Novel method for determining when a field-collected donor unit is sufficiently full

BACKGROUND

Whole blood (WB) collections can occur downrange for immediate administration. An important aspect of these collections is determining when the unit is sufficiently full. This project tested a novel method for determining when a field collection is complete.

METHODS

The amount of empty space at the top of WB units, destined to become LTOWB or separated into components, that were collected at blood centers or hospitals was measured by holding a WB unit off the ground and placing the top of a piece of string where the donor tubing entered the bag. The string was marked where it intersected the top of the column of blood in the bag and measured from the top. The WB units were also weighed.

RESULTS

A total of 15 different bags, two of which were measured in two different filling volumes, from 15 hospitals or blood centers were measured and weighed. The most commonly used blood bag, Terumo Imuflex SP, had a median string length of 9 mm (range: 2-24 mm) and weighed a median of 565.1 g (range: 524.8-636.7 g).

CONCLUSION

Pieces of string can be precut to the appropriate length depending on the type of bag before a mission where field WB collections might be required and a mark placed on the bag before the collection commences to indicate when the unit is full.

Retrospective analysis of the effects of hypocalcemia in severely injured trauma patients

BACKGROUND

It has been suggested that the Lethal Triad be modified to include hypocalcemia, coined as the Lethal Diamond. Hypocalcemia in trauma has been attributed to multiple mechanisms, but new evidence suggests that traumatic injury may result in the development of hypoCa independent of blood transfusion. We hypothesize that hypocalcemia is associated with increased blood product requirements and mortality.

METHODS

A retrospective study of 1,981 severely injured adult trauma patients from 2016 to 2019. Ionized calcium (iCa) levels were obtained on arrival and subjects were categorized by a threshold iCa level of 1.00 mmol/L and compared. Univariable and multivariable logistic regression analysis was performed.

RESULTS

The hypocalcemia (iCa <1.00 mmol/L) group had increased rate of overall (p = 0.001), 4-hr (p = 0.007), and 24-hr (p = 0.003) mortality. There was no difference in prehospital transfusion volume between groups (p = 0.25). Hypocalcemia was associated with increased blood product requirements at 4 h (p <0.001), 24 h (p <0.001), and overall hospital length of stay (p <0.001). Logistic regression analysis showed increased odds of 4-hour mortality (OR 0.077 [95 % CI 0.011, 0.523], p = 0.009) and 24-hour mortality (OR 0.121 [95 % CI 0.019, 0.758], p = 0.024) for every mmol/L increase in iCa.

CONCLUSIONS

This study shows the association of hypoCa and traumatic injury. Severe hypoCa was associated with increased odds of early and overall mortality and increased blood product requirements. These results support the need for future prospective trials assessing the role of hypocalcemia in trauma.

Efficacy and Safety of Whole Blood Transfusion in Non-Trauma Patients

Whole blood (WB) transfusion for trauma patients with severe hemorrhage has demonstrated early successful outcomes compared to conventional component therapy. The objective of this study was to demonstrate WB transfusion in the non-trauma patient. Consecutive adult patients receiving WB transfusion at a single academic institution were reviewed from February 2018 to January 2020. Outcomes measured were mortality and transfusion-related reactions. A total of 237 patients who received WB were identified with 55 (23.2%) non-trauma patients. Eight patients (14.5%) received pre-hospital WB. The most common etiology of non-traumatic hemorrhage was gastrointestinal bleeding (43.6%, n = 24/55). Approximately half of the non-trauma patients (n = 28/55) received component therapy. Transfusion-related events occurred in 3 patients. This study demonstrated that non-trauma patients could receive WB transfusions safely with infrequent transfusion-related events. Future studies should focus on determining if outcomes are improved in non-trauma patients who receive WB transfusions and defining specific transfusion criteria for this population.

The effects of hypocalcemia in severely injured pediatric trauma patients

INTRODUCTION

The role of calcium is ubiquitous in human physiology. Emerging evidence suggests that the lethal triad be revised to include hypocalcemia (hypoCa) and thus be known as the lethal diamond . There are data showing that traumatic injury may result in hypoCa independent from the mechanism of calcium chelation by citrate-based blood preservatives. Minimal literature exists analyzing the role of hypoCa in pediatric trauma patients. We hypothesize that there is an independent association of hypoCa with increased blood product requirements and mortality.

METHODS

A retrospective cohort study of severely injured pediatric trauma patients was conducted. Trauma registry data were collected from January 2016 to August 2021. Ionized calcium (iCa) levels were obtained from arrival blood draws. Subjects were categorized into two groups by a threshold iCa level of 1.00 mmol/L and compared. Shock Index Pediatric Adjusted scores were used to adjust for age-specific differences in vital signs.

RESULTS

A total of 142 patients were compared, of which 46.5% were hypocalcemic (iCa <1.00 mmol/L). Patients were well matched in terms of demographics and injury severity. The hypocalcemic group had lower systolic blood pressure and a higher percentage of Shock Index Pediatric Adjusted-positive patients. Weight-adjusted transfusion volumes were significantly higher in the hypocalcemic group at both the 4-hour and 24-hour time points without a difference in prehospital transfusion requirements. There was no observed difference in early or in-hospital mortality.

CONCLUSION

This study contributes to the body of literature regarding the association between hypoCa and traumatic injury in the pediatric population. Hypocalcemia was associated with increased blood product requirements without a difference in prehospital transfusion requirements, suggesting a possible independent association. Further prospective studies are needed to better understand this relationship.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Risk factors for massive transfusion in obstetrical hemorrhage and consideration of a whole blood program

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of obstetric complications. The goal of this study was to identify risk factors for obstetric (OB) massive transfusion (MT) and determine the feasibility of developing a low-titer group O RhD-positive whole blood (LTO + WB) protocol for OB hemorrhage.

