Oral mirtazapine decreases the gastrointestinal adverse effects in cats on doxorubicin chemotherapy

Anorexia, depression, and vomiting are the common adverse effects of chemotherapy in humans and animals. Mirtazapine is primarily used as an appetite stimulant and antiemetic in dogs and cats. Therefore, we evaluated the efficacy of mirtazapine in reducing the gastrointestinal adverse effects in cats receiving doxorubicin chemotherapy. This single-masked, placebo-controlled crossover study enrolled 11 cats with malignant mammary gland tumors. The cats were randomly assigned to receive either mirtazapine (1.88 mg/cat) or placebo every 48 h for 2 weeks from the first initiation of doxorubicin chemotherapy. Each cat was then crossed over to the alternate group on the subsequent chemotherapy with a 1-week wash-out period. The owners were asked to record appetite score, activity score, episodes of vomiting and diarrhea for 2 weeks after each doxorubicin administration. Cats treated with mirtazapine showed significantly increased bodyweight compared with those on placebo (P = 0.010). The appetite and activity scores during mirtazapine treatment was significantly higher than those during placebo treatment (P = 0.005 and 0.018, respectively). Furthermore, the prevalence of episodes of vomiting during mirtazapine treatment was significantly lower than that during placebo treatment (P = 0.026). Our results demonstrate that mirtazapine can significantly increase bodyweight, appetite, and activity and reduce vomiting in cats after doxorubicin chemotherapy.

Kondo screening in a Majorana metal

Kondo impurities provide a nontrivial probe to unravel the character of the excitations of a quantum spin liquid. In the S = 1/2 Kitaev model on the honeycomb lattice, Kondo impurities embedded in the spin-liquid host can be screened by itinerant Majorana fermions via gauge-flux binding. Here, we report experimental signatures of metallic-like Kondo screening at intermediate temperatures in the Kitaev honeycomb material α-RuCl3 with dilute Cr3+ (S = 3/2) impurities. The static magnetic susceptibility, the muon Knight shift, and the muon spin-relaxation rate all feature logarithmic divergences, a hallmark of a metallic Kondo effect. Concurrently, the linear coefficient of the magnetic specific heat is large in the same temperature regime, indicating the presence of a host Majorana metal. This observation opens new avenues for exploring uncharted Kondo physics in insulating quantum magnets.

Development of metal radioactive liquid reference material for proficiency test

This study developed liquid reference materials containing various metals, to be used for quality assurance of radiation measurements of the most common metallic wastes generated during the operation or decommissioning of nuclear power plants. The liquid reference materials were prepared by assuming the dissolution of stainless-steel using acid and melting of the major metals present in the stainless steel, namely Fe, Ni, Cr, and Mn, along with the standard sources (134Cs, 137Cs, 60Co, 90Sr). The theoretical massic activity of the standard sources added to the samples and the measured reference values of the gamma and beta emitters in the samples were compared, and they showed good agreement within a one-sigma confidence interval (k = 1). Using the developed reference materials, a proficiency test was conducted on three domestic labs, and the results were evaluated using Z-score. While the evaluation results showed good agreement between the reference values and the reported values for 137Cs and 60Co, all participating labs reported lower values than the reference value for 134Cs. For 90Sr, two out of the three labs reported significantly higher values than the reference value. Based on the results of this study, the developed metal radioactive liquid reference material is expected to be registered as certified reference material (CRM) in the future. They will be used as the CRM for measuring and ensuring the quality of radioactive metal waste.

The risk factors of the 72-h unscheduled return visit admission to emergency department in adults below 50 years old

BACKGROUND

An unscheduled return visit (URV) to the emergency department (ED) within 72-h is an indicator of ED performance. An unscheduled return revisit (URV) within 72-h was used to monitor adverse events and medical errors in a hospital quality improvement program. The study explores the potential factors that contribute to URV to the ED within 72-h and the unscheduled return revisit admission (URVA) in adults below 50 years old.

METHODS

The case-control study enrolled 9483 URV patients during 2015-2020 in National Cheng-Kung University Hospital. URVA and URV non-admission (URVNA) patients were analyzed. The Gini impurity index was calculated by decision tree (DT) to split the variables capable of partitioning the groups into URVA and URVNA. Logistic regression is applied to calculate the odds ratio (OR) of candidate variables. The α level was set at 0.05.

RESULTS

Among patients under the age of 50, the percentage of females in URVNA was 55.05%, while in URVA it was 53.25%. Furthermore, the average age of URVA patients was 38.20 ± 8.10, which is higher than the average age of 35.19 ± 8.65 observed in URVNA. The Charlson Comorbidity Index (CCI) of the URVA patients (1.59 ± 1.00) was significantly higher than that of the URVNA patients (1.22 ± 0.64). The diastolic blood pressure (DBP) of the URVA patients was 85.29 ± 16.22, which was lower than that of the URVNA (82.89 ± 17.29). Severe triage of URVA patients is 21.1%, which is higher than the 9.7% of URVNA patients. The decision tree suggests that the factors associated with URVA are "severe triage," "CCI higher than 2," "DBP less than 86.5 mmHg," and "age older than 34 years". These risk factors were verified by logistic regression and the OR of CCI was 2.42 (1.50-3.90), the OR of age was 1.84 (1.50-2.27), the OR of DBP less than 86.5 was 0.71 (0.58-0.86), and the OR of severe triage was 2.35 (1.83-3.03).

CONCLUSIONS

The results provide physicians with a reference for discharging patients and could help ED physicians reduce the cognitive burden associated with the diagnostic errors and stress.

Association of left atrial ejection fraction and cardiovascular outcomes in Asian patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme

Background

The optimal method of risk stratification of hyp­ertrophic cardiomyopathy (HCM) patients, especially in the Asian population, is unknown. Left atrial ejection fraction (LAEF) is an emerging risk marker for cardiovascular outcomes. This study aimed to investigate whether LAEF was associated with cardiovascular outcomes in Asian patients with HCM.

Methods

This was a retrospective cohort study performed in a tertiary academic centre involving 291 consecutive patients diagnosed with HCM between 2010 and 2017. We collected the relevant clinical characteristics of these patients and retrospectively analysed the index transthoracic echocardiograms for novel left atrial indices including LAEF. We obtained the maximum (LAVmax) and minimum left atrial volumes (LAVmin) using the biplane method of disks in apical 4- and 2-chamber views. LAEF was derived by dividing the difference between LAVmax and LAVmin by LAVmax. We assessed the patients for outcomes of (1) heart failure requiring admission, and (2) a composite of adverse outcomes including all-cause mortality, ventricular tachycardia / ventricular fibrillation (VT/VF) events, appropriate device therapy if an implantable cardioverter defibrillator (ICD) was implanted, stroke and heart failure hospitalization.

Results

The patients had a mean age of 59.0 ± 16.7 years-old at diagnosis and had a male preponderance (71.2%). The most common comorbidities were hypertension, diabetes mellitus and ischemic heart disease. On univariable logistic regression analysis, maximum and minimum left atrial volume index (LAVI) as well as LAEF showed a significant association with heart failure and the predefined composite outcome. On Cox regression analysis adjusting for variables of age, sex, left ventricular ejection fraction (LVEF), left ventricular maximal wall thickness >30mm, significant left ventricular outflow tract (LVOT) gradient of > 30mmHg and more than moderate mitral regurgitation, maximum and minimum LAVI as well as LAEF retained an association with heart failure admission but only minimum LAVI and LAEF were associated with the composite outcome [(OR 0.019, 95% CI 0.02-0.230, p=0.002), (OR 0.226, 95% CI 0.053-0.960, p=0.044), (OR 1.030, 95% CI 1.016-1.045, p<0.001), and (OR 1.016, 95% CI 1.005-1.026, p=0.004) respectively].

Conclusion

LAEF was an independently associated with congestive heart failure as well as a composite of adverse outcomes in Asian patients with HCM.

Prospective associations of circulating thrombospondin-2 level with heart failure hospitalization, left ventricular remodeling and diastolic function in type 2 diabetes

Background

Circulating thrombospondin-2 (TSP2) levels were associated with the development of heart failure (HF) in recent studies. However, these studies included only a minority of patients with type 2 diabetes, which is associated with an increased HF risk. As hyperglycemia induces TSP2 expression and its tissue expression increases in type 2 diabetes, we investigated the prospective association of circulating TSP2 with incident HF hospitalization (HHF), and its associations with longitudinal changes of echocardiographic parameters in type 2 diabetes.

Methods

Baseline serum TSP2 levels were measured in 4949 patients with type 2 diabetes to determine its association with incident HHF using multivariable Cox regression analysis. In the echocardiographic study, baseline serum TSP2 levels were measured in another 146 patients with type 2 diabetes but without cardiovascular diseases who underwent detailed transthoracic echocardiography at baseline and after 1 year.

