Derivation of a novel antimicrobial peptide from the Red Sea Brine Pools modified to enhance its anticancer activity against U2OS cells

Cancer associated drug resistance is a major cause for cancer aggravation, particularly as conventional therapies have presented limited efficiency, low specificity, resulting in long term deleterious side effects. Peptide based drugs have emerged as potential alternative cancer treatment tools due to their selectivity, ease of design and synthesis, safety profile, and low cost of manufacturing. In this study, we utilized the Red Sea metagenomics database, generated during AUC/KAUST Red Sea microbiome project, to derive a viable anticancer peptide (ACP). We generated a set of peptide hits from our library that shared similar composition to ACPs. A peptide with a homeodomain was selected, modified to improve its anticancer properties, verified to maintain high anticancer properties, and processed for further in-silico prediction of structure and function. The peptide's anticancer properties were then assessed in vitro on osteosarcoma U2OS cells, through cytotoxicity assay (MTT assay), scratch-wound healing assay, apoptosis/necrosis detection assay (Annexin/PI assay), RNA expression analysis of Caspase 3, KI67 and Survivin, and protein expression of PARP1. L929 mouse fibroblasts were also assessed for cytotoxicity treatment. In addition, the antimicrobial activity of the peptide was also examined on E coli and S. aureus, as sample representative species of the human bacterial microbiome, by examining viability, disk diffusion, morphological assessment, and hemolytic analysis. We observed a dose dependent cytotoxic response from peptide treatment of U2OS, with a higher tolerance in L929s. Wound closure was debilitated in cells exposed to the peptide, while annexin fluorescent imaging suggested peptide treatment caused apoptosis as a major mode of cell death. Caspase 3 gene expression was not altered, while KI67 and Survivin were both downregulated in peptide treated cells. Additionally, PARP-1 protein analysis showed a decrease in expression with peptide exposure. The peptide exhibited minimal antimicrobial activity on critical human microbiome species E. coli and S. aureus, with a low inhibition rate, maintenance of structural morphology and minimal hemolytic impact. These findings suggest our novel peptide displayed preliminary ACP properties against U2OS cells, through limited specificity, while triggering apoptosis as a primary mode of cell death and while having minimal impact on the microbiological species E. coli and S. aureus.

Does titanium cage subsidence affect clinical outcomes in ACDF surgery? A tertiary centre experience

BACKGROUND

Cage subsidence after anterior cervical discectomy and fusion (ACDF) surgery has been well documented with rates of up to 40%. Cages fill the void after cervical discectomy and promote fusion. These materials have different biomechanical profiles with differing rates of subsidence. This retrospective cohort study aimed to determine subsidence rates specifically associated with the novel Emerging Implant Technologies (EIT) titanium cage, identify risk factors associated with subsidence, and evaluate whether subsidence affects clinical outcomes.

METHODS

ACDF with insertion of stand-alone EIT cage was performed in 39 patients (64 levels) between December 2016 and February 2019 with a median follow-up of 11 months. Patients were classified into two groups; subsidence and non-subsidence, and were compared in terms of the resultant clinical outcomes as well as presence of risk factors. Health-related quality of life (HRQOL) outcomes were assessed using Visual Analogue Scale (VAS) for neck and arm pain, EuroQol 5-Dimension 5-Level (EQ-5D-5L), EuroQol Visual Analogue Scale (EQ VAS) and Neck Disability Index (NDI) scores.

RESULTS

Cage subsidence (>3mm) was present in nine patients (23%), which corresponded to ten levels treated (16%). Development of subsidence was not associated with gender (p = 0.12), age (p = 0.27), smoking (p = 0.13), number of treatment levels (p = 0.10) or cage size used (p = 0.34). It had no effect on any of the HRQOL outcomes, namely VAS Neck (p = 0.07), VAS Arms (p = 0.08), EQ-5D-5L (p = 0.36), EQ VAS (p = 0.85) and NDI (p = 0.80).

CONCLUSIONS

The EIT cage seems to be associated with lower rates of subsidence compared with other cage types. Cage subsidence was not associated with HRQOL outcomes or risk factors.

Exercise capacity as a predictor of coronary microvascular dysfunction

Introduction

Exercise capacity (EC) is an important prognostic test in patients with coronary artery disease (CAD). Positron-emission tomography (PET) is an important risk-stratifying tool to tailor management of patients with coronary artery disease.

Purpose

We aimed to assess EC in predicting positron emission tomography (PET) myocardial perfusion imaging (MPI) derived coronary flow reserve (CFR).

Methods

Consecutive patients who had clinically indicated PET MPI and EC were included. EC was defined based on peak metabolic equivalents (METS) achieved during exercise stress test. Myocardial blood flow (MBF) in ml/gm/min was obtained from dynamic PET MPI images at rest and peak hyperemia. The coronary flow reserve (CFR) was calculated as the ratio of stress to rest MBF of the left ventricle.

Results

The study population consisted of 511 patients who underwent PET MPI and EC testing (mean age 56 (±11), 71% male). Cardiovascular risk factors were prevalent (75% hypertensive, 82% dyslipidemic, 43% diabetics, 27% known CAD). Peak METS >6 was achieved in 81% of patients, and the CFR <2 was present in 27%. In multivariable logistic regression models adjusted for age, sex, cardiovascular risk factors (hypertension, diabetes, dyslipidemia) and medication use (angiotensin converting enzyme inhibitor/angiotensin receptor blocker, statins, beta-blockers), patients with peak METS >6 had a statistically significant lower odds of microvascular dysfunction (CFR <2: OR 0.43, 95% CI 0.26–0.71, p=0.001). Assessment of discrimination showed the model with CFR <2 had an incremental improvement of Harrell's C statistic over clinical variables (0.65 vs 0.69, p=0.02).

Conclusion

Our findings showed exercise capacity was a good predictor of CFR and microvascular coronary health over and above clinical variables. Further studies are needed to assess the prognostic interplay between EC and CFR.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of coronary flow reserve and coronary calcification in patients with suspected coronary artery disease

Introduction

Current cardiac PET and computed tomography imaging allows the simultaneous acquisition of anatomic and physiological data for patients suspected of CAD.

Purpose

We aimed to evaluate the incremental prognostic value of coronary artery calcium (CAC) score and coronary flow reserve (CFR) in patients with suspected coronary artery disease (CAD) undergoing positron emission tomography (PET) myocardial perfusion imaging (MPI).

Methods

We included consecutive patients who underwent PET MPI and CAC score calculation at Houston Methodist Hospital between August 2019 and January 2022. MPI and CAC scores were obtained in the same setting. The primary endpoint of the study was MACE. Cox proportional hazard regression was used to assess the incremental prognostic value of CAC and CFR by sequentially adding the variables to a model that included clinical and PET variables.

Results

A total of 2,072 patients (mean age 65.7±11.6 years, 54.7% women) were included in the analysis. Risk factors were prevalent (86.1% hypertension, 75.2% dyslipidemia, 45.5% diabetes). In total, 25.3% of the cohort had a CAC score of 0, 38.1% had CAC ≥400, and 39.9% had CFR <2. Over a median follow up of 6.26 (IQR 1.7–12.4) months, 66 (3.2%) patients had cardiac death/nonfatal myocardial infarction. CFR score added incremental prognostic value over clinical and perfusion variables alone (base model: c-index 0.75; Akaike information criterion [AIC]: 1,860.6; p<0.001; CFR model: c-index 0.78; AIC: 1,842.4; p=0.041). However, CAC score did not show an increased prognostic utility (CAC model: c-index 0.76; AIC: 1,854.8; p=0.087 vs. base model), and neither did the combined model of CAC and CFR scores (c-index 0.79; AIC: 1,839.4; p=0.366 vs. CFR model).

Conclusions

Among patients referred for PET MPI, CFR score added an increased prognostic value over clinical and MPI variables. However, when evaluating the prognostic utility of CAC alone, or of CAC and CFR combined, the multivariable model did not show any increased prognostic potential.

Funding Acknowledgement

Type of funding sources: None.

Incremental prognostic value of coronary flow reserve derived from SPIM digital positron emission tomography

Introduction

Positron emission tomography (PET) myocardial perfusion imaging (MPI) is an established test in the diagnosis and prognosis of patients with cardiac diseases. Silicon photomultiplier (SiPM) digital PET is the latest advancement in this technology with improved detector sensitivity, coincidence time resolution, and spatial resolution, allowing for Sub-milliSievert cardiac PET MPI.

Purpose

We aimed to assess the independent and incremental prognostic value of SiPM digital PET derived coronary flow reserve (CFR) to clinical and nuclear variables.

Methods

Consecutive patients who had clinically indicated digital Rubidium PET MPI were included. Rubidium dose was 10–20 mCi according to patient's weight. Patients were followed from the date of imaging to incident major adverse cardiovascular event (MACE: inclusive of all-cause death, myocardial infarction, admission for heart failure and late revascularization – percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) >90 days after imaging).

Results

The study population consisted of 2,893 patients with clinically indicated PET MPI (mean age 67 (±12), 53% male, 41% Caucasian). Cardiovascular risk factors were prevalent (88% hypertensive, 80% dyslipidemic, 47% diabetics, 18% ever smoking). After a mean follow-up of 8±7 months, 250 patients (8.6%, 10.7 per 1000 person-year) experienced MACE (90 D / 38 MI / 51 PCI / 11 CABG / 113 HF). In nested multivariable cox models, CFR was independently associated with incident MACE (HR 0.38, 95% CI 0.29–0.51, p<0.001) and incrementally improved risk prediction (Harrell's C=0.77, p=0.002).

