Association of EEG Background With Diffusion-Weighted Magnetic Resonance Neuroimaging and Short-Term Outcomes After Pediatric Cardiac Arrest

BACKGROUND AND OBJECTIVES

EEG and MRI features are independently associated with pediatric cardiac arrest (CA) outcomes, but it is unclear whether their combination improves outcome prediction. We aimed to assess the association of early EEG background category with MRI ischemia after pediatric CA and determine whether addition of MRI ischemia to EEG background features and clinical variables improves short-term outcome prediction.

METHODS

This was a single-center retrospective cohort study of pediatric CA with EEG initiated ≤24 hours and MRI obtained ≤7 days of return of spontaneous circulation. Initial EEG background was categorized as normal, slow/disorganized, discontinuous/burst-suppression, or attenuated-featureless. MRI ischemia was defined as percentage of brain tissue with apparent diffusion coefficient (ADC) <650 × 10-6 mm2/s and categorized as high (≥10%) or low (<10%). Outcomes were mortality and unfavorable neurologic outcome (Pediatric Cerebral Performance Category increase ≥1 from baseline resulting in ICU discharge score ≥3). The Kruskal-Wallis test evaluated the association of EEG with MRI. Area under the receiver operating characteristic (AUROC) curve evaluated predictive accuracy. Logistic regression and likelihood ratio tests assessed multivariable outcome prediction.

RESULTS

We evaluated 90 individuals. EEG background was normal in 16 (18%), slow/disorganized in 42 (47%), discontinuous/burst-suppressed in 12 (13%), and attenuated-featureless in 20 (22%) individuals. The median percentage of MRI ischemia was 5% (interquartile range 1-18); 32 (36%) individuals had high MRI ischemia burden. Twenty-eight (31%) individuals died, and 58 (64%) had unfavorable neurologic outcome. Worse EEG background category was associated with more MRI ischemia (p < 0.001). The combination of EEG background and MRI ischemia burden had higher predictive accuracy than EEG alone (AUROC: mortality: 0.92 vs 0.87, p = 0.03) or MRI alone (AUROC: mortality: 0.92 vs 0.84, p = 0.02; unfavorable: 0.83 vs 0.73, p < 0.01). Addition of percentage of MRI ischemia to clinical variables and EEG background category improved prediction for mortality (χ2 = 19.1, p < 0.001) and unfavorable neurologic outcome (χ2 = 4.8, p = 0.03) and achieved high predictive accuracy (AUROC: mortality: 0.97; unfavorable: 0.92).

DISCUSSION

Early EEG background category was associated with MRI ischemia after pediatric CA. Combining EEG and MRI data yielded higher outcome predictive accuracy than either modality alone. The addition of MRI ischemia to clinical variables and EEG background improved short-term outcome prediction.

Emergency Department Use and Hospital Mortality Among Heart Transplant Recipients in the United States

BACKGROUND

Annual heart transplant (HT) volumes have increased, as have post-HT outpatient care needs. Data on HT-related emergency department (ED) visits are limited.

METHODS AND RESULTS

A retrospective analysis of 177 450 HT patient ED visits from the 2009 to 2018 Nationwide Emergency Department Sample was conducted. HT recipients, primary diagnoses, and comorbidities associated with ED visits were identified via International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes. Multivariable logistic regression was used to predict outcomes of hospital admission and death. HT volumes and HT-related ED visits increased from 2009 to 2018. Infection was the most common primary diagnosis (24%), and cardiac primary diagnoses represented 10% of encounters. Hospital admissions occurred in 48% of visits, but overall mortality was low (1.6%). Length of stay was 3.1 days (interquartile range, 1.6-5.9 days), and comorbidity burden was high: 42% had hypertension, 38% had diabetes, and 31% had ≥2 comorbidities. Those aged ≥65 years had significantly higher odds of admission (odds ratio [OR], 2.14 [95% CI, 1.97-2.33]) and death (OR, 2.06 [95% CI, 1.61-2.62]). Comorbidities increased odds of admission (OR, 1.62 [95% CI, 1.51-1.75]) but not death. Renal primary diagnosis had the highest risk of admission (OR, 4.1 [95% CI, 3.6-4.6]), but cardiac primary diagnosis had the highest odds of death (OR, 11.6 [95% CI, 9.1-14.8]).

CONCLUSIONS

HT-related ED visits increased from 2009 to 2018 with high admission rates but low in-hospital mortality, suggesting an opportunity to improve prehospital care. Older patients and those with cardiac primary diagnoses had the highest risk of death. The observed contrast between predictors of admission and mortality signals a need for further study to improve risk stratification and outpatient care strategies.

Cardiac magnetic resonance predictors for successful primary biventricular repair of unbalanced complete common atrioventricular canal

BACKGROUND

Patients with unbalanced common atrioventricular canal can be difficult to manage. Surgical planning often depends on pre-operative echocardiographic measurements. We aimed to determine the added utility of cardiac MRI in predicting successful biventricular repair in common atrioventricular canal.

METHODS

We conducted a retrospective cohort study of children with common atrioventricular canal who underwent MRI prior to repair. Associations between MRI and echocardiographic measures and surgical outcome were tested using logistic regression, and models were compared using area under the receiver operator characteristic curve.

RESULTS

We included 28 patients (median age at MRI: 5.2 months). The optimal MRI model included the novel end-diastolic volume index (using the ratio of left ventricular end-diastolic volume to total end-diastolic volume) and the left ventricle-right ventricle angle in diastole (area under the curve 0.83, p = 0.041). End-diastolic volume index ≤ 0.18 and left ventricle-right ventricle angle in diastole ≤ 72° yield a sensitivity of 83% and specificity of 81% for successful biventricular repair. The optimal multimodality model included the end-diastolic volume index and the echocardiographic atrioventricular valve index with an area under the curve of 0.87 (p = 0.026).

