US Military Healthcare Professionals' Practice, Knowledge, and Misconceptions About Concussion

OBJECTIVE

To determine the US military healthcare professionals' knowledge and training preferences to improve diagnosis and management of concussion sustained in nondeployed settings.

PARTICIPANTS

US military healthcare professionals (physicians, physician assistants, and nurse practitioners) completed online surveys to investigate practices, knowledge, and attitudes about concussion diagnosis and treatment, as well as preferences on future training. There were 744 responses from active duty US military healthcare providers, all of whom had cared for at least one patient with mild traumatic brain injury (mTBI) in the previous 24 months.

RESULTS

The majority of physicians reported they were confident in their ability to evaluate a patient for a new mTBI (82.1%) and order appropriate imaging for mTBI (78.3%). Accuracy of identifying "red flag" symptoms ranged between 28.2% and 92.6%. A Likert scale from 1 ("not at all confident") to 4 ("very confident") was used to assess providers' confidence in their ability to perform services for patients with mTBI. With respect to barriers to optimal patient care, nurse practitioners consistently reported highest levels of barriers (90.8%).

CONCLUSIONS

Although US military providers regularly care for patients with concussion, many report experiencing barriers to providing care, low confidence in basic skills, and inadequate training to diagnose and manage these patients. Customized provider education based on branch of service and occupation, and broader dissemination and utilization of decision support tools or practice guidelines, and patient information tool kits could help improve concussion care.

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.

Uncommon Manifestation of Oligometastatic Prostate Cancer: Sister Mary Joseph Nodule

ABSTRACT

A 76-year-old man with a history of prostate cancer diagnosed in 2008 developed biochemical recurrence in 2010 and started intermittent androgen deprivation therapy. In 2021, due to rising prostate-specific antigen, an 18 F-piflufolastat PSMA PET/CT was performed. It showed a radiotracer-avid sclerotic lesion in the right iliac bone and an indeterminate radiotracer-avid nodule in the umbilical region, demonstrating progressive enlargement and increased uptake on subsequent imaging. Pathologic analysis of the umbilical nodule revealed metastatic prostate cancer-a finding eponymically referred to as a Sister Mary Joseph nodule.

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.

2045. IVAC Plus in the Time of COVID-19: An Imperfect Metric?

Background

Prior to the COVID-19 pandemic, the incidence of infection related ventilator associated complications plus possible ventilator associated pneumonias (IVAC+) was decreasing; however, as the number of COVID-19 hospitalizations increased, so did the number of IVAC+. Our goal was to investigate if there was a relationship between these two occurrences.

Methods

This was a retrospective study at the Audie Murphy VA Hospital (ALMVA) from October 2017 to December 2021. ALMVA is a level 1A facility with 232 beds and an active bone marrow transplant program in San Antonio, Texas. This study included acute care COVID-19 hospitalizations per 10,000 bed days of care and IVAC+ per 1000 ventilator days. Monthly acute and intensive care COVID-19 hospitalization rates were correlated with IVAC+ rates using Pearson correlation for the overall study period and in the subgroup of COVID pandemic months (Mar 2020-December 2021).

Results

During the overall study period, COVID-19 hospitalization rates were significantly associated with IVAC+ rates: acute care correlation 0.86 (p&lt; 0.01) and intensive care correlation 0.33 (p=0.04). During the COVID-19 pandemic months, acute care COVID-19 hospitalizations but not intensive care COVID-19 hospitalizations, were correlated with IVAC+ (correlation 0.90, p&lt; 0.01 and correlation 0.21, p=0.53, respectively). There were 0 IVAC+ before the pandemic months and this rose to 14 during (0 per 1000 ventilator days and 3.05 per 1000 ventilator days, respectively). All but 2 cases of IVAC+ had COVID-19.

COVID-19 Hospitalizations and IVAC Plus, October 2017 to December 2021

A sharp increase in COVID-19 hospitalizations correlated with a rise in patients meeting criteria for IVAC Plus.

Conclusion

The natural history of COVID-19 disease has presented challenges for IVAC+ monitoring. COVID-19 can cause persistent fevers and worsening oxygenation, and antibiotic use is common during periods of clinical deterioration. These factors can fulfill criteria for IVAC+. In this study, each IVAC+ case was traced for safety bundle compliance. These bundles were followed, along with conservative fluid management, low tidal volume ventilation, and sedation breaks. Patients met NHSN criteria for IVAC+ despite these measures and most had COVID-19. Given the common occurrence of IVAC+ in COVID-19 patients, futures studies are needed to define if IVAC+ are preventable in this population and whether IVAC+ surveillance has any value among COVID-19 patients.

Disclosures

All Authors: No reported disclosures.

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.

Fear conditioning as a pathogenic mechanism in the postural tachycardia syndrome

Despite its increasing recognition and extensive research, there is no unifying hypothesis on the pathophysiology of the postural tachycardia syndrome. In this cross-sectional study, we examined the role of fear conditioning and its association with tachycardia and cerebral hypoperfusion upon standing in 28 patients with postural tachycardia syndrome (31 ± 12 years old, 25 women) and 21 matched controls. We found that patients had higher somatic vigilance (p = 0.0167) and more anxiety (p < 0.0001). They also had a more pronounced anticipatory tachycardia right before assuming the upright position in a tilt-table test (p = 0.015), a physiologic indicator of fear conditioning to orthostasis. While standing, patients had faster heart rate (p < 0.001), higher plasma catecholamine levels (p = 0.020), lower end-tidal CO2 (p = 0.005), and reduced middle cerebral artery blood flow velocity (p = 0.002). Multi-linear logistic regression modeling showed that both epinephrine secretion and excessive somatic vigilance predicted the magnitude of the tachycardia and the hyperventilation. These findings suggest that the postural tachycardia syndrome is a functional psychogenic disorder in which standing may acquire a frightful quality, so that even when experienced alone, it elicits a fearful conditioned response. Heightened somatic anxiety is associated with and may predispose to a fear-conditioned hyperadrenergic state when standing. Our results have therapeutic implications.

