Genome-wide association meta-analysis of spontaneous coronary artery dissection identifies risk variants and genes related to artery integrity and tissue-mediated coagulation

Spontaneous coronary artery dissection (SCAD) is an understudied cause of myocardial infarction primarily affecting women. It is not known to what extent SCAD is genetically distinct from other cardiovascular diseases, including atherosclerotic coronary artery disease (CAD). Here we present a genome-wide association meta-analysis (1,917 cases and 9,292 controls) identifying 16 risk loci for SCAD. Integrative functional annotations prioritized genes that are likely to be regulated in vascular smooth muscle cells and artery fibroblasts and implicated in extracellular matrix biology. One locus containing the tissue factor gene F3, which is involved in blood coagulation cascade initiation, appears to be specific for SCAD risk. Several associated variants have diametrically opposite associations with CAD, suggesting that shared biological processes contribute to both diseases, but through different mechanisms. We also infer a causal role for high blood pressure in SCAD. Our findings provide novel pathophysiological insights involving arterial integrity and tissue-mediated coagulation in SCAD and set the stage for future specific therapeutics and preventions.

Dynamic nomogram for long-term survival in patients with locally advanced oropharyngeal cancer after (chemo)radiotherapy

PURPOSE

This study aimed to establish a nomogram for predicting overall survival (OS) in oropharyngeal cancer patients treated with curative (chemo)radiotherapy.

MATERIALS AND METHODS

The dynamic nomogram was constructed on 273 patients with oropharyngeal squamous cell carcinoma treated in a Tertiary Head and Neck Cancer Unit. The clinical features that were previously reported to be associated with OS were analyzed. The performance of the nomogram was assessed using concordance index (C-index) and calibration curves.

RESULTS

The nomogram incorporated three explanatory variables derived from a decision tree approach including HPV status, N classification according to 8th edition TNM and early response to (chemo)radiotherapy. The nomogram was capable to predict OS with a validation C-index of 0.768. The proposed stratification in risk groups allowed significant distinction between Kaplan-Meier curves for OS outcome (p < 0.0001).

CONCLUSIONS

The nomogram provided an accurate evaluation of OS for oropharyngeal cancer patients treated with curative (chemo)radiotherapy.

Wayfinding and spatial perception among adolescents with mild intellectual disability

BACKGROUND

The study's aim was to examine whether spatial orientation can be improved in students with cognitive disabilities.

METHOD

Participants were 55 boys and girls with attention deficit and mild cognitive impairment from a special education school. The procedure included an intervention for two experimental groups that studied wayfinding and orientation in the environment: group #1 learned to use a map while navigating, and group #2 learned to use a Google navigation app with voice instructions. Two pre-post tests were applied: (1) Mental folding test for children (MFTC) and (2) field test with map.

RESULTS

Both groups improved their ability in navigation and wayfinding. No advantage for one learning method over the other was demonstrated, except for shortened navigation time in the group navigating with a map, and a slight though not significant tendency of improvement in the MFTC task in the group learning navigation using a voice app.

CONCLUSION

It is worth noting that the study did not examine the students' own preferences for the way of learning, which may have implications for the degree of possible improvement. Also, a longer period of the learning process might yield a clearer understanding concerning the differences between the two teaching methods that were examined.

Can artificial intelligence prediction of successful atrial fibrillation catheter ablation therapy be interpretable?

Background

Radiofrequency catheter ablation (RFCA) therapy is the first-line treatment for atrial fibrillation (AF), the most common type of cardiac arrhythmia globally. However, the procedure currently has low success rates in dealing with persistent AF, with a reoccurrence rate of ∼50% post-ablation. Therefore, artificial intelligence (AI), particularly deep learning (DL), has increasingly been applied to improve and optimise treatments for AF. However, AI is limited by its black-box nature. Therefore, a factor hindering the broad clinical application of DL in AF is the lack of assurance that the DL model is using physiological relevant features when making its prediction. In order to provide this assurance, its decision process needs to be interpretable and have biomedical relevance.

Aim

This study aims to explore interpretability in DL prediction of successful ablation therapy for AF and evaluate if pro-arrhythmogenic regions in the left atrium (LA) were used in its decision process.

Methods

LA models with segmented fibrotic tissue were derived from 122 late gadolinium-enhanced magnetic resonance (LGE MR) images of persistent AF patients. To increase the dataset size, an additional 199 synthetic LA tissue models were generated from the LGE MR images. Two ablation strategies were simulated: fibrosis-based ablation (FIBRO) and a rotor-based ablation (ROTOR). RFCA strategy success was determined by its ability to terminate persistent AF in 2s with less than 40% of the tissue ablated [1]. A convolutional neural network (CNN) was developed to predict the success of each RFCA strategy, and gradient weighted class activation maps (GradCAM) were used to assess if the CNN was using locations of pro-arrhythmogenic regions in its decision process on an independent test set of 50 LA tissue models.

