Early outcomes of endovascular repairs of the aortic arch using thoracic branch endoprosthesis

OBJECTIVE

The only commercially available thoracic branched endoprosthesis (TBE) for treatment of the aortic arch was released in 2022. Limited data outside of clinical trial results have been reported. This study describes the demographics, anatomic details, and outcomes for patients treated for zone 0 to 2 using TBEs outside of a clinical trial.

METHODS

All patients treated using TBEs for zone 0 to 2 were included. Patients treated as part of the clinical trial for zone 0 to 1 (n = 6) were excluded. Patient demographics, comorbidities, anatomic and operative details, and outcomes were reported. Outcomes and survival were then compared between groups.

RESULTS

Of 40 patients, six patients underwent repair of zone 0, three of zone 1, and 31 of zone 2. There were no differences in demographics, comorbidities, or operative details by zone of treatment; however, the frequency of genetic aortopathy differed (zone 0: 0%; zone 1: 67%; and zone 2: 6.4%; P < .01). Seventy-three percent of patients were treated for dissection vs 27% with isolated aneurysms. Of the patients, 2.5% were treated for rupture, 22% were treated for symptomatic aneurysms, and 75% were treated electively. Forty-eight percent of repairs included a proximal cuff, and 83% received distal extension. Technical success was achieved in 100% of patients. Mean fluoroscopy time was 18 minutes, and median fluoroscopy dose was 416 mGy. Sixty percent of patients had prior aortic ascending/arch repair. TBE was planned as part of a complete thoracoabdominal repair in 45% of patients. Thirty-day mortality was 2.5% overall, with a single death in a zone 0 patient that occurred at day 1 due to a myocardial infarction. There were no reinterventions within 30 days. All other outcomes were similar. The 30-day stroke rate was 5.0%. The strokes occurred at day 6 (zone 1) and day 15 (zone 2); however, both were due to occlusion of a prior proximal surgical bypass and unrelated to the TBE side branch or embolization. Specifically, both patients had occlusion of a branch of their prior zone 1 or zone 2 arch replacement. An endoleak occurred in 7.5% of patients at 30-day follow-up (type II: 5.0%; unknown: 2.5%). At a mean follow-up of 6.6 months, 100% of side branches were patent.

CONCLUSIONS

Repair of the aortic arch including TBE can be performed electively and urgently with acceptable stroke and death rates. TBE provides a valuable tool for patients requiring complete repair of a thoracoabdominal aneurysm. Continued investigation is underway to assess long-term safety and efficacy outside of the clinical trial.

Yeast sexes: mating types do not determine the sexes in Metschnikowia species

Although filamentous Ascomycetes may produce structures that are interpreted as male and female gametangia, ascomycetous yeasts are generally not considered to possess male and female sexes. In haplontic yeasts of the genus Metschnikowia, the sexual cycle begins with the fusion of two morphologically identical cells of complementary mating types. Soon after conjugation, a protuberance emerges from one of the conjugants, eventually maturing into an ascus. The originating cell can be regarded as an ascus mother cell, hence as female. We tested the hypothesis that the sexes, female or male, are determined by the mating types. There were good reasons to hypothesize further that mating type α cells are male. In a conceptually simple experiment, we observed the early stages of the mating reaction of mating types differentially labeled with fluorescent concanavalin A conjugates. Three large-spored Metschnikowia species, M. amazonensis, M. continentalis, and M. matae, were examined. In all three, the sexes were found to be independent of mating type, cautioning that the two terms should not be used interchangeably.

Patient-derived three-dimensional cortical neurospheres to model Parkinson's disease

There are currently no preventive or disease-modifying therapies for Parkinson's Disease (PD). Failures in clinical trials necessitate a re-evaluation of existing pre-clinical models in order to adopt systems that better recapitulate underlying disease mechanisms and better predict clinical outcomes. In recent years, models utilizing patient-derived induced pluripotent stem cells (iPSC) have emerged as attractive models to recapitulate disease-relevant neuropathology in vitro without exogenous overexpression of disease-related pathologic proteins. Here, we utilized iPSC derived from patients with early-onset PD and dementia phenotypes that harbored either a point mutation (A53T) or multiplication at the α-synuclein/SNCA gene locus. We generated a three-dimensional (3D) cortical neurosphere culture model to better mimic the tissue microenvironment of the brain. We extensively characterized the differentiation process using quantitative PCR, Western immunoblotting and immunofluorescence staining. Differentiated and aged neurospheres revealed alterations in fatty acid profiles and elevated total and pathogenic phospho-α-synuclein levels in both A53T and the triplication lines compared to their isogenic control lines. Furthermore, treatment of the neurospheres with a small molecule inhibitor of stearoyl CoA desaturase (SCD) attenuated the protein accumulation and aberrant fatty acid profile phenotypes. Our findings suggest that the 3D cortical neurosphere model is a useful tool to interrogate targets for PD and amenable to test small molecule therapeutics.

