Anticoagulation strategies in COVID-19 infected patients receiving ECMO support

BACKGROUND

Hospitalized COVID-19 patients with hypoxemic respiratory failure may deteriorate despite invasive mechanical ventilation and thus require extracorporeal membrane oxygenation (ECMO) support. Unfractionated heparin (UFH) is the antithrombotic of choice, however, bivalirudin may offer more predictable pharmacokinetics resulting in consistent anticoagulant effects with lower bleeding and thrombotic occurrences. The aim of this study was to evaluate efficacy and safety outcomes in patients undergoing venovenous (VV) ECMO receiving bivalirudin or UFH-based anticoagulation.

METHODS

This retrospective, single-center, observational cohort study included patients with confirmed COVID-19 infection requiring VV ECMO support receiving anticoagulation with UFH or bivalirudin. Primary endpoints were time to reach therapeutic aPTT, percent time spent in aPTT range, and the occurrence of thrombotic events over the entire course of ECMO support. Secondary endpoints included the incidence of major/minor bleeding, the ability to wean off ECMO support, in-hospital mortality, and length of stay.

RESULTS

Twenty-two patients were included in the study (n = 10 UFH, n = 12 bivalirudin). Time to therapeutic aPTT was achieved faster with UFH (10 h vs. 20 h). The percentage time spent within the goal aPTT range was similar between UFH and bivalirudin (50% vs. 52%). Thrombotic events were significantly higher in the UFH group (40% DVT, 40% PE, 80% oxygenator thrombus in ECMO machine, 10% ischemic stroke) versus bivalirudin (8% DVT, 17% PE, 33% oxygenator thrombus, no ischemic strokes) (CI 95%, p = 0.04). The overall bleeding incidence was higher in the UFH arm (90% vs. 75%). The mortality rate was 90% in the UFH group and 58% in the bivalirudin group. The length of stay was similar between the two study arms.

CONCLUSION

In hospitalized patients with COVID-19-associated acute respiratory distress syndrome (ARDS) on VV ECMO support, the use of bivalirudin showed to be a viable anticoagulation alternative in terms of efficacy compared to UFH and resulted in a favorable safety profile with lower rates of bleeding and thrombotic events.

A universal tool for stability predictions of biotherapeutics, vaccines and in vitro diagnostic products

It is of particular interest for biopharmaceutical companies developing and distributing fragile biomolecules to warrant the stability and activity of their products during long-term storage and shipment. In accordance with quality by design principles, advanced kinetic modeling (AKM) has been successfully used to predict long-term product shelf-life and relies on data from short-term accelerated stability studies that are used to generate Arrhenius-based kinetic models that can, in turn, be exploited for stability forecasts. The AKM methodology was evaluated through a cross-company perspective on stability modeling for key stability indicating attributes of different types of biotherapeutics, vaccines and biomolecules combined in in vitro diagnostic kits. It is demonstrated that stability predictions up to 3 years for products maintained under recommended storage conditions (2-8 °C) or for products that have experienced temperature excursions outside the cold-chain show excellent agreement with experimental real-time data, thus confirming AKM as a universal and reliable tool for stability predictions for a wide range of product types.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

Baseline Findings of PreventE4: A Double-Blind Placebo Controlled Clinical Trial Testing High Dose DHA in APOE4 Carriers before the Onset of Dementia

INTRODUCTION

Lower blood levels of the omega-3 polyunsaturated fatty acid docosahexaenoic acid (DHA) are correlated with worse cognitive functions, particularly among APOE ε4 carriers. Whether DHA supplementation in APOE ε4 carriers with limited DHA consumption and dementia risk factors can delay or slow down disease progression when started before the onset of clinical dementia is not known.

METHODS

PreventE4 is a double-blind, single site, randomized, placebo-controlled trial in cognitively unimpaired individuals with limited omega-3 consumption and dementia risk factors (n=368). Its objectives are to determine (1) whether carrying the APOE ε4 allele is associated with lower delivery of DHA to the brain; and (2) whether high dose DHA supplementation affects brain imaging biomarkers of AD and cognitive function.

RESULTS

365 cognitively unimpaired individuals between 55 and 80 (mean age 66) were randomized to 2 grams of DHA per day or identically appearing placebo for a period of 2 years. Half the participants were asked to complete lumbar punctures at baseline and 6-month visits to obtain cerebrospinal fluid (CSF). The primary trial outcome measure is the change in CSF DHA to arachidonic acid ratio after 6 months of the intervention (n=181). Secondary trial outcomes include the change in functional and structural connectivity using resting state functional MRI at 24 months (n=365). Exploratory outcomes include the change in Repeatable Battery of the Assessment of Neuropsychological Status at 24 months (n=365).

CONCLUSIONS

Findings from PreventE4 will clarify the brain delivery of DHA in individuals carrying the APOE ε4 allele with implications for dementia prevention strategies. Trial was registered as NCT03613844.

Barriers and Challenges for Career Milestones Among Faculty Mentees

'Critical' career milestones for faculty (e.g., tenure, securing grant funding) relate to career advancement, job satisfaction, service/leadership, scholarship/research, clinical or teaching activities, professionalism, compensation, and work-life balance. However, barriers and challenges to these milestones encountered by junior faculty have been inadequately studied, particularly those affecting underrepresented minorities in science (URM-S). Additionally, little is known about how barriers and challenges to career milestones have changed during the COVID-19 pandemic for URM-S and non-URM faculty mentees in science. In this study, we conducted semi-structured interviews with 31 faculty mentees from four academic institutions (located in New Mexico, Arizona, Idaho, and Hawaii), including 22 URM-S (women or racial/ethnic). Respondents were given examples of 'critical' career milestones and were asked to identify and discuss barriers and challenges that they have encountered or expect to encounter while working toward achieving these milestones. We performed thematic descriptive analysis using NVivo software in an iterative, team-based process. Our preliminary analysis identified five key themes that illustrate barriers and challenges encountered: Job and career development, Discrimination and a lack of workplace diversity; Lack of interpersonal relationships and inadequate social support at the workplace; Personal and family matters; and Unique COVID-19-related issues. COVID-19 barriers and challenges were related to online curriculum creation and administration, interpersonal relationship development, inadequate training/service/conference opportunities, and disruptions in childcare and schooling. Although COVID-19 helped create new barriers and challenges for junior faculty mentees, traditional barriers and challenges for 'critical' career milestones continue to be reported among our respondents. URM-S respondents also identified discrimination and diversity-related barriers and challenges. Subsequent interviews will focus on 12-month and 24-month follow-ups and provide additional insight into the unique challenges and barriers to 'critical' career milestones that URM and non-URM faculty in science have encountered during the unique historical context of the COVID-19 pandemic.

