Utility of the Stanford Integrated Psychosocial Assessment for Transplant in predicting outcomes before and after lung transplantation

BACKGROUND

Optimizing donor use and achieving maximal survival following lung transplantation (LTx) require a pretransplant assessment that identifies clinical, physiological, and psychosocial patient factors associated with both poor and optimal post-LTx survival. We examined the utility of a psychosocial tool, the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT), to identify patient suitability for LTx, as well as its association with clinical outcomes before and after LTx.

METHODS

This was a retrospective single-center study analyzing LTx assessment clinical variables (age, gender, diagnosis, functional capacity, nutrition, renal function), with a particular focus on the utility of the SIPAT score, to predict patient suitability for LTx. The same variables were analyzed against LTx waitlist mortality, as well as post-LTx survival.

RESULTS

Over an 8-year period dating from December 2012, 914 patients (male 54.4%, mean age 55.2 years) underwent LTx assessment. Patients declined for LTx (n = 152, 16.6%) were older and had reduced functional capacity, nutritional markers, and renal function but had a higher SIPAT score. Once listed for LTx, a higher SIPAT score was not associated with waitlist mortality or reduced post-LTx survival.

CONCLUSIONS

The SIPAT tool measures psychosocial suitability for transplantation that can be incorporated into a standardized assessment of LTx suitability. While patients with higher SIPAT score were more likely to be declined for LTx, the SIPAT score did not predict outcome in transplanted patients. A subgroup of patients with high SIPAT scores were successfully transplanted, suggesting that unfavorable psychosocial variables are potentially modifiable with a well-resourced multidisciplinary LTx team.

Clinical outcomes following cessation of parenteral immunoglobulin therapy following lung transplantation

Broad use of parenteral immunoglobulin (IgG) therapy in lung transplant (LTx) patients occurs without robust clinical evidence or guidelines. Main indications include secondary hypogammaglobulinemia, antibody-mediated rejection (AMR), and treatment or prevention of graft rejection where the use of conventional immunosuppressive therapies is contraindicated. As part of routine auditing of IgG use in our LTx service, we assessed for adverse clinical outcomes related to IgG therapy cessation between November 2017 and February 2022. Of 220 LTx recipients receiving IgG therapy at our center during this period (approximately 20% of our total LTx cohort), 48 patients ceased therapy. No adverse outcomes were experienced in 83.3% patients. About 10.4% recommenced therapy for the same indication within 6 months with no longer term sequelae. One AMR patient developed progressive Chronic lung allograft dysfunction and died within 12 months, where therapy cessation was patient-initiated and associated with general noncompliance. These data provide reassurance that physician-directed cessation of IgG therapy is safe when based on sound clinical information and part of a robust clinical auditing process.

Observation of the density dependence of the closed-channel fraction of a 6Li superfluid

Atomic Fermi gases provide an ideal platform for studying the pairing and superfluid physics, using a Feshbach resonance between closed channel molecular states and open channel scattering states. Of particular interest is the strongly interacting regime. We show that the closed-channel fraction ${Z_{{\rm{cc}}}}$ provides an effective probe for the important many-body interacting effects, especially through its density dependence, which is absent from two-body theoretical predictions. Here we measure ${Z_{{\rm{cc}}}}$ as a function of interaction strength and the Fermi temperature ${T_{\rm{F}}}$ in a trapped 6Li superfluid throughout the entire BCS-BEC crossover, in quantitative agreement with theory when important thermal contributions outside the superfluid core are taken into account. Away from the deep BEC regime, the fraction ${Z_{cc}}$ is sensitive to ${{\rm{T}}_F}$. In particular, our data show ${Z_{{\rm{cc}}}} \propto T_{\rm{F}}^\alpha $ with $\alpha \ = {\rm{\ 1/2}}$ at unitarity, in quantitative agreement with calculations of a two-channel pairing fluctuation theory, and $\alpha $ increases rapidly into the BCS regime, reflecting many-body interaction effects as predicted.

