Whole-genome sequencing of clinical isolates from tuberculosis patients in India: real-world data indicates a high proportion of pre-XDR cases

Treatment decisions for tuberculosis (TB) in the absence of full drug-susceptibility data can result in amplifying resistance and may compromise treatment outcomes. Genomics of Mycobacterium tuberculosis (M.tb) from clinical samples enables detection of drug resistance to multiple drugs. We performed whole-genome sequencing (WGS) for 600 clinical samples from patients with tuberculosis to identify the drug-resistance profile and mutation spectrum. We documented the reasons reported by clinicians for referral. WGS identified a high proportion (51%) of pre-extensively drug-resistant (pre-XDR) cases followed by multidrug-resistant tuberculosis (MDR-TB) (15.5%). This correlates with the primary reason for referral, as non-response to the first-line treatment (67%) and treatment failure or rifampicin resistance (14%). Multivariate analysis indicated that all young age groups (P < 0.05), male gender (P < 0.05), and Beijing strain (P < 0.01) were significant independent predictors of MDR-TB or MDR-TB+ [pre-extensively drug-resistant tuberculosis (XDR-TB) and XDR-TB]. Ser315Thr (72.5%) in the inhA gene and Ser450Leu in the rpoB gene (65.5%) were the most prevalent mutations, as were resistance-conferring mutations to pyrazinamide (41%) and streptomycin (61.33%). Mutations outside the rifampicin resistance-determining region (RRDR), Ile491Phe and Val170Phe, were seen in 1.3% of cases; disputed mutations in rpoB (Asp435Tyr, His445Asn, His445Leu, and Leu430Pro) were seen in 6% of cases, and mutations to newer drugs such as bedaquiline and linezolid in 1.0% and 7.5% of cases, respectively. This study on clinical samples highlights that there is a high proportion of pre-XDR cases and emerging resistance to newer drugs; ongoing transmission of these strains can cause serious threat to public health; and whole-genome sequencing can effectively identify and support precision medicine for TB.

IMPORTANCE

The current study is based on real-world data on the TB drug-resistance profile by whole-genome sequencing of 600 clinical samples from patients with TB in India. This study indicates the clinicians' reasons for sending samples for WGS, which is for difficult-to-treat cases and/or relapse and treatment failure. The study reports a significant proportion of cases with pre-XDR-TB strains that warrant policy makers' attention. It reflects the current iterative nature of the diagnostic tests under programmatic conditions that leads to delays in appropriate diagnosis and empirical treatment. India had an estimated burden of 2.95 million TB cases in 2020 and 135,000 multidrug-resistant cases. However, WGS profiles of M.tb from India remains disproportionately poorly represented. This study adds a significant body of data on the mutation profiles seen in M.tb isolated from patients with TB in India, mutations outside the RRDR, disputed mutations, and resistance-conferring mutations to newer drugs such as bedaquiline and linezolid.

Effect of feeding Bengal gram residual forage-based pelleted total mixed ration on growth performance, nutrient availability, carcass traits and composition in finisher Barbari kids

The study aimed to assess the impact of feeding Bengal gram residual forage-based pelleted Total Mixed Ration (TMR) with varying concentrate (C) to roughage (R) ratios on feed intake, nutrient utilization, growth, and carcass characteristics in Barbari kids. Sixteen weaned male Barbari kids (av. age, 233 ± 11 days; weight, 13.86 ± 0.76 kg) were divided into two groups (T1 and T2), each receiving different pelleted diets (TMR) with distinct concentrate to roughage ratios (T1 with 60:40; T2 with 40:60). The kids were fed for 133 days, and a digestion trial was conducted at the end of the study. After completion, all kids were slaughtered. Although, kids under T1 consumed higher (P < 0.001) amount of dry matter, and crude protein compared to T2, which was due to a higher concentrate to roughage ratio in T1. But, the average daily body weight gain (ADG) of finisher kids was 88.53, and 79.83 g/d/kid in T1 and T2, respectively; however, the difference was non-significant. Digestibility of organic matter, crude protein, and total carbohydrate was also greater in T1 compared to T2. Total digestible nutrients intake was higher (P < 0.001) in T1; similarly intake of digestible energy, and metabolizable energy were significantly increased (P < 0.01) in T1 compared to T2. Concentrations of volatile fatty acids and NH3-nitrogen were also enhanced (P < 0.05) in T1 compared to T2. We observed similar carcass weight, and dressing percentage in both groups, and carcass composition remained unaffected. The pelleted diet containing greater ratio of concentrate: roughage (60:40) had no additional benefits in terms of ADG, and carcass traits in finisher kids. Therefore, it may be concluded that the Bengal gram residual forage-based pelleted TMR diet containing C40: R60 (TDN 57.13%, DCP 7.64%, ME 9.11MJ/kg feed) is suitable for optimizing growth performance with desirable carcass traits, and meat composition in finisher Barbari kids reared under the intensive system.

Art therapy masks reflect emotional changes in military personnel with PTSS

Among disabling post-traumatic stress symptoms (PTSS) are irritability, aggressive behavior, distressing memories and general impaired cognition and negative mood. Art therapy interventions, including mask-making, can potentially alleviate these symptoms. We tested the hypothesis that art conveys emotions and predicted that blinded viewers would be able to perceive changes in theoretically derived emotional profiles expressed in art made by military personnel with PTSS from the onset to the end of therapy. Five service members and veterans exhibiting PTSS were enrolled in an 8-session art therapy protocol, during which they artistically transformed papier-mâché masks at the beginning and end of the protocol. We found that blinded viewers without knowledge of the masks' creation stage (onset or end of therapy) read initial masks as conveying more negative emotions (e.g., angry, upset, and challenged) and later masks as conveying more positive emotions (calm and pleasure). Based on the assessments from the blinded evaluators, we infer the emotional transition experienced by the participants was expressed in the masks. In an exploratory arm of the study, we also found that viewers were better able to empathize with the negative emotions experienced by participants with PTSS when asked to explicitly take their perspective.