Results

For predicting the success of the FIBRO strategy, the CNN model had an AUC (area under the receiver operating characteristic curve) of 0.92±0.02, recall of 0.89±0.03 and precision of 0.82±0.02. For the ROTOR strategy, the AUC was 0.77±0.02, the recall was 0.93±0.04 and the precision was 0.76±0.02. Finally, the independent test set's GradCAM saliency maps showed that 62±25% and 71±13% of ablation lesions (known from the LA model simulations, but unseen by the CNN during training) coincided with informative regions in the saliency maps for the FIBRO and ROTOR strategies, respectively (Figure 1).

Conclusion

The most informative regions of the saliency maps coincided with the successful ablation lesions, suggesting that the DL model was able to identify ablated pro-arrhythmogenic regions by leveraging structural features of LGE MR images. In the future, this technique could provide a clinician with a decision support tool and increase confidence in the AI prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): UK Medical Research Council

Left ventricular myocardial tissue characteristics and function among healthy subjects with varying atherosclerotic cardiovascular disease risk

 

The Atherosclerotic Cardiovascular Disease Risk (ASCVD) score by pooled cohort equation is a reliable predictor for future ASCVD events and is used to guide primary prevention in asymptomatic aging subjects. ASCVD risk is associated with burden of coronary artery disease as measured from computed tomography angiography.

Purpose

We aim to investigate the association between ASCVD risk and cardiac magnetic resonance (CMR) derived left ventricular (LV) myocardial tissue characteristics (T1 values) and LV systolic and diastolic ventricular function in a large cohort of healthy subjects.

Methods

We selected all healthy subjects who underwent CMR from the UK-Biobank cohort study. We collected patient characteristics, cardiovascular risk factors, blood pressure at CMR, medication use and cholesterol levels. We used AI-CMRQC, our quality-controlled tool for analysis of cardiovascular function metrics from CMR using artificial intelligence [1,2], to automatically extract septal T1 values from native T1 maps and LV ejection fraction (EF), peak ejection and early filling rates (PER, PEFR), peak systolic longitudinal strain and diastolic strain-rate, mitral valve annular plane systolic excursion and diastolic peak velocity from cine long and short axis acquisitions. Subjects were stratified for low (&lt;7.5%), intermediate (7.5–21%) and high (&gt;21%) ASCVD risk. One-way repeated measures ANOVA was used to examine the association between cardiovascular metrics and ASCVD risk groups.

Results

12,493 healthy subjects were included (females n=6,000). Mean age was 62.7±7.5 years, 3.2% had diabetes, 12.5% received treatment for hypertension and 23% smoked. ASCVD risk score could be calculated in 9,487 subjects. Mean ASCVD risk was 12.7±9%. 38% of subjects had low, 43% intermediate and 19% high ASCVD risk.

T1 values fell across the incremental ASCVD groups (low: 943±51 ms, intermediate: 921±47 ms, high: 918±50 ms, P&lt;0.001). Indexed LV PEFR (low: 188±45 ml/ms·m2, intermediate: 170±48 ml/ms·m2, high: 147±45 ml/ms·m2, P&lt;0.001), diastolic longitudinal strain rate (low: 1.25±0.36, intermediate: 1.20±0.37, high: 1.17±0.36, P&lt;0.001) also fell consistently with incremental risk. A statistically significant, but clinically less relevant decrease was seen for LVEF (low: 59±6%, intermediate 58±6%, high: 57±6% p&lt;0.001) and longitudinal systolic strain (low: 21±3.5%, intermediate: 21±3.4%, high: 21±3.5%).

Conclusion

Increasing ASCVD risk was associated with lower native T1 values and decreasing metrics of diastolic and systolic LV function. The fall in T1 might suggest fibrofatty replacement in the LV myocardium in patients with incremental ASCVD risk that could contribute to the observed deterioration of LV function.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIHR MedTech cooperation awarded to Guy's and ST Thomas NHS Foundation Trust

455 The Changing Trends of Image Guided Biopsy of Small Renal Masses Before Intervention- an Analysis of European Multinational Prospective EuRECA Registry

Aim

To evaluate the use of pre-cryoablation biopsy for small renal masses (SRMs) and the effects of increasing up take on histological results of treated SMRs.

