Sudden vision loss heralding COVID-19-associated aspergillosis. Report of 2 cases

Purpose

To describe clinical, radiographic, laboratory and cytopathologic findings in 2 patients who developed vision loss due to endogenous aspergillus endophthalmitis during hospitalization for COVID-19 pneumonia.

Observations

Two unvaccinated sexagenarian male smokers lost vision within one month of contracting COVID-19 pneumonia. Initially, both received high dose steroids, nasal cannula oxygen and remdesivir. Immunomodulators tocilizumab or baricitinib were added during week 2 in case 1 and 2 respectively. Upon presentation after discharge from a post-COVID rehabilitation unit, visual acuities were light perception and hand motion. In both cases, inpatient blood and ocular fluid cultures were negative, serum 1,3-beta-D-glucan was positive, and vitreous cytopathology revealed filamentous fungi and PCR was positive for Aspergillus fumigatus. Large solitary intravitreal fungus balls were debulked in patient 1 and excised in patient 2. Final visual acuities were no light perception and 20/200 respectively. MRI revealed previously unsuspected brain and lung lesions consistent with disseminated aspergillosis in patient 2.

Conclusions

Vision loss due to fungal endophthalmitis may be the first or only sign of systemic aspergillosis associated with COVID-19 pneumonia. Aspergillosis should be suspected in patients who develop vision loss. Diagnosis limited by negative fungal cultures may be confirmed by vitreous cytopathology and PCR. Systemic imaging for disseminated aspergillosis is indicated. Ultimate visual acuity may depend upon surgical approach.

Serial D-dimers after anticoagulant cessation in unprovoked venous thromboembolism: Data from the REVERSE cohort study

INTRODUCTION

While several risk stratification tools have been developed to predict the risk of recurrence in patients with an unprovoked venous thromboembolism (VTE), only 1 in 4 patients are categorized as low-risk. Rather than a one-time measure, serial D-dimer assessment holds promise to enhance the prediction of VTE recurrence after oral anticoagulant (OAC) cessation.

METHODS

Using the REVERSE cohort, we compared VTE recurrence among patients with normal D-dimer levels (<490 ng/mL among males under age 70, <500 ng/mL in others) at OAC cessation and 1-month follow-up, to those with an elevated D-dimer level at either timepoint. We also evaluated VTE recurrence based on absolute increase in D-dimer levels between the two timepoints (e.g., ∆D-dimer) according to quartiles.

RESULTS

Among 214 patients with serial D-dimer levels measured at OAC cessation and 1-month follow-up, an elevated D-dimer level at either timepoint was associated with a numerically higher risk of recurrent VTE than patients with normal D-dimer levels at both timepoints (6.9 % vs. 4.2 % per year, hazard ratio 1.6; 95 % CI 0.9-2.7). Among women with <2 HERDOO2 criteria, a normal D-dimer level at both timepoints predicted a very low risk of recurrent VTE during follow-up (0.8 % per year, 95 % CI 0.1-2.8). Irrespective of baseline value, recurrent VTE risk was only 3 % per year (95 % CI 1.4-5.6) among patients in the lowest ∆D-dimer quartile.

CONCLUSION

Serial normal D-dimer levels have the potential to identify patients at a low risk of recurrent VTE. In addition, ∆D-dimer, irrespective of its elevation above cutoff threshold, may predict recurrent VTE.

A resonant sextuplet of sub-Neptunes transiting the bright star HD 110067

Planets with radii between that of the Earth and Neptune (hereafter referred to as 'sub-Neptunes') are found in close-in orbits around more than half of all Sun-like stars1,2. However, their composition, formation and evolution remain poorly understood3. The study of multiplanetary systems offers an opportunity to investigate the outcomes of planet formation and evolution while controlling for initial conditions and environment. Those in resonance (with their orbital periods related by a ratio of small integers) are particularly valuable because they imply a system architecture practically unchanged since its birth. Here we present the observations of six transiting planets around the bright nearby star HD 110067. We find that the planets follow a chain of resonant orbits. A dynamical study of the innermost planet triplet allowed the prediction and later confirmation of the orbits of the rest of the planets in the system. The six planets are found to be sub-Neptunes with radii ranging from 1.94R⊕ to 2.85R⊕. Three of the planets have measured masses, yielding low bulk densities that suggest the presence of large hydrogen-dominated atmospheres.

Pneumatic Retinopexy with Focal Laser Photocoagulation for Myopic Foveoschisis with Macular Detachment

PURPOSE

To describe the clinical course and imaging of a case of myopic foveoschisis (MF) with macular detachment (MD), microbreak and epiretinal membrane (ERM) managed with pneumatic retinopexy (PR) and focal laser photocoagulation (FLP) of the microbreak.

METHODS

Retrospective Case Review of a highly myopic, phakic Caucasian man who developed vision loss due to MF with MD.

RESULTS

66 year old phakic man with a refractive error of -13.25-2.25x150 in his left eye (OS) and one month visual loss who was diagnosed with MF with MD, microbreak and ERM developed recurrent, isolated, posterior, partial macular detachment one month after PR. CMT was 901um. Repeat PR with supplemental FLP surrounding the inferior macular periarteriolar microbreak achieved re-attachment and improvement in the retinoschisis with return of visual acuity from 20/150 to baseline 20/40+ at 18 month follow-up.

CONCLUSION

PR with FLP may provide an alternative to vitrectomy and MP for the repair of MF with MD and ERM.

The risk of major bleeding in patients with factor V Leiden or prothrombin G20210A gene mutation while on extended anticoagulant treatment for venous thromboembolism

BACKGROUND

Thrombophilia predisposes to venous thromboembolism (VTE) because of acquired or hereditary factors. Among them, it has been suggested that gene mutations of the factor V Leiden (FVL) or prothrombin G20210A mutation (PGM) might reduce the risk of bleeding, but little data exist for patients treated using anticoagulants.

OBJECTIVES

To assess whether thrombophilia is protective against bleeding.

METHODS

This multicentre, multinational, prospective cohort study evaluated adults receiving long-term anticoagulants after a VTE event. We analyzed the incidence of major bleeding as the primary outcome, according to the genotype for FVL and PGM (wild-type and heterozygous/homozygous carriers).

RESULTS

Of 2260 patients with genotype testing, during a median follow-up of 3 years, 106 patients experienced a major bleeding event (17 intracranial and 7 fatal). Among 439 carriers of FVL, 19 experienced major bleeding and there were no differences between any mutation vs wild-type (hazard ratio [HR], 0.89 [0.53-1.49]; p = .66). The comparison of major bleeding events between the 158 patients with any-PGM mutation (heterozygous or homozygous) vs wild-type also showed a nonstatistically significant difference with HR of 0.53 (0.19-1.43), p = .21. However, multivariate analysis demonstrated that major bleeds or clinically relevant nonmajor bleeding were statistically less likely for patients with either FVL and/or PGM compared with patients with both wild-type factor V and prothrombin genes (HR, 0.73; 95% CI = 0.55-0.97; p = .03).

CONCLUSION

This study demonstrates that thrombophilia, defined as the presence of either FVL or the prothrombin G20210A mutation, is related with a lower rate of major/clinically relevant nonmajor bleeding while on anticoagulants in the extended treatment for VTE.

