIH R01 DE027738, US Department of Defense CA210784, The Geoffrey Beene Cancer Research Center, The MSKCC Population Science Research Program, the Jayme Flowers Fund, the Sebastian Nativo Fund, and the NIH/NCI Cancer Center Support Grant P30 CA008748.

Cellulose nanofibers (CNFs) in the recycling of nickel and cadmium battery metals using electrodeposition

Cellulose nanofibers (CNFs) were employed in the aqueous electrodeposition of nickel and cadmium for battery metal recycling. The electrowinning of mixed Ni-Cd metal ion recycling solutions demonstrated that cadmium with a purity of over 99% could be selectively extracted while leaving the nickel in the solution. Two types of CNFs were evaluated: negatively charged CNFs (a-CNF) obtained through acid hydrolysis (-75 μeq. g-1) and positively charged CNFs (q-CNF) functionalized with quaternary ammonium groups (+85 μeq. g-1). The inclusion of CNFs in the Ni-Cd electrolytes induced growth of cm-sized dendrites in conditions where dendrites were otherwise not observed, or increased the degree of dendritic growth when it was already present to a lesser extent. The augmented dendritic growth correlated with an increase in deposition yields of up to 30%. Additionally, it facilitated the formation of easily detachable dendritic structures, enabling more efficient processing on a large scale and enhancing the recovery of the toxic cadmium metal. Regardless of the charged nature of the CNFs, both negatively and positively charged CNFs led to a significant formation of protruding cadmium dendrites. When deposited separately, dendritic growth and increased deposition yields remained consistent for the cadmium metal. However, dendrites were not observed during the deposition of nickel; instead, uniformly deposited layers were formed, albeit at lower yields (20%), when positively charged CNFs were present. This paper explores the potential of utilizing cellulose and its derivatives as the world's largest biomass resource to enhance battery metal recycling processes.

Patterns of immune equilibrium and escape in indolent and progressing tumors

By comparing indolent/slowly progressing with aggressive/rapidly progressing tumor types, Pandey et al. identify human evidence of immune equilibrium in indolent tumors and immune escape in progressing tumors, suggesting a link between these mechanisms and the epidemiologic phenomenon of overdiagnosis.

Cervical Instability and Quadriparesis Requiring Stabilization in Pediatric Patient Caused by a Mutation in COL2A1

A 3-year-old male with no past medical history presented with flaccid plegia of his upper extremities and significant weakness in his lower extremities after wrestling with his brother. Cervical spine magnetic resonance imaging was consistent with cord edema and intraparenchymal hemorrhage at C1-C2. A nonossified tissue mass at the expected location of the upper dens created narrowing of the canal at the C1-2 level and mass effect on the cord. Head computed tomography showed periventricular leukomalacia. Initial findings favored dysplasia of the odontoid with associated soft tissue mass/pannus caused by a possible underlying genetic or metabolic bone dyscrasia. The patient underwent suboccipital craniotomy/C1 laminectomy and occiput to C4 fusion, for decompression and stabilization. Genetic testing showed a COL2A1 collagen disorder, with the child harboring a de novo mutation for c.3455 G>T (p.G1152V). The patient was discharged to inpatient acute rehabilitation, with gradual improvement in strength in all 4 extremities.

AAV-based gene therapy prevents and halts the progression of dilated cardiomyopathy in a mouse model of phosphoglucomutase 1 deficiency (PGM1-CDG)

