Intention-to-treat outcomes utilising a stringent event definition in children and young people treated with tisagenlecleucel for r/r ALL through a national access scheme

CAR T-cell therapy has transformed relapsed/refractory (r/r) B-cell precursor acute lymphoblastic leukaemia (B-ALL) management and outcomes, but following CAR T infusion, interventions are often needed. In a UK multicentre study, we retrospectively evaluated tisagenlecleucel outcomes in all eligible patients, analysing overall survival (OS) and event-free survival (EFS) with standard and stringent definitions, the latter including measurable residual disease (MRD) emergence and further anti-leukaemic therapy. Both intention-to-treat and infused cohorts were considered. We collected data on feasibility of delivery, manufacture, toxicity, cause of therapy failure and followed patients until death from any cause. Of 142 eligible patients, 125 received tisagenlecleucel, 115/125 (92%) achieved complete remission (CR/CRi). Severe cytokine release syndrome and neurotoxicity occurred in 16/123 (13%) and 10/123 (8.1%), procedural mortality was 3/126 (2.4%). The 2-year intent to treat OS and EFS were 65.2% (95%CI 57.2-74.2%) and 46.5% (95%CI 37.6-57.6%), 2-year intent to treat stringent EFS was 35.6% (95%CI 28.1-44.9%). Median OS was not reached. Sixty-two responding patients experienced CAR T failure by the stringent event definition. Post failure, 1-year OS and standard EFS were 61.2% (95%CI 49.3-75.8) and 55.3% (95%CI 43.6-70.2). Investigation of CAR T-cell therapy for B-ALL delivered on a country-wide basis, including following patients beyond therapy failure, provides clinicians with robust outcome measures. Previously, outcomes post CAR T-cell therapy failure were under-reported. Our data show that patients can be successfully salvaged in this context with good short-term survival.

ForMAX - a beamline for multiscale and multimodal structural characterization of hierarchical materials

The ForMAX beamline at the MAX IV Laboratory provides multiscale and multimodal structural characterization of hierarchical materials in the nanometre to millimetre range by combining small- and wide-angle X-ray scattering with full-field microtomography. The modular design of the beamline is optimized for easy switching between different experimental modalities. The beamline has a special focus on the development of novel fibrous materials from forest resources, but it is also well suited for studies within, for example, food science and biomedical research.

Alemtuzumab, Dual Graft-versus-Host Disease Prophylaxis, and Lower CD3+ T Cell Doses Equalize Rates of Acute and Chronic Graft-versus-Host Disease in Pediatric Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation with Matched Unrelated Donor Peripheral Blood Stem Cells or Bone Marrow Grafts

Data comparing hematopoietic stem cell transplantation (HSCT) using bone marrow (BM) or peripheral blood stem cell (PBSC) grafts in children after alemtuzumab-based conditioning are lacking. We investigated whether in vivo T cell depletion using alemtuzumab could reduce the risk of severe acute graft-versus-host disease (aGVHD) and chronic GVHD (cGVHD) after HSCT with matched unrelated donor (MUD) BM or PBSCs. This retrospective multicenter study included 397 children (BM group, n = 202; PBSC group, n = 195) who underwent first MUD HSCT at 9 pediatric centers in the United Kingdom between 2015 and 2019. The median age at transplantation was 7.0 years (range, .1 to 19.3 years), and the median duration of follow-up was 3.1 years (range, .3 to 7.5 years). The 3-year overall survival was 81% for the entire cohort (BM group, 80%; PBSC group, 81%). The incidence of grade II-IV aGVHD was significantly higher in the PBSC group (31%) compared to the BM group (31% versus 19%; P = .003), with no difference in the incidence of grade III-IV aGVHD (BM, 7%; PBSC, 12%; P = .17). CD3+ T cell dose >5 × 108/kg and the use of PBSCs were independent predictors of grade II-IV aGVHD. When considering CD3+ T cell dose and GVHD prophylaxis, PBSC transplantation with a calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF) and a CD3+ T cell dose ≤5 × 108/kg had a comparable grade II-IV aGVHD to BM transplantation plus a CNI (20% versus 18%; P = .52). PBSC transplantation was associated with a lower incidence of cGVHD compared to BM transplantation (6% versus 11%; P = .03). Within the limits of this study, we identified a potential strategy to reduce the risk of severe GVHD in pediatric PBSC recipients that includes a combination of in vivo T cell depletion using alemtuzumab and dual GVHD prophylaxis (with a CNI and MMF) and limiting the CD3+ T cell dose to ≤5 × 108/kg.

Influence of at-risk family interactions on the course of psychiatric care in adolescence

Dysparenting, referring to inappropriate parental attitudes, is a vulnerability factor for mental disorders during adolescence and a therapeutic leverage, yet clinicians lack reliable tools to assess it in daily clinical practice. Moreover, the effect of this dysparenting on the amount of psychiatric care remains unclear. The Family and Care study aims to develop the at-risk family interactions and levers (ARFIL) scale, a comprehensive 30-item clinical scale, and to assess in a cross-sectional design, the impact of these at-risk family interactions on the care of adolescents (n = 425) hospitalized in psychiatry and aged 13-19 years old. Factorial analysis shows that the ARFIL scale consists of three main dimensions associated with cohesion/conflicts, love/hostility, and autonomy/control with good psychometric properties. Multivariate regressions show that the ARFIL intensity score predicts the duration of hospital care, regardless of age, gender, medical severity on admission, assessed by the Global Assessment of Functioning scale, the presence of maltreatment and psychiatric diagnoses. Moreover, the ARFIL diversity score (number of items present regardless of their severity) predicts both the number and duration of hospitalizations. At-risk family interactions are a determining dimension of psychiatric adolescent care, and the ARFIL scale could constitute a valuable tool, not only for holistic evaluation and treatment, but also for prevention.

Epilepsy phenotype and its reproducibility after lateral fluid percussion-induced traumatic brain injury in rats: Multicenter EpiBioS4Rx study project 1

OBJECTIVE

This study was undertaken to assess reproducibility of the epilepsy outcome and phenotype in a lateral fluid percussion model of posttraumatic epilepsy (PTE) across three study sites.

METHODS

A total of 525 adult male Sprague Dawley rats were randomized to lateral fluid percussion-induced brain injury (FPI) or sham operation. Of these, 264 were assigned to magnetic resonance imaging (MRI cohort, 43 sham, 221 traumatic brain injury [TBI]) and 261 to electrophysiological follow-up (EEG cohort, 41 sham, 220 TBI). A major effort was made to harmonize the rats, materials, equipment, procedures, and monitoring systems. On the 7th post-TBI month, rats were video-EEG monitored for epilepsy diagnosis.