Structural, chemical, and magnetic investigation of a graphene/cobalt/platinum multilayer system on silicon carbide

We investigate the magnetic interlayer coupling and domain structure of ultra-thin ferromagnetic (FM) cobalt (Co) layers embedded between a graphene (G) layer and a platinum (Pt) layer on a silicon carbide (SiC) substrate (G/Co/Pt on SiC). Experimentally, a combination of x-ray photoemission electron microscopy with x-ray magnetic circular dichroism has been carried out at the Co L-edge. Furthermore, structural and chemical properties of the system have been investigated using low energy electron diffraction (LEED) and x-ray photoelectron spectroscopy (XPS).In situLEED patterns revealed the crystalline structure of each layer within the system. Moreover, XPS confirmed the presence of quasi-freestanding graphene, the absence of cobalt silicide, and the appearance of two silicon carbide surface components due to Pt intercalation. Thus, the Pt-layer effectively functions as a diffusion barrier. The magnetic structure of the system was unaffected by the substrate's step structure. Furthermore, numerous vortices and anti-vortices were found in all samples, distributed all over the surfaces, indicating Dzyaloshinskii-Moriya interaction. Only regions with a locally increased Co-layer thickness showed no vortices. Moreover, unlike in similar systems, the magnetization was predominantly in-plane, so no perpendicular magnetic anisotropy was found.

An integrated method for targeted Oxford Nanopore sequencing and automated bioinformatics for the simultaneous detection of bacteria, fungi, and ARG

AIMS

The use of metagenomics for pathogen identification in clinical practice has been limited. Here we describe a workflow to encourage the clinical utility and potential of NGS for the screening of bacteria, fungi, and antimicrobial resistance genes (ARGs).

METHODS AND RESULTS

The method includes target enrichment, long-read sequencing, and automated bioinformatics. Evaluation of several tools and databases was undertaken across standard organisms (n = 12), clinical isolates (n = 114), and blood samples from patients with suspected bloodstream infections (n = 33). The strategy used could offset the presence of host background DNA, error rates of long-read sequencing, and provide accurate and reproducible detection of pathogens. Eleven targets could be successfully tested in a single assay. Organisms could be confidently identified considering ≥60% of best hits of a BLAST-based threshold of e-value 0.001 and a percent identity of >80%. For ARGs, reads with percent identity of >90% and >60% overlap of the complete gene could be confidently annotated. A kappa of 0.83 was observed compared to standard diagnostic methods. Thus, a workflow for the direct-from-sample, on-site sequencing combined with automated genomics was demonstrated to be reproducible.

CONCLUSION

NGS-based technologies overcome several limitations of current day diagnostics. Highly sensitive and comprehensive methods of pathogen screening are the need of the hour. We developed a framework for reliable, on-site, screening of pathogens.

Hyperon Polarization along the Beam Direction Relative to the Second and Third Harmonic Event Planes in Isobar Collisions at sqrt[s_{NN}]=200 GeV

The polarization of Λ and Λ[over ¯] hyperons along the beam direction has been measured relative to the second and third harmonic event planes in isobar Ru+Ru and Zr+Zr collisions at sqrt[s_{NN}]=200  GeV. This is the first experimental evidence of the hyperon polarization by the triangular flow originating from the initial density fluctuations. The amplitudes of the sine modulation for the second and third harmonic results are comparable in magnitude, increase from central to peripheral collisions, and show a mild p_{T} dependence. The azimuthal angle dependence of the polarization follows the vorticity pattern expected due to elliptic and triangular anisotropic flow, and qualitatively disagrees with most hydrodynamic model calculations based on thermal vorticity and shear induced contributions. The model results based on one of existing implementations of the shear contribution lead to a correct azimuthal angle dependence, but predict centrality and p_{T} dependence that still disagree with experimental measurements. Thus, our results provide stringent constraints on the thermal vorticity and shear-induced contributions to hyperon polarization. Comparison to previous measurements at RHIC and the LHC for the second-order harmonic results shows little dependence on the collision system size and collision energy.

Genomic revolution: Transforming tuberculosis diagnosis and treatment with the use of Whole Genome Sequencing - A consensus statement

Tuberculosis (TB) is a preventable, treatable, and curable disease. However, in 2020, 9∙9 million people were estimated to have developed tuberculosis, and 1.5 million people were estimated to have died from it. Whereas in India, 2.6 million were diagnosed with TB and 436,000 succumbed to TB in 2019. India (26%) is the major contributor to the global drop in TB cases. The COVID-19 pandemic has substantially reduced access to services for the diagnosis and treatment of TB, resulting in an increase in deaths and a reversal in global progress. [1] Presently, TB incidence is falling at a rate of 2% per year, obstructed mainly by the rearing pandemic of drug-resistant tuberculosis (DRTB). Particularly concerning is multi-drug resistant TB (MDRTB), defined as resistance towards isoniazid (INH) and rifampicin (RIF). [2] The World Health Organization (WHO) targeted to reduce worldwide TB incidence by 90% until 2035. (1) Early initiation of effective treatment based on susceptibility patterns of the Mycobacterium tuberculosis complex (MTBC) is considered key to successful TB control in countries with high DRTB incidence. Worldwide MDRTB treatment outcomes are poor, with cure rates less than 60% (2) due to the lack of comprehensive Drug Susceptibility Testing (DST) in most high MDRTB burden countries. This is leading to the inadequate anti-TB activity of the provided regimens (3-5), unlike regimens advised for DST assure optimal results. (6) In addition to resistances to the established regimens, the resistance to the newer DRTB drugs is increasing. On World TB Day 2022, Academy of Advanced Medical Education, Thyrocare Technologies Limited and HyastackAnalytics - IITB along with expert pulmonologist and renowned physicians from India convened for an advisory board meeting in Delhi on 20th March 2022 to discuss the role of Whole Genome Sequencing (WGS) in the diagnosis and management of TB. Objectives and specific topics relating to WGS in MDRTB were discussed, each expert shared their views, which led to a group discussion with a commitment to putting the patient first, and increasing their collective efforts, the organizations recognized that it is possible to make this goal a reality. The organizations involved in the discussion have declared their commitment to engaging in collaborative efforts to tackle DRTB detection efficiently. They advocate for strengthening access to WGS TB services, controlling and preventing TB, improving surveillance and drug resistance management, and investing in research and development. This Round Table serves as a framework to build on and ensure that the goal of ending TB is achievable with WGS services wherever needed. Post discussion, a uniform consensus was said to be arrived if more than 80% board members agreed to the statement. The present paper is the outcome of aspects presented and discussed in the advisory board meeting.