Phosphoglucomutase 1 (PGM1) deficiency is recognized as the third most common N-linked congenital disorders of glycosylation (CDG) in humans. Affected individuals present with liver, musculoskeletal, endocrine, and coagulation symptoms; however, the most life-threatening complication is the early onset of dilated cardiomyopathy (DCM). Recently, we discovered that oral D-galactose supplementation improved liver disease, endocrine, and coagulation abnormalities, but does not alleviate the fatal cardiomyopathy and the associated myopathy. Here we report on left ventricular ejection fraction (LVEF) in 6 individuals with PGM1-CDG. LVEF was pathologically low in most of these individuals and varied between 10% and 65%. To study the pathobiology of the cardiac disease observed in PGM1-CDG, we constructed a novel cardiomyocyte-specific conditional Pgm2 gene (mouse ortholog of human PGM1) knockout (Pgm2 cKO) mouse model. Echocardiography studies corroborated a DCM phenotype with significantly reduced ejection fraction and left ventricular dilation similar to those seen in individuals with PGM1-CDG. Histological studies demonstrated excess glycogen accumulation and fibrosis, while ultrastructural analysis revealed Z-disk disarray and swollen/fragmented mitochondria, which was similar to the ultrastructural pathology in the cardiac explant of an individual with PGM1-CDG. In addition, we found decreased mitochondrial function in the heart of KO mice. Transcriptomic analysis of hearts from mutant mice demonstrated a gene signature of DCM. Although proteomics revealed only mild changes in global protein expression in left ventricular tissue of mutant mice, a glycoproteomic analysis unveiled broad glycosylation changes with significant alterations in sarcolemmal proteins including different subunits of laminin-211, which was confirmed by immunoblot analyses. Finally, augmentation of PGM1 in KO mice via AAV9-PGM1 gene replacement therapy prevented and halted the progression of the DCM phenotype.

Prognostic impact of intra- and peritumoral immune cell subpopulations in head and neck squamous cell carcinomas - comprehensive analysis of the TCGA-HNSC cohort and immunohistochemical validation on 101 patients

Background

Due to the expanding role of immune checkpoint inhibition in the treatment of head and neck squamous cell carcinoma, understanding immunological processes in the tumor microevironment (TME) has strong translational importance. Though analytical methods for a comprehensive analysis of the immunological TME have constantly improved and expanded over the past years the prognostic relevance of immune cell composition in head and neck cancer TME largely remains ambiguous with most studies focusing on one or a small subset of immune cells.

Methods

The overall survival (OS) of the TCGA-HNSC patient cohort comprising 513 head and neck cancer patients was correlated with a total of 29 different immune metrics including a wide spectrum of immune cell subpopulations as well as immune checkpoint receptors and cytokines using RNAseq based immune deconvolution analyses. The most significant predictors of survival among these 29 immune metrics were validated on a separate HNSCC patient cohort (n=101) using immunohistochemistry: CD3, CD20+CXCR5, CD4+CXCR5, Foxp3 and CD68.

Results

Overall immune infiltration irrespective of immune cell composition showed no significant correlation with the patients' overall survival in the TCGA-HNSC cohort. However, when focusing on different immune cell subpopulations, naïve B cells (p=0.0006), follicular T-helper cells (p<0.0001), macrophages (p=0.0042), regulatory T cells (p=0.0306), lymphocytes (p=0.0001), and cytotoxic T cells (p=0.0242) were identified as highly significant predictors of improved patient survival. Using immunohistochemical detection of these immune cells in a second independent validation cohort of 101 HNSCC patients, we confirmed the prognostic relevance of follicular T helper cells, cytotoxic T cells and lymphocytes. In multivariable analysis, HPV negativity and advanced UICC stages were identified as additional prognostic biomarkers associated with poor outcome.

Conclusion

Our study highlights the prognostic relevance of the immunological tumor environment in head and neck cancer and demonstrates that a more detailed analysis of immune cell composition and immune cell subtypes is necessary to accurately prognosticate. We observed the highest prognostic relevance for lymphocytes, cytotoxic T cells, and follicular T helper cells, suggesting further investigations focusing on these specific immune cell subpopulations not only as predictors of patient prognosis but also as promising targets of new immunotherapeutic strategies.

Reversal of Solvent Migration in Poroelastic Folds

Polymer networks and biological tissues are often swollen by a solvent such that their properties emerge from a coupling between swelling and elastic stress. This poroelastic coupling becomes particularly intricate in wetting, adhesion, and creasing, for which sharp folds appear that can even lead to phase separation. Here, we resolve the singular nature of poroelastic surface folds and determine the solvent distribution in the vicinity of the fold tip. Surprisingly, two opposite scenarios emerge depending on the angle of the fold. In obtuse folds such as creases, it is found that the solvent is completely expelled near the crease tip, according to a nontrivial spatial distribution. For wetting ridges with acute fold angles, the solvent migration is reversed as compared to creasing, and the degree of swelling is maximal at the fold tip. We discuss how our poroelastic fold analysis offers an explanation for phase separation, fracture, and contact angle hysteresis.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