RESULTS

A total of 245 rats were video-EEG phenotyped for epilepsy on the 7th postinjury month (121 in MRI cohort, 124 in EEG cohort). In the whole cohort (n = 245), the prevalence of PTE in rats with TBI was 22%, being 27% in the MRI and 18% in the EEG cohort (p > .05). Prevalence of PTE did not differ between the three study sites (p > .05). The average seizure frequency was .317 ± .725 seizures/day at University of Eastern Finland (UEF; Finland), .085 ± .067 at Monash University (Monash; Australia), and .299 ± .266 at University of California, Los Angeles (UCLA; USA; p < .01 as compared to Monash). The average seizure duration did not differ between UEF (104 ± 48 s), Monash (90 ± 33 s), and UCLA (105 ± 473 s; p > .05). Of the 219 seizures, 53% occurred as part of a seizure cluster (≥3 seizures/24 h; p >.05 between the study sites). Of the 209 seizures, 56% occurred during lights-on period and 44% during lights-off period (p > .05 between the study sites).

SIGNIFICANCE

The PTE phenotype induced by lateral FPI is reproducible in a multicenter design. Our study supports the feasibility of performing preclinical multicenter trials in PTE to increase statistical power and experimental rigor to produce clinically translatable data to combat epileptogenesis after TBI.

CD19/CD22 targeting with cotransduced CAR T cells to prevent antigen-negative relapse after CAR T-cell therapy for B-cell ALL

ABSTRACT

CD19-negative relapse is a leading cause of treatment failure after chimeric antigen receptor (CAR) T-cell therapy for acute lymphoblastic leukemia. We investigated a CAR T-cell product targeting CD19 and CD22 generated by lentiviral cotransduction with vectors encoding our previously described fast-off rate CD19 CAR (AUTO1) combined with a novel CD22 CAR capable of effective signaling at low antigen density. Twelve patients with advanced B-cell acute lymphoblastic leukemia were treated (CARPALL [Immunotherapy with CD19/22 CAR Redirected T Cells for High Risk/Relapsed Paediatric CD19+ and/or CD22+ Acute Lymphoblastic Leukaemia] study, NCT02443831), a third of whom had failed prior licensed CAR therapy. Toxicity was similar to that of AUTO1 alone, with no cases of severe cytokine release syndrome. Of 12 patients, 10 (83%) achieved a measurable residual disease (MRD)-negative complete remission at 2 months after infusion. Of 10 responding patients, 5 had emergence of MRD (n = 2) or relapse (n = 3) with CD19- and CD22-expressing disease associated with loss of CAR T-cell persistence. With a median follow-up of 8.7 months, there were no cases of relapse due to antigen-negative escape. Overall survival was 75% (95% confidence interval [CI], 41%-91%) at 6 and 12 months. The 6- and 12-month event-free survival rates were 75% (95% CI, 41%-91%) and 60% (95% CI, 23%-84%), respectively. These data suggest dual targeting with cotransduction may prevent antigen-negative relapse after CAR T-cell therapy.

Tau Phosphorylation Patterns in the Rat Cerebral Cortex After Traumatic Brain Injury and Sodium Selenate Effects: An Epibios4rx Project 2 Study

Sodium selenate (SS) activates protein phosphatase 2 (PP2A) and reduces phosphorylated tau (pTAU) and late post-traumatic seizures after lateral fluid percussion injury (LFPI). In EpiBioS4Rx Project 2, a multi-center international study for post-traumatic targets, biomarkers, and treatments, we tested the target relevance and modification by SS of pTAU forms and PP2A and in the LFPI model, at two sites: Einstein and Melbourne. In Experiment 1, adult male rats were assigned to LFPI and sham (both sites) and naïve controls (Einstein). Motor function was monitored by neuroscores. Brains were studied with immunohistochemistry (IHC), Western blots (WBs), or PP2A activity assay, from 2 days to 8 weeks post-operatively. In Experiment 2, LFPI rats received SS for 7 days (SS0.33: 0.33 mg/kg/day; SS1: 1 mg/kg/day, subcutaneously) or vehicle (Veh) post-LFPI and pTAU, PR55 expression, or PP2A activity were studied at 2 days and 1 week (on treatment), or 2 weeks (1 week off treatment). Plasma selenium and SS levels were measured. In Experiment 1 IHC, LFPI rats had higher cortical pTAU-Ser202/Thr205-immunoreactivity (AT8-ir) and pTAU-Ser199/202-ir at 2 days, and pTAU-Thr231-ir (AT180-ir) at 2 days, 2 weeks, and 8 weeks, ipsilaterally to LFPI, than controls. LFPI-2d rats also had higher AT8/total-TAU5-ir in cortical extracts ipsilateral to the lesion (WB). PP2A (PR55-ir) showed time- and region-dependent changes in IHC, but not in WB. PP2A activity was lower in LFPI-1wk than in sham rats. In Experiment 2, SS did not affect neuroscores or cellular AT8-ir, AT180-ir, or PR55-ir in IHC. In WB, total cortical AT8/total-TAU-ir was lower in SS0.33 and SS1 LFPI rats than in Veh rats (2 days, 1 week); total cortical PR55-ir (WB) and PP2A activity were higher in SS1 than Veh rats (2 days). SS dose dependently increased plasma selenium and SS levels. Concordant across-sites data confirm time and pTAU form-specific cortical increases ipsilateral to LFPI. The discordant SS effects may either suggest SS-induced reduction in the numbers of cells with increased pTAU-ir, need for longer treatment, or the involvement of other mechanisms of action.

Successful harmonization in EpiBioS4Rx biomarker study on post-traumatic epilepsy paves the way towards powered preclinical multicenter studies

OBJECTIVE

Project 1 of the Preclinical Multicenter Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx) consortium aims to identify preclinical biomarkers for antiepileptogenic therapies following traumatic brain injury (TBI). The international participating centers in Finland, Australia, and the United States have made a concerted effort to ensure protocol harmonization. Here, we evaluate the success of harmonization process by assessing the timing, coverage, and performance between the study sites.

METHOD

We collected data on animal housing conditions, lateral fluid-percussion injury model production, postoperative care, mortality, post-TBI physiological monitoring, timing of blood sampling and quality, MR imaging timing and protocols, and duration of video-electroencephalography (EEG) follow-up using common data elements. Learning effect in harmonization was assessed by comparing procedural accuracy between the early and late stages of the project.

RESULTS

The animal housing conditions were comparable between the study sites but the postoperative care procedures varied. Impact pressure, duration of apnea, righting reflex, and acute mortality differed between the study sites (p < 0.001). The severity of TBI on D2 post TBI assessed using the composite neuroscore test was similar between the sites, but recovery of acute somato-motor deficits varied (p < 0.001). A total of 99% of rats included in the final cohort in UEF, 100% in Monash, and 79% in UCLA had blood samples taken at all time points. The timing of sampling differed on day (D)2 (p < 0.05) but not D9 (p > 0.05). Plasma quality was poor in 4% of the samples in UEF, 1% in Monash and 14% in UCLA. More than 97% of the final cohort were MR imaged at all timepoints in all study sites. The timing of imaging did not differ on D2 and D9 (p > 0.05), but varied at D30, 5 months, and ex vivo timepoints (p < 0.001). The percentage of rats that completed the monthly high-density video-EEG follow-up and the duration of video-EEG recording on the 7th post-injury month used for seizure detection for diagnosis of post-traumatic epilepsy differed between the sites (p < 0.001), yet the prevalence of PTE (UEF 21%, Monash 22%, UCLA 23%) was comparable between the sites (p > 0.05). A decrease in acute mortality and increase in plasma quality across time reflected a learning effect in the TBI production and blood sampling protocols.