95 EXPLORING HIP FRACTURE OUTCOMES IN POST-ACUTE REHABILITATION: A MULTI-SITE AUDIT

Background

In 2020, 28% of all hip fractures in Ireland were discharged to off-site rehabilitation. The annual Irish Hip Fracture Database (IHFD) report captures patient outcomes at the point of acute discharge however patient outcomes at discharge from offsite rehabilitation are unknown.

Methods

A multi-site retrospective audit was completed examining hip fracture outcomes for patients admitted to four post-acute rehabilitation hospitals during 2021, using IHFD HIPE portals as well as local databases. Descriptive statistics including demographics, pre-fracture mobility as well as outcomes measured including acute length of stay, rehabilitation length of stay, discharge destination and independence with mobility on discharge from rehabilitation. A comparison analysis between sites was completed.

Results

A total of 445 patients were admitted post hip fracture to the four rehabilitation hospitals in 2021. Most were female (69%, n=307), mean age 82.5, 49% lived alone and most (55%) had low pre-fracture mobility as measured by New Mobility Score of 0-6. The mean acute length of stay was 11.8 days and rehabilitation stay 37.6 days. Most (90.2% of complete data, n=333) discharged home, 4.5% (n=17) were transferred to hospital, 3.2% (n=12) were newly admitted to nursing home and 1% (n=4) died. Most (82.2% of complete data, n=256) were independently mobile (CAS 6) at discharge from rehabilitation. There was no significant difference in patient profile between sites however there were significant difference in both acute length of stay (median range 8-13days) as well as rehabilitation length of stay (median range 16-39days).

Conclusion

The findings of this audit provide a new perspective on recovery post hip fracture and insight into longer term hip fracture outcomes. It shows that data collection is feasible in off-site rehabilitation units and should be considered for inclusion in the IHFD. Further work could explore the establishment of standards of care in the post-acute phase of hip fracture rehabilitation.

Prevention and early treatment of the long-term physical effects of COVID-19 in adults: design of a randomised controlled trial of resistance exercise-CISCO-21

Background

Coronavirus disease-19 (COVID-19) infection causes persistent health problems such as breathlessness, chest pain and fatigue, and therapies for the prevention and early treatment of post-COVID-19 syndromes are needed. Accordingly, we are investigating the effect of a resistance exercise intervention on exercise capacity and health status following COVID-19 infection.

Methods

A two-arm randomised, controlled clinical trial including 220 adults with a diagnosis of COVID-19 in the preceding 6 months. Participants will be classified according to clinical presentation: Group A, not hospitalised due to COVID but persisting symptoms for at least 4 weeks leading to medical review; Group B, discharged after an admission for COVID and with persistent symptoms for at least 4 weeks; or Group C, convalescing in hospital after an admission for COVID.

Participants will be randomised to usual care or usual care plus a personalised and pragmatic resistance exercise intervention for 12 weeks. The primary outcome is the incremental shuttle walks test (ISWT) 3 months after randomisation with secondary outcomes including spirometry, grip strength, short performance physical battery (SPPB), frailty status, contacts with healthcare professionals, hospitalisation and questionnaires assessing health-related quality of life, physical activity, fatigue and dyspnoea.

Discussion

Ethical approval has been granted by the National Health Service (NHS) West of Scotland Research Ethics Committee (REC) (reference: GN20CA537) and recruitment is ongoing. Trial findings will be disseminated through patient and public forums, scientific conferences and journals.

Trial registration

ClinicialTrials.gov NCT04900961. Prospectively registered on 25 May 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06632-y.

O-187 An analysis of the outcome of 11,712 men applying to be sperm donors at Cryos International in Denmark and the USA

Study question

Is the outcome of donor recruitment influenced by the country in which recruitment took place or the initial ID-release choice of applicants?

Summary answer

More applicants are accepted as donors in Denmark than the USA and those who choose ID release are more frequently accepted than those who don’t.

What is known already

The successful recruitment of sperm donors is essential to provide a range of Assisted Reproductive Technologies (ART) which rely upon donor sperm. However, while much has been written about the medical screening and assessment of sperm donors from a safety perspective, relatively little has been written about the process of recruiting donors and how it works in practice. There are differences in attitudes between donors who choose to allow their identity to be released to any donor conceived people (ID-release) compared to those who don’t (non ID-release). Therefore, we reasoned this may also influence the likelihood of them being recruited.

Study design, size, duration

A total of 11,712 men applied to be sperm donors at Cryos International in Denmark and the USA during 2018 and 2019.

Participants/materials, setting, methods

Anonymised records of all donor applicants were examined to assess the number passing through (or lost) at each stage of the recruitment process. Statistical analysis was carried out by Chi Squared test, using Graphpad Prism (San Diego, USA) to examine differences between location (Denmark or USA) and/or donor type (ID-release vs non-ID release).