Conclusion

Our findings showed that a Sub-milliSievert SiPM digital PET-derived CFR provided incremental value in risk-stratifying patients and identifying those at increased risk of incident outcomes.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular volumes on positron emission tomography: validation against cardiovascular magnetic resonance

Introduction

Cardiovascular magnetic resonance (CMR) is the gold standard for determination of left ventricular volumes (LVV), including end diastolic volume (LVEDV) and end systolic volume (LVESV). With incorporation of ECG gating, the quantitative analysis of ventricular function can be achieved in Positron Emission Tomography (PET) studies. However, the accuracy of LVV quantification using PET has not been shown in previous studies.

Purpose

We aimed to assess the inter-study variability of LVEDV and LVESV between CMR and PET.

Methods

Consecutive patients who underwent both PET and CMR within 1 year were identified from prospective institutional registries. LVV on PET was compared against CMR as a reference standard using several statistical measures of agreement.

Results

The study population consisted of 233 patients (mean age 60.8±13.6 years, 64.8% male). The median (IQR) duration between CMR and PET was 41 (11–96) days. The median (IQR) LVEDV values were 144 (107–196) on PET and 178 (138–236) on CMR (mean difference 36.09±2.36, p<0.001). As shown in Figure 1, there was a good correlation (Spearman rho=0.88, p<0.001; Intraclass Correlation Coefficient 0.88, 95% CI 0.84–0.90, P<0.001) with moderate limits of agreement (95% limits of agreement −108.17–35.99). A total of 0% and 3.9% of the cohort had LVEDV >150 ml/m2 by CMR and PET respectively. Overall results were similar with LVESV values and similar in subgroup analysis of patients with a low EF (<40%), a coronary artery disease scar, LV hypertrophy and of patients with defibrillators.

Conclusion

Our analysis has shown a good correlation of LVV between PET and CMR, indicating PET derived LVV can accurately be used in the diagnosis and management of patients.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of PET derived coronary flow reserve: should we correct for resting perfusion product?

Introduction

Positron emission tomography (PET) myocardial perfusion imaging (MPI) derived coronary flow reserve (CFR) is an important risk-stratifying tool to tailor management of patients with coronary artery disease. Resting myocardial blood flow (MBF) is positively correlated to the product of resting heart rate and systolic blood product (resting pressure product – RPP), and can in turn lead to lower CFR in the setting of normal stress MBF.

Purpose

We aimed to assess the comparative incremental prognostic value of uncorrected to RPP-corrected CFR in predicting incident events.

Methods

Consecutive patients who had clinically indicated PET MPI were included. Patients were followed from the date of imaging to incident major adverse cardiovascular event (MACE: inclusive of all-cause death, myocardial infarction, admission for heart failure and late revascularization – percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) >90 days after imaging).

Results

The study population consisted of 2,893 patients with clinically indicated PET MPI (mean age 67 (±12), 53% male, 41% Caucasian). Cardiovascular risk factors were prevalent (88% hypertensive, 80% dyslipidemic, 47% diabetics, 18% ever smoking). After a mean follow-up of 8±7 months, 250 patients (8.6%, 10.7 per 1000 person-year) experienced MACE (90 D/38 MI/51 PCI/11 CABG/113 HF). Both uncorrected and corrected CFR were independently associated with incident MACE (HR 0.38, 95% CI 0.29–0.51, p<0.001 and 0.61, 95% CI 0.50–0.76, p<0.001 respectively). A comparison of model incremental prognostic value showed the model with uncorrected CFR had a statistically higher Harrell's C (0.76 vs 0.77, p=0.23).

Conclusion

Our findings showed that the prognostic value of CFR was preserved even in the setting of high resting blood pressure or heart rate. This suggests that correction for RPP should be selective.

Funding Acknowledgement

Type of funding sources: None.

Coronary microvascular health in patients with prior COVID-19 infection and no known CAD

Introduction

Although most patients recovering from acute COVID-19 infection have complete resolution of symptoms, some have cardiopulmonary symptoms lingering long after the acute phase of the disease. One proposed mechanism involves chronicity of COVID-19 associated with myocarditis and endotheliopathy.

Purpose

To determine the coronary microvascular health of patients with prior COVID-19 and no known coronary artery disease (CAD) using positron emission tomography (PET).

Methods

Cases consisting of patients without known CAD but previous COVID-19 infection who had clinically indicated PET imaging were matched 1:4 on clinical and cardiovascular risk factors to controls having no prior COVID-19 infection. Myocardial blood flow (MBF) in ml/gm/min was obtained from dynamic images at rest and peak hyperemia. The coronary flow reserve (CFR) was calculated as the ratio of stress to rest MBF of the left ventricle. Coronary microvascular dysfunction (CMD) was defined as CFR<2.

Results

The study population consisted of 315 patients, 25% (n=80) of which had prior COVID-19 infection (mean±SD age 64±11 years, 46% men). The median (IQR) number of days between COVID-19 infection and PET imaging was 190 (85–268) days. After adjusting for age, gender and cardiovascular risk factors, patients with prior COVID-19 and no known CAD had a statistically significant higher odds of having a CFR <2 (OR 4.9, 95% CI 2.3–10.1 p<0.001) and CFR <2 normalized to patient's rate-systolic blood pressure product (OR 2.8, 95% CI 1.6–5.0 p=0.001). The annualized event rate for the composite outcome of all-cause death, myocardial infarction, admission for heart failure exacerbation and late revascularization was higher in cases vs controls and in those with CMD.

Conclusion

Our analysis showed that patients with prior COVID-19 and no known CAD had higher rates of CMD, and that the presence of CMD was associated with higher risk of incident cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Comparative prognostic utility of visual grade and heart-to-contralateral lung ratio in patients undergoing 99mTc-pyrophosphate radiotracer cardiac scintigraphy

Introduction

Transthyretin (ATTR) cardiac amyloidosis (CA) is an underdiagnosed form of restrictive cardiomyopathy leading to a rapid progression into heart failure. 99mTc-labeled radiotracer cardiac scintigraphy is crucial for the evaluation of CA. Semiquantitative (Perugini visual grade) and quantitative (heart-to-contralateral lung ratio, H/CL) parameters are used to assessing CA via cardiac scintigraphy.

Purpose

We aimed to assess the comparative prognostic utility of the Perugini visual grade and heart to contralateral lung ratio.

Methods

The study population was identified based on an institutional registry of consecutive patients undergoing 99mTc-PYP radiotracer cardiac scintigraphy for suspected CA between January 2020-October 2021. The H/CL is calculated by the fraction of heart region of interest (ROI) mean uptake counts to the contralateral chest ROI. The visual scoring system compares uptake between bone (rib) and heart where 0 = absent cardiac uptake, 1 = uptake less than bone, 2 = uptake equal to bone, and 3 = is uptake greater than bone. Ejection fraction (EF) was obtained from echocardiographic studies done around the time of cardiac scintigraphy. MACE was defined as a composite of inclusive of all-cause death, myocardial infarction, admission for heart failure and late revascularization – percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) >90 days after imaging.

Results

A total of 330 patients (mean age 70.9±12.2 years, 62.2% male) were included in the analysis. Risk factors were prevalent (59.7% hypertension, Heart Failure 68.3%, 26.5% dyslipidemia, 26.2% diabetes) (Table 1). In total, 32.6% of the cohort had studies suggestive of ATTR CA. Median time between echocardiography and cardiac scintigraphy was 7 days (IQR 5–42 days). A higher frequency of MACE was reported in patients with a 2+ visual grade (30% vs 42%, p=0.03). A H/CL >1.5 was associated with borderline significance (43% vs 35% p=0.07).

Conclusion

Our analysis showed that the Perugini visual grading of transthyretin cardiac amyloidosis conferred the best prognostic utility contrary to heart to contralateral lung ratio in 99mTc-PYP radiotracer cardiac scintigraphy.

Funding Acknowledgement

Type of funding sources: None.

Outcome of sedentary patients: does the power of zero cac make a difference?

Introduction

Coronary artery calcium score (CACS) and exercise capacity (EC) are both independent prognostic tests in coronary artery disease (CAD).

Purpose

We aimed to assess the incremental prognostic role of EC to CACS, particularly in those with absent or low coronary calcification.

Methods

The cohort consisted of patients who had clinically indicated exercise stress testing and CACS assessment with a median of 27 days of each other. EC was defined based on peak metabolic equivalents (METS) achieved during exercise stress test. CACS was determined using the Agatston method. Patients were followed from the latest test date to incident MACE (inclusive of all-cause death, non-fatal myocardial infarction, late revascularization and admission for heart failure).

Results

There were a total of 1932 patients in the study population (mean age 56±12, 42% female, 48% hypertension, 21% diabetes, 48% dyslipidemia). Peak METS <6 was achieved in 8% of patients, and the median (IQR) CACS was 9 (0–203). Patients with EC <6 METS had doubling of their event rate across strata of CACS, even amongst patients with absent or low coronary calcifications (CACS 0: 4.6 vs 10.9; CACS 1–99: 10.4 vs 20.4; MACE per 1000 person year in patients with peak METS ≥ vs <6 respectively) (Figure 1).

Conclusion

Our findings showed that poor exercise capacity was associated with higher risk even in patients with absent or low coronary calcification.

Funding Acknowledgement

Type of funding sources: None.