STUDY DESIGN AND METHODS

A retrospective study of OB patients who received transfusion within 24 h. MT patients were those who received >3 U of pRBC within 1 h or > 10 U in 24 h. Patient demographics, OB history, comorbidities, blood type, antibody status, and known risk factors for PPH and maternal-fetal outcomes were compared. Logistic regression was used for univariate and multivariate analyses.

RESULTS

Of the 610 transfused OB patients, 12.0% (n = 73) required MT. Groups were well matched for body mass index (BMI), maternal comorbidities, and history of spontaneous vaginal deliveries. The incidence of the previous cesarean section was higher in the MT group. Exactly 93.9% of patients were RhD-positive and 3.77% of all patients possessed an antibody on pretransfusion testing. Patients with MT had a longer length of stay (LOS), higher rate of intensive care unit (ICU) admission, fetal death, and hysterectomy. Multivariate analysis found age >35, PPH, placenta percreta, accreta, and increta to be significant (p < .05) risk factors for MT.

DISCUSSION

Patients over 35 years and those with abnormal placentation are at increased risk of requiring MT. With a time to delivery of 2 days, potential MT patients can be identified early, and with a 94% rate of RhD-positive+, they are eligible to receive low-titer O whole blood (LTOWB) providing hemostatic resuscitation with reduced donor exposure.

First Measurement of Λ Electroproduction off Nuclei in the Current and Target Fragmentation Regions

We report results of Λ hyperon production in semi-inclusive deep-inelastic scattering off deuterium, carbon, iron, and lead targets obtained with the CLAS detector and the Continuous Electron Beam Accelerator Facility 5.014 GeV electron beam. These results represent the first measurements of the Λ multiplicity ratio and transverse momentum broadening as a function of the energy fraction (z) in the current and target fragmentation regions. The multiplicity ratio exhibits a strong suppression at high z and an enhancement at low z. The measured transverse momentum broadening is an order of magnitude greater than that seen for light mesons. This indicates that the propagating entity interacts very strongly with the nuclear medium, which suggests that propagation of diquark configurations in the nuclear medium takes place at least part of the time, even at high z. The trends of these results are qualitatively described by the Giessen Boltzmann-Uehling-Uhlenbeck transport model, particularly for the multiplicity ratios. These observations will potentially open a new era of studies of the structure of the nucleon as well as of strange baryons.

Transfusion-Related Cost Comparison of Trauma Patients Receiving Whole Blood Versus Component Therapy

INTRODUCTION

With the emergence of whole blood in trauma resuscitation, cost-related comparisons are of significant importance to providers, blood banks, and hospital systems throughout the country. The objective of this study is to determine if there is a transfusion-related cost difference between trauma patients that received low titer O+ whole blood (LTO + WB) and component therapy (CT).

METHODS

Retrospective review of adult and pediatric trauma patients who received either LTO + WB or CT from time of injury to within 4 hours of arrival. Annual mean cost per unit of blood product were obtained from the regional blood bank supplier. Pediatric and adult patients were analyzed separately and were compared on a cost per patient (cost/patient) and cost per patient per milliliter (cost/patient/mL) basis. Subgroup analysis was performed on severely injured adult patients (ISS > 15) and patients that underwent massive transfusion (MT).

RESULTS

Prehospital LTO + WB transfusion began at this institution in January 2018. After the initiation of the whole blood transfusion the mean annual cost decreased 17.3% for all blood products and the average net difference in cost related to component blood products and LTO + WB was over $927,000. In adults, LTO + WB was associated with a significantly lower cost/patient and cost/patient/mL compared to CT at 4-hours, (p < 0.001), at 24 hours (p < 0.001), and overall (p < 0.001). In the severely injured subgroup (ISS > 15), WB was associated with a lower cost/patient and cost/patient/mL at 4-hours (p < 0.001), 24 hours (p < 0.001), and overall (p < 0.001), with no difference in the prehospital setting. Similar findings were true in patients meeting MT criteria, although differences in injury severity may account for this finding.

CONCLUSION

With increased use of LTO + WB for resuscitation, cost comparison is of significant importance to all stakeholders. LTO + WB was associated with reduced cost in severely injured patients. Ongoing analyses may improve resource utilization and benefit overall healthcare cost.Level of Evidence: Therapeutic/Care Management, IV.

Histological evidence of superficial inflammation is associated with lower recurrence of equine sarcoids following surgical removal: A follow-up study of 106 tumours in 64 horses

Although the equine sarcoid is the most common skin neoplasm in domesticated horses, histopathological characteristics have not previously been evaluated for association with recurrence. The aim of this retrospective cohort study was to investigate clinical and histopathological features of excised equine sarcoids and to evaluate their association with recurrence at the original surgical site and at new sites. Clinical records and excisional biopsies from 106 equine sarcoids from 64 horses referred to Leahurst Equine Hospital, University of Liverpool, between March 2010 and February 2015 were retrieved. Biopsies were re-evaluated histologically. Clinical data were obtained from hospital records, and owner-reported follow-up data were obtained by telephone questionnaire. Associations between clinical and histopathological features of sarcoids and their recurrence at the surgical site were determined using uni- and multivariable mixed effects logistic regression. Recurrence of sarcoids at the surgical site occurred in 30 horses (46.9%). Sarcoids developed at a distant site in 21 horses (32.8%). In the final mixed effects logistic regression model, only superficial inflammation was associated with reduced odds of recurrence at the surgical site (adjusted odds ratio, 0.32; 95% confidence intervals, 0.10-0.96; P = 0.04). This suggests that the inflammatory process may play a role in protecting horses against the recurrence of sarcoids.