CONCLUSIONS

Cardiac MRI can successfully predict successful biventricular repair in patients with unbalanced common atrioventricular canal utilising the end-diastolic volume index alone or in combination with the MRI left ventricle-right ventricle angle in diastole or the echocardiographic atrioventricular valve index. A prospective cardiac MRI study is warranted to better define the multimodality characteristic predictive of successful biventricular surgery.

Pediatric Complex Regional Pain Syndrome With and Without a History of Prior Physical Trauma at Onset

OBJECTIVE

To determine whether differences exist between children with complex regional pain syndrome (CRPS) who identify an inciting physical traumatic event (group T) versus those without such history (group NT).

METHODS

We performed a single-center, retrospective study of children diagnosed with CRPS, 18 years old or younger, presenting between April 2008 and March 2021 and enrolled in a patient registry. Abstracted data included clinical characteristics, pain symptoms, Functional Disability Inventory, psychological history, and Pain Catastrophizing scale for children. Charts were reviewed for outcome data.

RESULTS

We identified 301 children with CRPS, 95 (64%) reported prior physical trauma. There was no difference between the groups regarding age, sex, duration, pain level, function, psychological symptoms, and scores on the Pain Catastrophizing Scale for Children. However, those in group T were more likely to have had a cast (43% vs 23%, P < 0.001). Those in group T were less likely to experience complete resolution of symptoms (64% vs 76%, P = 0.036). There were no other outcome differences between the groups.

DISCUSSION

We found minimal differences in children with CRPS who report a prior history of physical trauma to those who do not. Physical trauma may not play as significant a role as immobility, such as casting. The groups mostly had similar psychological backgrounds and outcomes.

Association Between Quantitative Diffusion-Weighted Magnetic Resonance Neuroimaging and Outcome After Pediatric Cardiac Arrest

BACKGROUND AND OBJECTIVES

Diffusion MRI can quantify the extent of hypoxic-ischemic brain injury after cardiac arrest. Our objective was to determine the association between the adult-derived threshold of apparent diffusion coefficient (ADC) <650 × 10-6 mm2/s in >10% of brain tissue and an unfavorable outcome after pediatric cardiac arrest. Since ADC decreases exponentially as a function of increasing age, we determined the association between (1) having >10% of brain tissue below a novel age-dependent ADC threshold, and (2) age-normalized whole-brain mean ADC and unfavorable outcome.

METHODS

This was a retrospective study of patients aged ≤18 years who had cardiac arrest and a clinically obtained brain MRI within 7 days. The primary outcome was unfavorable neurologic status at hospital discharge based on the Pediatric Cerebral Performance Category score. ADC images were extracted from 3-direction diffusion imaging. We determined whether each patient had >10% of voxels with an ADC below prespecified thresholds. We computed the whole-brain mean ADC for each patient.

RESULTS

One hundred thirty-four patients were analyzed. Patients with ADC <650 × 10-6 mm2/s in >10% of voxels had 15 times higher odds (95% CI 5-65) of an unfavorable outcome compared with patients with ADC <650 × 10-6 mm2/s (area under the receiver operating characteristic curve [AUROC] 0.72 [95% CI 0.63-0.80]). These ADC criteria had a sensitivity and specificity of 0.49 and 0.94, respectively, and positive and negative predictive values of 0.93 and 0.52, respectively, for an unfavorable outcome. The age-dependent ADC threshold that yielded optimal sensitivity and specificity for unfavorable outcomes was <300 × 10-6 mm2/s below each patient's predicted whole-brain mean ADC. The sensitivity, specificity, and positive and negative predictive values for this ADC threshold were 0.53, 0.96, 0.96, and 0.54, respectively (odds ratio [OR] 26.4 [95% CI 7.5-168.3]; AUROC 0.74 [95% CI 0.66-0.83]). Lower age-normalized whole-brain mean ADC was also associated with an unfavorable outcome (OR 0.42 [0.24-0.64], AUROC 0.76 [95% CI 0.66-0.82]).

DISCUSSION

Quantitative diffusion thresholds on MRI within 7 days after cardiac arrest were associated with an unfavorable outcome in children. The age-independent ADC threshold was highly specific for predicting an unfavorable outcome. However, the specificity and sensitivity increased when using age-dependent ADC thresholds. Age-dependent ADC thresholds may improve prognostic accuracy and require further investigation in larger cohorts.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that quantitative diffusion-weighted imaging within 7 days postarrest can predict an unfavorable clinical outcome in children.

Sex Differences in Left Ventricular Assist Device-related Emergency Department Encounters in the United States

BACKGROUND

There is a paucity of data regarding sex differences in the profiles and outcomes of ambulatory patients on left ventricular assist device (LVAD) support who present to the emergency department (ED).

METHODS AND RESULTS

We performed a retrospective analysis of 57,200 LVAD-related ED patient encounters from the 2010 to 2018 Nationwide Emergency Department Sample. International Classification of Diseases Clinical Modification, Ninth Revision and Tenth Revision, codes identified patients aged 18 years or older with LVADs and associated primary and comorbidity diagnoses. Clinical characteristics and outcomes were stratified by sex and compared. Multivariable logistic regression was used to evaluate predictors of hospital admission and death. Female patient encounters comprised 27.2% of ED visits and occurred at younger ages and more frequently with obesity and depression (all P < .01). There were no sex differences in presentation for device complication, stroke, infection, or heart failure (all P > .05); however, female patient encounters were more often respiratory- and genitourinary or gynecological related (both P < .01). After adjustment for age group, diabetes, depression, and hypertension, male patient encounters had a 38% increased odds of hospital admission (95% confidence interval 1.20-1.58), but there was no sex difference in the adjusted odds of death (odds ratio 1.11, 95% confidence interval 0.86-1.45).

CONCLUSIONS

Patient encounters of females on LVAD support have significantly different comorbidities and outcomes compared with males. Further inquiry into these sex differences is imperative to improve long-term outcomes.