Results

Over a median follow-up of 7.8 years, 330 of 4949 patients (6.7%) developed incident HHF. Baseline serum TSP2 levels were independently associated with the development of HHF (HR 1.31, 95%CI 1.06–1.62, p = 0.014) after adjustments for baseline conventional cardiovascular risk factors, atrial fibrillation, estimated glomerular filtration rate, albuminuria and high-sensitivity C-reactive protein level, use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop-diuretics, aspirin, insulin, metformin and sodium-glucose co-transporter 2 inhibitors. Moreover, baseline serum TSP2 levels were independently associated with increase in average E/e’ and left atrial volume index (p = 0.04 and < 0.01, respectively).

Conclusion

Serum TSP2 levels were independently associated with both incident HHF and deterioration in diastolic function in type 2 diabetes.

Trial registration

Not Applicable

Supplementary information

The online version contains supplementary material available at 10.1186/s12933-022-01646-x.

Sleep apnea and temporal changes in cardiac repolarization in patients undergoing coronary artery bypass grafting

Background

In coronary artery bypass grafting (CABG), despite re-establishing coronary reperfusion, myocardial recovery and restoration of contractility often occur later, and the risk of adverse cardiovascular events persists during the post-CABG period. The occurrence of adverse cardiovascular events is linked to abnorm-al cardiac repolarisation that can be measured by surface electrocardiograms (ECGs). Sleep apnoea is an emerging cardiovascular risk factor. The relationship between sleep apnoea, abnorm-al cardiac repolarisation, and the occurrence of adverse cardiovascular events is not well studied.

Purpose

We investigated the impact of sleep apnoea on the change in repolarisation after CABG, and if the change in repolarisation is associated with the occurrence of major adverse cardiac and cerebrovascular events (MACCE).

Methods

Between November 2013 and December 2018, 1007 patients from 4 hospitals underwent an overnight sleep study prior to a non-emergent CABG. ECGs were acquired prospectively within 48h before the CABG (T1), and within 24h after the CABG (T2). QTc intervals were measured in three consecutive heart beats in one lead - the preferential lead measurements were lead II, followed by lead V5. QTc intervals were measured using the BRAVO algorithm by Analysing Medical Parameters for Solutions (AMPS) LLC. The change of T2 from T1 for QTc (ΔQTc) was derived. The mean follow-up duration was 2.1 years. MACCE was a composite of cardiovascular death, myocardial infarction, stroke, and unplanned revascularisation.

Results

A total of 954 patients (median age: 62 years; male: 86%) survived the initial 24 hours and had quality ECGs for analysis. Lead II and V5 were measured in 72% and 25% of the cohort, respectively. A total of 115 patients developed MACCE (MACCE group). Compared with the non-MACCE group, the MACCE group was older, had (a) a higher prevalence of smoking, hypertension, diabetes mellitus, and chronic kidney disease, (b) higher apnoea-hypopnoea index (AHI) and oxygen desaturation index (ODI), and (c) a smaller ΔQTc (Table). In Cox regression analysis, a smaller ΔQTc was independently associated with occurrence of MACCE (HR: 1.003; 95% CI: 1.000–1.006; p=0.032).

Older age, history of previous stroke, chronic kidney disease, more severe sleep apnoea (higher AHI, ODI, and severe oxygen desaturation) were associated with smaller ΔQTc. After adjusting for the effects of confounding variables, a higher ODI was independently associated with a smaller ΔQTc (correlation coefficient: −0.58; p&lt;0.001).

Conclusions

In patients undergoing a non-emergent CABG, a smaller ΔQTc during the first 24 hours after the CABG is associated with a higher incidence of MACCE. A higher pre-operative ODI based on a sleep study is an independent predictor of a smaller ΔQTc. This suggests that change in QTc within 24 hours after CABG could be due to sleep apnoea, and it is a novel predictor of occurrence of MACCE at medium term follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Transition Award and Clinician Scientist Award from the National Medical Research Council of Singapore (award numbers: NMRC/TA/012/2012; NMRC/CSA-INV/002/2015)

Metabolic associated fatty liver disease increases risk of adverse events after acute coronary syndrome

 

Metabolic Associated Fatty Liver Disease (MAFLD) was recently introduced as an alternative definition for fatty liver, that has been linked to an increased risk of systemic end-organ damage. However, current studies have not examined the impact of MAFLD on patients presenting with acute coronary syndrome (ACS). Here, we present a retrospective analysis on the short and long-term outcomes of ACS patients with MAFLD.

Methods

A retrospective analysis was conducted in a tertiary care centre. Hepatic steatosis and fibrosis was examined with hepatic steatosis index and fibrosis-4 (FIB-4) index. The primary and secondary outcomes of the analysis were long term all-cause mortality, and in-hospital all-cause mortality, stroke, heart failure and cardiogenic shock respectively. Adjusted analysis was conducted for primary and secondary outcomes with covariates including age, sex, race, type of ACS and previous myocardial infarction.

Results

A total of 5770 patients were included in the analysis, and 21% of ACS patients had concomitant MAFLD. MAFLD resulted in a 23% increase in long-term all-cause mortality compared to non-MAFLD (HR: 1.230, CI: 1.065 to 1.420, p=0.005). MAFLD increased the risk of in-hospital mortality, stroke, heart failure and cardiogenic shock compared to non-MAFLD. A sensitivity analysis conducted based on MAFLD with advance fibrosis, chronic kidney disease and diabetes also demonstrated significantly increased effect size magnitude of all-cause mortality, compared to non-MAFLD.

Conclusion

MAFLD represents an encapsulation of metabolism dysregulation and has been associated with increased risk of systematic disease. The present study shows that MAFLD is associated with significantly increased adverse prognostic outcomes after ACS compared to non-MAFLD. An increase in awareness of MAFLD is required beyond the field of hepatology for improvements in multidisciplinary care and management.

Funding Acknowledgement

Type of funding sources: None.

Reconstructed meta-analysis of percutaneous coronary intervention versus coronary artery bypass grafting for left main disease

Background

Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results.

Objectives

We performed a systematic review from inception to 23 May 2021 and one-stage reconstructed individual-patient data meta-analysis (IPDMA) that included 10-year mortality outcomes.

Methods

The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke and unplanned revascularization at 5 years. We did IPDMA using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups.

Results

Of 583 articles retrieved, 5 RCTs were included. A total of 4595 patients from these 5 RCTs were randomly assigned to PCI (N=2297) or CABG (N=2298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6% respectively (HR 1.093, 95% CI: 0.925–1.292; p=0.296). PCI conferred similar time-to-MI (RMST ratio 1.006, 95% CI: 0.992–1.021, p=0.391) and stroke (RMST ratio 1.005, 95% CI: 0.998–1.013, p=0.133) at 5 years. Unplanned revascularization was more frequent following PCI compared with CABG (HR 1.807, 95% CI: 1.524–2.144, p&lt;0.001) at 5 years.

Conclusion

This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.

Funding Acknowledgement

Type of funding sources: None.

Coronary artery bypass grafting versus percutaneous coronary intervention with stenting for multivessel coronary artery disease without left main coronary disease:reconstructed individual patient data

Background and aims

Data are emerging on 10-year mortality comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with stenting for multivessel disease (MVD) without left main (LM) involvement. We conducted an updated two-stage meta-analysis using reconstructed individual patient data to compare long-term mortality between CABG and PCI for patients with MVD without significant LM coronary disease.

Methods

Medline and Embase databases were searched for articles comparing CABG with PCI for MVD. A two-stage meta-analysis was conducted using reconstructed patient level survival data for all-cause mortality with subgroups by SYNTAX score. The shared-frailty and stratified Cox models were fitted to compare survival endpoints.

Results

We screened 1496 studies and included six randomized controlled trials with 7181 patients. PCI was associated with greater 10-year all-cause mortality risk (HR: 1.282, CI: 1.118–1.469, p&lt;0.001) compared with CABG. In patients with low SYNTAX score, 10-year all-cause mortality after PCI was comparable to CABG (HR: 1.102, 0.822–1.479, p=0.516). However, in patients with moderate to high SYNTAX score, 10-year all-cause mortality was significantly higher after PCI compared with CABG (HR: 1.444, 1.122–1.858, p&lt;0.001; HR: 1.856, 1.380–2.497, p&lt;0.001 respectively).

Conclusion

This updated reconstructed individual patient-data meta-analysis revealed a sustained lower cumulative all-cause mortality of CABG over PCI for multivessel disease without LM involvement.

Funding Acknowledgement

Type of funding sources: None.

A 10-year cohort on prognostic outcomes in patients presenting with acute myocardial infarction complicated by cardiogenic shock and/or cardiac arrest

Background

Cardiogenic shock (CS) and cardiac arrest (CA) complicating acute myocardial infarction (AMI) portend unfavourable outcomes. This study examined the prognosis of patients presenting with AMI complicated by CS and/or CA.