Early Release Science of the exoplanet WASP-39b with JWST NIRCam

Measuring the metallicity and carbon-to-oxygen (C/O) ratio in exoplanet atmospheres is a fundamental step towards constraining the dominant chemical processes at work and, if in equilibrium, revealing planet formation histories. Transmission spectroscopy (for example, refs. 1,2) provides the necessary means by constraining the abundances of oxygen- and carbon-bearing species; however, this requires broad wavelength coverage, moderate spectral resolution and high precision, which, together, are not achievable with previous observatories. Now that JWST has commenced science operations, we are able to observe exoplanets at previously uncharted wavelengths and spectral resolutions. Here we report time-series observations of the transiting exoplanet WASP-39b using JWST's Near InfraRed Camera (NIRCam). The long-wavelength spectroscopic and short-wavelength photometric light curves span 2.0-4.0 micrometres, exhibit minimal systematics and reveal well defined molecular absorption features in the planet's spectrum. Specifically, we detect gaseous water in the atmosphere and place an upper limit on the abundance of methane. The otherwise prominent carbon dioxide feature at 2.8 micrometres is largely masked by water. The best-fit chemical equilibrium models favour an atmospheric metallicity of 1-100-times solar (that is, an enrichment of elements heavier than helium relative to the Sun) and a substellar C/O ratio. The inferred high metallicity and low C/O ratio may indicate significant accretion of solid materials during planet formation (for example, refs. 3,4,) or disequilibrium processes in the upper atmosphere (for example, refs. 5,6).

Rationing scarce healthcare capacity: A study of the ventilator allocation guidelines during the COVID-19 pandemic

In the United States, even though national guidelines for allocating scarce healthcare resources are lacking, 26 states have specific ventilator allocation guidelines to be invoked in case of a shortage. While several states developed their guidelines in response to the recent COVID-19 pandemic, New York State developed these guidelines in 2015 as "pandemic influenza is a foreseeable threat, one that we cannot ignore." The primary objective of this study is to assess the existing procedures and priority rules in place for allocating/rationing scarce ventilator capacity and propose alternative (and improved) priority schemes. We first build machine learning models using inpatient records of COVID-19 patients admitted to New York-Presbyterian/Columbia University Irving Medical Center and an affiliated community health center to predict survival probabilities as well as ventilator length-of-use. Then, we use the resulting point estimators and their uncertainties as inputs for a multiclass priority queueing model with abandonments to assess three priority schemes: (i) SOFA-P (Sequential Organ Failure Assessment based prioritization), which most closely mimics the existing practice by prioritizing patients with sufficiently low SOFA scores; (ii) ISP (incremental survival probability), which assigns priority based on patient-level survival predictions; and (iii) ISP-LU (incremental survival probability per length-of-use), which takes into account survival predictions and resource use duration. Our findings highlight that our proposed priority scheme, ISP-LU, achieves a demonstrable improvement over the other two alternatives. Specifically, the expected number of survivals increases and death risk while waiting for ventilator use decreases. We also show that ISP-LU is a robust priority scheme whose implementation yields a Pareto-improvement over both SOFA-P and ISP in terms of maximizing saved lives after mechanical ventilation while limiting racial disparity in access to the priority queue.

Improving Appropriate Use of Omega-3 Fatty Acids for Patients With Dyslipidemia: Effect of Online CME

Hypertriglyceridemia is associated with an increased risk of atherosclerotic cardiovascular (CV) disease. Clinical trials have demonstrated the effectiveness of eicosapentaenoic acid ethyl ester (EPA), an omega-3 polyunsaturated fatty acid, on triglyceride lowering and on CV risk reduction. However, many clinicians have limited understanding of the effects of EPA and limited experience using EPA to reduce the risk of CV disease. An analysis was conducted to determine whether an online continuing medical education (CME) intervention could improve knowledge and competence of primary care physicians (PCPs) and cardiologists related to the role of EPA in management of CV risk in patients with dyslipidemia. The intervention comprised 2 online video-based CME activities. The effects of education were assessed for learners who completed 4 pre- and postassessment questions for each activity, using a matched pre-/postassessment design. For all questions combined, a McNemar's χ2 test assessed differences from pre- to postassessment. Matched-learner data indicated that 34% of PCPs improved their knowledge as a result of participating in the activities, and 42% had their knowledge reinforced. Among cardiologists, 28% improved their knowledge, and 61% had their knowledge reinforced. For these learner subsets, there was a significant 17% relative increase in self-assessed confidence in appropriate use of EPA for PCPs (n = 1644, P < 0.001) and a 12% increase for cardiologists (n = 524; P < 0.001). The improvements observed in this online CME intervention demonstrate the benefits of educating the appropriate target audience base and suggest that this type of intervention can translate into improvements in clinical care.

Physical Activity Surveillance in the United States for Work and Commuting: Understanding the Impact on Population Health and Well-being

OBJECTIVE

To summarize and describe the current US surveillance systems that assess physical activity (PA) for work and commuting.

METHODS

An expert group conducted an environmental scan, generating a list (n = 18) which was ultimately reduced to 12, based on the inclusion of PA and/or sedentary behavior data.

RESULTS

The 12 surveys or surveillance systems summarized provide nationally representative data on occupational-level PA or individual-level PA at work, data on active commuting, some are scorecards that summarize workplace health best practices and allow benchmarking, and one is a comprehensive nationally representative survey of employers assessing programs and practices in different worksites.

CONCLUSIONS

The various surveillance systems and surveys/scorecards are disparate and need to be better analyzed and summarized to understand the impact of occupational-level PA and commuting on population health and well-being, life expectancy, and workforce productivity.

Cohort study of intervened functionally univentricular heart in England and Wales (2000-2018)

Objective

Given the paucity of long-term outcome data for complex congenital heart disease (CHD), we aimed to describe the treatment pathways and survival for patients who started interventions for functionally univentricular heart (FUH) conditions, excluding hypoplastic left heart syndrome.

Methods

We performed a retrospective cohort study using all procedure records from the National Congenital Heart Diseases Audit for children born in 2000–2018. The primary outcome was mortality, ascertained from the Office for National Statistics in 2020.

Results

Of 53 615 patients, 1557 had FUH: 55.9% were boys and 67.4% were of White ethnic groups. The largest diagnostic categories were tricuspid atresia (28.9%), double inlet left ventricle (21.0%) and unbalanced atrioventricular septal defect (AVSD) (15.2%). The ages at staged surgery were: initial palliation 11.5 (IQR 5.5–43.5) days, cavopulmonary shunt 9.2 (IQR 6.0–17.1) months and Fontan 56.2 (IQR 45.5–70.3) months. The median follow-up time was 10.8 (IQR 7.0–14.9) years and the 1, 5 and 10-year survival rates after initial palliation were 83.6% (95% CI 81.7% to 85.4%), 79.4% (95% CI 77.3% to 81.4%) and 77.2% (95% CI 75.0% to 79.2%), respectively. Higher hazards were present for unbalanced AVSD HR 2.75 (95% CI 1.82 to 4.17), atrial isomerism HR 1.75 (95% CI 1.14 to 2.70) and low weight HR 1.65 (95% CI 1.13 to 2.41), critical illness HR 2.30 (95% CI 1.67 to 3.18) or acquired comorbidities HR 2.71 (95% CI 1.82 to 4.04) at initial palliation.

Conclusion

Although treatment pathways for FUH are complex and variable, nearly 8 out of 10 children survived to 10 years. Longer-term analyses of outcome based on diagnosis (rather than procedure) can inform parents, patients and clinicians, driving practice improvements for complex CHD.