Sepsis-Related Brain MRI Abnormalities Are Associated With Mortality and Poor Neurological Outcome in Pediatric Sepsis

BACKGROUND

It is not known whether brain magnetic resonance imaging (MRI) abnormalities in pediatric sepsis are associated with clinical outcomes. Study objectives were to (1) determine the prevalence and type of sepsis-related neuroimaging abnormalities evident on clinically indicated brain MRI in children with sepsis and (2) test the association of these abnormalities with mortality, new disability, length of stay (LOS), and MRI indication.

METHODS

Retrospective cohort study of 140 pediatric patients with sepsis and a clinically indicated brain MRI obtained within 60 days of sepsis onset at a single, large academic pediatric intensive care unit (PICU). Two radiologists systematically reviewed the first post-sepsis brain MRI and determined which abnormalities were sepsis-related. Outcomes compared in patients with versus without sepsis-related MRI abnormalities.

RESULTS

PICU mortality was 7%. Thirty patients had one or more sepsis-related MRI abnormality, yielding a prevalence of 21% (95% confidence interval 15%, 28%). Among those, 53% (16 of 30) had sepsis-related white matter signal abnormalities; 53% (16 of 30) sepsis-related ischemia, infarction, or thrombosis; and 27% (eight of 30) sepsis-related posterior reversible encephalopathy. Patients with one or more sepsis-related MRI abnormality had increased mortality (17% vs 5%; P = 0.04), new neurological disability at PICU discharge (32% vs 11%; P = 0.03), and longer PICU LOS (median 18 vs 11 days; P = 0.04) compared with patients without.

CONCLUSIONS

In children with sepsis and a clinically indicated brain MRI, 21% had a sepsis-related MRI abnormality. Sepsis-related MRI abnormalities were associated with increased mortality, new neurological disability, and longer PICU LOS.

Novel Risk Model to Predict Emergency Department Associated Mortality for Patients Supported With a Ventricular Assist Device: The Emergency Department-Ventricular Assist Device Risk Score

Background The past decade has seen tremendous growth in patients with ambulatory ventricular assist devices. We sought to identify patients that present to the emergency department (ED) at the highest risk of death. Methods and Results This retrospective analysis of ED encounters from the Nationwide Emergency Department Sample includes 2010 to 2017. Using a random sampling of patient encounters, 80% were assigned to development and 20% to validation cohorts. A risk model was derived from independent predictors of mortality. Each patient encounter was assigned to 1 of 3 groups based on risk score. A total of 44 042 ED ventricular assist device patient encounters were included. The majority of patients were male (73.6%), <65 years old (60.1%), and 29% presented with bleeding, stroke, or device complication. Independent predictors of mortality during the ED visit or subsequent admission included age ≥65 years (odds ratio [OR], 1.8; 95% CI, 1.3-4.6), primary diagnoses (stroke [OR, 19.4; 95% CI, 13.1-28.8], device complication [OR, 10.1; 95% CI, 6.5-16.7], cardiac [OR, 4.0; 95% CI, 2.7-6.1], infection [OR, 5.8; 95% CI, 3.5-8.9]), and blood transfusion (OR, 2.6; 95% CI, 1.8-4.0), whereas history of hypertension was protective (OR, 0.69; 95% CI, 0.5-0.9). The risk score predicted mortality areas under the curve of 0.78 and 0.71 for development and validation. Encounters in the highest risk score strata had a 16-fold higher mortality compared with the lowest risk group (15.8% versus 1.0%). Conclusions We present a novel risk score and its validation for predicting mortality of patients with ED ventricular assist devices, a high-risk, and growing, population.

Mental health disorders and emergency resource use and outcomes in ventricular assist device supported patients

There are limited data describing the prevalence of mental health disorders (MHDOs) in patients with ventricular assist devices (VADs), or associations between MHDOs and resource use or outcomes. We used the Nationwide Emergency Department Sample administrative database to analyze 44,041 ED encounters for VAD-supported adults from 2010 to 2017, to assess the relationship between MHDOs and outcomes in this population. MHDO diagnoses were present for 23% of encounters, and were associated with higher charges and rates of admission, but lower mortality.

Factors influencing local and distant recurrence following resection of periampullary cancer

BACKGROUND

Recurrence of periampullary cancer after pancreatoduodenectomy is common. The aim of this study was to investigate patterns of recurrence, incidence, and factors associated with local and distant recurrences.

METHODS

This retrospective, single-centre study included consecutive patients with periampullary cancer who underwent resection with curative intent from January 2012 to January 2018. Survival, patterns of recurrence, and factors associated with recurrences were analysed.

RESULTS

Median overall survival (OS) and disease-free survival among 398 included patients was 58.4 and 49.5 months respectively. Twenty-three patients (5.8 per cent) developed isolated local recurrences (LR), 50 (12.6 per cent) developed LR along with distant metastasis (DM), and 103 (25.9 per cent) developed isolated DM. Median OS was 40.4 months for patients with isolated LR versus 23 months for those with DM (P < 0.001). Tumour subtype (distal common bile duct (CBD): odds ratio (OR) 6.18, 95 per cent c.i. 2.19 to 17.46) and node-positive status (OR 2.36, 1.26 to 4.43) were independently associated with higher rates of LR. The most common site for isolated LR was along the superior mesenteric artery (12 of 23 patients). Tumour subtype (distal CBD: OR 2.86, 1.09 to 7.52), nodal positivity (OR 2.46, 1.53 to 3.94), and presence of perineural invasion (OR 1.80, 1.02 to 3.18) were independently associated with DM.

CONCLUSION

Isolated LR is associated with better survival than DM and occurs most commonly along the superior mesenteric artery.

Standardized Feeding Approach Mitigates Weight Loss in Infants with Congenital Heart Disease

OBJECTIVE

To evaluate the effect of a standardized feeding approach using a clinical nutrition pathway on weight-for-age Z score (WAZ) over hospital length of stay (HLOS) for infants with congenital heart disease (CHD).