Main results and the role of chance

Few applicants (3.79%) were accepted as donors and had samples released for use. This was higher in Denmark (6.53%) than the USA (1.03%) (χ2 = 243.2; 1df; z = 15.60; p &lt; 0.0001) and was higher in donors who opted at the outset to be ID-release (4.70%) compared to those who didn’t (3.15%) (χ2 = 18.51; 1df; z = 4.303; p &lt; 0.0001). Most potential donors were lost during recruitment because they: (i) withdrew, failed to respond, did not attend an appointment, or return a questionnaire (54.91%); (ii) reported a disqualifying health issue or failed a screening test (17.41%); (iii) did not meet the eligibility criteria at the outset (11.71%); or (iv) had semen quality which was not adequate (11.20%). In each case, there were statistically significant differences between countries and the donor’s initial ID choice. During recruitment, some donors decided to change ID-type. There were no country differences in the frequency in which this occurred (χ2 = 0.2852; 1df; z = 0.5340; p = 0.5933), but it was more common for donors to change from non-ID release to ID release (27.19%) than the other way around (11.45%) (χ2 = 17.75; 1df; z = 4.213; p &lt; 0.0001) although movements in both directions did occur in both countries.

Limitations, reasons for caution

No information was available about the demographic characteristics of the applicants which may also have influenced their chances of being accepted as a donor (e.g., ethnicity, age etc). Donor recruitment procedures may differ in other locations according to local laws or guidelines.

Wider implications of the findings

A better understanding of when and why potential donors are lost in the recruitment process may help develop leaner and efficient pathways for interested donors and sperm banks. This could ultimately increase the number of donors recruited through enhanced information, support and reassurance during the recruitment process.

Trial registration number

not applicable

Postoperative Musculoskeletal Imaging and Interventions Following Hip Preservation Surgery, Deformity Correction, and Hip Arthroplasty

Total hip arthroplasty and hip preservation surgeries have substantially increased over the past few decades. Musculoskeletal imaging and interventions are cornerstones of comprehensive postoperative care and surveillance in patients undergoing established and more recently introduced hip surgeries. Hence the radiologist's role continues to evolve and expand. A strong understanding of hip joint anatomy and biomechanics, surgical procedures, expected normal postoperative imaging appearances, and postoperative complications ensures accurate imaging interpretation, intervention, and optimal patient care. This article presents surgical principles and procedural details pertinent to postoperative imaging evaluation strategies after common hip surgeries, such as radiography, ultrasonography, computed tomography, and magnetic resonance imaging. We review and illustrate the expected postoperative imaging appearances and complications following chondrolabral repair, acetabuloplasty, osteochondroplasty, periacetabular osteotomy, realigning and derotational femoral osteotomies, and hip arthroplasty.

A Brain-Penetrant Stearoyl-CoA Desaturase Inhibitor Reverses α-Synuclein Toxicity

Increasing evidence has shown that Parkinson's disease (PD) impairs midbrain dopaminergic, cortical and other neuronal subtypes in large part due to the build-up of lipid- and vesicle-rich α-synuclein (αSyn) cytotoxic inclusions. We previously identified stearoyl-CoA desaturase (SCD) as a potential therapeutic target for synucleinopathies. A brain-penetrant SCD inhibitor, YTX-7739, was developed and has entered Phase 1 clinical trials. Here, we report the efficacy of YTX-7739 in reversing pathological αSyn phenotypes in various in vitro and in vivo PD models. In cell-based assays, YTX-7739 decreased αSyn-mediated neuronal death, reversed the abnormal membrane interaction of amplified E46K ("3K") αSyn, and prevented pathological phenotypes in A53T and αSyn triplication patient-derived neurospheres, including dysregulated fatty acid profiles and pS129 αSyn accumulation. In 3K PD-like mice, YTX-7739 crossed the blood-brain barrier, decreased unsaturated fatty acids, and prevented progressive motor deficits. Both YTX-7739 treatment and decreasing SCD activity through deletion of one copy of the SCD1 gene (SKO) restored the physiological αSyn tetramer-to-monomer ratio, dopaminergic integrity, and neuronal survival in 3K αSyn mice. YTX-7739 efficiently reduced pS129 + and PK-resistant αSyn in both human wild-type αSyn and 3K mutant mice similar to the level of 3K-SKO. Together, these data provide further validation of SCD as a PD therapeutic target and YTX-7739 as a clinical candidate for treating human α-synucleinopathies.

Twenty-four-channel high-impedance glove array for hand and wrist MRI at 3T

PURPOSE

To present a novel 3T 24-channel glove array that enables hand and wrist imaging in varying postures.

METHODS

The glove array consists of an inner glove holding the electronics and an outer glove protecting the components. The inner glove consists of four main structures: palm, fingers, wrist, and a flap that rolls over on top. Each structure was constructed out of three layers: a layer of electrostatic discharge flame-resistant fabric, a layer of scuba neoprene, and a layer of mesh fabric. Lightweight and flexible high impedance coil (HIC) elements were inserted into dedicated tubes sewn into the fabric. Coil elements were deliberately shortened to minimize the matching interface. Siemens Tim 4G technology was used to connect all 24 HIC elements to the scanner with only one plug.

RESULTS

The 24-channel glove array allows large motion of both wrist and hand while maintaining the SNR needed for high-resolution imaging.

CONCLUSION

In this work, a purpose-built 3T glove array that embeds 24 HIC elements is demonstrated for both hand and wrist imaging. The 24-channel glove array allows a great range of motion of both the wrist and hand while maintaining a high SNR and providing good theoretical acceleration performance, thus enabling hand and wrist imaging at different postures to extract kinematic information.