OP0051 TRENDS FOR OPIOID PRESCRIPTIONS AMONG PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES BETWEEN 2006-2020

Background

Opioid prescribing has contributed to a North American epidemic with increasing trends in several European countries1. Rheumatic and musculoskeletal diseases (RMDs) are one of the most common indications for prescribed opioids despite there being little evidence on opioid prescribing and the benefit of long-term use in RMDs.

Objectives

To investigate national UK opioid prescribing trends by studying the patterns of opioid prescribing in new users with the following six RMDs: rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (AxSpA), systemic lupus erythematosus (SLE), osteoarthritis (OA) and fibromyalgia.

Methods

Patients aged 18 years and older with a diagnosis of RA, PsA, AxSpA, SLE and OA with a new episode of opioid use without cancer in the Clinical Practice Research Datalink (CPRD) were included between 01/01/2006 and 31/12/2020. CPRD is a database of anonymised UK primary care electronic health records representative of the national population. New opioid users were defined as individuals with RMDs who had a new episode of opioid use in a 2-year time window up to 6 months before or after an RMD diagnosis. Rates of new opioid users were calculated by dividing the number of new opioid users with an RMD per year by the number of eligible patients registered in CPRD per year. Age- and gender-standardised rates for new opioid users were obtained using direct standardisation for each RMD. Rates of opioid prescriptions among new users for each RMD were calculated by dividing the number of opioid prescriptions among new users with an RMD in the year they had new opioid episodes by patient-years of the new users with an RMD. Trends for the rates in the study period were tested using negative binomial regression. Significant change points were identified by looking at the points where the derivative (i.e. rate of change) of the trends for the rates crossed zero. Recurrent opioid users were defined as patients who had at least 3 opioid prescriptions issued within 3 months after a new opioid episode.

Results

This study included 21,505 RA patients, 8,392 PsA patients, 4,491 AxSpA patients, 4,508 SLE patients, 944,078 OA patients, and 33,829 fibromyalgia patients, who had new opioid episodes between 2006-2020. Whilst the overall trend for RA (2.7* vs 3.9*), PsA (1.0* vs 1.8*) and fibromyalgia (3.7* vs 8.3*) has significantly increased over 15 years, from 2018 onwards, trends of new opioid users appeared to stabilise/decrease (Figure 1). The year 2018 was found to be a significant decreasing change point in the trends of new opioid users for RA, AxSpA, and SLE, whilst this was 2013 in OA and 2019 for fibromyalgia. Opioid prescription rates among new opioid users increased in SLE (4.3# vs 5.4#), OA (4.6# vs 4.9#) and fibromyalgia (5.6# vs 6.5#) but decreased in RA (5.7# vs 5.3#) from 2006 to 2020, despite fluctuations in the rates observed in this period. The highest proportions of recurrent opioid users among the 6 RMDs were patients with RA (32.6%) and fibromyalgia (31.9%).

* The number of new opioid users per 10000 persons

# The number of opioid prescriptions in new users per patient years

Figure 1.

Trends of new opioid users by RMD, 2006-2020.

Conclusion

RA, PsA and fibromyalgia had an overall increase in new opioid users since 2006. The slight decrease in the trends of new opioid users among most of the RMDs after 2018 may reflect an increasing awareness of the opioid epidemic. The high proportions of recurrent opioid users in RA and fibromyalgia patients highlight the importance of exploring the safety of long-term opioid use and effective pain interventions for patients with RMDs.

References

[1]Jani M et al (2020) Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study. PLoS Med 17(10): e1003270

Acknowledgements

This work was funded by a FOREUM grant (grant ID: 125059), MJ is funded through an NIHR Advanced Fellowship (NIHR301413). Thanks to the CPRD fob holders in our centre, Ruth Costello and Ramiro Bravo, for downloading the data.

Disclosure of Interests

Joyce (Yun-Ting) Huang: None declared, David Jenkins: None declared, Belay Birlie Yimer: None declared, Jose Benitez-Aurioles: None declared, Niels Peek: None declared, Mark Lunt: None declared, William Dixon Consultant of: WGD has received consultancy fees from Abbvie and Google., Meghna Jani: None declared.

Improved Λp Elastic Scattering Cross Sections between 0.9 and 2.0 GeV/c as a Main Ingredient of the Neutron Star Equation of State

Strange matter is believed to exist in the cores of neutron stars based on simple kinematics. If this is true, then hyperon-nucleon interactions will play a significant part in the neutron star equation of state. Yet, compared to other elastic scattering processes, there is very little data on Λ-N scattering. This experiment utilized the CEBAF Large Acceptance Spectrometer (CLAS) detector to study the Λp→Λp elastic scattering cross section in the incident Λ momentum range 0.9-2.0  GeV/c. These are the first data on this reaction since the 1970s. The new cross sections have significantly better accuracy and precision than the existing world data, and the techniques developed here can also be used in future experiments.