V-018 PREOPERATIVE OPTIMIZATION AND POSTERIOR COMPONENT SEPARATION WITH INTRAOPERATIVE MONITORING OF RECTUS MUSCLE INERVATION FOR LOSS OF DOMAIN INCISIONAL HERNIA

Aim

The importance of an appropriate patient optimization (botulin toxin and pneumoperitoneum) and adequate surgical technique is highlighted.The possibility of intraoperative monitoring of the nerves that may be injured during posterior component separation is explained

Material and methods

We present a 74 years old man, past smoker, with history of hypertension, steatohepatitis and chronic bronchopathy

Results

This is a disastrous but unfortunately not so uncommon story of a failed repair of a simple umbilical hernia with 3 previous unsuccessful attempts of repair with and without mesh. After the last surgery the patient developed a giant incisional hernia with loss of domain. Optimization consisted of improving nutritional status, respiratory physiotherapy, botulin toxin and pneumoperitoneum. The surgery was made using previous skin scar. After dissecting the retrorectus space, a posterior component separation was made with the aid of monitoring the nerves that come to innervate the rectus abdominis. An overextended overlapped was obtained. A patch of absorbable mesh was used to completely close the peritoneum. A combination of absorbable and permanent synthetic mesh was used as giant reinforcement of the visceral sac. The only points of fixation were the Cooper Ligaments. The patient had a satisfactory recovery without complications and was discharged on the 8th postoperative day.

Conclusions

Loss of domain incisional hernias is a real surgical challenge. The combination of a good preoperative strategy (preoperative neumoperitoneum) and surgical technique (TAR and pannniculectomy) gives a great opportunity to solve very complex cases of incisional hernia.

V-007 LESSONS LEARNED DURING THE ABDOMINAL WALL RECONSUTRCTION FOR A MULTIRECURRENT LUMBAR HERNIA AFTER BONE GRAFT HARVESTING

The best approach for lateral incisional hernia is not known. Among these difficult hernias, those arising from iliac crest harvesting can be particularly challenging. The objective of this video is to illustrate the surgical approach of a multirecurrent case with the need of adding a posterior component separation

A 70 years old woman with 2 previous attempts of repair was referred to our center. With the patient in a 45 degrees lateral decubitus, a posterior lumbar approach was initiated through the previous scar. The retromuscular preperitoneal plane was accessed with difficulty due to previous meshes in the subdiaphragmatic, iliac and posterior areas. A big tear on the medial peritoneum changed our plan to add a posterior component separation. As we did not want to enlarge the lumbar incision to denervate more the lateral abdominal wall, we decided to make an accessory midline incision. Probably, an ETEP approach could have been better even before making the posterior incision. Once the retromuscular plane was dissected, the hole in the peritoneum could be closed. The reconstructive phase consisted in making a taco configuration using the combination of a permanent and absorbable mesh.

We have learned from this case, that an eTEP dissection of the retromuscular plane could have helped to avoid the accessory midline incision. It is also important to consider the potential iatrogenic denervation we could add in case of enlargement of the incision.

Severe smallness as predictor of adverse perinatal outcome in suspected late small-for-gestational-age fetuses: systematic review and meta-analysis

OBJECTIVE

To investigate the performance of severe smallness in the prediction of adverse perinatal outcome among fetuses with suspected late-onset small-for-gestational age (SGA).

METHODS

A systematic search was performed to identify relevant studies in PubMed, Web of Science and Scopus. Late-onset SGA was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 10^th percentile diagnosed at or after 32 weeks' gestation, while severe SGA was defined as EFW or AC < 3^rd percentile or < 2 SD. Random-effects modeling was used to generate hierarchical summary receiver-operating-characteristics (HSROC) curves. The performance of severe SGA (as a presumptive diagnosis) in predicting adverse perinatal outcome among singleton pregnancies with suspected late-onset SGA was expressed as area under the HSROC curve (AUC), sensitivity, specificity and positive/negative likelihood ratios. The association between suspected severe SGA and adverse perinatal outcome was also assessed by random-effects modeling using the Mantel-Haenszel method and presented as odds ratio (OR). The non-exposed group was defined as non-severe SGA (EFW ≥ 3^rd centile).

RESULTS

Twelve cohort studies were included in this systematic review and meta-analysis. The studies included a total of 3639 fetuses with suspected late-onset SGA, of which 1246 had suspected severe SGA. Significant associations were found between suspected severe SGA and composite adverse perinatal outcome (OR, 1.97 (95% CI, 1.33-2.92)), neonatal intensive care unit admission (OR, 2.87 (95% CI, 1.84-4.47)) and perinatal death (OR, 4.26 (95% CI, 1.07-16.93)). However, summary ROC curves showed limited performance of suspected severe SGA in predicting perinatal outcomes, with AUCs of 60.9%, 66.9%, 53.6%, 57.2%, 54.6% and 64.9% for composite adverse perinatal outcome, neonatal intensive care unit admission, neonatal acidosis, Cesarean section for intrapartum fetal compromise, low Apgar score and perinatal death, respectively.