A modeling approach to derive baseline risk estimates for GRADE recommendations:Concepts, development, and results of its application to the American Society of Hematology 2019 guidelines on prevention of venous thromboembolism in surgical hospitalized patients

OBJECTIVE

The goal of this study was to develop an approach that can be used where baseline risk estimates that are directly applicable to prioritized patient-important outcomes are not available from published studies.

STUDY DESIGN

The McMaster University GRADE Centre and the ASH guideline panel for the prevention of VTE in surgical patients developed a modeling approach based on explicit assumptions about the distribution of symptoms, anatomical location, and severity of VTE events.

RESULTS

We applied the approach to derive modeled estimates of baseline risk. These estimates were used to calculated absolute measures of anticipated effects that informed the discussion of the evidence and the formulation of 30 guideline recommendations.

CONCLUSIONS

Our approach can assist guideline developers facing a lack of information about baseline risk estimates that directly apply to outcomes of interest. The use of modeled estimates increases transparency in the process and makes the baseline risk used by guideline experts explicit during their decision-making.

Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial

OBJECTIVE

To determine the efficacy and safety of dalteparin postoperative bridging treatment versus placebo for patients with atrial fibrillation or mechanical heart valves when warfarin is temporarily interrupted for a planned procedure.

DESIGN

Prospective, double blind, randomised controlled trial.

SETTING

10 thrombosis research sites in Canada and India between February 2007 and March 2016.

PARTICIPANTS

1471 patients aged 18 years or older with atrial fibrillation or mechanical heart valves who required temporary interruption of warfarin for a procedure.

INTERVENTION

Random assignment to dalteparin (n=821; one patient withdrew consent immediately after randomisation) or placebo (n=650) after the procedure.

MAIN OUTCOME MEASURES

Major thromboembolism (stroke, transient ischaemic attack, proximal deep vein thrombosis, pulmonary embolism, myocardial infarction, peripheral embolism, or vascular death) and major bleeding according to the International Society on Thrombosis and Haemostasis criteria within 90 days of the procedure.

RESULTS

The rate of major thromboembolism within 90 days was 1.2% (eight events in 650 patients) for placebo and 1.0% (eight events in 820 patients) for dalteparin (P=0.64, risk difference -0.3%, 95% confidence interval -1.3 to 0.8). The rate of major bleeding was 2.0% (13 events in 650 patients) for placebo and 1.3% (11 events in 820 patients) for dalteparin (P=0.32, risk difference -0.7, 95% confidence interval -2.0 to 0.7). The results were consistent for the atrial fibrillation and mechanical heart valves groups.

CONCLUSIONS

In patients with atrial fibrillation or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postoperative dalteparin bridging to prevent major thromboembolism.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00432796.

Long-term risk of recurrent venous thromboembolism after a first contraceptive-related event: Data from REVERSE cohort study

INTRODUCTION

The risk of recurrent venous thromboembolism (VTE) after combined oral contraceptive (COC) use is variably reported. We assessed the long-term risk of recurrent VTE in women on COC at the time of a first VTE, in comparison to women without COC use. Our secondary aim assessed the impact of COC use on the recurrent VTE risk in high-risk and low-risk hyperpigmentation, edema, or redness in either leg; D-dimer level ≥250 μg/L; obesity with body mass index ≥30; or older age, ≥65 years (HERDOO2) subgroups.

METHODS

The REVERSE cohort study derived the HERDOO2 clinical decision rule to predict recurrent VTE in patients who discontinued anticoagulation after 5-7 months for a first unprovoked VTE. Incidence rates of recurrent VTE among women with and without COC exposure were calculated as the number of recurrent VTE over the number of person-years of follow-up, and Cox proportional hazards model was used to compare risks between groups.

RESULTS

The risk of recurrent VTE among COC users was 1.1% (95% confidence interval [CI] 0.3-2.9) per patient-year as compared with 3.2% per patient-year (95% CI 2.4-4.3) among nonusers (hazard ratio 0.37; 95% CI 0.1-1.0). Women who were COC users and high risk by HERDOO2 score had a recurrence rate of 3.5% (95% CI 0.4-12.5) compared with 6.1% (95% CI 4.3-8.5) among women who were non-COC users and at high risk by HERDOO2 score (HR 0.6, 95% CI 0.1-2.5).

CONCLUSIONS

Women who were COC users at the time of an otherwise unprovoked VTE event had a lower VTE recurrence rate during long-term follow-up, compared with nonusers. The use of HERDOO2 rule may help identify higher risk women with COC use.

Body Mass Index and Risk for Intubation or Death in SARS-CoV-2 Infection : A Retrospective Cohort Study

BACKGROUND

Obesity is a risk factor for pneumonia and acute respiratory distress syndrome.

OBJECTIVE

To determine whether obesity is associated with intubation or death, inflammation, cardiac injury, or fibrinolysis in coronavirus disease 2019 (COVID-19).

DESIGN

Retrospective cohort study.

SETTING

A quaternary academic medical center and community hospital in New York City.

PARTICIPANTS

2466 adults hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection over a 45-day period with at least 47 days of in-hospital observation.

MEASUREMENTS

Body mass index (BMI), admission biomarkers of inflammation (C-reactive protein [CRP] level and erythrocyte sedimentation rate [ESR]), cardiac injury (troponin level), and fibrinolysis (D-dimer level). The primary end point was a composite of intubation or death in time-to-event analysis.

RESULTS

Over a median hospital length of stay of 7 days (interquartile range, 3 to 14 days), 533 patients (22%) were intubated, 627 (25%) died, and 59 (2%) remained hospitalized. Compared with overweight patients, patients with obesity had higher risk for intubation or death, with the highest risk among those with class 3 obesity (hazard ratio, 1.6 [95% CI, 1.1 to 2.1]). This association was primarily observed among patients younger than 65 years and not in older patients (P for interaction by age = 0.042). Body mass index was not associated with admission levels of biomarkers of inflammation, cardiac injury, or fibrinolysis.

LIMITATIONS

Body mass index was missing for 28% of patients. The primary analyses were conducted with multiple imputation for missing BMI. Upper bounding factor analysis suggested that the results are robust to possible selection bias.

CONCLUSION

Obesity is associated with increased risk for intubation or death from COVID-19 in adults younger than 65 years, but not in adults aged 65 years or older.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Diagnosing deep vein thrombosis in cancer patients with suspected symptoms: An individual participant data meta-analysis

BACKGROUND

A previous individual participant data (IPD) meta-analysis showed that the Wells rule and D-dimer testing cannot exclude suspected deep vein thrombosis (DVT) in cancer patients.

OBJECTIVES

To explore reasons for this reduced diagnostic accuracy and to optimize the diagnostic pathway for cancer patients suspected of DVT.

PATIENTS AND METHODS

Using IPD from 13 studies in patients with suspected DVT, DVT prevalence and the predictive value of the Wells rule items and D-dimer testing were compared between patients with and without cancer. Next, we developed a prediction model with five variables selected from all available diagnostic predictors.