Method

From 2015 to 2019, patients with sporadic T1N0M0 SRMs undergoing percutaneous, laparoscopic or open cryoablation from 14 European institutions within the European Registry For Renal Cryoablation (EuRECA) were included for the retrospective analysis. Univariate and multivariate logistic models were used to evaluate the trends, histological results and the factors influencing use of pre-cryoablation biopsy.

Results

871 patients (Median [IQR] age, 69[14], 298 women) undergoing cryoablation were evaluated. The use of pre-cryoablation biopsy has significantly increased from 42% (65/156) in 2015 to 72% (88/122) in 2019 (p&lt;0.001). Patients treated for a benign histology are significantly more likely to have presented later in the trend, where pre-cryoablation biopsy is more prevalent (OR: 0.64, 95% CI 0.51–0.81, p&lt;0.001). Patients treated for undiagnosed histology are also significantly less likely to have presented in 2018 compared to 2016 (OR 0.31, 95% CI 0.10–0.97, p=0.044). Patients aged 70+ are less likely to be biopsies pre-cryoablation (p&lt;0.05). R.E.N.A.L. nephrometry score of 10+ and a Charlson Comorbidity Index &gt;1 are factors associated with lower likelihood to not have received a pre-cryoablation biopsy (p&lt;0.05).

Conclusion

An increased use of pre-cryoablation biopsy was observed and cryoablation patients treated with a benign histology is more likely to have presented in periods where pre-cryoablation biopsy is not as prevalent. Comparative studies are needed to draw definitive conclusions on the effect of pre-cryoablation biopsy on SRM treatments.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

Clinical features associated with ADB-BUTINACA exposure in patients attending emergency departments in England

OBJECTIVE

Synthetic cannabinoid receptor agonists (SCRA) are commonly encountered new psychoactive substances. Here we report the recent detection of ADB-BUTINACA in samples from patients attending United Kingdom emergency departments with toxicity after suspected drug misuse and describe the associated clinical features.

METHODS

Consenting adults (≥16 y) presenting to participating hospitals with toxicity after suspected drug misuse have been included in the Identification Of Novel psychoActive substances (IONA) study since March 2015. Demographic and clinical features are recorded and blood and/or urine samples analysed using high-resolution accurate mass liquid chromatography-mass spectrometry.

RESULTS

By December 2021, analytical data were available for 1279 IONA participants and ADB-BUTINACA was detected in at least one sample from 10 (9 males, age range 16-51 median 45 years), all presenting since February 2021. Smoking 'spice' was reported by four patients, two had ingested edible "cannabis" gums and four reported heroin use (2 intravenous, 1 smoked, 1 route not known). Co-use of pregabalin (oral) and crack cocaine (smoked) were also reported. In 3 cases ADB-BUTINACA was the only substance detected, while in seven other substances of misuse were also detected including other SCRA, opioids, benzodiazepines cocaine and pregabalin. Clinical features reported in these 2 groups respectively included reduced level of consciousness (3/3, 6/7), agitation (0/3, 4/7), tachycardia (0/3, 3/7), seizures (1/3, 1/7), hallucinations (1/3, 1/7), hypotension (1/3, 1/7). Metabolic acidosis (1/3, 0/7) and respiratory acidosis (1/3, 0/7), All 10 patients recovered with supportive care, including intubation and ventilation for one case. The median length of hospital stay was 19 h (range 2.6-131 h).

CONCLUSIONS

ADB-BUTINACA has recently emerged as a drug of misuse in England. Clinical features of toxicity are consistent with those of other SCRA and include reduced level of consciousness, respiratory and/or metabolic acidosis, seizures, confusion and hallucinations.

Tracking NSZD mass removal rates over decades: Site-wide and local scale assessment of mass removal at a legacy petroleum site

Long-term estimates of natural source zone depletion (NSZD) rates for petroleum LNAPL (light non-aqueous phase liquid) sites are not available. One-off measurements are often thought valid over the lifetime of LNAPL sites. In the context of site-wide LNAPL mass estimates, we report site-specific gasoline and diesel NSZD rates spanning 21-26 years. Using depth profiles of soil gases (oxygen, carbon dioxide, methane, volatiles) above LNAPL, NSZD rates were estimated in 1994, 2006 and 2020 for diesel and 1999, 2009 and 2020 for gasoline. Each date also had soil-core mass estimates, which together with NSZD rates allow estimation of the longevity for LNAPL presence. Site-wide coring (in 1992, 2002, 2007) estimated LNAPL mass reductions of 12,000 t. For diesel NSZD, the ratio of NSZD rates for 2006 (16,000-49,000 L/ha/y) to those in 2020 (2600-14,000 L/ha/y) was ~3-6. By 2020, the 1994 diesel NSZD rates would have predicted the entire removal of measured mass (16-42 kg/m²). For gasoline, NSZD rates in 1999 were extremely high (50,000-270,000 L/ha/y) but 9-27 times lower (5800-10,000 L/ha/y) a decade later. The gasoline NSZD rates in 1999 predicted near complete mass removal in 2-12 years, but 10-11 kg/m² was measured 10 and 21 years later which is 26% of the initial mass in 1999. The outcomes substantiate the need to understand NSZD rate changes over the lifetime of LNAPL-impacted sites.