Improved Functional Outcome Scores Associated with Greater Reduction in Cam Height Using the Femoroacetabular Impingement Resection Arc During Hip Arthroscopy

PURPOSE

We sought to evaluate the association between postoperative cam lesion measured by the femoroacetabular impingement resection (FAIR) arc and show 2-year patient outcomes following hip arthroscopy.

METHODS

A retrospective review of prospectively gathered data from 2013-2017 was performed. All patients who underwent hip arthroscopy for femoroacetabular impingement resection (FAI) with ≥2-year follow-up were included. Cam FAIR arc measurements were made preoperatively and postoperatively on a 45° Dunn view radiograph. The clinical effect of postoperative cam maximal radial distance (MRD) was assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were divided into subgroups based on relationship to the mean and standard deviations for cam MRD. One half standard deviation above the mean was found to be 3.15 mm.

RESULTS

Sixty-one hips in 59 consecutive patients (age 38.1 ± 13.1; body mass index [BMI]: 25.5 ± 4.3; 36 females) were included. Mean preoperative and postoperative cam maximal radial distances (MRD) were 4.5 ± 1.7 mm and 2.3 ± 1.7 mm (P < .001), respectively. The interclass correlation coefficient was excellent (>.9) for all measurements. There were no differences in age, sex, BMI or preoperative mHHS/NAHS between <3.15 mm and >3.15 mm cam MRD groups (P > .05). Using linear regression, cam MRD was found to be significantly associated with 2-year outcomes for both mHHS (R² = .21, P < .001) and NAHS (R² = .004). Subgroup analysis demonstrated that patients in the cam MRD < 3.15 mm group had significantly higher mHHS (89.7 vs 70.0, P < .001) and NAHS scores (90.5 vs 72.9, P < .001) than those in the >3.15 mm group. Additionally, more patients in the <3.15 mm group reached the minimal clinically important difference (95.2% vs 78.9%, P = .048) and were above patient acceptable symptomatic state (95.2% vs 52.6%, P < .001) compared to the >3.15 mm group.

CONCLUSION

Patients with a lower postoperative cam MRD relative to the FAIR arc demonstrated significantly improved outcomes as compared to those with higher postoperative MRD at two-year follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

222 OLDER ADULT INPATIENTS’ PERCEPTIONS OF PROGRESSIVE RESISTANCE TRAINING IN A SPECIALIST GERIATRIC REHABILITATION SETTING

Background

Progressive resistance training (PRT) has the potential to reduce age-related disability and has been proven to benefit the older adult in a variety of ways. PRT is prescribed routinely by physiotherapists for frail older adults in an inpatient setting. To date little is known of their experiences engaging in PRT. This study aimed to explore older adult inpatients’ perceptions and experience of PRT as part of their overall physiotherapy program in a Specialised Geriatric Rehabilitation Unit.

Methods

The study had a qualitative design. Semi-structured interviews explored experiences and perceptions of PRT along with motivators and barriers to participation. Interviews were face to face and conducted in the unit. Data was analysed using thematic analysis. 11 frail older inpatients with orthogeriatric (n = 5), neurological (n = 2), general surgical (n = 2) and general medical (n = 2) diagnoses were interviewed.

Results

The study identified three overarching themes: Acceptability, Facilitators and Barriers. In the category of Acceptability participants identified the subthemes: (1) PRT is challenging, (2) PRT is Rewarding and (3) PRT is Enjoyable. In the category of Facilitators, the following subthemes emerged: (4) Positive outcomes as motivators and (5) Supervision is necessary for engagement. In the category of Barriers, (6) Low self-efficacy beliefs and (7) the Negative effects of PRT, such as pain and fatigue affected participation.

Conclusion

Frail older inpatients find PRT to be an acceptable form of exercise. It is perceived to be challenging, but rewarding and enjoyable for most. Participants were motivated to participate in PRT by the positive outcomes (improved strength, general health, function, independence, confidence) they experienced. They felt supervision from professionals with medical expertise was essential to participation; and had low self-efficacy beliefs surrounding independent practice; fearing falling and causing harm. Pain and fatigue also impacted participation.

Evaluation of a Pharmacist-Driven Procalcitonin Protocol for Lower Respiratory Tract Infections Using a Clinical Decision Support System

Purpose: Procalcitonin (PCT) may be an effective biomarker in the management of lower respiratory tract infections (LRTI) when combined with antimicrobial stewardship support. We assessed the impact of a PCT protocol with clinical pharmacy support for LRTI using a clinical decision support system (CDSS) for monitoring. Methods: This was a single-center retrospective cohort study conducted at a large, nonteaching hospital in Nashville, TN. All patients who met eligibility requirements and were initiated on the PCT protocol for a suspected LRTI between February and March 2018 were included and matched to historical control patients from 2016 to 2017 on a 1:1 basis based on antibiotics, indication, and time of year. Results: During this 2-month period, a total of 126 patients met eligibility requirements for inclusion in the PCT group and were matched to historical control patients. Patients in the PCT group received decreased median antibiotic days of therapy (DOT) compared to controls (11 vs 14, P = .004). There was no change in median length of stay (LOS) between groups. The acceptance rate for patient-specific antibiotic de-escalation recommendations from the clinical pharmacist was 62.5%. Conclusion: PCT protocols that utilize clinical pharmacist interpretation and a CDSS may be an effective intervention of the antimicrobial stewardship program (ASP) for decreasing antibiotic DOT for LRTI.