Methods

Consecutive patients presented with AMI to a percutaneous coronary intervention-capable tertiary institution between 2011 and 2021 were studied. Patients were stratified based on the presence or absence of CS (CS+ or CS−) and CA (CA+ or CA−). The primary outcome was 30-day cardiovascular-related mortality. Subgroup analyses based on AMI-type and sex were conducted. Kaplan-Meier curves for cardiovascular-related mortality based on the AMI-type and sex were constructed.

Results

The study included 11,608 AMI patients, 283 of whom had CS+/CA+, 1,068 had CS+/CA−, 54 had CS−/CA+ and 10,203 had CS−/CA−. Cardiovascular-related mortality was significantly higher for CS+/CA+ (57.6%), followed by CS+/CA− (41.6%), CS−/CA+ (20.4%) and CS−/CA− (2.4%). Kaplan-Meier curves demonstrated CS+/CA+ group had the highest mortality (HR=36.26; 95% CI: 29.71–44.25, p&lt;0.001), followed by CS+/CA− (HR=21.59; 95% CI: 18.47–25.24, p&lt;0.001) and CS−/CA+ (HR=9.18; 95% CI: 5.02–16.80, p&lt;0.001), with CS−/CA− as the reference. Those with NSTEMI had consistently higher cardiovascular-related mortality rates than their STEMI counterparts for all groups, apart from the CS+/CA+ group. The sex-specific analysis demonstrated that the survival curves for females with CS+/CA+, CS+/CA− and CS−/CA+ converged, whilst the survival curves for males diverged over time. The multivariable Cox regression revealed the presence of CS and CA are independent predictors of cardiovascular-related mortality, but not NSTEMI, when adjusted for age, gender, diabetes, left ventricular ejection fraction, chronic renal failure, and culprit vessel.

Conclusions

AMI associated with CA and CS portends the least favourable survival, followed by those with CS or CA alone. Excess mortality was observed in the traditionally perceived lower-risk groups, particularly in women. This calls for increased awareness amongst clinicians when managing this subset of high-risk patients.

Funding Acknowledgement

Type of funding sources: None.

Legacy effects of infection in patients with heart failure: a national cohort study of 31,318 patients in Taiwan

Background

Although infection is a common cause of hospitalization in patients (pts) with heart failure (HF), the long-term cardiovascular (CV) prognosis in HF after infection is not well studied.

Methods and results

From 2009 to 2015, 310,485 pts with their first HF admissions and survival to discharge were identified from the National Health Insurance Research Database. Among the pts, 103,505 (33.3%) were readmitted within 1 year after HF discharge for infection, including pneumonia (44.2%), urinary tract infection (UTI) (37.9%), skin and soft tissue infections (9.7%), and others (8.1%). Those without admission for any infection were controls. We compared the primary composite endpoint, including all-cause death, acute myocardial infarction (AMI), stroke, and hospitalization for HF (HHF) between the 2 groups after the infection episode. After propensity score matching, the clinical characteristics (age 71.7±13.9 years, male 52.0%) and treatment were similar between the groups (n=15,659 in each group). In a mean follow-up time of 4.3±2.9 years, 86.2% pts with a history of infection admission and 63.6% pts in the control group met the primary endpoint. Multivariate Cox proportional hazards analysis showed the infection group had a higher risk of the primary composite endpoint (HR 1.760, 95% CI 1.714–1.807), including all-cause death (HR 1.587, 95% CI: 1.540–1.636), HHF (HR 1.993, 95% CI 1.922–2.066), AMI (HR 1.332, 95% CI 1.224–1.450), and stroke (HR 1.769, 95% CI 1.664–1.882). In infection group, HHF was the earliest outcome event with a mean time of 17.5 months and mortality is the second early event with a mean time of 23 months after discharge from the infection episode. Pneumonia carried a higher risk than UTI for the primary composite endpoint (HR 1.140, 95% CI 1.104–1.178).

Conclusions

One-third of HF pts discharged from the hospital experienced acute infection that required readmission. The pts had worse CV prognosis after readmission for infectious disease compared to those without infection

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): This study is supported by National Cheng Kung University Hospital and Tainan Hospital, Ministry of Health and Welfare, Taiwan.

Higher long-term mortality in patients with concomitant acute coronary syndrome and aortic stenosis

Background

Aortic stenosis (AS) and acute coronary syndrome (ACS) share similar cardiovascular risk factors, and their concomitant presentation is increasing in incidence with the aging population. Yet literature regarding the prognosis of patients with concomitant ACS and AS remains scarce.

Methods

This retrospective cohort study examined consecutive patients presenting with ACS (ST-segment elevation myocardial infarction [STEMI] and non-STEMI [NSTEMI]) and concomitant AS between 1 January 2011 and 31 March 2021 in a tertiary hospital. The cohort was divided into mild, moderate and severe AS based on index echocardiogram. The primary outcome was all-cause mortality. Kaplan-Meier curves were constructed to compare all-cause mortality among the three groups of patients, based on ACS type and left ventricular ejection fraction (LVEF). Multivariable Cox regression was performed to identify independent predictors of all-cause mortality.

Results

Of a total of 563 patients, 264 had mild (46.9%), 193 moderate (34.3%) and 106 severe AS (18.8%). The mean follow-up duration was 2.5 (± 2.4) years. Majority of patients (72.5%) presented with NSTEMI. Patients with moderate and severe AS had higher rates of all-cause mortality compared to those with mild AS (49.7% vs. 51.4% vs. 35.6% respectively, p=0.002). Concomitant moderate (HR 1.439, 95% CI 1.012–2.048, p=0.043) and severe AS (HR 1.844, 95% CI 1.159–2.933, p=0.010) were independent predictors of all-cause mortality after adjusting for age, gender, LVEF, ACS type, chronic kidney disease, diabetes, hypertension, coronary artery bypass grafting and aortic valve replacement as a time-dependent variable. The Kaplan-Meier curves demonstrated excess mortality in moderate and severe AS, compared to the mild AS group (p&lt;0.001), with similar survival trends observed in the STEMI and the NSTEMI groups, as well as those with preserved LVEF.

Conclusion

Regardless of the ACS presentation type, long-term excess mortality in those with concomitant moderate or severe AS was observed. The adverse prognosis typically observed in patients with concomitant severe AS, in the setting of ACS, extends to patients with moderate AS.

Funding Acknowledgement

Type of funding sources: None.

Prenatal exposure to nickel and atopic dermatitis at age 3 years: a birth cohort study with cytokine profiles

BACKGROUND

Nickel, the fifth most common element on Earth, is the leading inducer of contact allergies in humans, with potent immunological effects. Nickel-induced contact allergies predominantly affect females. Maternal exposure to nickel has been associated with several developmental abnormalities. However, how a maternal nickel exposure affects the development of atopic diathesis and immune abnormalities in children has never been addressed.

OBJECTIVES

We aimed to determine whether maternal Ni exposure affects the development of atopic dermatitis and immune abnormalities in their children.

METHODS

Using a birth cohort study, we analysed 140 mother-child pairs recruited in 2012-2015 from central Taiwan. Maternal exposure to nickel was estimated using urinary nickel levels measured by inductively coupled plasma mass spectrometry (ICP-MS). The serum levels of 65 analytes and IgE in 3-year-old children were profiled with a multiplex ELISA. The correlation between the maternal urinary nickel concentration and serum analyte levels was assessed using Spearmen's correlation. Multivariant regression analysis was performed to evaluate the association between maternal urinary nickel levels and serum analyte concentrations in their children.

RESULTS

The geometric means of the maternal urinary nickel and the children's serum IgE levels were 2.27 μg/L and 69.71 IU/ml, respectively. The maternal nickel exposure was associated with increased serum levels of IL-1β, IL-2, TNF-α, and leukaemia inhibitory factor (LIF) but with decreased serum levels of matrix metalloproteinase-1 (MMP-1), IL-2R, and eotaxin-1 in the children. In addition, the development of childhood atopic dermatitis at 3 years old was significantly associated with the child's serum levels of IgE and IL-2R, but it was negatively associated with the maternal nickel exposure.

CONCLUSIONS

This is the first study showing the potential immunological effects of maternal nickel exposure in their children at an early developmental stage.

Prognostic Effects of Delayed Administration of Appropriate Antimicrobials in Bacteraemic Adults Initially Presenting with Various Body Temperatures

Purpose

To investigate the different impact of delayed administration of appropriate antimicrobial therapy (AAT) on short-term mortality of bacteraemia patients initially presenting with various body temperatures (BTs).

Materials and Methods

A six-year, two-center cohort consisting of adults with community-onset bacteraemia in emergency departments (EDs) was retrospectively collected. Through the multivariable analyses, clinical impacts of delayed AAT, assessed by the time gap between the first dose of AAT and ED arrival, on 30-day mortality (primary outcomes) were respectively examined in the different groups of initial BTs (iBTs).