RESULTS

Among the 10 002 suspected DVT patients, there were 834 patients with cancer. The median prevalence of DVT in these patients with cancer was 37.5% (interquartile range [IQR], 30.8-45.5), whereas it was 15.1% (IQR, 11.5-16.7) in patients without cancer. Diagnostic performance of individual Wells rule items and D-dimer testing was similar across patients with and without cancer, except "immobility" and "history of DVT." The newly developed rule showed a pooled c-statistic 0.80 (95% confidence interval [CI], 0.75-0.83) and good calibration. However, using this model, still only 4.3% (95% CI, 3.0-5.7) of the suspected patients with cancer could be identified with a predicted DVT posttest probability of <2%.

CONCLUSIONS

Likely because of the high prevalence of DVT, clinical models followed by D-dimer testing fail to rule out DVT efficiently in cancer patients suspected of DVT. Direct referral for compression ultrasonography appears to be the preferred approach for diagnosis of suspected DVT in cancer patients.

Methodology for the American Society of Hematology VTE guidelines: current best practice, innovations, and experiences

BACKGROUND

Methods for the development of clinical guidelines have advanced dramatically over the past 2 decades to strive for trustworthiness, transparency, user-friendliness, and rigor. The American Society of Hematology (ASH) guidelines on venous thromboembolism (VTE) have followed these advances, together with application of methodological innovations.

OBJECTIVE

In this article, we describe methods and methodological innovations as a model to inform future guideline enterprises by ASH and others to achieve guideline standards. Methodological innovations introduced in the development of the guidelines aim to address current challenges in guideline development.

METHODS

We followed ASH policy for guideline development, which is based on the Guideline International Network (GIN)-McMaster Guideline Development Checklist and current best practices. Central coordination, specialist working groups, and expert panels were established for the development of 10 VTE guidelines. Methodological guidance resources were developed to guide the process across guidelines panels. A methods advisory group guided the development and implementation of methodological innovations to address emerging challenges and needs.

RESULTS

The complete set of VTE guidelines will include >250 recommendations. Methodological innovations include the use of health-outcome descriptors, online voting with guideline development software, modeling of pathways for diagnostic questions, application of expert evidence, and a template manuscript for publication of ASH guidelines. These methods advance guideline development standards and have already informed other ASH guideline projects.

CONCLUSIONS

The development of the ASH VTE guidelines followed rigorous methods and introduced methodological innovations during guideline development, striving for the highest possible level of trustworthiness, transparency, user-friendliness, and rigor.

The Value of Shorter Initial Opioid Prescriptions: A Simulation Evaluation

BACKGROUND

During the period from 1999 to 2016, more than 350,000 Americans died from overdoses related to the use of prescription opioids. To the extent that supply is directly related to overprescribing, policy interventions aimed at changing prescriber behavior, such as the recent Centers for Disease Control and Prevention guideline, are clearly warranted. Although these could plausibly reduce the prevalence of opioid overuse and dependency, little is known about their economic and health-related impacts.

OBJECTIVE

The aim of this study was to quantify the efficacy of a policy intervention aimed at reducing the length of initial opioid prescriptions.

STUDY DESIGN AND METHODS

A Markov decision process model was fitted on a retrospective cohort of 827,265 patients, and patient cost and health trajectories were simulated over a 24-month period. The model's parameters were based on patients who received short (≤ 3 days) or long (> 7 days) initial opioid prescriptions, matched using propensity score methods.

STUDY POPULATION

All active-duty US Army soldiers from 2011 to 2014; the data contained detailed medical and administrative information on over 11 million soldier-months corresponding to 827,265 individual soldiers.

MAIN OUTCOME MEASURE

Overall costs of a policy change, quality-adjusted life-years (QALYs) gained, and $/QALY gained.

RESULTS

Over a 2-year horizon, a reassignment of 10,000 patients to short initial duration would generate a cost saving in the vicinity of $3.1 million (excluding program costs), and would also lead to an estimated 4451 additional opioid-free months, i.e. months without any opioid prescriptions.

CONCLUSION

The analysis found that efforts to change prescriber behavior can be cost effective, and further studies into the implementation of such policies are warranted.

American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients

BACKGROUND

Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality.

OBJECTIVE

These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.

RESULTS

The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2).

CONCLUSIONS

For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.

Characterisation of thiocyanate degradation in a mixed culture activated sludge process treating coke wastewater

Microbial degradation of thiocyanate (SCN^-) has been reported to suffer from instability highlighting the need for improved understanding of underlying mechanisms and boundaries. Respirometry, batch tests and DNA sequencing analysis were used to improve understanding of a mixed culture treating coke wastewater rich in SCN^-. An uncultured species of Thiobacillus was the most abundant species (26%) and displayed similar metabolic capabilities to Thiobacillus denitrificans and Thiobacillus thioparus. Thiocyanate was hydrolysed/oxidised to NH₄⁺-N, HCO₃^- and SO₄^2-. Nevertheless, at 360-2100 mg SCN^-/L a breakdown in the degradation pathway was observed. Respirometry tests demonstrated that NH₄⁺-N was inhibitory to SCN^- degradation (IC₅₀: 316 mg/L). Likewise, phenol (180 mg/L) and hydroxylamine (0.25-16 mg/L) reduced SCN^- degradation by 41% and ca. 7%, respectively. The understanding of the SCN^- degradation pathways can enable stable treatment efficiencies and compliance with effluent of <4 mg SCN/L, required by the Industrial Emissions Directive.

Application of the Boston Technical Performance Score to intraoperative echocardiography

Background

The Technical Performance Score (TPS) developed by Boston Children’s Hospital showed surgical outcomes correlate with adequacy of technical repair when implemented on pre-discharge echocardiograms. We applied this scoring system to intraoperative imaging in a tertiary UK congenital heart surgical centre.

Methods

After a period of training, intraoperative TPS (epicardial and/or transesophageal echocardiography) was instituted. TPS was used to inform intraoperative discussions and recorded on a custom-made database using the previously published scoring system. After a year, we reviewed the feasibility, results and relationship between the TPS and mortality, extubation time and length of stay.

Results

From 01 September 2015 to 04 July 2016, there were 272 TPS procedures in 251 operations with 208 TPS recorded. Seven patients had surgery with no documented TPS, three had operations with no current TPS score template available. Patients left the operating theatre with TPS optimal in 156 (75%), adequate 34 (16%) and inadequate 18 (9%). Of those with an optimal score on leaving theatre, ten had more than one period of cardiopulmonary bypass. All four deaths <30 days after surgery (1.9%) had optimal TPS. There was a statistically significant difference in extubation times in the RACHS category 4 patients (3 days vs 5 days, P < 0.05) and in PICU and total length of stay in the RACHS category three patients (2 and 8 days vs 12.5 and 21.5 days respectively) if leaving theatre with an inadequate result.

Conclusions

Application of intraoperative TPS is feasible and provides a way of objectively recording intraoperative imaging assessment of surgery. An ‘inadequate’ TPS did not predict mortality but correlated with a longer ventilation time and longer length of stay compared to those with optimal or adequate scores.