Non-invasive delineation of ventricular tachycardia substrates for cardiac stereotactic body radiotherapy: utility of in-silico pace-mapping

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): EPSRC

Background

Cardiac stereotactive body radiotherapy (CSBRT) is an emerging, non-invasive ablation modality that targets ventricular tachycardia (VT) substrates in patients with limited conventional treatment options. Success of CSBRT hinges primarily on the correct identification of VT targets, which requires non-invasive planning. Current non-invasive, pre-procedure strategies employ multi-electrode electrocardiographic imaging (ECGi). Given its significant cost and potential challenges in detecting endocardial, intramural and/or septal VT sites, there is a need to optimise VT delineation strategies for CSBRT; patient-specific simulations may show promise at guiding such planning non-invasively.

Purpose

We aim to perform non-invasive, in-silico pace-mapping on an image-based computational model to identify VT substrates for CSBRT. We intend to show the utility of our fast computational pipeline - relying on CT imaging data only - to provide further insights on inaccessible, scar-related VT episodes.

Methods

A detailed computational torso model of a CSBRT candidate with incessant VT was generated from CT imaging data. Extracellular content volumes (ECVs) were used to identify different tissue types (healthy, border zone and non-conducting), and scale model tissue conductivities accordingly. In-silico pace-mapping was performed by simulating ~360 paced beats across the LV, and computing corresponding 12-lead ECGs within a fast electrophysiological (EP) simulation environment combining reaction-eikonal and lead field methods. QRS complexes from simulated paced beats were used to construct the virtual correlation pace-map against the measured QRS of the clinically-induced VT, along with a ‘reference-less’ virtual pace-map constructed from neighbouring paced-beat QRSs (within a 20 mm radius). An epicardial activation map of the clinically-induced VT was reconstructed from ECGi measurement, and used for comparison against our virtual pace-maps.

Results

Correlations between simulated paced-beat QRS complexes and the clinically-induced VT QRS were higher in mid-apical, infero-septal segments - segment 9 (85.71%), 10 (87.95%) and 15 (89.58%) - identifying septal origin and pathway of the induced re-entrant circuit. A possible septal VT isthmus was also identified by a high gradient in the virtual reference-less pace-map in segment 9 (&gt; 2.5%/mm). Our in-silico predictions were in agreement with the clinical regions identified for CSBRT (segment 9 and 15), and provided additional information on the 3D and septal dynamics of the VT episode.

Conclusions

Our in-silico pace-mapping study successfully localised VT substrates in a patient unable to receive standard ablative procedures, and provided further clinical insight on the induced VT dynamics. Our rapid in-silico pace-mapping approach may be utilised to support optimal identification of VT target volumes for CSBRT.

Automated detection of scar-related ventricular tachycardia origins from implanted device electrograms: a combined computational-AI platform

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): EPSRC

Background

Existing strategies that identify ventricular tachycardia (VT) ablation targets either employ invasive and time-consuming electrophysiological (EP) mapping, or non-invasive modalities that utilise standard electrocardiogram (ECG) signals. Success of these pre-procedure ablation approaches in localising re-entrant VTs often relies on VT induction, which could be avoided by utilising recordings of clinical VT episodes stored as electrograms (EGMs) in implanted devices. Such a non-invasive approach that localises VT substrates from EGMs may aid ablation planning, enhancing safety and speed.

Purpose

Our goal is to automate scar-related VT localisation by utilising EGM recordings of VT episodes from implanted devices. To achieve this, deep-learning algorithms will be trained on computational data to return VT sites of origin from implanted device EGMs. Ultimately, we intend to utilise this computational-artificial intelligence (AI) framework to detect ablation targets of clinical VT episodes and guide pre-procedure ablation planning non-invasively.