Nano Zinc Versus Bulk Zinc Form as Dietary Supplied: Effects on Growth, Intestinal Enzymes and Topography, and Hemato-biochemical and Oxidative Stress Biomarker in Nile Tilapia (Oreochromis niloticus Linnaeus, 1758)

Five isonitrogenous diets were formulated to comprise two forms of zinc (Zn): convention zinc oxide named Bulk-ZnO or zinc oxide nanoparticles (Nano-ZnO) supplemented at two levels 30 and 60 mg kg^-1 compared to the control diet. Nile tilapia, Oreochromis niloticus, fingerlings (5.02-5.05 g) were fed tested diets two times a day for 84 days. The results displayed that the best growth and digestive enzyme activity (P < 0.05) were noticed in fish fed 60 mg kg^-1 Nano-ZnO. Moreover, significant (P < 0.05) improvement in intestinal topography was observed in 60 mg kg^-1 Nano-ZnO group versus other treatments. Furthermore, fish fed 30 mg kg^-1 Nano-ZnO recorded the best values of hematological indices (P < 0.05). The alanine and aspartate aminotransferase (ALT and AST) values were lower, while total serum protein, albumin, and globulin contents were clearly higher in fish fed diet that contained 30 mg kg^-1 Nano-ZnO versus other groups. The significant highest values of oxidative enzyme activity escorted with lower malondialdehyde value recorded of fish fed diet supplemented with 60 mg kg^-1 Nano-ZnO. The results indicated that inclusion of Nano-ZnO at 60 mg kg^-1 was the recommended source to enhance growth, feed utilization, amylase and lipase enzymes activity, intestinal morphology, hemato-biochemical, and oxidative response biomarkers of Nile tilapia compared with Bulk-ZnO in commercial tilapia feeds.

Acute and Subclinical Myocardial Injury in COVID-19

Coronavirus disease 2019 (COVID-19) is a global pandemic that, at the time of this writing, has led to 178,000,000 cases worldwide and more than 3,875,000 deaths. Cardiovascular complications of COVID-19 have become the focus of investigation after many hospitalized COVID-19 patients-with or without established cardiovascular disease-incurred clinical or subclinical myocardial injury, including isolated biomarker elevations, myocardial infarction, arrhythmia, heart failure, myocarditis, and cardiogenic shock. In this review, we highlight the most recent evidence of the prevalence and potential etiologies of acute and subclinical myocardial injury in COVID-19 patients.

Prevalence of primary painless chronic pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

While pain is the predominant symptom of chronic pancreatitis (CP), a subset of patients may experience a painless course. This systematic review aimed to determine the prevalence of primary painless CP.

METHODS

MEDLINE (PubMed), EMBASE and Web of Science Core Collection databases were searched for published studies through September 15, 2020 that included at least 10 consecutive patients with CP and which reported the number with painless CP. The presence of a history of recurrent acute pancreatitis (RAP), exocrine pancreatic insufficiency (EPI), diabetes mellitus (DM) and pancreatic adenocarcinoma (PA) in the painless CP patients was also recorded. A random effects model was used to determine pooled prevalence estimates with 95% confidence intervals (95% CI).

RESULTS

Among the 5057 studies identified and screened, 42 full-text articles were included in the final analysis. There were a total of 14,277 patients with CP among whom 1569 had painless CP. The pooled prevalence of painless CP was 12% (95% CI 10-15%). Among a subset of studies that reported on calcifications (n = 11), DM (n = 12), EPI (n = 8) and history of RAP (n = 14), the pooled prevalence estimates were 96% (95% CI 73-100%), 51% (95% CI 32-70%), and 47% (95% CI 15-81%), respectively. Alcohol, idiopathic/genetic and other etiologies were attributed to be the cause of painless CP in 32.4%, 56.9% and 8.9% patients, respectively.

CONCLUSION

Approximately one in ten patients with CP have primary painless disease with the majority being attributable to an idiopathic/genetic etiology. Further research is needed to determine the optimal management of these patients.

Racial disparities of internet access in the united states: a multiyear analysis of the national behavioral risk factors surveillance system

Introduction

The COVID 19 pandemic has led to a dramatic rise in the use of Telehealth. Studies have shown racial/ethnic disparities in internet access, a basic prerequisite for telehealth. However, little is known on the extent of this “digital divide” amongst racial minorities with cardiovascular comorbidities.

Purpose

To investigate racial disparities in internet access amongst those with cardiovascular diseases and risk factors, and explore the degree to which this exists amongst those with different levels of comorbidities.

Methods

Behavioral Risk Factors Surveillance System data from the years 2013–2017, during which survey respondents were asked the main outcome of interest (“Have you used the internet in the past 30 days”) were pooled. Respondents were included if they responded yes to questions on selected cardiovascular diseases and risk factors of interest. Multivariable logistic regression was used to analyze the odds of internet use by racial groups adjusting for several socioeconomic factors.

Results

There were a total of 1,478,214 individuals representing 150,235,244 million adults (non-Hispanic Blacks 11.31% and Hispanics 13.75%). Hispanics and Non-Hispanic Blacks reported the lowest prevalence of internet use (66.1% and 64.4% respectively) compared to Non-Hispanic Whites (81.9%). On regression analysis, racial minorities consistently reported lower rates of internet use, averaging 50% lower odds compared to non-Hispanic Whites. Results remained statistically significant even after controlling for several sociodemographic variables.

Conclusion

Using a large nationally representative cohort, we demonstrated differences in internet access amongst racial minorities and those with multiple comorbidities, placing them at distinct disadvantage with access to telecare. Our study adds to a growing body of literature that shows the disproportionate impact of the pandemic on minorities and calls for a concerted effort to reduce disparities in healthcare delivery.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of computed tomography derived fractional flow reserve

Introduction

Cardiac computed tomography angiography (CCTA) derived fractional flow reserve (FFRCT) has been shown to add incremental diagnostic value by providing functional severity of coronary lesion in patients with coronary artery disease (CAD).

Purpose

We aimed to assess the prognostic value of FFRCT in patients with suspected CAD.

Methods

Consecutive patients who had clinically indicated CCTA and FFRCT determination at a tertiary care cardiology practice were included. FFRCT was determined off-site using computational flow dynamics. Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and late percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) 90-days after imaging test.)

Results

A total of 667 patients with at least Coronary Artery Disease Reporting & Data System (CAD-RADS) 2 were included. Mean age was 68±10 years, 37% were women, 73% had hypertension, 12% had diabetes and 61% had dyslipidemia. More than half (57%) of the patients had moderate (CAD-RADS 3) stenosis. FFRCT&lt;0.8 was found in 59% of patients, with increasing percent across categories of CAD-RADS. After a median follow-up of 9 months, 52 patients (7.2%, 6.7 events per 1000 person-year) experienced a MACE. In multivariable Cox regression models adjusted for age and sex, FFRCT &lt;0.8 significantly predicted outcomes (HR 2.48 95% CI 1.26–4.87 p=0.008). Sensitivity analysis using lower thresholds of FFRCT failed to show similar results in intermediate stenosis.

Conclusion

Our results suggest that in a real-world cohort of patients with suspected CAD, FFRCT can identify patients at higher risk of incident cardiovascular outcomes.

Funding Acknowledgement

Type of funding sources: None.

Added prognostic value of plaque burden to computed tomography angiography anatomic assessment and myocardial perfusion imaging in patients with diabetes Mellitus

Introduction

Cardiac computed tomographic angiography (CCTA)-derived measures of coronary artery disease (CAD) burden such as segment involvement score (SIS), which quantifies the number of segments with plaque, have been shown to independently predict incident cardiovascular events.

Purpose

We aimed to compare the added prognostic value of plaque burden to CCTA anatomic assessment and single photon emission computed tomography (SPECT) physiologic assessment in patients with diabetes undergoing both tests.

Methods

Consecutive patients with diabetes who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected coronary artery disease at a tertiary care center were retrospectively identified from medical records. Stenosis severity and segment involvement score (SIS) were determined from CCTA, and presence of ischemia was determined from SPECT. Patients were followed from date of imaging for major adverse cardiovascular events (MACE; inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.)

Results

A total of 778 patients were included (mean age 60.6±14.4 years, 55% males). Obstructive stenosis (left main ≥50%, all other coronary segments ≥70%) and ischemia were found in 15% and 16% of patients respectively. After a median follow-up of 31 months, 87 (11%) patients experienced a MACE. In multivariable Cox regression models, SIS significantly predicted outcomes in models including obstructive stenosis and ischemia (HR 1.17, 95% CI 1.10 - 1.24, p&lt;0.001; 1.16, 95% CI 1.10 - 1.23, p&lt;0.001). The addition of SIS also significantly improved discrimination (Harrel's C 0.75, p=0.006; 0.76, p=0.006 in models with CCTA obstructive stenosis and SPECT ischemia respectively). Results were consistent using subgroups of summed scores by composition of plaque (calcified vs non-calcified) and alternate definitions of obstructive stenosis.

Conclusion

Our results suggest that in high-risk patients with diabetes and suspected coronary disease, SIS has incremental prognostic value over ischemia by SPECT or stenosis by CCTA in predicting incident cardiovascular outcomes.

Funding Acknowledgement

Type of funding sources: None.

Incremental prognostic value of calcified vs non-calcified plaque burden on computed tomography angiography and myocardial perfusion imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Coronary computed tomography angiography (CCTA) is currently guideline-endorsed for diagnosing suspected coronary artery disease (CAD) in low-intermediate risk patients. Single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has an established role in both the accurate detection of ischemia and identification of patients at high risk of future cardiovascular events. Recent studies have shown that the burden of atherosclerotic plaque is an independent predictor of cardiovascular events, and that this effect depends on the degree of calcification.

Purpose

To compare the incremental prognostic value of calcified vs non-calcified plaque burden to CCTA anatomic assessment and SPECT physiologic assessment in patients evaluated with both tests.

Methods

Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD were included. Ischemia on SPECT was defined as summed difference score &gt; 0 using perfusion graded on a 5-point scale. Anatomically obstructive CAD by CCTA was defined as ≥50% in the left main artery and ≥70% stenosis severity in proximal, mid and distal branches of the left anterior descending, left circumflex and right coronary artery without including side branches. Segment involvement score was defined as the sum of segments with plaque irrespective of the degree of stenosis using an 18-segment coronary artery model. A Hounsfield unit threshold of &gt; =130 was used to classify plaques composition as calcified/mixed (C-SIS) vs non-calcified plaque (NC-SIS). Patients were followed for major adverse cardiovascular events (MACE, inclusive of all-cause death, non-fatal myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting 90-days after imaging test.)

