Investigation of type 1 collagen a1 chain in plasma as a potential novel biomarker for prediction of coronary heart disease

Background

Remodeling of the extracellular matrix (ECM) plays a crucial role in development and progression of atherosclerosis. Collagens, in particular type I collagen, are the most abundant ECM proteins in an atherosclerotic plaque. Recently, type I collagen α1 chain (COL1α1) in plasma was identified as a potential predictor of coronary heart disease (CHD).

Aim

The aim was to further confirm the predictive value of COL1α1 and also to investigate its correlates in a population-based cohort as well as changes over time in patients with manifest CHD in Sweden.

Methods

In a total of 1007 well-characterized individuals (50% women), 86 CHD cases and 184 sex- and age-matched controls were identified at 13 years follow-up. CHD at follow-up was defined as first-time event of myocardial infarction (MI) or invasive coronary intervention. Plasma levels of COL1α1 was quantified by the Luminex assay while PRO-C1 and C1M, two markers of type I collagen synthesis and degradation, respectively, were quantified by ELISA. In Cox proportional hazard analysis, log2 values of biomarker levels were used. In addition, temporal change of COL1α1 levels was also examined in a cohort of 125 patients with acute MI followed for 6 months.

Results

COL1α1 levels were significantly associated with incident CHD, both unadjusted (HR = 0.69, 95% CI 0.56–0.87, p=0.001) and after multiple adjustment (HR = 0.55, 95% CI 0.41–0.75, p<0.001). PRO-C1 was similarly associated with CHD, unadjusted (HR = 0.62, 95% CI 0.47–0.82, p=0.001) as well as adjusted (HR = 0.61, 95% CI 0.43–0.86, p=0.005), while C1M was not. In patients with acute MI, COL1α1 levels remained stable over 6 months. COL1α1 was significantly correlated to PRO-C1 (r=0.73, p<0.001), while there were no correlations to C1M, markers of inflammation (C-reactive protein, interleukin-6, matrix metalloproteinase-9) or myocardial injury (troponin T).

Conclusions

Circulating COL1α1 in plasma was independently and inversely associated with incident CHD. Furthermore, COL1α1 levels appeared to be relatively stable after an acute MI. COL1α1 levels seem to reflect collagen synthesis rather than collagen degradation and inflammation. Future studies are needed to confirm whether COL1α1 is a clinically useful marker and/or predictor of CHD.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This research was in part financed by a grant from the Region of Östergötland, Sweden, aimed towards scientists early in their career. We would like to thank the people behind this grant for contributing to this research.This research was also partly supported by Futurum - the academy for healthcare in Region Jönköping County.

P–179 Timing of blastocyst observation on day 5: effect on the assessment to predict live birth, and the incorporation into a blastocyst selection model

Study question

Does variation in day 5 observation timing confound embryo-morphology-based live birth prediction, and is it possible to develop a robust comprehensive numerical prediction model.

Summary answer

Day 5 observation timing confounds embryo-morphology-based live birth prediction. A robust comprehensive numerical prediction model can be developed after considering a number of contributing variables.

What is known already

Embryo development is a dynamic process, and therefore the widely used static observations potentially lead to biased prediction of live birth outcomes. So far, little is known in regard to potential confounding impact of day 5 assessment timing on the static-morphology-based live birth prediction. In addition, the inter-observer variation in morphology-based embryo assessment requires a more robust system to improve consistency of selection.

Study design, size, duration

This retrospective multi-center cohort study included 8866 autologous oocyte in vitro fertilisation treatment cycles performed at 14 associated clinics within the same network during 2012–2018. Only fresh cycles with single day 5 embryo transfers were included for analysis with all pregnancies followed up until birth. Repeat cycles of same patients were excluded to avoid clustering effect in statistical analysis.

Participants/materials, setting, methods

Dataset was randomly split into two subsets at 60:40 ratio, with one (n = 5274) used for regression analysis and model development and the other (n = 3592) used for model testing. Multiple logistic regression was performed to evaluate live birth predicting power of several potential contributors, expressed by odds ratio (OR) and 95% confidence interval (CI). A comprehensive prediction model was subsequently developed based on calculated weights of contributing factors, then tested via receiver operating characteristics (ROC) analysis.