THOR-AABB Working Party Recommendations for a Prehospital Blood Product Transfusion Program

The evidence for the lifesaving benefits of prehospital transfusions is increasing. As such, emergency medical services (EMS) might increasingly become interested in providing this important intervention. While a few EMS and air medical agencies have been providing exclusively red blood cell (RBC) transfusions to their patients for many years, transfusing plasma in addition to the RBCs, or simply using low titer group O whole blood (LTOWB) in place of two separate components, will be a novel experience for many services. The recommendations presented in this document were created by the Trauma, Hemostasis and Oxygenation Research (THOR)-AABB (formerly known as the American Association of Blood Banks) Working Party, and they are intended to provide a framework for implementing prehospital blood transfusion programs in line with the best available evidence. These recommendations cover all aspects of such a program including storing, transporting, and transfusing blood products in the prehospital phase of hemorrhagic resuscitation.

Are medical procedures that induce coughing or involve respiratory suctioning associated with increased generation of aerosols and risk of SARS-CoV-2 infection? A rapid systematic review

BACKGROUND

The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern.

AIM

To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing.

METHODS

The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice.

FINDINGS

Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions.

CONCLUSION

There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.

Operationalizing the Deployment of Low-Titer O-Positive Whole Blood Within a Regional Trauma System

INTRODUCTION

The implementation of a low-titer O+ whole blood (LTOWB) resuscitation algorithm, particularly in the prehospital environment, has several inherent challenges, including cost, limited and inconsistent supply, and the logistics of cold-chain management. The Southwest Texas Regional Advisory Council has implemented the nation's first multidisciplinary, multi-institutional regional LTOWB program. This research effort was to illustrate the successful deployment of LTOWB within a regional trauma system.

MATERIALS AND METHODS

A deliberate systems approach to the deployment of LTOWB was used. Tenets of this program included the active management of blood donor sources and blood supply levels to minimize wastage as a result of expiration, maximize product utilization, the use of prehospital transfusion triggers, and efforts to decrease program costs prehospital agencies. A novel LTOWB rotation system was established using the concept of a "rotation site" and "rotation center." Standardized transfusion criteria, a regional approved equipment list, a regional Prehospital Blood Product Transfusion Record, and a robust multilevel communication plan serves as the framework for the program. The San Antonio Whole Blood Consortium was developed to create a consensus driven forum to manage and guide the program.

RESULTS

From January 2018 to October 2019, LTOWB has been placed at 18 helicopter emergency medical services (HEMS) bases, 12 ground emergency medical service (EMS) agencies, 1 level I trauma center, and 1 level IV trauma center. A total of 450 patients have received a prehospital LTOWB transfusion. Program wide, the wastage rate of LTOWB due to expiration is between 1% and 2%. No complications related to prehospital LTOWB administration have been identified.

DISCUSSION

This work demonstrates a novel model for the development of a trauma system LTOWB program. The program's implementation augments remote damage control resuscitation strategies and requires the integration and collaboration of a multidisciplinary stakeholder team to optimize efficiency, performance, and safety of the program.

Evidence-Based and Clinically Relevant Outcomes for Hemorrhage Control Trauma Trials

OBJECTIVE

To address the clinical and regulatory challenges of optimal primary endpoints for bleeding patients by developing consensus-based recommendations for primary clinical outcomes for pivotal trials in patients within 6 categories of significant bleeding, (1) traumatic injury, (2) intracranial hemorrhage, (3) cardiac surgery, (4) gastrointestinal hemorrhage, (5) inherited bleeding disorders, and (6) hypoproliferative thrombocytopenia.

BACKGROUND

A standardized primary outcome in clinical trials evaluating hemostatic products and strategies for the treatment of clinically significant bleeding will facilitate the conduct, interpretation, and translation into clinical practice of hemostasis research and support alignment among funders, investigators, clinicians, and regulators.

METHODS

An international panel of experts was convened by the National Heart Lung and Blood Institute and the United States Department of Defense on September 23 and 24, 2019. For patients suffering hemorrhagic shock, the 26 trauma working-group members met for almost a year, utilizing biweekly phone conferences and then an in-person meeting, evaluating the strengths and weaknesses of previous high quality studies. The selection of the recommended primary outcome was guided by goals of patient-centeredness, expected or demonstrated sensitivity to beneficial treatment effects, biologic plausibility, clinical and logistical feasibility, and broad applicability.

CONCLUSIONS

For patients suffering hemorrhagic shock, and especially from truncal hemorrhage, the recommended primary outcome was 3 to 6-hour all-cause mortality, chosen to coincide with the physiology of hemorrhagic death and to avoid bias from competing risks. Particular attention was recommended to injury and treatment time, as well as robust assessments of multiple safety related outcomes.

Photoproduction of the f_{2}(1270) Meson Using the CLAS Detector

The quark structure of the f_{2}(1270) meson has, for many years, been assumed to be a pure quark-antiquark (qq[over ¯]) resonance with quantum numbers J^{PC}=2^{++}. Recently, it was proposed that the f_{2}(1270) is a molecular state made from the attractive interaction of two ρ mesons. Such a state would be expected to decay strongly to final states with charged pions due to the dominant decay ρ→π^{+}π^{-}, whereas decay to two neutral pions would likely be suppressed. Here, we measure for the first time the reaction γp→π^{0}π^{0}p, using the CEBAF Large Acceptance Spectrometer detector at Jefferson Lab for incident beam energies between 3.6 and 5.4 GeV. Differential cross sections, dσ/dt, for f_{2}(1270) photoproduction are extracted with good precision due to low backgrounds and are compared to theoretical calculations.

