Metal- and solvent-free domino reaction of 2-isocyanophenol esters to benzoxazines: long-range 1,5-acyl migration on 1,4-diazabutatriene

The first example of intramolecular nucleophilic addition of 1,4-diazabutatriene to ester is disclosed. This approach provides a facile and versatile synthesis for functionalized 2H-1,4-benzoxazines under metal-, reagent-, and solvent-free conditions. Experimental and computational studies revealed the pivotal role of 1,5-acyl migration as the self-catalytic step in the reaction selectivity.

Redefining the concept of residual renal function with kidney sodium MRI: a pilot study

RATIONALE & OBJECTIVE

The concept of residual kidney function (RKF) is exclusively based upon urine volume and small solute clearance, making RKF challenging to assess in clinical practice. The aim of this study was to test the technical feasibility of obtaining useable 23Na-MRI kidney images in hemodialysis (HD) participants.

STUDY DESIGN

We conducted an exploratory prospective study to quantify the cortico-medullary sodium gradient in healthy and HD participants. Participants fasted for eight hours prior to their study visit. Urine samples were collected to measure urinary osmolarity, before MRI. Proton and sodium pictures were merged; ROIs were delineated for the medulla and cortex when feasible. In cases where cortex could not be identified, we considered the cortico to medulla gradient (CMG) to be no longer present, resulting in a medulla-to-cortex ratio of 1.

SETTING & PARTICIPANTS

17 healthy volunteers and 21 HD participants.

FINDINGS

Median (IQR) fasting medulla to cortex ratio was significantly higher 1.56 [1.5-1.61] in healthy volunteers compared to HD patients 1.22 [1.13-1.3], p < 0.0001. Medulla to cortex ratio and median urinary osmolarity were correlated (r = 0.87, p < 0.0001) in the whole population. We found a significant association between HD vintage and medulla to cortex ratio whereas we did not find any association with urine volume. Sodium signal intensity distribution within healthy kidney describes two different peaks- relating to well defined cortex and medulla; whereas HD participants displays only a single peak indicative of the markedly lower sodium concentration.

LIMITATIONS

This study is only an exploratory study with a modest number of patients.

CONCLUSIONS

the application of kidney sodium MRI to the study of RKF in patients receiving maintenance HD is practical and provides a previously unavailable ability to interrogate the function of remnant tubular function.

Primary repair with no flaps for lower lip defects (30-80 %) after cancer excision

Reconstruction of the lip is a necessary procedure when lip tumors are excised. Although many good techniques have been described, they often have disadvantages such as necrosis and extensive suture lines. In our approach, we aim to minimize the suture line and avoid tissue necrosis for medium-sized lip defects (30-80 %). This is a surgical technique report from a single center. After tumor resection, we made a bilateral 15 mm horizontal skin and mucosa incision from the angles of the lip to the lateral sides. The mucosa and skin were dissected from the underlying muscle, and the muscle was cut approximately 15 mm on each side. The lip defect was then closed and sutured in four layers. Finally, the released mucosa was sutured to the corner of the incised skin. We followed the patients for 36 months and found that their speech intelligibility, sensation, mobility, and aesthetic satisfaction were preserved. The scars were also less pronounced compared to flaps, and there were no signs of edema or drooling. In conclusion, our technique offers many advantages for moderate defects of lower lip tumors. By avoiding the use of flaps, we eliminate the complications associated with flap surgery while achieving aesthetically satisfactory results. However, further evaluation by other surgeons is necessary to fully examine the technique's benefits.

Reassuring Data on the Cardiovascular Risk in Adults With X-linked Hypophosphatemia Receiving Conventional Therapy

CONTEXT

X-linked hypophosphatemia (XLH) is a rare genetic disorder that results in increased plasma levels of fibroblast growth factor 23 (FGF23). Several studies have demonstrated a direct association between FGF23 and cardiovascular mortality in cohorts of patients with chronic renal failure. However, in patients with XLH, studies on the cardiovascular impact of the disease are rare, with contradictory results.

OBJECTIVE

The aim was to assess whether the disease led to an increased cardiovascular risk.

METHODS

We conducted a single-center retrospective observational study on a local cohort of adult patients with XLH. The primary endpoint was a composite endpoint of the frequency of left ventricular hypertrophy (LVH) or presence of high blood pressure. Our secondary objectives were to assess echocardiographic, pulse wave velocity, and central blood pressure data as other markers of CV health. Independently of this cohort, tissue sodium content with magnetic resonance imaging was studied in 2 patients with XLH before and after burosumab.

RESULTS

Twenty-two patients were included. Median serum phosphate was 0.57 (0.47-0.72) mmol/L and FGF23 94 pg/L (58-2226). Median blood pressure was 124 (115-130)/68 (65-80) mm Hg, with only 9% of patients being hypertensive. A majority of patients (69%) had no LVH, only 1 had a left ventricular mass >100 g/m² and 25% of patients had left ventricular remodeling. Pulse wave velocity was normal in all patients. No differences in skin and muscle sodium content were observed before and after burosumab in the 2 patients who underwent sodium magnetic resonance imaging.

CONCLUSION

We found no elevated risk of developing hypertension or LVH in patients with XLH.

Impact of socio-economic conditions and perinatal factors on risk of becoming a child looked after: a whole population cohort study using routinely collected data in Wales

OBJECTIVES

Between 1997 and 2021, the number of children looked after (CLA) in Wales, UK, increased steadily, with stark inequalities. We aimed to assess how deprivation and maternal and child perinatal characteristics influence the risk of becoming CLA in Wales.

STUDY DESIGN

We constructed a prospective longitudinal cohort of children born in Wales between April 2006 and March 2021 (n = 395,610) using linked administrative records.

METHODS

Survival models examined the risk of CLA from birth by small-area deprivation and maternal and child perinatal characteristics. Population attributable fractions quantify the potential impact of action on modifiable risk factors.

RESULTS

Children from the most deprived fifth of the population were 3.4 times more likely to enter care than those in the least deprived (demographic adjusted hazard ratios [aHRs] 3.40, 95% confidence interval [CI] 3.08, 3.74). Maternal mental health problems in pregnancy (fully aHR, 2.03, 95% CI 1.88, 2.19) and behavioural factors, such as smoking (aHR 2.46, 95% CI 2.34-2.60), alcohol problems (aHR 2.35, 95% CI 1.70-3.23) and substance use in pregnancy (aHR 5.72, 95% CI 5.03-6.51), as well as child congenital anomalies (aHR 1.46, 95% CI 1.16-1.84), low birth weight (aHR 1.28, 95% CI 1.17, 1.39) and preterm birth (aHR 1.16, 95% CI 1.06, 1.26), were associated with higher risk of CLA status. The risk of CLA in the population may be reduced by 35% (95% CI 0.33, 0.38) if children in the two most deprived fifths of the population experienced the conditions of those in the least deprived.

CONCLUSIONS

Deprivation and perinatal maternal health are important modifiable risk factors for children becoming CLA. Our analysis provides insight into the mechanisms of intergenerational transfer of disadvantage in a vulnerable section of the child population and identifies targets for public health action.

Towards optimal use of antithrombotic therapy of people with cancer at the end of life: A research protocol for the development and implementation of the SERENITY shared decision support tool

BACKGROUND

Even though antithrombotic therapy has probably little or even negative effects on the well-being of people with cancer during their last year of life, deprescribing antithrombotic therapy at the end of life is rare in practice. It is often continued until death, possibly resulting in excess bleeding, an increased disease burden and higher healthcare costs.

METHODS

The SERENITY consortium comprises researchers and clinicians from eight European countries with specialties in different clinical fields, epidemiology and psychology. SERENITY will use a comprehensive approach combining a realist review, flash mob research, epidemiological studies, and qualitative interviews. The results of these studies will be used in a Delphi process to reach a consensus on the optimal design of the shared decision support tool. Next, the shared decision support tool will be tested in a randomised controlled trial. A targeted implementation and dissemination plan will be developed to enable the use of the SERENITY tool across Europe, as well as its incorporation in clinical guidelines and policies. The entire project is funded by Horizon Europe.

RESULTS

SERENITY will develop an information-driven shared decision support tool that will facilitate treatment decisions regarding the appropriate use of antithrombotic therapy in people with cancer at the end of life.