Main results and the role of chance

The timings of day 5 observation of 8866 included embryos, measured by hours post insemination (HPI), distributed in a bell shape ranging from 112.0 to 120.0 h (mean±SD 115.7±1.7 h). After taking into account female age at egg collection (grouped as < 30 yr, 30–34 yr, 35–39 yr, 40–44 yr, and 45 yr or older), whether or not the first egg collection, number of eggs collected, embryo developmental stage (grouped as pre-blastocyst, early blastocyst, expanding blastocyst, expanded blastocyst, and hatching/hatched blastocyst) and morphology score(A/B/C/D); multivariate logistic regression analysis showed significant association (OR 1.096, 95% CI 1.020–1.177, P = 0.012) between HPI groups (112–113.9 h, 114–115.9 h, 116–117.9 , and 118–120 h) and subsequent live birth outcomes. A comprehensive numerical scoring system was developed based on the statistically significant predictors including female age (OR 1.465, 95% CI 1.364–1.574, P = 0.000), embryo developmental stage (OR 1.341, 95% CI 1.244–1.445, P = 0.000), morphology score (OR 1.520, 95% CI 1.392–1.661, P = 0.000) and HPI (OR mentioned above); with a formula of Score = (Female_age_group/5)*1.465 + (Developmental_stage/5)*1.341 + (Morpho_Score/4)*1.520 + (HPI_Group/4)*1.096. ROC analysis showed statistically significant predictive power of the resulting model as expressed by area under the ROC curve using both the development (0.690, 0.675–0.704, P = 0.000) and testing (0.685, 0.667–0.703, P = 0.000) subsets.

Limitations, reasons for caution

The retrospective design does not allow for controlling of unknown confounders. HPI was based on static observations in this study so future time-lapse study may bring more insights with more accurate observation and measurement.

Wider implications of the findings: The varying HPIs at day 5 observation were alarming as this could confound live birth prediction using embryology parameters. It is important to standardise the timing of embryo observations. The inclusion of HPI into a comprehensive numerical scoring system for live birth prediction may potentially improve its robustness

Trial registration number

Not applicable

O-213 Slow day 5 development affects implantation potential of fresh transferred embryos but not birthweight once pregnancy occurs: A multi-center retrospective cohort study

Study question

Does slow development of fresh transferred day 5 embryos lead to decreased implantation potential and birthweight?

Summary answer

Slow day 5 development was associated with reduced implantation potential when transferred fresh but the subsequent birthweight of the resulting baby was not impacted.

What is known already

Slow development of in vitro cultured cleavage stage embryos is associated with reduced blastocyst development and implantation rates. There is no current consensus regarding whether to transfer fresh slow developing day 5 embryos or to extend culture for a subsequent day with potential for cryopreservation. It is therefore important to understand the true prognosis of fresh transferred day 5 embryos at less advanced developmental stages. This would provide evidence based guidelines for the decision making process in regard to embryo transfer.

Study design, size, duration

This is a retrospective multi-center cohort study, including 1213 consecutive patients undergoing autologous oocyte in vitro fertilization (IVF) treatment during 2016-2019,with fresh transfer of a single day 5 embryo (selection based on developmental stage and inner cell mass and trophectoderm morphology if blastocyst was at the ≥expanding stage). Cycle data were collected from 4 associated private clinics, with repeat cycles of same patients excluded to avoid clustering effect at statistical analysis.

Participants/materials, setting, methods

Live birth and birthweight were followed up in all 1213 fresh day 5 SETs. Multiple regression (logistic or linear) was performed to investigate association between slow day 5 development (defined as ≤ early blastocyst) and (a)live birth, (b) birthweight, and (c) gestation-adjusted birthweight (Z score) to account for gestational age, gender and compared to embryos at ≥ expanded stage. Results were expressed as adjusted odds ratio (aOR) with 95% confidence interval (CI)or coefficients (β).

Main results and the role of chance

No implantation was achieved following single fresh transfer of day 5 embryos that failed to reach early blastocyst stage (n = 76) and were transferred as ≤ morula stage. Live birth rate was significantly lower following single day 5 fresh transfer of an early blastocyst (n = 237, 16%), in comparison to expanding (n = 329, 27%, P = 0.001), expanded(n = 392, 41%, P = 0.000), and hatching/hatched blastocysts (n = 169, 44%, P = 0.000). After adjusting for potential confounding factors including; maternal age, hours post insemination at day 5 assessment, number of oocytes collected, number of 2PN embryos, and number of embryos frozen; multiple logistic regression showed significantly reduced likelihood of live birth resulting from early blastocysts in reference to those at the expanding (aOR=0.584, 0.371-0.917, P = 0.020), expanded (aOR=0.322, 0.208-0.501, P = 0.000), or hatching/hatched stages (aOR=0.255, 0.147-0.443, P = 0.000). However, multivariate linear regression indicated that early blastocysts resulting in a live birth (n = 39) did not lead to altered birthweight (β=-9.091, P = 0.904; β=-34.960, P = 0.343; β=-26.074, P = 0.414; respectively) or Z score (β = 0.045, P = 0.706; β=-0.051, P = 0.426; β=-0.028, P = 0.506; respectively) in reference to the expanding (n = 90), expanded (n = 160), or hatching/hatched stages (n = 75).

Limitations, reasons for caution

The retrospective nature of this study does not allow controlling of unknown confounders. The 4 participating clinics are associated within the same network with shared protocols, therefore, results may not be generalized to other clinics with different settings.