Results

A total of 956 patients were included. (Mean age 61.1 ± 14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive stenosis (left main ≥ 50%, all other coronary segments ≥ 70%) and ischemia were observed in similar number of patients (14%). After a median follow-up of 31 months, 102 patients (11%, 29.2 events per 1000 person-year) experienced a MACE. In multivariable Cox regression models, C-SIS, but not NC-SIS significantly predicted outcomes and improved risk discrimination in models with CCTA obstructive stenosis (HR 1.14 95% CI 1.08 - 1.20 p= &lt;0.001; Harrel’s C 0.74, p = 0.011) and SPECT ischemia (HR 1.14 95% CI 1.08 - 1.20, p &lt; 0.001; Harrel’s C 0.76, p = 0.015).

Conclusion

In the current study of high-risk patients with suspected CAD, calcified plaque burden, but not non-calcified plaque incrementally added to measures in predicting incident cardiovascular outcomes

Inter-operator reliability of an onsite machine learning-based prototype to estimate CT angiography-derived fractional flow reserve

Funding Acknowledgements

Type of funding sources: None.

Background

Advances in computed tomography (CT) and machine learning have enabled on-site non-invasive assessment of fractional flow reserve (ML-FFRCT). However, reproducibility of measurements across operators is not well demonstrated.

Purpose

This study was designed to measure the inter-operator variability and reproducibility of Coronary CT Angiography–derived fractional flow reserve values using a post-processing prototype based on a machine learning algorithm (ML-FFRCT).

Methods

We included 60 symptomatic patients who underwent coronary CT angiography. FFRCT was calculated by 2 independent operators after training using a machine learning based on-site prototype. FFRCT was measured 1 cm distal to the coronary plaque or in the middle of the segments if no coronary lesions were present.  Intraclass correlation coefficient (ICC) and Bland-Altman analysis were used to evaluate inter-operator variability effect in FFRCT estimates. Sensitivity analysis was done by cardiac risk factors, degree of stenosis and image quality.

Results

A total of 535 coronary segments in 60 patients were assessed. The overall ICC was 0.986 per patient (95% CI: 0.977 - 0.992) and 0.972 per segment (95% CI: 0.967 - 0.977). The absolute mean difference in FFRCT estimates was 0.012 per patient (95% CI for limits of agreement: -0.035 - 0.039) and 0.02 per segment (95% CI for limits of agreement: -0.077 - 0.080). Tight limits of agreement were seen on Bland-Altman analysis. Distal segments had greater variability compared to proximal/mid segments (absolute mean difference 0.011 vs 0.025, p &lt; 0.001). Sensitivity analysis showed similar results across degrees of stenosis, image quality and those with cardiac risk factors such as hypertension, diabetes and dyslipidemia.

Conclusion

A high degree of inter-operator reproducibility can be achieved by onsite machine learning based ML-FFRCT assessment. Future research is required to evaluate the physiological relevance and prognostic value of ML-FFRCT.

The prognostic role of PET myocardial perfusion imaging in patients with cardiac sarcoidosis: a systematic review

Funding Acknowledgements

Type of funding sources: None.

Background

Sarcoidosis is a multi-systemic inflammatory disease of unknown etiology. Cardiac Sarcoidosis (CS) has been reported in as much as 25% of patients with systemic involvement. 18Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) has a high diagnostic sensitivity/specificity in the diagnosis of CS.

Purpose

The aim of this review is to summarize evidence on the prognostic role of FDG PET.

Methods

Studies were identified by searching MEDLINE from inception to October 2020. Medical Subject Headings (MeSH) terms for sarcoidosis; cardiac and FDG PET imaging were used. Studies of any design assessing the prognostic role of FDG PET in patients with either suspected or confirmed cardiac sarcoidosis imaging done at baseline were included. Abnormal PET was defined as abnormal metabolism (presence of focal or focal-on-diffuse uptake of FDG) OR abnormal metabolism and a perfusion defect. Studies reporting any outcome measure were included. Pooled risk ratio for the composite outcome of MACE was done.

Results

A total of 6 studies were selected for final inclusion (515 patients, 53.4% women, 19.8% racial minorities.) Studies were institution based, retrospective in design and enrolled consecutive patients. All were observational in nature and published in English. All studies used a qualitative assessment of PET scans (abnormal FDG uptake with or without abnormal perfusion). Two studies assessed quantitative metrics (summed stress score in segments with abnormal FDG uptake, standardized uptake value and cardiac metabolic activity.) All studies reported Major Adverse Cardiovascular Events (MACE) as a composite outcome. After a mean follow up ranging from 1.4 to 4.1 years, there were a total of 105 MACE. All studies included death (either all-cause death or sudden cardiac death) and ventricular arrhythmia (ventricular tachycardia or ventricular fibrillation) as a component of MACE. Four of the six studies adjusted for several characteristics in their analysis. All four studies used Left Ventricular Ejection Fraction (LVEF). However, other adjustment variables were not consistent across studies. Five studies found a positive prognostic association with the primary outcome, two of which assessing right ventricular uptake.

Conclusion

Although available evidence indicates FDG PET can be used in the risk stratification of patients with CS, our findings show further studies are needed to quantify the effect in this patient group.

Molecular Characterization of Infectious Bursal Disease Virus Isolated from Naturally Infected Broiler Chickens in Erbil, Iraq

The infectious bursal disease (IBD) is a highly contagious and immunosuppressive disease of broiler chickens and the development of a new genetic variant of the virus is responsible for major economic losses in the poultry industry. For this purpose, it was essential to isolate the molecular characterization of the virus from vaccinated broiler in Erbil, Iraq. Clinically, the infectious bursal disease is characterized by high mortality (10-15%) with hemorrhagic lesions on the breast and thigh muscles, hemorrhagic and edematous bursa of diseased chickens. In this study, the Bursa of Fabricus (BF) samples were collected between June 2018 and January 2019. Histopathological changes of the bursal sections showed existence of the cystic vacuolation of the lymphoid follicles with leukocytes infiltration as pathognomic features for IBD virus infection; and homogenates samples inoculated in chorioallantoic-membrane showed mortality in the second passage with varying degrees of hemorrhages. Agar gel precipitation test (AGPT) was positive with specific antisera. Reverse transcription polymerase chain reaction (RT-PCR) and nucleotide sequence analysis of five fragments in the hypervariable region of VP2 gene revealed transition and transversion changes. Among the five recent IBD virus isolates, the rate of identity was approximately 99% as compared with the very virulent IBD virus from Iran (ID: DQ785171.1). Phylogenetic analysis revealed that the five isolates were closely related to the Asian group with a different percentage ranged from 98-99% while it was 97% in the European group. The local isolate of the virus was registered in the Genebank under the accession number MN48052.1. In conclusion, the isolated IBDVs belong to a very virulent group. In addition, this study demonstrates the spread of this virulent virus to poultry industries in Erbil, Iraq. Further widespread surveys could help in delivering more information on the virus variability and might assist in designing novel vaccines for this pathogen.

Characterization and assessment of naturally mutant non-pathogenic O27 strain Escherichia coli and their potential use as poultry probiotics

Objective

The purpose of the current study was to evaluate the molecular characteristics of naturally mutant non-pathogenic O27 strain of Escherichia coli and its efficacy as probiotic in broilers and determine the best age at which it can be administered.

Materials and methods

A total of 24 virulence genes using 24 sets of primers were detected using the polymerase chain reaction technique. For probiotics experiments, 60 chicks (day 1 old) were divided into three groups, 20 per group, and reared for 4 weeks. The first group was considered as a negative control. The second group was treated orally with O27 strain at first day of life for three successive days and repeated at day 21. The third group was administered orally with O27 strain at day 10 old, and repeated at day 21 old.

Results

The data revealed that type 1 fimbrial adhesion, salmochelin siderophore receptor, and sigma factor-binding protein were detected in O27 strain, but temperature-sensitive hemagglutinin, hemolysin secretion gene, pyelonephritis-associated Pili gene, polysaccharide capsule synthesis gene, Shiga-toxin1 gene, Shiga-toxin2 gene, Brain microvascular endothelial cell invasion, E. coli attaching and effacing gene, heat-stable enterotoxin, heat-labile enterotoxin, east 1 toxin, colicin V, verotoxin type 2, necrotizing cytotoxic factor type 1, colonization factor antigen I, colonization factor antigen III, coli surface 2, coli surface 4, serine protease pic autransporter, vacuolating autotransporter toxin, and serine protease EspP precursor were not detected in O27 strain. Group 2 performance parameters were significantly better (p < 0.01) than groups 3 and 1. Hematological and biochemical parameters did not be influenced (p > 0.05) by the administration of O27 strain. Antibody titers of infectious bursal disease virus and Newcastle disease virus in groups 2 and 3 were improved as compared to group 1. Group 2 had significantly higher titers than group 3. Histopathologically, all groups showed normal histopathological pictures. However, jejunum in groups 2 and 3 showed more tall, intact, and densely packed microvilli and more crypt depth than the control group.

Conclusion

The O27 strain of E. coli is non-pathogenic bacteria. Its effects on growth performances and enhancement of immunity in broilers match with the same impact of probiotics, and these candidates will fit to be a good probiotic in the future. The results revealed that the effects of O27 strain at the day 1 old of life for three successive days and repeated at day 21 old are better for improving the performance and immunity of the birds. More research works about the characterized non-pathogenic E. coli strain O27 are required for field and commercial use.