Short-course Palliative Hypofractionated Radiotherapy in Patients with Poor-prognosis High-grade Glioma: Survival and Quality of Life Outcomes from a Prospective Phase II Study

AIMS

To report longitudinal quality of life (QoL) outcomes and survival in patients with poor-prognosis high-grade glioma (HGG) treated with palliative hypofractionated radiotherapy.

MATERIALS AND METHODS

Patients with poor-prognosis HGG were accrued on a prospective study of short-course palliative hypofractionated radiotherapy (35 Gy/10 fractions/2 weeks). The European Organization for Research and Treatment of Cancer QoL core questionnaire (QLQ-C30) and brain cancer module (BN20) were used in English or validated Indian vernacular languages (Hindi and Marathi) for QoL assessment at baseline (before radiotherapy), the conclusion of radiotherapy, 1 month post-radiotherapy and subsequently at 3-monthly intervals until disease progression/death. Baseline QoL scores were compared with corresponding scores from a historical HGG cohort. Summary QoL scores were compared longitudinally over time by related samples Friedman's two-way test. Progression-free survival and overall survival were calculated using the Kaplan-Meier method and reported as 1-year estimates with 95% confidence intervals.

RESULTS

Forty-nine (89%) of 55 patients completed the planned course of hypofractionated radiotherapy. Longitudinal QoL data were available in 42 (86%) of 49 patients completing radiotherapy, comprising the present cohort. The median age of included patients, comprised mainly of glioblastoma patients (81%), was 57 years, with an interquartile range (IQR) of 50-66 years and a median baseline Karnofsky score of 60 (IQR = 50-60). Baseline QoL scores were significantly worse for several domains compared with a historical institutional cohort of HGG patients treated previously with conventionally fractionated radiotherapy, indicating negative selection bias. QoL scores remained stable for most domains after palliative hypofractionated radiotherapy, with statistically significant improvements in fatigue (P = 0.032), dyspnoea (P = 0.042) and motor dysfunction (P = 0.036) over time. At a median follow-up of 8 months, Kaplan-Meier estimates of 1-year progression-free survival and overall survival were 33.3% (95% confidence interval 21.7-51.1%) and 38.1% (95% confidence interval 25.9-56%), respectively.

CONCLUSION

Short-course palliative hypofractionated radiotherapy in patients with poor-prognosis HGG is associated with stable and/or improved QoL scores in several domains, making it a viable resource-sparing regimen.

Erratum: Global Polarization of Ξ and Ω Hyperons in Au+Au Collisions at sqrt[s_{NN}]=200 GeV [Phys. Rev. Lett. 126, 162301 (2021)]

This corrects the article DOI: 10.1103/PhysRevLett.126.162301.

Measurements of the Elliptic and Triangular Azimuthal Anisotropies in Central ^{3}He+Au, d+Au and p+Au Collisions at sqrt[s_{NN}]=200 GeV

The elliptic (v_{2}) and triangular (v_{3}) azimuthal anisotropy coefficients in central ^{3}He+Au, d+Au, and p+Au collisions at sqrt[s_{NN}]=200  GeV are measured as a function of transverse momentum (p_{T}) at midrapidity (|η|<0.9), via the azimuthal angular correlation between two particles both at |η|<0.9. While the v_{2}(p_{T}) values depend on the colliding systems, the v_{3}(p_{T}) values are system independent within the uncertainties, suggesting an influence on eccentricity from subnucleonic fluctuations in these small-sized systems. These results also provide stringent constraints for the hydrodynamic modeling of these systems.

ICARUS at the Fermilab Short-Baseline Neutrino program: initial operation

The ICARUS collaboration employed the 760-ton T600 detector in a successful 3-year physics run at the underground LNGS laboratory, performing a sensitive search for LSND-like anomalous ν e appearance in the CERN Neutrino to Gran Sasso beam, which contributed to the constraints on the allowed neutrino oscillation parameters to a narrow region around 1 eV2 . After a significant overhaul at CERN, the T600 detector has been installed at Fermilab. In 2020 the cryogenic commissioning began with detector cool down, liquid argon filling and recirculation. ICARUS then started its operations collecting the first neutrino events from the booster neutrino beam (BNB) and the Neutrinos at the Main Injector (NuMI) beam off-axis, which were used to test the ICARUS event selection, reconstruction and analysis algorithms. ICARUS successfully completed its commissioning phase in June 2022. The first goal of the ICARUS data taking will be a study to either confirm or refute the claim by Neutrino-4 short-baseline reactor experiment. ICARUS will also perform measurement of neutrino cross sections with the NuMI beam and several Beyond Standard Model searches. After the first year of operations, ICARUS will search for evidence of sterile neutrinos jointly with the Short-Baseline Near Detector, within the Short-Baseline Neutrino program. In this paper, the main activities carried out during the overhauling and installation phases are highlighted. Preliminary technical results from the ICARUS commissioning data with the BNB and NuMI beams are presented both in terms of performance of all ICARUS subsystems and of capability to select and reconstruct neutrino events.