Nitrogen removal from coke making wastewater through a pre-denitrification activated sludge process

Under the Industrial Emissions Directive (IED), coke production wastewater must be treated to produce an effluent characterised by a total nitrogen (TN) <50 mg/L. An anoxic-aerobic activated sludge pilot-plant (1 m³) fed with coke production wastewater was used to investigate the optimal operational requirements to achieve such an effluent. The loading rates applied to the pilot-plant varied between 0.198-0.418 kg COD/m³.day and 0.029-0.081 kg TN/m³.day, respectively. The ammonia (NH₄⁺-N) removals were maintained at 96%, after alkalinity addition. Under all conditions, phenol and SCN^- remained stable at 96% and 100%, respectively with both being utilised as carbon sources during denitrification. The obtained results showed that influent soluble chemical oxygen demand (sCOD) to TN ratio of should be maintained at >5.7 to produce an effluent TN <50 mg/L. Furthermore, nitrite accumulation was observed under all conditions indicating a disturbance to the denitrification pathway. Overall, the anoxic-aerobic activated sludge process was shown to be a robust and reliable technology to treat coke making wastewater and achieve the IED requirements. Nevertheless, the influent to the anoxic tank should be monitored to ensure a sCOD:TN ratio >5.7 or, alternately, the addition of an external carbon source should be considered.

Measuring Participation in Employer-Sponsored Health and Well-Being Programs: A Participation Index and Its Association With Health Risk Change

PURPOSE

To develop an index of participation in workplace health and well-being programs and assess its relationship with health risk status.

DESIGN

Study design comprised a retrospective longitudinal analysis of employee health risk assessment (HRA) and program participation data.

SETTING

Data from 6 companies that implemented health and well-being programs from 2014 to 2016.

PARTICIPANTS

Employee participants (n = 95 318) from 6 companies who completed an HRA in 2014 to 2016. After matching those who completed the HRA in all 3 years, the longitudinal file included 38 789 respondents.

MEASURES

Participation indicators were created for 9 different program components. The sum of these 9 components established the total participation index.

ANALYSIS

Descriptive and correlation analyses were conducted on all participation measures. Repeated-measures analysis of variance was used to assess the impact of participation level on health risk over time.

RESULTS

Higher levels of participation were associated with a greater reduction in risks, with each participation dose yielding a reduction of 0.038 risks (P < .001).

CONCLUSION

Results suggest that employees who participate more in workplace health and well-being programs experience more health risk improvement. The study also supports a more granular definition of participation based on the number of interactions and type of program.

Review of Disability studies and the environmental humanities: Toward an eco-crip theory

No abstract available.

Alkalinity and external carbon requirements for denitrification-nitrification of coke wastewater

The Industrial Emissions Directive requires that coke wastewater is treated to reach an effluent with < 50 mg/L total nitrogen (TN). A shortage of alkalinity (3.6 mg as CaCO₃/mg [Formula: see text]) in the wastewater limited nitrification to 45%. Various compounds were tested as a source of additional alkalinity, with optimal results being found for sodium carbonate, which enabled 95% nitrification at 300 mg/L (as CaCO₃). Sodium bicarbonate led to incomplete ammonia oxidation (76%) whilst soda ash prevented nitrite oxidation. Addition of sodium hydroxide enabled 98% nitrification but was associated with [Formula: see text] accumulation. Ammonia and nitrite oxidation had optimal pH ranges of 7.0-8.3 and 5.5-6.8, respectively. As organic carbon concentrations in coke wastewater are at times insufficient for effective denitrification external organic carbon was also considered to enhance denitrification. A laboratory-scale anoxic-aerobic activated sludge process was used to investigate glycerol and acetic acid as carbon sources. Glycerol was associated with a low biomass production (0.18 mg of biomass produced per 1 mg of glycerol) and mixed liquor suspended solids (MLSS) declined from 2235 to 750 mg/L leading to incomplete nitrification (< 30%) and an effluent TN of 59 mg/L. Acetic acid had a higher biomass production (0.31 mg of biomass produced per 1 mg of acetic acid) maintaining stable MLSS concentrations (3137 mg/L). Overall, a denitrification-nitrification process with alkalinity (Na₂CO₃ at 300 mg/L) and acetic acid dosing enabled an effluent TN of 24 mg/L.

Comparison of the Accuracy of Impedance Plethysmography and Compression Ultrasonography in Outpatients with Clinically Suspected Deep Vein Thrombosis

Impedance plethysmography (IPG) and compression ultrasonography (CUS) have been reported to be highly accurate for the diagnosis of deep vein thrombosis (DVT) in symptomatic patients. In many centres CUS has become the method of choice. However, direct comparisons of the accuracy of IPG to CUS have not been performed. To determine the test of choice we performed a two centre prospective comparison of IPG and CUS, with venography, and determined how the size and distribution of thrombi influenced the accuracy of each test. 495 symptomatic outpatients with suspected DVT had evaluable venograms. The prevalence of DVT was 27% (130/495), 84% (109) of which were proximal. The sensitivity of IPG and CUS for proximal vein thrombosis was 77% and 90% respectively (p = .002). The specificity of IPG was 93% whereas the specificity of CUS was 98% (p = 0.04). There were significant differences in accuracy between the two centres as a consequence of differences in the size and location of thrombi. The majority of proximal thrombi not detected by IPG and CUS involved less than 5 cm of the distal half of the popliteal vein and most of these thrombi occurred in one centre. Exclusion of these thrombi from the analysis increases the sensitivity of CUS to 99% (86/87) and IPG to 91% (72/79), for proximal thrombi (p = .019). The positive predictive value of CUS was strongly influenced by the number of abnormal venous segments (three sites were examined); 100% (80/80) if two or three sites were abnormal, but only 68% if a single site was involved. We conclude that: 1) CUS is more accurate than the IPG for the diagnosis of DVT in symptomatic outpatients, and this relationship holds true regardless of the size or location of the DVT, 2) the sensitivities of IPG and CUS are much lower for small proximal DVT, and 3) confirmatory venography is warranted if the abnormality with CUS is limited to one venous segment.

Subcutaneous Heparin Therapy during Pregnancy: a Need for Concern at the Time of Delivery

Subcutaneous heparin is the treatment of choice for women requiring anticoagulant therapy during pregnancy. However, heparin therapy presents a management problem at delivery because of its potential to cause a persistent anticoagulant effect and thus increase the risk of bleeding. In order to avoid therapeutic complications it has been our practice to have women eithei discontinue their heparin injections with the onset of labour or to terminate heparin injections 12 h prior to elective induction. To determine the safety of our anticoagulant protocol at delivery we reviewed consecutive patients treated with subcutaneous heparin therapy during pregnarcl, at our centre. Over a 23 month period we found that six of 11 women receiving subcutaneous heparin during pregnancy delivered while their aPTT was prolonged. In addition, three women received intravenous protamine sulphate prior to delivery and in one patient major bleeding occurred during an emergency cesarean section. Those women who had elevated aPTTs at the time of delivery all gave birth within 28 h of their last injection of heparin. In order to avoid a prolonged aPTT at delivery, we have now adopted a more conservative approach to the management of subcutaneous heparin use at term. Subcutaneous heparin is discontinued 24 h prior to commencing an elective induction of labour.