Results

Of the 3171 adults, despite the similarities of delayed AAT in six iBT categories, hourly AAT delay was associated with an average increase in 30-day mortality rates of 0.24% in the group of iBT <36.0℃, 0.40% in the 36.0℃–36.9℃ group, 0.48% in the 37.0℃–37.9℃ group, 0.59% in the 38.0℃–38.9℃ group, 0.58% in the 39.0℃–39.9℃ group, and 0.71% in the ≥40.0℃ group, after respective adjusting independent predictors of mortality. Furthermore, for 589 patients who inappropriately received empirical antimicrobial treatment (ie, delayed AAT ≥ 24 hours), with a cutoff of 34.0℃, each 1℃ increase in iBTs was independently associated with an average increase in 30-day mortality rates of 42%.

Conclusion

For adults with community-onset bacteraemia, the iBT-related differences in the prognostic impacts of delayed administration of appropriate antimicrobials might be evident.

Prognostic Effects of Inappropriate Empirical Antimicrobial Therapy in Adults With Community-Onset Bacteremia: Age Matters

Background

Studies have reported the effects of delayed administration of appropriate antimicrobial therapy (AAT) on the short-term prognosis of patients with bloodstream infections; however, whether there is an age-related difference in these effects remains debated.

Methods

In this 4-year multicenter case-control study, patients with community-onset bacteremia were retrospectively categorized into the "middle-aged" (45-64 years), "old" (65-74 years), and "very old" (≥75 years) groups. Two methods were adopted to investigate the prognostic effects of delayed AAT in each age group. First, its effects were, respectively, investigated, after adjustment for the independent predictors of 30-day mortality. Second, patients in each age group were matched by the closest propensity-score (PS), which was calculated by independent predictors of mortality; the survival curves and Pearson chi-square tests were adopted to disclose its effects in each PS-matching group.

Results

Each hour of delayed AAT resulted in an average increase in the 30-day crude mortality rate of 0.2% (P = 0.03), 0.4% (P < 0.001), and 0.7% (P < 0.001) in middle-aged (968 patients), old (683), and very old (1,265) patients, after, respectively, adjusting the independent predictors of mortality in each group. After appropriate PS-matching, no significant proportion differences in patient demographics, bacteremia characteristics, severity of bacteremia and comorbidities, and 15-day or 30-day crude mortality rates were observed between three matched groups (582 patients in each group). However, significant differences in survival curves between patients with delayed AAT > 24 or >48 h and those without delayed administration were demonstrated in each age group. Furthermore, the odds ratios of 30-day mortality for delayed AAT > 24 or >48 h were 1.73 (P = 0.04) or 1.82 (P = 0.04), 1.84 (P = 0.03) or 1.95 (P = 0.02), and 1.87 (P = 0.02) or 2.34 (P = 0.003) in the middle-aged, old, and very old groups, respectively. Notably, the greatest prognostic impact of delayed AAT > 24 or >48 h in the very old group and the smallest impact in the middle-aged group were exhibited.

Conclusion

For adults (aged ≥45 years) with community-onset bacteremia, the delayed AAT significantly impacts their short-term survival in varied age groups and the age-related differences in its prognostic impact might be evident.

Effect of iron deficiency without anaemia on days alive and out of hospital in patients undergoing valvular heart surgery

Comprehensive evidence regarding the treatment of non-anaemic iron deficiency in patients undergoing valvular heart surgery is lacking. This study aimed to investigate the association between non-anaemic iron deficiency and postoperative outcomes in these patients. We retrospectively analysed 321 patients of which 180 (56%) had iron deficiency (defined as serum ferritin < 100 ng.ml^-1 or < 300 ng.ml^-1 with transferrin saturation < 20%). While the iron-deficient group had lower pre-operative haemoglobin levels than the non-iron deficient group (median (IQR [range]) 134 (127-141 [120-172]) g.l^-1 , 143 (133-150 [120-179]) g.l^-1 , p = 0.001), there was no between-group difference in allogeneic red blood cell transfusion. Median (IQR [range]) days alive and out of hospital at postoperative day 90 was 1 day shorter in the iron-deficient group (80 (77-82 [9-85]) days vs. 81 (79-83 [0-85]) days, p = 0.026). In multivariable analysis, only cardiopulmonary bypass duration (p = 0.032) and intra-operative allogeneic red blood cell transfusion (p = 0.011) were significantly associated with reduced days alive and out of hospital at postoperative day 90. Iron deficiency did not exert any adverse influence on secondary outcomes except length of hospital stay. Our findings indicate that non-anaemic iron deficiency alone is not associated with adverse effects in patients undergoing valvular heart surgery when it does not translate into an increased risk of allogeneic transfusion.

Non-alcoholic fatty liver disease and type 2 diabetes - An Update

The global prevalence of non‐alcoholic fatty liver disease (NAFLD) is rising, along with the epidemic of diabesity. NAFLD is present in >70% of individuals with type 2 diabetes. Although the mutually detrimental relationship between NAFLD and type 2 diabetes has been well established, a multitude of recent studies have further shown that type 2 diabetes is closely linked to the development of cirrhosis, hepatocellular carcinoma, liver‐related morbidity and mortality. In contrast, NAFLD also negatively impacts type 2 diabetes both in terms of its incidence and related adverse clinical outcomes, including cardiovascular and chronic kidney diseases. In response to these global health threats, clinical care pathways for NAFLD and guidelines for metabolic dysfunction‐associated fatty liver disease have been developed. Several antidiabetic agents have been evaluated for their potential hepatic benefits with promising results. Furthermore, type 2 diabetes patients are increasingly represented in clinical trials of novel therapeutics for NAFLD. However, despite the wealth of knowledge in NAFLD and type 2 diabetes, lack of awareness of the disease and the potential weight of this problem remains a major challenge, especially among clinicians who are outside the field of hepatology and gastroenterology. This review therefore aimed to provide all diabetes care providers with a summary of the latest evidence that supports NAFLD as an emerging diabetic complication of increasing importance, and to present the current recommendations, focusing on the assessment and therapeutic strategies, on the management of NAFLD among type 2 diabetes patients.

Clinical impact of intravascular ultrasound guidance in patients of ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention with drug eluting stent

Background

There is little data about clinical role of intravascular ultrasound (IVUS)-guided Percutaneous (PCI) in the setting of ST-segment elevation myocardial infarction (STEMI).

Methods

From 2005 to 2018, a total of 8,129 patients who underwent PCI with STEMI were investigated from the Korea Acute Myocardial Infarction Registry-National Institute of Health database. Patients with Non-ST segment elevation myocardial infarction, cardiogenic shock, bare metal stent implantation, thrombolytic treatment, and coronary artery bypass graft surgery were excluded. We categorized patients into two groups based on the treatment strategy: IVUS-guided PCI group (n=1,544), and coronary angiography guidance (CAG)-guided PCI group (n=6,585). The primary endpoint was composite of major adverse cardiovascular (MACE), including, cardiac death, myocardial infarction (MI), repeat target vessel revascularization (TVR) and stent thrombosis (ST).

Results

IVUS-guided PCI was performed in 19% patients (1544/8129). After propensity score matching, there were no statistically difference in the rate of cardiac death (0% in IVUS vs. 0.26% in CAG, p=0.947), MI (2.01% vs. 2.01%, p=0.408), TVR (1.23% vs. 0.91%, p=0.131), ST (0.32% vs. 0.45%, p=0.828) and composite of MACE at 1 year between two groups (2.01% vs. 2.40%, p=0.843). Independent risk factors for MACE were diabetes mellitus and multi-vessel disease, but not IVUS-guided PCI (HR 1.167, 95% CI, 0.896–1.520, p=0.251).

Conclusion

This study suggests that routine usage of IVUS in the setting of STEMI may not be necessary. Large-scaled random study will be needed for further evaluation.

Funding Acknowledgement

Type of funding sources: None.

Potential role of fibroblast growth factor 21 in the deterioration of bone quality in impaired glucose tolerance

PURPOSE

Findings on trabecular bone score (TBS), an index of bone quality, have been reported in prediabetes defined by impaired fasting glucose or HbA1c. Here, we assessed the bone mineral density (BMD) and TBS in prediabetes individuals with impaired glucose tolerance (IGT), and investigated the association of these bone parameters with serum levels of fibroblast growth factor 21 (FGF21), a hormone implicated in bone metabolism and with higher levels in IGT.

METHODS

Chinese postmenopausal women aged 55-80 years, without diabetes, were recruited from the Hong Kong Cardiovascular Risk Factor Prevalence Study in 2016-2018. Normal glucose tolerance (NGT) was defined by fasting glucose < 5.6 mmol/L and 2-h plasma glucose (2hG) < 7.8 mmol/L, and IGT by 2hG 7.8-11 mmol/L. Serum levels of FGF21 and other bone metabolism regulators were measured. Insulin sensitivity was assessed by the Matsuda index. Independent determinants of TBS were evaluated using multivariable stepwise linear regression.