CONCLUSIONS

We aim to develop an intervention that guides the appropriate use of antithrombotic therapy, prevents bleeding complications, and saves healthcare costs. Hopefully, usage of the tool leads to enhanced empowerment and improved quality of life and treatment satisfaction of people with advanced cancer and their care givers.

Recent Advances in Sodium Magnetic Resonance Imaging and Its Future Role in Kidney Disease

Sodium imbalance is a hallmark of chronic kidney disease (CKD). Excess tissue sodium in CKD is associated with hypertension, inflammation, and cardiorenal disease. Sodium magnetic resonance imaging (23Na MRI) has been increasingly utilized in CKD clinical trials especially in the past few years. These studies have demonstrated the association of excess sodium tissue accumulation with declining renal function across whole CKD spectrum (early- to end-stage), biomarkers of systemic inflammation, and cardiovascular dysfunction. In this article, we review recent advances of 23Na MRI in CKD and discuss its future role with a focus on the skin, the heart, and the kidney itself.

COVID-19 vaccination uptake in people with epilepsy in wales

PURPOSE

People with epilepsy (PWE) are at increased risk of severe COVID-19. Assessing COVID-19 vaccine uptake is therefore important. We compared COVID-19 vaccination uptake for PWE in Wales with a matched control cohort.

METHODS

We performed a retrospective, population, cohort study using linked, anonymised, Welsh electronic health records within the Secure Anonymised Information Linkage (SAIL) Databank (Welsh population=3.1 million).We identified PWE in Wales between 1st March 2020 and 31st December 2021 and created a control cohort using exact 5:1 matching (sex, age and socioeconomic status). We recorded 1st, 2nd and booster COVID-19 vaccinations.

RESULTS

There were 25,404 adults with epilepsy (127,020 controls). 23,454 (92.3%) had a first vaccination, 22,826 (89.9%) a second, and 17,797 (70.1%) a booster. Comparative figures for controls were: 112,334 (87.8%), 109,057 (85.2%) and 79,980 (62.4%).PWE had higher vaccination rates in all age, sex and socioeconomic subgroups apart from booster uptake in older subgroups. Vaccination rates were higher in older subgroups, women and less deprived areas for both cohorts. People with intellectual disability and epilepsy had higher vaccination rates when compared with controls with intellectual disability.

CONCLUSIONS

COVID-19 vaccination uptake for PWE in Wales was higher than that for a matched control group.

Did the UK's public health shielding policy protect the clinically extremely vulnerable during the COVID-19 pandemic in Wales? Results of EVITE Immunity, a linked data retrospective study

INTRODUCTION

The UK shielding policy intended to protect people at the highest risk of harm from COVID-19 infection. We aimed to describe intervention effects in Wales at 1 year.

METHODS

Retrospective comparison of linked demographic and clinical data for cohorts comprising people identified for shielding from 23 March to 21 May 2020; and the rest of the population. Health records were extracted with event dates between 23 March 2020 and 22 March 2021 for the comparator cohort and from the date of inclusion until 1 year later for the shielded cohort.

RESULTS

The shielded cohort included 117,415 people, with 3,086,385 in the comparator cohort. The largest clinical categories in the shielded cohort were severe respiratory condition (35.5%), immunosuppressive therapy (25.9%) and cancer (18.6%). People in the shielded cohort were more likely to be female, aged ≥50 years, living in relatively deprived areas, care home residents and frail. The proportion of people tested for COVID-19 was higher in the shielded cohort (odds ratio [OR] 1.616; 95% confidence interval [CI] 1.597-1.637), with lower positivity rate incident rate ratios 0.716 (95% CI 0.697-0.736). The known infection rate was higher in the shielded cohort (5.9% vs 5.7%). People in the shielded cohort were more likely to die (OR 3.683; 95% CI: 3.583-3.786), have a critical care admission (OR 3.339; 95% CI: 3.111-3.583), hospital emergency admission (OR 2.883; 95% CI: 2.837-2.930), emergency department attendance (OR 1.893; 95% CI: 1.867-1.919) and common mental disorder (OR 1.762; 95% CI: 1.735-1.789).

CONCLUSION

Deaths and healthcare utilisation were higher amongst shielded people than the general population, as would be expected in the sicker population. Differences in testing rates, deprivation and pre-existing health are potential confounders; however, lack of clear impact on infection rates raises questions about the success of shielding and indicates that further research is required to fully evaluate this national policy intervention.

Genome-wide transcriptional profiling provides clues to molecular mechanisms underlying cold tolerance in chickpea

Chickpea is an important food legume cultivated in several countries. A sudden drop in autumn temperature, freezing winter temperature, and late spring cold events result in significant losses in chickpea production. The current study used RNA sequencing of two cold tolerant (Saral) and sensitive (ILC533) Kabuli chickpea genotypes to identify cold tolerance-associated genes/pathways. A total of 200.85 million raw reads were acquired from the leaf samples by Illumina sequencing, and around 86% of the clean reads (199 million) were mapped to the chickpea reference genome. The results indicated that 3710 (1980 up- and 1730 down-regulated) and 3473 (1972 up- and 1501 down-regulated) genes were expressed differentially under cold stress in the tolerant and sensitive genotypes, respectively. According to the GO enrichment analysis of uniquely down-regulated genes under cold stress in ILC533, photosynthetic membrane, photosystem II, chloroplast part, and photosystem processes were enriched, revealing that the photosynthesis is severely sensitive to cold stress in this sensitive genotype. Many remarkable transcription factors (CaDREB1E, CaMYB4, CaNAC47, CaTCP4, and CaWRKY33), signaling/regulatory genes (CaCDPK4, CaPP2C6, CaMKK2, and CaHSFA3), and protective genes (CaCOR47, CaLEA3, and CaGST) were identified among the cold-responsive genes of the tolerant genotype. These findings would help improve cold tolerance across chickpea genotypes by molecular breeding or genetic engineering.

Magnetic excitations in the helical Rashba superconductor

We investigate the magnetic excitation spectrum in the helical state of a noncentrosymmetric superconductor with inversion symmetry breaking and strong Rashba spin-orbit coupling. For this purpose we derive the general expressions of the dynamical spin response functions under the presence of strong Rashba splitting of conduction bands, superconducting gap and external field which lead to stabilization of Cooper pairs with finite overall momentum in a helical state. The latter is characterized by momentum space regions of paired and unpaired states with different quasiparticle dispersions. The magnetic response is determined by i) excitations within and between both paired and unpaired regions ii) anomalous coherence factors and iii) additional spin matrix elements due to helical Rashba spin texture of bands. We show that as a consequence typical correlated real space and spin space anisotropies appear in the dynamical susceptibility which would be observable as a characteristic fingerprint for a helical superconducting state in inelastic neutron scattering investigations.

Role of multiple- and single-pregnancy complications with incident cardiovascular diseases: a nationwide data linkage study in Wales

Background

Prior evidence has suggested that pregnancy complications are associated with a higher risk of cardiovascular disease in women. However, associations between coexisting multiple pregnancy complications and incident cardiovascular disease remains unclear.

Purpose

To examine the risk of ischemic heart disease (IHD), stroke, atrial fibrillation or heart failure among women after their first pregnancy with a history of multiple pregnancy complications and women with a history of single-pregnancy complications, compared to women without pregnancy complications.

Methods

This retrospective cohort included women aged 16–45 years who had their first pregnancy between 2000 and 2018 in Wales using the Secure Anonymised Information Linkage (SAIL) Databank. Data were extracted from various sources such as Office for National Statistics (ONS) birth and death extracts, hospital admission, outpatient, emergency department and General Practice data sources, and pregnancy related data such as maternal indicators and national community child health. Cox proportional hazard regression was used to evaluate the association between multiple or specific single pregnancy complications and incidence of cardiovascular disease.