Beam Energy Dependence of Triton Production and Yield Ratio (N_{t}×N_{p}/N_{d}^{2}) in Au+Au Collisions at RHIC

We report the triton (t) production in midrapidity (|y|<0.5) Au+Au collisions at sqrt[s_{NN}]=7.7-200  GeV measured by the STAR experiment from the first phase of the beam energy scan at the Relativistic Heavy Ion Collider. The nuclear compound yield ratio (N_{t}×N_{p}/N_{d}^{2}), which is predicted to be sensitive to the fluctuation of local neutron density, is observed to decrease monotonically with increasing charged-particle multiplicity (dN_{ch}/dη) and follows a scaling behavior. The dN_{ch}/dη dependence of the yield ratio is compared to calculations from coalescence and thermal models. Enhancements in the yield ratios relative to the coalescence baseline are observed in the 0%-10% most central collisions at 19.6 and 27 GeV, with a significance of 2.3σ and 3.4σ, respectively, giving a combined significance of 4.1σ. The enhancements are not observed in peripheral collisions or model calculations without critical fluctuation, and decreases with a smaller p_{T} acceptance. The physics implications of these results on the QCD phase structure and the production mechanism of light nuclei in heavy-ion collisions are discussed.

A130 ENDOSCOPIC ULTRASOUND GUIDED THROMBIN INJECTION: A NOVEL TECHNIQUE IN THE MANAGEMENT OF RECURRENT UPPER GASTROINTESTINAL BLEEDING CAUSED BY GASTRODUODENAL ARTERY PSEUDOANEURYSMS

Background

Gastroduodenal artery (GDA) aneurysm is a rare vascular condition that is potentially life-threatening. It is associated with significant morbidity and mortality and most often encountered in patients with chronic pancreatitis. Other etiologies including atherosclerosis, peptic ulcer disease, alcohol abuse, cholecystectomy and absence of celiac axis, have been reported. False and true GDA aneurysms account for about 1.5% of all visceral artery aneurysms however are associated with a risk of rupturing and hemorrhage up to 75%. Mainstay of GDA aneurysm management involves aneurysm repair with open surgery with vessel ligation or endovascular repair with coil embolization or stent placement, depending on the patient’s comorbidities and overall hemodynamic stability. The use of percutaneous thrombin injection via computed tomography (CT) and ultrasound has also been described in the literature and is being increasingly used to promote clot formation and pseudoaneurysm occlusion as a less invasive option.

Purpose

To present a case of endoscopic ultrasound guided thrombin injection as an effective and safe management strategy for GDA pseudoaneurysms.

Method

At this time, there are limited data in the literature on endoscopic ultrasound guided thrombin injection for pseudoaneurysms. To our knowledge, this is the first case report describing a patient with recurrent gastrointestinal bleeding from a duodenal ulcer, who had undergone multiple endoscopic and angiographic procedures, with subsequent development of a gastroduodenal pseudoaneurysm unrelated to pancreatitis which was successfully managed by occluding the pseudoaneurysm with thrombin injection under endoscopic ultrasound guidance. EUS guided thrombin injection is a viable alternative to traditional interventional radiology guided thrombin injection for management of pseudoaneurysms.

Result(s)

In clinic follow-up three weeks after thrombin injection, our patient continued to do clinically well, without abdominal pain or symptoms. Repeat CT angiogram demonstrated the GDA pseudoaneurysm had remained thrombosed, indicating successful endoscopic obliteration. He had no further signs of gastrointestinal bleeding.

Conclusion(s)

EUS guided thrombin injection is a novel approach that has been presented as an option in the management of bleeding gastroduodenal pseudoaneurysms, especially when radiology guided or surgical options are higher risk or have previously failed. The paucity of available data highlights the need for ongoing clinical studies comparing the different therapeutic strategies that can effectively and safely manage these rare but life-threatening vascular entities.

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None

Disclosure of Interest

None Declared

Facial recognition lock technology for social care settings: A qualitative evaluation of implementation of facial recognition locks at two residential care sites

Background

There is limited literature on security and access for social care settings despite policy highlighting importance, and no published research exploring facial recognition lock technology (FRLT) for potential improvements. This study explored FRLT device implementation, use, barriers and benefits.

Methods

One residential care home with 43 older adults and 68 staff members (Site A), and one supported living facility caring for six individuals with mental health issues with 18 staff members (Site B) were provided with FRLT for six months. Nine pre-implementation staff interviews explored existing access and security perceptions. Ten post-implementation staff interviews and one staff focus group were conducted; all were analysed using content analysis to understand, alongside process mapping, the use and impact of the FRLT. Interview participants included site care staff and other visiting healthcare professionals. We additionally report feedback from the technology developers to demonstrate impact of industry-academia collaboration.

Results

Pre-implementation interviews highlighted issues with current pin-pad or lock-box systems, including; code sharing; code visibility, ineffective code changes, security issues following high staff turnover, lack of efficiency for visitors including NHS staff and lack of infection control suggesting requirement for innovation and improvement. Pre-implementation interviews showed openness and interest in FRLT, although initial queries were raised around cost effectiveness and staff skills. Following implementation, good levels of adoption were achieved with 72% and 100% (49/68 and 18/18) of staff members uploading their face at the two sites, and 100% of residents at Site B using the system (6/6). Additionally, Site B made a positive procurement decision and continues to discuss wider rollout. Post implementation interviews suggested FRLT was useful and acceptable for improving security and access. Benefits identified included staff/visitor time saving, enhanced security, team ease of access, resident autonomy and fewer shared touch points. Integration was suggested including with fire alarm systems, staff clocking in/out, and Covid monitoring to improve usefulness. The developers have since responded to feedback with design iterations.

Conclusion

We identified concerns on security and access in social care settings, which warrant further exploration and research. FRLT could increase resident autonomy and reduce staff burden, particularly considering frequent multi-agency health and care visits.