Repurposed major urinary protein pheromones and adult sensory neurons: roles in neuron plasticity and experimental diabetes

Major urinary proteins (MUPs), members of the broader lipocalin protein family, are classified as pheromones that are excreted in male rodent urine to define conspecific territoriality. In screening for differentially regulated mRNA transcripts in a mouse model of type 1 experimental diabetes mellitus (DM), we identified an unexpected upregulation of several closely related MUP transcripts within diabetic sensory dorsal root ganglia (DRG). Both sexes expressed overall MUP protein content as identified by an antibody widely targeting these upregulated family members, and immunohistochemistry identified expression within neurons, satellite glial cells, and Schwann cells. In dissociated adult sensory neurons, knockdown by an siRNA targeting upregulated MUP mRNAs, enhanced neurite outgrowth, indicating a growth-suppressive role, an impact that was synergistic with subnanomolar insulin neuronal signaling. While MUP knockdown did not generate rises in insulin signaling transcripts, the protein did bind to several mitochondrial and glial targets in DRG lysates. Analysis of a protein closely related to MUPs but that is expressed in humans, lipocalin-2, also suppressed growth, but its impact was unrelated to insulin. In a model of chronic type 1 DM, MUP siRNA knockdown improved electrophysiological and behavioral abnormalities of experimental neuropathy. MUPs have actions beyond pheromone signaling in rodents that involve suppression of growth plasticity of sensory neurons. Its hitherto unanticipated actions overlap with those of lipocalin-2 and may identify a common and widely mediated impact on neuron growth properties by members of the lipocalin family. Knockdown of MUP supports the trophic actions of insulin as a strategy that may improve features of type 1 experimental diabetic neuropathy.NEW & NOTEWORTHY New molecular mechanisms are important to unravel and understand diabetic polyneuropathy, a disorder prevalent in over half of persons with diabetes mellitus (DM). MUPs, members of the lipocalin family of molecules, have an unexpected impact on the plasticity of sensory neurons that are targeted in type 1 experimental diabetic neuropathy. This work explores this potential target in neuropathy in the context of the lipocalin family of molecules.

Newly updated activity results of alrizomadlin (APG-115), a novel MDM2/p53 inhibitor, plus pembrolizumab: Phase 2 study in adults and children with various solid tumors

9517

Background: Alrizomadlin restores TP53 function, activating p53-mediated apoptosis in tumor cells with wild-type TP53 and/or MDM2 amplification. Alrizomadlin also functions as a host immunomodulator and may restore antitumor activity in pts with cancers that progressed on PD-1/PD-L1 inhibitors. Methods: This US/Australian multicenter trial evaluated alrizomadlin, an investigational MDM2-selective, small-molecule inhibitor, combined with pembrolizumab, in pts with unresectable/metastatic melanoma that progressed on I-O drugs; pts with malignant peripheral nerve sheath tumor (MPNST), well-differentiated/dedifferentiated liposarcoma, non-small cell lung cancer (NSCLC), or solid tumors with ATM mutations that progressed on available standard therapy; or pts for whom therapy was unavailable. Eligible pts had ECOG performance status of 0-2 and, if present, stable brain metastases. Alrizomadlin 150 mg PO was administered QOD for 2 consecutive weeks, with 1 week off, and pembrolizumab 200 mg IV over 30 minutes on Day 1 of a 21-day cycle. Results: As of November 3, 2021, preliminary and interim results are reported for 130 pts in 6 cohorts: melanoma (n = 44), NSCLC (n = 26), ATM mutation (n = 18), liposarcoma (n = 17), urothelial (n = 13), and MPNST (n = 12). In the melanoma cohort, confirmed ORR by RECIST, (PR + CR) was 13% (2 CRs + 3 PRs/38 efficacy evaluable [EE] pts). In cutaneous and uveal melanoma subcohorts, confirmed ORR was 24% (2 CRs + 2 PRs/17 EE pts) and 9% (1 PR/11 EE pts), respectively. In the MPNST cohort, the clinical benefit rate, defined by confirmed ORR + SD of > 4 cycles, was 40% (4 SDs/10 EE pts). Additional confirmed PRs were reported in NSCLC, urothelial, and liposarcoma cohorts (1 each). Common treatment (alrizomadlin or pembrolizumab)-related adverse events (TRAEs; ≥ 10%) were nausea (62%), thrombocytopenia (39%), vomiting (38%), fatigue (38%), decreased appetite (29%), diarrhea (25%), neutropenia (15%), and anemia (12%). Grade 3+ TRAEs (≥ 5%) included thrombocytopenia (23%), neutropenia (10%), and anemia (7%). A total of 16 pts discontinued treatment due to AEs; 6 were treatment related, including grade 4 thrombocytopenia (n = 3), grade 2 vomiting (n = 1), grade 2 fatigue (n = 1), and grade 2 posterior reversible encephalopathy syndrome (PRES; n = 1). A total of 10 pts reported treatment-related SAEs: 1 each of abdominal pain, asthenia, colitis, febrile neutropenia, hypophysitis, peripheral edema, overdose, PRES, pulmonary embolism, pyrexia, and thrombocytopenia. Conclusions: Alrizomadlin, combined with pembrolizumab, is well tolerated and demonstrates preliminary antitumor activity in multiple tumor types and may restore antitumor effects in pts with cancer resistant or intolerant to I-O drugs. Internal study identifiers: APG-115-US-002; Keynote MK-3475-B66. Clinical trial information: NCT03611868.

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.

Three-dimensional control of layer by layer thin films via laser modification

A novel modification to the traditional layer by layer process that adds three-dimensional control to the technique is introduced. In this modification to the process, the substrate is irradiated with laser light during the polycation and/or polyanion dipping cycles. An array of PAH/PCBS polymer thin films were fabricated using the laser modified approach with varied bilayer numbers, laser powers, and laser irradiation times. The modification was conducted with a semiconductor laser with powers from 1.1 to 5.5 W at 450 nm. Surface profilometry results show a change in height of more than 500 nm for a 55 bilayer PAH/PCBS thin film. For 25 bilayer films, the addition of laser modification during the PAH cycle leads to a reduction in absorbance of up to 54% compared to the areas not being irradiated. The absorbance at 365 nm associated with PCBS shows a nonlinear relationship with bilayer number, in contrast to the usual linear relationship between absorbance and bilayer without laser irradiation. By adjusting irradiation time, irradiation power, number of bilayers, and the location of irradiation, a variety of structures with controlled thicknesses can be fabricated.