Airway cilia recovery post lung transplantation

BACKGROUND

Normally functioning airway cilia is essential for efficient mucociliary clearance to protect the airway from various insults. Impaired clearance may lead to increased risk of infections and progressive lung damage. Significant morbidity in the immediate post lung transplantation period is associated with airway infection, which we hypothesize may be caused by impaired cilia function.

METHODS

Airway cilia beating pattern (CBP) and frequency (CBF) were studied on brushing samples taken from above and below the transplant anastomosis of adult lung transplant recipients (n = 20) during routine bronchoscopies at 6, 12, and 26 weeks posttransplant. Bronchoaveolar Lavage (BAL) samples were also collected at each time points.

RESULTS

At 6 weeks posttransplant (n = 16), CBP from the donated lung showed reduced beating amplitude with the overall CBF 2.28 Hz slower than the patients' native upper airway cilia (median ± SIQR: 5.36 ± 0.93 Hz vs. 7.64 ± 0.92 Hz, p value < .001). At 12 weeks (n = 16), donor lungs CBP showed recovery with the difference in CBF reduced to 0.74 Hz (6.36 ± 1.46 Hz vs. 7.10 ± 0.86 Hz, p value < .05). Impaired cilia function was not associated with positive BAL cultures.

CONCLUSION

Reduced cilia function is evident in the first 12 weeks post lung transplant, with both CBP and CBF returning to levels of function indistinguishable to the patients' upper airway cilia beyond this time.

Jet Substructure in Fireworks Emission from Nonuniform and Rotating Bose-Einstein Condensates

We show that jet emission from a Bose condensate with periodically driven interactions, also known as "Bose fireworks", contains essential information on the condensate wave function, which is difficult to obtain using standard detection methods. We illustrate the underlying physics with two examples. When condensates acquire phase patterns from external potentials or from vortices, the jets display novel substructure, such as oscillations or spirals, in their correlations. Through a comparison of theory, numerical simulations, and experiments, we show how one can quantitatively extract the phase and the helicity of a condensate from the emission pattern. Our work, demonstrating the strong link between jet emission and the underlying quantum system, bears on the recent emphasis on jet substructure in particle physics.

An update on chronic lung allograft dysfunction

Chronic lung allograft dysfunction (CLAD) remains a significant challenge and the major determinant of morbidity and mortality post lung transplantation (LTx). The definition of CLAD has evolved significantly over the last ten years, reflecting better understanding of pathophysiology and different phenotypes. While there is an agreed consensus approach to CLAD, questions remain regarding the limitations of lung function parameters as well as the role of imaging and histopathology. Here we present a current snapshot of the definition of CLAD, its evolution and future directions.

Atrial Flutter and Fibrillation Following Lung Transplantation: Incidence, Associations and a Suggested Therapeutic Algorithm

BACKGROUND

Atrial arrhythmias are relatively common following lung transplantation and confer considerable perioperative risk, specifically haemodynamic instability, pulmonary congestion, dyspnoea, and can mask other post-transplant complications such as infection or acute rejection. However, for most patients, arrhythmias are limited to the short-term perioperative period.

METHODS

We present a retrospective case-control analysis of 200 lung transplant recipients and using multivariate regression analysis, document the present incidence, risk factors, and outcomes between the two groups.

RESULTS

Twenty-five per cent (25%) of lung transplantation patients developed atrial flutter or fibrillation, most frequently at day 5-7 post lung transplantation, and more commonly present in older recipients and those with underlying chronic obstructive pulmonary disease (COPD), but not in those with previously noted structural heart disease, or in those undergoing single rather than double lung transplants. Atrial arrhythmias were associated with increased intensive care unit and overall length of stay, but were not associated with increased risk of in-hospital stroke, or mortality. Based on our experience, we propose a suggested management algorithm for pharmacological and mechanical rate/rhythm control strategies, for anticoagulation, and discuss the appropriate duration of treatment.