Awareness and perception of an Indian dental professional in context to the process and their role in disaster victim identification as a taskmaster

Forensic odontology is a young area in India. However, it has been used as an integral component in a various medicolegal cases in India. However, the involvement of a dentist in mass disasters still needs to be well recognized. The role of the dentists in any unforeseen circumstances is to contribute as an adjunct hand in Disaster Victim Identification (DVI) which is in an emergent stage in India. This study aimed to assess an Indian dental professional's knowledge and awareness of their role in DVI. A pre-tested, self-administered anonymous questionnaire consisting of 6 open-ended and 14 close-ended questions was mailed to the participants. A total of 441 responses were recorded. The study indicated adequate knowledge and awareness among dental practitioners. Conversely, only a handful of people had first-hand autopsy experience. Thus, to supplement the skills needed to work at ground zero, it is recommended to develop hands-on training programs for dentists in each state of India. Also, creating a pool of experts in each state of India can strengthen the task force.

An in situ exploratory analysis of diesel cars' emission: way forward on policy evaluation

Keeping in view the significant number of diesel-driven passenger cars in the existing light motor vehicle fleet in Delhi, India, a case study on smoke emission measurement from 460 number of such cars was conducted. Smoke exhaust data was collected from the diesel cars while the vehicles presented themselves for periodic renewal of pollution under control (PUC) certification at authorized emission testing centers across Delhi, India. Along with the smoke emission, various vehicle- and engine-related aspects, supposed to affect tailpipe smoke emission, were also recorded aiming at data analysis for two datasets, namely whole and top 5 makes. The smoke density under no-loading condition in the free acceleration test mode was measured. The study reported a strong correlation between vehicle parameters, such as age, mileage, maintenance category, emission norm, and engine aspiration; and the smoke emission (R² values for vehicle age and mileage vs. smoke emission for whole dataset = 0.872 and 0.873, respectively). Top 5 make-wise correlations fared even better (R² for age and mileage vs. emission in the range of 0.85-0.92 and 0.86-0.93, respectively). Further, the predictive emission equations using best-fit trendlines were also developed for both datasets. Such equations may be used by the car manufacturers to adopt a suitable strategy for tuning of engine or vehicle as such, to retain their cars in the longer state of compliance to the extant emission norms. Further, the study recommends to include vehicle mileage as an important factor in upgrading the existing inspection and maintenance programs, especially in the developing countries.

Sustained usage of an app-based clinical-decision making aid for the management of atherosclerotic cardiovascular disease

Background

Complexity of therapies for atherosclerotic cardiovascular disease (ASCVD) risk reduction represents a challenge for clinicians and may lead to poor uptake of these therapies.

Purpose

The goal of this project was to design an easy-to-use, point-of-care tool to risk stratify ASCVD patients and provide individualized guidance for clinicians to incorporate these agents.

Methods

Based on the REACH registry trial and predictive modeling (including 49,689 patients with ASCVD in 44 countries), we designed and implemented an app for secondary risk assessment. Using demographic and comorbidity profiles, this tool was used to calculate an individual's 20-month risk of cardiovascular events and mortality. It also provided graphical comparison to an age-matched control with optimized cardiovascular risk profile to illustrate the modifiable residual risk. The app then utilized the patient's risk profile to provide specific guidance for possible therapeutic interventions SGLT2-inhibitors, GLP1-agonists, PCSK9-inhibitors, Vascular-dose Rivaroxaban, and Icosapent Ethyl. Additionally, it identified individuals who qualified for cardiac rehabilitation or may benefit from smoking cessation interventions, including counselling or pharmacological therapies.

We launched a pilot test of the “Residual Cardiovascular Risk: Assessment and Management Guide” app at a regional cardiac center. 240 referring physicians (including family doctors, emergency physicians, internists, and cardiologists) were invited by email or fax to utilize the app. Feedback was solicited from all users three months into the test period. Following this, no further marketing of the app was performed for all users. Usage data was recorded using Google Analytics over a 12-month period and analyzed in 4-month increments.

Results

From January to December 2021, our app was used to risk stratify 1576 patients. A total of 47 individual users utilized the app over this period. From January to April, the app was used on average 160 times monthly. From May to August, it was used 115 times monthly. From September to December, it was used 118 times monthly. Twenty-four physicians provided feedback; 100% affirmed the functionality, ease of use, and utility of the tool. The app was described as “useful for discussions with patients”, “helpful to optimize patients” and “similar to a mini-cardiology consult”. User suggestions resulted in further improvements to the app, including integration of reports into Electronic Medical Records.