Shape Changes in the Mirror Nuclei ^{70}Kr and ^{70}Se

We studied the proton-rich T_{z}=-1 nucleus ^{70}Kr through inelastic scattering at intermediate energies in order to extract the reduced transition probability, B(E2;0^{+}→2^{+}). Comparison with the other members of the A=70 isospin triplet, ^{70}Br and ^{70}Se, studied in the same experiment, shows a 3σ deviation from the expected linearity of the electromagnetic matrix elements as a function of T_{z}. At present, no established nuclear structure theory can describe this observed deviation quantitatively. This is the first violation of isospin symmetry at this level observed in the transition matrix elements. A heuristic approach may explain the anomaly by a shape change between the mirror nuclei ^{70}Kr and ^{70}Se contrary to the model predictions.

Beam Spin Asymmetry in Semi-Inclusive Electroproduction of Hadron Pairs

A first measurement of the longitudinal beam spin asymmetry A_{LU} in the semi-inclusive electroproduction of pairs of charged pions is reported. A_{LU} is a higher-twist observable and offers the cleanest access to the nucleon twist-3 parton distribution function e(x). Data have been collected in the Hall-B at Jefferson Lab by impinging a 5.498-GeV electron beam on a liquid-hydrogen target, and reconstructing the scattered electron and the pion pair with the CLAS detector. One-dimensional projections of the A_{LU}^{sinϕ_{R}} moments are extracted for the kinematic variables of interest in the valence quark region. The understanding of dihadron production is essential for the interpretation of observables in single-hadron production in semi-inclusive DIS, and pioneering measurements of single-spin asymmetries in dihadron production open a new avenue in studies of QCD dynamics.

Defence Medical Rehabilitation Centre (DMRC) COVID-19 Recovery Service

Coronavirus disease 2019 (COVID-19) causes significant mortality and morbidity, with an unknown impact in the medium to long term. Evidence from previous coronavirus epidemics indicates that there is likely to be a substantial burden of disease, potentially even in those with a mild acute illness. The clinical and occupational effects of COVID-19 are likely to impact on the operational effectiveness of the Armed Forces. Collaboration between Defence Primary Healthcare, Defence Secondary Healthcare, Defence Rehabilitation and Defence Occupational Medicine resulted in the Defence Medical Rehabilitation Centre COVID-19 Recovery Service (DCRS). This integrated clinical and occupational pathway uses cardiopulmonary assessment as a cornerstone to identify, diagnose and manage post-COVID-19 pathology.

Extraction of Beam-Spin Asymmetries from the Hard Exclusive π^{+} Channel off Protons in a Wide Range of Kinematics

We have measured beam-spin asymmetries to extract the sinϕ moment A_{LU}^{sinϕ} from the hard exclusive e[over →]p→e^{'}nπ^{+} reaction above the resonance region, for the first time with nearly full coverage from forward to backward angles in the center of mass. The A_{LU}^{sinϕ} moment has been measured up to 6.6  GeV^{2} in -t, covering the kinematic regimes of generalized parton distributions (GPD) and baryon-to-meson transition distribution amplitudes (TDA) at the same time. The experimental results in very forward kinematics demonstrate the sensitivity to chiral-odd and chiral-even GPDs. In very backward kinematics where the TDA framework is applicable, we found A_{LU}^{sinϕ} to be negative, while a sign change was observed near 90° in the center of mass. The unique results presented in this Letter will provide critical constraints to establish reaction mechanisms that can help to further develop the GPD and TDA frameworks.

Distribution of the Red Imported Fire Ant Solenopsis invicta (Hymenoptera: Formicidae) in Central Florida Pastures

Habitat disturbance has been found to facilitate the introduction of a wide range of species, including the red imported fire ant Solenopsis invicta Buren (Hymenoptera: Formicidae: Myrmicinae). Despite the link between S. invicta colonization and disturbance, little is known about how different intensities or types of disturbance might impact S. invicta populations. In this study, we used S. invicta populations in cattle pastures to understand how variation in disturbance type and frequency correlates with the density of S. invicta mounds. In total, 56 plots were surveyed for mound abundance during both the wet and dry seasons on a subtropical south Florida ranch. Explanatory variables were grouped into five categories based on disturbance type: 1) historic pasture conversion; 2) modern pasture management (mowing, dragging, chopping, or aerating); 3) grazing intensity (a measure vegetation height and dung pat abundance); 4) distance to human-made and natural localized disturbance (roads, ditches, and wetlands); and 5) abiotic conditions (soil temperature, soil moisture). Overall, the average number of mounds per plot was not significantly different between seasons, but was significantly higher in intensive pastures, which are converted to nonnative forage grasses than in seminative pastures during the dry season. Time since soil disturbance (aeration and chopping of pasture) was a significant predictor of S. invicta densities in both dry and wet seasons, with an increase in time since disturbance being associated with higher mound densities. Other forms of pasture management that did not disturb the soil, such as dragging and mowing, as well as distance to localized disturbances (wetlands, roads, and ditches) were not found to have a significant correlation in either season.

OP0331-HPR BARRIERS TO SHARED DECISION-MAKING WITH WOMEN OF REPRODUCTIVE AGE AFFECTED BY CHRONIC INFLAMMATORY DISEASES

Background:

Previous research has indicated that women with a chronic inflammatory disease (CID) are likely to discontinue treatment during pregnancy. [1] Reasons for this are complex, including sub-optimal integration of shared decision-making (SDM) into practice.

Objectives:

The purpose of this study was to assess: 1) physicians’ competencies in risk assessment, treatment and management of women of reproductive age (WoRA) with a CID, and 2) clinical gaps, barriers and challenges to SDM with these patients.