Perinatal mental health services for mothers from ethnic minority and migrant backgrounds

Perinatal mental health disorders are among the most common morbidities of the perinatal period with considerable adverse effects on mothers and their offspring. Members of ethnic minority groups, particularly those from migrant backgrounds, are at higher risk of developing mental illness with evidence of ongoing inequality in access to support. We will present an exploratory mixed-methods study scoping ethnic minority and migrant women's experiences accessing perinatal mental health services in the UK. Results showed how women perceived access to services as very challenging and how they experienced ‘suffering in silence', a ‘need for a safe space to talk and to be listened to', and a ‘need of finding other women like them'. We will complement these findings with the lessons learned from a related project, a three-site European study (ORAMMA) evaluating the feasibility of implementing an integrated perinatal care model for migrant mothers comprising maternity peer supporters (MPSs)-women from migrant backgrounds who had lived in the country for a longer time and were trained to support other migrant women during the childbearing continuum-. Results showed that MPSs supported migrant women accessing maternity care, overcoming language barriers, and advocating for them in their encounters with healthcare professionals. Besides, they provided emotional support and increased women's confidence, helping them overcome loneliness, encouraging them to build relationships with others and promoting bonding with the new baby. Bringing these two projects together, we will discuss how MPSs have the potential to help overcome barriers that immigrant women experience in seeking perinatal mental health and how the benefits of maternity peer supporters have the potential to reduce perinatal mental health risks amongst migrant mothers. Findings will point to the need for future research to evaluate the direct impacts of MPSs on immigrant's mother perinatal mental health.

P–537 What is the attitude of gamete donors towards expanded genetic testing

Study question

What is the opinion of gamete donors on extended carrier screening in Denmark and in US?

Summary answer

This study showed that the overwhelming majority of the donors were very positive towards genetic testing in general and the expanded carrier screening.

What is known already

There is a lack of empirical studies on the experiences of and attitudes of donors towards expanded carrier screening (ECS) (Amor et al. 2018). Oocyte donors in a Spanish clinic were surprised by the information on testing and the possibility of being carriers (Abuli et al., 2016). After adequate genetic counselling before and after the test, the results of testing did not seem to have a meaningful emotional or psychological impact on the donors.

Study design, size, duration

A questionnaire was emailed to all active sperm donors in a sperm bank in Denmark and in a sperm bank in US.

Participants/materials, setting, methods

A total of 393 donors received the email of which 233 donors completed the questionnaire, 196 in Denmark (response rate of 60.7%) and 37 in the United States (response rate of 52.9%).

Main results and the role of chance

We systematically compared the US and DK donors and ID-release versus non-ID-release donors for all characteristics and items. ID-release donors with a partner significantly more informed their partner about their donor status than non-ID-release donors (90.5% vs. 72.4%, p 0.027). ID-release donors significantly more intended to tell their own children (57.5% vs. 21.2%, p 0.001). ID-release donors significantly more thought about their potential donor children (56.2% vs. 35.0%; p 0.002) and significantly more likely to want information on whether a pregnancy occurred from their donation (70.6% vs. 55.0%, p 0.017). In addition, they also significantly more wished to obtain information about the children conceived with their sperm: the number of children (64.0% vs. 50.0%, p 0.048), their gender (40% vs. 26.2%, p 0.042), and their health (59.3% vs. 42.5%, p 0.018). The ID-release donors were much less likely than the other type not to want any information (19.3% vs. 32.5%, p 0.034). This general attitude is extended to the wish to be informed if a child with a hereditary disease is born after using their sperm. The ID-release donors were more likely to desire contact if their genetic child was diagnosed with a genetic disease (73.9% vs. 55.0%, p 0.003).

Limitations, reasons for caution

The main element that makes the study unique (i.e., the choice between ID-release and non-ID-release) also renders the generalization of the findings more difficult. Wider implications of the findings: A better understanding of the attitude among gamete doners will possibly guide future legislation and ensure the safety and welfare of the donors too.

Trial registration number

none

Generalized Joint Hypermobility Is Associated With Decreased Hip Labrum Width: A Magnetic Resonance Imaging-Based Study

Purpose

To explore the relationship between generalized joint hypermobility and hip labrum width.

Methods

A retrospective review was performed of a single-surgeon database containing patients who underwent hip arthroscopy between 2014 and 2017. Patients were assessed for generalized laxity via Beighton Test Scoring (BTS), which tests for hyperextension of the fifth metacarpophalangeal joint, thumb apposition, elbow hyperextension, knee hyperextension, and trunk flexion on a 9-point scale. Patients were stratified into a "high BTS cohort" with a BTS ≥4, and a control cohort with BTS <4. Magnetic resonance imaging measurements of labral width for each patient were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clockface" locations using a previously validated technique. Statistical analyses used to determine associations between BTS and labral width included Mann-Whitney U and Fisher exact testing as well as linear regression.