Methods

A comprehensive library of ECGs and EGMs from simulated paced beats (~15000) and scar-related VTs (500) was generated across five detailed torso models within a fast EP computational environment, combining reaction-eikonal and lead field methods. ECG (or EGM) traces from simulated paced beats were used to initially pre-train two convolutional neural network (CNN) long short-term (LSTM) attention-based architectures. Subsequently, signals of the in-silico, re-entrant VTs were used to re-train the networks to output the sites of origin of these episodes in a standardised ventricular coordinate space. Finally, the retrained CNN architectures were tested on re-entrant VTs of unseen models, and median localisation errors (LEs) were estimated against known VT origins from simulations.

Results

The performance of the networks to localise scar-related VT episodes was asserted for each torso model. When a torso model was only seen during initial training on simulated paced beats, implanted device EGMs and ECGs successfully localised VT sources with LEs 10.04 – 16.36 mm and 10.05 – 12.79 mm, respectively. When a torso model was not seen during pacing or VT training, recreating potential clinical application settings where ECGs or EGMs of clinical VTs would be the only inputs to the networks, LEs ranged 12.42 - 22.79 mm and 12.41 - 19.68 mm for EGM and ECG-based testing, respectively.

Conclusions

Our study successfully detected VT ablation substrates with accuracy that could be beneficial in clinical ablation settings. The proposed computational-AI framework may be used to automate the localisation of scar-related VTs from clinical ECGs or EGM recordings from implanted devices, ultimately aiding ablation planning.

In situ characterization of liquids at high pressure combining X-ray tomography, X-ray diffraction and X-ray absorption using the white beam station at PSICHÉ

A novel experimental setup dedicated to the study of liquid and amorphous materials, on the white beam station of the PSICHÉ beamline at SOLEIL, is described. The Beer-Lambert absorption method has been developed using a broad-spectrum (white) incident beam for in situ density measurements at extreme conditions of pressure and temperature. This technique has been combined with other existing X-ray techniques (radiographic imaging, tomography and combined angle energy dispersive X-ray diffraction). Such a multi-technical approach offers new possibilities for the characterization of liquid and amorphous materials at high pressure and high temperature. The strength of this approach is illustrated by density measurements of liquid gallium at pressures up to 4 GPa, combining the three independent X-ray techniques (the Beer-Lambert absorption method, tomography and X-ray diffraction).

Combined angular and energy dispersive diffraction: optimized data acquisition, normalization and reduction

Combined angular and energy dispersive diffraction is particularly well suited to experiments at high pressures in large-volume presses, and to the study of liquid or amorphous systems. This work describes the data acquisition, correction and reduction approach developed at the PSICHE beamline of the SOLEIL synchrotron. The measured data were normalized for both the scattering volume and the effective incident energy spectrum. By optimizing the acquisition strategy, the measurement time and radiation dose are greatly reduced. The correction and reduction protocol outputs normalized scattering profiles that are suitable for pair distribution function or liquid structure analysis. These processes are demostrated with examples from a number of real experimental data sets.

Complex gastroschisis: a new indication for fetal surgery?

Gastroschisis (GS) is a congenital abdominal wall defect, in which the bowel eviscerates from the abdominal cavity. It is a non-lethal isolated anomaly and its pathogenesis is hypothesized to occur as a result of two hits: primary rupture of the 'physiological' umbilical hernia (congenital anomaly) followed by progressive damage of the eviscerated bowel (secondary injury). The second hit is thought to be caused by a combination of mesenteric ischemia from constriction in the abdominal wall defect and prolonged amniotic fluid exposure with resultant inflammatory damage, which eventually leads to bowel dysfunction and complications. GS can be classified as either simple or complex, with the latter being complicated by a combination of intestinal atresia, stenosis, perforation, volvulus and/or necrosis. Complex GS requires multiple neonatal surgeries and is associated with significantly greater postnatal morbidity and mortality than is simple GS. The intrauterine reduction of the eviscerated bowel before irreversible damage occurs and subsequent defect closure may diminish or potentially prevent the bowel damage and other fetal and neonatal complications associated with this condition. Serial prenatal amnioexchange has been studied in cases with GS as a potential intervention but never adopted because of its unproven benefit in terms of survival and bowel and lung function. We believe that recent advances in prenatal diagnosis and fetoscopic surgery justify reconsideration of the antenatal management of complex GS under the rubric of the criteria for fetal surgery established by the International Fetal Medicine and Surgery Society (IFMSS). Herein, we discuss how conditions for fetoscopic repair of complex GS might be favorable according to the IFMSS criteria, including an established natural history, an accurate prenatal diagnosis, absence of fully effective perinatal treatment due to prolonged need for neonatal intensive care, experimental evidence for fetoscopic repair and maternal and fetal safety of fetoscopy in expert fetal centers. Finally, we propose a research agenda that will help overcome barriers to progress and provide a pathway toward clinical implementation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

601 The Effect of the COVID-19 Pandemic on Hip Fracture Mortality in The South West of England

Aim

High perioperative mortality rates in surgical patients suffering concomitant COVID-19 infection have contributed to a fall in elective and urgent surgery. However, data and debate have centred around post hoc infected cases, without the context of the rest of the surgical cohort, and without comparable historical control groups. We aimed to address this by studying patients with a neck of femur fracture. This common condition has a stable incidence with good prospective data collected routinely for the National Hip Fracture Database (NHFD).