Collision-System and Beam-Energy Dependence of Anisotropic Flow Fluctuations

Elliptic flow measurements from two-, four-, and six-particle correlations are used to investigate flow fluctuations in collisions of U+U at sqrt[s_{NN}]=193  GeV, Cu+Au at sqrt[s_{NN}]=200  GeV and Au+Au spanning the range sqrt[s_{NN}]=11.5-200  GeV. The measurements show a strong dependence of the flow fluctuations on collision centrality, a modest dependence on system size, and very little if any, dependence on particle species and beam energy. The results, when compared to similar LHC measurements, viscous hydrodynamic calculations, and trento model eccentricities, indicate that initial-state-driven fluctuations predominate the flow fluctuations generated in the collisions studied.

Evidence for Nonlinear Gluon Effects in QCD and Their Mass Number Dependence at STAR

The STAR Collaboration reports measurements of back-to-back azimuthal correlations of di-π^{0}s produced at forward pseudorapidities (2.6<η<4.0) in p+p, p+Al, and p+Au collisions at a center-of-mass energy of 200 GeV. We observe a clear suppression of the correlated yields of back-to-back π^{0} pairs in p+Al and p+Au collisions compared to the p+p data. The observed suppression of back-to-back pairs as a function of transverse momentum suggests nonlinear gluon dynamics arising at high parton densities. The larger suppression found in p+Au relative to p+Al collisions exhibits a dependence of the saturation scale Q_{s}^{2} on the mass number A. A linear scaling of the suppression with A^{1/3} is observed with a slope of -0.09±0.01.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Measurements of Proton High-Order Cumulants in sqrt[s_{NN}]=3 GeV Au+Au Collisions and Implications for the QCD Critical Point

We report cumulants of the proton multiplicity distribution from dedicated fixed-target Au+Au collisions at sqrt[s_{NN}]=3.0  GeV, measured by the STAR experiment in the kinematic acceptance of rapidity (y) and transverse momentum (p_{T}) within -0.5<y<0 and 0.4<p_{T}<2.0  GeV/c. In the most central 0%-5% collisions, a proton cumulant ratio is measured to be C_{4}/C_{2}=-0.85±0.09 (stat)±0.82 (syst), which is 2σ below the Poisson baseline with respect to both the statistical and systematic uncertainties. The hadronic transport UrQMD model reproduces our C_{4}/C_{2} in the measured acceptance. Compared to higher energy results and the transport model calculations, the suppression in C_{4}/C_{2} is consistent with fluctuations driven by baryon number conservation and indicates an energy regime dominated by hadronic interactions. These data imply that the QCD critical region, if created in heavy-ion collisions, could only exist at energies higher than 3 GeV.

Measurements of _{Λ}^{3}H and _{Λ}^{4}H Lifetimes and Yields in Au+Au Collisions in the High Baryon Density Region

We report precision measurements of hypernuclei _{Λ}^{3}H and _{Λ}^{4}H lifetimes obtained from Au+Au collisions at sqrt[s_{NN}]=3.0  GeV and 7.2 GeV collected by the STAR experiment at the Relativistic Heavy Ion Collider, and the first measurement of _{Λ}^{3}H and _{Λ}^{4}H midrapidity yields in Au+Au collisions at sqrt[s_{NN}]=3.0  GeV. _{Λ}^{3}H and _{Λ}^{4}H, being the two simplest bound states composed of hyperons and nucleons, are cornerstones in the field of hypernuclear physics. Their lifetimes are measured to be 221±15(stat)±19(syst)  ps for _{Λ}^{3}H and 218±6(stat)±13(syst)  ps for _{Λ}^{4}H. The p_{T}-integrated yields of _{Λ}^{3}H and _{Λ}^{4}H are presented in different centrality and rapidity intervals. It is observed that the shape of the rapidity distribution of _{Λ}^{4}H is different for 0%-10% and 10%-50% centrality collisions. Thermal model calculations, using the canonical ensemble for strangeness, describes the _{Λ}^{3}H yield well, while underestimating the _{Λ}^{4}H yield. Transport models, combining baryonic mean-field and coalescence (jam) or utilizing dynamical cluster formation via baryonic interactions (phqmd) for light nuclei and hypernuclei production, approximately describe the measured _{Λ}^{3}H and _{Λ}^{4}H yields. Our measurements provide means to precisely assess our understanding of the fundamental baryonic interactions with strange quarks, which can impact our understanding of more complicated systems involving hyperons, such as the interior of neutron stars or exotic hypernuclei.

Probing the Gluonic Structure of the Deuteron with J/ψ Photoproduction in d+Au Ultraperipheral Collisions

Understanding gluon density distributions and how they are modified in nuclei are among the most important goals in nuclear physics. In recent years, diffractive vector meson production measured in ultraperipheral collisions (UPCs) at heavy-ion colliders has provided a new tool for probing the gluon density. In this Letter, we report the first measurement of J/ψ photoproduction off the deuteron in UPCs at the center-of-mass energy sqrt[s_{NN}]=200  GeV in d+Au collisions. The differential cross section as a function of momentum transfer -t is measured. In addition, data with a neutron tagged in the deuteron-going zero-degree calorimeter is investigated for the first time, which is found to be consistent with the expectation of incoherent diffractive scattering at low momentum transfer. Theoretical predictions based on the color glass condensate saturation model and the leading twist approximation nuclear shadowing model are compared with the data quantitatively. A better agreement with the saturation model has been observed. With the current measurement, the results are found to be directly sensitive to the gluon density distribution of the deuteron and the deuteron breakup process, which provides insights into the nuclear gluonic structure.

769 IMPROVING THE DIAGNOSIS AND MANAGEMENT OF PATIENTS WITH COMMUNITY AND HOSPITAL ACQUIRED PNEUMONIA WITHIN ELDERLY CARE

Introduction

In 2017 pneumonia was the most cited cause of death in elderly care at our hospital, and in 2019, we were shown to be an outlier in the incidence of hospital acquired pneumonia (HAP). Therefore, accurate diagnosis and management of pneumonia is paramount and an area for improvement in our trust. From 2017–20 we focussed on the care of elderly patients with pneumonia, aiming to improve the diagnosis and subsequent management plans.