RESULTS

173 individuals with NGT and 73 with IGT were included. TBS was lower in those with IGT compared to those with NGT, while BMD was comparable. Individuals with IGT had significantly higher serum FGF21 levels, which in turn showed an independent inverse relationship with TBS, attenuated after inclusion of the Matsuda index. Serum FGF21 levels, however, did not correlate with BMD.

CONCLUSION

Among Chinese postmenopausal women, bone quality was worse in IGT, despite comparable bone density. FGF21 levels showed a significant independent inverse relationship with TBS, partly attributed to insulin resistance. Whether FGF21 contributes to the impaired bone quality in IGT remains speculative.

HbA1c variability, in addition to mean HbA1c, predicts incident hip fractures in Chinese people with type 2 diabetes

Type 2 diabetes is associated with an increased risk of hip fractures. We hypothesize that long-term glycemic variability predicts incident hip fractures. We demonstrated that HbA1c variability predicted incident hip fractures independent of mean HbA1c, suggesting the potential benefits of minimizing glycemic variability in addition to optimizing mean glycemia for bone health.

INTRODUCTION

Type 2 diabetes is associated with an increased risk of hip fractures, and a linear relationship between HbA1c levels and hip fracture incidence has been observed. We hypothesize that HbA1c variability also predicts incident hip fractures in type 2 diabetes.

METHODS

Chinese individuals with type 2 diabetes aged ≥ 60 years were identified from electronic health records in Hong Kong between 2008 and 2012 and observed for incident hip fractures. Hip fracture was defined by the International Classification of Diseases (Ninth Revision) code 820. HbA1c variability was determined using standard deviation, adjusted standard deviation, and coefficient of variation of HbA1c measurements in the 5 years preceding the entry date. Multivariable Cox regression analysis was used to evaluate associations between HbA1c variability and incident hip fractures.

RESULTS

A total of 83,282 participants were included. Their mean age was 71.3 ± 7.5 years, duration of diabetes 11.7 ± 7.7 years, baseline HbA1c 56.6 ± 13.5 mmol/mol (7.33 ± 1.23%), and median follow-up 6.8 years. All indices of HbA1c variability were significant independent predictors of incident hip fractures, with an adjusted hazard ratio of up to 1.29 (all p < 0.001), and remained to be independent predictors across groups of different intensity of glycemic control. Mean HbA1c ≥ 64 mmol/mol (8.0%) was associated with a 25% increase in incident hip fractures compared with mean HbA1c < 53 mmol/mol (7.0%).

CONCLUSION

HbA1c variability is an independent positive predictor of hip fracture in type 2 diabetes, across the spectrum of varying degree of glycemic control, while a high HbA1c is also not advisable from the perspective of bone health.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.

The Hypotension Period after Initiation of Appropriate Antimicrobial Administration Is Crucial for Survival of Bacteremia Patients Initially Experiencing Severe Sepsis and Septic Shock

Bacteremia is linked to substantial morbidity and medical costs. However, the association between the timing of achieving hemodynamic stability and clinical outcomes remains undetermined. Of the multicenter cohort consisted of 888 adults with community-onset bacteremia initially complicated with severe sepsis and septic shock in the emergency department (ED), a positive linear-by-linear association (γ = 0.839, p < 0.001) of the time-to-appropriate antibiotic (TtAa) and the hypotension period after appropriate antimicrobial therapy (AAT) was exhibited, and a positive trend of the hypotension period after AAT administration in the 15-day (γ = 0.957, p = 0.003) or 30-day crude (γ = 0.975, p = 0.001) mortality rate was evidenced. Moreover, for every hour delay of the TtAa, 30-day survival dropped an average of 0.8% (adjusted odds ratio [AOR], 1.008; p < 0.001); and each additional hour of the hypotension period following AAT initiation notably resulted in with an average 1.1% increase (AOR, 1.011; p < 0.001) in the 30-day crude mortality rate, after adjusting all independent determinants of 30-day mortality recognized by the multivariate regression model. Conclusively, for bacteremia patients initially experiencing severe sepsis and septic shock, prompt AAT administration might shorten the hypotension period to achieve favourable prognoses.

Factors affecting the dormancy and germination of bleeding heart [Lamprocapnos spectabilis (L.) Fukuhara] seeds

Information on the optimal conditions to promote the germination of Lamprocapnos spectabilis (L.) Fukuhara seeds is limited; consequently, this study was conducted to establish the requirements to break seed dormancy and promote germination. The selected seeds had morphophysiological dormancy and had not begun embryo development. To study the dormancy breaking and embryo development processes, seeds were subjected to constant or changing temperature treatments during moist stratification. High temperature and humidity resulted in vigorous embryo growth, with the longest embryos occurring after 1 month of incubation at 20 °C. At 4 °C, the seeds required incubation period of at least 3 months to germinate. Embryo growth and germination were higher with changing high and low temperatures than under a constant temperature, and changing temperatures also considerably changed the endogenous hormone levels, embryo development and germination. Bioactive gibberellin (GA) content was higher in seeds incubated at 20 °C for 1 month, then at 4 °C for 2 months. The content of endogenous abscisic acid in seeds subjected to the same treatment decreased by 97.6% compared with that of the untreated seeds. Embryo growth and seed germination require changing high and low temperatures; however, exogenous GA₃ could substitute for high temperatures, as it also causes accelerated germination. In this study, the seeds of L. spectabilis were identified as an intermediate simple type, a sub-level of morphophysiologically dormant seeds.

A Simple Scoring Algorithm That Predicts Abscesses in Adults with Community-Onset Klebsiella pneumoniae Bacteremia: Hypermucoviscosity Matters

Introduction

Klebsiella pneumoniae is a pathogen commonly found in community-onset bacteremia. It causes an invasive syndrome that is frequently presented by metastatic infections and abscesses elsewhere and that is necessary for surgical or drainage intervention. To achieve a scoring algorithm to identify patients with community-onset K. pneumoniae bacteremia (CoKPB) who are at risk for abscess occurrences, a retrospective cohort study consisting of adults with CoKPB was conducted.

Methods

A 6-year cohort study consisting of adults having community-onset monomicrobial K. pneumoniae bacteremia was conducted. In addition to clinical variables collected from medical records, the hypermucoviscosity (HMV)-related gene (rmpA and magA) and an HMV phenotype were integrated into the proposed scoring algorithm.

Results

Of the 258 eligible adults, only 79 (30.6%) had abscesses related to bacteremia. Besides the presence of magA (ie, capsular serotype K1) and the HMV-phenotype, five clinical predictors were significantly associated with abscesses in a multivariate analysis: male gender, comorbidities with diabetes mellitus or neurological disorders, recent chemotherapy, and high c-reactive protein levels. Together, these predictors were used to calculate the CoKPB abscess score. Based on the scoring algorithm, a cut-off value of +2 yielded the high sensitivity (93.7%) and the acceptable specificity (50.8%); the area under the ROC curve was 0.83.

Conclusion

A simple scoring algorithm that has substantial sensitivity and satisfactory specificity was proposed and the importance of the HMV phenotype or capsular K1 serotype was emphasized. The proposed predictive model needs external validation, but this scoring algorithm might be convenient and useful for clinicians.

Impact of climate change on disaster events in metropolitan cities -trend of disasters reported by Taiwan national medical response and preparedness system

BACKGROUND

Taiwan is geographically located in a zone that is vulnerable to earthquakes, typhoons, floods, and landslide hazards and has experienced various disasters. Six Regional Emergency Medical Operation Centers (REMOCs) are integrated and administered by the Ministry of Health and Welfare (MOHW) to be responsible for emergency situations during disastrous events, such as the emission of chemical toxicants, traffic accidents, industrial materials containment, and typhoons.

OBJECTIVE

To analyze events reported by the six REMOCs during the 2014 to 2018 for the government policy reference.

METHODS

Data were collected from injured and death toll reports provided by local designated hospitals in the emergency medical reporting system. Disaster events were categorized into three categories: natural disaster (NDs), disasters associated with technology (DTs), and disasters associated with security/violence/others (DSVOs). The three categories were further subdivided into sub-categories. Variables considered for trend analyses included the number of wounded and deaths, event characteristics, date/time, and triage. The frequency of disaster events among the six REMOCs was compared using the chi-square test. We used the global information system (GIS) to describe the distribution of events in Taiwan metropolitan cities. The α-level was set at 0.05.