CONCLUSION

Although suspected severe SGA was associated with a higher risk of perinatal complications, it performed poorly as a standalone parameter in predicting adverse perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Creating a Digital Psychoeducation Programme for bipolar disorder in the COVID-19 pandemic

Introduction

The Covid-19 pandemic profoundly affected delivery and accessibility of mental health care services at a time when most needed. The OPTIMA Mood Disorder Service, a specialist bipolar disorder service, adapted group psychoeducation programme for delivery on-line.

Objectives

We report the feasibility of creating a digital psychoeducation programme.

Methods

The OPTIMA ten session group psychoeducation programme was converted into a ‘Digital’ intervention using video-conferencing. Sessions offered a range of key topics, derived from the initial Barcelona Group Psychoeducation Programme. At the time of writing, OPTIMA had fully completed two 10 session digital courses.

Results

A total of 12 people (6 in each group) consented to be part of a service evaluation of the digital groups. Just over half of the participants were women (7/12; 58.3%) and one identified as being non-binary (8.3); remaining participants were men. Age of participants ranged from 25 years to 65 years (Mean=42.3; SD=13.1). Data showed a high level of engagement (77%) All participants reported some improvement with a mean Bipolar Self-Efficacy scale (BPSES) post-group score of 105.6 (SD=14.8). At group level, this change was not statistically significant (F (1, 15) = 0.71, p=0.41). At an individual level, two out of five showed a reliable change index >1.96.

Conclusions

Delivering a ‘digital’ group psychoeducation programme was possible due to careful planning and programme development. There was good uptake from service users suggesting it is a feasible approach with preliminary evidence of clinical benefit.

Disclosure

No significant relationships.

Transdiagnostic Role of Glutamate and White Matter Damage in Neuropsychiatric Disorders: A Systematic Review

Introduction

Neuropsychiatric disorders including Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Major Depressive Disorder (MDD), Bipolar Disorder (BD), and Schizophrenia (SZ) have been considered distinct categories of diseases despite their overlapping characteristics and symptomatology.

Objectives

We aimed to provide an in-depth review elucidating the role of glutamate/Glx and white matter (WM) abnormalities from a transdiagnostic perspective.

Methods

The PubMed online database was searched for studies published between 2010 and 2021. After careful screening, 399 studies were included.

Results

The findings point to decreased levels of glutamate in the Anterior Cingulate Cortex in both SZ and BD, whereas Glx is elevated in the Hippocampus in SZ and MDD. With regard to WM abnormalities, the Corpus Callosum and superior Longitudinal Fascicle were the most consistently identified brain regions showing decreased fractional anisotropy (FA) across all the reviewed disorders, except GAD. Additionally, the Uncinate Fasciculus was found to be affected in all the reviewed disorders, except OCD. Decreased FA was also found in the inferior Longitudinal Fasciculus, inferior Fronto-Occipital Fasciculus, Thalamic Radiation, and Corona Radiata in SZ, BD, and MDD. Decreased FA in the Fornix and Corticospinal Tract were found in BD and SZ patients. The Cingulum and Anterior Limb of Internal Capsule exhibited decreased FA in MDD and SZ patients.

Conclusions

The results suggest a gradual increase in severity from GAD to SZ defined by the number of brain regions with WM abnormality which may be partially caused by abnormal glutamate levels. WM damage could thus be considered a potential marker of some of the main neuropsychiatric disorders.

Disclosure

No significant relationships.

In-kitchen aerosol exposure in twelve cities across the globe

Poor ventilation and polluting cooking fuels in low-income homes cause high exposure, yet relevant global studies are limited. We assessed exposure to in-kitchen particulate matter (PM_2.5 and PM₁₀) employing similar instrumentation in 60 low-income homes across 12 cities: Dhaka (Bangladesh); Chennai (India); Nanjing (China); Medellín (Colombia); São Paulo (Brazil); Cairo (Egypt); Sulaymaniyah (Iraq); Addis Ababa (Ethiopia); Akure (Nigeria); Blantyre (Malawi); Dar-es-Salaam (Tanzania) and Nairobi (Kenya). Exposure profiles of kitchen occupants showed that fuel, kitchen volume, cooking type and ventilation were the most prominent factors affecting in-kitchen exposure. Different cuisines resulted in varying cooking durations and disproportional exposures. Occupants in Dhaka, Nanjing, Dar-es-Salaam and Nairobi spent > 40% of their cooking time frying (the highest particle emitting cooking activity) compared with ∼ 68% of time spent boiling/stewing in Cairo, Sulaymaniyah and Akure. The highest average PM_2.5 (PM₁₀) concentrations were in Dhaka 185 ± 48 (220 ± 58) μg m^-3 owing to small kitchen volume, extensive frying and prolonged cooking compared with the lowest in Medellín 10 ± 3 (14 ± 2) μg m^-3. Dual ventilation (mechanical and natural) in Chennai, Cairo and Sulaymaniyah reduced average in-kitchen PM_2.5 and PM₁₀ by 2.3- and 1.8-times compared with natural ventilation (open doors) in Addis Ababa, Dar-es-Salam and Nairobi. Using charcoal during cooking (Addis Ababa, Blantyre and Nairobi) increased PM_2.5 levels by 1.3- and 3.1-times compared with using natural gas (Nanjing, Medellin and Cairo) and LPG (Chennai, Sao Paulo and Sulaymaniyah), respectively. Smaller-volume kitchens (<15 m³; Dhaka and Nanjing) increased cooking exposure compared with their larger-volume counterparts (Medellin, Cairo and Sulaymaniyah). Potential exposure doses were highest for Asian, followed by African, Middle-eastern and South American homes. We recommend increased cooking exhaust extraction, cleaner fuels, awareness on improved cooking practices and minimising passive occupancy in kitchens to mitigate harmful cooking emissions.