Method

We analysed NHFD data for all hospitals within our region over a 3-month period, covering the height of the first outbreak and compared this with the same months in 2019.

Results

The incidence of hip fracture was stable (463 in 2019, 448 in 2020). 30-day mortality was 6.26% in 2019 and 7.14% in 2020 (p = 0.595). In the second cohort, 14 patients tested positive for COVID-19 perioperatively. Of these, 3 died (21%) compared to 29 who tested negative (p &lt; 0.001). Mean time to operation reduced by 1.90 hours, with a significant drop in patients waiting over 36 hours (190 to 85, p &lt; 0.001). There were no significant differences between gender, ASA grade or pre-operative AMTS.

Conclusions

We have confirmed high perioperative mortality for those with COVID-19 infection but have not shown a statistically significant difference in overall mortality from hip fracture during the initial phase of the pandemic. We argue from this data set that the hypothetical risk of surgery during this pandemic may have been overestimated.

Large-scale, multi-vendor, multi-protocol, quality-controlled analysis of clinical cine CMR using artificial intelligence

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Advancing Impact Award scheme of the EPSRC Impact Acceleration Account at King’s College London

Background

Artificial intelligence (AI) has the potential to facilitate the automation of CMR analysis for biomarker extraction. However, most AI algorithms are trained on a specific input domain (e.g., scanner vendor or hospital-tailored imaging protocol) and lack the robustness to perform optimally when applied to CMR data from other input domains.

Purpose

To develop and validate a robust CMR analysis tool for automatic segmentation and cardiac function analysis which achieves state-of-the-art performance for multi-vendor short-axis cine CMR images. 

Methods

The current work is an extension of our previously published quality-controlled AI-based tool for cine CMR analysis [1]. We deployed an AI algorithm that is equipped to handle different image sizes and domains automatically - the ‘nnU-Net’ framework [2] - and retrained our tool using the UK Biobank (UKBB) cohort population (n = 4,872) and a large database of clinical CMR studies obtained from two NHS hospitals (n = 3,406). The NHS hospital data came from three different scanner types: Siemens Aera 1.5T (n = 1,419), Philips Achieva 1.5T and 3T (n = 1,160), and Philips Ingenia 1.5T (n = 827). The ‘nnU-net’ was used to segment both ventricles and the myocardium. The proposed method was evaluated on randomly selected test sets from UKBB (n = 488) and NHS (n = 331) and on two external publicly available databases of clinical CMRs acquired on Philips, Siemens, General Electric (GE), and Canon CMR scanners – ACDC (n = 100) [3] and M&Ms (n = 321) [4]. We calculated the Dice scores - which measure the overlap between manual and automatic segmentations - and compared manual vs AI-based measures of biventricular volumes and function. 

Results

 Table 1 shows that the Dice scores for the NHS, ACDC, and M&Ms scans are similar to those obtained in the highly controlled, single vendor and single field strength UKBB scans. Although our AI-based tool was only trained on CMR scans from two vendors (Philips and Siemens), it performs similarly in unseen vendors (GE and Canon). Furthermore, it achieves state-of-the-art performance in online segmentation challenges, without being specifically trained on these databases. Table 1 also shows good agreement between manual and automated clinical measures of ejection fraction and ventricular volume and mass.

Conclusions

We show that our proposed AI-based tool, which combines training on a large-scale multi-domain CMR database with a state-of-the-art AI algorithm, allows us to robustly deal with routine clinical data from multiple centres, vendors, and field strengths. This is a fundamental step for the clinical translation of AI algorithms. Moreover, our method yields a range of additional metrics of cardiac function (filling and ejection rates, regional wall motion, and strain) at no extra computational cost.

Are schools drivers of COVID-19 infections-an analysis of outbreaks in Colorado, USA in 2020

BACKGROUND

The impact of school closures/reopening on transmission of SARS-CoV-2 in the wider community remains contested.

METHODS

Outbreak data from Colorado, USA (2020), alongside data on implemented public health measures were analyzed.