Methods

Notes were reviewed retrospectively, examining patient notes, EPR data, radiological imaging and pathology results. We had 3 interventions across our project using teaching, posters, screensavers, and involvement of the wider MDT. HAP nursing champions were appointed, and new guidelines were published.

Results

Poor diagnostic accuracy of pneumonia was a recurrent problem. In 2017–18, focus to improve diagnosis rested on improved use of baseline investigations. By early 2019, following interventions, 75% of diagnoses were correct for community acquired pneumonia (CAP), despite ongoing poor use of investigations. Conversely, HAP patients had increased investigations but no improvement in diagnosis. Over winter 2019/20, 65% of patients had an inaccurate diagnosis of HAP. The most common reasons for misdiagnosis related to interpretation of chest x-rays and timing of diagnosis. 71% of patients misdiagnosed with HAP received antibiotics which were unlikely to be effective.

Conclusion

Improvements were made in the care of patients with both HAP and CAP. Simple interventions such as teaching, screensavers and posters affect decision-making and can improve patient outcomes. Diagnostic accuracy of both CAP and HAP can be a challenge—there were specific areas that were addressed effectively via teaching. To improve sustainability, future success of this project lies with continuous education and training of staff. A steering group will review the whole project and aim to sustain patient outcomes by digital transformation.

Search for the Chiral Magnetic Effect via Charge-Dependent Azimuthal Correlations Relative to Spectator and Participant Planes in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

The chiral magnetic effect (CME) refers to charge separation along a strong magnetic field due to imbalanced chirality of quarks in local parity and charge-parity violating domains in quantum chromodynamics. The experimental measurement of the charge separation is made difficult by the presence of a major background from elliptic azimuthal anisotropy. This background and the CME signal have different sensitivities to the spectator and participant planes, and could thus be determined by measurements with respect to these planes. We report such measurements in Au+Au collisions at a nucleon-nucleon center-of-mass energy of 200 GeV at the Relativistic Heavy-Ion Collider. It is found that the charge separation, with the flow background removed, is consistent with zero in peripheral (large impact parameter) collisions. Some indication of finite CME signals is seen in midcentral (intermediate impact parameter) collisions. Significant residual background effects may, however, still be present.

Development of a PNA–DiSc2 based portable absorbance platform for the detection of pathogen nucleic acids

A PortAbs based pathogen nucleic acid detection system using peptide nucleic acid (PNA) and a cyanine dye, DiSc2(5). The shift is measured of the absorbance induced by binding of a PNA probe to a complementary DNA strand using a portable two-color absorption system.

Measurement of the Sixth-Order Cumulant of Net-Proton Multiplicity Distributions in Au+Au Collisions at sqrt[s_{NN}]=27, 54.4, and 200 GeV at RHIC

According to first-principle lattice QCD calculations, the transition from quark-gluon plasma to hadronic matter is a smooth crossover in the region μ_{B}≤T_{c}. In this range the ratio, C_{6}/C_{2}, of net-baryon distributions are predicted to be negative. In this Letter, we report the first measurement of the midrapidity net-proton C_{6}/C_{2} from 27, 54.4, and 200 GeV Au+Au collisions at the Relativistic Heavy Ion Collider (RHIC). The dependence on collision centrality and kinematic acceptance in (p_{T}, y) are analyzed. While for 27 and 54.4 GeV collisions the C_{6}/C_{2} values are close to zero within uncertainties, it is observed that for 200 GeV collisions, the C_{6}/C_{2} ratio becomes progressively negative from peripheral to central collisions. Transport model calculations without critical dynamics predict mostly positive values except for the most central collisions within uncertainties. These observations seem to favor a smooth crossover in the high-energy nuclear collisions at top RHIC energy.

The coevolution of large and small terminases of bacteriophages is a result of purifying selection leading to phenotypic stabilization

Genome packaging in many dsDNA phages requires a series of precisely coordinated actions of two phage-coded proteins, namely, large terminase (TerL) and small terminase (TerS) with DNA and ATP, and with each other. Despite the strict functional conservation, TerL and TerS homologs exhibit large sequence variations. We investigated the sequence variability across eight phage types and observed a coevolutionary framework wherein the genealogy of TerL homologs mirrored that of the corresponding TerS homologs. Furthermore, a high purifying selection observed (dN/dS«1) indicated strong structural constraints on both TerL and TerS, and identify coevolving residues in TerL and TerS of phage T4 and lambda. Using the highly coevolving (correlation coefficient of 0.99) TerL and TerS of phage N4, we show that their biochemical features are similar to the phylogenetically divergent phage λ terminases. We also demonstrate using the Surface Plasma Resonance (SPR) technique that phage N4 TerL transiently interacts with TerS.

Observation of D_{s}^{±}/D^{0} Enhancement in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the first measurement of charm-strange meson D_{s}^{±} production at midrapidity in Au+Au collisions at sqrt[s_{NN}]=200  GeV from the STAR experiment. The yield ratio between strange (D_{s}^{±}) and nonstrange (D^{0}) open-charm mesons is presented and compared to model calculations. A significant enhancement, relative to a pythia simulation of p+p collisions, is observed in the D_{s}^{±}/D^{0} yield ratio in Au+Au collisions over a large range of collision centralities. Model calculations incorporating abundant strange-quark production in the quark-gluon plasma and coalescence hadronization qualitatively reproduce the data. The transverse-momentum integrated yield ratio of D_{s}^{±}/D^{0} at midrapidity is consistent with a prediction from a statistical hadronization model with the parameters constrained by the yields of light and strange hadrons measured at the same collision energy. These results suggest that the coalescence of charm quarks with strange quarks in the quark-gluon plasma plays an important role in D_{s}^{±}-meson production in heavy-ion collisions.