Real-World Association of Insurance Status with Cardio-metabolic Risk for Hispanic/Latino Adults Living on the Central Coast of California

The primary aim of this study was to evaluate cardio-metabolic burden by insurance status for Hispanic/Latino adults in Santa Barbara, CA. HbA1c, body mass index (BMI), and health insurance status were evaluated via community-based screenings. Cardiovascular (CV) risk was assessed using the Framingham Heart Study calculator and compared with a National Health and Nutrition Examination Survey background population. Of 593 participants (73% female, age 47.3 years (SD ± 15.2), 44.5% had no insurance or did not know if they had insurance. 16% had an HbA1c in the diabetes range, comprised of 9% self-reporting diabetes and 7% self-reporting no diabetes. 39% had an HbA1c in the prediabetes range. Elevated HbA1c was associated with significantly higher BMI (p = 0.003) and lack of health insurance (p = 0.031). 10-year CV risk was significantly higher than the general population (p < 0.001). This program identified a high burden of cardio-metabolic disease and uninsurance coverage in Hispanic/Latino adults in Santa Barbara.

Stakeholder Engagement in OT Research: Raising the Standard for Dementia Care

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

This presentation will characterize our experiences integrating stakeholder engagement into a multisite pragmatic clinical trial focused on optimizing care for nursing home residents with dementia. We will discuss our methods for building OT capacity to conduct research that includes the voices of stakeholders.

Primary Author and Speaker: Jenny Martinez

Additional Authors and Speakers: Catherine Piersol

Contributing Authors: Lauren Terhorst, Sherrie Holloway, Felicia Chew, and Natalie Elizabeth Leland

The cyto-protective effects of LH on ovarian reserve and female fertility during exposure to gonadotoxic alkylating agents in an adult mouse model

STUDY QUESTION

Does LH protect mouse oocytes and female fertility from alkylating chemotherapy?

SUMMARY ANSWER

LH treatment before and during chemotherapy prevents detrimental effects on follicles and reproductive lifespan.

WHAT IS KNOWN ALREADY

Chemotherapies can damage the ovary, resulting in premature ovarian failure and reduced fertility in cancer survivors. LH was recently suggested to protect prepubertal mouse follicles from chemotoxic effects of cisplatin treatment.

STUDY DESIGN, SIZE, DURATION

This experimental study investigated LH effects on primordial follicles exposed to chemotherapy. Seven-week-old CD-1 female mice were randomly allocated to four experimental groups: Control (n = 13), chemotherapy (ChT, n = 15), ChT+LH-1x (n = 15), and ChT+LH-5x (n = 8). To induce primary ovarian insufficiency (POI), animals in the ChT and ChT+LH groups were intraperitoneally injected with 120 mg/kg of cyclophosphamide and 12 mg/kg of busulfan, while control mice received vehicle. For LH treatment, the ChT+LH-1x and ChT+LH-5x animals received a 1 or 5 IU LH dose, respectively, before chemotherapy, then a second LH injection administered with chemotherapy 24 h later. Then, two animals/group were euthanized at 12 and 24 h to investigate the early ovarian response to LH, while remaining mice were housed for 30 days to evaluate short- and long-term reproductive outcomes. The effects of LH and chemotherapy on growing-stage follicles were analyzed in a parallel experiment. Seven-week-old NOD-SCID female mice were allocated to control (n = 5), ChT (n = 5), and ChT+LH-1x (n = 6) groups. Animals were treated as described above, but maintained for 7 days before reproductive assessment.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In the first experiment, follicular damage (phosphorylated H2AX histone (γH2AX) staining and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay), apoptotic biomarkers (western blot), and DNA repair pathways (western blot and RT-qPCR) were assessed in ovaries collected at 12 and 24 h to determine early ovarian responses to LH. Thirty days after treatments, remaining mice were stimulated (10 IU of pregnant mare serum gonadotropin (PMSG) and 10 IU of hCG) and mated to collect ovaries, oocytes, and embryos. Histological analysis was performed on ovarian samples to investigate follicular populations and stromal status, and meiotic spindle and chromosome alignment was measured in oocytes by confocal microscopy. Long-term effects were monitored by assessing pregnancy rate and litter size during six consecutive breeding attempts. In the second experiment, mice were stimulated and mated 7 days after treatments and ovaries, oocytes, and embryos were collected. Follicular numbers, follicular protection (DNA damage and apoptosis by H2AX staining and TUNEL assay, respectively), and ovarian stroma were assessed. Oocyte quality was determined by confocal analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

LH treatment was sufficient to preserve ovarian reserve and follicular development, avoid atresia, and restore ovulation and meiotic spindle configuration in mature oocytes exposed at the primordial stage. LH improved the cumulative pregnancy rate and litter size in six consecutive breeding rounds, confirming the potential of LH treatment to preserve fertility. This protective effect appeared to be mediated by an enhanced early DNA repair response, via homologous recombination, and generation of anti-apoptotic signals in the ovary a few hours after injury with chemotherapy. This response ameliorated the chemotherapy-induced increase in DNA-damaged oocytes and apoptotic granulosa cells. LH treatment also protected growing follicles from chemotherapy. LH reversed the chemotherapy-induced depletion of primordial and primary follicular subpopulations, reduced oocyte DNA damage and granulosa cell apoptosis, restored mature oocyte cohort size, and improved meiotic spindle properties.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

This was a preliminary study performed with mouse ovarian samples. Therefore, preclinical research with human samples is required for validation.

WIDER IMPLICATIONS OF THE FINDINGS

The current study tested if LH could protect the adult mouse ovarian reserve and reproductive lifespan from alkylating chemotherapy. These findings highlight the therapeutic potential of LH as a complementary non-surgical strategy for preserving fertility in female cancer patients.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by grants from the Regional Valencian Ministry of Education (PROMETEO/2018/137), the Spanish Ministry of Science and Innovation (CP19/00141), and the Spanish Ministry of Education, Culture and Sports (FPU16/05264). The authors declare no conflict of interest.