STUDY DESIGN

A 10-year retrospective cohort study examined eligible infants who underwent neonatal cardiac surgery between July 2009 and December 2018 (n = 987). Eligibility criteria included infants born at least 37 weeks of gestation and a minimum birth weight of 2 kg who underwent cardiac surgery for CHD within the first 30 days of life. Using the best linear unbiased predictions from a linear mixed effects model, WAZ change over HLOS was estimated before and after January 2013, when the standardized feeding approach was initiated. The best linear unbiased predictions model included adjustment for patient characteristics including sex, race, HLOS, and class of cardiac defect.

RESULTS

The change in WAZ over HLOS was significantly higher from 2013 to 2018 than from 2009 to 2012 (β = 0.16; SE = 0.02; P < .001), after controlling for sex, race, HLOS, and CHD category, indicating that infants experienced a decreased WAZ loss over HLOS after the standardized feeding approach was initiated. Additionally, differences were found in WAZ loss over HLOS between infants with single ventricle CHD (β = 0.26; SE = 0.04; P < .001) and 2 ventricle CHD (β = 0.04; SE = 0.02; P = .04).

CONCLUSIONS

These data suggest that an organized, focused approach for nutrition therapy using a standardized pathway improves weight change outcomes before hospital discharge for infants with single and 2 ventricle CHD who require neonatal cardiac surgery.

Assessment of an Educational Tool for Pediatric Cardiac Nurses on Individualized Family-Centered Developmental Care

BACKGROUND

Prevention of neurodevelopmental sequelae is a high priority in the care of infants with congenital heart defects. Individualized family-centered developmental care has been identified as a promising approach to promote infant neurodevelopment during hospitalization.

OBJECTIVE

To educate nurses on the concept of individualized family-centered developmental care and its application to nursing practice and to reduce perceived barriers to its implementation.

METHODS

Two evidence-based visual educational tools called "developmental care flowers" were created and implemented in the inpatient and procedural units of a cardiac center. Each flower petal represented a core component of individualized family-centered developmental care: cue-based care, patient positioning, supportive environment, and parent engagement. Surveys were administered before and after the educational intervention to assess changes in nurses' knowledge and perceptions of individualized family-centered developmental care.

RESULTS

Nurses reported that the developmental care flowers improved their understanding of individualized family-centered developmental care. The educational tools reduced some perceived barriers to implementation of this care model and increased nurse-reported inclusion of parents in care. Qualitative feedback from staff members regarding the tools was positive and acknowledged that individualized family-centered developmental care should be an ongoing priority.

CONCLUSIONS

The inpatient and procedural developmental care flowers are useful tools for educating nurses about individualized family-centered developmental care. They could be revised into more interactive tools that might be used to educate parents and further support the integration of this care concept into nursing practice.

An Increasing Burden of Disease: Emergency Department Visits Among Patients With Ventricular Assist Devices From 2010 to 2017

Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD-related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter-level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, >880 million ED visits were evaluated, with 44 042 VAD-related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16-fold from 2010 to 2017 (824 versus 13 155). VAD-related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation-adjusted charges were $25 679 (interquartile range, $7450, $63 119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively (P for trends <0.001, both). Conclusions We present the first study using national-level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision-making be optimized for patients with VAD to maximize good outcomes.

Predicting the length of stay at admission for emergency general surgery patients a cohort study

Introduction

Predicting length of stay (LOS) is beneficial to patients and the health service. When a prolonged LOS is predicted, it gives the opportunity for focused therapies and allocation of resources to reduce this period. In emergency general surgery (EGS) there has been limited investigation of variables that may be important predictors of LOS. This study examines social characteristics alongside measures of severity of acute illness and co-morbidities in an adult EGS population to establish their contribution to LOS.

Methods

Data were collected prospectively from patients at admission including medical variables, demographics, and therapeutic requirements. The length of hospital admission was measured, and multiple regression analysis was used to identify variables which predicted the LOS.

Results

Data were collected from 105 patients. The regression model gave an R² of 0.34, p = 0.0006. Barthal index (measure of independence in activities of daily living) was a significant predictor of LOS [logworth 1.649, p0.02243]. Housing status and Level of social support both correlated in one-way analysis with LOS.

Conclusion

There are non-surgical variables, measurable at admission which are of significant value in predicting LOS of EGS patients. This warrants further investigation through a larger study to better quantify the contributions of these variables, and establish potential early interventions to reduce the LOS.

•

Barthal Index is a significant predictor of length of stay at admission for patients admitted under EGS.

•

Unstable housing and a lack of social support independently correlate with a longer length of stay.

•

It may be possible to intervene at admission to reduce the length of stay for patients admitted under EGS.

Association of MRI Brain Injury With Outcome After Pediatric Out-of-Hospital Cardiac Arrest

OBJECTIVE

To determine the association between the extent of diffusion restriction and T2/fluid-attenuated inversion recovery (FLAIR) injury on brain MRI and outcomes after pediatric out-of-hospital cardiac arrest (OHCA).

METHODS

Diffusion restriction and T2/FLAIR injury were described according to the pediatric MRI modification of the Alberta Stroke Program Early Computed Tomography Score (modsASPECTS) for children from 2005 to 2013 who had an MRI within 14 days of OHCA. The primary outcome was unfavorable neurologic outcome defined as ≥1 change in Pediatric Cerebral Performance Category (PCPC) from baseline resulting in a hospital discharge PCPC score 3, 4, 5, or 6. Patients with unfavorable outcomes were further categorized into alive with PCPC 3-5, dead due to withdrawal of life-sustaining therapies for poor neurologic prognosis (WLST-neuro), or dead by neurologic criteria.