Geographic disparities in donor lung supply and lung transplant waitlist outcomes: A cohort study

Despite the Final Rule mandate for equitable organ allocation in the United States, geographic disparities exist in donor lung allocation, with the majority of donor lungs being allocated locally to lower-priority candidates. We conducted a retrospective cohort study of 19 622 lung transplant candidates waitlisted between 2006 and 2015. We used multivariable adjusted competing risk survival models to examine the relationship between local lung availability and waitlist outcomes. The primary outcome was a composite of death and removal from the waitlist for clinical deterioration. Waitlist candidates in the lowest quartile of local lung availability had an 84% increased risk of death or removal compared with candidates in the highest (subdistribution hazard ratio [SHR]: 1.84, 95% confidence interval [CI]: 1.51-2.24, P < .001). The transplantation rate was 57% lower in the lowest quartile compared with the highest (SHR: 0.43, 95% CI: 0.39-0.47). The adjusted death or removal rate decreased by 11% with a 50% increase in local lung availability (SHR: 0.89, 95% CI: 0.85-0.93, P < .001) and the adjusted transplantation rate increased by 19% (SHR: 1.19, 95% CI: 1.17-1.22, P < .001). There are geographically disparate waitlist outcomes in the current lung allocation system. Candidates listed in areas of low local lung availability have worse waitlist outcomes.

Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty

BACKGROUND

Clinical trials and meta-analyses have suggested that aspirin may be effective for the prevention of venous thromboembolism (proximal deep-vein thrombosis or pulmonary embolism) after total hip or total knee arthroplasty, but comparisons with direct oral anticoagulants are lacking for prophylaxis beyond hospital discharge.

METHODS

We performed a multicenter, double-blind, randomized, controlled trial involving patients who were undergoing total hip or knee arthroplasty. All the patients received once-daily oral rivaroxaban (10 mg) until postoperative day 5 and then were randomly assigned to continue rivaroxaban or switch to aspirin (81 mg daily) for an additional 9 days after total knee arthroplasty or for 30 days after total hip arthroplasty. Patients were followed for 90 days for symptomatic venous thromboembolism (the primary effectiveness outcome) and bleeding complications, including major or clinically relevant nonmajor bleeding (the primary safety outcome).

RESULTS

A total of 3424 patients (1804 undergoing total hip arthroplasty and 1620 undergoing total knee arthroplasty) were enrolled in the trial. Venous thromboembolism occurred in 11 of 1707 patients (0.64%) in the aspirin group and in 12 of 1717 patients (0.70%) in the rivaroxaban group (difference, 0.06 percentage points; 95% confidence interval [CI], -0.55 to 0.66; P<0.001 for noninferiority and P=0.84 for superiority). Major bleeding complications occurred in 8 patients (0.47%) in the aspirin group and in 5 (0.29%) in the rivaroxaban group (difference, 0.18 percentage points; 95% CI, -0.65 to 0.29; P=0.42). Clinically important bleeding occurred in 22 patients (1.29%) in the aspirin group and in 17 (0.99%) in the rivaroxaban group (difference, 0.30 percentage points; 95% CI, -1.07 to 0.47; P=0.43).

CONCLUSIONS

Among patients who received 5 days of rivaroxaban prophylaxis after total hip or total knee arthroplasty, extended prophylaxis with aspirin was not significantly different from rivaroxaban in the prevention of symptomatic venous thromboembolism. (Funded by the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT01720108 .).

The fingerprint nature of PCDD in iron ore sinter strand emissions, the effect of suppressants and alternative fuels, and the potential for comparison with the isomer profile of PCDF

It has been previously shown that the isomer profile of PCDF emissions from iron ore sinter plant only varies within limits even when suppressants or alternative fuels are added, to the extent that it can be said to have a 'fingerprint'. The isomer profiles of PCDD from tetra- to hexacholrodibenzo-p-dioxin from the same samples examined for PCDF emissions have been obtained, and show the same tendency for a 'fingerprint ' isomer distribution to occur. Occasional exceptionally high isomer abundances are observed, but these are uncommon. The potential for comparison of the abundances of PCDF and PCDD isomers with similar chlorination patterns to determine whether the same formation process is involved has been examined. It is found that co-elutions prevent extensive comparisons irrespective of whether the SP2331 or DB5ms column is used in the analyses for separation of isomers to provide the results used for comparisons, although they allow limited results to be obtained. It is suggested that analyses using the two chromatography columns to analyse the same sample in parallel could provide more resolution of the isomer profiles for use in comparisons. A pilot study using samples analysed using each column is limited because of detailed differences in the emissions profiles, but demonstrates that greater resolution is possible if the two columns are used to analyse one sample.

Application of a Diagnostic Clinical Model for the Management of Hospitalized Patients with Suspected Deep-vein Thrombosis

The purpose of this study was to evaluate whether the determination of pretest probability using a simple clinical model and the SimpliRED D-dimer could be used to improve the management of hospitalized patients with suspected deep-vein thrombosis. Consecutive hospitalized patients with suspected deep-vein thrombosis, had their pretest probability determined using a clinical model and had a SimpliRED D-dimer assay. Patients at low pretest probability underwent a single ultrasound test. A negative ultrasound excluded the diagnosis of deep-vein thrombosis whereas a positive ultrasound was confirmed by venography. Patients at moderate pretest probability with a positive ultrasound were treated for deep-vein thrombosis whereas patients with an initial negative ultrasound underwent a single follow-up ultrasound one week later. Patients at high pretest probability with a positive ultrasound were treated whereas those with negative ultrasound underwent venography. All patients were followed for three months for the development of venous thromboembolic complications. Overall, 28% (42/150), and 10% (5/50), 21% (14/71) and 76% (22/29) of the low, moderate and high pretest probability patients, respectively, had deep vein thrombosis. Two of 111 (1.8%; 95% CI = 0.02% to 6.4%) patients considered to have deep vein thrombosis excluded had events during three-month follow-up. Overall 13 of 150 (8.7%) required venography and serial testing was limited to 58 of 150 (38.7%) patients. The negative predictive value of the SimpliRED D-dimer in patients with low pretest probability was 96.2%, which is not statistically different from the negative predictive value of a negative ultrasound result in low pretest probability patients (97.8%). Management of hospitalized patients with suspected deep-vein thrombosis based on clinical probability and ultrasound of the proximal deep veins is safe and feasible.

Dr. Philip Wells and Dr. David Anderson are the recipients of Research Scholarships from the Heart and Stroke Foundation of Canada.

The contribution of the C5 protein subunit of Escherichia coli ribonuclease P to specificity for precursor tRNA is modulated by proximal 5' leader sequences

Recognition of RNA by RNA processing enzymes and RNA binding proteins often involves cooperation between multiple subunits. However, the interdependent contributions of RNA and protein subunits to molecular recognition by ribonucleoproteins are relatively unexplored. RNase P is an endonuclease that removes 5' leaders from precursor tRNAs and functions in bacteria as a dimer formed by a catalytic RNA subunit (P RNA) and a protein subunit (C5 in E. coli). The P RNA subunit contacts the tRNA body and proximal 5' leader sequences [N(-1) and N(-2)] while C5 binds distal 5' leader sequences [N(-3) to N(-6)]. To determine whether the contacts formed by P RNA and C5 contribute independently to specificity or exhibit cooperativity or anti-cooperativity, we compared the relative k_cat/K_m values for all possible combinations of the six proximal 5' leader nucleotides (n = 4096) for processing by the E. coli P RNA subunit alone and by the RNase P holoenzyme. We observed that while the P RNA subunit shows specificity for 5' leader nucleotides N(-2) and N(-1), the presence of the C5 protein reduces the contribution of P RNA to specificity, but changes specificity at N(-2) and N(-3). The results reveal that the contribution of C5 protein to RNase P processing is controlled by the identity of N(-2) in the pre-tRNA 5' leader. The data also clearly show that pairing of the 5' leader with the 3' ACCA of tRNA acts as an anti-determinant for RNase P cleavage. Comparative analysis of genomically encoded E. coli tRNAs reveals that both anti-determinants are subject to negative selection in vivo.