Results

A total of 298,515 women were included in the study, of which 64,794 (21.7%) women experienced a single pregnancy complication, and 10,038 (3.38%) women experienced more than one complication during their first pregnancy. During the a median of 9.7 years of follow-up, 2,484 women developed incident cardiovascular disease. IHD had the highest incidence rate among women with multiple pregnancy complications at 9.06 (7.36–11.15) per 10,000 person-years, compared to 4.24 (3.77–4.78) among women with a single pregnancy complication and 2.40 (2.20–2.61) among women without any pregnancy complications. After adjusting for potential confounding factors, compared to no previous pregnancy complications, a history of multiple pregnancy complications was associated with a higher risk of heart failure [hazard ratio (HR) 3.18 (95% confidence interval (CI) 2.34–4.32)], IHD [HR 2.88 (95% CI 2.27–3.67)], stroke [HR 2.03 (95% CI 1.55–2.65)] and atrial fibrillation [HR 1.80 (95% CI 1.20–2.72)]. There was also a consistent trend for a higher risk of all outcomes in women with a history of single-pregnancy complications compared to women without complications during the first pregnancy (Figure 1).

Conclusion

This population-scale study used anonymised individual-level linked data from multiple routinely collected data sources. In almost 300,000 women with a previous pregnancy, multiple pregnancy complications were associated with a higher risk of incident cardiovascular disease, including heart failure, ischaemic heart disease, stroke and atrial fibrillation. Women who experience multiple pregnancy complications may benefit from targeted intervention strategies to reduce their risk of incident cardiovascular disease.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Saudi Arabia governmental PhD studentship

Associations between pregnancy complications and incident cardiovascular disease: a nationwide data linkage study in Wales

Background

Previous studies have associated pregnancy complications with a higher risk of cardiovascular disease. However, previous studies have not sufficiently evaluated the impact of broad range of pregnancy complications or common cardiovascular conditions individually. Furthermore, most previous studies have relied on data from hospital admission records only, which may not have adequately accounted for conditions that may not result in an inpatient hospital admission, such as atrial fibrillation.

Purpose

To examine the risk of ischemic heart disease (IHD), stroke, atrial fibrillation or heart failure among women after their first pregnancy with a history of pregnancy complications compared to women without pregnancy complications in a large nationwide study using linked routinely collected data.

Methods

A retrospective cohort study was conducted using the Secure Anonymised Information Linkage (SAIL) Databank and included women aged 16–45 years who had their first pregnancy between 2000 and 2018 in Wales. Data were extracted from various sources such as Office for National Statistics (ONS) birth and death extracts, hospital admission, outpatient, emergency department and General Practice data sources, and pregnancy related data such as maternal indicators and national community child health. Survival analyses were conducted using Cox proportional hazard regression models adjusted for hypertension, diabetes, hyperlipidaemia, congenital and valvular heart diseases, multifetal pregnancy ethnicity, maternal age, calendar year of first birth and index of multiple deprivation.

Results

A total of 298,515 women were included in the study, of which 74,832 (25.1%) had a history of any pregnancy complication during their first pregnancy. During a median of 9.7 years follow-up time, 2,484 women developed at least one cardiovascular condition. Among women with a history of pregnancy complication in their first pregnancy, IHD had the highest incidence rate at 4.94 (95% confidence interval (CI) 4.44–5.49) per 10,000 person-years, and atrial fibrillation was the lowest at 1.92 (95% CI 1.62–2.28). The history of any pregnancy complication during the first pregnancy was associated with a higher risk of all cardiovascular conditions examined, including heart failure [hazard ratio (HR) 1.93 95% CI 1.61–2.31)], IHD [HR 1.82 (95% CI 1.58–2.10)], stroke [HR 1.39 (95% CI 1.20–1.61)] and atrial fibrillation [HR 1.33 (95% CI 1.08–1.65) (Figure 1).

Conclusion

This population-scale study used anonymised individual-level linked data from multiple routinely collected data sources. A history of pregnancy complications during first pregnancy was associated with a higher risk of incident cardiovascular conditions, including heart failure, ischaemic heart disease, stroke and atrial fibrillation. Applying primary preventive measures and risk assessments for cardiovascular disease after the first pregnancy may mitigate the higher risk among these women.

Funding Acknowledgement

Type of funding sources: Other.

Factors associated with prescription of oral anticoagulation for atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018

Background

Prescription of oral anticoagulants (OAC) is paramount for stroke prevention in people with atrial fibrillation (AF), but treatment decisions in older care home residents are complicated by frailty, multi-morbidity and heightened stroke and bleeding risk. There is a paucity of data on factors influencing the decision to prescribe OAC in this high-risk population who are under-represented in research studies.

Purpose

To explore the factors associated with OAC prescription for care home residents aged ≥65 years with AF.

Methods

Nationwide retrospective cohort study of people aged ≥65 years entering a care home in Wales between 1 January 2003 and 31 December 2018, using anonymised individual-level electronic health record and administrative data sources available within the Secure Anonymised Information Linkage Databank. Unadjusted and adjusted logistic regression models were used to explore the association between resident characteristics and OAC prescription or non-prescription.

Results

Between 2003 and 2018, 14,493 people with AF aged ≥65 years became new residents in care homes in Wales and 7,057 (48.7%) were prescribed OAC (32.7% in 2003 compared to 72.7% in 2018), Figure 1. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per one year age increase [95% confidence interval, 0.95 to 0.96] and aOR 0.91 [0.84 to 0.98], respectively). Conversely, prior venous thromboembolism (aOR 4.06 [3.17 to 5.20]), advancing frailty (mild: aOR 4.61 [3.95 to 5.38]; moderate: aOR 6.69 [5.74 to 7.80]; severe: aOR 8.42 [7.16 to 9.90]) and year of care home entry in the post-non-vitamin K antagonist oral anticoagulant (NOAC) era from 2011 onwards (aOR 1.91 [1.76 to 2.06]) were associated with higher odds of OAC prescription, Figure 2.

Conclusions

The proportion of care home residents prescribed OAC therapy has increased over time with the introduction of NOACs in 2011, but OAC prescription rates are still sub-optimal. Although there is an expected rise in OAC prescribing for increasingly frail people, further work is needed to investigate the interaction with deprivation and other socio-economic and demographic factors to assess potential inequalities in prescribing across these groups. Targeted educational tools for clinicians are needed to address barriers to OAC prescription for AF, such as older age and separate indications for antiplatelet therapy.

Funding Acknowledgement

Type of funding sources: None.

Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018

Background

Older care home residents are a high-risk group of people with atrial fibrillation (AF) who are under-represented in clinical trials. Improved understanding of AF epidemiology and management in this population is paramount for health and social care organisations to strategically plan services.

Purpose

To determine the trends in AF prevalence and compare adverse health outcomes in older care home residents aged ≥65 years with AF compared to those without AF.

Methods

Retrospective cohort study of people entering a care home between 2003–2018 using nationwide, population-scale anonymised health and administrative data, provisioned from the Secure Anonymised Information Linkage (1 January 2000–31st December 2018). Direct standardisation was used to calculate AF prevalence by year of care entry (2010–2018). Cox regression analyses were used to estimate the risk of adverse health outcomes.

Results

Between 2003 and 2018, 86,602 people aged ≥65 years became new residents in care homes in Wales. Residents with AF (n=14,493) had a significantly higher risk (adjusted hazard ratio [aHR], 95% confidence interval [CI]) of cardiovascular (aHR 1.27 [1.17 to 1.37], p&lt;0.001) and all-cause mortality (aHR 1.14 [1.11 to 1.17], p&lt;0.001), Figure 1. The risk (sub-distribution hazard ratio [sHR], 95% CI) of ischaemic stroke (adjusted sHR 1.55 [1.36 to 1.76], p&lt;0.001) and cardiovascular hospitalisation (adjusted sHR 1.28 [1.22 to 1.34], p&lt;0.001) was also higher in residents with AF, even when mortality was considered a competing event, Figure 1. There was no significant change in age- and sex-standardised prevalence of AF between 2010 and 2018, 16.79% (95% CI 15.85 to 17.94) and 17.02% (95% CI 16.05 to 17.98), respectively (absolute change 2010–2018: 0.06% [95% CI: −1.38 to 1.50], p=0.93), Figure 2.

Conclusions

This study demonstrates unique data on the epidemiology of AF and associated outcomes in older care home residents. Whilst the prevalence of AF remained stable between 2010–2018, residents with AF had significantly higher risk of adverse health events. Treatment of AF in accordance with guidelines is critical in this population to optimise management and reduce adverse health outcomes.