RESULTS

We evaluated MRI scans from 77 patients (median age 2.21 [interquartile range 0.44, 13.07] years) performed 4 (2, 6) days postarrest. Patients with unfavorable outcomes had more extensive diffusion restriction (median 7 [4, 10.3] vs 0 [0, 0] regions, p < 0.001) and T2/FLAIR injury (5.5 [2.3, 8.2] vs 0 [0, 0.75] regions, p < 0.001) compared to patients with favorable outcomes. Area under the receiver operating characteristic curve for the extent of diffusion restriction and unfavorable outcome was 0.96 (95% confidence interval [CI] 0.91, 0.99) and 0.92 (95% CI 0.85, 0.97) for T2/FLAIR injury. There was no difference in extent of diffusion restriction between patients who were alive with an unfavorable outcome and patients who died from WLST-neuro (p = 0.11).

CONCLUSIONS

More extensive diffusion restriction and T2/FLAIR injury on the modsASPECTS score within the first 14 days after pediatric cardiac arrest was associated with unfavorable outcomes at hospital discharge.

WPI-13 Lack of association of cranial lacunae with intracranial hypertension in children with crouzon syndrome and apert syndrome: a 3D morphometric quantitative analysis

Objectives

Cranial lacunae on CT is equivalent to the plain X-ray ‘copper beating’ seen in craniosynostosis. Copper beating has not been shown to correlate to intracranial hypertension (IH). However it is a purely quantitative assessment – can qualitative measurement of CT cranial lacunae more accurately predict IH in children with craniosynostosis?

Design

Retrospective cohort study.

Subjects

18 consecutive children with Crouzon and 17 with Apert syndrome were identified.

Methods

Patients were divided into IH and non-IH groups defined on an intention to treat basis. 3D software was used to analyse% of calvarial lacunae.

Results

Mean age at CT scan was 380 days (range 6–1778). Of the 35 children, 21 required surgery for raised ICP (17 posterior vault expansion 2 ventriculo-peritoneal shunts (VPS), 1 spring-assisted cranioplasty and 1 fronto-orbital advancement) at mean age of 512 days (range 38–1710). Of the 21 children with raised ICP, 15 had lacunae with mean lacuna/calvarium percentage of 3% (0%–28%). Of the 14 non-raised ICP children, 8 had lacunae with mean lacuna/calvarium percentage of 2% (0%–8%). T-test demonstrated no significant difference between the 2 groups. For both groups, parietal bones were most likely to show lacunae (IH 14/21, non-IH 9/14), followed by occipital (IH 8/21, non-IH 3/14), followed by frontal (IH 6/21, non-IH 2/14).

Conclusions

Results suggest that cranial lacunae, measured using quantitative 3D methods, do not predict IH, in agreement with evidence from qualitative plain skull radiograph studies.

Spin glass like transition and the exchange bias effect in Co3O4 nanoparticles anchored onto graphene sheets

We have synthesized Co3O4 nanoparticles having 40 nm average size, which are anchored on reduced graphene oxide. X-ray diffraction, FESEM, TEM and Raman spectroscopy are performed for the characterization. The temperature dependence of field cooled (FC) and zero field cooled (ZFC) magnetization curves exhibits antiferromagnetic (AFM) transition around ∼30 K, as observed for bulk Co3O4. The exchange bias effect is observed below ∼30 K. A significant change in the exchange bias effect is noted around ∼8 K, which is close to a spin-glass-like transition. The spin-glass-like phase has been confirmed by the memory effects observed by different experimental protocols. The possible origin of exchange bias is discussed in the manuscript.

Personalized cumulative UV tracking on mobiles & wearables

Maintaining a balanced Ultra Violet (UV) exposure level is vital for a healthy living as the excess of UV dose can lead to critical diseases such as skin cancer while the absence can cause vitamin D deficiency which has recently been linked to onset of cardiac abnormalities. Here, we propose a personalized cumulative UV dose (CUVD) estimation system for smartwatch and smartphone devices having the following novelty factors; (a) sensor orientation invariant measurement of UV exposure using a bootstrap resampling technique, (b) estimation of UV exposure using only light intensity (lux) sensor (c) optimal UV exposure dose estimation. Our proposed method will eliminate the need for a dedicated UV sensor thus widen the user base of the proposed solution, render it unobtrusive by eliminating the critical requirement of orienting the device in a direction facing the sun. The system is implemented on android mobile platform and validated on 1200 minutes of lux and UV index (UVI) data collected across several days covering morning to evening time frames. The result shows very impressive final UVI estimation accuracy. We believe our proposed solution will enable the future wearable and smartphone users to obtain a seamless personalized UV exposure dose across a day paving a way for simple yet very useful recommendations such as right skin protective measure for reducing risk factors of long term UV exposure related diseases like skin cancer and, cardiac abnormality.

Umbrella Sampling and X-ray Crystallographic Analysis Unveil an Arg-Asp Gate Facilitating Inhibitor Binding Inside Phosphopantetheine Adenylyltransferase Allosteric Cleft

Phosphopantetheine adenylyltransferase (PPAT) is a rate-limiting enzyme essential for biosynthesis of coenzyme A (CoA), which in turn is responsible to regulate the secretion of exotoxins via type III secretion system in Pseudomonas aeruginosa, causing severe health concerns ranging from nosocomial infections to respiratory failure. Acetyl coenzyme A (AcCoA) is a newly reported inhibitor of PPAT, believed to regulate the cellular levels of CoA and thereby the pathogenesis. Very little is known so far regarding the mechanistic details of AcCoA binding inside PPAT-binding cleft. Herein, we have used extensive umbrella sampling simulations to decipher mechanistic insight into the inhibitor accommodation inside the binding cavity. We found that R90 and D94 residues act like a gate near the binding cavity to accommodate and stabilize the incoming ligand. Mutational models concerning these residues also show considerable difference in AcCoA-binding thermodynamics. To substantiate our findings, we have solved the first crystal structure of apo-PPAT from P. aeruginosa, which also found to agree with the simulation results. Collectively, these results describe the mechanistic details of accommodation of inhibitor molecule inside PPAT-binding cavity and also offer valuable insight into regulating cellular levels of CoA/AcCoA and thus controlling the pathogenicity.