Methods:

A mixed-methods needs assessment was conducted. [2] Participants included rheumatologists and dermatologists practicing in Germany, United Kingdom, or United States, with at least three years of experience. Exposure to patients diagnosed with rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis or psoriasis was required. A first phase involved collection and thematic analysis of data from semi-structured interviews to identify main challenge areas. The second phase consisted of online surveys to validate and quantify identified challenges, gaps and barriers. Chi-square and Kruskal Wallis H statistical tests were performed to assess differences by specialty, country and gender. Qualitative and quantitative findings were triangulated with insight from experts in medical education and relevant behavioural and clinical fields. [3] The present summary reports data pertaining to rheumatologists only.

Results:

A total of 24 interviews and 173 surveys were completed with rheumatologists. Depending on the country and specific item, 22% to 64% reported having sub-optimal knowledge of treatment options, patient education aids, and strategies to assess treatment adherence among WoRA with a CID (see figure 1). In addition, 36% reported having sub-optimal knowledge of methods to achieve SDM. Unplanned pregnancies were reported as a barrier to prescribing biologics to WoRA with a CID. Yet, 61% of rheumatologists reported having sub-optimal skills discussing contraceptive methods with patients. In addition, 41% reported having sub-optimal skills adjusting treatment according to changes in pregnancy status or child-bearing aspirations. Few differences in clinical gaps were observed by gender. Notably, a greater proportion of male rheumatologists reported having sub-optimal skills approaching WoRA in a way that makes them feel comfortable discussing their health concerns, compared to female rheumatologists (52% vs. 30%, p=0.046). This skill gap was identified as a contributing barrier to SDM with these patients.

Conclusion:

This study identified multiple challenges, gaps and barriers relevant to rheumatologists that prevent optimal SDM, risk assessment, treatment and management of WoRA with CID. Findings may be used to develop medical education and continuous professional development interventions for target learners.

References:

[1]Tsao NW, Lynd LD, Sadatsafavi M, Hanley G and De Vera MA. Patterns of biologics utilization and discontinuation before and during pregnancy in women with autoimmune diseases: a population-based cohort study.Arthritis Care Res.,2018;70(7):979-986.

[2]Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixed methods research in the health sciences, 2nd Ed. Bethesda: NIH, 2018:541-545,.

[3]Turner SF, Cardinal LB, Burton RM, A triangulation-based framework and roadmap.Organ. Res. Methods,2017;20(2): 243-26.

Acknowledgments:

This research was financially supported with educational funds from UCB BioPharma SRL. The authors thank T. Kellner for his contribution.

Disclosure of Interests:

Suzanne Murray: None declared, Rebecca Fischer-Betz Consultant of: UCB, Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celgene, Chugai, GSK, Janssen, Lilly, Medac, MSD, Novartis, Roche, UCB, Pfizer., Monica Augustyniak: None declared, Jenny Murase Consultant of: I have led advisory boards for UCB., Speakers bureau: I have done non-branded talks on psoriasis management in women for UCB., Catherine Nelson-Piercy Consultant of: I have received consultancy fees from UCB, Speakers bureau: I have received fees for speaking from UCB., Ivo Vlaev Consultant of: For UCB., Speakers bureau: For UCB, Pfizer, Novartis and boehringer Ingelheim., Cecile Ecoffet Shareholder of: UCB, Employee of: UCB, Morgan Peniuta: None declared, Dean Jenkins Employee of: UCB

1117 Associations Between Health Behaviors And Sleep Duration In Women With Depression

Introduction

Sleep duration can have important effects on health. Long and short sleep has been associated with negative health outcomes in women. Depression may aggravate an already impaired sleep quality. This study explored associations between sleep duration and depression in pregnant women.

Methods

We analyzed data for adult women (n=9,372) from the 2017 and 2018 National Health Interview Survey (NHIS), which is a nationally representative study of the US civilian non-institutionalized population. Sleep was categorized by short (≤6 hrs), normal/healthy (7-8 hrs), and long (≥9 hrs) sleep. Using STATA 15.0 for Windows, we report weighted frequencies and Chi-and square tests. Alpha of 0.05 was used for all significance levels.

Results

Of the sample, 81.7% of the women were White, 10.6% were Black and 7.7% were other minorities. The mean age was 51.4±18.3. We found that the proportion of women who reported short sleep increased with age (p&lt;0.000). Current drinkers (37%) had higher numbers of normal sleep than those who were former drinkers or abstainers (p&lt;0.000). With respect to BMI, more obese women were short and sleepers (17% and 4% respectively), but women with normal BMI (19%) were normal sleepers (p&lt;0.000). In short sleepers, more women had trouble falling asleep (13%) and staying asleep (17%), but reported not using medication and never feeling rested. Similar results were found for long sleepers. Higher proportions of normal sleepers reported not have trouble falling asleep (27%), staying asleep (26%), or using medication for sleep (40%) (p&lt;0.000). However, of those who reported normal sleep, greater frequencies of working up feeling rested occurred only 3-6 times in the past week (p&lt;0.000).

Conclusion

In this study, women with depression self-reported more normal sleep duration. This finding is inconsistent with previous research. Whether this association is causal and what pathways explain this association is unknown.

Support

This study was supported by funding from the NIH: R01MD007716, R01HL142066, K01HL135452, and K07AG052685.