Measurement of e^{+}e^{-} Momentum and Angular Distributions from Linearly Polarized Photon Collisions

The Breit-Wheeler process which produces matter and antimatter from photon collisions is experimentally investigated through the observation of 6085 exclusive electron-positron pairs in ultraperipheral Au+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements reveal a large fourth-order angular modulation of cos4Δϕ=(16.8±2.5)% and smooth invariant mass distribution absent of vector mesons (ϕ, ω, and ρ) at the experimental limit of ≤0.2% of the observed yields. The differential cross section as a function of e^{+}e^{-} pair transverse momentum P_{⊥} peaks at low value with sqrt[⟨P_{⊥}^{2}⟩]=38.1±0.9  MeV and displays a significant centrality dependence. These features are consistent with QED calculations for the collision of linearly polarized photons quantized from the extremely strong electromagnetic fields generated by the highly charged Au nuclei at ultrarelativistic speed. The experimental results have implications for vacuum birefringence and for mapping the magnetic field which is important for emergent QCD phenomena.

528 EVALUATING THE PRESCRIPTION OF OPIATES IN PATIENTS WITH NECK OF FEMUR FRACTURES IN OUT OF HOSPITAL AND EMERGENCY CARE SETTING

Introduction

Opiate based analgesia forms a key component of Hip Fracture management. If prescribed inappropriately, opiate based analgesia can lead to respiratory depression, nephrotoxicity, and delayed recovery. The aim of this project was to evaluate opiate prescription in NOF patients in both out of hospital (OOH) and Emergency Department (ED).

Methods

100 consecutive patients were identified from National Hip Fracture Database between January and August 2019. Medical records were reviewed in both care settings, reviewing dose of morphine in comparison to body weight and renal function. Outcomes measured include constipation, acute kidney injury, respiratory compromise, and mortality. Statistical tests (t-test and chi square) were used to discern significance. Following the first cycle of results, results were disseminated to paramedics and at local governance meetings. Teaching was undertaken to increase awareness of harms associated with inappropriate opiate prescribing. A second cycle evaluated 30 consecutive NOFs from July 2020.

Results

In our study population, 74% were female and the average age was 84. The range of morphine doses given OOH ranged from 2-40 mg, in comparison to 2.5-20 mg in ED. 18% of patient suffered from Respiratory depression with 48 hours of their admission with a further 7% suffering from an acute kidney injury. After intervention, OOH morphine doses ranged between 5-10 mg, a reduction of 75% on maximum dose, with increased use of adjuvants as guided by the WHO pain ladder. No adverse outcomes were noted within 48 hours of admission.

Conclusion

Patient safety should be high on the agenda whilst caring for frail patients with Hip Fractures and opiate prescription is one of the most critical in the patient’s journey. Reducing harm by prescribing the optimal opiates helps to reduce mortality, morbidity, improve rehabilitation and patient flow within the NHS pathways. A guideline has been published to aid opiate prescription in elderly patients.

Covalent and Hydrogen Bonding in Adsorption of Alanine Molecules on Si(111)7×7

Molecular adsorption bonding configurations and specific interfacial chemistry of alanine on Si(111)7×7 have been determined by combining the results from scanning tunneling microscopy (STM) and X-ray photoelectron spectroscopy (XPS) with ab initio calculations based on the density functional theory (DFT). XPS spectra of the N 1s region show that alanine molecules bind to the 7×7 surface by N-Si covalent bonding, while STM imaging reveals that such N-H dissociative adsorption of alanine occurs on an adjacent Si adatom-restatom pair, with the dehydrogenated alanine moiety and dissociated H atom occupying the Si adatom and restatom sites, respectively. At a sample bias above +2 V, the dehydrogenated alanine appears as a bright round protrusion, slightly off-center from a Si adatom site and leaning toward the opposite Si adatom across the dimer wall. The off-center character can be attributed to an electrostatic attraction between the electron-rich carbonyl O of the dehydrogenated alanine and electron-deficient nearest Si adatom across the dimer wall. Our DFT calculation also shows that the monodentate O-Si bonding configuration resulting from O-H dissociative adsorption is more thermodynamically favorable than the experimentally observed N-Si bonding configuration, suggesting that the interfacial dissociative adsorption reaction is a kinetically controlled rather than a thermodynamically driven process. Alanine molecules in the second adlayer (transitional layer) are found to attach to those in the first adlayer (interfacial layer) by N···HO hydrogen bonding, as supported by the presence of the N 1s feature at 401.0 eV. An alanine molecule H-bonded to a dehydrogenated alanine in the first adlayer has also been observed in STM as a brighter and larger protrusion close to the expected location of the free OH group in the dehydrogenated first-adlayer alanine. No thick zwitterionic alanine film can be obtained at room temperature possibly due to steric constraint caused by the methyl group.

Global Polarization of Ξ and Ω Hyperons in Au+Au Collisions at sqrt[s_{NN}]=200 GeV

Global polarization of Ξ and Ω hyperons has been measured for the first time in Au+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements of the Ξ^{-} and Ξ[over ¯]^{+} hyperon polarization have been performed by two independent methods, via analysis of the angular distribution of the daughter particles in the parity violating weak decay Ξ→Λ+π, as well as by measuring the polarization of the daughter Λ hyperon, polarized via polarization transfer from its parent. The polarization, obtained by combining the results from the two methods and averaged over Ξ^{-} and Ξ[over ¯]^{+}, is measured to be ⟨P_{Ξ}⟩=0.47±0.10(stat)±0.23(syst)% for the collision centrality 20%-80%. The ⟨P_{Ξ}⟩ is found to be slightly larger than the inclusive Λ polarization and in reasonable agreement with a multiphase transport model. The ⟨P_{Ξ}⟩ is found to follow the centrality dependence of the vorticity predicted in the model, increasing toward more peripheral collisions. The global polarization of Ω, ⟨P_{Ω}⟩=1.11±0.87(stat)±1.97(syst)% was obtained by measuring the polarization of daughter Λ in the decay Ω→Λ+K, assuming the polarization transfer factor C_{ΩΛ}=1.