Wider implications of the findings

The findings suggest no clinical value of fresh day 5 transfer of embryos ≤morula stage. Although early blastocysts implant at reduced rate, assuring birthweight outcomes suggest clinical value. Future studies intend to investigate slow growing day 5 fresh transfers versus embryos that were slow growing but transferred after day 6.

Trial registration number

NA

P–191 Time-lapse videography reveals morphometric and morphokinetic differences in the pronuclei of male and female human zygotes

Study question

Do morphometric and morphokinetic profiles of pronuclei (PN) following intracytoplasmic sperm injection (ICSI) vary between male and female human zygotes?

Summary answer

Male and female zygotes displayed different PN morphometrics and morphokinetics. Additionally, variations were identified between sperm-originated (SPN) and oocyte-originated (OPN) pronuclei.

What is known already

Previous studies have investigated the use of PN-associated parameters via static observations as indicators of zygote viability, including size equality or juxtaposition. However, recent clinical application of time-lapse videography (TLV) provides a novel opportunity to assess these pronuclear events with greater accuracy and precision of morphometric and morphokinetic measurement. A number of recent TLV studies have also investigated potential live birth prediction by such PN associated measures, however whether or not there are gender associated differences in such measures which could in turn confound live birth prediction is unknown. Study design, size, duration: This retrospective cohort study included 94 consecutive autologous single day 5 transfer cycles (either fresh or frozen) performed between January 2019 and March 2020. Only ICSI cycles (maternal age <40 years) leading to a singleton live birth (43 males and 51 females) were included for analysis. All oocytes were placed in the EmbryoScope incubator for culture immediately post sperm injection with all annotation performed retrospectively by one embryologist (L-SO).

Participants/materials, setting, methods

Timings included 2nd polar body extrusion (tPb2), SPN(tSPNa)/OPN(tOPNa) appearance (differentiated by proximity to Pb2) and PN fading (tPNF). Morphometrics were evaluated at 8 (stage 1), 4 (stage 2) and 0 hour before PNF (stage 3), measuring PN area (um2), PN juxtaposition, and nucleolus precursor body (NPB) arrangement. Means ± standard deviation were compared using student t test or logistic regression as odds ratio (OR) and 95% confidence interval (CI), and proportional data by chi-squared analysis.

Main results and the role of chance

Logistic regression indicated that male zygotes had longer time intervals of tPb2_tSPNa than female zygotes (4.8±1.5 vs 4.2±1.0 h, OR = 1.442, 95% CI 1.009–2.061, p = 0.044), but not tPb2_tOPNa (4.7±1.8 vs 4.5±1.3 h, OR = 1.224, 95% CI 0.868–1.728, p = 0.250) and tPb2_tPNF (19.9±2.8 vs 19.1±2.3 h, OR = 1.136, 95% CI 0.957–1.347, p = 0.144). SPN increased in size from stage 1 through 2 to 3 (435.3±70.2, 506.7±77.3, and 556.3±86.4 um2, p = 0.000) and OPN did similarly (399.0±59.4, 464.3±65.2, and 513.8±63.5 um2, p = 0.000), with SPN being significantly larger than OPN at each stage (p < 0.05 respectively). However, relative size difference between SPN and OPN was similar between male and female zygotes at 3 stages (33.6±61.7 vs 38.6±50.8 um2, p = 0.664; 38.5±53.1 vs 45.7±71.9 um2, p = 0.585; 38.4±77.4 vs 45.8±63.9 um2, p = 0.615; respectively). More male than female zygotes reached central PN juxtaposition at stage 1 (77% vs 51%, p = 0.010), stage 2 (98% vs 86%, p = 0.048) and stage 3 (98% vs 86%, p = 0.048). Furthermore, more OPN showed aligned NPBs than in SPN at stage 1 (45% vs 29%, p = 0.023), but similar proportions at stage 2 (64% vs 50%, p = 0.056) and stage 3 (76% vs 72%, p = 0.618). There were no gender associated differences detected in NPB alignment in either SPN or OPN (p > 0.05 respectively).

Limitations, reasons for caution

The retrospective design does not allow for control of unknown confounders. Sample size is considered relatively small. PN area measurement may not truly represent volume as PN may not be perfectly spherical. Findings were based on women <40 years old so may not apply to older population.

Wider implications of the findings: These findings augment and extend previous studies investigating PN parameters via static observations. The reported variations between male and female embryos may confound live birth prediction when using pronuclei morphometrics and morphokinetics. Larger scaled studies are warranted to verify these findings.

Trial registration number

Not applicable

Changing paradigm of sacral neuromodulation and external anal sphincter repair for faecal incontinence in specialist centres

AIM

The aim of this study was to determine whether the paradigm of surgical intervention for faecal incontinence (FI) has changed between 2000 and 2013.