SIGNIFICANCE

Our study is the first demonstration of the feasibility of protocol harmonization for performing powered preclinical multi-center trials for biomarker and therapy discovery of post-traumatic epilepsy.

Surgeon experience in second-look transurethral resection of bladder cancer - a prospective study

INTRODUCTION AND OBJECTIVES

Transurethral resection of bladder tumor (TURBT) is crucial in the treatment of bladder tumors and when incorrectly performed can cause staging mistakes. To avoid these errors, a second resection is recommended in selected cases. The aim of this study is to evaluate the surgeon's ability to predict histologically complete primary resection of newly diagnosed bladder tumors avoiding the need for a second TURBT.

METHODS

This is a prospective, observational study involving 47 consecutive patients with newly diagnosed bladder tumors who had previously undergone primary TURBT, and met EAU criteria for second-look TURBT. Second-look TURBT specimens were analyzed for routine histological assessment and compared with the surgeon's impression of the tumor at initial resection.

RESULTS

Of 91 patients submitted to primary TURBT, 47 met the criteria for second-look TURBT. Second-look specimens revealed residual disease in 20.9% of patients and 3 (6.4%) of patients showed upstaging disease. The sensitivity of a senior to detect disease on second-look TURBT in relation to muscle invasion was 75%, and the specificity was 85%.

CONCLUSIONS

Second-look TURBT is crucial in the treatment of bladder cancer and cannot be replaced by a surgeon's opinion, so international recommendations should be followed. Supervision of less experienced surgeons is a cornerstone.

Two- and three-dimensional transesophageal echocardiographic assessment and successful occlusion of a window-like patent ductus arteriosus in two dogs

A 16-month-old Labrador-poodle cross (case 1) and a 3-month-old German shorthaired pointer (case 2) were referred for patent ductus arteriosus (PDA) occlusion. Two-dimensional transthoracic and two- and three-dimensional transesophageal echocardiography revealed a window-like PDA characterized by a wide and short ductus. Due to the atypical PDA morphology with no ampulla in case 1, ductal occlusion was attempted with non-canine-specific Amplatzer occluder devices. However, these were too small and failed to remain stable. Amplatz Canine Duct Occluder (ACDO) devices were used with success in both cases. Due to the defects' morphology, the proximal ACDO disc protruded into the aorta but there were no signs of obstruction to aortic blood flow 16 months (case 1) and 1 month (case 2) post-occlusion. We describe two cases of a window-like type PDA that were successfully occluded with an ACDO.

Hypertrophic cardiomyopathy in a dog: a systematic diagnostic approach

A seven-year-old female neutered Parson Russel Terrier was referred for syncopal episodes. An electrocardiogram revealed paroxysmal atrial flutter followed by periods of sinus arrest, suggesting sick sinus syndrome. Echocardiography showed severe biventricular wall thickening (hypertrophic cardiomyopathy (HCM) phenotype) with no signs of fixed or dynamic left ventricular outflow tract obstruction. Blood pressure, abdominal ultrasound, serum total thyroxin and thyroid-stimulating hormone, and insulin-like growth factor-1 were all within normal limits. Cardiac troponin I was elevated (1.7 ng/mL, ref<0.07). Serological tests for common infectious diseases were negative. A 24-h Holter confirmed that the syncopal episodes were associated with asystolic pauses (sinus arrest after runs of atrial flutter) ranging between 8.5 and 9.6 s. Right ventricular endomyocardial biopsies (EMB) were performed at the time of pacemaker implantation to assess for storage or infiltrative diseases that mimic HCM in people. Histological analysis of the EMB revealed plurifocal inflammatory infiltrates with macrophages and lymphocytes (CD3+ > 7/mm2) associated with myocyte necrosis, but no evidence of myocyte vacuolisation or infiltrative myocardial disorders. These findings were compatible with myocardial ischaemic injury or acute lymphocytic myocarditis. Molecular analysis of canine cardiotropic viruses were negative. The dog developed refractory congestive heart failure and was euthanised 16 months later. Cardiac post-mortem examination revealed cardiomyocyte hypertrophy and disarray with diffuse interstitial and patchy replacement fibrosis, and small vessel disease, confirming HCM. We described a systemic diagnostic approach to an HCM phenotype in a dog, where a diagnosis of HCM was reached by excluding HCM phenocopies.

E2730, an uncompetitive γ-aminobutyric acid transporter-1 inhibitor, suppresses epileptic seizures in a rat model of chronic mesial temporal lobe epilepsy

OBJECTIVE

More than one third of mesial temporal lobe epilepsy (MTLE) patients are resistant to current antiseizure medications (ASMs), and half experience mild-to-moderate adverse effects of ASMs. There is therefore a strong need to develop and test novel ASMs. The objective of this work is to evaluate the pharmacokinetics and neurological toxicity of E2730, a novel uncompetitive inhibitor of γ-aminobutyric acid transporter-1, and to test its seizure suppression effects in a rat model of chronic MTLE.

METHODS

We first examined plasma levels and adverse neurological effects of E2730 in healthy Wistar rats. Adult male rats were implanted with osmotic pumps delivering either 10, 20, or 100 mg/kg/day of E2730 subcutaneously for 1 week. Blood sampling and behavioral assessments were performed at several timepoints. We next examined whether E2730 suppressed seizures in rats with chronic MTLE. These rats were exposed to kainic acid-induced status epilepticus, and 9 weeks later, when chronic epilepsy was established, were assigned to receive one of the three doses of E2730 or vehicle for 1 week in a randomized crossover design. Continuous video-electroencephalographic monitoring was acquired during the treatment period to evaluate epileptic seizures.

RESULTS

Plasma levels following continuous infusion of E2730 showed a clear dose-related increase in concentration. The drug was well tolerated at all doses, and any sedation or neuromotor impairment was mild and transient, resolving within 48 h of treatment initiation. Remarkably, E2730 treatment in chronically epileptic rats led to seizure suppression in a dose-dependent manner, with 65% of rats becoming seizure-free at the highest dose tested. Mean seizure class did not differ between the treatment groups.

SIGNIFICANCE

This study shows that continuous subcutaneous infusion of E2730 over 7 days results in a marked, dose-dependent suppression of spontaneous recurrent seizures, with minimal adverse neurological effects, in a rat model of chronic MTLE. E2730 shows strong promise as an effective new ASM to be translated into clinical trials.