Funding Acknowledgement

Type of funding sources: None.

Outcomes and predictors of skin sodium concentration in dialysis patients

Background

Sodium-23 magnetic resonance imaging (23Na MRI) allows the measurement of skin sodium concentration ([Na+]). In patients requiring dialysis, no data are available relating to the clinical outcomes associated with skin sodium accumulation or the determinants of increasing deposition.

Methods

This was an exploratory, observational study of adult hemodialysis (HD) and peritoneal dialysis (PD) patients. Participants underwent skin [Na+] quantification with leg 23Na MRI at the study's beginning. Outcomes of interest were all-cause mortality and composite all-cause mortality plus major adverse cardiovascular events. Cumulative total and event-free survival were assessed using the Kaplan-Meier survival function after stratification into skin [Na+] quartiles. Cox proportional hazards regression was used to model the association between skin [Na+] and outcomes of interest. Multiple linear regression was used to model the predictors of skin [Na+].

Results

A total of 52 participants (42 HD and 10 PD) underwent the study procedures. The median follow-up was 529 days (interquartile range: 353-602). Increasing skin [Na+] quartiles were associated with significantly shorter overall and event-free survival (log-rank χ2(1) = 3.926, log-rank χ2(1) = 5.685; P for trend <0.05 in both instances). Skin [Na+] was associated with all-cause mortality {hazard ratio (HR) 4.013, [95% confidence interval (95% CI) 1.988-8.101]; P < 0.001} and composite events [HR 2.332 (95% CI 1.378-3.945); P < 0.01], independently of age, sex, serum [Na+] and albumin. In multiple regression models, dialysate [Na+], serum albumin and congestive heart failure were significantly associated with skin [Na+] in HD patients (R2 adj = 0.62).

Conclusions

Higher skin [Na+] was associated with worse clinical outcomes in dialysis patients and may represent a direct therapeutic target.

146 Epilepsy, deprivation and mortality in Wales 2005–2017

Background

Public Health England have recently reported that deaths associated with epilepsy are increasing and are associated with increased deprivation. We investigated comparable Welsh mortality trends and associations between epilepsy mortality and deprivation.

Method

We used routinely-collected health data within the Secure Anonymised Information Linkage (SAIL) Databank. We recorded deaths associated with epilepsy (DAE), epilepsy recorded on death certificates, and deaths in people with epilepsy (DPWE), people with diagnoses of epilepsy and epilepsy prescriptions before death. We compared death rates in different deprivation deciles adjusting for epilepsy prevalence.

Results

During 2005–2017 (41million patient-years) there were 2116 DAE and 7821 DPWE. DAE and DPWE increased from 4.3/100,000/yr and 17.2/100,000/yr in 2005–2007 to 5.7/100,000/yr and 20.9/100,000/yr in 2015–2017. The age-standardised mortality rates (ASMR) in 2006–2008 for DAE and DPWE were 5.3/100,000/yr and 20/100,000/yr respectively, in 2015–2017 they were 5.8/100,000/yr and 20/100,000/yr. DAE were not significantly associated with deprivation when adjusted for epilepsy prevalence.

Conclusion

When adjusting for age, deaths associated wtih epilepsy and deaths in people with epilepsy did not increase significantly in Wales between 2005–2007 and 2015–2017. The association between dep- rivation and deaths associated with epilepsy appears to be explained by higher epilepsy prevalence in areas of higher deprivation.

w.o.pickrell@swansea.ac.uk

MO645: Does Sodium Magnetic Resonance Imaging Help for Initiation of Incremental Dialysis?

BACKGROUND AND AIMS

Incremental hemodialysis (HD) (twice a week) can be proposed to some patients who had a significant residual renal function (RRF) when HD is initiated. However, renal urea clearance is a very limited tool to predict the ability of the kidney to extract significantly water and sodium. We hypothesized that corticomedullary gradient (CMG) measurement with 23NaMRI could provide a new tool to select HD patients for incremental dialysis. We have already validated the use of 23NaMRI in healthy control. However, we had to prove first the feasibility of such a measure for HD patients.

METHOD

We conducted a prospective observational study to better characterize CMG in HD patients with 23NaMRI. We performed blood (urea, creatinine, sodium), urine collection (osmolarity, creatinine, sodium) and CMG with 23NaMRI in fasting patients. All MR experiments were carried out on a GE MR750 3T (GE Healthcare, WI). A custom-built two-loop (18 cm in diameter) butterfly radiofrequency surface coil tuned for 23Na frequency (33.786 MHz) was used to acquire renal 23Na images. We compared CMG in healthy controls (n = 15) and HD patients (n = 4) with or without RRF.

RESULTS

For healthy controls, median (IQR) age was 50 (32–60) years, 46% men, estimated glomerular filtration rate (eGFR) 103 (84–108) mL/min/1.73m2 urinary osmolarity (osmU) 786 (587–938) osm/L, sodium excretion fraction (FeNa) 0.27% (0.21–0.49). For HD patients, median (IQR) age was 68 (60–73) years, 50% men, creatinine 499 (366–606) umol/L, urinary osmolarity (osmU) 279 (193–317) osm/L, sodium excretion fraction (FeNa) 1.14% (0.44–2.21). Corticomedullary gradient for controls [1.53 (1.47–1.61)], was significantly different to HD 1.28 (1.17–1.4) (P = .001) as expected. There was a significant correlation between osmolarity and CMG (r = 0.73, P &lt; .001). We showed a significant association between CMG and age (P = .03). The patient with RRF (diuresis to 1.3L/day) didn't display a different CMG compared with patients without RRF.

Figure 1 shows the difference in corticomedullary pictures (A) control and (B) HD patients.

CONCLUSION

We showed that it is possible to assess corticomedullary gradient in HD patients. More patients are needed to explore the ability of the 23NaMRI to discriminate patients who could benefit from incremental dialysis.

Healthcare contacts with self-harm during COVID-19: An e-cohort whole-population-based study using individual-level linked routine electronic health records in Wales, UK, 2016-March 2021

INTRODUCTION

Reduced rates of help seeking by those who self-harmed during the COVID-19 pandemic have been reported.

OBJECTIVES

To understand changes in healthcare service contacts for self-harm during the COVID-19 pandemic across primary, emergency and secondary care.

METHODS

This retrospective cohort study used routine electronic healthcare data for Wales, United Kingdom, from 2016 to March 14, 2021. Population-based data from primary care, emergency departments and hospital admissions were linked at individual-level. All Welsh residents aged ≥10 years over the study period were included in the study. Primary, emergency and secondary care contacts with self-harm at any time between 2016 and March 14, 2021 were identified. Outcomes were counts, incidence, prevalence and proportion of self-harm contacts relative to all contacts in each and all settings, as well as the proportion of people contacting one or more settings with self-harm. Weekly trends were modelled using generalised estimated equations, with differences between 2020 (to March 2021) and comparison years 2016-2018 (to March 2017-2019) quantified using difference in differences, from which mean rate of odds ratios (μROR) across years was reported.

RESULTS

The study included 3,552,210 individuals over the study period. Self-harm contacts reduced across services in March and December 2020 compared to previous years. Primary care contacts with self-harm reduced disproportionately compared to non-self-harm contacts (μROR = 0.7, p<0.05), while their proportion increased in emergency departments during April 2020 (μROR = 1.3, p<0.05 in 2/3 comparison years) and hospital admissions during April-May 2020 (μROR = 1.2, p<0.05 in 2/3 comparison years). Despite this, those who self-harmed in April 2020 were more likely to be seen in primary care than other settings compared to previous years (μROR = 1.2, p<0.05). A lower proportion of those with self-harm contacts in emergency departments were subsequently admitted to hospital in December 2020 compared to previous years (μROR = 0.5, p<0.05).

CONCLUSIONS

These findings suggest that those who self-harmed during the COVID-19 pandemic may have been less likely to seek help, and those who did so faced more stringent criteria for admission. Communications encouraging those who self-harm to seek help during pandemics may be beneficial. However, this needs to be supported by maintained provision of mental health services.