METHOD

This was a multi-centre retrospective study of patients who had undergone either sacral neuromodulation (SNM) or delayed sphincter repair or sphincteroplasty (SR) as a primary surgical intervention for FI in five centres in Europe and one in the United States. The flow of patients according to the intervention, sustainability of the treatment at a minimum follow-up of 5 years, complications and requirement for further interventions were recorded.

RESULTS

A total of 461 patients (median age 56 years, range 24-90 years, 41 men) had either SNM or SR as an index operation during the study period [SNM 284 (61.6%), SR 177 (38.4%)]. Among SNM patients, there were 169 revisional operations (change of battery and/or lead, re-siting or removal). At the time of last follow-up 203 patients (71.4%) continued to use SNM. Among SR patients, 30 (16.9%) had complications, most notably wound infection (22, 12.4%). During follow-up 32 patients (18.1%) crossed over to SNM. Comparing two 4-year periods (2000-2003 and 2007-2010), the proportion of patients operated on who had a circumferential sphincter defect of less than 90° was 48 (68%) and 45 (46%), respectively (P = 0.03), while those who had SNM as the primary intervention increased from 29% to 89% (P < 0.05).

CONCLUSION

The paradigm of surgical intervention for FI has changed with increasing use of SNM.

Vertebrae Destruction with Cauda Equina Syndrome Secondary to Spinal Gouty Arthritis: A Case Report

Gouty arthritis commonly affects peripheral joints and is associated with hyperuricaemia. Spinal manifestations of gouty arthritis are not common, and majority of published articles worldwide were case reports. This is a case report of spinal gouty arthritis that presented with spinal vertebrae destruction and cauda equina syndrome. The magnetic resonance imaging (MRI) showed destruction of L5/S1end plates with cystic collection mimicking infective changes. The tissue histological examination confirmed presence of urate crystal needles that displayed negative double refraction on light microscopy. Spinal gouty arthritis is part of the differential diagnoses in gouty arthritis patients.

Number Needed to Treat with Vertebral Augmentation to Save a Life

BACKGROUND AND PURPOSE

Evidence from randomized controlled trials for the efficacy of vertebral augmentation in vertebral compression fractures has been mixed. However, claims-based analyses from national registries or insurance datasets have demonstrated a significant mortality benefit for patients with vertebral compression fractures who receive vertebral augmentation. The purpose of this study was to calculate the number needed to treat to save 1 life at 1 year and up to 5 years after vertebral augmentation.

MATERIALS AND METHODS

A 10-year sample of the 100% US Medicare data base was used to identify patients with vertebral compression fractures treated with nonsurgical management, balloon kyphoplasty, and vertebroplasty. The number needed to treat was calculated between augmentation and nonsurgical management groups from years 1-5 following a vertebral compression fracture diagnosis, using survival probabilities for each management approach.

RESULTS

The adjusted number needed to treat to save 1 life for nonsurgical management versus kyphoplasty ranged from 14.8 at year 1 to 11.9 at year 5. The adjusted number needed to treat for nonsurgical management versus vertebroplasty ranged from 22.8 at year 1 to 23.8 at year 5.

CONCLUSIONS

Both augmentation modalities conferred a prominent mortality benefit over nonsurgical management in this analysis of the US Medicare registry, with a low number needed to treat. The calculations based on this data base resulted in a low number needed to treat to save 1 life at 1 year and at 5 years.

Total hip arthroplasty following failed intertrochanteric hip fracture fixation treated with a cephalomedullary nail

AIMS

Cephalomedullary nails (CMNs) are commonly used for the treatment of intertrochanteric hip fractures. Total hip arthroplasty (THA) may be used as a salvage procedure when fixation fails in these patients. The aim of this study was to analyze the complications of THA following failed intertrochanteric hip fracture fixation using a CMN.

PATIENTS AND METHODS

Patients who underwent THA were identified from the 5% subset of Medicare Parts A/B between 2002 and 2015. A subgroup involving those with an intertrochanteric fracture that was treated using a CMN during the previous five years was identified and compared with the remaining patients who underwent THA. The length of stay (LOS) was compared using both univariate and multivariate analysis. The incidence of infection, dislocation, revision, and re-admission was compared between the two groups, using multivariate analysis adjusted for demographic, hospital, and clinical factors.

RESULTS

The Medicare data yielded 56 522 patients who underwent primary THA, of whom 369 had previously been treated with a CMN. The percentage of THAs that were undertaken between 2002 and 2005 in patients who had previously been treated with a CMN (0.346%) more than doubled between 2012 and 2015 (0.781%). The CMN group tended to be older and female, and to have a higher Charlson Comorbidity Index and lower socioeconomic status. The mean LOS was 1.5 days longer (5.3 vs 3.8) in the CMN group (p < 0.0001). The incidence of complications was significantly higher in the CMN group compared with the non-CMN group: infection (6.2% vs 2.6%), dislocation (8.1% vs 4.5%), revision (8.4% vs 4.3%), revision for infection (1.1% vs 0.37%), and revision for dislocation (2.2% vs 0.6%).