Results

Thirty-four patients met inclusion criteria (17 cases, 17 controls). Both groups were composed exclusively of female patients. There was no significant difference between cases or controls in terms of age (33.3 ± 10.4 years vs 35.2 ± 8.3 years, P = .57) or body mass index (26.1 ± 9.3 vs 23.6 ± 3.4, P = .36). The high Beighton score cohort had significantly thinner labrae at the indirect rectus (5.35 ± 1.2 mm vs 7.1 ± 1.1 mm, P < .001) and anterosuperior position (5.53 ± 1.4 mm vs 7.27 ± 1.6 mm, P = .003). There was no statistical difference between the high Beighton score cohort and controls at the psoas U position (6.47 ± 1.6 mm vs 7.43 ± 1.7 mm, P = .112). Linear regression analysis demonstrated Beighton score was significantly negatively associated with labrum width at the indirect rectus position (R² = 0.33, P < .001) and the anterosuperior position (R² = 0.25, P = .004).

Conclusions

Patients with a BTS ≥4 were found to have significantly thinner labra than those with a BTS of <4.

Level of Evidence

III, retrospective comparative trial.

Artificial Intelligence for Classification of Soft-Tissue Masses at US

Purpose

To train convolutional neural network (CNN) models to classify benign and malignant soft-tissue masses at US and to differentiate three commonly observed benign masses.

Materials and Methods

In this retrospective study, US images obtained between May 2010 and June 2019 from 419 patients (mean age, 52 years ± 18 [standard deviation]; 250 women) with histologic diagnosis confirmed at biopsy or surgical excision (n = 227) or masses that demonstrated imaging characteristics of lipoma, benign peripheral nerve sheath tumor, and vascular malformation (n = 192) were included. Images in patients with a histologic diagnosis (n = 227) were used to train and evaluate a CNN model to distinguish malignant and benign lesions. Twenty percent of cases were withheld as a test dataset, and the remaining cases were used to train the model with a 75%-25% training-validation split and fourfold cross-validation. Performance of the model was compared with retrospective interpretation of the same dataset by two experienced musculoskeletal radiologists, blinded to clinical history. A second group of US images from 275 of the 419 patients containing the three common benign masses was used to train and evaluate a separate model to differentiate between the masses. The models were trained on the Keras machine learning platform (version 2.3.1), with a modified pretrained VGG16 network. Performance metrics of the model and of the radiologists were compared by using the McNemar test, and 95% CIs for performance metrics were estimated by using the Clopper-Pearson method (accuracy, recall, specificity, and precision) and the DeLong method (area under the receiver operating characteristic curve).

Results

The model trained to classify malignant and benign masses demonstrated an accuracy of 79% (95% CI: 68, 88) on the test data, with an area under the receiver operating characteristic curve of 0.91 (95% CI: 0.84, 0.98), matching the performance of two expert readers. Performance of the model distinguishing three benign masses was lower, with an accuracy of 71% (95% CI: 61, 80) on the test data.

Conclusion

The trained CNN was capable of differentiating between benign and malignant soft-tissue masses depicted on US images, with performance matching that of two experienced musculoskeletal radiologists.© RSNA, 2020.

Development of a novel secondary phenotypic screen to identify hits within the mycobacterial protein synthesis pipeline

Background

Whole‐cell phenotypic screening is the driving force behind modern anti‐tubercular drug discovery efforts. Focus has shifted from screening for bactericidal scaffolds to screens incorporating target deconvolution. Target‐based screening aims to direct drug discovery toward known effective targets and avoid investing resources into unproductive lines of enquiry. The protein synthesis pipeline, including RNA polymerase and the ribosome, is a clinically proven target in Mycobacterium tuberculosis. Screening for new hits of this effective target pathway is an invaluable tool in the drug discovery arsenal.

Methods

Using M. tuberculosis H37Rv augmented with anhydrotetracycline‐inducible expression of mCherry, a phenotypic screen was developed for the identification of protein synthesis inhibitors in a medium throughput screening format.

Results

The assay was validated using known inhibitors of protein synthesis to show a dose‐dependent reduction in mCherry fluorescence. This was expanded to a proprietary screen of hypothetical protein synthesis hits and modified to include quantitative viability measurement of cells using resazurin.

Conclusion

Following the success of the proprietary screen, a larger scale screen of the GlaxoSmithKline anti‐tubercular library containing 2799 compounds was conducted. Combined single shot and dose‐response screening yielded 18 hits, 0.64% of all screened compounds.