Routine third-trimester ultrasound for the detection of small-for-gestational age in low-risk pregnancies (ROTTUS study): randomized controlled trial

OBJECTIVE

To compare the proportion of small-for-gestational-age (SGA) infants detected by routine third-trimester ultrasound vs those detected by selective ultrasound based on serial symphysis-fundus height (SFH) measurements (standard care) in low-risk pregnancy.

METHODS

This was an open-label randomized controlled trial conducted at a hospital in Kenya between May 2018 and February 2020. Low-risk pregnant women were randomly allocated (ratio of 1:1) to routine ultrasound for fetal growth assessment between 36 + 0 and 37 + 6 weeks' gestation (intervention group) or to standard care, which involved a selective growth scan on clinical suspicion of fetal growth abnormality based on serial SFH measurements (control group). During ultrasound examination, fetal growth was assessed by measurement of the abdominal circumference (AC), and AC < 10^th centile was used to diagnose a SGA fetus. The main prespecified outcomes were the detection of neonatal SGA, defined as birth weight < 10^th centile, and of severe neonatal SGA, defined as birth weight < 3^rd centile. The predictive performance of routine third-trimester ultrasound and selective ultrasound based on serial SFH measurements was determined using receiver-operating-characteristics (ROC)-curve analysis.

RESULTS

Of 566 women assessed for eligibility, 508 (89.8%) were randomized, of whom 253 were allocated to the intervention group and 255 to the control group. Thirty-six babies in the intervention group and 26 in the control group had a birth weight < 10^th centile. The detection rate of SGA infants by routine third-trimester ultrasound vs that by standard care was 52.8% (19/36) vs 7.7% (2/26) (P < 0.001) and the specificity was 95.5% (191/200) and 97.9% (191/195), respectively (P = 0.08). The detection rate of severe SGA was 66.7% (12/18) by routine ultrasound vs 8.3% (1/12) by selective ultrasound based on SFH measurements (P < 0.001), with specificities of 91.7% (200/218) and 98.1% (205/209), respectively (P = 0.006). The area under the ROC curve of routine third-trimester ultrasound in prediction of SGA was significantly greater than that of selective ultrasound based on SFH measurements (0.92 (95% CI, 0.87-0.96) vs 0.68 (95% CI, 0.58-0.77); P < 0.001).

CONCLUSIONS

In low-risk pregnancy, routine ultrasound performed between 36 + 0 and 37 + 6 weeks is superior to selective ultrasound based on serial SFH measurements for the detection of true SGA, with high specificity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

In-car particulate matter exposure across ten global cities

Cars are a commuting lifeline worldwide, despite contributing significantly to air pollution. This is the first global assessment on air pollution exposure in cars across ten cities: Dhaka (Bangladesh); Chennai (India); Guangzhou (China); Medellín (Colombia); São Paulo (Brazil); Cairo (Egypt); Sulaymaniyah (Iraq); Addis Ababa (Ethiopia); Blantyre (Malawi); and Dar-es-Salaam (Tanzania). Portable laser particle counters were used to develop a proxy of car-user exposure profiles and analyse the factors affecting particulate matter ≤2.5 μm (PM_2.5; fine fraction) and ≤10 μm (PM_2.5-10; coarse fraction). Measurements were carried out during morning, off- and evening-peak hours under windows-open and windows-closed (fan-on and recirculation) conditions on predefined routes. For all cities, PM_2.5 and PM₁₀ concentrations were highest during windows-open, followed by fan-on and recirculation. Compared with recirculation, PM_2.5 and PM₁₀ were higher by up to 589% (Blantyre) and 1020% (São Paulo), during windows-open and higher by up to 385% (São Paulo) and 390% (São Paulo) during fan-on, respectively. Coarse particles dominated the PM fraction during windows-open while fine particles dominated during fan-on and recirculation, indicating filter effectiveness in removing coarse particles and a need for filters that limit the ingress of fine particles. Spatial variation analysis during windows-open showed that pollution hotspots make up to a third of the total route-length. PM_2.5 exposure for windows-open during off-peak hours was 91% and 40% less than morning and evening peak hours, respectively. Across cities, determinants of relatively high personal exposure doses included lower car speeds, temporally longer journeys, and higher in-car concentrations. It was also concluded that car-users in the least affluent cities experienced disproportionately higher in-car PM_2.5 exposures. Cities were classified into three groups according to low, intermediate and high levels of PM exposure to car commuters, allowing to draw similarities and highlight best practices.

Ten-year experience of protocol-based management of small-for-gestational-age fetuses: perinatal outcome in late-pregnancy cases diagnosed after 32 weeks

OBJECTIVE

To report our 10-year experience of protocol-based management of small-for-gestational-age (SGA) fetuses, based on standardized clinical and Doppler criteria, in late-pregnancy cases.

METHODS

A retrospective cohort was constructed of consecutive singleton pregnancies referred for late-onset (> 32 weeks) SGA (defined as estimated fetal weight (EFW) < 10^th centile) that were classified as fetal growth restriction (FGR) or low-risk SGA, based on the severity of smallness (EFW < 3^rd centile) and the presence of Doppler abnormalities (uterine artery pulsatility index (UtA-PI) ≥ 95^th centile or cerebroplacental ratio (CPR) < 5^th centile). Low-risk SGA pregnancies were followed at 2-week intervals and delivered electively at 40 weeks. FGR pregnancies were followed at 1-week intervals, or more frequently if there were signs of fetal deterioration, and were delivered electively after 37 + 0 weeks' gestation. The occurrence of stillbirth and composite adverse outcome (CAO; defined as neonatal death, metabolic acidosis, need for endotracheal intubation or need for admission to the neonatal intensive care unit) was analyzed in low-risk SGA and FGR pregnancies.