CONCLUSION

The incidence of conversion to THA following failed intertrochanteric hip fracture fixation using a CMN continues to increase. This occurs in elderly patients with increased comorbidities. There is a significantly increased risk of infection, dislocation, and LOS in these patients. Patients with failed intertrochanteric hip fracture fixation using a CMN who require THA should be made aware of the increased risk of complications, and steps need to be taken to reduce this risk. Cite this article: Bone Joint J 2019;101-B(6 Supple B):91-96.

Correction to: Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?

The article Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?, written by K. L. Ong, D. P. Beall, M. Frohbergh, E. Lau, and J. A. Hirsch was originally published electronically on the publisher's internet portal.

Adult height, coronary heart disease and stroke: a multi-locus Mendelian randomization meta-analysis

Background: We investigated causal effect of completed growth, measured by adult height, on coronary heart disease (CHD), stroke and cardiovascular traits, using instrumental variable (IV) Mendelian randomization meta-analysis.

Methods: We developed an allele score based on 69 single nucleotide polymorphisms (SNPs) associated with adult height, identified by the IBCCardioChip, and used it for IV analysis against cardiovascular risk factors and events in 21 studies and 60 028 participants. IV analysis on CHD was supplemented by summary data from 180 height-SNPs from the GIANT consortium and their corresponding CHD estimates derived from CARDIoGRAMplusC4D.

Results: IV estimates from IBCCardioChip and GIANT-CARDIoGRAMplusC4D showed that a 6.5-cm increase in height reduced the odds of CHD by 10% [odds ratios 0.90; 95% confidence intervals (CIs): 0.78 to 1.03 and 0.85 to 0.95, respectively],which agrees with the estimate from the Emerging Risk Factors Collaboration (hazard ratio 0.93; 95% CI: 0.91 to 0.94). IV analysis revealed no association with stroke (odds ratio 0.97; 95% CI: 0.79 to 1.19). IV analysis showed that a 6.5-cm increase in height resulted in lower levels of body mass index (P < 0.001), triglycerides (P < 0.001), non high-density (non-HDL) cholesterol (P < 0.001), C-reactive protein (P = 0.042), and systolic blood pressure (P = 0.064) and higher levels of forced expiratory volume in 1 s and forced vital capacity (P < 0.001 for both).

Conclusions: Taller individuals have a lower risk of CHD with potential explanations being that taller people have a better lung function and lower levels of body mass index, cholesterol and blood pressure.

Were VCF patients at higher risk of mortality following the 2009 publication of the vertebroplasty "sham" trials?

The 5-year period following 2009 saw a steep reduction in vertebral augmentation volume and was associated with elevated mortality risk in vertebral compression fracture (VCF) patients. The risk of mortality following a VCF diagnosis was 85.1% at 10 years and was found to be lower for balloon kyphoplasty (BKP) and vertebroplasty (VP) patients.

INTRODUCTION

BKP and VP are associated with lower mortality risks than non-surgical management (NSM) of VCF. VP versus sham trials published in 2009 sparked controversy over its effectiveness, leading to diminished referral volumes. We hypothesized that lower BKP/VP utilization would lead to a greater mortality risk for VCF patients.

METHODS

BKP/VP utilization was evaluated for VCF patients in the 100% US Medicare data set (2005-2014). Survival and morbidity were analyzed by the Kaplan-Meier method and compared between NSM, BKP, and VP using Cox regression with adjustment by propensity score and various factors.

RESULTS

The cohort included 261,756 BKP (12.6%) and 117,232 VP (5.6%) patients, comprising 20% of the VCF patient population in 2005, peaking at 24% in 2007-2008, and declining to 14% in 2014. The propensity-adjusted mortality risk for VCF patients was 4% (95% CI, 3-4%; p < 0.001) greater in 2010-2014 versus 2005-2009. The 10-year risk of mortality for the overall cohort was 85.1%. BKP and VP cohorts had a 19% (95% CI, 19-19%; p < 0.001) and 7% (95% CI, 7-8%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the NSM cohort, respectively. The BKP cohort had a 13% (95% CI, 12-13%; p < 0.001) lower propensity-adjusted 10-year mortality risk than the VP cohort.

CONCLUSIONS

Changes in treatment patterns following the 2009 VP publications led to fewer augmentation procedures. In turn, the 5-year period following 2009 was associated with elevated mortality risk in VCF patients. This provides insight into the implications of treatment pattern changes and associated mortality risks.

Subacute Combined Degeneration of the Spinal Cord

We report a case of a 79-year-old gentleman presenting with numbness of both hands. A magnetic resonance imaging of the cervical spine demonstrated features suggestive of subacute combined degeneration of the spinal cord which was further supported by a low serum vitamin B12. This is a reversible condition if early diagnosis can be made and vitamin B12 therapy promptly given. Delayed treatment can result in irreversible neurological impairment.