MO610: A Graphene-Based Bioactive Compound Reduces Adipogenesis and Increases Lipolysis Via Integrin-Beta1 Interaction: A New Therapeutical Approach Against Obesity

BACKGROUND AND AIMS

Type 2 diabetes and obesity are metabolic disorders related to kidney risk and associated with white adipose tissue (WAT) hypertrophy, which is based in a pro-adipogenic transdifferentiation of the adipocytes and their precursors’ stem cells present in WAT. Several transcription factors are key regulators during this transdifferentiation. The consequence is that adipocytes’ size increases due to the excessive storage of triglycerides (TG) inside the cells. Therapeutic strategies for reducing WAT size may be based in the capacity of increasing lipolysis and reducing adipogenesis. We have previously demonstrated the implication of the extracellular matrix (ECM) mediator integrin beta 1 (INTB1) and intracellular mediation of actin cytoskeleton during obesity (Hatem-Vaquero. J Endocrinol 2017; Cell Physiol Biochem 2020). Here, we demonstrate for the first time the antiobesogenic properties of a new highly biocompatible and bioactive graphene-based product named BioGraph (Llorens-Gámez M. Int J Biol Macromol 2020; Salesa B. Biomedicines 2021), which physicochemical interaction with INTB1 give a great potential as a diagnostic and bioactive therapeutic tool.

METHOD

Pluripotent c3h10t1/2 cells were differentiated into adipocytes using a specific culture medium. After 7 days of differentiation, the adipocytes were treated for 24 h with a suspension of the graphene derivative BioGraph, developed, registered and patented by Graphenano Medical Care S.L. To determine viability and toxicity on adipocytes, trypan blue and MTT labeling techniques were used. The levels of intracellular TG contained in the lipid droplets were determined by fluorescent labeling with AdipoRed. PPARgamma, CEBP and INTB1 mRNA levels were determined by RT-qPCR. Actin polymerization in the cytoskeleton was quantified by fluorescent phalloidin staining. Active INTB1 quantification (phosphorylated isoform at thr788/9) and total and active lipase HSL (phosphorylated isoform at ser660) were performed by western blot.

RESULTS

BioGraph is safe and non-toxic on adipocytes in a two-order concentration range. The TG content is reduced in a dose-dependent manner. Adipogenesis markers PPARgamma and CEBP and actin polymerization were reduced after treatment with an intermediate dose. The expression of INTB1 was not modified, but its phosphorylation was increased rapidly after treatment. Lipolysis-main enzyme HSL expression and activity were increased 24 h after treatment.

CONCLUSION

BioGraph is biocompatible and bioactive on adipocytes. A rapid modulation of INTB1 produces the depolymerization of the cytoskeleton, the reduction of intracellular TG content and the expression of adipogenesis markers, while HSL-mediated lipolysis is increased. We demonstrate for the first time the mechanism followed by a graphene-based material modulating the adipocyte phenotype and behavior. BioGraph may be considered a new anti-obesogenic agent.

mTOR Inhibition with Sirolimus in Multiple System Atrophy: A Randomized, Double-Blind, Placebo-Controlled Futility Trial and 1-Year Biomarker Longitudinal Analysis

BACKGROUND

Multiple system atrophy (MSA) is a fatal neurodegenerative disease characterized by the aggregation of α-synuclein in glia and neurons. Sirolimus (rapamycin) is an mTOR inhibitor that promotes α-synuclein autophagy and reduces its associated neurotoxicity in preclinical models.

OBJECTIVE

To investigate the efficacy and safety of sirolimus in patients with MSA using a futility design. We also analyzed 1-year biomarker trajectories in the trial participants.

METHODS

Randomized, double-blind, parallel group, placebo-controlled clinical trial at the New York University of patients with probable MSA randomly assigned (3:1) to sirolimus (2-6 mg daily) for 48 weeks or placebo. Primary endpoint was change in the Unified MSA Rating Scale (UMSARS) total score from baseline to 48 weeks. (ClinicalTrials.gov NCT03589976).

RESULTS

The trial was stopped after a pre-planned interim analysis met futility criteria. Between August 15, 2018 and November 15, 2020, 54 participants were screened, and 47 enrolled and randomly assigned (35 sirolimus, 12 placebo). Of those randomized, 34 were included in the intention-to-treat analysis. There was no difference in change from baseline to week 48 between the sirolimus and placebo in UMSARS total score (mean difference, 2.66; 95% CI, -7.35-6.91; P = 0.648). There was no difference in UMSARS-1 and UMSARS-2 scores either. UMSARS scores changes were similar to those reported in natural history studies. Neuroimaging and blood biomarker results were similar in the sirolimus and placebo groups. Adverse events were more frequent with sirolimus. Analysis of 1-year biomarker trajectories in all participants showed that increases in blood neurofilament light chain (NfL) and reductions in whole brain volume correlated best with UMSARS progression.

CONCLUSIONS

Sirolimus for 48 weeks was futile to slow the progression of MSA and had no effect on biomarkers compared to placebo. One-year change in blood NfL and whole brain atrophy are promising biomarkers of disease progression for future clinical trials. © 2022 International Parkinson and Movement Disorder Society.

A blood atlas of COVID-19 defines hallmarks of disease severity and specificity

Treatment of severe COVID-19 is currently limited by clinical heterogeneity and incomplete description of specific immune biomarkers. We present here a comprehensive multi-omic blood atlas for patients with varying COVID-19 severity in an integrated comparison with influenza and sepsis patients versus healthy volunteers. We identify immune signatures and correlates of host response. Hallmarks of disease severity involved cells, their inflammatory mediators and networks, including progenitor cells and specific myeloid and lymphocyte subsets, features of the immune repertoire, acute phase response, metabolism, and coagulation. Persisting immune activation involving AP-1/p38MAPK was a specific feature of COVID-19. The plasma proteome enabled sub-phenotyping into patient clusters, predictive of severity and outcome. Systems-based integrative analyses including tensor and matrix decomposition of all modalities revealed feature groupings linked with severity and specificity compared to influenza and sepsis. Our approach and blood atlas will support future drug development, clinical trial design, and personalized medicine approaches for COVID-19.

Continuously updated forecasting of SARS-CoV-2 in a regional health system

OBJECTIVES

To build a model of local hospital utilization resulting from SARS-CoV-2 and to continuously update it with new data.

STUDY DESIGN

Retrospective analysis of real performance resulting from a model deployed in a major regional health system.

METHODS

Using hospitalization data from the Kaiser Permanente Mid-Atlantic States integrated care system during the period from March 10, 2020, through December 31, 2020, and a custom-developed genetic particle filtering algorithm, we modeled the SARS-CoV-2 outbreak in the mid-Atlantic region. This model produced weekly forecasts of COVID-19-related hospital admissions, which we then compared with actual hospital admissions over the same period.