RESULTS

A total of 1197 pregnancies with EFW < 10^th centile were identified and classified at diagnosis as low-risk SGA (n = 619; 51.7%) or FGR (n = 578; 48.3%). Of these, 160 were delivered before 37 weeks' gestation; for obstetric reasons in 93 (58.1%) cases, severe pre-eclampsia in 33 (20.6%), FGR with severe hypoxia in 47 (29.4%) and stillbirth in four (2.5%) (indications are non-exclusive). During follow-up, 52/574 (9.1%) low-risk SGA pregnancies were reclassified as FGR, whereas 22/463 (4.8%) FGR pregnancies were reclassified as low-risk SGA. Overall, there were no stillbirths in the low-risk SGA group and four in the FGR group, all of which occurred before 37 weeks. There were no instances of neonatal death in pregnancies delivered ≥ 37 weeks. The risk of CAO was higher in those meeting antenatal criteria for FGR at 37 weeks than in those classified as low-risk SGA (32/493 (6.5%) vs 15/544 (2.8%); odds ratio, 2.5 (95% CI, 1.3-4.6)). In FGR pregnancies, the adjusted odds ratio (95% CI) for CAO was 6.3 (1.8-21.1) in those with EFW < 3^rd centile, while it was 3.2 (1.5-6.8) and 4.2 (1.9-8.9) in those with UtA-PI ≥ 95^th centile and CPR < 5^th centile, respectively, as compared to FGR pregnancies without each of these criteria.

CONCLUSION

Protocol-based risk stratification with different management and monitoring schemes for late pregnancy with a suspected SGA baby, based on clinical and Doppler criteria, enables identification and tailored assessment of high-risk FGR, while allowing expectant management with safe perinatal outcome for low-risk SGA fetuses. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Stakeholder Engagement in OT Research: Raising the Standard for Dementia Care

Date Presented 03/28/20

This presentation will characterize our experiences integrating stakeholder engagement into a multisite pragmatic clinical trial focused on optimizing care for nursing-home residents with dementia. We will discuss our methods for building OT capacity to conduct research that includes the voices of stakeholders.

Primary Author and Speaker: Jenny Martinez

Contributing Authors: Catherine Piersol, Lauren Terhorst, Sherrie Holloway, Carin Wong, Felicia Chew, Natalie Leland

Molecular detection of Rickettsia species in ticks collected in the Mexico-USA transboundary region

Zoonotic tick-borne diseases, including those caused by Rickettsia species, continue to have serious consequences for public health worldwide. One such disease that has emerged as a major problem in several countries of the American continent is the Rocky Mountain Spotted Fever (RMSF) caused by the bacterium Rickettsia rickettsii. Several tick species are capable of transmitting R. rickettsia, including Amblyomma cajennense, A. aureolatum, A. imitator, Rhipicephalus sanguineus, Dermacentor andersoni, D. variabilis and possibly A. americanum. Despite previous reports in Mexico linking new outbreaks of RMSF to the presence of these tick species, no robust measures have tackled transmission. In the present study, we amplified R. rickettsii from 109 test DNA samples extracted from ticks collected from several animals and humans of Tamaulipas, Mexico, between November 2015 and December 2017. Our analysis revealed the presence of R. rickettsii in six samples and these findings contribute to a spatial distribution map that is intended to minimize the risk of transmission to humans.

Ocorrência de ectoparasitas no roedor Oligoryzomys microtis em regiões ao norte do Departamento de La Paz, Bolívia

RESUMO O objetivo deste trabalho foi mapear e descrever a ocorrência de roedores e seus ectoparasitas nas regiões norte do departamento de La Paz, Bolívia. De abril a maio e julho a agosto de 2017, 80 indivíduos da espécie Oligoryzomys microtis foram capturados em armadilhas vivas. Uma amostra aleatória de 36 indivíduos foi analisada quanto à presença de ectoparasitas, encontrando um total de 458 ectoparasitas. Os roedores foram capturados em dois tipos de ambientes: floresta secundária e áreas cultivadas, sendo a área cultivada a área com maior captação de roedores. Dos ectoparasitas, Laelaps sp. foi o gênero com maior abundância e Mysolaelaps sp. o mais prevalente; o gênero Polygenis sp. é aparentemente descrito pela primeira vez na selva amazônica, exigindo estudos adicionais para entender melhor os patógenos que são transmitidos no parasitismo desta pulga em roedores devido à sua importância no ecossistema e para a saúde pública.

Stakeholder engagement in research: a scoping review of current evaluation methods

Aim: Evaluating stakeholder engagement can capture what meaningful engagement in research entails, how it develops, and how it is experienced by all collaborators. We conducted a scoping review of recent approaches for evaluating engagement in research and present a descriptive overview of our findings. Methods: We searched peer-reviewed journal articles published worldwide in English between January 2013 and June 2018. Results: Our final sample consisted of 17 articles. Various approaches for evaluating stakeholder engagement were identified including qualitative approaches, surveys and engagement logs. Discussion & conclusion: We identified evaluation approaches that varied in quality, detail and methods. Valid, systematic and inclusive approaches that are developed with research partners and are inclusive of diverse perspectives are an important area for future research.

Measuring Stakeholder Engagement in Research: A Review of the Evidence

Date Presented 04/04/19

This presentation will highlight the findings of a scoping review examining measurement and evaluation of stakeholder engagement in clinical research. We will also discuss strategies for using our findings to enhance future investigations as an additional strategy for enhancing OT’s distinct value and building capacity for rehabilitation-specific stakeholder engagement.

Primary Author and Speaker: Jenny Martinez

Contributing Authors: Carin Wong, Karin Saric, Dawn Clayton Bieber, Bonita Perry, Natalie Leland

Activism as Occupation: Promoting Health in Marginalized Communities

Date Presented 04/05/19

This presentation will highlight the current national context for activism in marginalized communities and summarize the findings of a scoping review examining its impact on the health and well-being of people who engage in activism. Finally, this session will provide strategies for OTs to apply these findings in their daily practice.