Effect of Annealing on Optical, Electrical and Charge Trapping Properties of TiO₂ NPs Arrays

Glancing angle deposition technique has been carried out to synthesize TiO₂ nanoparticles over SiO(x) thin film. The samples were annealed at different temperatures 550 °C and 950 °C. The average grain sizes and surface RMS roughness have been increased from 9 nm, 0.62 nm (as deposited); 21 nm, 2.47 nm (550 °C annealed) to 37 nm, 4.2 nm (950 °C annealed). Fivefold maximum increase in optical absorption has been recorded for the 950 °C annealed sample as compared to that of the as grown. The absorption and photoluminescence peaks show the red shift with an increase in annealing temperature and grain sizes. Transmission electron microscopy (TEM) has been used to investigate phases of nanoparticles. The junction capacitance of the Au/TiO₂ NPs device was observed to decrease with an increase in frequency. A minimum change in junction capacitance of 1 pF was calculated for 950 °C annealed device for the variation of frequency from 500 Hz to 1 MHz. The results are used to simulate the capacitance as a function of frequency and voltage characteristic of TiO₂ NPs based device in different temperature. Simulated results are exceptionally close to experimental results. The TiO₂ NPs based device annealed at 950 °C possessed higher impedance and lower conductance among all three type of devices. The sample annealed at 950 °C showed the maximum capacitance (0.09 pF at 0 V) as well as charge (˜0.6 Coulomb at +8 V) retention compared to that of the 550 °C annealed and as deposited samples.

Evaluation of synergistic effects of sulforaphene with photodynamic therapy in human cervical cancer cell line

Sulforaphene from cruciferous vegetable has shown to modulate various signaling pathways of apoptosis. But it has not yet been studied extensively for the cervical cancer treatment. Previous studies show the promising role of photodynamic therapy for cervical cancer. Here, we confirm that sulforaphene can synergistically enhance the efficacy of photodynamic therapy. Human cervical cancer cells HeLa were treated with a very low dose of sulforaphene (2.0 μg/ml) and photodynamic therapy with radachlorin (0.5 μg/ml) at a fluence of 27 J/cm² (30 milliwatts/cm², λmax ∼ 670 ± 3 nm). The combination treatment showed a synergistic effect to induce apoptosis. The mitochondrial apoptotic pathway was activated via caspase 3 and caspase 9. On the other hand, caspase 12 and C/EBP homologous protein (CHOP) were expressed that indicated endoplasmic reticulum stress. This combination treatment also activated death receptor pathway via activation of caspase 8 and inhibited cell proliferation via down-regulation of EGFR. Thus, several apoptotic pathways were simultaneously activated in this combination treatment which results in a synergistic efficacy of sulforaphene with photodynamic therapy. Therefore, this study could be useful in the improvement of therapies for human cervical and other types of cancers.

Efficacy of stem cell in improvement of left ventricular function in acute myocardial infarction--MI3 Trial

Background & objectives:

Acute myocardial infarction (AMI) is characterized by irreparable and irreversible loss of cardiac myocytes. Despite major advances in the management of AMI, a large number of patients are left with reduced left ventricular ejection fraction (LVEF), which is a major determinant of short and long term morbidity and mortality. A review of 33 randomized control trials has shown varying improvement in left ventricular (LV) function in patients receiving stem cells compared to standard medical therapy. Most trials had small sample size and were underpowered. This phase III prospective, open labelled, randomized multicenteric trial was undertaken to evaluate the efficacy in improving the LVEF over a period of six months, after injecting a predefined dose of 5-10 × 10⁸ autologous mononuclear cells (MNC) by intra-coronary route, in patients, one to three weeks post ST elevation AMI, in addition to the standard medical therapy.

Methods:

In this phase III prospective, multicentric trial 250 patients with AMI were included and randomized into stem cell therapy (SCT) and non SCT groups. All patients were followed up for six months. Patients with AMI having left ventricular ejection fraction (LVEF) of 20-50 per cent were included and were randomized to receive intracoronary stem cell infusion after successfully completing percutaneous coronary intervention (PCI).

Results:

On intention-to-treat analysis the infusion of MNCs had no positive impact on LVEF improvement of ≥ 5 per cent. The improvement in LVEF after six months was 5.17 ± 8.90 per cent in non SCT group and 4.82 ± 10.32 per cent in SCT group. The adverse effects were comparable in both the groups. On post hoc analysis it was noted that the cell dose had a positive impact when infused in the dose of ≥ 5 × 10⁸(n=71). This benefit was noted upto three weeks post AMI. There were 38 trial deviates in the SCT group which was a limitation of the study.

Interpretation & conclusions:

Infusion of stem cells was found to have no benefit in ST elevation AMI. However, the procedure was safe. A possible benefit was seen when the predefined cell dose was administered which was noted upto three weeks post AMI, but this was not significant and needs confirmation by larger trials.

TiO2 Nanowires/Poly(Methyl Methacrylate) Based Hybrid Photodetector: Improved Light Detection

Hybrid photodetector with a maximum external quantum efficiency of ~3.08% in the UV region at 370 nm, was fabricated by spin-coated poly(methyl methacrylate) (PMMA) polymer onto glancing angle deposited (GLAD) vertically aligned TiO2 nanowire (NW) arrays. The TiO2 NWs/PMMA detector shows excellent rectification and constant 1.3 times photo-responsivity in the reverse bias condition from -1 V to -10 V. The photodiode possesses a low ideality factor of 5.1 as compared to bared TiO2 NWs device of 7.1. The hybrid device produces sharp turn-on of -0.8 s and turn-off transient of -0.9 s respectively.

An {Fe60} tetrahedral cage: building nanoscopic molecular assemblies through cyanometallate and alkoxo linkers

A nanoscopic {Fe₆₀} coordination cage (approximately 3 nm) was prepared by the self assembly of a partially blocked tricyanidoferrate(iii) complex and tris(alkoxo)-based iron(iii) coordination motifs.