CONCLUSIONS

Atrial arrhythmias are relatively common post lung transplantation. Carefully managed, the associated risk of perioperative morbidity and mortality can be mitigated. Further prospective studies are required to validate these strategies.

Impact of a community respiratory service on emergency hospital admissions

Background

A community respiratory service was implemented in the North West of Glasgow in January 2013, comprising a team of physiotherapists, occupational therapists and support workers, to provide education, self-management advice, and, where appropriate, treatment at home, for COPD patients, to reduce the risk of hospital admission. This study measures the impact of the service on emergency admission to hospital.

Methods

COPD EAs were defined as emergency admissions to hospital with a primary diagnosis of COPD. Rate of COPD EAs per 1000 population aged 65 years+ in Glasgow City was compared before and after onset of the service, using segmented linear regression with 21-month pre- and 17-month post-intervention periods. COPD EAs for residents of South and North East Glasgow (S+NE) - areas with no such service in place - were used as a comparison group. The model adjusted for the rate of all-cause emergency admissions. Autoregressive terms were included in the model, as well as a fourier term to adjust for seasonality. Models were similarly run for outcome emergency admissions with COPD in any of the other five fields of diagnosis.

Results

Adjusting for all cause EAs and changes in S+NE, thus factoring out the impact of other initiatives that may have affected emergency admission to hospital, the impact of the service was found to be a level change of -0.33 (-0.51, -0.16) and a trend change of -0.03 (-0.05, -0.02) COPD EAs per 1000 per month. This is equivalent to a predicted reduction due to the service of -0.88 COPD EAs per 1000 popn per month, in March 2015, and a relative reduction of 35.8%. Rate of COPD EAs per month reduced over time after the introduction of the service (from the point of full staffing). Rate of EAs with COPD in a field of diagnosis other than primary saw no significant change in level or trend associated with the service.

Conclusions

The community respiratory service was associated with a significant reduction in the rate of COPD EAs.

Key messages

The Community Respiratory service was associated with reductions in emergency hospital admissions with COPD as a primary diagnosis. There was no significant change in emergency admissions with COPD as a secondary diagnosis, suggesting hospital attendance for patients with COPD overall reduced following the intervention.

Impact of the Govan SHIP case management project on emergency hospital admission and GP interactions

Background

The Social and Health Integration Partnership (SHIP) project was implemented in Govan, a deprived area in Glasgow in 2015. This involved multidisciplinary teams, including GPs and social workers, identifying and supporting vulnerable patients at risk of attending A&E and GP surgeries. This study measures the impact of SHIP on A&E presentations and GP interactions.

Methods

Rate of A&E presentations per 1000 population in 3 participating GP practices in Govan was compared before and after onset of the service, using segmented linear regression with 9-month pre- and 36-month post- intervention periods. Rates of GP interactions were also compared, using 21-month pre- and 36-month post- intervention periods. Rates of A&E presentations and GP interactions for practice population in Drumchapel- an area with similar rates of deprivation - were used as a control. Models included autoregressive and moving average terms, and a fourier term to adjust for seasonality.

Results

Govan had a lower rate of A&E presentations than Drumchapel. A&E presentations did not change significantly over time prior to SHIP in either area. At April 2015, SHIP onset, a level change of -4.34 (-7.44, -1.24) A&E presentations per 1000 was observed in both areas, however , onset of SHIP was not associated with a reduction in level or trend in A&E presentations. Rate of interactions with GP was greater in Govan than Drumchapel prior to SHIP, increasing over time in both areas. After SHIP implementation there was a significant level change of 33.78 (19.57, 47.99) per 1000 across both areas. GP interactions in Govan however saw a further reduction of -1.48 (-2.87, -0.09) per 1000 per month. This is equivalent to SHIP being associated with an absolute reduction of 37 GP interactions per thousand and a relative reduction of 7.2% by March 2018.

Conclusions

The Govan SHIP initiative was associated with no significant change in A&E presentations and some small reduction in GP interactions.