Impact of acute psychosocial stress on attentional control in humans. A study of evoked potentials and pupillary response

Psychosocial stress has increased considerably in our modern lifestyle, affecting global mental health. Deficits in attentional control are cardinal features of stress disorders and pathological anxiety. Studies suggest that changes in the locus coeruleus-norepinephrine system could underlie the effects of stress on top-down attentional control. However, the impact of psychosocial stress on attentional processes and its underlying neural mechanisms are poorly understood. This study aims to investigate the effect of psychosocial stress on attentional processing and brain signatures. Evoked potentials and pupillary activity related to the oddball auditory paradigm were recorded before and after applying the Montreal Imaging Stress Task (MIST). Electrocardiogram (ECG), salivary cortisol, and subjective anxiety/stress levels were measured at different experimental periods. The control group experienced the same physical and cognitive effort but without the psychosocial stress component. The results showed that stressed subjects exhibited decreased P3a and P3b amplitude, pupil phasic response, and correct responses. On the other hand, they displayed an increase in Mismatch Negativity (MMN). N1 amplitude after MIST only decreased in the control group. We found that differences in P3b amplitude between the first and second oddball were significantly correlated with pupillary dilation and salivary cortisol levels. Our results suggest that under social-evaluative threat, basal activity of the coeruleus-norepinephrine system increases, enhancing alertness and decreasing voluntary attentional resources for the cognitive task. These findings contribute to understanding the neurobiological basis of attentional changes in pathologies associated with chronic psychosocial stress.

Technological features of smartphone apps for physical activity promotion in patients with COPD: A systematic review

INTRODUCTION

Low physical activity (PA) levels have a negative impact on the health status of patients with Chronic Obstructive Pulmonary Disease (COPD). Smartphone applications (apps) focused on PA promotion may mitigate this problem; however, their effectiveness depends on patient adherence, which can be influenced by the technological features of the apps. This systematic review identified the technological features of smartphone apps aiming to promote PA in patients with COPD.

METHODS

A literature search was performed in the databases ACM Digital Library, IEEE Xplore, PubMed, Scopus and Web of Science. Papers including the description of a smartphone app for PA promotion in patients with COPD were included. Two researchers independently selected studies and scored the apps features based on a previously developed framework (38 possible features).

RESULTS

Twenty-three studies were included and 19 apps identified, with an average of 10 technological features implemented. Eight apps could be connected to wearables to collect data. The categories 'Measuring and monitoring' and 'Support and Feedback' were present in all apps. Overall, the most implemented features were 'progress in visual format' (n = 13), 'advice on PA' (n = 14) and 'data in visual format' (n = 10). Only three apps included social features, and two included a web-based version of the app.

CONCLUSIONS

The existing smartphone apps include a relatively small number of features to promote PA, which are mostly related to monitoring and providing feedback. Further research is warranted to explore the relationship between the presence/absence of specific features and the impact of interventions on patients' PA levels.

Levetiracetam Pharmacokinetics and Brain Uptake in a Lateral Fluid Percussion Injury Rat Model

Post-traumatic epilepsy (PTE) occurs in some patients following moderate/severe traumatic brain injury (TBI). While there are no approved therapies to prevent epileptogenesis, levetiracetam (LEV) is commonly given for seizure prophylaxis due to its good safety profile. This led us to study LEV as part of the Epilepsy Bioinformatics Study for Antiepileptogenic Therapy (EpiBioS4Rx) Project. The objective of this work is to characterize the pharmacokinetics (PK) and brain uptake of LEV in naïve control rats and in the lateral fluid percussion injury (LFPI) rat model of TBI following either single intraperitoneal doses or a loading dose followed by a 7-day subcutaneous infusion. Sprague Dawley rats were used as controls and for the LFPI model induced at the left parietal region, using injury parameters optimized for moderate-severe TBI. Naïve and LFPI rats received either a bolus injection (intraperitoneal) or a bolus injection followed by subcutaneous infusion over 7days. Blood and parietal cortical samples were collected at specified timepoints throughout the study. LEV concentrations in plasma and brain were measured using validated HPLC-MS/MS methods. Non-compartmental analysis and a compartmental PK modeling approach were utilized. Brain-to-plasma ratios ranged from 0.54-1.4-1. LEV concentrations were well fit by one-compartment, first-order absorption PK models with a clearance of 112 mL/hr/kg and volume of distribution of 293 mL/kg. The single dose pharmacokinetic data were used to guide dose selection for the longer term studies and target drug exposures were confirmed. Obtaining LEV PK information early in the screening phase allowed us to guide optimal treatment protocols in EpiBioS4Rx. Significance Statement The characterization of levetiracetam pharmacokinetics and brain uptake in an animal model of post-traumatic epilepsy is essential to identify target concentrations and guide optimal treatment for future studies.

Splenic Infarction: A Rare Complication of Infectious Mononucleosis

Infectious mononucleosis (IM) is caused by Epstein-Barr virus (EBV), and the condition is characterized by sore throat, fever, lymphadenopathy, and atypical lymphocytosis. These infections are common in early childhood, with a second peak occurring in late adolescence. EBV is spread by contact with oral secretions. Most cases of IM are self-limited. However, there are associated complications, some of which can be serious and fatal. We report the case of a 20-year-old man with splenic infarction and exuberant peritonsillar abscess secondary to an EBV infection. This case highlights the importance of accurate diagnoses and frequent monitoring in IM patients, given the risk of airway obstruction.

Nannochloropsis oceanica microalga feeding increases long-chain omega-3 polyunsaturated fatty acids in lamb meat

To test the hypothesis that lambs fed freeze-dried Nannochloropsis oceanica (NO) biomass will have a higher deposition of EPA in tissues than those fed other Nannochloropsis EPA-sources, we fed 28 lambs with one of four diets: i) C, control, without EPA; ii) O, with 1.2% Nannochloropsis oil; iii) SD, with 12.3% spray-dried NO biomass; iv) FD, with 9.2% freeze-dried NO biomass. Dry matter intake, growth, tissues fatty acid composition, oxidative stability and sensory traits of the resultant meat were evaluated. The EPA was highest in tissues of lambs fed SD and FD compared with O but was similar between SD and FD. Total trans-18:1 did not differ among treatments, but the t10/t11-18:1 ratio decreased with all EPA containing diets. EPA diets were also supplemented with Vitamin E preventing the lipid oxidation in EPA-enriched meat and the meat sensory traits were not affected although occasionally some off-flavours were detected in FD meat.

Thin and hypokinetic myocardial segments in cats with cardiomyopathy

INTRODUCTION/OBJECTIVES

Thin and hypokinetic myocardial segments (THyMS) represent adverse ventricular (LV) remodeling in human hypertrophic cardiomyopathy. We describe the echocardiographic features and outcome in cats with THyMS, and in a subpopulation, the echocardiographic phenotype before LV wall thinning was detected (pre-THyMS).