Epidemiological Characteristics and Economic Impact of Lumpy Skin Disease, Sheeppox and Goatpox Among Subsistence Farmers in Northeast Nigeria

Lumpy skin disease (LSD), sheeppox (SP), and goatpox (GP) are contagious viral infections, affecting cattle (LSD), sheep and goats (SP and GP) with highly characteristic clinical signs affecting multiple body systems. All three diseases are widely reported to reduce meat, milk, wool and cashmere production although few studies have formally evaluated their economic impact on affected farms. This study aimed to estimate the economic impact and epidemiological parameters of LSD, SP, and GP among backyard and transhumance farmers in northeast Nigeria. A retrospective study was conducted on herds and flocks affected between August 2017 and January 2018 in Bauchi, Nigeria. Herds and flocks were diagnosed based on clinical signs and information was collected once the outbreak concluded using a standardized questionnaire. Data were collected from 99 farmers (87 backyard and 12 transhumance). The median incidence risk and fatality rate were 33 and 0% in cattle, 53 and 34 % in sheep; 50 and 33% in goats, respectively, with young stock having higher incidence risk and fatality rates than adults. Almost all farmers (94%) treated affected animals with antibiotics, spending a median of US$1.96 (min US$0.19–max US$27.5) per herd per day. Slaughtering or selling affected animals at low prices were common coping strategies. Farmers sold live cattle for 47% less than would have been sold if the animal was healthy, while sheep and goats were sold for 58 and 57% less, respectively. Milk production dropped 65% when cows were clinically affected and 35% after they recovered. Cattle lost a median of 10% of their live weight and sheep and goats lost 15%. Overall economic losses at farm level range from US$9.6 to US$6,340 depending on species affected and production system. Most of the farmers (72%) had not replaced all affected animals at the time of the study. Livestock markets were the most common place to sell affected animals and buy replacements, suggesting these are likely hubs for spreading infections. This study confirms the immediate and long-lasting impact of these diseases on subsistence farmers' livelihoods in North-East Nigeria and suggests potential mechanisms for targeted control.

P26 Bridging the gap – benefits of neurosurgical tissue for pre-clinical research

Objectives

The use of primary human neural tissue for research provides an invaluable insight into human neural function that cannot be achieved in any other way. Despite this it is successfully collected and used in only a small minority of units. We have established a collaboration between Neurosurgical Unit and the University that allows us to study using human tissue resected during neurosurgery. Tissue is most commonly collected from oncological, epilepsy and vascular operations. Here we share our experiences of the practicalities and try to provide some insights for practicing neurosurgeons.

Subjects

We discuss the practical difficulties of the co-ordination of the clinical and academic teams, and challenge of optimization of the tissue for the research. We will present the mechanisms in place to optimize the study of human neural tissue. We will review the progression from resection of limited tissue to any neurosurgical procedure in which the normal brain is resected and tissue discarded. We discuss the different models that can be used and the application locally to glioma stem cells, pathways activated in TBI and the electrophysiology of the normal brain.

Conclusions

We will present examples of the value of human tissue studies, including electrophysiological differences between humans and rodent that could only be investigated through the use of live human tissue. We will also demonstrate how we have moved to streamline tissue collection and propose a move to establish a national framework.

Sonographic Measurement of Cervical Volume in Pregnant Women at High Risk of Preterm Birth Using a Geometric Formula for a Frustum Versus 3-Dimensional Automated Virtual Organ Computer-Aided Analysis

OBJECTIVES

To compare cervical volume measurements by 3-dimensional (3D) sonography using Virtual Organ computer-aided analysis (VOCAL; GE Healthcare, Milwaukee, WI) versus a manual method using a geometric formula for a frustum.

METHODS

We included 142 asymptomatic pregnant women at 16 to 24 weeks gestation at high risk for preterm birth. With a Voluson 730 Expert system (GE Healthcare), they underwent 2-dimensional (2D) transvaginal sonographic cervical length measurements and 3D cervical volume acquisition. The stored volumes were processed by VOCAL on a surface tablet. Cervical volume was manually calculated from the 2D images by using the formula V = 1/3 × π × h × (r1²  + r2²  + r1 × r2), where V represents cervical volume; π was approximated as 3.14159; h, cervical length; r1, radius at the internal os; and r2, radius at the external os.

RESULTS

Cervical volume was lower when obtained manually than by VOCAL, with a coefficient of variation of 30%, a mean difference of 10.1 ± 14.9 cm³ (P < .0001), and a poor interclass correlation coefficient of 0.62 (95% confidence interval [CI], 0.31 to 0.78). Both methods had good reproducibility; however, VOCAL had wider limits of agreement. A positive correlation was found between both methods (r = 0.63; P < .0001). No correlation was found between cervical length by 2D transvaginal ultrasound and cervical volume by the VOCAL technique (r = 0.06; 95% CI, -0.10 to 0.22) or cervical volume by the manual method (r = 0.2; 95% CI, 0.08 to 0.39).

CONCLUSIONS

The cervix represents a frustum (truncated cone, r1 is not equal to r2) in shape rather than a cylinder. Both methods are reproducible; VOCAL is less reliable but provides higher values of cervical volume.

Clinical chorioamnionitis at term VII: the amniotic fluid cellular immune response

OBJECTIVES

1) To characterize the cellular composition of the amniotic fluid of patients diagnosed with clinical chorioamnionitis at term, as a function of the presence or absence of microorganisms determined by cultivation techniques, and 2) to characterize the cytokine production by white blood cells present in the amniotic fluid using flow cytometry-based techniques.

MATERIALS AND METHODS

Amniotic fluid samples from 20 women who had the diagnosis of clinical chorioamnionitis at term were analyzed using cultivation techniques (for aerobic and anaerobic bacteria as well as genital Mycoplasmas). Amniotic fluid IL-6 concentrations were determined by an enzyme-linked immunosorbent assay. Amniotic fluid leukocytes were visualized by using hematoxylin and eosin staining and immunofluorescence. Immunophenotyping of surface markers and cytokines was performed in amniotic fluid leukocytes using flow cytometry.

RESULTS

1) Neutrophils (CD45+CD15+ cells) were the most common leukocyte subset found in the amniotic fluid, followed by monocytes (CD45+CD14+ cells); other white blood cells (such as lymphocytes and natural killer cells) were scarce in the amniotic fluid; 2) the absolute counts of neutrophils and monocytes were significantly higher in patients with microorganisms found in the amniotic fluid than in those without detectable microorganisms, using cultivation techniques; 3) there was a significant correlation between the absolute counts of neutrophils and monocytes determined by flow cytometry (Spearman's correlation=0.97; P<0.001); 4) there was a significant correlation between the absolute white blood cell count determined with a hemocytometer chamber and by flow cytometric analysis (Spearman's correlation=0.88; P<0.001); and 5) the profile of cytokine expression differed between monocytes and neutrophils; while neutrophils predominantly produced TNF-α and MIP-1β, monocytes expressed higher levels of IL-1β and IL-1α.

CONCLUSION

Flow cytometry analysis of the amniotic fluid of patients with intra-amniotic infection and clinical chorioamnionitis at term demonstrated that neutrophils and monocytes are the most common cells participating in the inflammatory process. We have characterized, for the first time, the differential cytokine expression by these cells in this important complication of pregnancy.

The First Reported Case of Erdheim-Chester Disease in Egypt with Bilateral Exophthalmos, Loss of Vision, and Multi-Organ Involvement in a Young Woman

Patient: Female, 19

Final Diagnosis: Erdheim-Chester disease

Symptoms: Exophthalmos, orthopnea

Medication: Prednisolone • azathioprine

Clinical Procedure: —

Specialty: Internal Medicine

Uterine tachysystole in spontaneous labor at term

OBJECTIVES

The objective of this study is to determine the incidence of uterine tachysystole and its association with spontaneous labor at term.

METHODS

A retrospective cohort study of 8008 women in spontaneous labor (without prostaglandins or oxytocin). Fetal heart tracings and uterine activity were recorded every 15 min.

PRIMARY OUTCOME

occurrence of tachysystole (> 5 uterine contractions /10 min over 30 min periods).

SECONDARY OUTCOMES

non-reassuring fetal heart tracings (NRFHT), NICU admissions, and cesarean deliveries.

RESULTS

About 890 patients (11.1 %) had at least one episode of tachysystole. Non-whites have higher incidence of uterine tachysystole; adjusted odds ratio (aOR) was 1.66 for Hispanics (95% CI 1.28-2.05), 1.58 for African Americans (95% CI 1.05-2.38), and 1.51 for Asians (95% CI = 1.13-2.0). The use of epidural analgesia was higher in the tachysystole group (62.2% versus 40.9%, aOR 1.89, CI 1.58-2.26; p < 0.001). Tachysystole was more frequent among nulliparous women and in women carrying higher weight fetuses. Oligohydramnios (aOR 1.62, CI 0.70-3.72; p < 0.004), and NRFHT were more common in the tachysystole group (4.2% versus 2.5%, p = 0.002). Newborns in the tachysystole group were two times more likely to be admitted to NICU (30 /890 [3.4%] versus 122 /7118 [1.7%], OR = 2, p=0.001). There was no difference in the frequency of meconium-stained amniotic fluid or Apgar scores <7 at 5 min.

CONCLUSION

Uterine tachysystole occurs in more than 10% of spontaneous labors and is associated with NRFHR, increased rate of caesarean deliveries and NICU admissions. It is not associated with low Apgar scores or meconium-stained amniotic fluid.

Clinical chorioamnionitis at term VI: acute chorioamnionitis and funisitis according to the presence or absence of microorganisms and inflammation in the amniotic cavity

OBJECTIVE

Neonates born to mothers with clinical chorioamnionitis at term are at an increased risk of infection. Acute subchorionitis, chorioamnionitis, and funisitis are considered placental histologic features consistent with acute inflammation according to the Society for Pediatric Pathology. The objectives of this study were to examine the performance of placental histologic features in the identification of: 1) microbial-associated intra-amniotic inflammation (intra-amniotic infection); and 2) fetal inflammatory response syndrome (FIRS).