Key messages

The Govan SHIP initiative was associated with no significant change in A&E presentations and a small significant reduction in GP interactions. A cost effectiveness analysis of the project is recommended, given the relatively small benefits observed.

Sex, age and socioeconomic inequalities in older people’s unscheduled care

Background

In Scotland, unscheduled care is usually received at hospital accident and emergency (A&E) departments or referral by GPs to medical assessment units (MAU). Almost a quarter attendances are for those aged 65 years+. Demand for unscheduled care will increase as the population ages. This study measures inequalities in unscheduled care presentations among those aged 65 years+.

Methods

A&E and MAU attendance data between April 2017 and March 2018 for Glasgow residents were analysed. Data were modelled using poisson modelling for outcome measures attendances, rate of attendance and length of stay, adjusting for agegroup, sex and deprivation. A second set of models also adjusted for time of day, month and referral source, including interaction terms.

Results

While there was a higher number of attendances among females (RR and 95% CI = 0.30 (0.28, 0.32)), and among those aged 65-69 years compared with older ages (RR = 0.03 (0.01, 0.06)), modelling rates showed that males were significantly more likely to attend (RR = 0.14 (0.13, 0.16)) and that likelihood rose with age, eg RR for 85+ years significantly greater than 80-84 years, significantly greater than for 75-79 years etc. There was no gender difference in length of stay but this increased with increasing age. Attendance was significantly more likely for those living in the most deprived quintile of deprivation (RR = 0.30 (0.27, 0.34) compared with the most affluent quintile). SES inequalities in attendance and length of stay became less pronounced with increasing age. Referrals via 999 emergency services increased with age while referrals by GP and NHS24 reduced with age. Attendance was more likely in December (RR = 0.15 (0.11, 0.18)) and likelihood of a morning attendance reduced significantly with increasing age and deprivation.

Conclusions

Inequalities in attendance, length of stay and methods of referral are observed which should be considered when planning to meet the demand for unscheduled care.

Key messages

Age, sex and socioeconomic inequalities in unscheduled care exist even at the oldest ages. When planning to meet the demand of future unscheduled care, patterns of current use and population projections should be considered in tandem.

Artificial stone-associated silicosis: clinical-pathological-radiological correlates of disease

Occupational lung disease secondary to inhalation of silica particles is variable and potentially life-threatening. As the artificial stone industry has grown over the last two decades, the development of silicosis has been seen to accelerate and behave differently to chronic silicosis. In this case report, we present two patients who underwent lung transplantation for silicosis at the Alfred Hospital, both with predominantly artificial stone masonry exposure. We have identified the presence of both fibrotic/nodular silicosis and conspicuous alveolar proteinosis within the same lung parenchyma of both patients. We then demonstrate the radiological and histopathological correlates of disease; the first time this has been shown clearly in the literature.

Density Waves and Jet Emission Asymmetry in Bose Fireworks

A Bose condensate, subject to periodic modulation of the two-body interactions, was recently observed to emit matter-wave jets resembling fireworks [Nature (London) 551, 356 (2017)NATUAS0028-083610.1038/nature24272]. In this Letter, combining experiment with numerical simulation, we demonstrate that these "Bose fireworks" represent a late stage in a complex time evolution of the driven condensate. We identify a "density wave" stage which precedes jet emission and results from the interference of matter waves. The density waves self-organize and self-amplify without breaking long range translational symmetry. This density wave structure deterministically establishes the template for the subsequent patterns of the emitted jets. Moreover, our simulations, in good agreement with experiment, address an apparent asymmetry in the jet pattern, and show that it is fully consistent with momentum conservation.

Observation of Density-Dependent Gauge Fields in a Bose-Einstein Condensate Based on Micromotion Control in a Shaken Two-Dimensional Lattice

We demonstrate a density-dependent gauge field, induced by atomic interactions, for quantum gases. The gauge field results from the synchronous coupling between the interactions and micromotion of the atoms in a modulated two-dimensional optical lattice. As a first step, we show that a coherent shaking of the lattice in two directions can couple the momentum and interactions of atoms and break the fourfold symmetry of the lattice. We then create a full interaction-induced gauge field by modulating the interaction strength in synchrony with the lattice shaking. When a condensate is loaded into this shaken lattice, the gauge field acts to preferentially prepare the system in different quasimomentum ground states depending on the modulation phase. We envision that these interaction-induced fields, created by fine control of micromotion, will provide a stepping stone to model new quantum phenomena within and beyond condensed matter physics.