RESULTS

We found that the model was able to accurately capture the data-generating process (weekly mean absolute percentage error, 10.0%-48.8%; Anderson-Darling P value of .97 when comparing percentiles of observed admissions with the uniform distribution) once the effects of social distancing could be accurately measured in mid-April. We also found that our estimates of key parameters, including the reproductive rate, were consistent with consensus literature estimates.

CONCLUSIONS

The genetic particle filtering algorithm that we have proposed is effective at modeling hospitalizations due to SARS-CoV-2. The methods used by our model can be reproduced by any major health care system for the purposes of resource planning, staffing, and population care management to create an effective forecasting regimen at scale.

Life Expectancy Trends Among Integrated Health Care System Enrollees, 2014-2017

INTRODUCTION

The Centers for Disease Control and Prevention (CDC) has reported downward trends in life expectancy and racial/ethnic differences between 2014 and 2017.

OBJECTIVE

To determine the life expectancy of the Kaiser Permanente Mid-Atlantic States (KPMAS) insured population as compared to the CDC National Vital Statistics data from 2014 to 2017. We also aimed to highlight the utilization of membership data to inform population statistical estimates such as life expectancy. We examine whether national trends in life expectancy are reflected in an insured population with relatively uniform access to care.

METHODS

This retrospective, data only study examined life expectancy between 2014 and 2017. Data from electronic medical records and the National Death Index were combined to construct complete life tables by race and sex for the KPMAS population, which was compared to the CDC National Vital Statistics data.

RESULTS

From 2014 to 2017, the overall KPMAS population life expectancy at birth varied between 84.6 and 85.2 years compared to the CDC reported national average of 78.6-78.9 years (p < 0.001). While the CDC dataset reported a 3.5- to 3.7-year life expectancy gap between non-Hispanic White and non-Hispanic Black populations, in the KPMAS population, this gap was significantly smaller (0.0-0.9 years). The gap in life expectancy between males and females was consistent across KPMAS and the CDC data; however, overall KPMAS male and female patient life expectancy was extended in comparison.

CONCLUSION

Among members who disclosed their race/ethnicity, KPMAS Hispanic, non-Hispanic Black, and non-Hispanic White members had significantly higher life expectancies than the CDC dataset in all years reported.

A comparison of attentional neural network architectures for modeling with electronic medical records

Objective

Attention networks learn an intelligent weighted averaging mechanism over a series of entities, providing increases to both performance and interpretability. In this article, we propose a novel time-aware transformer-based network and compare it to another leading model with similar characteristics. We also decompose model performance along several critical axes and examine which features contribute most to our model's performance.

Materials and methods

Using data sets representing patient records obtained between 2017 and 2019 by the Kaiser Permanente Mid-Atlantic States medical system, we construct four attentional models with varying levels of complexity on two targets (patient mortality and hospitalization). We examine how incorporating transfer learning and demographic features contribute to model success. We also test the performance of a model proposed in recent medical modeling literature. We compare these models with out-of-sample data using the area under the receiver-operator characteristic (AUROC) curve and average precision as measures of performance. We also analyze the attentional weights assigned by these models to patient diagnoses.

Results

We found that our model significantly outperformed the alternative on a mortality prediction task (91.96% AUROC against 73.82% AUROC). Our model also outperformed on the hospitalization task, although the models were significantly more competitive in that space (82.41% AUROC against 80.33% AUROC). Furthermore, we found that demographic features and transfer learning features which are frequently omitted from new models proposed in the EMR modeling space contributed significantly to the success of our model.

Discussion

We proposed an original construction of deep learning electronic medical record models which achieved very strong performance. We found that our unique model construction outperformed on several tasks in comparison to a leading literature alternative, even when input data was held constant between them. We obtained further improvements by incorporating several methods that are frequently overlooked in new model proposals, suggesting that it will be useful to explore these options further in the future.

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.

Predictors of the Pressor Response to the Norepinephrine Transporter Inhibitor, Atomoxetine, in Neurogenic Orthostatic Hypotension

[Figure: see text].

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.

Case Series: Exacerbation of Insulin Resistance With Active COVID 19 Infection

Background: Severe hyperglycemia due to insulin resistance is associated with increased mortality due to induction of pro-inflammatory cytokines, immunodepression, impairing cellular function and healing. We describe 6 patients admitted with COVID19 pneumonia complicated with DKA requiring high dose insulin infusion.

# 1 19 yo African American (AA) male with history of pre-DM and obesity (BMI 41 kg/m2) presented with polyuria, polydipsia, obtunded and intubated in ER. Labs showed pH 7.35, serum sodium (Na) 138 mmol/L, potassium (K) 6.8 mmol/L, chloride (Cl) 85 mmol/L, bicarbonate (HCO3) 10 mmol/L, glucose 1140 mg/dL, lactate 1.4 mmol/L, anion gap (AG) 43, Beta Hydroxybutyrate (BOH) &gt; 4.50 mmol/L. A1c 13.4%. Placed on insulin drip at 29.5 U/hr or 5.7 U/kg/hr. Discharged on Detemir 60 U TID and Novolog 20 U TID ac.

# 2 55 yo female with T2DM and obesity (BMI 37.42 kg/m2) presented with shortness of breath, intubated for hypoxia in ER. Labs showed pH 7.21, serum Na 138 mmol/L, K 5.6 mmol/L, Cl 101 mmol/L, HCO3 13 mmol/L, glucose 557 mg/dL, lactate 5 mmol/L, AG 24, BOH &gt; 0.27 mmol/L. A1c 7.8%. Placed on insulin drip at 23 U/hr or 5 U/kg/hr. Died from multiorgan failure on day 7.

# 3 75 yo Hispanic female with T2DM, HCV, post liver-kidney transplant on immunosuppressants, HTN presented with weakness. Intubated on day 6 for hypoxemia. Placed on stress dose steroids for transplant failure. BMI 30 kg/m2. Labs on day 6 showed pH 6.98, serum Na 140 mmol/L, K 3.5 mmol/L, Cl 100 mmol/L, HCO3 20 mmol/L, glucose 590 mg/dL, AG 20, BOH 1.40 mmol/L. A1c 6.6% a year ago. Placed on insulin drip at 34 U/hr or 10.9 U/kg/hr. She developed ESRD requiring CRRT dialysis. She was made comfort care. Died on day 7.