Functional Sodium MRI Helps to Measure Corticomedullary Sodium Content in Normal and Diseased Human Kidneys

Background To the knowledge of the authors, urinary osmolarity is the only tool currently available to assess kidney corticomedullary gradient (CMG). Comparisons between CMG and urinary osmolarity and the use of modalities such as sodium MRI to evaluate renal disease in humans are lacking. Purpose To investigate the ability of sodium MRI to measure CMG dynamics compared with urinary osmolarity after water load in healthy volunteers and CMG in participants with kidney disease. Materials and Methods A prospective study was conducted from July 2020 to January 2021 in fasting healthy volunteers undergoing water load and participants with chronic kidney disease (CKD) from cardiorenal syndrome included in a clinical trial. In both groups, CMG was estimated by measuring the medulla-to-cortex signal ratio from sodium MRI at 3.0 T. A custom-built two-loop (diameter, 18 cm) butterfly radiofrequency surface coil, tuned for sodium frequency (33.786 MHz), was used to acquire renal sodium images. Two independent observers measured all sodium MRI cortical and medullary values for each region of interest to compute the intraclass correlation coefficient. Pearson correlation was performed between urinary osmolarity and CMG. Results Five participants with CKD (mean age, 77 years ± 12 [standard deviation]; all men) and 10 healthy volunteers (mean age, 42 years ± 15; six men, four women) were evaluated. A reduction was observed between baseline and peak urinary dilution time for both mean medulla-to-cortex ratios (1.55 ± 0.11 to 1.31 ± 0.09, respectively; P < .001) and mean urinary osmolarity (756 mOsm/L ± 157 to 73 mOsm/L ± 14, respectively; P < .001) in healthy volunteers. Medulla-to-cortex and corresponding urinary osmolarity were correlated in both groups (r² = 0.22; P < .001). Kidney sodium tissue content was successfully acquired in all five participants with CKD. The intraclass correlation coefficient measurement was 0.99 (P < .001). Conclusion Functional sodium MRI accurately depicted corticomedullary gradient (CMG) dynamic changes in healthy volunteers and demonstrated feasibility of CMG measurement in participants with reduced kidney function. Clinical trial registration no. NCT04170855. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Laustsen and Bøgh in this issue.

In vitro cytotoxicity, antibacterial activity and HSA and ct-DNA interaction studies of chlorogenic acid loaded on γ-Fe2O3@SiO2 as new nanoparticles

In this study, nanoparticles with both anticancer and antibacterial features were synthesized through loading chlorogenic acid (CGA) of essential oils on magnetic nanoparticles (MNPs). Characterization of γ-Fe₂O₃@SiO₂-CGA MNPs was performed using Fourier transform infrared (FT-IR) spectroscopy and transmission electron microscopy (TEM) that show effective coating of the MNPs with SiO₂ and CGA ligand and spherical shape of the nanoparticles with a mean diameter of 16 nm, respectively. The cytotoxicity study demonstrated that γ-Fe₂O₃@SiO₂-CGA MNPs had fewer toxic effects on normal cells (Huvec) than on cancerous cells (U-87 MG, A-2780 and A-549), and could be a new potential candidate for use in biological and pharmaceutical applications. The interaction of calf thymus deoxyribonucleic acid (ct-DNA) with γ-Fe₂O₃@SiO₂-CGA MNPs indicated that the anticancer activity might be associated with the DNA binding properties of γ-Fe₂O₃@SiO₂-CGA MNPs. Moreover, the interaction of γ-Fe₂O₃@SiO₂-CGA MNPs with human serum albumin (HSA) suggests that the native conformation of HSA was preserved at the level of secondary structure, indicating that the γ-Fe₂O₃@SiO₂-CGA MNPs do not show any cytotoxicity effect when they are injected into the blood. Antibacterial tests were performed and represented γ-Fe₂O₃@SiO₂-CGA MNPs attained better antibacterial function than CGA as free.

Investigating the association between COVID-19 vaccination and care home outbreak frequency and duration

OBJECTIVES

At the end of 2020, many countries commenced a vaccination programme against SARS-CoV-2. Public health authorities aim to prevent and interrupt outbreaks of infectious disease in social care settings. We aimed to investigate the association between the introduction of the vaccination programme and the frequency and duration of COVID-19 outbreaks in Northern Ireland (NI).

STUDY DESIGN

We undertook an ecological study using routinely available national data.

METHODS

We used Poisson regression to measure the relationship between the number of RT-PCR confirmed COVID-19 outbreaks in care homes, and as a measure of community COVID-19 prevalence, the Office for National Statistics COVID-19 Infection Survey estimated the number of people testing positive for COVID-19 in NI. We estimated the change in this relationship and estimated the expected number of care home outbreaks in the absence of the vaccination programme. A Cox proportional hazards model estimated the hazard ratio of a confirmed COVID-19 care home outbreak closure.

RESULTS

Care home outbreaks reduced by two-thirds compared to expected following the introduction of the vaccination programme, from a projected 1625 COVID-19 outbreaks (95% prediction interval 1553-1694) between 7 December 2020 and 28 October 2021 to an observed 501. We estimated an adjusted hazard ratio of 2.53 of the outbreak closure assuming a 21-day lag for immunity.

CONCLUSIONS

These findings describe the association of the vaccination with a reduction in outbreak frequency and duration across NI care homes. This indicates probable reduced harm and disruption from COVID-19 in social care settings following vaccination. Future research using individual level data from care home residents will be needed to investigate the effectiveness of the vaccines and the duration of their effects.

Intravital microscopic observation of the microvasculature during hemodialysis in healthy rats

Hemodialysis (HD) provides life-saving treatment for kidney failure. Patient mortality is extremely high, with cardiovascular disease (CVD) being the leading cause of death. This results from both a high underlying burden of cardiovascular disease, as well as additional physiological stress from the HD procedure itself. Clinical observations indicate that HD is associated with microvascular dysfunction (MD), underlining the need for a fundamental pathophysiological assessment of the microcirculatory consequences of HD. We therefore successfully developed an experimental small animal model, that allows for a simultaneous real-time assessment of the microvasculature. Using in-house built ultra-low surface area dialyzers and miniaturized extracorporeal circuit, we successfully dialyzed male Wistar Kyoto rats and combined this with a simultaneous intravital microscopic observation of the EDL microvasculature. Our results show that even in healthy animals, a euvolemic HD procedure can induce a significant systemic hemodynamic disturbance and induce disruption of microvascular perfusion (as evidence by a reduction in the proportion of the observed microcirculation receiving blood flow). This study, using a new small animal hemodialysis model, has allowed direct demonstration that microvascular blood flow in tissue in skeletal muscle is acutely reduced during HD, potentially in concert with other microvascular beds. It shows that preclinical small animal models can be used to further investigate HD-induced ischemic organ injury and allow rapid throughput of putative interventions directed at reducing HD-induced multi-organ ischemic injury.

Tissue Sodium Storage in Patients With Heart Failure: A New Therapeutic Target?

BACKGROUND

Preclinical data suggest sodium deposited (without water) in tissues may lead to aberrant remodeling and systemic inflammation, independently of fluid overload in patients with heart failure (HF). Tissue salt storage can be measured noninvasively and quantitatively with ²³Na-magnetic resonance imaging. We aimed to investigate the possibility that patients with HF complicated by renal dysfunction are subject to higher tissue sodium concentration exposure than patients with chronic kidney disease alone.

METHODS

We conducted an exploratory study including 18 patients with HF, 34 hemodialysis patients (with no meaningful renal clearance of sodium), and 31 patients with chronic kidney disease, with glomerular filtration rate matched to the patients with HF. Every patient underwent ²³Na-magnetic resonance imaging of the calf, to quantify tissue sodium and allow comparison among the 3 patient groups.

RESULTS

There were no differences in age, sex, and body mass index between groups. Median (interquartile range) skin sodium content in HF (31 [23-37] mmol/L) was very high and indistinguishable from skin sodium content in hemodialysis patients (30 [22-35] mmol/L), P=0.6. Patients with HF exhibited significantly higher skin sodium content than matched estimated glomerular filtration rate chronic kidney disease patients (22 [19-26] mmol/L), P=0.005. Median muscle sodium content in patients with HF was significantly higher than in patients with chronic kidney disease, P=0.002. There was no relationship with estimated glomerular filtration rate in patients with HF. We report a significant correlation between skin sodium and urinary sodium (P=0.04) but no correlation with muscle sodium. Patients who were assessed as being volume depleted (sodium excretion fraction <1%) had lower skin sodium content than patients with sodium excretion fraction >1% (P=0.03).