Primary Author and Speaker: Jenny Martinez

Additional Authors and Speakers: Loralei Bingamon

Caracterización productiva y organoléptica de huevos de gallinas de campo de la región sierra del Ecuador

En la Estación Experimental Tunshi de la Escuela Superior Politécnica de Chimborazo, parroquia Licto, a 2712 msnm a una temperatura promedio de 14,92°c. Se evaluó el comportamiento productivo para huevos de gallinas de campo y se analizó las características organolépticas, en 94 aves de traspatios identificadas en la región sierra del Ecuador de las provincias: Pichincha, Bolívar, Loja, Cañar, Tungurahua, y Chimborazo, una vez adaptadas in situ, la investigación tuvo una duración de 120 días. Los datos recogidos fueron tabulados en el programa estadístico SPSS versión Statistic 19, se obtuvo estadísticos descriptivos. Los resultados para peso inicial promedio fue de 1508,78 g; peso final 1502,36 ± 247,61 g; ganancia de peso 175,26 ± 137,20 g; Los parámetros de calidad del huevo fueron: peso promedio 54,95 ± 5,24 g; masa del huevo de 48,15 ± 4,68 g; ancho del huevo de 42,25 mm; longitud del huevo de 55,40 ± 2,60 mm; peso de la cáscara de 6,80 g; grosor de la cáscara de 0,32 ± 0,02mm. Para la medición organoléptica se realizó un análisis sensorial triangular, utilizando 6 combinaciones con 3 repeticiones, total 18 catadores, estos resultados fueron sometidos a Chi-cuadrado obteniendo diferencias significativas en sabor del huevo de campo con relación al comercial. Cabe indicar que la característica de rusticidad en las gallinas, representa un factor importante para la conservación de recursos genéticos, ya que han demostrado poseer una capacidad de adaptación al medio ambiente, que aseguran buenos rendimientos productivos y que resultan interesantes para la seguridad y soberanía alimentaria.

SAT-LB023 Elevated Fasting Plasma Glucose Predicts Higher Odds For Becoming A Super-responder With Gelesis100 In The GLOW Pivotal Weight-loss Study

Background: In a previous pilot weight-loss study, an association was observed between baseline fasting plasma glucose (FPG) levels and the effectiveness of the Gelesis100 treatment. The aim of this subanalysis of the Gelesis Loss Of Weight (GLOW; NCT02307279) study is to further assess the association between FPG and body weight (BW) responders in subjects with overweight or obesity treated with Gelesis100, a non-systemic hydrogel. Methods: This subanalysis was conducted in subjects who were overweight or had obesity and who completed the GLOW study. GLOW was a multicenter, double-blind, placebo-controlled pivotal study with subjects randomized to 2.25 g of Gelesis100 or placebo in capsules taken with 500 mL of water before lunch and dinner while on a hypocaloric diet (-300 kcal/day) for 24 weeks. BW responders at 5% and 10% (super-responders) were analyzed using Logit model comparing Gelesis100 to placebo arms in 2 subgroups of subjects defined by their initial FPG (two consecutive consistent values). Subgroup 1 had normoglycemia (FPG < 100 mg/dL) and subgroup 2 had prediabetes (PD) (FPG ≥ 100 mg/dL and < 126 mg/dL) or untreated type 2 diabetes (T2D) (FPG ≥ 126 mg/dL). Results: The population included 206 subjects (94 males, 112 females, 138 in subgroup 1, 68 in subgroup 2, 105 on Gelesis100, 101 on placebo). In subgroup 1 (mean baseline FPG = 91 mg/dL), BW responders at 5% and 10% in Gelesis100 arm were 60% (placebo arm = 34%, adjusted odds ratio (OR) = 3.1, P = 0.0022) and 22% (placebo arm = 15%, OR = 1.5, P = 0.4254), respectively. In subgroup 2 (mean baseline FPG = 113 mg/dL), BW responders at 5% and 10% in Gelesis100 arm were 72% (placebo arm = 56%, OR = 2.2, P = 0.1509) and 44% (placebo arm = 14%, OR = 6.1, P = 0.0071), respectively. In the overall population, baseline FPG was inversely correlated with BW percent change in the Gelesis100 arm (r = -0.24, P = 0.0144). The safety and tolerability of Gelesis100 demonstrated no increased risk compared to placebo. No serious adverse events were observed in any arm. Conclusion: Gelesis100 offers a compelling new approach in the management of overweight and obesity. Notably, in Gelesis100-treated subjects with PD or untreated T2D, the odds of being super-responders are 6 times higher compared to placebo. This finding may be used as a tool for identifying subjects who are both at higher clinical risk and more likely to achieve greater levels of BW loss when treated with Gelesis100. The mechanisms underlying this finding require further investigations. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

MON-112 Gelesis100 Reduces Insulin Resistance in Patients Who Are Overweight or Have Obesity with High Insulin Resistance: Results of the GLOW Study