Clinical and Ultrasonographic Diagnosis of Acute Appendicitis

Appendicitis is one of the most common acute abdominal conditions encountered in the Emergency Department. It is a surgical condition that can affect any person of any age and often with varying clinical presentations. In the majority of cases, the diagnosis is straightforward. However in some, the diagnosis requires a heightened clinical suspicion. The application of adjuvant laboratory tests and diagnostic imaging helps to reduce the associated complications, morbidity and mortality of delayed diagnosis.

Painless Gross Haematuria

Inflammatory pseudotumour is a benign mesenchymal lesion that has distinct pathological features. Patients often present with haematuria, abdominal pain or recurrent cystitis. There are overlapping features with bladder sarcoma in presentation, age range, and size, but the pseudotumour does not metastasise. Awareness of this unusual lesion is important to prevent its misinterpretation. Complete surgical excision of the tumour mass is the treatment of choice.

An Elderly with Purple Urine

Purple discolouration of urine is not commonly encountered in accident and emergency departments. We report a case of an elderly gentleman on long-term urinary catheter who presented with purple discolouration of urine. He was found to have urinary tract infection caused by the bacteria Proteus mirabilis. The urine became clear after urinary catheter change and antibiotic treatment. This is called the purple urine bag syndrome and emergency physicians should be aware of this uncommon condition and the associated potentially dangerous conditions in order to initiate appropriate management.

Impact of a Sepsis Guideline in Emergency Department on Outcome of Patients with Severe Sepsis

Objective

A dedicated program with guideline to enhance sepsis care was launched in July 2014 in Emergency Department (ED) of two regional hospitals. The study aimed to evaluate the effectiveness of the interventional program for severe sepsis patients, in antibiotic delivery rate and survival outcome.

Methods

It is a before-and-after interventional study with data from July to December 2013 and August 2014 to January 2015. A dedicated program for severe sepsis patients was introduced in July 2014. The outcome measures were blood culture rate, antibiotic administration rate in ED and mortality. Kaplan-Meier analysis and log-rank test was used for comparison of the survival. Multivariate Cox proportional hazards model was constructed to predict time to mortality adjusted for covariates.

Results

64 patients were included, 31 patients were in the pre-intervention group whereas 33 post-intervention. Both blood culture rate (29% vs 72.7%; p<0.001) and antibiotics administration in ED (38.7% vs 72.7%, p=0.0011) were significantly increased. Survival outcome was significantly improved in patients receiving timely antibiotics in ED (log-rank test p=0.016). Antibiotics administered in ED had hazard ratio of 0.178 (95% CI 0.053 to 0.595; p=0.005) in the Cox Proportional hazard regression model with adjustment of covariates. Age (adjusted odds ratio 1.06, 95% CI 1.01 to 1.12, p=0.033) and initial hypotension (adjusted odds ratio 0.97, 95% CI 0.95 to 0.99, p=0.005) were significant predictors of mortality.

Conclusion

A dedicated guideline for severe sepsis management could improve blood culture rate, early antibiotics administration in the emergency department. Patients received early antibiotic had better outcome and survival.

Artifacts in Computed Radiography

Computed radiography offers many advantages over the conventional radiography. With new technological breakthroughs and the development of systems that are more cost-effective, there has been an increase in its use in the recent years. However, like all imaging modalities, one must be aware of the various artifacts that are likely to lead to misdiagnosis. In this article, we illustrate the potential hardware and software artifacts that are associated with its use.

Spontaneous Pneumomediastinum: An Uncommon Complication from an Augmented Physiological Belching (Imitating a TV Show Game)

Noisy belching in front of other people, often considered to be an impolite manner, may not be as harmless as it seems. We report on a patient who had spontaneous pneumomediastinum after intentional induction of noisy belching by rapid excessive intake of carbonated drinks (imitating the game played in a popular local television program “The Super Trio Continues…”). The clinical features, investigations and management of spontaneous pneumomediastinum are discussed.

Painful Malignant Embryonal Carcinoma of the Testis

Patients with clinically palpable testicular nodule, regardless of absence or accompanying symptom of pain, require further evaluation. Testicular carcinoma including embryonal carcinoma has varied appearances and the diagnosis can be difficult unless there is presence of local infiltration or distant metastatic deposits. Ultrasound examination is the imaging modality of choice to quickly confirm the clinical findings of testicular mass at the Emergency Department and distinguish a testicular mass from an extra-testicular mass and extent of the disease. Despite presentations in varying stages of disease, the treatment will include orchiectomy.

Sudden Onset of Calf Pain

Avulsion of the myo-tendinous junction of the medial head of the gastrocnemius muscle is commonly associated with strenuous physical activities such as racquet sports, skiing, and running. The injury is painful, distressing and can be disabling. Ready availability makes ultrasound study the imaging modality of choice in the emergency department.