RESULTS

Of 580 events during the study period, the distribution of disaster characteristics in the jurisdictions of the six REMOCs were different. The majority of disaster events were DTs (64.5%), followed by NDs (24.5%) and DSVOs (11.0%). Events for the three disaster categories in the six REMOCs were different (χ²-test, p < 0.001). Furthermore, for the Taipei branch (Northern Taiwan), other NDs, especially heatwaves and cold spells, were most reported in New Taipei City (92.2%) and showed an increasing annual trend; for the Kaohsiung branch (Southern Taiwan), DT events were the most reported, especially in Kaohsiung City; and for the Taichung branch (Central Taiwan), DSVOs were the most reported, especially in Taichung City.

CONCLUSION

Our data revealed that extreme weather precautions reported in the Taipei branch were increasing. Disaster characteristics were different in each metropolitan city. Upgrading the ability to respond to natural disasters is ineluctable.

Randomly Hopping Majorana Fermions in the Diluted Kitaev System α-Ru_{0.8}Ir_{0.2}Cl_{3}

dc and ac magnetic susceptibility, magnetization, specific heat, and Raman scattering measurements are combined to probe low-lying spin excitations in α-Ru_{1-x}Ir_{x}Cl_{3} (x≈0.2), which realizes a disordered spin liquid. At intermediate energies (ℏω>3  meV), Raman spectroscopy evidences linearly ω-dependent Majorana-like excitations, obeying Fermi statistics. This points to robustness of a Kitaev paramagnetic state under spin vacancies. At low energies below 3 meV, we observe power-law dependences and quantum-critical-like scalings of the thermodynamic quantities, implying the presence of a weakly divergent low-energy density of states. This scaling phenomenology is interpreted in terms of the random hoppings of Majorana fermions. Our results demonstrate an emergent hierarchy of spin excitations in a diluted Kitaev honeycomb system subject to spin vacancies and bond randomness.

Definitive Cefazolin Therapy for Stabilized Adults with Community-Onset Escherichia coli, Klebsiella Species, and Proteus mirabilis Bacteremia: MIC Matters

Background: Cefazolin is in vitro active against wild isolates of Escherichia coli, Klebsiella species, and Proteus mirabilis (EKP), but clinical evidence supporting the contemporary susceptibility breakpoint issued by the Clinical and Laboratory Standards Institute (CLSI) are limited. Methods: Between 2010 and 2015, adults with monomicrobial community-onset EKP bacteremia with definitive cefazolin treatment (DCT) at two hospitals were analyzed. Cefazolin minimum inhibitory concentrations (MICs) were correlated with clinical outcomes, including primary (treatment failure of DCT) and secondary (30-day mortality after bacteremia onset, recurrent bacteremia, and mortality within 90 days after the end of DCT) outcomes. Results: Overall, 466 bacteremic episodes, including 340 (76.2%) episodes due to E. coli, 90 (20.2%) Klebsiella species, and 16 (3.6%) P. mirabilis isolates, were analyzed. The mean age of these patients was 67.8 years and female-predominated (68.4%). A crude 15- and 30-day mortality rate was 0.7% and 2.2%, respectively, and 11.2% experienced treatment failure of DCT. A significant linear-by-linear association of cefazolin MICs, with the rate of treatment failure, 30-day crude mortality, recurrent bacteremia or 90-day mortality after the DCT was present (all γ = 1.00, p = 0.01). After adjustment, the significant impact of cefazolin MIC breakpoint on treatment failure and 30-day crude mortality was most evident in 2 mg/L (>2 mg/L vs. ≤2 mg/L; adjusted hazard ratio, 3.69 and 4.79; p < 0.001 and 0.02, respectively). Conclusion: For stabilized patients with community-onset EKP bacteremia after appropriate empirical antimicrobial therapy, cefazolin might be recommended as a definitive therapy for cefazolin-susceptible EKP bacteremia, based on the contemporary CLSI breakpoint.

Beneficial effects of early empirical administration of appropriate antimicrobials on survival and defervescence in adults with community-onset bacteremia

Background

Bloodstream infections are associated with high morbidity and mortality, both of which contribute substantially to healthcare costs. The effects of early administration of appropriate antimicrobials on the prognosis and timing of defervescence of bacteremic patients remain under debate.

Methods

In a 6-year retrospective, multicenter cohort, adults with community-onset bacteremia at the emergency departments (EDs) were analyzed. The period from ED arrival to appropriate antimicrobial administration and that from appropriate antimicrobial administration to defervescence was regarded as the time-to-appropriate antibiotic (TtAa) and time-to-defervescence (TtD), respectively. The primary study outcome was 30-day mortality after ED arrival. The effects of TtAa on 30-day mortality and delayed defervescence were examined after adjustment for independent predictors of mortality, which were recognized by a multivariate regression analysis.

Results

Of the total 3194 patients, a TtAa-related trend in the 30-day crude (γ = 0.919, P = 0.01) and sepsis-related (γ = 0.909, P = 0.01) mortality rate was evidenced. Each hour of TtAa delay was associated with an average increase in the 30-day crude mortality rate of 0.3% (adjusted odds ratio [AOR], 1.003; P < 0.001) in the entire cohort and 0.4% (AOR, 1.004; P < 0.001) in critically ill patients, respectively, after adjustment of independent predictors of 30-day crude mortality. Of 2469 febrile patients, a TtAa-related trend in the TtD (γ = 0.965, P = 0.002) was exhibited. Each hour of TtAa delay was associated with an average 0.7% increase (AOR, 1.007; P < 0.001) in delayed defervescence (TtD of ≥ 7 days) after adjustment of independent determinants of delayed defervescence. Notably, the adverse impact of the inappropriateness of empirical antimicrobial therapy (TtAa > 24 h) on the TtD was noted, regardless of bacteremia severity, bacteremia sources, or causative microorganisms.

Conclusions

The delay in the TtAa was associated with an increasing risk of delayed defervescence and 30-day mortality for adults with community-onset bacteremia, especially for critically ill patients. Thus, for severe bacteremia episodes, early administration of appropriate empirical antimicrobials should be recommended.

Definitive Cefazolin Treatment for Community-Onset Enterobacteriaceae Bacteremia Based on the Contemporary CLSI Breakpoint: Clinical Experience of a Medical Center in Southern Taiwan

Cefazolin is traditionally active against Escherichia coli, Klebsiella species, and Proteus mirabilis (EKP) isolates. The Clinical and Laboratory Standards Institute (CLSI) has twice updated cefazolin susceptibility breakpoints for EKP since 2010, but its role in the definitive treatment of cefazolin-susceptible EKP bacteremia remains debated. To assess its efficacy as a definitive agent, the 8-year cohort study consisted of 941 adults with monomicrobial cefazolin-susceptible EKP bacteremia, based on the CLSI criteria issued in 2019, was retrospectively established in a medical center. Based on the definitive antimicrobial prescription, eligible patients were categorized into the cefazolin (399 patients, 42.4%) and broader-spectrum antibiotic (BSA) (542, 57.6%) groups. Initially, fewer proportions of patients with fatal comorbidities (the McCabe classification) and the critical illness (a Pitt bacteremia score ≥4) at the onset and day 3 of the bacteremia episode were found in the cefazolin group, compared to the BSA group. After propensity-score matching, no significant difference of patient proportions between the cefazolin (345 patients) and BSA (345) groups was observed, in terms of the elderly, types and severity of comorbidities, bacteremia severity at the onset and day 3, major bacteremia sources, and the 15-day and 30-day crude mortality. In early outcomes, lengths of time to defervescence, intravenous (IV) antimicrobial administration, and hospitalization were similar in the two matched groups; lower costs of IV antimicrobial administration were observed in the cefazolin group. Notably, for late outcomes, lower proportions of post-treatment infections caused by antimicrobial-resistant pathogens (ARPs) and post-treatment mortality rates were evidenced in the cefazolin group. Conclusively, cefazolin is definitively efficacious and cost-effective for adults with community-onset cefazolin-susceptible EKP bacteremia in this one-center study, compared to BSAs. However, a prospective multicenter study should be conducted for external validation with other communities.

Search for Subsolar Mass Ultracompact Binaries in Advanced LIGO's Second Observing Run

We present a search for subsolar mass ultracompact objects in data obtained during Advanced LIGO's second observing run. In contrast to a previous search of Advanced LIGO data from the first observing run, this search includes the effects of component spin on the gravitational waveform. We identify no viable gravitational-wave candidates consistent with subsolar mass ultracompact binaries with at least one component between 0.2  M_{⊙}-1.0  M_{⊙}. We use the null result to constrain the binary merger rate of (0.2  M_{⊙}, 0.2  M_{⊙}) binaries to be less than 3.7×10^{5}  Gpc^{-3} yr^{-1} and the binary merger rate of (1.0  M_{⊙}, 1.0  M_{⊙}) binaries to be less than 5.2×10^{3}  Gpc^{-3} yr^{-1}. Subsolar mass ultracompact objects are not expected to form via known stellar evolution channels, though it has been suggested that primordial density fluctuations or particle dark matter with cooling mechanisms and/or nuclear interactions could form black holes with subsolar masses. Assuming a particular primordial black hole (PBH) formation model, we constrain a population of merging 0.2  M_{⊙} black holes to account for less than 16% of the dark matter density and a population of merging 1.0  M_{⊙} black holes to account for less than 2% of the dark matter density. We discuss how constraints on the merger rate and dark matter fraction may be extended to arbitrary black hole population models that predict subsolar mass binaries.