RESULTS

There were three waves (n = 3169 outbreaks; 61 650 individuals). The first was led by healthcare settings, the second leisure/entertainment and the third workplaces followed by other settings where the trajectory was equally distributed amongst essential workplaces, non-essential workplaces, schools and non-essential healthcare.Non-acute healthcare, essential and non-essential workplace experienced more outbreaks compared to education, entertainment, large-group-living and social gatherings.Schools experienced 11% of identified outbreaks, yet involved just 4% of total cases. Conversely, adult-education outbreaks (2%) had disproportionately more cases (9%).

CONCLUSION

Our findings suggest schools were not the key driver of the latest wave in infections. School re-opening coinciding with returning to work may have accounted for the parallel rise in outbreaks in those settings suggesting contact-points outside school being more likely to seed in-school outbreaks than contact points within school as the wave of outbreaks in all other settings occurred either prior to or simultaneously with the schools wave.School re-opening is a priority but requires mitigation measures to do so safely including staggering opening of different settings whilst maintaining low levels of community transmission.

A systematic review and meta-analysis of laparotomy compared with laparoscopic management of interstitial pregnancy

BACKGROUND

Interstitial pregnancy is a rare but life-threatening condition accounting for 1-4% of all types of tubal ectopic pregnancies. It can be managed by open and minimally invasive surgical techniques. Our goal was to compare laparoscopic and open surgery for managing interstitial pregnancy.

SEARCH STRATEGY

We searched PubMed, Scopus, Web of Science, and Cochrane up to May 2020.

SELECTION CRITERIA

1) Women with interstitial pregnancy, 2) Intervention: laparoscopic surgery, 3) Comparator: open surgery, 4) Outcomes: Hospital stay, operation time, pain scale, blood loss. Secondary outcomes: any other reported 5) Study designs: interventional and observational.

DATA COLLECTION AND ANALYSIS

Data was extracted from the relevant articles and was pooled as mean difference (MD) or relative risk (RR) with a 95% confidence interval (CI).

MAIN RESULTS

We included six studies, three of which provided eligible data. The duration of hospital stay was lower in the laparoscopic surgery group (MD = -1.42, 95% CI [-1.72, -0.76], P < 0.0001). There was no significant difference in operative time (MD = 5.90, 95% CI [-11.30, 23.09], P = 0.50, blood loss (MD = -9.43, 95% CI [-214.18, 195.32], P = 0.93), complications (RR = 1.54, 95% CI [0.20, 11.85], P = 0.68), or blood transfusions (RR = 0.77, 95% CI [0.50, 1.25], P = 0.30).

CONCLUSION

Laparoscopic surgery is associated with shorter hospital stay, with no difference in terms of blood loss, post-, and intraoperative complications, and need for blood transfusion compared with laparotomy.

A plasma proteogenomic signature for fibromuscular dysplasia

AIMS

Fibromuscular dysplasia (FMD) is a poorly understood disease that predominantly affects women during middle-life, with features that include stenosis, aneurysm, and dissection of medium-large arteries. Recently, plasma proteomics has emerged as an important means to understand cardiovascular diseases. Our objectives were: (i) to characterize plasma proteins and determine if any exhibit differential abundance in FMD subjects vs. matched healthy controls and (ii) to leverage these protein data to conduct systems analyses to provide biologic insights on FMD, and explore if this could be developed into a blood-based FMD test.

METHODS AND RESULTS

Females with 'multifocal' FMD and matched healthy controls underwent clinical phenotyping, dermal biopsy, and blood draw. Using dual-capture proximity extension assay and nuclear magnetic resonance-spectroscopy, we evaluated plasma levels of 981 proteins and 31 lipid sub-classes, respectively. In a discovery cohort (Ncases = 90, Ncontrols = 100), we identified 105 proteins and 16 lipid sub-classes (predominantly triglycerides and fatty acids) with differential plasma abundance in FMD cases vs. controls. In an independent cohort (Ncases = 23, Ncontrols = 28), we successfully validated 37 plasma proteins and 10 lipid sub-classes with differential abundance. Among these, 5/37 proteins exhibited genetic control and Bayesian analyses identified 3 of these as potential upstream drivers of FMD. In a 3rd cohort (Ncases = 506, Ncontrols = 876) the genetic locus of one of these upstream disease drivers, CD2-associated protein (CD2AP), was independently validated as being associated with risk of having FMD (odds ratios  = 1.36; P = 0.0003). Immune-fluorescence staining identified that CD2AP is expressed by the endothelium of medium-large arteries. Finally, machine learning trained on the discovery cohort was used to develop a test for FMD. When independently applied to the validation cohort, the test showed a c-statistic of 0.73 and sensitivity of 78.3%.