CONCLUSIONS

We have demonstrated that patients with HF characteristically have very high levels of skin sodium storage, comparable to well-characterized extreme levels seen in patients with end-stage kidney disease requiring hemodialysis. ²³Na-magnetic resonance imaging may allow precision medicine in the management of this challenging group of patients with HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03004547.

Impact of a physician - critical care practitioner pre-hospital service in Wales on trauma survival: a retrospective analysis of linked registry data

The Emergency Medical Retrieval and Transfer Service for Wales launched in 2015. This service delivers senior pre-hospital doctors and advanced critical care practitioners to the scene of time-critical life- and limb-threatening incidents to provide advanced decision-making and pre-hospital clinical care. The impact of the service on 30-day mortality was evaluated retrospectively using a data linkage system. The study included patients who sustained moderate-to-severe blunt traumatic injuries (injury severity score ≥ 9) between 27 April 2015 and 30 November 2018. The association between pre-hospital management by the Emergency Medical Retrieval and Transfer Service and 30-day mortality was assessed using multivariable logistic regression. In total, data from 4035 patients were analysed, of which 412 (10%) were treated by the Emergency Medical Retrieval and Transfer Service. A greater proportion of patients treated by the Emergency Medical Retrieval and Transfer Service had an injury severity score ≥ 16 and Glasgow coma scale ≤ 12 (288 (70%) vs. 1435 (40%) and 126 (31%) vs. 325 (9%), respectively). The unadjusted 30-day mortality rate was 11.7% for patients managed by the Emergency Medical Retrieval and Transfer Service compared with 9.6% for patients managed by standard pre-hospital care services. However, after adjustment for differences in case-mix, the 30-day mortality rate for patients treated by the Emergency Medical Retrieval and Transfer Service was 37% lower (adjusted odds ratio 0.63 (95%CI 0.41-0.97); p = 0.037). The introduction of an emergency medical retrieval service was associated with a reduction in 30-day mortality for patients with blunt traumatic injury.

Mortality after surgery with SARS-CoV-2 infection in England: a population-wide epidemiological study

BACKGROUND

The COVID-19 pandemic has heavily impacted elective and emergency surgery around the world. We aimed to confirm the incidence of perioperative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and associated mortality after surgery.

METHODS

Analysis of routine electronic health record data from NHS hospitals in England. We extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between January 1, 2020 and February 28, 2021. The exposure was SARS-CoV-2 infection defined by International Classification of Diseases (ICD)-10 codes. The primary outcome measure was 90 day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson Comorbidity Index, Index of Multiple Deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

We identified 2 666 978 patients undergoing surgery of whom 28 777 (1.1%) had SARS-CoV-2 infection. In total, 26 364 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 6153/28 777 [21.4%] vs no SARS-CoV-2: 20 211/2 638 201 [0.8%]; OR=5.7 [95% CI, 5.5-5.9]; P<0.001). Amongst patients undergoing elective surgery, 2412/1 857 586 (0.1%) had SARS-CoV-2, of whom 172/2412 (7.1%) died, compared with 1414/1 857 586 (0.1%) patients without SARS-CoV-2 (OR=25.8 [95% CI, 21.7-30.9]; P<0.001). Amongst patients undergoing emergency surgery, 22 918/582 292 (3.9%) patients had SARS-CoV-2, of whom 5752/22 918 (25.1%) died, compared with 18 060/559 374 (3.4%) patients without SARS-CoV-2 (OR=5.5 [95% CI, 5.3-5.7]; P<0.001).

CONCLUSIONS

The low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed.

FC 054FUNCTIONAL SODIUM MAGNETIC RESONANCE IMAGING OF THE HUMAN KIDNEY

Background and Aims

Maintenance of a cortico-medullary concentration gradient (CMG) required for urine concentration, is one of most important tubular function. However, we are lacking of functional tubular parameters to explore this function. The only tool available to assess it currently, is urinary osmolarity that is an indirect and nonspecific maker of CMG.

In this study, we explore the ability of 23NaMRI in measuring 1) the dynamics of CMG for the first time compared to urinary osmolarity after a water load 2) the CMG in kidney disease.

Method

We conducted an exploratory pilot study for 10 healthy controls with water load then 5 cardiorenal patients with kidney disease. 1) Healthy controls were asked to be fasting since midnight. Urines sample were collected to measure fasting osmolarity and a first MRIscan were performed to acquire baseline anatomical and sodium images. Once the baseline was completed, healthy participants were asked to ingest water (15 mL/kg) within 15 minutes. Four subsequent sodium pictures were acquired an hour after water ingestion. Urine samples were obtained after each sodium acquisition every 15 min during one hours. 2) Cardiorenal patients underwent an MRI scan, provided a spot urine sample and have blood work collected.

All MR experiments were carried out on a GE MR750 3T (GE Healthcare, WI). A custom-built two-loop (18cm in diameter) butterfly radiofrequency surface coil tuned for 23Na frequency (33.786 MHz) was used to acquire renal 23Na images.

Results

Mean age of the 10 healthy controls was 41.8 ± 15.3 years, mean body mass index (BMI) was 24.3 ± 3.8 kg/m2. Mean water intake was 1092 ± 233 mL, total water excreted was 1250 ± 301 mL . Mean age of the 5 cardiorenal patients was 76.6 ± 12.2 years, mean BMI was 28.1 ± 6.9 kg/m2. eGFR was 54 ± 37 mL/min/1.73m2. Urinary osmolarity was 498 ± 145 mosm/L and medulla/cortex ratio was 1.35 ± 0.11.

Sodium imaging was successfully acquired in all volunteers. In the morning fasting, medulla/cortex ratio was 1.55 ± 0.11 regarding to a urinary osmolarity to 814 ± 121 mosm/L. Mean ± SD fasting urinary osmolarity dropped significantly to 73 ± 14 mosm/L for maximal dilution, p=0.001. Mean medulla/cortex ratio dropped significantly to 1.31 ± 0.09 mosm/L for maximal dilution, p=0.002. Figure 1 displays changes of 23NaMRI pictures before (A) then 1h (B), 1H15 (C), 1h30 (D) and 1h45 (E) after a water load. Urinary osmolarity and medulla/cortex ratio are significantly correlated, r=0.54, p=0.0001.

We measured corticomedullary gradient in cardiorenal patient with different level of eGFR to show the ability and feasibility to measure this gradient in pathological settings. We were able to measure medulla/cortex ratio in patients with CKD with a mean SNR of 20.45 ± 9.45.

Conclusion

We explored CMG dynamically every 15 min and we were able to discriminate significant changes after a water load. We were also able to provide efficient 23NaMRI pictures in cardiorenal patients with kidney disease.

CMG exploration would provide a relevant assessment of tubular dysfunction independently of glomerular alteration and thus could be of prognostic value.

Long-term trends in critical care admissions in Wales

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

Spatially dispersing Yu-Shiba-Rusinov states in the unconventional superconductor FeTe0.55Se0.45

By using scanning tunneling microscopy (STM) we find and characterize dispersive, energy-symmetric in-gap states in the iron-based superconductor FeTe_0.55Se_0.45, a material that exhibits signatures of topological superconductivity, and Majorana bound states at vortex cores or at impurity locations. We use a superconducting STM tip for enhanced energy resolution, which enables us to show that impurity states can be tuned through the Fermi level with varying tip-sample distance. We find that the impurity state is of the Yu-Shiba-Rusinov (YSR) type, and argue that the energy shift is caused by the low superfluid density in FeTe_0.55Se_0.45, which allows the electric field of the tip to slightly penetrate the sample. We model the newly introduced tip-gating scenario within the single-impurity Anderson model and find good agreement to the experimental data.