Painless Benign Epidermoid Cyst of the Testis

Benign intratesticular lesions such as epidermoid cyst are rare, but recognition is important to avoid unnecessary surgical intervention (orchiectomy). The combination of ultrasonographic findings and negative tumour markers can help differentiate benign from malignant intratesticular lesions. At surgery, the lesion can be enucleated and frozen sections obtained to confirm the diagnosis, thus avoiding the need for orchiectomy.

Lipids, lipoprotein distribution and depressive symptoms: the Multi-Ethnic Study of Atherosclerosis

Previous studies suggest lower concentrations of total and high-density lipoprotein (HDL) cholesterol to be predictive of depression. We therefore investigated the relationship of lipids and lipoprotein distribution with elevated depressive symptoms (EDS) in healthy men and women from the Multi-Ethnic Study of Atherosclerosis (MESA). Participants were followed up over a 9.5-year period. EDS were defined as a Center for Epidemiological Studies Depression (CES-D) score ⩾16 and/or use of antidepressant drugs. Lipoprotein distribution was determined from plasma using nuclear magnetic resonance spectroscopy. Among 4938 MESA participants (mean age=62 years) without EDS at baseline, 1178 (23.9%) developed EDS during follow-up. In multivariable Cox regression analyses, lower total, low-density lipoprotein (LDL) and non-HDL cholesterol concentrations at baseline were associated with incident EDS over 9.5 years (hazards ratio (HR)=1.11-1.12 per s.d. decrease, all P<0.01), after adjusting for demographic factors, traditional risk factors including LDL cholesterol, HDL cholesterol and triglycerides. Lipoprotein particle subclasses and sizes were not associated with incident EDS. Among participants without EDS at both baseline and visit 3, a smaller increase in total or non-HDL cholesterol between these visits was associated with lower risk of incident EDS after visit 3 (HR=0.88-0.90 per s.d. decrease, P<0.05). Lower baseline concentrations of total, LDL and non-HDL cholesterol were significantly associated with a higher risk of incident EDS. However, a short-term increase in cholesterol concentrations did not help to reduce the risk of EDS. Further studies are needed to replicate our findings in cohorts with younger participants.

Visualization of in vivo septin ultrastructures by platinum replica electron microscopy

Septins are cytoskeletal proteins involved in diverse biological processes including cytokinesis, cell morphogenesis, motility, and ciliogenesis. Septins form various filamentous structures in vitro and in vivo, but the higher-order architecture of septin structures in vivo remains poorly defined. The best understood system in this respect is the budding yeast Saccharomyces cerevisiae, where septins form a ring structure that undergoes multiple stages of remodeling during the cell cycle. In this chapter, we describe a method for visualizing supramolecular septin structures in yeast at high spatial resolution using platinum replica electron microscopy. This approach can be applied to further understand the regulation of assembly and remodeling of septin higher-order structures, as well as the relationship between septin architecture and function.

Prediction of en-route complications during interfacility transport by outcome predictive scores in ED

OBJECTIVE

The objective was to determine the accuracy of the outcome predictive scores (Modified Early Warning Score [MEWS]; Hypotension, Low Oxygen Saturation, Low Temperature, Abnormal ECG, Loss of Independence [HOTEL] score; and Simple Clinical Score [SCS]) in predicting en-route complications during interfacility transport (IFT) in emergency department.

DESIGN

This was a retrospective cohort study.

METHODS

All IFT cases by ambulances with either nurse-led or physician-led escort, occurring between 1 January 2011 and 31 December 2012, were included. Obstetric and pediatric cases (age < 18 years) were excluded. The condition of patients was quantified by using the predictive scores (MEWS, HOTEL, and SCS) at triage station and on ambulance departure. The accuracy of predictive scores was compared by the receiver operating characteristic (ROC) curves.

RESULTS

A total of 659 cases were included. Seventeen cases had en-route complications (2.6%). The complication rate in physician-escorted transport (2.2%) was similar to that in nurse-escorted transport (2.6%). None of the 57 intubated cases had en-route complications. The area under the ROC curve for MEWS was 0.662 (triage) and 0.479 (departure). The accuracy of MEWS at triage was better than that at departure (P = .049). The area under the ROC curve for HOTEL was 0.613 (triage) and 0.597 (departure), and that for SCS was 0.6 (triage) and 0.568 (departure). In general, the predictive scores at triage were better than those on departure.

CONCLUSION

None of the scores had good accuracy in prediction of en-route complications during IFT. MEWS at triage was among the best one already but was not ideal.

Adiponectin gene variants and the risk of coronary heart disease: a 16-year longitudinal study

OBJECTIVE

Circulating adiponectin levels have been shown to be associated with a risk of coronary heart disease (CHD). However, its primary role in protecting against the development of CHD remains controversial due to conflicting observations in prospective studies. To gain further insight into the primary role of adiponectin, our major objective was to investigate the relationship between single nucleotide polymorphisms (SNPs) of the adiponectin gene (ADIPOQ) and incident CHD in a population-based cohort with no CHD at baseline.