ANIMALS

Eighty client-owned cats.

MATERIALS AND METHODS

Retrospective multicenter study. Clinical records were searched for cats with THyMS, defined as LV segment(s) with end-diastolic wall thickness (LVWT) <3 mm and hypokinesis in the presence of ≥one LV segment(s) with LVWT >4 mm and normal wall motion. When available, echocardiograms pre-THyMS were assessed. Survival time was defined as time from first presentation with THyMS to death.

RESULTS

Mean thickest LV wall segment (MaxLVWT) was 6.1 mm (95% CI 5.8-6.4 mm) and thinnest (MinLVWT) was 1.7 mm (95% CI 1.6-1.9 mm). The LV free wall was affected in 74%, apex in 13% and septum in 5%. Most cats (85%) presented with heart failure and/or arterial thromboembolism. Median circulating troponin I concentration was 1.4 ng/mL ([range 0.07-180 ng/mL]). Prior echocardiography results were available for 13/80 cats, a mean of 2.5 years pre-THyMS. In segments subsequently undergoing thinning, initial MaxLVWT measured 6.7 mm (95% CI 5.8-7.7 mm) vs. 1.9 mm (95% CI 1.5-2.4 mm) at last echocardiogram (P<0.0001). Survival data were available for 56/80 cats, median survival time after diagnosing THyMS was 153 days (95% CI 83-223 days). Cardiac histopathology in one cat revealed that THyMS was associated with severe transmural scarring.

CONCLUSIONS

Cats with THyMS had advanced cardiomyopathy and a poor prognosis.

Lewy Body Pathology and Alzheimer Disease in Down Syndrome

Introduction/Objective

Aging adults with Down syndrome (DS) develop Alzheimer disease neuropathology (AD) by the age of 40 years, primarily due to the overexpression of the amyloid precursor protein on chromosome 21. Lewy bodies (LBs), containing alpha-synuclein protein, are observed in 7-60% of AD patients in the amygdala and in cortex. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. We hypothesized that LB pathology would also be present in DS brain with similar locations and prevalence to AD. Thus, we evaluated the frequency of LB in our UCI cohort of DS cases that we have collected over the past 25 years.

Methods/Case Report

Neuropathology reports from 55 cases with DS from the UCI-ADRC were included in this study. Cases were stained for beta-amyloid, phosphor-tau, alpha-synuclein and TDP-43 as per NACC protocols (one case each v7,8,9 and three v11).

Results (if a Case Study enter NA)

We identified 6 cases (10.9%), all male, with a mean age of 57 years (SD=3) that showed LB and/or Lewy neurites. LB pathology was classified as amygdala predominant in 3 cases, brainstem predominant in one, intermediate/transitional in one, and diffuse/neocortical in one. Five cases were BRAAK stage 6 and one was stage 5. Five cases had CERAD neuritic plaque score C and one case had a B score. Two of 3 cases were Thal phase 5, and one was phase 4. The case with diffuse/neocortical LB pathology demonstrated hippocampal sclerosis.

Conclusion

The observation that all our LB positive cases were male may reflect a sample bias. In our study, Lewy pathology was most common in amygdala but other sites of involvement are seen similar to a prior DS study and AD studies. Prior DS studies (n=20-56 cases) find the frequency of LB pathology to range between 8-50% of cases being affected. The prevalence of LB in our DS cohort (10.9%) is in the low end of the range seen in other DS and AD studies.

P-064 Clinical outcomes of 127 patients with recurrent implantation failure treated with testicular sperm aspiration (TESA)

Study question

Are the embryological, clinical and newborn outcomes using aspirated testicular sperm improved in cases with recurrent implantation failure previously treated with ejaculated sperm?

Summary answer

Aspirated testicular sperm enabled to obtain significant higher embryological, clinical and newborn outcomes in cases with recurrent implantation failure previously treated with ejaculated sperm.

What is known already

High levels of sperm DNA fragmentation (SDF) were associated to poor clinical outcomes (1-Simon et al., 2017). Testicular sperm display lower SDF than ejaculated sperm (2-Sakas and Alvarez, 2010), improving clinical outcomes in cases with abnormal semen parameters (3-Awaga et al., 2018; 4-Kang et al., 2018), recurrent implantation failure (RIF) and pregnancy loss (RPL) (5-Esteves et al., 2017), and elevated SDF (6-Ambar et al., 2021). As only a few studies are specifically dedicated to RIF, we expanded the number of cases and first provided full demographic, stimulation, embryological, clinical and newborn outcomes.

References

1-(https://doi.org/10.4103/1008-682X.182822);

2-(https://doi.org/10.1016/j.fertnstert.2009.10.046);

3-(https://doi.org/10.1016/j.rbmo.2018.08.017);

4-(https://doi.org/10.1038/s41598-018-26280-0);

5-(https://doi.org/10.1016/j.fertnstert.2017.06.018);

6-(https://doi.org/10.5534/wjmh.200084

Study design, size, duration

We retrospectively evaluated during consecutive years (2010-2020) 63 patients with recurrent implantation failure, which accepted to perform testicular sperm aspiration (TESA) as an alternative treatment. These patients presented a long history of failed treatments (153 cycles) using ejaculated sperm. From these cycles, no pregnancy ensued. The present study compares 127 treatment cycles, 80 with testicular sperm (17 cases repeated TESA) and 47 with ejaculated sperm from the same patients performed at the present IVF clinic.

Participants/materials, setting, methods

Patients were screened for karyotype abnormalities, for Y-chromosome microdeletions (7-Gonçalves et al., 2016), and for SDF with the TUNEL assay (8-Sá et al., 2015). Conventional semen analysis was performed according to World Health Organization guidelines (9-WHO, 2010). Male evaluation and TESA was performed by the same experienced urologist (LF) according to established protocols (10-Madureira et al 2014). The procedure was performed entirely on an outpatient basis, with no complications reported.

References

7-(https://doi.org/10.4103/1008-682X.172827);

8-(https://doi.org/10.1016/j.rbmo.2015.06.019);

9-(https://apps.who.int/iris/handle/10665/44261);

10-(https://doi.org/10.1111/j.2047-2927.2014.00231.x).