Grading immunohistochemical markers p16INK4a and HPV E4 identifies productive and transforming lesions caused by low- and high-risk HPV within high-grade anal squamous intraepithelial lesions

OBJECTIVES

Because current guidelines recognise high-grade anal squamous intraepithelial lesions (HSILs) and low-grade SILs (LSILs), and recommend treatment of all HSILs although not all progress to cancer, this study aims to distinguish transforming and productive HSILs by grading immunohistochemical (IHC) biomarkers p16INK 4a (p16) and E4 in low-risk human papillomavirus (lrHPV) and high-risk (hr)HPV-associated SILs as a potential basis for more selective treatment.

METHODS

Immunostaining for p16 and HPV E4 was performed and graded in 183 biopsies from 108 HIV-positive men who have sex with men. The causative HPV genotype of the worst lesion was identified using the HPV SPF10-PCR-DEIA-LiPA25 version 1 system, with laser capture microdissection for multiple infections. The worst lesions were scored for p16 (0-4) to identify activity of the hrHPV E7 gene, and panHPV E4 (0-2) to mark HPV production and life cycle completion.

RESULTS

There were 37 normal biopsies, 60 LSILs and 86 HSILs, with 85% of LSILs caused by lrHPV and 93% of HSILs by hrHPV. No normal biopsy showed E4, but 43% of LSILs and 37% of HSILs were E4 positive. No differences in E4 positivity rates were found between lrHPV and hrHPV lesions. Most of the lesions caused by lrHPV (90%) showed very extensive patchy p16 staining; p16 grade in HSILs was variable, with frequency of productive HPV infection dropping with increasing p16 grade.

CONCLUSIONS

Combined p16/E4 IHC identifies productive and nonproductive HSILs associated with hrHPV within the group of HSILs defined by the Lower Anogenital Squamous Terminology recommendations. This opens the possibility of investigating selective treatment of advanced transforming HSILs caused by hrHPV, and a 'wait and see' policy for productive HSILs. What's already known about this topic? For preventing anal cancer in high-risk populations, all patients with high-grade squamous intraepithelial lesions (HSILs) are treated, even though this group of lesions is heterogeneous, the histology is variable and regression is frequent. What does this study add? By adding human papillomavirus (HPV) E4 immunohistochemistry to p16 INK4a (p16), and grading expression of both markers, different biomarker expression patterns that reflect the heterogeneity of HSILs can be identified. Moreover, p16/E4 staining can separate high-risk HPV-associated HSILs into productive and more advanced transforming lesions, providing a potential basis for selective treatment.

P2540Sex-specific differences in the clinical presentation, surgical complications, and course of chronic thromboembolic pulmonary hypertension

Background

Women are more susceptible to develop several forms of pulmonary hypertension, but they may have better survival rates than men. Sparse data are available concerning sex-specific differences in chronic thromboembolic pulmonary hypertension (CTEPH).

Purpose and methods

We investigated sex-specific differences in the clinical presentation of CTEPH, functional parameters, exposure to pulmonary endarterectomy (PEA), and survival.

Results

Women constituted half of the study population (N=679 treatment-naïve patients from the European CTEPH registry) and were characterized by a lower prevalence of some cardiovascular risk factors (e.g. prior acute coronary syndrome, smoking habit, chronic obstructive pulmonary disease), but more prevalent obesity, cancer, and thyroid diseases. Median age was 62 (IQR 50–73) years in women and 63 (IQR 53–70) in men. Women underwent PEA less often than men (54% vs 65%; Figure 1, Panel A) and were exposed to fewer additional cardiac procedures, notably coronary artery bypass graft surgery (0.5% vs. 9.5%). The prevalence of specific reasons for not being operated, including the patient's refusal and the proportion of proximal vs. distal lesions, did not differ between sexes. A total of 57 (17.0%) deaths in women and 70 (20.7%) in men were recorded over long-term follow-up. Female sex was positively associated with long-term survival (adjusted Hazard Ratio 0.66; 95% Confidence Interval 0.46–0.94). Short-term mortality was identical in the two groups (Figure 1, Panel B).

Conclusions

Women with CTEPH had a lower prevalence of cardiovascular risk factors and underwent PEA less frequently than men, who, in turn, were more often exposed to additional major cardiac surgery procedures. Women had more favorable long-term survival.

Acknowledgement/Funding

The CTEPH registry is supported by a research grant from Actelion Pharmaceuticals Ltd.

Exploring the Structure of the Bound Proton with Deeply Virtual Compton Scattering

In the past two decades, deeply virtual Compton scattering of electrons has been successfully used to advance our knowledge of the partonic structure of the free proton and investigate correlations between the transverse position and the longitudinal momentum of quarks inside the nucleon. Meanwhile, the structure of bound nucleons in nuclei has been studied in inclusive deep-inelastic lepton scattering experiments off nuclear targets, showing a significant difference in longitudinal momentum distribution of quarks inside the bound nucleon, known as the EMC effect. In this Letter, we report the first beam spin asymmetry (BSA) measurement of exclusive deeply virtual Compton scattering off a proton bound in ^{4}He. The data used here were accumulated using a 6 GeV longitudinally polarized electron beam incident on a pressurized ^{4}He gaseous target placed within the CLAS spectrometer in Hall-B at the Thomas Jefferson National Accelerator Facility. The azimuthal angle (ϕ) dependence of the BSA was studied in a wide range of virtual photon and scattered proton kinematics. The Q^{2}, x_{B}, and t dependencies of the BSA on the bound proton are compared with those on the free proton. In the whole kinematical region of our measurements, the BSA on the bound proton is smaller by 20% to 40%, indicating possible medium modification of its partonic structure.