First-dose ChAdOx1 and BNT162b2 COVID-19 vaccines and thrombocytopenic, thromboembolic and hemorrhagic events in Scotland

Reports of ChAdOx1 vaccine-associated thrombocytopenia and vascular adverse events have led to some countries restricting its use. Using a national prospective cohort, we estimated associations between exposure to first-dose ChAdOx1 or BNT162b2 vaccination and hematological and vascular adverse events using a nested incident-matched case-control study and a confirmatory self-controlled case series (SCCS) analysis. An association was found between ChAdOx1 vaccination and idiopathic thrombocytopenic purpura (ITP) (0-27 d after vaccination; adjusted rate ratio (aRR) = 5.77, 95% confidence interval (CI), 2.41-13.83), with an estimated incidence of 1.13 (0.62-1.63) cases per 100,000 doses. An SCCS analysis confirmed that this was unlikely due to bias (RR = 1.98 (1.29-3.02)). There was also an increased risk for arterial thromboembolic events (aRR = 1.22, 1.12-1.34) 0-27 d after vaccination, with an SCCS RR of 0.97 (0.93-1.02). For hemorrhagic events 0-27 d after vaccination, the aRR was 1.48 (1.12-1.96), with an SCCS RR of 0.95 (0.82-1.11). A first dose of ChAdOx1 was found to be associated with small increased risks of ITP, with suggestive evidence of an increased risk of arterial thromboembolic and hemorrhagic events. The attenuation of effect found in the SCCS analysis means that there is the potential for overestimation of the reported results, which might indicate the presence of some residual confounding or confounding by indication. Public health authorities should inform their jurisdictions of these relatively small increased risks associated with ChAdOx1. No positive associations were seen between BNT162b2 and thrombocytopenic, thromboembolic and hemorrhagic events.

Longitudinal study of adherence to anticoagulation guidelines in patients with atrial fibrillation

Introduction

Anticoagulation (AC) reduces the risk of stroke and systemic embolism (SSE) in patients with Atrial Fibrillation (AF). However, the association between changes in AF prevalence, risk factors for SSE, uptake of AC and incidence of SSE has not been documented specifically in these patients within a national population.

Purpose

Identifying antithrombotic prescribing and evaluating associations between changes in AF prevalence, SSE risk factors (CHA2DS2-VASC score) and uptake of AC. Evaluating relationships between changes in proportion of AF patients treated with AC and SSE rate at a population level. Developing a modelling tool which estimates rates of SSE (past and future) based on these factors, which can be used to drive improvements in health care.

Method

AF patients were identified in the population of Wales (SAIL databank) between 2012–2018. Temporal trends of AF, CHA2DS2-VASC scores, anti-thrombotic prescriptions and SSE events were evaluated. Multi-state Markov models were used to estimate SSE rates adjusted for AC and CHA2DS2-VASC scores. Simulation methods modelled SSE outcomes for the subsequent 7-years based on differing proportional population AC coverage.

Results

AF prevalence increased from 51,492 to 64,852 from 2012–18, with mean CHA2DS2-VASC score increasing from 3.0 to 3.9. AC prescription coverage increased (24,892 [48.3%] to 44,195 [68.1%]), whilst antiplatelet therapy alone or no antithrombotic therapy decreased (14,532 [28.0%] to 5,385 [8.3%] and 26,602 [52.0%] to 21,164 [33.0%] respectively). Hospitalisation rate for SSE in AF population decreased by over 20%, from 1,039 per 100,000 patients/quarter in 2012 to 809 per 100,000 patients/quarter in 2018.

Markov modelling demonstrated a 39% lower SSE rate with AC compared to no AC over time, after adjustment for individual CHA2DS2-VASC (HR=0.61, 95% CI [0.58, 0.63]). Using the estimated progression rates, simulation models shown that an expected 3,574 SSE events per 100,000 per year could have been reduced to 2,956 (17% reduction rate) if AC adherence had been at the now recommended 90% rate from 2012. This model also predicts that improving AC coverage to 90% of patients over the next 7-years would reduce SSE rates by 12% per year (assuming no further increase in mean CHA2DS2-VASC score).

Conclusion

Despite the increase in both prevalence of AF and CHA2DS2-VASC between 2012–18, we observed a progressive decrease in SSE events along with increasing AC prescribing. Our study suggests not only that improved AC coverage is associated with better clinical outcomes, but also that the rate of therapeutic implementation is likely a crucial factor. Reducing transition time between evidence-based guideline publication and widespread clinical uptake of the recommendations appears to be an important opportunity to improve clinical outcomes at a population level and should inform healthcare policy development and implementation.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Funded by research grant

Pruritus: Is there a grain of salty truth?

Hemodialysis patients characteristically suffer from a range of unpleasant symptoms. Uremic pruritus effects close to half of the chronic kidney disease population, reducing quality of life and associated with increased mortality. Its pathophysiology though is poorly understood; currently deployed therapeutic approaches are ineffective. Excessive levels of skin and soft tissue sodium accumulate in dialysis patients, producing a range of biological consequences, including inflammation. We report an index case of a hemodialysis patient with debilitating pruritus and extreme levels of tissue sodium, measured with Sodium-23 magnetic resonance imaging. Both the tissue sodium loading and pruritus responded fully to initiation of expanded hemodialysis therapy with a recently introduced medium cutoff dialysis membrane-based dialyzer.

Identifying children with Cystic Fibrosis in population-scale routinely collected data in Wales: A Retrospective Review

INTRODUCTION

The challenges in identifying a cohort of people with a rare condition can be addressed by routinely collected, population-scale electronic health record (EHR) data, which provide large volumes of data at a national level. This paper describes the challenges of accurately identifying a cohort of children with Cystic Fibrosis (CF) using EHR and their validation against the UK CF Registry.

OBJECTIVES

To establish a proof of principle and provide insight into the merits of linked data in CF research; to identify the benefits of access to multiple data sources, in particular the UK CF Registry data, and to demonstrate the opportunity it represents as a resource for future CF research.

METHODS

Three EHR data sources were used to identify children with CF born in Wales between 1st January 1998 and 31st August 2015 within the Secure Anonymised Information Linkage (SAIL) Databank. The UK CF Registry was later acquired by SAIL and linked to the EHR cohort to validate the cases and explore the reasons for misclassifications.

RESULTS

We identified 352 children with CF in the three EHR data sources. This was greater than expected based on historical incidence rates in Wales. Subsequent validation using the UK CF Registry found that 257 (73%) of these were true cases. Approximately 98.7% (156/158) of individuals identified as CF cases in all three EHR data sources were confirmed as true cases; but this was only the case for 19.8% (20/101) of all those identified in just a single data source.

CONCLUSION

Identifying health conditions in EHR data can be challenging, so data quality assurance and validation is important or the merit of the research is undermined. This retrospective review identifies some of the challenges in identifying CF cases and demonstrates the benefits of linking cases across multiple data sources to improve quality.

How effective are population health surveys for estimating prevalence of chronic conditions compared to anonymised clinical data?

INTRODUCTION

Population health surveys are used to record person-reported outcome measures for chronic health conditions and provide a useful source of data when evaluating potential disease burdens. The reliability of survey-based prevalence estimates for chronic diseases is unclear nonetheless. This study applied methodological triangulation via a data linkage method to validate prevalence of selected chronic conditions (angina, myocardial infarction, heart failure, and asthma).

METHODS

Linked healthcare records were used for a combined cohort of 11,323 adults from the 2013 and 2014 sweeps of the Welsh Health Survey (WHS). The approach utilised consented survey data linked to primary and secondary care electronic health record (EHR) data back to 2002 within the Secure Anonymised Information Linkage (SAIL) Databank.

RESULTS

This descriptive study demonstrates validation of survey and clinical data using data linkage for selected chronic cardiovascular conditions and asthma with varied success. The results indicate that identifying cases for separate cardiovascular conditions was limited without specific medication codes for each condition, but more straightforward for asthma, where there was an extensive list of medications available. For asthma there was better agreement between prevalence estimates based on survey and clinical data as a result.

CONCLUSION

Whilst the results provide external validity for the WHS as an instrument for estimating the burden of chronic disease, they also indicate that a data linkage appproach can be used to produce comparable prevalence estimates using clinical data if a defined condition-specific set of clinical codes are available.