METHODS

This retrospective cohort study included women with the diagnosis of clinical chorioamnionitis at term (n=45), who underwent an amniocentesis to determine: 1) the presence of microorganisms using both cultivation and molecular biologic techniques [polymerase chain reaction (PCR) with broad range primers]; and 2) interleukin (IL)-6 concentrations by enzyme-linked immunosorbent assay (ELISA). The diagnostic performance (sensitivity, specificity, accuracy, and likelihood ratios) of placental histologic features consistent with acute inflammation was determined for the identification of microbial-associated intra-amniotic inflammation and FIRS.

RESULTS

1) The presence of acute histologic chorioamnionitis and funisitis was associated with the presence of proven intra-amniotic infection assessed by amniotic fluid analysis; 2) funisitis was also associated with the presence of FIRS; 3) the negative predictive value of acute funisitis ≥stage 2 for the identification of neonates born to mothers with intra-amniotic infection was <50%, and therefore, suboptimal to exclude fetal exposure to bacteria in the amniotic cavity; and 4) acute funisitis ≥stage 2 had a negative predictive value of 86.8% for the identification of FIRS in a population with a prevalence of 20%.

CONCLUSION

Acute histologic chorioamnionitis and funisitis are associated with intra-amniotic infection and the presence of FIRS. However, current pathologic methods have limitations in the identification of the fetus exposed to microorganisms present in the amniotic cavity. Further studies are thus required to determine whether molecular markers can enhance the performance of placental pathology in the identification of neonates at risk for neonatal sepsis.

Clinical chorioamnionitis at term IV: the maternal plasma cytokine profile

INTRODUCTION

Fever is a major criterion for clinical chorioamnionitis; yet, many patients with intrapartum fever do not have demonstrable intra-amniotic infection. Some cytokines, such as interleukin (IL)-1, IL-6, interferon-gamma (IFN-γ), and tumor necrosis factor alpha (TNF-α), can induce a fever. The objective of this study was to determine whether maternal plasma concentrations of cytokines could be of value in the identification of patients with the diagnosis of clinical chorioamnionitis at term who have microbial-associated intra-amniotic inflammation.

METHODS

A retrospective cross-sectional study was conducted, including patients with clinical chorioamnionitis at term (n=41; cases) and women in spontaneous labor at term without clinical chorioamnionitis (n=77; controls). Women with clinical chorioamnionitis were classified into three groups according to the results of amniotic fluid culture, broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry (PCR/ESI-MS), and amniotic fluid IL-6 concentration: 1) no intra-amniotic inflammation; 2) intra-amniotic inflammation without detectable microorganisms; or 3) microbial-associated intra-amniotic inflammation. The maternal plasma concentrations of 29 cytokines were determined with sensitive and specific V-PLEX immunoassays. Nonparametric statistical methods were used for analysis, adjusting for a false discovery rate of 5%.

RESULTS

1) The maternal plasma concentrations of pyrogenic cytokines (IL-1β, IL-2, IL-6, IFN-γ, and TNF-α) were significantly higher in patients with clinical chorioamnionitis at term than in those with spontaneous term labor without clinical chorioamnionitis; 2) the maternal plasma concentrations of cytokines were not significantly different among the three subgroups of patients with clinical chorioamnionitis (intra-amniotic inflammation with and without detectable bacteria and those without intra-amniotic inflammation); and 3) among women with the diagnosis of clinical chorioamnionitis, but without evidence of intra-amniotic inflammation, the maternal plasma concentrations of pyrogenic cytokines were significantly higher than in patients with spontaneous labor at term. These observations suggest that a fever can be mediated by increased circulating concentrations of these cytokines, despite the absence of a local intra-amniotic inflammatory response.

CONCLUSIONS

1) The maternal plasma concentrations of pyrogenic cytokines (e.g. IL-1β, IL-2, IL-6, IFN-γ, and TNF-α) are higher in patients with intra-partum fever and the diagnosis of clinical chorioamnionitis at term than in those in spontaneous labor at term without a fever; and 2) maternal plasma cytokine concentrations have limited value in the identification of patients with bacteria in the amniotic cavity. Accurate assessment of the presence of intra-amniotic infection requires amniotic fluid analysis.

Clinical chorioamnionitis at term III: how well do clinical criteria perform in the identification of proven intra-amniotic infection?

OBJECTIVE

The diagnosis of clinical chorioamnionitis is based on a combination of signs [fever, maternal or fetal tachycardia, foul-smelling amniotic fluid (AF), uterine tenderness and maternal leukocytosis]. Bacterial infections within the amniotic cavity are considered the most frequent cause of clinical chorioamnionitis and an indication for antibiotic administration to reduce maternal and neonatal morbidity. Recent studies show that only 54% of patients with the diagnosis of clinical chorioamnionitis at term have bacteria in the AF and evidence of intra-amniotic inflammation. The objective of this study was to examine the performance of the clinical criteria for the diagnosis of chorioamnionitis to identify patients with microbial-associated intra-amniotic inflammation (also termed intra-amniotic infection).

MATERIALS AND METHODS

This retrospective cross-sectional study included 45 patients with the diagnosis of clinical chorioamnionitis at term, whose AF underwent analysis for: 1) the presence of microorganisms using both cultivation and molecular biologic techniques [polymerase chain reaction (PCR) with broad primers], and 2) interleukin (IL)-6 concentrations by enzyme-linked immunosorbent assay. The diagnostic performance (sensitivity, specificity, accuracy, and likelihood ratios) of each clinical sign and their combination to identify clinical chorioamnionitis were determined using microbial-associated intra-amniotic inflammation [presence of microorganisms in the AF using cultivation or molecular techniques and elevated AF IL-6 concentrations (≥2.6 ng/mL)] as the gold standard.

RESULTS

The accuracy of each clinical sign for the identification of microbial-associated intra-amniotic inflammation (intra-amniotic infection) ranged between 46.7% and 57.8%. The combination of fever with three or more clinical criteria did not substantially improve diagnostic accuracy.

CONCLUSION

In the presence of a fever during labor at term, signs used to diagnose clinical chorioamnionitis do not accurately identify the patient with proven intra-amniotic infection (i.e., those with microorganisms detected by culture or molecular microbiologic techniques and an associated intra-amniotic inflammatory response).

Sterile and microbial-associated intra-amniotic inflammation in preterm prelabor rupture of membranes

OBJECTIVE

The objectives of this study were to: (1) determine the amniotic fluid (AF) microbiology of patients with preterm prelabor rupture of membranes (PROM); and (2) examine the relationship between intra-amniotic inflammation with and without microorganisms (sterile inflammation) and adverse pregnancy outcomes in patients with preterm PROM.

METHODS

AF samples obtained from 59 women with preterm PROM were analyzed using cultivation techniques (for aerobic and anaerobic bacteria as well as genital mycoplasmas) and with broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). AF concentration of interleukin-6 (IL-6) was determined using ELISA. Results of both tests were correlated with AF IL-6 concentrations and the occurrence of adverse obstetrical/perinatal outcomes.

RESULTS

(1) PCR/ESI-MS, AF culture, and the combination of these two tests each identified microorganisms in 36% (21/59), 24% (14/59) and 41% (24/59) of women with preterm PROM, respectively; (2) the most frequent microorganisms found in the amniotic cavity were Sneathia species and Ureaplasma urealyticum; (3) the frequency of microbial-associated and sterile intra-amniotic inflammation was overall similar [ 29% (17/59)]: however, the prevalence of each differed according to the gestational age when PROM occurred; (4) the earlier the gestational age at preterm PROM, the higher the frequency of both microbial-associated and sterile intra-amniotic inflammation; (5) the intensity of the intra-amniotic inflammatory response against microorganisms is stronger when preterm PROM occurs early in pregnancy; and (6) the frequency of acute placental inflammation (histologic chorioamnionitis and/or funisitis) was significantly higher in patients with microbial-associated intra-amniotic inflammation than in those without intra-amniotic inflammation [93.3% (14/15) versus 38% (6/16); p = 0.001].

CONCLUSIONS

(1) The frequency of microorganisms in preterm PROM is 40% using both cultivation techniques and PCR/ESI-MS; (2) PCR/ESI-MS identified microorganisms in the AF of 50% more women with preterm PROM than AF culture; and (3) sterile intra-amniotic inflammation was present in 29% of these patients, and it was as or more common than microbial-associated intra-amniotic inflammation among those presenting after, but not before, 24 weeks of gestation.

Molecular epidemiology of avian influenza virus and incidence of H5 and H9 virus subtypes among poultry in Egypt in 2009-2011

Egypt has experienced outbreaks of avian influenza (AI) since 2006. A total of 3583 cloacal swabs were collected from chickens, ducks, geese and turkeys from commercial farms, backyards and local bird markets in Qena and Luxor governorates in South Egypt during 2009-2011. These samples were examined for the presence of AI virus (AIV) and positive samples were further subtyped for the H5 and H9 by real time RT-PCR. In this way, 202 (5.64%) samples were found to be AIV-positive of which 186 (92.08%) and 7 (3.46%) belonged to H5 and H9 subtypes, respectively. Higher infection rates were observed in backyard birds and birds from local bird markets in comparison to birds from commercial farms. In conclusion, the predominance of H5 infection indicates a need for continuous monitoring of AIV among avian species and the awareness against public health risk.

Clinical chorioamnionitis at term I: microbiology of the amniotic cavity using cultivation and molecular techniques

INTRODUCTION

The objectives of this study were: 1) to determine the amniotic fluid (AF) microbiology of patients with the diagnosis of clinical chorioamnionitis at term using both cultivation and molecular techniques; and 2) to examine the relationship between intra-amniotic inflammation with and without microorganisms and placental lesions consistent with acute AF infection.