# 4 38 yo AA male with obesity (BMI 59.5 kg/m2) presenting with confusion, polyuria, polydipsia. Labs showed pH 7.22. serum Na 133 mmol/L, K 6.8 mmol/L, Cl 81 mmol/L, HCO3 15 mmol/L, glucose 1760 mg/dL, lactate 3.8 mmol/L, AG 37, BOH &gt; 4.50 mmol/L. A1c 12.6%. Placed on insulin drip at 36 U/hr or 6 U/kg/hr. Discharged on Detemir 20 U qhs.

# 5 27 yo AA female with T2DM, HTN and obesity (BMI 51 kg/m2), pituitary adenoma presented with seizures. Labs showed pH 7.15, serum Na 133 mmol/L, K 7.0 mmol/L, Cl 84 mmol/L, HCO3 7 mmol/L, serum glucose 951 mg/dL, lactate 1.6 mmol/L, AG 24, BOH &gt;2.45 mmol/L. A1c &gt;15%. Placed on insulin drip at 24 U/hr or 5 U/kg/hr. Died on day 5 from multiorgan failure.

# 6 74 yo Hispanic female with T2DM, HTN and asthma presented with altered mental status. BMI 28 kg/m2. Labs showed pH 7.25, serum Na 155 mmol/L, K 4.6 mmol/L, Cl 125 mmol/L, HCO3 17 mmol/L, serum glucose 779 mg/dL, lactate 2.6 mmol/L, AG 13, BOH &gt;2.45 mmol/L. A1c &gt; 15%. Placed on insulin drip at 24 U/hr or 3.5 U/kg/hr. Died on day 5.

Conclusion: Patients with DM and obesity admitted with Covid19 infection presented with severe insulin resistance and poor outcomes. Cconsideration should be given to assessing therapeutic interventions to enhance insulin sensitivity and improve outcomes.

Need for Screening Triglyceride Levels in Women on Oral Contraceptives

Introduction: Oral contraceptive pills (OCPs) are the most used form of reversible contraceptives by women. Major risks are cardiovascular but OCPs also cause secondary hypertriglyceridemia (HTG) through effects of estrogen, which decreases hepatic triglyceride lipase and lipoprotein lipase activity. This causes increased triglycerides, cholesterol and free fatty acids,¹ which then in turn can lead to life-threatening acute pancreatitis.

Case Description: A 23-year-old morbidly obese (BMI 38.2 mg/kg²) female presented with severe epigastric pain, nausea and vomiting. She had a history of mild intermittent asthma, recently diagnosed pre-diabetes and recently started on OCPs. Initial labs were consistent with diabetic ketoacidosis with glucose 528 mg/dL (65-115 mg/dL), anion gap 21 mEq/L (5-15 mEq), and beta-hydroxybutyrate 2.00 mmol/L (0.02-0.27 mmol/L); and acute pancreatitis with triglyceride 4,425 mg/dL (30-200 mg/dL) and lipase >600 U/L (8-78 UL), confirmed on imaging.

She rapidly deteriorated, developing acute hypoxemic respiratory distress requiring intubation and distributive shock requiring three vasopressors. She progressed into multi-organ failure with acute respiratory distress syndrome, ischemic liver and acute renal failure despite insulin drip, colloidal fluid resuscitation, continuous veno-venous hemofiltration and high positive end-exploratory pressures. She developed rhabdomyolysis, followed by abdominal compartment syndrome requiring decompressive laparotomy that resulted in large volume blood loss and retroperitoneal necrosis needing multiple laparotomies. Ultimately, she became non-responsive off sedation, attributed to malignant cerebral edema that progressed to brain herniation.

While HTG was likely the cause of her pancreatitis, she had normal triglyceride levels on prior routine lab work while not on OCPs.

Discussion: Severe acute pancreatitis is a life-threatening complication of HTG which may be precipitated by use of OCPs. We believe that there is a need for more research in this field and even propose periodic monitoring of HTG in women taking OCPs given the severity of the consequences. While there are currently no guidelines for monitoring lipid levels in women on OCP, appropriate clinical awareness of physicians prescribing OCPs to patients may prevent fatal outcomes.

References: 1. Stumpf, M., Kluthcovsky, A., Okamoto, J., Schrut, G., Cajoeiro, P., Chacra, A. and Bizeli, R. (2018). Acute pancreatitis secondary to oral contraceptive-induced hypertriglyceridemia: a case report. Gynecological Endocrinology, 34(11), pp.930-932.

A haemagglutination test for rapid detection of antibodies to SARS-CoV-2

Serological detection of antibodies to SARS-CoV-2 is essential for establishing rates of seroconversion in populations, and for seeking evidence for a level of antibody that may be protective against COVID-19 disease. Several high-performance commercial tests have been described, but these require centralised laboratory facilities that are comparatively expensive, and therefore not available universally. Red cell agglutination tests do not require special equipment, are read by eye, have short development times, low cost and can be applied at the Point of Care. Here we describe a quantitative Haemagglutination test (HAT) for the detection of antibodies to the receptor binding domain of the SARS-CoV-2 spike protein. The HAT has a sensitivity of 90% and specificity of 99% for detection of antibodies after a PCR diagnosed infection. We will supply aliquots of the test reagent sufficient for ten thousand test wells free of charge to qualified research groups anywhere in the world.

Exploiting hierarchy in medical concept embedding

Objective

To construct and publicly release a set of medical concept embeddings for codes following the ICD-10 coding standard which explicitly incorporate hierarchical information from medical codes into the embedding formulation.

Materials and Methods

We trained concept embeddings using several new extensions to the Word2Vec algorithm using a dataset of approximately 600,000 patients from a major integrated healthcare organization in the Mid-Atlantic US. Our concept embeddings included additional entities to account for the medical categories assigned to codes by the Clinical Classification Software Revised (CCSR) dataset. We compare these results to sets of publicly released pretrained embeddings and alternative training methodologies.

Results

We found that Word2Vec models which included hierarchical data outperformed ordinary Word2Vec alternatives on tasks which compared naïve clusters to canonical ones provided by CCSR. Our Skip-Gram model with both codes and categories achieved 61.4% normalized mutual information with canonical labels in comparison to 57.5% with traditional Skip-Gram. In models operating on two different outcomes, we found that including hierarchical embedding data improved classification performance 96.2% of the time. When controlling for all other variables, we found that co-training embeddings improved classification performance 66.7% of the time. We found that all models outperformed our competitive benchmarks.