Dose assessment from chronic exposure to industrial NORM in iron ore processing

Radiological exposures due to naturally occurring radioactive material (NORM) can occur during a wide range of work-related activities in the mineral processing and chemical industries. However, evaluation of such exposures in industrial settings remains a difficult exercise owing inter alia to the large number of personnel, operations and plants affected; assumptions that often have to be made concerning the actual duration and frequency of exposures; the complex chemistry and radioactive disequilibria involved and typically, the paucity of historical data. In our study, the challenges associated with assessing chronic exposure to fugitive dust enriched in 210Pb and 210Po and the determination of the associated internal dose by inhalation and ingestion are described by reference to a case study undertaken at an iron ore sintering plant between June 2013 and July 2015. The applicability of default dose coefficients and biokinetic models provided by the International Commission for Radiological Protection (ICRP) was verified by combining air and dust monitoring with information on the characteristics of the aerosols and in-vitro solubility experiments. The disparity between particulate matter 100 microns or less in diameter (PM100), particulate matter 10 microns or less in diameter (PM10) and 210Pb/210Po activity concentrations observed over the different monitoring campaigns and sampling locations confirmed that use of positional short-term monitoring surveys to extrapolate intake over a year was not appropriate and could lead to unrealistic intake and dose figures. Personal air sampling is more appropriate for estimating the dose in such situations, though it is not always practical and may collect insufficient quantities of material for radiochemical analysis; this is an important constraint when dealing with low specific activity materials.

Association Between Sleep and Productivity Loss Among 598 676 Employees From Multiple Industries

PURPOSE

To examine the relationship between sleep habits and employee productivity.

DESIGN

Cross-sectional health risk assessment analysis.

SETTING

Employer-sponsored health and well-being programs.

PARTICIPANTS

A total of 598 676 employed adults from multiple industries.

MEASURES

Self-reported average hours of sleep, fatigue, absence days, and presenteeism.

ANALYSIS

Bivariate analyses to assess the relationships between self-reported hours of sleep and self-reported fatigue and mean and median absence and presenteeism.

RESULTS

The relationship between sleep hours and both measures of productivity was U-shaped, with the least productivity loss among employees who reported 8 hours of sleep. More daytime fatigue correlated with more absence and presenteeism. Median absence and presenteeism was consistently lower than mean absence and presenteeism, respectively, for the various hours of sleep and levels of fatigue.

CONCLUSION

Organizations looking to expand the value of their investment in employee health and well-being should consider addressing the employee sleep habits that may be negatively impacting productivity.

Quality of Life, Dyspnea, and Functional Exercise Capacity Following a First Episode of Pulmonary Embolism: Results of the ELOPE Cohort Study

BACKGROUND

We aimed to evaluate health-related quality of life (QOL), dyspnea, and functional exercise capacity during the year following the diagnosis of a first episode of pulmonary embolism.

METHODS

This was a prospective multicenter cohort study of 100 patients with acute pulmonary embolism recruited at 5 Canadian hospitals from 2010-2013. We measured the outcomes QOL (by Short-Form Health Survey-36 [SF-36] and Pulmonary Embolism Quality of Life [PEmb-QoL] measures), dyspnea (by the University of California San Diego Shortness of Breath Questionnaire [SOBQ]) and 6-minute walk distance at baseline and 1, 3, 6, and 12 months after acute pulmonary embolism. Computed tomography pulmonary angiography was performed at baseline, echocardiogram was performed within 10 days, and cardiopulmonary exercise testing was performed at 1 and 12 months. Predictors of change in QOL, dyspnea, and 6-minute walk distance were assessed by repeated-measures mixed-effects models analysis.

RESULTS

Mean age was 50.0 years; 57% were male and 80% were treated as outpatients. Mean scores for all outcomes improved during 1-year follow-up: from baseline to 12 months, mean SF-36 physical component score improved by 8.8 points, SF-36 mental component score by 5.3 points, PEmb-QoL by -32.1 points, and SOBQ by -16.3 points, and 6-minute walk distance improved by 40 m. Independent predictors of reduced improvement over time were female sex, higher body mass index, and percent-predicted VO₂ peak <80% on 1 month cardiopulmonary exercise test for all outcomes; prior lung disease and higher pulmonary artery systolic pressure on 10-day echocardiogram for the outcomes SF-36 physical component score and dyspnea score; and higher main pulmonary artery diameter on baseline computed tomography pulmonary angiography for the outcome PEmb-QoL score.

CONCLUSIONS

On average, QOL, dyspnea, and walking distance improve during the year after pulmonary embolism. However, a number of clinical and physiological predictors of reduced improvement over time were identified, most notably female sex, higher body mass index, and exercise limitation on 1-month cardiopulmonary exercise test. Our results provide new information on patient-relevant prognosis after pulmonary embolism.

Dose assessment from chronic exposure to industrial NORM in iron ore processing

Radiological exposures due to naturally occurring radioactive material (NORM) can occur during a wide range of work-related activities in the mineral processing and chemical industries. However, evaluation of such exposures in industrial settings remains a difficult exercise owing inter alia to the large number of personnel, operations and plants affected; assumptions that often have to be made concerning the actual duration and frequency of exposures; the complex chemistry and radioactive disequilibria involved and typically, the paucity of historical data. In our study, the challenges associated with assessing chronic exposure to fugitive dust enriched in ²¹⁰Pb and ²¹⁰Po and the determination of the associated internal dose by inhalation and ingestion are described by reference to a case study undertaken at an iron ore sintering plant between June 2013 and July 2015. The applicability of default dose coefficients and biokinetic models provided by the International Commission for Radiological Protection was verified by combining air and dust monitoring with information on the characteristics of the aerosols and in-vitro solubility experiments. The disparity between particulate matter 100 microns or less in diameter (PM₁₀₀), particulate matter 10 microns or less in diameter (PM₁₀) and ²¹⁰Pb/²¹⁰Po activity concentrations observed over the different monitoring campaigns and sampling locations confirmed that use positional short-term monitoring surveys to extrapolate intake over a year was not appropriate and could lead to unrealistic intake and dose figures. Personal air sampling is more appropriate for estimating the dose in such situations, though it is not always practical and may collect insufficient quantities of material for radiochemical analysis; this is an important constraint when dealing with low specific activity materials.

Discovery of Clinical Candidate 1-{[(2S,3S,4S)-3-Ethyl-4-fluoro-5-oxopyrrolidin-2-yl]methoxy}-7-methoxyisoquinoline-6-carboxamide (PF-06650833), a Potent, Selective Inhibitor of Interleukin-1 Receptor Associated Kinase 4 (IRAK4), by Fragment-Based Drug Design

Through fragment-based drug design focused on engaging the active site of IRAK4 and leveraging three-dimensional topology in a ligand-efficient manner, a micromolar hit identified from a screen of a Pfizer fragment library was optimized to afford IRAK4 inhibitors with nanomolar potency in cellular assays. The medicinal chemistry effort featured the judicious placement of lipophilicity, informed by co-crystal structures with IRAK4 and optimization of ADME properties to deliver clinical candidate PF-06650833 (compound 40). This compound displays a 5-unit increase in lipophilic efficiency from the fragment hit, excellent kinase selectivity, and pharmacokinetic properties suitable for oral administration.