Prehospital Use of Ketamine: Effectiveness in Critically Ill and Injured Patients

BACKGROUND

The military use of ketamine is well established. The benefits of prehospital civilian use have not been extensively reported.

METHODS

A retrospective review was performed of patients with prehospital ketamine use in Mayo One's air and critical care ground transport.

RESULTS

The medical records were reviewed from 2014 to 2016 to assess the efficacy of Ketamine. During this time frame, 158 (167 instances) patients were treated with ketamine for analgesia (38%), sedation (44%), or procedural (18%) use. The patient population had a mean age of 49 (range: 1-100), with 105 (67%) male patients. Indications included trauma (69%), which was further broken down into blunt (57%), penetrating (4%), and miscellaneous (8%), and medical illness (31%). The mean ketamine dose was 52.6 mg (range: 5-200 mg) via intravenous route. Ketamine was utilized in 61% of patients after other medications were ineffective. Overall success rate was 98%. Mean pain scale before and after ketamine use was 9/10 and 3/10, respectively. Ketamine use increased yearly from 21 (13%) in 2014, 56 (36%) in 2015, and 81 (51%) in 2016.

CONCLUSION

Prehospital ketamine use is effective alone or in conjunction with other medications for analgesia, sedation, and procedural use in trauma and critically ill patients with minimal hemodynamic and respiratory consequences.

Damage Control Resuscitation

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

First Measurements of the Double-Polarization Observables F, P, and H in ω Photoproduction off Transversely Polarized Protons in the N^{*} Resonance Region

First measurements of double-polarization observables in ω photoproduction off the proton are presented using transverse target polarization and data from the CEBAF Large Acceptance Spectrometer (CLAS) FROST experiment at Jefferson Lab. The beam-target asymmetry F has been measured using circularly polarized, tagged photons in the energy range 1200-2700 MeV, and the beam-target asymmetries H and P have been measured using linearly polarized, tagged photons in the energy range 1200-2000 MeV. These measurements significantly increase the database on polarization observables. The results are included in two partial-wave analyses and reveal significant contributions from several nucleon (N^{*}) resonances. In particular, contributions from new N^{*} resonances listed in the Review of Particle Properties are observed, which aid in reaching the goal of mapping out the nucleon resonance spectrum.

HPV testing in first-void urine provides sensitivity for CIN2+ detection comparable with a smear taken by a clinician or a brush-based self-sample: cross-sectional data from a triage population

OBJECTIVE

To compare the sensitivity of high-risk human papillomavirus (hrHPV) and genotype detection in self-collected urine samples in the morning (U1), and later on (U2), brush-based self-samples (SS), and clinician-taken smears (CTS) for detecting cervical intraepithelial neoplasia grade 2+ (CIN2+) in a colposcopic referral population.

DESIGN

Cross-sectional single-centre study.

SETTING

A colposcopy clinic in Spain.

POPULATION

A cohort of 113 women referred for colposcopy after an abnormal Pap smear.

METHODS

Women undergoing colposcopy with biopsy for abnormal Pap smears were sent a device (Colli-Pee™, Novosanis, Wijnegem, Belgium) to collect U1 on the morning of colposcopy. U2, CTS, and SS (Evalyn brush™, Rovers Medical Devices B.V., Oss, the Netherlands) were also analysed. All samples were tested for HPV DNA using the analytically sensitive SPF10-DEIA-LiPA25 assay and the clinically validated GP5+/6+-EIA-LMNX.

MAIN OUTCOME MEASURES

Histologically confirmed CIN2+ and hrHPV positivity for 14 high-risk HPV types.

RESULTS

Samples from 91 patients were analysed. All CIN3 cases (n = 6) tested positive for hrHPV in CTS, SS, U1, and U2 with both HPV assays. Sensitivity for CIN2+ with the SPF10 system was 100, 100, 95, and 100%, respectively. With the GP5+/6+ assay, sensitivity was 95% in all sample types. The sensitivities and specificities for both tests on each of the sample types did not significantly differ. There was 10-14% discordance on hrHPV genotype.

CONCLUSIONS

CIN2+ detection using HPV testing of U1 shows a sensitivity similar to that of CTS or brush-based SS, and is convenient. There was substantial to almost excellent agreement between all samples on genotype with both hrHPV assays. There was no advantage in testing U1 compared with U2 samples.

TWEETABLE ABSTRACT

Similar CIN2+ sensitivity for HPV testing in first-void urine, physician-taken smear and brush-based self-sample.

Center of Mass Motion of Short-Range Correlated Nucleon Pairs studied via the A(e,e^{'}pp) Reaction

Short-range correlated (SRC) nucleon pairs are a vital part of the nucleus, accounting for almost all nucleons with momentum greater than the Fermi momentum (k_{F}). A fundamental characteristic of SRC pairs is having large relative momenta as compared to k_{F}, and smaller center of mass (c.m.) which indicates a small separation distance between the nucleons in the pair. Determining the c.m. momentum distribution of SRC pairs is essential for understanding their formation process. We report here on the extraction of the c.m. motion of proton-proton (pp) SRC pairs in carbon and, for the first time in heavier and ansymetric nuclei: aluminum, iron, and lead, from measurements of the A(e,e^{'}pp) reaction. We find that the pair c.m. motion for these nuclei can be described by a three-dimensional Gaussian with a narrow width ranging from 140 to 170  MeV/c, approximately consistent with the sum of two mean-field nucleon momenta. Comparison with calculations appears to show that the SRC pairs are formed from mean-field nucleons in specific quantum states.