Conclusions

The early success of this app demonstrates a need for simple, accessible, and individualized guidance for management of ASCVD patients to improve uptake of guideline-based medical therapies. This tool demonstrates sustained usage among clinicians, as well as subjective utility in aiding therapeutic decision making. Future clinical research will focus on the ability of this tool to impact physician prescribing patterns and clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

A novel algorithm for rapid sequence optimization of guideline directed medical therapy for heart failure with reduced ejection fraction

Introduction

Current guidelines for management of Heart Failure with Reduced Ejection Fraction (HFrEF) recommend Beta-blockers, Angiotensin Receptor Neprilysin Inhibitors (ARNI), Mineralocorticoid Receptor Antagonists (MRA) and SGLT2 inhibitors. However, guideline-directed medical therapies (GDMT) remain underutilized. The 2018 CHAMP-HF registry of HFrEF patients demonstrated that only 1% of patients were treated with target doses of Beta-blockers, MRA and ACE-inhibitors (ACE-I) and Angiotensin Receptor Blocker (ARB) or ARNI. Historically, HFrEF therapies were initiated and up-titrated sequentially. Recent expert commentary has suggested a more aggressive approach of initiating all 4 classes of therapy at low doses after which patients should be up-titrated to target dose

Purpose

This study tested a novel, virtual HFrEF optimization program with the goal of achieving GDMT using a novel “rapid sequence” algorithm.

Methods

We conducted a single center study at a regional cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from both inpatient and outpatient settings were enrolled in a virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a program nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications. At week 1, patients started on ARNI and SGLT2i. After week 3, Beta-Blocker was initiated. After week 5, MRA was initiated. Following this, medications were up-titrated every two weeks, based on clinical judgement of the overseeing cardiologist. Vital signs and bloodwork were obtained after all medication adjustments. In addition, all patients were seen once weekly by a kinesiologist for lifestyle optimization and counselling.

Results

From April 2020 to January 2021, 297 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 69 and 63% were male. Mean ejection fraction was 28% and 54% had ischemic cardiomyopathy. At intake, the proportion of patients prescribed maximally-tolerated dosage was 64% for Beta-Blockers, 7% for MRA, 1% for ARNI and 1% for SGLT2i. At 3-month follow-up, maximally-tolerated dose was prescribed in 84% of patients for beta-blockers (p&lt;0.01), 58% for MRA (p&lt;0.01), 77% for SGLT2i (p&lt;0.01) and 96% for ARNI (p&lt;0.01). 39% of patients achieved maximal doses of all 4 classes of medications at follow-up. No medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up.

Conclusions

This study demonstrates that a program using aggressive GDMT initiation can safely and effectively improve uptake of therapy in HFrEF patients. Future research should examine HFrEF “rapid sequence” optimization on patient outcomes in a randomized setting.

Funding Acknowledgement

Type of funding sources: None.

Impact of diabetes and glucose-lowering therapy on post-operative atrial fibrillation after cardiac surgery: secondary analysis of the SEARCH-AF CardioLink-1 randomized clinical trial

Background

Diabetes mellitus is an important risk factor for atrial fibrillation (AF) and is associated with an increased risk of complications for patients with AF. The impact of diabetes on post-operative AF after cardiac surgery is not well-defined.

Purpose

We sought to characterize the effect of diabetes, insulin, and oral hypoglycemic agents on the incidence of post-operative atrial fibrillation (POAF) after cardiac surgery. Accordingly, we conducted a secondary analysis of the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary outcome was occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead electrocardiogram within 30 days of randomization. We assessed the association between diabetes and occurrence of post-operative AF. In addition, we examined the association between POAF and glucose-lowering therapy among patients with diabetes.