Main results and the role of chance

The mean ages were 35.5±3.4 (26-42)-female and 38.1±5.7 (29-59)-male. There were 4 abnormal karyotypes (3-female, 1-male), all without known relevance. Most cases had asthenozoospermia and teratozoospermia (65.1%), or oligoasthenoteratozoospermia (41.8%). Of the 19 cases with &lt;5M/ml, none presented Y-chromosome microdeletions. Although we do not routinely perform SDF testing, 15 patients had previous SDF values (12, &gt;20%; 8, &gt;36%). Female basal characteristics and testicular evaluation were under normal values. The TESA procedure took about 15-20 min, and the time of laboratorial search around 30-60 min. Cases using testicular sperm showed significant higher rates of fertilization (64% vs 73%-p=0.005), blastocyst development (47% vs 62%-p=0.010), implantation (6% vs 27%-p=0.000), clinical pregnancy (10% vs 39%-p=0.001), live birth delivery (5% vs 28%-p=0.005) and newborn (5% vs 32%-p=0.000) than ejaculated sperm. No significant differences were observed regarding the rates of embryo cleavage (95% vs 94.8%) and high quality embryos (89.4% vs 94%), in the mean number of transferred embryos (1.8±0.4 vs 1.9±0.4), or in the abortion rate (2 cases-50% vs 7 cases-25.9%). Cases using testicular sperm had 22 frozen-thawed embryo transfer cycles, enabling per initiated cycle a cumulative pregnancy rate of 45%, live birth delivery rate of 31.3% and newborn rate of 37.5% (32 newborn).

Limitations, reasons for caution

Although presenting the higher number of cycles using TESA in the treatment of RIF, this number needs to be increased for drawing more definitive conclusions, as these women present a diversity of conditions, rendering subgrouping difficult. In the future, it would also be important to evaluate SDF in all cases.

Wider implications of the findings

In conclusion, the present results gave further evidence for the superiority of using testicular sperm instead of ejaculated sperm in cases with recurrent implantation failure. Data also evidences the security of using testicular sperm aspiration, as there were no pregnancy or delivery complications, or congenital anomalies among the 32 newborn.

Trial registration number

Not Applicable

AB0926 ENTHESITIS OF THE HAND IS A DOMINANT LESION IN PSORIATIC ARTHRITIS AND MAY HELP DISTINGUISH IT FROM RHEUMATOID ARTHRITIS: CASE-CONTROL, SINGLE-CENTRE, ULTRASOUND STUDY

Background

Enthesitis is the hallmark of psoriatic arthritis (PsA) and may assist in distinguishing PsA from other forms of arthritis (1,2). Its clinical evaluation is hampered by lack of specificity of physical examination (3). Ultrasound (US) may provide information about its presence and response to treatment. Although some previous works have shown that enthesitis of the hand is important in PsA (4), most US studies and scores focused on greater size entheses.

Objectives

To explore the prevalence of enthesitis of the hand in PsA patients as evaluated by US, and compare it with other inflammatory arthritides, namely rheumatoid arthritis (RA).

Methods

Cross-sectional study in which consecutive patients with PsA and RA were recruited for an US protocol evaluating 4 entheses of the hand including: 1. measurement of the extensor digitorum tendon central slip at its insertion at the middle phalanx of the 2nd and 3rd finger bilaterally; 2. search for the presence of power-Doppler (PD) sign; 3. identification of structural lesions.

Linear regression models were built to test if diagnosis (PsA vs RA) explained part of the variance of the thickness of tendons insertion while controlling possible influences of age, type of work and body surface area. A ROC curve was built to find a mean thickness cut-off allowing distinction between PsA and RA. The prevalence of PD sign and structural lesions of the entheses was compared between groups.

Results

Fifty-eight patients were recruited (29 with PsA and 29 with RA) and a total of 232 entheses were evaluated.

Mean thickness of the interest entheses was superior in PsA patients compared to RA patients (2nd finger – 0.96 ± 0.16mm vs. 0.74 ± 0.09mm; 3rd finger – 0.96 ± 0.20mm vs. 0.76 ± 0.11mm).

Linear regression models including diagnosis and potential confounders significantly explained mean thickness of both entheses (2nd finger – R2=0.56, p<.001; 3rd finger – R2=0.41, p<.001), with the diagnosis group being the most important predictor (Table 1). ROC curve (AUC 0.897, p<.001) showed a cut-off value of 0.925mm for the mean of the 4 entheses had a specificity of 93.1% for the identification of PsA patients.

Table 1.

Multiple linear regression models explaining thickness of the entheses.

2nd finger (mean of both sides)3rd finger (mean of both sides)Linear regression modelR2=0.56p<.001***R2=0.39p<.001***Diagnosis (PsA vs RA)β=0.587; B=0.203mmp<.001***β=0.483; B = 0.182mmp<.001***

In our sample, 8 (3.5%) entheses had a measured thickness above mean + 2 SD, all belonging to PsA patients; 6 (75%) had signs of ongoing inflammatory process as proved by the presence of PD sign (Figure 1). Regarding structural lesions, enthesophytes or bone irregularities/erosions were found in 13.8% of PsA entheses, which compared to 1.7% of RA entheses.

Figure 1.

Enthesitis of the central slip of extensor digitorum of the 3rd finger in a patient with PsA: swelling of the 3rd proximal interphalangeal joint (A) due to inflammatory process originating in the enthesis, with no signs of synovitis, as evaluated by US (B).

Conclusion

This work reinforces enthesitis as a key lesion in PsA. It also shows enthesitis occurs significantly in small entheses, like the ones of the hand and that, in some instances, it may be the dominant lesion in a swollen joint. US may be valuable for establishing a diagnosis in the setting of inflammatory arthritis of unknown etiology.

References

[1]Mease P. Enthesitis in psoriatic arthritis (Part 3): clinical assessment and management. Rheumatology. 2020 Mar 1;59(Supplement_1):i21–8.

[2]Sapundzhieva T, Karalilova R, Batalov A. Hand ultrasound patterns in rheumatoid and psoriatic arthritis: the role of ultrasound in the differential diagnosis. Rheumatol Int. 2020 Jun;40(6):837–48.

[3]Kaeley GS. Enthesitis in psoriatic arthritis (Part 2): imaging. Rheumatology. 2020 Mar 1;59(Supplement_1):i15–20.

[4]Smerilli G, Di Matteo A, Cipolletta E, Grassi W, Filippucci E. Enthesitis in Psoriatic Arthritis, the Sonographic Perspective. Curr Rheumatol Rep. 2021 Sep;23(9):75.

Disclosure of Interests

None declared

Depression and health-related quality of life in critical COVID-19 survivors

Introduction

Long-term neuropsychiatric consequences of critical illness are well known. Therefore, it is expected that critical COVID-19 patients might also present several psychiatric symptoms such as depression, with inevitable negative effect on health-related quality of life (HRQoL), commonly used as an indicator of illness and treatment impact.

Objectives

To identify depressive symptoms in critical COVID-19 survivors and to examine its association with HRQoL domains.

Methods

This preliminary study involved critical COVID-19 patients admitted into the Intensive Care Medicine Department (ICMD) of a University Hospital, between October and December of 2020. Patients with an ICMD length of stay (LoS)≤24h, terminal illness, major auditory loss, or inability to communicate at the follow-up time were excluded. From 1-2 months after discharge, all participants were evaluated by telephone at follow-up appointment, with Patient Health Questionnaire (PHQ-9) (depression) and EuroQol 5-dimension 5-level EQ-5D-5L (HRQoL). This study is part of the longitudinal MAPA project.