Improved Photo-Detection Using Zigzag TiO2 Nanostructures as an Active Medium

Zigzag TiO2 nanostructures were fabricated using oblique angle deposition technique. The field emission gun-scanning electron microscope (FEG-SEM) image shows that the TiO2 zigzag nanostructures were ~500 nm in length. Averagely two times enhanced UV-Vis absorption was recorded for zigzag structure compared to perpendicular TiO2 nanowires. The main band transition was observed at ~3.4 eV. The zigzag TiO2 exhibited high turn on voltage (+11 V) than that of nanowire (+2 V) detector under dark which were reduced to +0.2 V and +1.0 V under white light illumination, respectively. A maximum ~6 fold photo-responsivity was observed for the zigzag TiO2 compared with nanowire device at + 1.0 V applied potential. The maximum photo-responsivity of 0.36 A/W at 370 nm was measured for the zigzag TiO2 detector. The TiO2 zigzag detector showed slow response with rise time of 10.2 s and fall time of 10.3 s respectively. The UV (370 nm) to visible (450 nm) wavelength rejection ratio of photo-responsivity was recorded ~4 times for the detector.

Rikkunshito induces gastric relaxation via the β-adrenergic pathway in Suncus murinus

BACKGROUND

Rikkunshito (RKT) is a gastroprotective herbal medicine. In this study, we investigated the role of RKT in the relaxation of the gastric body (fundus and corpus) and antrum.

METHODS

We used Suncus murinus, a unique small model animal with similar gastrointestinal motility to humans and dogs. RKT was added at 0.1, 1.0, and 5.0 mg/mL to induce relaxation in vitro; the outcome measure was the intensity of relaxation. The number of spontaneous antral contractions in the absence or the presence of RKT was also counted.

KEY RESULTS

Rikkunshito induced the relaxation of the gastric body and antrum and decreased the number of spontaneous antral contractions in a dose-dependent manner. The responses to RKT (1.0 mg/mL) were not affected by pretreatment with atropine, N-nitro-l-arginine methyl ester, ritanserin, or ondansetron. On the other hand, timolol almost completely reversed the relaxation induced by RKT (1.0 mg/mL) on the gastric body and antrum and the occurrence of the spontaneous antral contractions. Both butoxamine, a β(2) -adrenoreceptor antagonist, and L 748337, a β(3) -adrenoreceptor antagonist, but not CGP 20712, a β(1) -adrenoreceptor antagonist, significantly reversed the RKT-induced (1.0 mg/mL) gastric relaxation.

CONCLUSIONS & INFERENCES

These results indicate that RKT stimulates and modulates gastric relaxation through β(2) - and β(3) -adrenergic, but not β(1) -adrenergic, pathways in S. murinus.

PerFlexMEA: a thin microporous microelectrode array for in vitro cardiac electrophysiological studies on hetero-cellular bilayers with controlled gap junction communication

The new microelectrode array device presented is called PerFlexMEA and it enables controlled coupling between myocytes and nonmyocytes used in cardiovascular conduction studies. The device consists of an 8 μm thin parylene microporous membrane with a 4 × 5 microelectrode array patterned on one side. Myocytes and nonmyocytes can be plated on either side of the parylene membrane to create a tissue bilayer. The 3-3.5 μm diameter pores allow inter-layer dye and electrical coupling without transmembrane cell migration. Cell migration was found to vary with cell-type and micropore diameter. Pore density can be varied based on desired coupling ratio. The flexible parylene membrane is packaged between two rigid thermoplastic layers, such that the microelectrode array region is exposed, while the rest of the device remains insulated. The packaged PerFlexMEA fits in a 60 mm culture dish. Recording experiments are performed by simply plugging it into a commercially available multielectrode amplifier system. Recorded signals were processed and analysed using scripts generated in MATLAB. Our experimental results provide evidence of the reliability of this device, as conduction velocity was observed to decrease after inducing lateral hetero-cellular controlled coupling between myocytes and HeLa cells expressing connexin 43.

Band Gap Tailoring of TiO2 Nanowires by Nitrogen Doping Under N2/Ar Plasma Environment

Glancing angle deposited TiO2 nanowires (NWs) were doped with nitrogen (N) using plasma-enhanced chemical vapour deposition technique, under the treatment of N2/Ar plasma. A red shift (- 0.51 eV) in the main band transition and oxygen defect related transition (-2.1 eV) was observed for the N doped TiO2 nanowires. The interstitial nitrogen introduces mid-gap levels N (2P) above the O (2P) in the TiO2 forbidden gap. The photoluminescence measurement revealed a small red shift of -7 nm of anatase band gap from N doped TiO2 nanowires due to radiative recombination of carriers from conduction band to the N (2P) trap state. The low frequency Raman peaks at 304 cm(-1) (acoustical phonons with LA mode), 618 cm(-1) (optical phonons with LO modes) and the high frequency peak at 832 cm(-1) was observed from Ti-O-N due to the partial replacement of oxygen molecules by nitrogen into TiO2, during the doping process.

Utility and impact of early t(15;17) identification by Fluorescence In Situ Hybridization (FISH) in clinical decision making for patients in Acute Promyelocytic Leukemia (APL)

INTRODUCTION

Acute Promyelocytic Leukemia (APL) is a curable malignancy with studies showing above 90% survival. However, population-based studies looking at survival suggest that approximately 30% of patients with APL die during induction. Early demonstration of t(15;17) will lead to accurate decision making regarding treatment. The aim of this project was to validate earlier time frames for the Abbott Molecular Vysis LSI promyelocytic leukemia (PML)/ retinoic acid receptor alpha (RARA) fluorescence in situ hybridization (FISH) probe (ASR 6-16 h).

METHODS

Twenty patients (15 APL cases and five non-APL cases) were selected for validating various hybridization times for the FISH probe. Expected normal signal pattern was two red and two green signals (2R2G), and the most common expected abnormal signal pattern was two fusion (yellow) signals, one red and one green (2F1R1G) and/or one fusion, one red and one green (1F1R1G).