METHODS

The AF samples obtained by transabdominal amniocentesis from 46 women with clinical signs of chorioamnionitis at term were analyzed using cultivation techniques (for aerobic and anerobic bacteria as well as genital mycoplasmas) and broad-range polymerase chain reaction (PCR) coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). The frequency of microbial invasion of the amniotic cavity (MIAC), intra-amniotic inflammation [defined as an AF interleukin 6 (IL-6) concentration ≥2.6 ng/mL], and placental lesions consistent with acute AF infection (acute histologic chorioamnionitis and/or acute funisitis) were examined according to the results of AF cultivation and PCR/ESI-MS as well as AF IL-6 concentrations.

RESULTS

1) Culture identified bacteria in AF from 46% (21/46) of the participants, whereas PCR/ESI-MS was positive for microorganisms in 59% (27/46) – combining these two tests, microorganisms were detected in 61% (28/46) of patients with clinical chorioamnionitis at term. Eight patients had discordant test results; one had a positive culture and negative PCR/ESI-MS result, whereas seven patients had positive PCR/ESI-MS results and negative cultures. 2) Ureaplasma urealyticum (n=8) and Gardnerella vaginalis (n=10) were the microorganisms most frequently identified by cultivation and PCR/ESI-MS, respectively. 3) When combining the results of AF culture, PCR/ESI-MS and AF IL-6 concentrations, 15% (7/46) of patients did not have intra-amniotic inflammation or infection, 6.5% (3/46) had only MIAC, 54% (25/46) had microbial-associated intra-amniotic inflammation, and 24% (11/46) had intra-amniotic inflammation without detectable microorganisms. 4) Placental lesions consistent with acute AF infection were significantly more frequent in patients with microbial-associated intra-amniotic inflammation than in those without intra-amniotic inflammation [70.8% (17/24) vs. 28.6% (2/7); P=0.04].

CONCLUSION

Microorganisms in the AF were identified in 61% of patients with clinical chorioamnionitis at term; 54% had microbial-associated intra-amniotic inflammation, whereas 24% had intra-amniotic inflammation without detectable microorganisms.

The frequency of acute atherosis in normal pregnancy and preterm labor, preeclampsia, small-for-gestational age, fetal death and midtrimester spontaneous abortion

OBJECTIVE

Acute atherosis is characterized by subendothelial lipid-filled foam cells, fibrinoid necrosis and perivascular lymphocytic infiltration. This lesion is generally confined to non-transformed spiral arteries and is frequently observed in patients with preeclampsia. However, the frequency of acute atherosis in the great obstetrical syndromes is unknown. The purpose of this study was to determine the frequency and topographic distribution of acute atherosis in placentas and placental bed biopsy samples obtained from women with normal pregnancy and those affected by the "great obstetrical syndromes". We also examined the relationship between acute atherosis and pregnancy outcome in patients with preeclampsia.

MATERIAL AND METHODS

A retrospective cohort study of pregnant women who delivered between July 1998 and July 2014 at Hutzel Women's Hospital/Detroit Medical Center was conducted to examine 16, 345 placentas. Patients were classified into the following groups: (1) uncomplicated pregnancy; (2) spontaneous preterm labor (sPTL) and preterm prelabor rupture of membranes (PPROM); (3) preeclampsia; (4) gestational hypertension; (5) small-for-gestational age (SGA); (6) chronic hypertension; (5) fetal death; (6) spontaneous abortion and (7) others. A subset of patients had placental bed biopsy. The incidence of acute atherosis was compared among the different groups.

RESULTS

(1) The prevalence of acute atherosis in uncomplicated pregnancies was 0.4% (29/6961) based upon examination of nearly 7000 placentas; (2) the frequency of acute atherosis was 10.2% (181/1779) in preeclampsia, 9% (26/292) in fetal death, 2.5% (3/120) in midtrimester spontaneous abortion, 1.7% (22/1,298) in SGA neonates and 1.2% (23/1,841) in sPTL and PPROM; (3) among patients with preeclampsia, those with acute atherosis than in those without the lesion had significantly more severe disease, earlier onset, and a greater frequency of SGA neonates (p < 0.05 all) and (4) the lesion was more frequently observed in the decidua (parietalis or basalis) than in the decidual segment of the spiral arteries in patients with placental bed biopsies.

CONCLUSIONS

Acute atherosis is rare in normal pregnancy, and occurs more frequently in patients with pregnancy complications, including preeclampsia, sPTL, preterm PROM, midtrimester spontaneous abortion, fetal death and SGA.

Placental lesions associated with acute atherosis

OBJECTIVE

Acute atherosis is a lesion of the spiral arteries characterized by fibrinoid necrosis of the vessel wall, an accumulation of fat-containing macrophages, and a mononuclear perivascular infiltrate, which can be found in patients with preeclampsia, fetal death, small-for-gestational age, spontaneous preterm labor/premature prelabor rupture of membrane, and spontaneous mid-trimester abortion. This lesion is thought to decrease blood flow to the intervillous space which may lead to other vascular lesions of the placenta. The objective of this study was to test whether there is an association between acute atherosis and placental lesions that are consistent with maternal vascular underperfusion (MVU), amniotic fluid infection (AFI), fetal vascular thrombo-occlusive disease (FVTOD) or chronic inflammation.

MATERIAL AND METHODS

A retrospective cohort study of pregnant women who delivered between July 1998 and July 2014 at Hutzel Women's Hospital/Detroit Medical Center was conducted examine 16 457 placentas. The frequency of placenta lesions (diagnosed using the criteria of the Perinatal Section of the Society for Pediatric Pathology) was compared between pregnancies with and without acute atherosis.

RESULTS

Among 16 457 women who were enrolled, 10.2% (1671/16 457) were excluded, leaving 14 786 women who contributed data for analysis. Among them, the prevalence of acute atherosis was 2.2% (326/14 786). Women with acute atherosis were more than six times as likely as those without to have placental lesions consistent with maternal underperfusion (adjusted odds ratio - aOR: 6.7; 95% CI 5.2-8.6). To a lesser degree, acute atherosis was also associated with greater risks of having either lesions consistent with FVTOD (aOR 1.7; 95% CI 1.2-2.3) or chronic chorioamnionitis (aOR 1.9; 95% CI 1.3-3), but not with other chronic inflammatory lesions, after adjusting for gestational age at delivery. In contrast, women with acute atherosis were 60% less likely to have lesions consistent with AFI, adjusting for gestational age at delivery (aOR 0.4; 95% CI 0.3-0.5).

CONCLUSIONS

Acute atherosis is associated with increased risks of having placental lesions consistent with MVU, and to a lesser extent, chronic chorioamnionitis and those consistent with FVTOD.

Maternal plasma fetuin-A concentration is lower in patients who subsequently developed preterm preeclampsia than in uncomplicated pregnancy: a longitudinal study

Objective: Fetuin-A is a negative acute phase protein reactant that acts as a mediator for lipotoxicity, leading to insulin resistance. Intravascular inflammation and insulin resistance have been implicated in the mechanisms of disease responsible for preeclampsia (PE). Maternal plasma concentrations of fetuin-A at the time of diagnosis of preterm PE are lower than in control patients with a normal pregnancy outcome. However, it is unknown if the changes in maternal plasma fetuin-A concentrations precede the clinical diagnosis of the disease. We conducted a longitudinal study to determine whether patients who subsequently developed PE had a different profile of maternal plasma concentrations of fetuin-A as a function of gestational age (GA) than those with uncomplicated pregnancies. Methods: A longitudinal case-control study was performed and included 200 singleton pregnancies in the following groups: (1) patients with uncomplicated pregnancies who delivered appropriate for gestational age (AGA) neonates (n = 160); and (2) patients who subsequently developed PE (n = 40). Longitudinal samples were collected at each prenatal visit and scheduled at 4-week intervals from the first or early second trimester until delivery. Plasma fetuin-A concentrations were determined by ELISA. Analysis was performed using mixed-effects models. Results: The profiles of maternal plasma concentrations of fetuin-A differ between PE and uncomplicated pregnancies. Forward analysis indicated that the rate of increase of plasma fetuin-A concentration in patients who subsequently developed PE was lower at the beginning of pregnancy (p = 0.001), yet increased faster mid-pregnancy (p = 0.0017) and reached the same concentration level as controls by 26 weeks. The rate of decrease was higher towards the end of pregnancy in patients with PE than in uncomplicated pregnancies (p = 0.002). The mean maternal plasma fetuin-A concentration was significantly lower in patients with preterm PE at the time of clinical diagnosis than in women with uncomplicated pregnancies (p < 0.05). In contrast, there were no significant differences in maternal plasma fetuin-A concentration in patients who developed PE at term. Conclusions: (1) The profile of maternal plasma concentrations of fetuin-A over time (GA) in patients who develop PE is different from that of normal pregnant women; (2) the rate of change of maternal plasma concentrations of fetuin-A is positive (increases over time) in the midtrimester of normal pregnancy, and negative (decreases over time) in patients who subsequently develop PE; (3) at the time of diagnosis, the maternal plasma fetuin-A concentration is lower in patients with preterm PE than in those with a normal pregnancy outcome; however, such differences were not demonstrable in patients with term PE.

Sterile intra-amniotic inflammation in asymptomatic patients with a sonographic short cervix: prevalence and clinical significance

OBJECTIVE

To determine the frequency and clinical significance of sterile and microbial-associated intra-amniotic inflammation in asymptomatic patients with a sonographic short cervix.

METHODS

Amniotic fluid (AF) samples obtained by transabdominal amniocentesis from 231 asymptomatic women with a sonographic short cervix [cervical length (CL) ≤25 mm] were analyzed using cultivation techniques (for aerobic and anaerobic as well as genital mycoplasmas) and broad-range polymerase chain reaction (PCR) coupled with electrospray ionization mass spectrometry (PCR/ESI-MS). The frequency and magnitude of intra-amniotic inflammation [defined as an AF interleukin (IL)-6 concentration ≥2.6 ng/mL], acute histologic placental inflammation, spontaneous preterm delivery (sPTD), and the amniocentesis-to-delivery interval were examined according to the results of AF cultures, PCR/ESI-MS and AF IL-6 concentrations.