Timing of follow-up blood cultures for community-onset bacteremia

Bacteremia is associated with high morbidity and mortality, but the utility and optimal timing of follow-up blood cultures (FUBCs) remain undefined. To assess the optimal timing of FUBCs related to appropriate antibiotic therapy (AAT), adults with community-onset bacteremia and FUBCs after bacteremia onset were retrospectively studied during the 6-year period in two hospitals. Based on the time gap between the initiation of AAT and FUBC sampling, 1,247 eligible patients were categorized as FUBCs prior to AAT (65 patients, 5.2%), 0–3 days (202, 16.2%), 3.1–6 days (470, 37.7%), 6.1–9 days (299, 24.0%), and ≥9 days (211, 16.9%) after AAT. The prognostic impact of the growth of the same bacteria in FUBCs on 30-day mortality was evidenced only in patients with FUBCs at 3.1–6 days after AAT (adjusted odds ratio [AOR], 3.75; P < 0.001), not in those with FUBCs prior to AAT (AOR, 2.86; P = 0.25), 0–3 days (AOR, 0.39; P = 0.08), 6.1–9 days (AOR, 2.19; P = 0.32), and ≥9 days (AOR, 0.41; P = 0.41) of AAT, after adjusting independent factors of 30-day mortality recognized by the multivariable regression in each category. Conclusively, persistent bacteremia in FUBCs added prognostic significance in the management of adults with community-onset bacteremia after 3.1–6 days of AAT.

Differential effects of inappropriate empirical antibiotic therapy in adults with community-onset gram-positive and gram-negative aerobe bacteremia

Bacteremia is associated with high morbidity and mortality, which contribute substantially to health care costs. A beneficial influence of appropriate empirical antimicrobial therapy (EAT) on patient outcome is evidenced; However, the evidence highlighting a comparison of clinical manifestations and of the effects of inappropriate EAT between Gram-positive and Gram-negative bacteremia is insufficient. In a retrospective 6-year cohort study, the total 2053 adults (Gram-positive, 566; Gram-negative 1487) presenting with community-onset monomicrobial aerobes bacteremia were recruited. Inappropriate EAT was defined as the first dose of an appropriate antimicrobial agent not being administered within the first 24 h after blood cultures were drawn. Although the bacteremia severity (a Pitt bacteremia score) at onset, comorbidity severity (the McCabe-Johnson classification), and 28-day mortality rate were similar in the two groups. Furthermore, after adjustment of independent predictors of 28-day mortality respectively recognized by the multivariate regression model in Gram-negative and Gram-positive groups, the Kaplan-Meier curve and Cox regression analysis revealed a significant difference (adjust odds ratio [AOR], 2.68; P < 0.001) between appropriate and inappropriate EAT in the Gram-negative group, but not in the Gram-positive group (AOR, 1.54; P = 0.06). Conclusively, patients with Gram-positive and Gram-negative bacteremia exhibited the similar presentation in bacteremia severity, but a greater impact of inappropriate EAT on survival of patients with Gram-negative aerobe bacteremia was evidenced.

Clinical Benefit of Empiric High-Dose Levofloxacin Therapy for Adults With Community-onset Enterobacteriaceae Bacteremia

PURPOSE

Levofloxacin is commonly prescribed to treat varied community-acquired gram-negative infections; knowledge of the therapeutic efficacies of high-dose (HD) administration is helpful to improve patient care.

METHODS

In this 6-year cohort, adults with community-onset Enterobacteriaceae bacteremia were retrospectively studied in 2 hospitals. To overcome the confounding factors in the dosage choice of empiric administration, patients receiving empiric intravenous HD (750 mg/d) therapy were matched with those receiving the conventional dose (CD; 500 mg/d) by using individual propensity scores, calculated by the independent predictors of 30-day crude mortality.

FINDINGS

Initially, more patients with critical illness (Pitt bacteremia score [PBS] ≥4) at bacteremia onset and comorbid malignancies and the higher 15- and 30-day mortality rate were recorded in 136 patients receiving HD therapy, compared to 103 receiving CD therapy. After appropriate matching, differences in patient demographic and clinical characteristics between the HD (n = 103) and CD (n = 103) groups were nonsignificant. Consequently, crude mortality rates at 3, 15, or 30 days after onset of bacteremia did not differ. However, the period of time to defervescence, total intravenous antimicrobial administration, and hospital stay was shorter in the HD group than in the CD group. Similarly, regardless if patients had more critical illness (PBS ≥2) or stabilized illness (PBS <2), the advantage of empiric HD therapy on defervescence remained significant. Within 60 days after discontinuation of intravenous levofloxacin therapy, the proportion of recurrent bacteremia, posttreatment overall infections, and posttreatment crude mortality was similar between the HD and CD groups.

IMPLICATIONS

For adults with community-onset Enterobacteriaceae bacteremia, empiric administration of HD levofloxacin was as effective as CD levofloxacin in reducing mortality and, notably, led to more rapid defervescence compared with CD administration.

Tests of General Relativity with GW170817

The recent discovery by Advanced LIGO and Advanced Virgo of a gravitational wave signal from a binary neutron star inspiral has enabled tests of general relativity (GR) with this new type of source. This source, for the first time, permits tests of strong-field dynamics of compact binaries in the presence of matter. In this Letter, we place constraints on the dipole radiation and possible deviations from GR in the post-Newtonian coefficients that govern the inspiral regime. Bounds on modified dispersion of gravitational waves are obtained; in combination with information from the observed electromagnetic counterpart we can also constrain effects due to large extra dimensions. Finally, the polarization content of the gravitational wave signal is studied. The results of all tests performed here show good agreement with GR.

Validation of MEDS score in predicting short-term mortality of adults with community-onset bacteremia

BACKGROUND

The Mortality in Emergency Department Sepsis (MEDS) score can be used to stratify ED patients with suspected infections according to mortality risk. However, it has yet to be externally validated for patients having bloodstream infections.

METHODS

We retrospectively computed clinical information for the MEDS score, Pitt bacteremia score (PBS), Charlson comorbidity index (CCI), and McCabe-Jackson comorbid classification (MJCC) for adults with community-onset bacteremia. The MEDS score was validated by the comparisons with the following scoring systems: the PBS, CCI, MJCC, PBS plus MJCC, and PBS plus CCI. We evaluated goodness-of-fit statistics and c-statistics as measures of model calibration and discrimination, respectively.

RESULTS

Of 2328 adults, a good calibration for 28-day crude mortality was obtained only in the MEDS score and PBS plus MJCC; a higher c-statistic (0.870, P < 0.001) were achieved by the MEDS score, compared to the PBS, CCI MJCC, PBS plus MJCC, and PBS plus CCI. A high c-statistic was observed in two combinative scoring system: the PBS plus CCI (0.855, P < 0.001) and PBS plus MJCC (0.843, P < 0.001). According to the Kaplan-Meier curves, 28-day crude mortality significantly differed between patients with scores equal to or higher than selected cutoff values and those with scores lower than selected cutoff values: 10 in the MEDS score and 5 in the PBS plus MJCC, respectively.

CONCLUSION

The MEDS score is an excellent predictor of short-term outcomes in patients with community-onset bacteremia because it provides estimates with higher calibration and discrimination than those of the other scoring systems.

Exotic Low-Energy Excitations Emergent in the Random Kitaev Magnet Cu_{2}IrO_{3}

We report on magnetization M(H), dc and ac magnetic susceptibility χ(T), specific heat C_{m}(T) and muon spin relaxation (μSR) measurements of the Kitaev honeycomb iridate Cu_{2}IrO_{3} with quenched disorder. In spite of the chemical disorders, we find no indication of spin glass down to 260 mK from the C_{m}(T) and μSR data. Furthermore, a persistent spin dynamics observed by the zero-field muon spin relaxation evidences an absence of static magnetism. The remarkable observation is a scaling relation of χ[H,T] and M[H,T] in H/T with the scaling exponent α=0.26-0.28, expected from bond randomness. However, C_{m}[H,T]/T disobeys the predicted universal scaling law, pointing towards the presence of additional low-lying excitations on the background of bond-disordered spin liquid. Our results signify a many-faceted impact of quenched disorder in a Kitaev spin system due to its peculiar bond character.