Discussion

We found significant evidence that our proposed algorithms can express the hierarchical structure of medical codes more fully than ordinary Word2Vec models, and that this improvement carries forward into classification tasks. As part of this publication, we have released several sets of pretrained medical concept embeddings using the ICD-10 standard which significantly outperform other well-known pretrained vectors on our tested outcomes.

Variants in GNAI1 cause a syndrome associated with variable features including developmental delay, seizures, and hypotonia

PURPOSE

Neurodevelopmental disorders (NDDs) encompass a spectrum of genetically heterogeneous disorders with features that commonly include developmental delay, intellectual disability, and autism spectrum disorders. We sought to delineate the molecular and phenotypic spectrum of a novel neurodevelopmental disorder caused by variants in the GNAI1 gene.

METHODS

Through large cohort trio-based exome sequencing and international data-sharing, we identified 24 unrelated individuals with NDD phenotypes and a variant in GNAI1, which encodes the inhibitory Gαi1 subunit of heterotrimeric G-proteins. We collected detailed genotype and phenotype information for each affected individual.

RESULTS

We identified 16 unique variants in GNAI1 in 24 affected individuals; 23 occurred de novo and 1 was inherited from a mosaic parent. Most affected individuals have a severe neurodevelopmental disorder. Core features include global developmental delay, intellectual disability, hypotonia, and epilepsy.

CONCLUSION

This collaboration establishes GNAI1 variants as a cause of NDDs. GNAI1-related NDD is most often characterized by severe to profound delays, hypotonia, epilepsy that ranges from self-limiting to intractable, behavior problems, and variable mild dysmorphic features.

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.

Performance characteristics of five immunoassays for SARS-CoV-2: a head-to-head benchmark comparison

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a global pandemic in 2020. Testing is crucial for mitigating public health and economic effects. Serology is considered key to population-level surveillance and potentially individual-level risk assessment. However, immunoassay performance has not been compared on large, identical sample sets. We aimed to investigate the performance of four high-throughput commercial SARS-CoV-2 antibody immunoassays and a novel 384-well ELISA.

METHODS

We did a head-to-head assessment of SARS-CoV-2 IgG assay (Abbott, Chicago, IL, USA), LIAISON SARS-CoV-2 S1/S2 IgG assay (DiaSorin, Saluggia, Italy), Elecsys Anti-SARS-CoV-2 assay (Roche, Basel, Switzerland), SARS-CoV-2 Total assay (Siemens, Munich, Germany), and a novel 384-well ELISA (the Oxford immunoassay). We derived sensitivity and specificity from 976 pre-pandemic blood samples (collected between Sept 4, 2014, and Oct 4, 2016) and 536 blood samples from patients with laboratory-confirmed SARS-CoV-2 infection, collected at least 20 days post symptom onset (collected between Feb 1, 2020, and May 31, 2020). Receiver operating characteristic (ROC) curves were used to assess assay thresholds.

FINDINGS

At the manufacturers' thresholds, for the Abbott assay sensitivity was 92·7% (95% CI 90·2-94·8) and specificity was 99·9% (99·4-100%); for the DiaSorin assay sensitivity was 96·2% (94·2-97·7) and specificity was 98·9% (98·0-99·4); for the Oxford immunoassay sensitivity was 99·1% (97·8-99·7) and specificity was 99·0% (98·1-99·5); for the Roche assay sensitivity was 97·2% (95·4-98·4) and specificity was 99·8% (99·3-100); and for the Siemens assay sensitivity was 98·1% (96·6-99·1) and specificity was 99·9% (99·4-100%). All assays achieved a sensitivity of at least 98% with thresholds optimised to achieve a specificity of at least 98% on samples taken 30 days or more post symptom onset.

INTERPRETATION

Four commercial, widely available assays and a scalable 384-well ELISA can be used for SARS-CoV-2 serological testing to achieve sensitivity and specificity of at least 98%. The Siemens assay and Oxford immunoassay achieved these metrics without further optimisation. This benchmark study in immunoassay assessment should enable refinements of testing strategies and the best use of serological testing resource to benefit individuals and population health.

FUNDING

Public Health England and UK National Institute for Health Research.

Carbidopa for Afferent Baroreflex Failure in Familial Dysautonomia: A Double-Blind Randomized Crossover Clinical Trial

Afferent lesions of the arterial baroreflex occur in familial dysautonomia. This leads to excessive blood pressure variability with falls and frequent surges that damage the organs. These hypertensive surges are the result of excess peripheral catecholamine release and have no adequate treatment. Carbidopa is a selective DOPA-decarboxylase inhibitor that suppresses catecholamines production outside the brain. To learn whether carbidopa can inhibit catecholamine-induced hypertensive surges in patients with severe afferent baroreflex failure, we conducted a double-blind randomized crossover trial in which patients with familial dysautonomia received high dose carbidopa (600 mg/day), low-dose carbidopa (300 mg/day), or matching placebo in 3 4-week treatment periods. Among the 22 patients enrolled (13 females/8 males), the median age was 26 (range, 12-59 years). At enrollment, patients had hypertensive peaks to 164/116 (range, 144/92 to 213/150 mm Hg). Twenty-four hour urinary norepinephrine excretion, a marker of peripheral catecholamine release, was significantly suppressed on both high dose and low dose carbidopa, compared with placebo (P=0.0075). The 2 co-primary end points of the trial were met. The SD of systolic BP variability was reduced at both carbidopa doses (low dose: 17±4; high dose: 18±5 mm Hg) compared with placebo (23±7 mm Hg; P=0.0013), and there was a significant reduction in the systolic BP peaks on active treatment (P=0.0015). High- and low-dose carbidopa were similarly effective and well tolerated. This study provides class Ib evidence that carbidopa can reduce blood pressure variability in patients with congenital afferent baroreflex failure. Similar beneficial effects are observed in patients with acquired baroreflex lesions.