Temporally Altered miRNA Expression in a Piglet Model of Hypoxic Ischemic Brain Injury

Hypoxic ischemic encephalopathy (HIE) is the most frequent cause of acquired infant brain injury. Early, clinically relevant biomarkers are required to allow timely application of therapeutic interventions. We previously reported early alterations in several microRNAs (miRNA) in umbilical cord blood at birth in infants with HIE. However, the exact timing of these alterations is unknown. Here, we report serial changes in six circulating, cross-species/bridging biomarkers in a clinically relevant porcine model of neonatal HIE with functional analysis. Six miRNAs—miR-374a, miR-181b, miR-181a, miR-151a, miR-148a and miR-128—were significantly and rapidly upregulated 1-h post-HI. Changes in miR-374a, miR-181b and miR-181a appeared specific to moderate-severe HI. Histopathological injury and five miRNAs displayed positive correlations and were predictive of MRS Lac/Cr ratios. Bioinformatic analysis identified that components of the bone morphogenic protein (BMP) family may be targets of miR-181a. Inhibition of miR-181a increased neurite length in both SH-SY5Y cells at 1 DIV (days in vitro) and in primary cultures of rat neuronal midbrain at 3 DIV. In agreement, inhibition of miR-181a increased expression of BMPR2 in differentiating SH-SY5Y cells. These miRNAs may therefore act as early biomarkers of HIE, thereby allowing for rapid diagnosis and timely therapeutic intervention and may regulate expression of signalling pathways vital to neuronal survival.

Impacts of a Pediatric Extracorporeal Cardiopulmonary Resuscitation (ECPR) Simulation Training Program

OBJECTIVE

To examine the impacts of a large-scale simulation-based extracorporeal cardiopulmonary resuscitation (ECPR) training program in an academic children's hospital.

METHODS

The study followed a quasi-experimental, mixed-method, time series design. Two-hour high-fidelity ECPR simulations were held monthly in the pediatric, cardiac, and neonatal intensive care units. Intensive care unit-specific cases were used in each unit. The learning objectives for all cases were the same. Each simulation included an average of 11 health care professionals, including nurses, physicians, respiratory therapist, and perfusionists. Impacts of training were examined using Kirkpatrick's 4-level model: reactions, learning, behaviors, and results. Participant surveys, semistructured interviews, facilitator observations, applied cognitive task analysis, and hospital code data were used to examine the impacts of training.

RESULTS

From February 2014 to October 2016, a total of 332 health care professionals participated in 29 ECPR simulations. Participants enjoyed the simulations and reported learning gains. Applied cognitive task analysis revealed 2 specific behaviors, coordination of compressions with surgical cannulation and performing sterile compressions, that were targeted for further training. The rate of adherence to the ECPR activation protocol improved from 83% (48/58) before simulations started to 95% (92/97) after simulations (P = .02). ECPR activation time decreased from 7 minutes (interquartile range, 4-9 minutes) before simulations started to 2 minutes (interquartile range, 1-4 minutes) after simulations (P < .01).

CONCLUSIONS

Large-scale simulation-based ECPR training was associated with positive reactions, learning gains, behavioral change, improved adherence to the ECPR activation protocols, and faster activation times. Other children's hospital that perform ECPR should consider simulation-based training.

Development of a whole-cell high-throughput phenotypic screen to identify inhibitors of mycobacterial amino acid biosynthesis

Anti-tubercular drug discovery continues to be dominated by whole-cell high-throughput screening campaigns, enabling the rapid discovery of new inhibitory chemical scaffolds. Target-based screening is a popular approach to direct inhibitor discovery with a specified mode of action, eliminating the discovery of anti-tubercular agents against unsuitable targets. Herein, a screening method has been developed using Mycobacterium bovis BCG to identify inhibitors of amino acid biosynthesis. The methodology was initially optimized using the known branched-chain amino acid biosynthetic inhibitors metsulfuron-methyl (MSM) and sulfometuron-methyl (SMM), and subsequently, whole genome sequencing of resistant mutants and the use of over-expressor strains confirming their mode of action. The GlaxoSmithKline compound library of small molecule inhibitors with known activity against Mycobacterium tuberculosis was then used to validate the screen. In this paper, we have shown that media supplementation with amino acids can rescue M bovis BCG from known amino acid synthesis inhibitors, MSM and SMM, in a pathway specific manner. The therapeutic potential of amino acid biosynthesis inhibitors emphasizes the importance of this innovative screen, enabling the discovery of compounds targeting a multitude of related essential biochemical pathways, without limiting drug discovery toward a single target.

Monocytopenia in clozapine-induced agranulocytosis: insights into pathophysiology and treatment

A 26-year-old man with history of schizophrenia was admitted for neutropaenia. He was started on clozapine 3 months prior to admission. As a result he had weekly monitoring of his blood counts and on day of admission was noted to have an absolute neutrophil count (ANC) of 450 cells/μL. He was admitted for clozapine-induced agranulocytosis. Clozapine was held and the patient was started on granulocyte colony-stimulating factor (G-CSF) filgrastim and received two doses without any signs of ANC recovery. On further review, it was noted that the absolute monocyte count (AMC) was also low and tracked with the trend of ANC. We then theorised that the impact of clozapine was on a haematopoietic precursor (colony-forming unit granulocyte-macrophage, CFU-GM) which gives rise to both monocytic and myeloid lineages. Therefore, sargramostim GM-CSF was started. After two doses, the ANC and AMC started trending up and by the third dose, both counts had fully recovered. He was discharged from the hospital and there are no plans to rechallenge with clozapine. Thus, we demonstrate a case of monocytopenia accompanying clozapine-induced agranulocytosis with successful use of GM-CSF. At least in this case, the target of the clozapine injury appears to be the CFU-GM, explaining the rapid and full response to GM-CSF after lack of response to G-CSF.