DESIGN AND METHODS

We conducted a 16-year longitudinal study in 2196 subjects from the Hong Kong Cardiovascular Risk Factor Prevalence Study (CRISPS). During 33 862 person-years of follow-up, 184 subjects developed CHD (cumulative incidence rate=5.4 per 1000 person-years). Nine ADIPOQ SNPs with potential functional relevance or shown to be associated with adiponectin levels and/or CHD were genotyped.

RESULTS

Among the nine ADIPOQ SNPs, +276G>T (rs1501299) was independently associated with incident CHD in men but not in women, even after adjustments for traditional cardiovascular risk factors (Padjusted=5.5×10(-3) to 0.023; hazard ratio=1.39-1.54). Furthermore, there was a significant association of the T allele of +276G>T with a lower adiponectin level (P=0.027; β (95% CI)=-0.05 (-0.10, -0.01).

CONCLUSIONS

This study demonstrated that +276G>T may be an independent predictor of CHD development. Our findings suggest that low adiponectin levels, as may be influenced by +276G>T, confer a higher risk of CHD, in keeping with a role of hypoadiponectinaemia in the development of CHD in the general population.

First Report of Fusarium oxysporum f. sp. palmarum in Texas Causing Fusarium Wilt of Washingtonia robusta

Fusarium wilt of palms occurs worldwide, caused by different Fusarium oxysporum ff. spp. including F. oxysporum f. sp. elaeidis, F. oxysporum f. sp. canariensis, and F. oxysporum f. sp. albedinis (3). Prior to 2010, F. oxysporum f. sp. canariensis was the only palm infecting species known to occur in the United States. In 2010, isolates of F. oxysporum were reported from dying Syagrus romanzoffiana and Washingtonia robusta in Florida. Based on morphological and molecular data, as well as the unique host species affected by the pathogen, this fungus was determined to be a new forma specialis of F. oxysporum, designated f. sp. palmarum (1). The pathogen infects foliar tissue, causing complete necrosis of the crown and leading to tree death within 2 to 3 months. In June 2012, the Texas Plant Disease Diagnostic Laboratory (TPDDL) received a plant sample from a dying W. robusta palm, exhibiting reddish-brown stripes on the petiole with chlorotic and necrotic leaves, from an established palm in the landscape from Harris County, Texas. Fungal cultures were obtained from symptomatic foliar tissue and identified as F. oxysporum based on morphology. Microconidia were oval to reniform, 1- to 2-septate, measuring 5 to 18 × 2.5 to 5 μm. Phialides were short with microconidia produced in false heads. Macroconidia were curved and slender with a foot-shaped basal cell, usually 3-septate, and 22 to 37 × 2.5 to 5 μm. Chlamydospores were roundish and ranged from 7 to 13 μm in diameter. Fungal colonies had white to purple mycelia when grown on potato dextrose agar. DNA from a single spore culture was extracted, amplified by PCR using primers corresponding to a segment of the translation elongation factor 1α (EF-1α) gene, and the PCR product sequenced (2). Using the sequence alignment tool (BLASTn) in GenBank, the TPDDL's sequence (GenBank Accession No. KC897693) was aligned with EF-1α regions from F. oxysporum f. sp. palmarum isolates previously entered into the database ([1]; accessions GQ154455[=NRRL53544] and GQ154456[=NRRL46589]), revealing 100% homology between the isolates. Based on host source and sequence similarity, the fungus was tentatively identified as F. oxysporum f. sp. palmarum. Pathogenicity tests were performed on three leaf seedlings of W. robusta and W. filifera. Fifteen plants of each species were inoculated with the suspect isolate (designated KB2012) and 10 control plants were mock-inoculated as described by (1). Plants were grown in a greenhouse for 8 weeks post-inoculation. During this time, 83% of inoculated plants developed foliar lesions and died or severely declined, and all control plants remained healthy. F. oxysporum was recovered in culture from 100% of the symptomatic plants. DNA was extracted from fungal cultures, and EF-1α was amplified by PCR and sequenced, as described above. The amplicon was determined to share 100% homology with known F. oxysporum f. sp. palmarum isolates, confirming this fungus as the cause of disease in W. robusta. This is the first report of this pathogen in Texas, as well as the first report outside of Florida. This is also the first documentation of W. filifera as a host of this pathogen. References: (1) M. L. Elliott et al. Plant Dis. 94:31, 2010. (2) D. M. Geiser et al. Eur. J. Plant Pathol. 110:473, 2004. (3) G. W. Simone. Pages 17-19 in: Compendium of Ornamental Palm Diseases and Disorders, M. L. Elliott et al., eds. The American Phytopathological Society, St. Paul, MN, 2004.