RESULTS

The specificity of the probe ranged from 84% at 2 h, 86% at 4 h, 84% at 6 h, and 87% for overnight hybridization. The sensitivity increased from 79% at 2 h, 80% at 4 h, 81% at 6 h to 87% for overnight hybridization.

CONCLUSION

Based on the validation studies, we recommend reading of FISH results at the 4-h incubation mark for a preliminary diagnosis and confirmation with overnight hybridization.

Magnetic memory in nanocrystalline α-Fe2O3 embedded in reduced graphene oxide

Single phase iron oxide (α-Fe₂O₃) of nearly regular ellipsoidal shape, embedded in reduced graphene oxide (RGO) has been prepared by the chemical route. Memory effect is observed in magnetization study.

TiO2 embedded Si nanowire network based Schottky detector for enlarged light detection

The Si nanowire (NW) network was fabricated on the Si substrate with the help of glancing angle synthesized Ag NPs assisted etching technique. The horizontal Si NWs network was characterized by field emission gun-scanning electron microscopy which shows the formation of long Si NWs of diameter within the range of 110-180 nm. The TiO2 thin film (TF) was deposited on the Si NWs, which shows -2.5 times enlarged optical absorption than that of bare Si substrate. Ag-TiO2 contacts exhibit Schottky behaviour and higher photoconduction was observed for TiO2-Si NW detector than that of TiO2 TF under illumination. The dark currents of TiO2 TF and TiO2-Si NW devices were exerted to be 0.1 mA/cm2 and 0.2 mA/cm2 at +1 V, which increased to 0.2 mA/cm2 and 1.23 mA/cm2, respectively, under the illumination of 100 W filament bulb. A threefold enhanced photodetection for the Si NW device was observed compared to the TiO2 TF device. The nonlinear rise of photocurrent of 2 x 10(-2) mA/cm2, after 5 min light illumination was observed due to carrier diffusion effect.

Efficient removal of arsenic (V) from water using steel-making slag

This study describes the potential use of steel-making slag as an arsenic-removal medium. Systematic analysis of slag material revealed a composition of oxides of calcium, iron, silicon, and phosphorous. Under the experimental conditions of this study, the equilibrium time was shown to be 2 hours, and the removal capacity to be 99%, with an adsorbent loading capacity of 1.25g/l. The adsorption kinetics were shown to follow a pseudo-second-order rate equation, and the adsorption isotherm closely followed both the Langmuir and Freundlich isothermic models. Variations in solution pH levels demonstrated that with a decrease in the initial solution pH, the adsorption capacity decreases. This is attributed to the leaching of silica and phosphate from the slag to the solution, which imparted a competing effect for adsorption sites. However, with an alkaline pH, such leaching was reduced, and due to formation of calcium carbonate from the leached calcium from the slag material, the arsenic removal efficiency increased as it was co-precipitated with calcium carbonate.

Optimization of fermentation conditions for green pigment production from Bacillus cereus M¹ 16 (MTCC 5521) and its pharmacological application

Optimal culture conditions for the production of green pigment was investigated. The optimal culture condition for the production of an extracellular green pigment by growing Bacillus cereus M(1) 16 (MTCC 5521) in a complex medium containing (g l(-1) ) Peptone-4.0, Beef Extract-9.0, NaCl-7.0, MgSO4 .7H2 O-1.0 and KH2 PO4 -5.0 was as follows pH-7.0 at 30°C for 72 h in a 5 l fermenter. Aeration rate and agitator speed had no effect on the pigment production. Thin layer chromatogram of the pigment extracted from the fermented broth with chloroform on silica gel GF254 using ethyl acetate and hexane (1 : 1) as solvent showed three fractions. The major fraction (C3 ) was separated out and identified as 9-methyl-1, 4, 5, 8-tetra-azaphenanthrene. Acute toxicity test revealed the nontoxic nature upto a dose of 2000 mg kg(-1) , b.wt., of mice. MTT assay showed the cytotoxic nature in HL60 cells having an IC50 of 2.47 mmol. So, this biopigment may have application in food, textile colorant and pharmaceutical industry.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study demonstrated the optimum production of a biopigment (9-methyl-1, 4, 5, 8-tetra-azaphenanthrene) by fermentation of a complex medium with Bacillus cereus M(1) 16 (MTCC 5521) in submerged fermentation. This is the first investigation of toxicity and cytotoxicity activities of this biopigment. The study showed that the purified pigment had no toxicity to healthy albino mice but a high cytotoxicity activity in HL60 cancer cell line in vitro. The biopigment had further displayed dyeing capability to both solidified agar and cotton cloth. Therefore, it may represent a nontoxic and natural alternative to chemical dyes and pigments.

Neuronal beacon

The controlled navigation of the axonal growth cone of a neuron toward the dendrite of its synaptic partner neuron is the fundamental process in forming neuronal circuitry. While a number of technologies have been pursued for axonal guidance over the past decades, they are either invasive or not controllable with high spatial and temporal resolution and are often limited by low guidance efficacy. Here, we report a neuronal beacon based on light for highly efficient and controlled guidance of cortical primary neurons.

High speed synchrotron x-ray phase contrast imaging of dynamic material response to split Hopkinson bar loading

The successful process of amalgamating both the time-resolved imaging capabilities present at the Advanced Photon Source beamline 32ID-B and the proficiency of high-rate loading offered by the split Hopkinson or Kolsky compression/tension bar apparatus is discussed and verification of system effectiveness is expressed via dynamic experiments on various material systems. Single particle sand interaction along with glass cracking during dynamic compression, and fiber-epoxy interfacial failure, ligament-bone debonding, and single-crystal silicon fragmentation due to dynamic tension, were imaged with 0.5 μs temporal resolution and μm-level spatial resolution. Synchrotron x-ray phase contrast imaging of said material systems being loaded with the Kolsky bar apparatus demonstratively depicts the effectiveness of the novel union between these two powerful techniques, thereby allowing for in situ analysis of the interior of the material system during high-rate loading for a variety of applications.