An Intramolecular Salt Bridge Linking TDP43 RNA Binding, Protein Stability, and TDP43-Dependent Neurodegeneration

The majority of individuals with amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) exhibit neuronal cytoplasmic inclusions rich in the RNA binding protein TDP43. Even so, the relation between the RNA binding properties of TDP43 and neurodegeneration remains obscure. Here, we show that engineered mutations disrupting a salt bridge between the RNA recognition motifs of TDP43 interfere with RNA binding and eliminate the recognition of native TDP43 substrates. The same mutations dramatically destabilize TDP43, alter its subcellular localization, and abrogate TDP43-dependent neuro-degeneration. Worms harboring homologous TDP-1 mutations phenocopy knockout strains, confirming the necessity of salt bridge residues for TDP43 function. Moreover, the accumulation of functional TDP43, but not RNA binding-deficient variants, disproportionately affects transcripts encoding ribo-some and oxidative phosphorylation components. These studies demonstrate the significance of the salt bridge in sustaining TDP43 stability and RNA binding properties, factors that are crucial for neurodegeneration arising from TDP43 deposition in ALS and FTD.

Flores et al. uncover essential roles for an intramolecular salt bridge in the function of TDP43, an RNA binding protein implicated in neurodegenerative diseases. Salt bridge interruption attenuates TDP43 RNA binding affinity and specificity, destabilizes the protein, and prevents TDP43-mediated neurotoxicity arising from misprocessing of ribosomal and mitochondrial transcripts.

Antibody testing for COVID-19: A report from the National COVID Scientific Advisory Panel

Background: The COVID-19 pandemic caused >1 million infections during January-March 2020. There is an urgent need for reliable antibody detection approaches to support diagnosis, vaccine development, safe release of individuals from quarantine, and population lock-down exit strategies. We set out to evaluate the performance of ELISA and lateral flow immunoassay (LFIA) devices. Methods: We tested plasma for COVID (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) IgM and IgG antibodies by ELISA and using nine different LFIA devices. We used a panel of plasma samples from individuals who have had confirmed COVID infection based on a PCR result (n=40), and pre-pandemic negative control samples banked in the UK prior to December-2019 (n=142). Results: ELISA detected IgM or IgG in 34/40 individuals with a confirmed history of COVID infection (sensitivity 85%, 95%CI 70-94%), vs. 0/50 pre-pandemic controls (specificity 100% [95%CI 93-100%]). IgG levels were detected in 31/31 COVID-positive individuals tested ≥10 days after symptom onset (sensitivity 100%, 95%CI 89-100%). IgG titres rose during the 3 weeks post symptom onset and began to fall by 8 weeks, but remained above the detection threshold. Point estimates for the sensitivity of LFIA devices ranged from 55-70% versus RT-PCR and 65-85% versus ELISA, with specificity 95-100% and 93-100% respectively. Within the limits of the study size, the performance of most LFIA devices was similar. Conclusions: Currently available commercial LFIA devices do not perform sufficiently well for individual patient applications. However, ELISA can be calibrated to be specific for detecting and quantifying SARS-CoV-2 IgM and IgG and is highly sensitive for IgG from 10 days following first symptoms.

SUN-LB88 Thyrotoxic Periodic Paralysis in Hispanic Patients

BACKGROUND: Thyrotoxic periodic paralysis (TPP) presents as acute intermittent attacks of weakness related to hypokalemia, commonly reported in Asians and rare in Hispanics(1). Patients with TPP will have triiodothyronine (T3) triggered increased Na+/K+ ATPase pump activity and transcription of the KCNJ18 gene that encodes for the Kir2.6 channel(2). This permits insulin, catecholamines, stress and alcohol(3) to increase cellular intake of potassium, which causes depolarization and leads to weakness and paralysis. We report a case of TPP in a young Hispanic man who presented with lower extremity weakness and falls. CASE PRESENTATION: A 34-year-old Hispanic man with Graves’ disease, non-adherent to medications presented with generalized weakness, more pronounced in legs, and recurrent falls. Physical examination was unremarkable except for mild enlargement of thyroid gland and abnormal gait due to weakness. Laboratory data showed hypokalemia of 1.8 mmol/L (3.7-5.1 mmol/L) and a TSH level of &lt;0.004 mIU/L (0.34-5.6 mIU/L). Free T4 3.74 ng/dL (0.6-1.6 ng/dL), free T3 597 pg/dL (230-420 Pg/dL), thyroid stimulating Ig 148 (&lt;130). Electrocardiogram did not show U waves. Radio iodine 123 scan of thyroid revealed diffusely increased 24-hour radioactive uptake of 66.5% (10-30%). The patient was diagnosed with TPP and supplemented with three doses of potassium 40 mEq IV infusion. Methimazole and metoprolol were started. He made a good clinical recovery within days. After discharge, he was treated with I-131 (13 mci) and developed postablative hypothyroidism on long term. He was euthyroid on levothyroxine. He did not have any recurrence of weakness at 7-year follow-up. CONCLUSION: TPP is uncommonly seen in Hispanics patients as opposed to Asians(3). Physicians should consider TPP as part of the differential diagnosis in young hyperthyroid Hispanic men presenting with weakness or paralysis, as early recognition and treatment can reduce recovery time and potentially prevent tachyarrhythmia or death. REFERENCES: 1. Matta A, Koppala J, Gossman W. Thyrotoxic hypokalaemic periodic paralysis: a rare presentation of Graves’ disease in a Hispanic patient. BMJ Case Rep. 2014;2014. 2. Ryan DP, Ptacek LJ. Mutations in Potassium Channel Kir2.6 Cause Susceptibility to Thyrotoxic Hypokalemic Periodic Paralysis. Cell, 140(1), pp.88-98. 3. Amblee, A. and Gulati, S. (2016). Thyrotoxic Periodic Paralysis: Eight Cases in Males of Hispanic Origin from a Single Hospital. AACE Clinical Case Reports, 2(1), pp.e58-e64.

Impact of depressive symptoms on self-perceived severity of autonomic dysfunction in multiple system atrophy: relevance for patient-reported outcomes in clinical trials

PURPOSE

To assess the relationship between depressive symptoms and self-perceived severity of autonomic dysfunction in patients with multiple system atrophy (MSA).

METHODS

Cross-sectional evaluation of patients with MSA who underwent autonomic testing, Unified MSA Rating Scale (UMSARS)-1 and -2, rating of the presence and severity of depressive symptoms (Zung scale), quality of life (SF-36), body vigilance, anxiety (Spielberger's anxiety scale), severity of autonomic dysfunction with the Composite Autonomic Symptoms Score (COMPASS-31), and severity of orthostatic hypotension (OH) symptoms with the Orthostatic Hypotension Questionnaire (OHQ).