Safe Surgical Retrieval of Embolized Atrial Septal Defect Closure Device

Surgical retrieval of atrial septal closure device is associated with significant morbidity. We present a technique for safer removal of such devices from the heart.

Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study

Objective To prospectively validate the HERDOO2 rule (Hyperpigmentation, Edema, or Redness in either leg; D-dimer level ≥250 μg/L; Obesity with body mass index ≥30; or Older age, ≥65 years), which states that women with none or one of the criteria can safely discontinue anticoagulants after short term treatment.Design Prospective cohort management study.Setting 44 secondary or tertiary care centres in seven countries.Participants Of 3155 consecutive eligible participants with a first unprovoked venous thromboembolism (VTE, proximal leg deep vein thrombosis or pulmonary embolism) who completed 5-12 months of short term anticoagulant treatment, 370 declined to participate, leaving 2785 enrolled participants. 2.3% were lost to follow-up.Interventions Women with none or one of the HERDOO2 criteria were classified as at low risk of recurrent VTE and discontinued anticoagulants (intervention arm), whereas anticoagulant management for high risk women (≥2 HERDOO2 criteria) and men was left to the discretion of the clinicians and patients (observation arm).Main outcome measure Recurrent symptomatic VTE (independently and blindly adjudicated) over one year of follow-up.Results Of 1213 women, 631 (51.3%) were classified as low risk and 591 discontinued oral anticoagulant treatment. In the primary analysis, 17 low risk women who discontinued anticoagulants developed recurrent VTE during 564 patient years of follow-up (3.0% per patient year, 95% confidence interval 1.8% to 4.8%). In 323 high risk women and men who discontinued anticoagulants, 25 had VTE during 309 patient years of follow-up (8.1%, 5.2% to 11.9%), whereas in 1802 high risk women and men who continued anticoagulants 28 had recurrent VTE during 1758 patient years of follow-up (1.6%, 1.1% to 2.3%).Conclusions Women with a first unprovoked VTE event and none or one of the HERDOO2 criteria have a low risk of recurrent VTE and can safely discontinue anticoagulants after completing short term treatment.Trial registration clinicaltrials.gov NCT00967304.

Comparison of Conservation Training Procedures

Direct comparisons were made among four different conservation training procedures, reversibility training, compensation training, addidition/subtraction training and a verbal reinforcement method in order to determine which might best facilitate conservation acquisition in previously nonconserving first grade students. The data indicated that verbal methods stressing principles of reversibility and addition/subtraction resulted in the acquisition of concepts of conservation statistically comparable to that of a group of natural conservers.

Understanding the Relationship between Health Risks and Health-Related Costs

Dr. Anderson reflects on the lack of consistency in studies on the relationship between health risks and medical costs. Part of the inconsistency is caused by differences in risk assessment instruments, but a more important concern is lack of clear conceptualization and statement of research goals. One reason for exploring this relationship is to be able to predict health care costs accurately: a very different reason is to identify causal variables, the modification of which will have an impact on costs.

Determination of the Specificity Landscape for Ribonuclease P Processing of Precursor tRNA 5' Leader Sequences

Maturation of tRNA depends on a single endonuclease, ribonuclease P (RNase P), to remove highly variable 5' leader sequences from precursor tRNA transcripts. Here, we use high-throughput enzymology to report multiple-turnover and single-turnover kinetics for Escherichia coli RNase P processing of all possible 5' leader sequences, including nucleotides contacting both the RNA and protein subunits of RNase P. The results reveal that the identity of N(-2) and N(-3) relative to the cleavage site at N(1) primarily control alternative substrate selection and act at the level of association not the cleavage step. As a consequence, the specificity for N(-1), which contacts the active site and contributes to catalysis, is suppressed. This study demonstrates high-throughput RNA enzymology as a means to globally determine RNA specificity landscapes and reveals the mechanism of substrate discrimination by a widespread and essential RNA-processing enzyme.

The polychlorinated dibenzofuran fingerprint of iron ore sinter plant: Its persistence with suppressant and alternative fuel addition

An earlier demonstration that the relative concentrations of isomers of polychlorinated dibenzofuran do not vary as the flamefront of an iron ore sinter plant progresses through the bed, and profiles are similar for two sinter strands has been widened to include studies of the similarity or otherwise between full scale strand and sinter pot profiles, effect of addition of suppressants and of coke fuel substitution with other combustible materials. For dioxin suppressant addition, a study of the whole of the tetra- penta- and hexaCDF isomer range as separated by the DB5MS chromatography column, indicates no significant change in profile: examination of the ratios of the targeted penta- and hexaCDF isomers suggests the profile is similarly unaffected by coke fuel replacement. Addition of KCl at varied levels has also been shown to have no effect on the 'fingerprint' and there is no indication of any effect by the composition of the sinter mix. The recently published full elution sequence for the DB5MS column is applied to the results obtained using this column. It is confirmed that isomers with 1,9-substitution of chlorine atoms are invariably formed in low concentrations. This is consistent with strong interaction between the 1 and 9 substituted chlorine atoms predicted by DFT thermodynamic calculations. Non-1,9-substituted PCDF equilibrium isomer distributions based on DFT-derived thermodynamic data differ considerably from stack gas distributions obtained using SP2331 column separation. A brief preliminary study indicates the same conclusions (apart from the 1,9-interaction effect) hold for the much smaller content of PCDD.

MPX-004 and MPX-007: New Pharmacological Tools to Study the Physiology of NMDA Receptors Containing the GluN2A Subunit

GluN2A is the most abundant of the GluN2 NMDA receptor subunits in the mammalian CNS. Physiological and genetic evidence implicate GluN2A-containing receptors in susceptibility to autism, schizophrenia, childhood epilepsy and neurodevelopmental disorders such as Rett Syndrome. However, GluN2A-selective pharmacological probes to explore the therapeutic potential of targeting these receptors have been lacking. Here we disclose a novel series of pyrazine-containing GluN2A antagonists exemplified by MPX-004 (5-(((3-chloro-4-fluorophenyl)sulfonamido)methyl)-N-((2-methylthiazol-5-yl)methyl)pyrazine-2-carboxamide) and MPX-007 (5-(((3-fluoro-4-fluorophenyl)sulfonamido)methyl)-N-((2-methylthiazol-5-yl)methyl)methylpyrazine-2-carboxamide). MPX-004 and MPX-007 inhibit GluN2A-containing NMDA receptors expressed in HEK cells with IC50s of 79 nM and 27 nM, respectively. In contrast, at concentrations that completely inhibited GluN2A activity these compounds have no inhibitory effect on GluN2B or GluN2D receptor-mediated responses in similar HEK cell-based assays. Potency and selectivity were confirmed in electrophysiology assays in Xenopus oocytes expressing GluN2A-D receptor subtypes. Maximal concentrations of MPX-004 and MPX-007 inhibited ~30% of the whole-cell current in rat pyramidal neurons in primary culture and MPX-004 inhibited ~60% of the total NMDA receptor-mediated EPSP in rat hippocampal slices. GluN2A-selectivity at native receptors was confirmed by the finding that MPX-004 had no inhibitory effect on NMDA receptor mediated synaptic currents in cortical slices from GRIN2A knock out mice. Thus, MPX-004 and MPX-007 offer highly selective pharmacological tools to probe GluN2A physiology and involvement in neuropsychiatric and developmental disorders.