Effect of probiotics on fecal excretion, colonization in internal organs and immune gene expression in the ileum of laying hens challenged with Salmonella Enteritidis

A study was conducted to evaluate the supplementation of probiotics on Salmonella colonization in the ceca and various internal organs as well as immune response in laying hens challenged with Salmonella enterica serovar Enteritidis (SE). Thirty-two 46-wk-old White Leghorns (W-36) were housed individually in wired laying cages under 16L:8D lighting schedule. Hens were challenged individually with nalidixic acid resistant Salmonella Enteritidis (SENAR) after which time they were grouped into four treatments: T1 = SENAR unchallenged control, T2 = SENAR challenged control, T3 = SENAR challenged + 0.05% probiotics (Lactobacillus plantarum), and T4 = SENAR challenged + 0.1% probiotics. All hens, including T1, were euthanized and sampled for the liver with gall bladder (L/GB), ileum, ovary, spleen, and ceca on 7-days post-infection (dpi). Fecal screening was performed on individual hens at both 3 and 6 dpi. No difference was detected between the treatments in cecal SENAR enumeration, and the mean log 10 cfu/gm of SENAR in the ceca was 3.7 for all three treatments. The prevalence of SENAR was lowest for ovary in all treatments and was highest in the spleen. However, there were no significant differences among the treatments in the internal organs. There was no significant difference in the fecal shedding among the treatments on either 3 or 6 dpi, with incidence of positive feces higher at 3 dpi compared to 6 dpi (100 vs. 70% to 80%). SENAR challenge resulted in significant upregulation (P < 0.05) of interleukin (IL)-1β, 6, 10, interferon gamma (IFN-γ), and toll-like receptor (TLR)-4 mRNA expression. Highest level of probiotics resulted in a significant decrease in IFN-γ and elevation of IL-6 and IL-10 gene expression in the ileum. However, IL-1B and TLR-4 gene expression were not different from the SENAR challenge control. This study reveals that there was important regulation of immune genes by probiotics supplementation.

Constraining the p-Mode-g-Mode Tidal Instability with GW170817

We analyze the impact of a proposed tidal instability coupling p modes and g modes within neutron stars on GW170817. This nonresonant instability transfers energy from the orbit of the binary to internal modes of the stars, accelerating the gravitational-wave driven inspiral. We model the impact of this instability on the phasing of the gravitational wave signal using three parameters per star: an overall amplitude, a saturation frequency, and a spectral index. Incorporating these additional parameters, we compute the Bayes factor (lnB_{!pg}^{pg}) comparing our p-g model to a standard one. We find that the observed signal is consistent with waveform models that neglect p-g effects, with lnB_{!pg}^{pg}=0.03_{-0.58}^{+0.70} (maximum a posteriori and 90% credible region). By injecting simulated signals that do not include p-g effects and recovering them with the p-g model, we show that there is a ≃50% probability of obtaining similar lnB_{!pg}^{pg} even when p-g effects are absent. We find that the p-g amplitude for 1.4  M_{⊙} neutron stars is constrained to less than a few tenths of the theoretical maximum, with maxima a posteriori near one-tenth this maximum and p-g saturation frequency ∼70  Hz. This suggests that there are less than a few hundred excited modes, assuming they all saturate by wave breaking. For comparison, theoretical upper bounds suggest ≲10^{3} modes saturate by wave breaking. Thus, the measured constraints only rule out extreme values of the p-g parameters. They also imply that the instability dissipates ≲10^{51}  erg over the entire inspiral, i.e., less than a few percent of the energy radiated as gravitational waves.

P77 Type II PEG fractures: collar or no collar

Objectives

Type 2 peg fractures are known to have low fusion rates but most are elderly with comorbidities and not fit for surgery. Increasingly, clinicians want to stop using hard collars due to its complications, but with little supporting evidence. We aim to provide data to add to this debate.

Design

Single centre cohort study.

Subjects

145 consecutive patients referred to a Major Trauma Centre as type 2 peg fracture.

Methods

All patients referred with a suspected peg fracture between March 2015 and December 2017 were included. All imaging were assessed and case notes reviewed for patient demographics, fracture management, complications and outcomes.

Results

102 cases were peg fractures (mean age=80 years). 92 (90.2%) were managed conservatively with a hard collar (mean of 87 days). 37% developed symptoms from the collar, namely pain, stiffness and non-tolerance. Bony union was achieved in only 39.1% of patients with increasing age being an independent risk factor (p<0.001). Of the 56 patients who did not have bony union, there were no reported symptoms and 90% were discharged without a collar. 2 patients were offered but declined fixation and neither reported any on-going symptoms.

Conclusions

This study adds to the body of evidence that fusion rates are low, and collar complications are not insignificant when type 2 peg fractures are treated in a hard collar. However, outcomes are good regardless of union, potentially rendering the collar unnecessary. We aim to conduct a randomised prospective study to further investigate.

Search for Subsolar-Mass Ultracompact Binaries in Advanced LIGO's First Observing Run

We present the first Advanced LIGO and Advanced Virgo search for ultracompact binary systems with component masses between 0.2  M_{⊙}-1.0  M_{⊙} using data taken between September 12, 2015 and January 19, 2016. We find no viable gravitational wave candidates. Our null result constrains the coalescence rate of monochromatic (delta function) distributions of nonspinning (0.2  M_{⊙}, 0.2  M_{⊙}) ultracompact binaries to be less than 1.0×10^{6}  Gpc^{-3}  yr^{-1} and the coalescence rate of a similar distribution of (1.0  M_{⊙}, 1.0  M_{⊙}) ultracompact binaries to be less than 1.9×10^{4}  Gpc^{-3}  yr^{-1} (at 90% confidence). Neither black holes nor neutron stars are expected to form below ∼1  M_{⊙} through conventional stellar evolution, though it has been proposed that similarly low mass black holes could be formed primordially through density fluctuations in the early Universe and contribute to the dark matter density. The interpretation of our constraints in the primordial black hole dark matter paradigm is highly model dependent; however, under a particular primordial black hole binary formation scenario we constrain monochromatic primordial black hole populations of 0.2  M_{⊙} to be less than 33% of the total dark matter density and monochromatic populations of 1.0  M_{⊙} to be less than 5% of the dark matter density. The latter strengthens the presently placed bounds from microlensing surveys of massive compact halo objects (MACHOs) provided by the MACHO and EROS Collaborations.

Effects of Fabric Counts and Weave Designs on the Properties of Laminated Woven Kenaf/Carbon Fibre Reinforced Epoxy Hybrid Composites

The effects of different fabric materials namely weave designs (plain and satin) and fabric counts (5 × 5 and 6 × 6) on the properties of laminated woven kenaf/carbon fibre reinforced epoxy hybrid composites were evaluated. The hybrid composites were fabricated from two types of fabric, i.e., woven kenaf that was made from a yarn of 500tex and carbon fibre, by using vacuum infusion technique and epoxy resin as matrix. The panels were tested for tensile, flexural, and impact strengths. The results have revealed that plain fabric is more suitable than satin fabric for obtaining high tensile and impact strengths. Using a fabric count of 5 × 5 has generated composites that are significantly higher in flexural modulus as compared to 6 × 6 which may be attributed to their structure and design. The scanned electron micrographs of the fractured surfaces of the composites demonstrated that plain woven fabric composites had better adhesion properties than satin woven fabric composites, as indicated by the presence of notably lower amount of fibre pull out.

GW170817: Measurements of Neutron Star Radii and Equation of State

On 17 August 2017, the LIGO and Virgo observatories made the first direct detection of gravitational waves from the coalescence of a neutron star binary system. The detection of this gravitational-wave signal, GW170817, offers a novel opportunity to directly probe the properties of matter at the extreme conditions found in the interior of these stars. The initial, minimal-assumption analysis of the LIGO and Virgo data placed constraints on the tidal effects of the coalescing bodies, which were then translated to constraints on neutron star radii. Here, we expand upon previous analyses by working under the hypothesis that both bodies were neutron stars that are described by the same equation of state and have spins within the range observed in Galactic binary neutron stars. Our analysis employs two methods: the use of equation-of-state-insensitive relations between various macroscopic properties of the neutron stars and the use of an efficient parametrization of the defining function p(ρ) of the equation of state itself. From the LIGO and Virgo data alone and the first method, we measure the two neutron star radii as R_{1}=10.8_{-1.7}^{+2.0}  km for the heavier star and R_{2}=10.7_{-1.5}^{+2.1}  km for the lighter star at the 90% credible level. If we additionally require that the equation of state supports neutron stars with masses larger than 1.97  M_{⊙} as required from electromagnetic observations and employ the equation-of-state parametrization, we further constrain R_{1}=11.9_{-1.4}^{+1.4}  km and R_{2}=11.9_{-1.4}^{+1.4}  km at the 90% credible level. Finally, we obtain constraints on p(ρ) at supranuclear densities, with pressure at twice nuclear saturation density measured at 3.5_{-1.7}^{+2.7}×10^{34}  dyn cm^{-2} at the 90% level.