CONCLUSION

FMD exhibits a plasma proteogenomic and lipid signature that includes potential causative disease drivers, and which holds promise for developing a blood-based test for this disease.

Evaluation of the Assurance GDS® for Salmonella Method in Foods and Environmental Surfaces: Multilaboratory Collaborative Study

A multilaboratory collaborative study was conducted to compare the detection of Salmonella by the Assurance GDS® for Salmonella method and the Reference culture methods. Six foods, representing a variety of low microbial and high microbial load foods were analyzed. Seventeen laboratories in the United States and Canada participated in this study. No statistical differences (P &lt; 0.05) were observed between the Assurance GDS for Salmonella and the Reference culture methods for any inoculation level of any food type or naturally contaminated food, except for pasta, for which the Assurance GDS method had a higher number of confirmed test portions for Salmonella compared to the Reference method.

Neurodevelopmental multimorbidity and educational outcomes of 766,244 Scottish schoolchildren

Background

Neurodevelopmental conditions commonly co-exist in children but, in comparison with adults, childhood multimorbidity has attracted less attention in research and clinical practice.

Methods

Record linkage of five Scotland-wide databases produced a cohort of 766,244 children attending Scottish schools between 2009 and 2013. Autistic spectrum disorder (ASD) and intellectual disabilities were ascertained from records of special educational need in the annual Pupil Census and attention deficit hyperactivity disorder (ADHD) and depression through relevant encashed prescriptions.

Results

Neurodevelopmental multimorbidity (≥2 conditions) was identified in 4,789 (0·6%) children; with ASD and ADHD the most common combination. Multimorbidity was associated with significantly increased risk of school absenteeism (adjusted IRR 1·23, 95% CI 1·20-1·28), school exclusion (adjusted IRR 3·04, 95% CI 2·74-3·38), low attainment (adjusted OR 12·07, 95% CI 9·15-15·94) and unemployment (adjusted OR 2·11, 95% CI 1·83-2·45) with clear dose relationships evident between number of conditions (0, 1, ≥2) and the last three outcomes. The associations with multimorbidity were stronger in girls than boys. Co-existence of depression was the strongest driver of absenteeism and co-existence of ADHD the strongest driver of exclusion. Low attainment and unemployment were, in part, mediated by absence and attainment respectively, and were not driven by specific conditions but rather multimorbidity from any cause.

Conclusions

Structuring clinical practice and training around single conditions may disadvantage children with multimorbidity who are at significantly increased risk of adverse outcomes if their complex needs are not recognised and managed.

Key messages

Neurodevelopmental multimorbidity can have significant impacts on children’s education. A holistic healthcare approach is needed to reduce the address their needs and reduce the risk of adverse outcomes.

Current status of scoliosis school screening: targeted screening of underserved populations may be the solution

OBJECTIVES

The growing body of evidence documenting the effectiveness of brace treatment for scoliosis has renewed interest in potential benefits of early detection through school screening. We aimed to assess the prevalence and identify barriers of screening. We hypothesized that school screening is more frequent in schools that have a nurse on staff compared to schools without nurse on staff.

STUDY DESIGN

A questionnaire survey.

METHODS

All schools located in four counties in Louisiana, United States of America comprising the New Orleans metropolitan area between September 2015 and January 2016 were contacted by phone to assess rates of scoliosis screening, report the availability of a school nurse, and specify barriers if screening was not performed.

RESULTS

Two hundred and ninety-one schools responded to the survey including 152 public, 30 charter, and 109 private schools (101 had religious affiliation). A staff nurse was available in 180 schools (61.8%). Only 21 schools (7.2%) performed scoliosis screening. The majority were charter schools (11 schools), while six were private and four were public (P < 0.0001). Of these 21 schools, 16 (76.2%) had a nurse on staff while five schools did not (P = 0.16). Lack of a referral pathway in the event of a positive screen was the most common barrier to performing scoliosis screening.

CONCLUSION

Scoliosis screening is infrequent in the examined school districts. Efforts to support school screening can facilitate clear referral pathways for schools in the event of a positive screen. These findings suggest a potential need for different pathway of scoliosis screening. Pediatricians and family physicians can assist with scoliosis screening during the annual visit. While universal screening is overburdensome and likely unnecessary, targeted screening of underserved populations may prove to be beneficial. Further investigation should include assessment of the economic viability of targeted screening programs.

LEVEL OF EVIDENCE

IV.