Significant magneto-elastic coupling at Griffiths-like phase boundaries in low dimensional oxides,ASb2O6(ANi and Mn)

The compounds, NiSb₂O₆(NSO) and MnSb₂O₆(MSO) attract the community for the quasi one-dimensional and layered structure composed of Ni²⁺and Mn²⁺, which orders antiferromagnetically atT_N= 6.7 and 12 K, respectively. Here, we report the Griffiths-like phase much aboveT_Nin the range of 37-85 K and 25-80 K for NSO and MSO, respectively. The dc magnetization results indicate the Griffiths-like phase, following the modified Curie-Weiss law. The magneto-capacitive responses for both the compounds show anomalies at the onset of the Griffiths-like phase. Intriguingly, the low temperature synchrotron diffraction results are conclusive for determining the singularities for both the compounds. Interplay between the low-dimensionality, magnetic frustration, and magneto-elastic coupling correlates the observed short range ordered state, which is suggested as a Griffiths-like phase, aboveT_Nfor both the compounds.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Pembrolizumab-induced large duct cholangiopathy: Diagnosis and follow.up imaging

Immune-checkpoint inhibitor mediated hepatobiliary injury is an emerging concern in cancer treatment. Most of these adverse reactions are attributed to nivolumab and are characterized by panlobular hepatitis. Large duct cholangiopathy related to these drugs is extremely rare. We present a case of adenocarcinoma of lung treated with pembrolizumab who developed biochemical and imaging features consistent with cholangiopathy characterized by common bile duct dilatation, wall enhancement, and gallbladder wall edema. On follow-up in the fourth month, the imaging features persisted despite the normalization of liver enzymes. To the best of our knowledge, this is the first description of diagnosis and follow-up imaging of pembrolizumab-related cholangiopathy in imaging literature.

Nonmonotonic Energy Dependence of Net-Proton Number Fluctuations

Nonmonotonic variation with collision energy (sqrt[s_{NN}]) of the moments of the net-baryon number distribution in heavy-ion collisions, related to the correlation length and the susceptibilities of the system, is suggested as a signature for the quantum chromodynamics critical point. We report the first evidence of a nonmonotonic variation in the kurtosis times variance of the net-proton number (proxy for net-baryon number) distribution as a function of sqrt[s_{NN}] with 3.1  σ significance for head-on (central) gold-on-gold (Au+Au) collisions measured solenoidal tracker at Relativistic Heavy Ion Collider. Data in noncentral Au+Au collisions and models of heavy-ion collisions without a critical point show a monotonic variation as a function of sqrt[s_{NN}].

High-dose salvage re-irradiation for recurrent/progressive adult diffuse glioma: healing or hurting?

PURPOSE

To report survival outcomes and identify prognostic factors of salvage re-irradiation (re-RT) in recurrent/progressive glioma.

METHODS

Medical records of patients treated with high-dose re-RT as part of multi-modality salvage therapy for recurrence/progression of adult diffuse glioma from 2010 to 2019 were analyzed retrospectively.

RESULTS

A total of 111 patients developing recurrent/progressive high-grade glioma after adequate upfront treatment at initial diagnosis were included. The first course of radiotherapy (RT) had been delivered to a median dose of 59.4 Gy with an inter-quartile range (IQR) of 54-60 Gy. Median time to recurrence/progression was 4.3 years (IQR = 2.3-7.4 years) while the median time to re-RT was 4.8 years (IQR = 3.6-7.9 years). Re-RT was delivered with intensity-modulated radiation therapy (IMRT) using 1.8 Gy/fraction to a median dose of 54 Gy (IQR = 50.4-55.8 Gy) for a cumulative median equivalent dose in 2-Gy fractions (EQD2) of 104.3 Gy (IQR = 102.6-109.4 Gy). At a median follow-up of 14 months after re-RT, the 1-year Kaplan-Meier estimates of post-re-RT progression-free survival (PFS) and overall survival (OS) were 42.8 and 61.8%, respectively. Univariate analysis identified histological grade at recurrence/progression; histological subtype; disease-free interval (DFI) and time interval between both courses of RT; performance status at re-RT; dose at re-RT and cumulative EQD2; isocitrate dehydrogenase (IDH) mutation; and O⁶-methyl-guanine DNA methyl transferase (MGMT) gene promoter methylation as significant prognostic factors. Preserved performance status, longer DFI, prolonged time interval between both courses of RT, and presence of IDH mutation were associated with significantly improved PFS on multi-variate analysis. However, only performance status retained independent prognostic significance for OS on multi-variate analysis. Post-treatment changes were seen in 33 (30%) patients on follow-up imaging, with higher cumulative dose (EQD2 ≥ 104.3 Gy) being associated with increased risk of post-re-RT pseudo-progression.

CONCLUSION

This clinical audit reports encouraging survival outcomes and identifies key prognostic factors associated with high-dose salvage re-RT in recurrent/progressive glioma.

Readily usable strategies to control mastitis for production augmentation in dairy cattle: A review

Mastitis in dairy cattle is the most common management disorder that causes higher economic losses by lowering production and quality of milk leads to substantial economical loss. The aim of this article was to review worldwide important advances in strategies to control mastitis for production augmentation in dairy cattle. Many scientists worked to identify effective strategies to control mastitis caused by Streptococcus agalactiae, Staphylococcus aureus, and others. It is necessary to identify mechanisms of infection, define clinical and subclinical states of disease, determine exposure time, and identify pathogen-specific characteristics. Evolvement of management strategies that incorporated hygienic procedures (animal, floor, and milkman), post milking standing period of animal and strategic use of antibiotic or herbal therapy at dry-off, nutritional supplementation, fly control, body condition score optimization, etc., resulted in widespread control of mastitis. The udder, teat of animal, scientific management of milking, automatic milking procedure, genetic selection are considered as important factors to control mastitis. As farm management changed, scientists were directed to redefine control of mastitis caused by opportunistic pathogens of environmental sources and have sought to explore management strategies which will maintain animal well-being in a judicial way. Although significant advances in mastitis management have been made changing herd structure, changing climatic scenario and more rigorous milk processing standards ensure that mastitis will remain important issue for future research.