Background: Overweight and obesity are predisposing conditions for the development of prediabetes and type 2 diabetes. Insulin resistance caused by excess adiposity is a key factor in this process. Methods: The effect of Gelesis100, a novel hydrogel, was assessed in patients who were overweight or had obesity, without antidiabetic medications, and who completed the Gelesis Loss Of Weight (GLOW; NCT02307279) study. GLOW was a multicenter, double-blind, placebo-controlled pivotal study with patients randomized to 2.25 g of Gelesis100 or placebo in capsules taken with 500 mL of water before lunch and dinner while on a hypocaloric diet (-300 kcal/day) for 24 weeks. Insulin resistance was measured by homeostasis model assessment-insulin resistance (HOMA-IR). Data were analyzed using analysis of covariance and Logit models comparing Gelesis100 to placebo arms in 2 subgroups of patients based on baseline HOMA-IR (subgroup 1, HOMA-IR ≥ 3.0, subgroup 2, HOMA-IR < 3.0). Results: The overall population included 290 patients (132 males, 158 females, 91 in subgroup 1, 199 in subgroup 2, 155 on Gelesis100, 135 on placebo), who were normoglycemic, had prediabetes, or had untreated type 2 diabetes. Statistically significant difference in reduction of HOMA-IR was observed in subgroup 1 (mean baseline HOMA-IR = 5.0) but not in subgroup 2 (mean baseline HOMA-IR = 1.8). Indeed, placebo-subtracted HOMA-IR changes (mean, SE) were -22.3 ± 9.5% (P = 0.0212) and -9.0 ± 9.5% (P = 0.3432) in subgroup 1 and subgroup 2, respectively. Furthermore, in subgroup 1, patients who lost < 5% body weight (n = 44, mean body weight loss = 1.3%) had a statistically significant placebo-subtracted HOMA-IR change of -27.6 ± 13.2% (P = 0.0435), while patients who lost ≥ 5% body weight (n = 47, mean body weight loss = 9.7%) had no statistically significant placebo-subtracted HOMA-IR change (-15.6 ± 13.6%, P = 0.2584). The effect on HOMA-IR decrease was driven by significant reduction in fasting serum insulin. Safety and tolerability of Gelesis100 demonstrated no increased risk compared to placebo. Conclusion: Treatment with Gelesis100 results in a significantly higher reduction in insulin resistance compared to placebo as assessed by HOMA-IR in patients who are overweight or have obesity with elevated baseline HOMA-IR. The results also suggest a potential weight-independent effect of Gelesis100 in the reduction of insulin resistance. If these findings are confirmed in future studies with larger subgroups, Gelesis100 could become a potential new treatment for insulin-resistant clinical conditions associated with overweight and obesity.

Advancing Occupational Therapy Care Through Stakeholder and Patient-Engaged Quality Improvement Initiatives

Date Presented 4/22/2018

We describe the development and implementation of a stakeholder engagement framework within a federally funded study evaluating postacute care. Strategies for using this framework to enhance clinical quality improvement initiatives and future research efforts are discussed.

Primary Author and Speaker: Jenny Martinez

Additional Authors and Speakers: Natalie Leland

Contributing Authors: Jeremy Furniss, Addie Middleton, Kendra Hanley, Eunjoo Pacifici, Theresa Murphy, Holly Holyk, David Karchem

Understanding Communication Between Rehabilitation Practitioners and Nurses: Implications for Post-Acute Care Quality

Objective: This study examined post-acute care (PAC) rehabilitation practitioner's perspectives on communication. Method: This is a secondary data analysis of a larger qualitative study, which included PAC rehabilitation provider (n = 99) focus groups that were held in a purposive sample of 13 skilled nursing facilities (SNFs). Results: Participants emphasized the importance of bidirectional communication between rehabilitation and nursing. Three themes were identified: (a) communication between rehabilitation practitioners and registered nurses or licensed practical nurses, (b) communication between rehabilitation practitioners and certified nursing assistants, and (c) communication between rehabilitation practitioners and nursing leaders. Two subthemes within each of the three themes were further characterized to understand how information was exchanged: (a) static communication and (b) action-oriented communication. Conclusion: Our findings highlight opportunities for better communication in PAC between rehabilitation practitioners and nursing and thus lay a foundation for future efforts to improve care coordination through enhancing interdisciplinary communication.

Effect of electrode material on the sensitivity of interdigitated electrodes used for Electrical Cell-Substrate Impedance Sensing technology

This study explores the effect of the electrode material on the sensitivity of interdigitated electrodes (IDEs) used in Electrical Cell-Substrate Impedance Sensing (ECIS) technology. This technique is a label-free method to evaluate cellular activity of adherent cells. IDEs of gold (Au), indium tin oxide (ITO) and ITO functionalized with iridium oxide (IrO_x) were characterized with impedance spectroscopy and their interfacial impedances were evaluated in potassium chloride (KCl) solutions. In parallel, ECIS measurements were performed on these three electrode materials during the proliferation of the human breast cancer cell line, MCF-7. The results indicate that the difference in sensitivity to MCF-7 of the three materials might be strongly correlated to their interfacial impedances. We found that ITO electrodes coated with IrO_x show slightly higher sensitivity to MCF-7 breast cancer cells while still offering transparency compared to gold, which is considered the conventional material in ECIS devices.

Diagnostic exome sequencing in children: A survey of parental understanding, experience and psychological impact

Clinical exome sequencing (CES) is increasingly being used as an effective diagnostic tool in the field of pediatric genetics. We sought to evaluate the parental experience, understanding and psychological impact of CES by conducting a survey study of English-speaking parents of children who had diagnostic CES. Parents of 192 unique patients participated. The parent's interpretation of the child's result agreed with the clinician's interpretation in 79% of cases, with more frequent discordance when the clinician's interpretation was uncertain. The majority (79%) reported no regret with the decision to have CES. Most (65%) reported complete satisfaction with the genetic counseling experience, and satisfaction was positively associated with years of genetic counselor (GC) experience. The psychological impact of CES was greatest for parents of children with positive results and for parents with anxiety or depression. The results of this study are important for helping clinicians to prepare families for the possible results and variable psychological impact of CES. The frequency of parental misinterpretation of test results indicates the need for additional clarity in the communication of results. Finally, while the majority of patients were satisfied with their genetic counseling, satisfaction was lower for new GCs, suggesting a need for targeted GC training for genomic testing.

FT-IR and NMR structural markers for thiazole-based γ-peptide foldamers

Nuclear magnetic resonance (NMR) spectroscopy has been established as a potent method for the determination of foldamer structures in solution. However, the NMR techniques could be limited by averaging, so additional experimental techniques are often needed to fully endorse the folding properties of a sequence. We have recently demonstrated that oligo-γ-peptides composed of 4-amino(methyl)-1,3-thiazole-5-carboxylic acids (ATCs) adopt an original helical fold stabilized by hydrogen bonds forming C₉ pseudocycles. The main objective of the present work is to reinvestigate the folding of ATC oligomer 1 in order to identify reliable FT-IR and NMR structural markers that are of value for tracking the degree of organization of ATC-based peptides.