RESULTS

Fifty-eight patients (32 women) with probable MSA (aged 61.8 ± 8.6 years; disease duration 4.3 ± 2.1 years) were studied. Forty patients (69%) had symptoms of depression in the Zung scale. Age, disease duration, and motor disability were similar in those with and without symptoms of depression. Despite a similar orthostatic blood pressure fall, the severity of orthostatic symptoms was higher in patients with symptoms of depression (p = 0.004). Depression scores were associated with higher burden of autonomic symptoms (R = 0.401, p = 0.02), specifically with the COMPASS-31 items related to orthostatic intolerance (R = 0.337, p = 0.045), and with the OHQ (R = 0.529; p < 0.001). A multivariable regression model including age, sex, UMSARS, and drop in systolic blood pressure upon head-up tilt as covariates showed that the burden of depressive symptoms was independently associated with the OHQ score: for every 1-unit increase in the Zung depression score, there was a 1.181-point increase in the total OHQ score.

CONCLUSIONS

In patients with MSA, depressive symptoms worsen the perceived severity of autonomic symptoms in general and orthostatic hypotension in particular. Our findings have implications for clinical trial design.

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.

Polyacrylic acid based plasma fractionation for the production of albumin and IgG: Compatibility with existing commercial downstream processes

Commercial fractionation of human plasma into immunoglobulin- and albumin-rich fractions is often initiated with sequential cold ethanol-based precipitation methods, which have changed little over the past 70 years. The required low temperature (-4 to -8°C) and high concentrations of ethanol 8-40%) necessitate large-scale fixed processing lines, and major capital investment and operating costs. The resulting fractions are then further purified by ethanol based precipitation or chromatographic procedures to obtain the purified final product. Aqueous polyacrylic acid (PAA) based precipitation, which readily interfaces with existing downstream processing, could offer advantages with respect to cost, safety, environmental impact, and flexibility. Sequential precipitation with 7%, 12%, and 20% (w/v) solutions of PAA 8000 in the presence of a kosmotropic salt (sodium citrate) gave fibrinogen-, immunoglobulin-, and albumin-rich fractions with 80-90% yield and 64%, 55%, and 82% purity, respectively. Further purification of the IgG-rich precipitate by caprylic acid precipitation and anion exchange chromatography, achieved a target purity of >99%. This was also achieved for the downstream processing of the albumin-rich precipitate using a two-step ion exchange chromatographic procedure. This work shows that PAA precipitation can be used in place of cold ethanol precipitation to generate crude IgG and albumin fractions which can be purified to final products of acceptable purity.

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.

Antibody testing for COVID-19: A report from the National COVID Scientific Advisory Panel

Background: The COVID-19 pandemic caused >1 million infections during January-March 2020. There is an urgent need for reliable antibody detection approaches to support diagnosis, vaccine development, safe release of individuals from quarantine, and population lock-down exit strategies. We set out to evaluate the performance of ELISA and lateral flow immunoassay (LFIA) devices. Methods: We tested plasma for COVID (severe acute respiratory syndrome coronavirus 2; SARS-CoV-2) IgM and IgG antibodies by ELISA and using nine different LFIA devices. We used a panel of plasma samples from individuals who have had confirmed COVID infection based on a PCR result (n=40), and pre-pandemic negative control samples banked in the UK prior to December-2019 (n=142). Results: ELISA detected IgM or IgG in 34/40 individuals with a confirmed history of COVID infection (sensitivity 85%, 95%CI 70-94%), vs. 0/50 pre-pandemic controls (specificity 100% [95%CI 93-100%]). IgG levels were detected in 31/31 COVID-positive individuals tested ≥10 days after symptom onset (sensitivity 100%, 95%CI 89-100%). IgG titres rose during the 3 weeks post symptom onset and began to fall by 8 weeks, but remained above the detection threshold. Point estimates for the sensitivity of LFIA devices ranged from 55-70% versus RT-PCR and 65-85% versus ELISA, with specificity 95-100% and 93-100% respectively. Within the limits of the study size, the performance of most LFIA devices was similar. Conclusions: Currently available commercial LFIA devices do not perform sufficiently well for individual patient applications. However, ELISA can be calibrated to be specific for detecting and quantifying SARS-CoV-2 IgM and IgG and is highly sensitive for IgG from 10 days following first symptoms.

Increased Myocardial Stiffness in Patients With High-Risk Left Ventricular Hypertrophy: The Hallmark of Stage-B Heart Failure With Preserved Ejection Fraction

BACKGROUND

Individuals with left ventricular hypertrophy (LVH) and elevated cardiac biomarkers in middle age are at high risk for the development of heart failure with preserved ejection fraction (HFpEF). However, it is unknown what the pathophysiological underpinnings of this high-risk state may be. We tested the hypothesis that patients with LVH and elevated cardiac biomarkers would demonstrate elevated left ventricular (LV) myocardial stiffness in comparison with healthy controls as a key marker for future HFpEF.

METHODS

Forty-six patients with LVH (LV septum >11 mm) and elevated cardiac biomarkers (N-terminal pro-B-type natriuretic peptide [>40 pg/mL] or troponin T [>0.6 pg/mL]) were recruited, along with 61 age- and sex-matched (by cohort) healthy controls. To define LV pressure-volume relationships, right heart catheterization and 3-dimensional echocardiography were performed while preload was manipulated using lower body negative pressure and rapid saline infusion.

RESULTS

There were significant differences in body size, blood pressure, and baseline pulmonary capillary wedge pressure between groups (eg, pulmonary capillary wedge pressure: LVH, 13.4±2.7 versus control, 11.7±1.7 mm Hg, P<0.0001). The LV was less distensible in LVH than in controls (smaller volume for the same filling pressure). When preload was expressed as transmural filling pressure (pulmonary capillary wedge pressure - right atrial pressure), LV myocardial stiffness was nearly 30% greater in LVH than in controls (LVH stiffness constant, 0.053±0.027 versus controls, 0.042±0.020, P=0.028).

CONCLUSIONS

LV myocardial stiffness in patients with LVH and elevated biomarkers (stage-B HFpEF) is greater than in age- and sex-matched controls and thus appears to represent a transitional state from a normal healthy heart to HFpEF. Although the LV myocardial stiffness of patients with LVH is greater than that of healthy controls at this early stage, further studies are required to clarify whether interventions such as exercise training to improve LV compliance may prevent the full manifestation of the HFpEF syndrome in these high-risk individuals.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifiers: NCT03476785 and NCT02039154.