Results

Eighty-three patients were included with a median age of 63 years (range: 31-86) and the majority were male (63%). The most reported problems on EQ-5D-5L domains were usual activities (82%) and mobility (76%). About 27% presented depressive symptoms, and with more problems of self-care (68%vs41%; p=0.029), pain/discomfort (86%vs49%; p=0.002), and anxiety/depression (96%vs54%; p<0.001).

Conclusions

These preliminary results are in line in previous studies in critical COVID-19 survivors, with depression being associated with worse HRQoL. Bearing this in mind, follow-up approaches with an early screening and treatment of these psychiatric symptoms will be fundamental to optimize the recovery of these patients.

Disclosure

No significant relationships.

POS1518-HPR BELIEFS ABOUT MEDICATION IN A POPULATION OF PATIENTS WITH INFLAMMATORY ARTHROPATHY

Background

The beliefs that patients have regarding their medication, namely about its need and concerns regarding possible adverse effects, are a determining factor for adherence and therapeutic success1.

Objectives

Determine which sociodemographic and clinical factors are associated with beliefs related to medication, either in terms of necessity or concerns about medication, in patients with Rheumatoid Arthritis (RA) or Psoriatic Arthritis (PsA).

Methods

Observational study, with a sample consisting of 58 patients (female 72,4%, male 27,6%; mean age = 51,0 ± 13,2 years; education < 9 years 39,7%, ≥ 9 years 60,3%). Of these, 33 had a diagnosis of RA and 25 of PsA (mean years of disease duration = 8,2 ± 7,3 years; mean disease activity by DAS28-PCR or DAS28-PCR 3 variables = 2,32 ± 0,95). Between March 2021 and June 2021, a brief questionnaire was applied with sociodemographic and clinical variables, such as the use of classic or biological DMARDs and their administration´s route. The Specific Beliefs About Medication Scale (BMQ) was anonymously applied, adapted from the Beliefs About Medicines Questionnaire, comprising 2 sections: section 1 – Specific Needs, patients beliefs about the need for medication; section 2 – Specific Concerns, beliefs related to the dangers of addiction and long-term toxicity or side effects. Higher scores (scale from 5 to 25 points), in sections 1 and 2, reflect the belief of greater need and greater concern regarding medication, respectively. The average scores in section 1 and in section 2 of the BMQ were 9 and 15,7 points, respectively. Statistics: descriptive, Student t-Test, Pearson Correlation and ANOVA, p<0,05.

Results

Patients with PsA and younger age had a higher mean score in section 2 of the BMQ (p= 0,049 e p<0,01, respectively). The variables male gender, education ≥ 9 years and shorter duration of the disease also showed a tendency to be associated with the higher score in section 2 of the BMQ, with p-values close to statistical significance (p=0,091, p=0,074 and p=0,094, respectively). In the multivariate analysis with the above variables, only the diagnosis of PsA showed a statistically significant association with the score in section 2 of the BMQ (B=4,269; p<0,001; CI 95%=[2,060-6,477]). There was also a statistically significant correlation (p=0,007) between the scores in section 1 and section 2 of the BMQ. Regarding analysis of the sample by diagnosis, there was an association between the subcutaneous route of drug administration in individuals with RA and greater concern with the adverse effects of the medication (p=0,007), and between low disease activity and greater belief in the specific need for medication for the disease (p=0,006).

Conclusion

In this study, patients with PsA were more concerned about the possible adverse effects of medication than patients with RA. RA patients who take subcutaneous drugs are more afraid of the drug’s toxic potential, and those with lower disease activity have a greater need to comply with the prescribed therapy, which can be explained by the previous effectiveness of the drug in disease control. It was also found that the greater the belief in the need for medication, the greater the concern with its possible long-term harmful effects.

References

[1]Smolen JS, Gladman D, McNeil HP, et al. Predicting adherence to therapy in rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis: A large cross-sectional study. RMD Open. 2019;5(1):1-13. doi:10.1136/rmdopen-2017-000585

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

The Mediating Role of Resilience and Life Satisfaction in the Relationship between Stress and Burnout in Medical Students during the COVID-19 Pandemic

Following the WHO's declaration of a public health emergency due to the COVID-19 outbreak, the subsequent quarantine and confinement measures that were adopted, including distance learning measures, were shown to have caused a significant deterioration in the mental health of medical students. The goal of this study was to explore the mediating role of resilience and life satisfaction in the relationship between perceived stress and burnout among medical students in the context of COVID-19. A transversal assessment was performed using an online questionnaire, to which 462 students responded. The instruments applied were the Perceived Stress Scale-10, the Resilience Scale-25 items, the Satisfaction with Life Scale (SWLS), and the Burnout Scale (Oldenburg Inventory). A regression model was estimated for each dimension of burnout. The results revealed that resilience and life satisfaction play a mediating role in the association between stress and the dimensions of burnout. This suggests that measures of promoting mental health based on resilience and improving perceptions of life should be implemented.

Case report: Advice for schools on managing functional tic-like behaviours

There has been an increase in the occurrence of sudden onset functional tic-like behaviours in adolescents during the COVID-19 pandemic, which has had a significant impact on the affected individual's ability to engage with education. The aim of this article is to generate discussion and inform practice within schools with regard to the management of functional tic-like behaviours. An advice sheet for schools has been produced based on clinical expertise and experience of consulting with schools around the management within education settings. Case examples are presented highlighting the importance and impact of these strategies. We also highlight the need for further evaluation of the effectiveness of the advice sheet in collaboration with schools and families.

Sociocultural factors of cervical cancer screening uptake among migrant women: a mixed methods study

 

Cervical cancer has a high mortality in Europe despite being preventable by cervical cancer screening (CCS). Migrant women have a lower CCS attendance compared to non-migrants. This study aims to describe CCS uptake among migrant women in Portugal and explore sociocultural influences. Within a mixed-methods approach, an online survey and focus group discussions (FGs) were conducted. The survey included 655 migrant women and collected data on sociodemographics, attendance and attitudes toward CCS. Four FGs with 12 healthcare workers and a FG with 5 community workers were conducted exploring perceptions on CCS attendance and barriers among migrant women. Quantitative data was analyzed using descriptive analysis and Chi-Square test and qualitative data through content analysis. Survey data shows that 24.9% of women never had CCS or had it over 5 years ago, more Asian and African women (51.3% and 36.7%, respectively) (p &lt; 0.001). Non-attenders reported significantly more often embarrassment towards CCS (21.7% vs. 18.8% of CCS attenders, p = 0.002) and being unaware of their risk of cancer and the relevance of CCS (28.8% vs. 12.5%, p &lt; 0.001). Around 24% of non-attenders reported concern with having a consultation with a male doctor. For FGs participants, CCS is a taboo in some communities, particularly African, Asian and Muslim. Lack of information about CCS along with feelings of embarrassment and discomfort related to pap smear and with being seen by a male doctor were referred as reasons for avoidance of CCS. Participants also stated that some women have low autonomy and often their husbands have a key role in deciding whether they should attend CCS. Lack of a preventive mindset was also stated as reason for low CCS attendance. The sociocultural background can influence migrant women's attendance to CCS. A culturally grounded approach is needed to provide tailored information on CCS and to create opportunities to engage migrant communities on CCS and improve their uptake.