Data Resource: population level family justice administrative data with opportunities for data linkage

INTRODUCTION

Although there has been considerable progress in the use of administrative data for applied health research, the family justice field lags behind. Better use of administrative data are essential to enhance understanding of how the family justice system is working, as well as the characteristics of, and outcomes for, children and families. The Family Justice Data Partnership (FJDP) supports this aim through analyses of core family justice and linked datasets in the SAIL Databank (Secure Anonymised Information Linkage). Cafcass Cymru provide expert advice for children involved in family court proceedings in Wales, ensuring decisions are made in the best interests of the child. We provide an overview of Cafcass Cymru data. We also describe and illustrate linkage to administrative datasets within SAIL.

METHODS

Cafcass Cymru data was transferred to SAIL using a standardised approach to provide de-identified data with Anonymised Linking Fields (ALF) for successfully matched records. Three cohorts were created: all individuals involved in family court applications; all individuals with an ALF allowing subsequent health data linkage; and all individuals with a Residential Anonymised Linking Field (RALF) enabling area-level deprivation analysis.

RESULTS

Cafcass Cymru application data are available for child protection matters (public law, range 2011-2019, n=12,745), and child arrangement disputes (private law, range 2005-2019, n=52,023). An 80% data linkage match rate was achieved. 40% had hospital admissions within two years pre or post application; 54% had emergency department attendances and 61% had outpatient appointments. Individuals were more likely to reside in deprived areas regardless of law type.

CONCLUSION

Cafcass Cymru data can be accessed through the SAIL Databank. The FJDP will continue to enhance research opportunities for all to better understand the family justice system, and outcomes for those involved, such as health and wellbeing for children and family members.

P0215EXCESSIVE TISSUE SODIUM STORAGE IN PATIENTS WITH NON-DIALYSIS DEPENDENT CARDIO-RENAL SYNDROME IS COMPARABLE TO HEMODIALYSIS PATIENTS

Background and Aims

Both CKD and heart failure (HF) are characterized by a propensity to retain sodium. Renal dysfunction worsens the progression of heart failure and is associated with worse outcomes. This may be a result of synergistic aggravation of sodium retention by the two conditions. We aimed to compare tissue Na storage in skin and muscle between cardiorenal (CR) patients and patients with a range of renal dysfunction, including those requiring hemodialysis (HD).

Method

Proton and 23Na images of the lower limb were acquired on a 3T MRI. We studied 9 CR patients, 7 matched CKD 2-5 patients (without HF) and 31 established HD patients. Regions of interest including skin and soleus were drawn on images to provide a quantitative sodium measurement and these tissue concentrations compared between groups. Blood samples were drawn at each scan in all patients. Spot urine samples were collected for CR patients.

Results

For CR patients, mean age was 66 ± 8 years, 78% of male, mean estimated glomerular filtration rate (eGFR) was 52 ± 18 mL/min/1.73m2, urea was 11 ± 6 mmol/L. For HD patients, mean age was 66 ± 8.7 years, 68% of male and mean dialysis vintage was 38 ± 37 months for HD patients. Mean age was 63 ± 8, 71 % of male, eGFR 45 ± 29 mL/min/1.73m2 for CKD patients. CR patients displayed an increased amount of salt in skin (32.5 ± 13 mmol/L) and muscle (26 ±4 mmol/L) with levels significantly higher than that seen in GFR matched controls (without HF) and comparable to HD patients (31 ±12 and 28 ± 6 mmol/L p=0.9 and p=0.3 respectively) without meaningful residual renal function.

Conclusion

The combination of HF and CKD is associated with intense tissue Na storage; resulting in tissue Na accumulation in CR patients (with reasonably well-preserved renal function) similar to CKD patients requiring HD.

SO027ASSOCIATIONS OF MUSCLE SODIUM DEPOSITION WITH SODIUM-23 MRI IN HEMODIALYSIS PATIENTS

Background and Aims

The development of sodium-23 magnetic resonance imaging (23Na MRI) allows the clinical quantification of tissue sodium. Recent studies have shown that hemodialysis (HD) patients have a tendency to retain tissue sodium due to impaired mechanisms in local tissue sodium clearance. However, the clinical significance of tissue sodium deposition in the HD patient population is unclear yet. The aim of this study was to investigate the association of tissue sodium deposition with well-established biomarkers of clinical outcomes.

Method

Chronic, thrice weekly HD patients underwent 23Na MRI of the leg on a non-dialysis day, during either the long or short interdialytic interval. Blood samples were also taken for the measurement of standard blood-based biomarkers. A multinuclear-capable 3.0-T MRI (GE Healthcare, Milwaukee WI) was used to acquire proton and sodium images. Maps of tissue 23Na concentration were generated using an in-house software developed within MATLAB (Mathworks, Natick, USA, R2018a). 23Na concentration maps were superimposed with the proton-anatomy images to delineate the regions of interest. Using the Horos (The Horos Project, Version 4.0.0) software, the soleus muscle was segmented (Figure, Panel A) and the sodium concentration in the region of interest was recorded for analysis.

Results

28 HD patients completed both 23Na MRI and bloodwork; 7/28 (25%) patients were females; mean±SD age was 66.1±8.3 years, mean body mass index was 30.9±6.5 kg/m2, and mean HD vintage was 30.2±34.9 months. Soleus muscle sodium concentration showed a strong, negative correlation with serum albumin (Figure, Panel B; r=-0.66, p&lt;0.0001). Furthermore, soleus muscle sodium concentration showed a minor association with plasma hemoglobin (r=-0.46, p=0.01).

Conclusion

Serum albumin is a recognized, powerful predictor of mortality in the hemodialysis patient population. The strong relationship between muscle sodium concentration and serum albumin levels suggests that tissue sodium deposition may be a relevant biomarker of clinical outcomes. In addition, muscle sodium deposition may be involved in the development of anemia. These findings warrant further studies investigating the consequences of sodium removal on these biomarkers.

Corrigendum to "Plant growth promoting Streptomyces strains are selectively interacting with the wheat cultivars especially in saline conditions" [Heliyon 6 (2) (2020) e03445]

[This corrects the article DOI: 10.1016/j.heliyon.2020.e03445.].

The association of smoking and socioeconomic status on cutaneous melanoma: a population-based, data-linkage, case-control study

BACKGROUND

Previous studies have identified an inverse association between melanoma and smoking; however, data from population-based studies are scarce.

OBJECTIVES

To determine the association between smoking and socioeconomic (SES) on the risk of development of melanoma. Furthermore, we sought to determine the implications of smoking and SES on survival.

METHODS

We conducted a population-based case-control study. Cases were identified from the Welsh Cancer Intelligence and Surveillance Unit (WCISU) during 2000-2015 and controls from the general population. Smoking and SES were obtained from data linkage with other national databases. The association of smoking status and SES on the incidence of melanoma were assessed using binary logistic regression. Multivariate survival analysis was performed on a melanoma cohort using a Cox proportional hazard model using survival as the outcome.

RESULTS

During 2000-2015, 9636 patients developed melanoma. Smoking data were obtained for 7124 (73·9%) of these patients. There were 26 408 controls identified from the general population. Smoking was inversely associated with melanoma incidence [odds ratio (OR) 0·70, 95% confidence interval (CI) 0·65-0·76]. Smoking was associated with an increased overall mortality [hazard ratio (HR) 1·30, 95% CI 1·09-1·55], but not associated with melanoma-specific mortality. Patients with higher SES had an increased association with melanoma incidence (OR 1·58, 95% CI 1·44-1·73). Higher SES was associated with an increased chance of both overall (HR 0·67, 95% CI 0·56-0·81) and disease-specific survival (HR 0·69, 95% CI 0·53-0·90).

CONCLUSIONS

Our study has demonstrated that smoking appeared to be associated with reduced incidence of melanoma. Although smoking increases overall mortality, no association was observed with melanoma-specific mortality. Further work is required to determine if there is a biological mechanism underlying this relationship or an alternative explanation, such as survival bias. What's already known about this topic? Previous studies have been contradictory with both negative and positive associations between smoking and the incidence of melanoma reported. Previous studies have either been limited by publication bias because of selective reporting or underpowered. What does this study add? Our large study identified an inverse association between smoking status and melanoma incidence. Although smoking status was negatively associated with overall disease survival, no significant association was noted in melanoma-specific survival. Socioeconomic status remains closely associated with melanoma. Although higher socioeconomic populations are more likely to develop the disease, patients with lower socioeconomic status continue to have a worse prognosis.