Results

Among the 176 (52%) patients with diabetes in the study cohort, 80 (45%) patients were treated with at least 1 oral hypoglycemic agent and 44 (25%) patients were treated with insulin. The incidence of POAF occurring within 30 days after discharge from surgery was similar between patients with or without diabetes (cumulative incidence: 10.8% vs. 10.0%, log-rank p=0.77). Among patients with diabetes, the incidence of POAF was highest in those who were not treated with glucose-lowering therapy (17.3%) when compared with those treated with oral hypoglycemic agents (10.0%) or insulin (4.5%) (log-rank ptrend=0.045 among the 3 groups). In an exploratory analysis, we observed a trend suggesting a lower incidence of POAF among cardiac surgical patients who were treated with SGLT-2 inhibitors (log-rank ptrend=0.084).

Conclusion

The incidence of POAF occurring after discharge from cardiac surgery is equally high among patients with or without diabetes. Our results suggest a potential association between specific glucose-lowering therapies and risk of POAF after cardiac surgery, meriting further investigations.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

Valvular surgery is associated with an increased risk of post-operative atrial fibrillation: secondary analysis of the SEARCH-AF CardioLink-1 randomized trial

Background

Patients undergoing valve surgery have a higher risk of developing post-operative atrial fibrillation (POAF) relative to those undergoing isolated coronary artery bypass grafting (CABG). Whether this risk extends beyond hospital discharge is unknown.

Purpose

We examined the association between surgery type (isolated CABG vs. valve repair/replacement) on the incidence of post-operative atrial fibrillation (POAF) by conducting a secondary analysis of the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary outcome was occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead ECG within 30 days of randomization. We compared the risk of POAF between patients who underwent CABG vs. valve repair/replacement. Patients who experienced post-operative AF during hospitalization were excluded from this analysis.

Results

The overall cohort consisted of 255, 39, and 42 patients who underwent isolated CABG, isolated valve replacement/repair, and CABG + valve repair/replacement, respectively. Baseline characteristics were similar among the groups except for younger age (p=0.0014), higher prevalence of preoperative myocardial infarction (p=0.002) and lower ejection fraction (p=0.025) in the isolated CABG group. Eighteen patients experienced post-operative AF during hospitalization. Patients who underwent CABG + valve surgery or isolated valve surgery were more likely to experience post-operative AF compared with those who underwent isolated CABG (Log-Rank ptrend=0.0096). Among patients who were randomized to continuous cardiac rhythm monitoring, the probability of post-operative AF among patients who underwent isolated CABG, valve surgery, and CABG + valve surgery was 15.8%, 29.4%, and 35.0%, respectively (Log-Rank ptrend=0.017). After multivariable adjustment, the risk of developing post-operative AF within 30 days after discharge remained higher among patients who underwent valve surgery compared with those who underwent isolated CABG (hazard ratio (HR) 2.22, 95% CI 1.01–4.87. Patients who underwent CABG + repair/replacement had the highest risk of experiencing post-operative AF when compared to patients who underwent isolated CABG (HR 2.78, 95% CI 1.12–6.86).

Conclusion

Patients undergoing valve repair or bioprosthetic valve replacement have a substantial risk of post-operative AF within 30 days after discharge from surgery. An aggressive cardiac rhythm monitoring strategy during this vulnerable period should be considered for this high-risk patient population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

The impact of statin on post-operative atrial fibrillation after discharge from cardiac surgery: secondary analysis of the SEARCH-AF CardioLink-1 randomized trial

Background

There is conflicting evidence regarding the use of statins to reduce the risk of post-operative atrial fibrillation (POAF) in patients undergoing cardiac surgery.

Purpose

We sought to determine the effects of statin use on the burden of new-onset post-discharge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial.

Methods

In the SEARCH-AF trial, 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥2) and no history of preoperative AF were randomized to usual care or continuous cardiac rhythm monitoring for 30 days after discharge from cardiac surgery with a wearable, patched-based device. The primary endpoint was the occurrence of cumulative atrial fibrillation/flutter (AF/AFL) lasting for ≥6 minutes detected by continuous monitoring or AF/AFL documented by a 12-lead electrocardiogram within 30 days of randomization. Using time-to-event analysis and Cox regression, we evaluated the association between the risk of post-operative AF in relation to statin use and dosing intensity (low, moderate, high) at the time of discharge. We excluded patients who experienced post-operative AF during hospitalization in this analysis.