Clinical Pharmacist Impact on Intensive Care Unit Delirium: Intervention and Monitoring

Purpose: The purpose of this study was to determine the impact of pharmacist monitoring with a clinical decision support system (CDSS) on clinical outcomes related to intensive care unit (ICU) delirium. Methods: This was a single-center, before-and-after study. This study compares patient outcomes of the preintervention group, which is the standard of care of pharmacist rounding, and the intervention group of pharmacy rounding with the CDSS rules. Using a CDSS, specific delirium risk factor rules were created to alert pharmacists to patients who have an increased risk of developing ICU delirium. Patients were included in the study if they were ⩾18 years of age, admitted to the trauma intensive care unit (TICU), and had one of the CDSS rule alerts. The CDSS notified pharmacists in real time to patients in the intervention group that met these criteria to provide timely recommendations in an effort to prevent ICU delirium. Results: Compared with the preintervention group receiving the standard of care (n = 28), the intervention CDSS group (n = 33) had a nonsignificant trend in decreased incidence of delirium (33.3% vs 24.1%, P = .45), ICU length of stay (LOS) (10.11 vs 7.55 days, P = .26), and ventilator duration (7.11 vs 5.03 days, P = .26). The intervention group had a significantly shorter hospital LOS (14.74 vs 9.98 days, P = .04). There was a nonsignificant increase in mortality with the intervention group from nondelirium causes (24.2% vs 7%, P = .07). Conclusion: The utilization of a CDSS by clinical pharmacists to monitor for delirium-specific risk factors led to a significantly shorter hospital LOS. Further studies using this model are warranted to see the impact on the ICU population.

Metastatic gestational choriocarcinoma: a masquerader in obstetrics

We describe a case of a 36-year-old woman presenting with vaginal bleeding and suboptimally rising serum human chorionic gonadotropin levels, who was investigated for a pregnancy of unknown location. Ultrasonography, laparoscopy and dilatation and curettage failed to reveal signs of an intra-uterine or intra-abdominal pregnancy. Following computed tomography imaging, a mediastinal mass was histologically determined to be a gestational choriocarcinoma. Following surgical resection and chemotherapy, the patient recovered and proceeded to have a successful intra-uterine pregnancy. We describe this exceptionally rare case and emphasise the importance of follow-up of hCG levels in pregnancy of unknown location.

AxGxE: Using Flies to Interrogate the Complex Etiology of Neurodegenerative Disease

Progressive and late-onset neurological disorders such as Parkinson's disease and Alzheimer's disease affect up to 50 million people globally-a number postulated to double every 20 years in a continually aging population. While predisposing allelic variants in several genes clearly confer risk, individual age and specific environmental influences are equally important discriminators of disease onset age and progression. However, none of these factors can independently predict disease with significant precision. Therefore, we must actively develop models that accommodate contributions from all factors, potentially resulting in an A × G × E (age-gene-environment) metric that reflects individual cumulative risk and reliably forecasts disease outcomes. This effort can only be enabled by a deep quantitative understanding of the contribution of these factors to neurodegenerative disease, both individually and in combination. This is also an important consideration because neuronal loss typically precedes clinical presentation and disease-modifying therapies are contingent on early diagnosis that is likely to be informed by an accurate estimation of individual risk. Although epidemiological studies continue to make strong advances in these areas with the advent of powerful "omics"-based approaches, systematic phenotypic modeling of AxGxE interactions is currently more feasible in model organisms such as Drosophila melanogaster where all three parameters can be manipulated with manageable experimental burden. Here, we outline the advantages of using fruit flies for investigating these complex interactions and highlight potential approaches that might help synthesize existing information from diverse fields into a cogent description of age-dependent, environmental, and genetic risk factors in the pathophysiology of neurological disorders.

Patient Satisfaction and Acceptability: A Journey through an Ambulatory Gynaecology Clinic in the West of Ireland

Ambulatory Gynaecology allows a 'see-and-treat' approach to managing gynaecological conditions, providing a more streamlined, integrated care pathway than the traditional gynaecology clinic and inpatient care model. This study was designed to assess patient satisfaction and acceptability of Ambulatory Gynaecology services in Mayo University Hospital, Castlebar, Ireland. It also provided for feedback from patients as to how the service might be improved. Eighty questionnaires were appropriately completed. Outcomes revealed positive responses in 84% with respect to their experience before attending the clinic, 93% relating to the Ambulatory Gynaecology clinic environment, 96% for communication within the service, 91% for their experience during the procedure and 88% for aftercare information. This study concludes that an ambulatory approach to managing a range of gynaecology referrals is a highly acceptable approach in an Irish gynaecological population. Valuable feedback was gained from the study, which will allow us to further enhance the service for our patients.