Key messages

Lack of information, embarrassment and low autonomy hinder some migrant women’s attendance to CCS. The sociocultural influences on CCS uptake call for a culturally grounded approach to provide tailored information and engage migrant communities on CCS.

Associations between Cues of Sexual Desire and Sexual Attitudes in Portuguese Women

Sexuality is defined as a multidimensional experience that involves genital, mental, and bodily components. It is also assumed as a basic condition inherent to the human existence that encourages the search for love, intimacy, sex, and proximity to others. The main objective of this study is to assess the relationship between cues of sexual desire and sexual attitudes in Portuguese women. This is a cross-sectional study with 804 Portuguese women to whom the protocol was applied. It included an informed consent, a sociodemographic questionnaire, a questionnaire related to intimacy, a scale of sexual attitudes, and the scale of cues of sexual desire. The protocol was applied via Google Forms due to the current pandemic situation (COVID-19). Differences were found in sexual attitudes and the cues of sexual desire in terms of sociodemographic characteristics, as well as in terms of women's intimacy. Significant correlations were found between the brief sexual attitudes scale (BSAS) and the cues of sexual desire scale (CSDS). Age, sexual orientation, relation nature, sexual practices, visual proximity cues, erotic explicit cues, and sensory explicit cues explain, altogether, 25% of the total sexual attitudes. Additionally, age, sexual orientation, the relation's nature, sexual practices, visual proximity cues, emotional bonding cues, romantic implicit cues, erotic explicit cues, and sensory explicit cues explain, altogether, 30% of the permissiveness. Sexual attitudes are developed under the influence of sociodemographic variables, variables related to women's intimacy, and cues of sexual desire, which are new data in the study of sexual attitudes and have implications at the level of gender issues.

Stent strategies in left main bifurcation lesions: the simpler, the better?

Introduction

Although percutaneous coronary intervention (PCI) for ostial or midshaft lesions in left main (LM) disease has shown similar results as compared with coronary artery bypass grafting (CABG), distal LM bifurcations are associated with an increase in procedural complexity and higher rates of target lesion revascularization. Several studies have investigated the optimal stenting strategy in patients with coronary bifurcation lesions and showed no benefit for systematic two-stent approach in comparison with provisional stenting. This is reflected in the current guidelines that recommend provisional stenting of the side branch as the preferred approach for most bifurcation lesions. However, there is still debate about the optimal strategy according to lesion location.

Objectives

This analysis aimed to compare the clinical outcomes of LM bifurcation PCI using a provisional strategy versus a two-stent strategy.

Methods

Retrospective, observational study including patients submitted to LM bifurcation (Medina 1,1,1) PCI between January 2010 and December 2019. Data was collected from the emergency department and hospitalization registries. Patients were divided according to the stenting approach. We made a global analysis including baseline clinical and angiographic data. The primary endpoint was target lesion failure (TLF), defined as the composite of myocardial infarction, cardiac death, and target lesion revascularization (TLR). Secondary endpoints included the individual components.

Results

A total of 106 patients were included (median age 74 [66–82], 79 (74.5%) males), 57 (53.8%) submitted to provisional stenting and 49 (46.2%) to a two-stent technique. Baseline characteristics were well matched (table 1). The mean SYNTAX score was 29.6±10.0 and LM stenosis grade was ≥70% in all lesions. Median follow-up was 26.6 [12.0–48.6] months. No differences were found regarding the primary endpoint (TLF in provisional stenting was 21.7% vs 21.4%, HR 2.432; 95% confidence interval, 0.472–12.450; p=0.233.). Although target lesion revascularization within the LM complex was numerically higher in the two-stent group (10.2% vs. 3.5%, p=0.245), the opposite was found in cardiac death (provisional group 10.5% vs. 4.3%, p=0.289).

Conclusions

Besides being a “simpler” technique, provisional stenting had no significant differences in outcomes compared to two-stent techniques. Without further evidence, revascularization strategies should primarily rely on operator expertise.

Funding Acknowledgement

Type of funding sources: None.

An Apparently Balanced Complex Chromosome Rearrangement Involving Seven Breaks and Four Chromosomes in a Healthy Female and Segregation/Recombination in Her Affected Son

Duplication of the distal 1q and 4p segments are both characterized by the presence of intellectual disability/neurodevelopmental delay and dysmorphisms. Here, we describe a male with a complex chromosome rearrangement (CCR) presenting with overlapping clinical findings between these 2 syndromes. In order to better characterize this CCR, classical karyotyping, FISH, and chromosomal microarray analysis were performed on material from the patient and his parents, which revealed an unbalanced karyotype with duplications at 1q41q43 and 4p15.2p14 in the proband. The rearrangements, which were derived from a maternal balanced karyotype, included an insertion of a segment from the long to the short arm of chromosome 1, a balanced translocation involving chromosomes 14 and 18, and an insertion of a segment from the short arm of chromosome 4 into the derived chromosome 14. This study aimed to better define the clinical history and prognosis of a patient with this rare category of chromosomal aberration. Our results suggest that the frequency of CCR in the general population may be underestimated; when balanced, they may not have a phenotypic effect. Moreover, they emphasize the need for cytogenetic techniques complementary to chromosomal microarray for proper genetic counseling.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Histological findings after non-ablative Er:YAG laser therapy in women with severe vaginal atrophy

Objective: The aim of this study was to evaluate the effect of non-ablative erbium vaginal laser treatment on vaginal mucosa tissue affected by severe atrophy.Methods: Ten patients with severe genitourinary syndrome of menopause were treated with two sessions of the non-ablative erbium-doped yttrium aluminium garnet laser (Er:YAG laser) separated by 4 weeks. Vaginal biopsies were performed before and 3 months after the second treatment. The improvement in vaginal atrophy was assessed using multiple measuring tools before and 6 months after the treatment. The degree of patients' satisfaction was also assessed.Results: Microscopic examination showed significant changes in the main structural components of the vaginal wall mucosa after two non-ablative Er:YAG laser sessions. The epithelial thickness increased from 45 µm (10-106 µm) to 153 µm (97-244 µm) measured 3 months after the final laser treatment. Vaginal atrophy improved in all patients by all measured outcomes. The degree of patient satisfaction was very high (3.6 on the Likert four-point scale). No adverse events or complications were observed in any of the sessions. Conclusion: The non-ablative Er:YAG laser seems to be a safe and effective method to increase epithelial thickness of the vaginal mucosa in patients with severe vaginal atrophy.