Results

In the overall cohort (n=336), 260 (77.4%) patients were treated with statins at the time of hospital discharge. There were 18 (5.4%) patients who experienced post-operative AF during hospitalization. Patients prescribed with statins were more likely to be male (p=0.018), had lower CHA2DS2-VASc scores (p=0.011), and were more likely to undergo isolated coronary artery bypass grafting (CABG) (p=0.083). Baseline characteristics were otherwise similar between the 2 groups. Patients treated with statins at discharge had a 2-fold lower rate of post-operative AF than those who were not treated with statins in the overall cohort (17.6% vs. 8.2%, Log-Rank p=0.017) and among those who were randomized to continuous cardiac rhythm monitoring (31.6% vs. 16.0%, Log-Rank p=0.027) (Figure). After adjusting for surgery type (CABG vs. valve surgery) and the CHA2DS2-VASc score, statin use at discharge was associated with a lower risk of post-operative AF within 30 days after surgery (hazard ratio 0.48, 95% CI 0.24–0.97). Furthermore, increasing intensity of statin therapy was associated with lower risk of POAF (ptrend=0.0012) (Figure 1)

Conclusion

Among cardiac surgery patients with risk factors for stroke and no history of pre-operative AF, the use of statins was associated with a reduction in post-operative AF risk within 30 days of discharge. The routine use of high-intensity statin to prevent post-operative AF after cardiac surgery deserves further study.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Heart and Stroke Foundation of Canada

Applying the indexing system for assessment of effectiveness of the exhaust emission compliance certification process for passenger cars

The inspection/maintenance programmes exist in most countries, aiming at vehicular emission reduction through exhaust emission monitoring and compliance policy to the extant norms. However, considering the absence of an intra-vehicle approach, the higher success rate of vehicles towards compliance policy remains a grey area. The paper attempts to examine this issue through the application of an exhaust emission index (EEI) for petrol-driven cars. The study observed two different scales finding that the Bharat Stage emission norm scale method reports lower ranges of EEI compared with the linear scale (LS) method (EEI min-BSNS  = 1.12 and EEI min-LS  = 1.25; EEI max-BSNS  = 20.70 and EEI max-LS  = 29.54). The LS method and the maximum operator form of aggregation are recommended as these can find the highest number of non-compliant cars (21.81% and 12.03% of the ‘poor’ class, respectively) in the whole fleet tested. The EEI gives a more scientific approach to vehicular emission evaluation, like what the air quality index does in the case of the ambient air quality. It helps vehicle owners know their car's emission status as a quick reference index (EEI). The accurate status of such emission further helps the policymakers affect the better phasing-out norms.

Building Programs to Eradicate Toxoplasmosis Part III: Epidemiology and Risk Factors

Purpose of Review

Review comprehensive data on rates of toxoplasmosis in Panama and Colombia.

Recent Findings

Samples and data sets from Panama and Colombia, that facilitated estimates regarding seroprevalence of antibodies to Toxoplasma and risk factors, were reviewed.

Summary

Screening maps, seroprevalence maps, and risk factor mathematical models were devised based on these data. Studies in Ciudad de Panamá estimated seroprevalence at between 22 and 44%. Consistent relationships were found between higher prevalence rates and factors such as poverty and proximity to water sources. Prenatal screening rates for anti-Toxoplasma antibodies were variable, despite existence of a screening law. Heat maps showed a correlation between proximity to bodies of water and overall Toxoplasma seroprevalence. Spatial epidemiological maps and mathematical models identify specific regions that could most benefit from comprehensive, preventive healthcare campaigns related to congenital toxoplasmosis and Toxoplasma infection.

Building Programs to Eradicate Toxoplasmosis Part II: Education

Purpose of Review

Review work to create and evaluate educational materials that could serve as a primary prevention strategy to help both providers and patients in Panama, Colombia, and the USA reduce disease burden of Toxoplasma infections.

Recent Findings

Educational programs had not been evaluated for efficacy in Panama, USA, or Colombia.

Summary

Educational programs for high school students, pregnant women, medical students and professionals, scientists, and lay personnel were created. In most settings, short-term effects were evaluated. In Panama, Colombia, and USA, all materials showed short-term utility in transmitting information to learners. These educational materials can serve as a component of larger public health programs to lower disease burden from congenital toxoplasmosis. Future priorities include conducting robust longitudinal studies of whether education correlates with reduced adverse disease outcomes, modifying educational materials as new information regarding region-specific risk factors is discovered, and ensuring materials are widely accessible.