RESULTS

Ten percent (24/231) of patients with a sonographic short cervix had sterile intra-amniotic inflammation (an elevated AF IL-6 concentration without evidence of microorganisms using cultivation and molecular methods). Sterile intra-amniotic inflammation was significantly more frequent than microbial-associated intra-amniotic inflammation [10.4% (24/231) versus 2.2% (5/231); p < 0.001]. Patients with sterile intra-amniotic inflammation had a significantly higher rate of sPTD <34 weeks of gestation [70.8% (17/24) versus 31.6% (55/174); p < 0.001] and a significantly shorter amniocentesis-to-delivery interval than patients without intra-amniotic inflammation [median 35, (IQR: 10-70) versus median 71, (IQR: 47-98) days, (p < 0.0001)].

CONCLUSION

Sterile intra-amniotic inflammation is more common than microbial-associated intra-amniotic inflammation in asymptomatic women with a sonographic short cervix, and is associated with increased risk of sPTD (<34 weeks). Further investigation is required to determine the causes of sterile intra-amniotic inflammation and the mechanisms whereby this condition is associated with a short cervix and sPTD.

Prevalence and clinical significance of sterile intra-amniotic inflammation in patients with preterm labor and intact membranes

PROBLEM

Inflammation and infection play a major role in preterm birth. The purpose of this study was to (i) determine the prevalence and clinical significance of sterile intra-amniotic inflammation and (ii) examine the relationship between amniotic fluid (AF) concentrations of high mobility group box-1 (HMGB1) and the interval from amniocentesis to delivery in patients with sterile intra-amniotic inflammation.

METHOD OF STUDY

AF samples obtained from 135 women with preterm labor and intact membranes were analyzed using cultivation techniques as well as broad-range PCR and mass spectrometry (PCR/ESI-MS). Sterile intra-amniotic inflammation was defined when patients with negative AF cultures and without evidence of microbial footprints had intra-amniotic inflammation (AF interleukin-6 ≥ 2.6 ng/mL).

RESULTS

(i) The frequency of sterile intra-amniotic inflammation was significantly greater than that of microbial-associated intra-amniotic inflammation [26% (35/135) versus 11% (15/135); (P = 0.005)], (ii) patients with sterile intra-amniotic inflammation delivered at comparable gestational ages had similar rates of acute placental inflammation and adverse neonatal outcomes as patients with microbial-associated intra-amniotic inflammation, and (iii) patients with sterile intra-amniotic inflammation and high AF concentrations of HMGB1 (≥8.55 ng/mL) delivered earlier than those with low AF concentrations of HMGB1 (P = 0.02).

CONCLUSION

(i) Sterile intra-amniotic inflammation is more frequent than microbial-associated intra-amniotic inflammation, and (ii) we propose that danger signals participate in sterile intra-amniotic inflammation in the setting of preterm labor.

A novel molecular microbiologic technique for the rapid diagnosis of microbial invasion of the amniotic cavity and intra-amniotic infection in preterm labor with intact membranes

PROBLEM

The diagnosis of microbial invasion of the amniotic cavity (MIAC) has been traditionally performed using traditional cultivation techniques, which require growth of microorganisms in the laboratory. Shortcomings of culture methods include the time required (days) for identification of microorganisms, and that many microbes involved in the genesis of human diseases are difficult to culture. A novel technique combines broad-range real-time polymerase chain reaction with electrospray ionization time-of-flight mass spectrometry (PCR/ESI-MS) to identify and quantify genomic material from bacteria and viruses.

METHOD OF STUDY

AF samples obtained by transabdominal amniocentesis from 142 women with preterm labor and intact membranes (PTL) were analyzed using cultivation techniques (aerobic, anaerobic, and genital mycoplasmas) as well as PCR/ESI-MS. The prevalence and relative magnitude of intra-amniotic inflammation [AF interleukin 6 (IL-6) concentration ≥ 2.6 ng/mL], acute histologic chorioamnionitis, spontaneous preterm delivery, and perinatal mortality were examined.

RESULTS

(i) The prevalence of MIAC in patients with PTL was 7% using standard cultivation techniques and 12% using PCR/ESI-MS; (ii) seven of ten patients with positive AF culture also had positive PCR/ESI-MS [≥17 genome equivalents per PCR reaction well (GE/well)]; (iii) patients with positive PCR/ESI-MS (≥17 GE/well) and negative AF cultures had significantly higher rates of intra-amniotic inflammation and acute histologic chorioamnionitis, a shorter interval to delivery [median (interquartile range-IQR)], and offspring at higher risk of perinatal mortality, than women with both tests negative [90% (9/10) versus 32% (39/122) OR: 5.6; 95% CI: 1.4-22; (P < 0.001); 70% (7/10) versus 35% (39/112); (P = 0.04); 1 (IQR: <1-2) days versus 25 (IQR: 5-51) days; (P = 0.002), respectively]; (iv) there were no significant differences in these outcomes between patients with positive PCR/ESI-MS (≥17 GE/well) who had negative AF cultures and those with positive AF cultures; and (v) PCR/ESI-MS detected genomic material from viruses in two patients (1.4%).

CONCLUSION

(i) Rapid diagnosis of intra-amniotic infection is possible using PCR/ESI-MS; (ii) the combined use of biomarkers of inflammation and PCR/ESI-MS allows for the identification of specific bacteria and viruses in women with preterm labor and intra-amniotic infection; and (iii) this approach may allow for administration of timely and specific interventions to reduce morbidity attributed to infection-induced preterm birth.

Effects of local low-dose rocuronium on the quality of peribulbar anesthesia for cataract surgery

OBJECTIVES

Peribulbar anesthesia is associated with delayed and/or incomplete orbital akinesia compared with retrobulbar anesthesia. This study examined the effects of adding rocuronium 5 mg to two different concentrations of lidocaine-bupivacaine mixture on onset time of orbital and eyelid akinesia in patients undergoing cataract surgery.

METHODS

In a double-blind study, 90 patients were equally randomized to receive a mixture of 0.5 ml normal saline, 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group I), a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 2%, and 4 ml bupivacaine 0.5% (group II), or a mixture of rocuronium 0.5 ml (5 mg), 4 ml lidocaine 1%, and 4 ml bupivacaine 0.25% (group III). Orbital akinesia was assessed on a 0-8 score (0 = no movement, 8 = normal) at 2 min intervals for 10 min. Time to adequate anesthesia was also recorded. Results are presented as mean±SD.

RESULTS

Ocular movement score decreased during the assessment period in all groups. However, at 2 min after block administration, the score decreased to 4±2 (95% CI 3,5) in groups II and III compared with 5±2 (95% CI 4,6) in group I (P<0.01). Time to adequate condition to begin surgery was 9.8±2.9 vs. 6.9±4.1 vs. 7.9±3.9 min for groups I, II, and III, respectively (P=0.01).

CONCLUSION

The addition of rocuronium 5 mg to a mixture of lidocaine 2% and bupivacaine 0.5% shortened the onset time of peribulbar anesthesia in patients undergoing cataract surgery without causing adverse effects.

Pasteurella multocida in backyard chickens in Upper Egypt: incidence with polymerase chain reaction analysis for capsule type, virulence in chicken embryos and antimicrobial resistance

The prevalence of Pasteurella multocida strains among 275 backyard chickens from different regions of Upper Egypt was studied. A total of 21 isolates of P. multocida were recovered in 21 out of 275 chickens tested (7.6%) and were confirmed using phenotypic characterisation. Somatic serotyping of the 21 isolates resulted in 12 isolates being classed as serotype A:1 (57.14%), 4 as serotype A:3 (19.05%) and 5 could not be typed (23.8%). Capsular typing, using multiplex polymerase chain reaction (PCR), demonstrated that 18 strains were capsular type A (85.7%), and 3 were type D (14.3%). The present findings suggest that a multiplex capsular PCR could be valuable for the rapid identification of P. multocida in cases of fowl cholera infection. A total of 5 isolates of P. multocida were selected to study their pathogenicity in embryonated chicken eggs instead of conducting a study in mature chickens. The results showed a variation in pathogenicity between the strains tested, namely: serotype A:1 strains caused 80% mortality, in contrast to 20% mortality by type D strains. Pathological findings included severe congestion of the entire embryo, haemorrhaging of the skin, feather follicles and toe, and ecchymotic haemorrhages on the liver of the inoculated embryos. The observations in this study indicate that P. multocida serogroup A could be highly pathogenic for mature chickens and therefore might be a cause of considerable economic losses in commercial production. A total of 10 isolates were subjected to antimicrobial susceptibility to determine the minimal inhibitory concentration of 7 antimicrobials. All isolates were susceptible to ciprofloxacin, florfenicol, streptomycin and sulphamethoxazol with trimethoprim and with varying degrees of sensitivity to the other agents.

Decompressive craniectomy for acute disseminated encephalomyelitis

BACKGROUND

Acute disseminated encephalomyelitis (ADEM) is a rare, acute demyelinating condition. Although it usually presents in an acute or subacute manner over days, its clinical course may be rapid with symptoms and signs of severe intracerebral mass effect secondary to cerebral oedema.

METHODS

Case report and literature review.

RESULTS

We report a case of a patient presenting with a hyperacute course manifested by rapid loss of consciousness and focal neurological signs. Management with emergency hemicraniectomy and steroids resulted in rapid neurological improvement and minimal long-term deficit.

CONCLUSIONS

We believe that only surgical decompression is likely to be life saving in similar cases of hyperacute cerebral oedema due to ADEM. The wide decompression performed was concordant with that indicated for traumatic brain swelling. Such aggressive management is vindicated by the rapid recovery shown by our patient within days of surgery and the finding of minimal neurological sequelae at 3 months.