A Point Prevalence Study of the Use of Antibiotics in Six Tertiary Care Hospitals in the Kathmandu Valley, Nepal

Background Point prevalence survey (PPS) on antibiotic use developed by the WHO has already been used in many hospitals globally. Objective To obtain information on antibiotic prescribtion using point prevalence survey methodology in six private hospitals in the Kathmandu valley. Method This descriptive cross-sectional study was completed during 20th July to 28th July 2021 using point prevalence survey methodology. The study was conducted among inpatients admitted at or before 8:00 AM on the day of survey in various wards. Data was presented as frequencies and percentages. Result Maximum number of patients were above 60 years [34 (18.7%)]. Number of male and female participants were equal [91 (50%)]. Only one antibiotic was used in 81 patients (44.5%) followed by two antibiotics in 71 (39%) patients. Duration of prophylactic antibiotic use was one day in 66 (63.7%) patients. Blood, urine, sputum, and wound swabs were the common samples for culture. Cultures were positive for 17 (24.7%) samples. The common organisms isolated were E. Coli, Pseudomonas aeruginosa and Klebsiella pneumoniae. Ceftriaxone was the most used antibiotic. Drug and therapeutics, infection control committee and pharmacovigilance activities were present in 3/6 (50%) study sites. Antimicrobial stewardship was present in 3/6 (50%) and microbiological services was present in all hospitals. Antibiotic formulary and antibiotic guideline were present in 4/6 sites and facilities to audit or review surgical antibiotic prophylaxis choice in 2/6 (33.3%) sites, facility to monitor antibiotic use in 4/6 (66.6%) and cumulative antibiotic susceptibility reports in 2/6 (33.3%) study sites. Conclusion Ceftriaxone was the most used antibiotic. E. Coli, Pseudomonas aeruginosa and Klebsiella pneumonia were the commonly isolated organisms. Not all parameters for infrastructure, policy and practice and monitoring and feedback were present at the study sites. KEY WORDS.

Prognostic significance of polyvascular disease in patients admitted with acute decompensated heart failure: the ARIC Study Community Surveillance

Introduction

The prevalence and outcomes of polyvascular disease (PVD) in patients admitted with acute decompensated heart failure (ADHF) have not been previously reported, nor is it known whether associations differ for heart failure (HF) with reduced vs. preserved ejection fraction (HFrEF vs HFpEF, respectively).

Purpose

To investigate the relationship between atherosclerotic involvement of multiple arterial territories and mortality in patients hospitalized with ADHF.

Methods

The Atherosclerosis Risk in Communities (ARIC) study conducted hospital surveillance of adjudicated heart failure in 4 US areas from 2005–2014, with events verified by physician review. Medical histories were abstracted from the hospital record. PVD was defined by coexisting disease in ≥2 arterial beds, identified by prevalent coronary artery disease, peripheral arterial disease, and cerebrovascular disease. Mortality hazards of PVD vs. no PVD were analyzed separately for HFpEF and HFrEF, with adjustment for age, race, sex, year of admission and geographic region. All analyses were weighted by the inverse of the sampling probability.

Results

Of 24,936 ADHF hospitalizations (52% female, 32% Black, mean age 75 years), 19% had PVD (22% among HFrEF hospitalizations, 17% among HFpEF hospitalizations), Figure 1. There was an increasing trend in 1-year mortality with 0, 1 and ≥2 arterial bed involvement, both for patients with HFrEF (29% to 32% to 38%; P-trend=0.0006) and HFpEF (26% to 32% to 37%; P-trend &lt;0.0001). After adjustments, PVD was associated with a 20% higher hazard of 1-year mortality in patients with HFrEF (HR=1.23; 95% CI: 1.06–1.44) and a 30% higher hazard in patients with HFpEF (HR=1.33; 95% CI: 1.09–1.63), with no significant interaction by HF type (P-interaction = 0.5).

Conclusion

Patients hospitalized with ADHF and coexisting PVD have an increased risk of death, irrespective of HF type. Clinical attention should be directed toward PVD, with secondary prevention strategies enacted to improve the prognosis of this vulnerable population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health Distributions of arterial diseaseTrends in 1-year mortality outcomes