Donation after Brain Death versus Donation after Circulatory Death: Lung Donor Management Issues

Lung transplantation (LTx) has traditionally been limited by a lack of suitable donor lungs. With the recognition that lungs are more robust than initially thought, the size of the donor pool of available lungs has increased dramatically in the past decade. Donation after brain death (DBD) and donation after circulatory death (DCD) lungs, both ideal and extended are now routinely utilized. DBD lungs can be damaged. There are important differences in the public's understanding, legal and consent processes, intensive care unit strategies, lung pathophysiology, logistics, and potential-to-actual donor conversion rates between DBD and DCD. Notwithstanding, the short- and long-term outcomes of LTx from any of these DBD versus DCD donor scenarios are now similar, robust, and continue to improve. Large audits suggest there remains a large untapped pool of DCD (but not DBD) lungs that may yet further dramatically increase lung transplant numbers. Donor scoring systems that might predict the donor conversion rates and lung quality, the role of ex vivo lung perfusion as an assessment and lung resuscitation tool, as well as the potential of donor lung quality biomarkers all have immense promise for the clinical field.

Characteristics of patients who progress from bridging to long-term oxygen therapy

BACKGROUND

Patients with persistent hypoxia following an acute hospital admission may be discharged with 'bridging' domiciliary oxygen as per criteria defined by the Thoracic Society of Australia and New Zealand. The need for continuous long-term oxygen therapy (LTOT) is then reassessed at a clinic review 1-2 months later.

AIM

To describe the characteristics of patients discharged from an acute hospital admission with continuous short-term oxygen therapy (STOT), and subsequently to investigate for differences between subjects who proceeded to qualify for continuous LTOT versus those who were able to cease STOT at review.

METHODS

This is a retrospective cohort study involving all subjects discharged from Alfred Health between 2011 and 2015 inclusive with bridging domiciliary oxygen. Multiple biochemical, physiological and demographic characteristics were collated and analysed.

RESULTS

Of all patients prescribed continuous STOT at time of discharge, 47.3% qualified for LTOT at outpatient review. This cohort had a significantly lower PaO₂ measurement at time of discharge, compared with those who no longer qualified.

CONCLUSION

PaO₂ at time of discharge provides a signal with the potential to identify who will require continuous LTOT following an acute hospital admission. Additionally, this study highlights the need to re-evaluate patients' oxygen requirements during a period of clinical stability.

How can we improve the quality of transplantable lungs?

INTRODUCTION

Optimization of lungs for organ donation is becoming increasingly important as donation rates stagnate despite growing waiting lists. Improving procurement and utilization of donated lungs has the ability to reduce mortality and time on the lung transplantation (LTx) waiting list. Additionally, assessment and optimization of donor lungs can reduce both early and late post-LTx morbidity and mortality, as well as reduce overall costs and resource utility. Areas covered: Strategies that we will discuss in detail include intensive care management practices, such as targeted ventilation protocols and therapeutic bronchoscopy, as well as the ever expanding possibilities within the arena of ex vivo lung perfusion (EVLP). Expert commentary: Donor lung quality is currently optimized both in vivo prior to organ procurement, and also via EVLP circuits. Despite good evidence demonstrating the utility of both approaches, data remain elusive as to whether EVLP is beneficial for all donor lungs prior to implantation, or instead as a tool by which we can evaluate and recondition sub-optimal donor lungs.

Evaluating the interstitial lung disease multidisciplinary meeting: a survey of expert centres

BACKGROUND

Multidisciplinary meetings (MDM) are the current "gold standard" in interstitial lung disease (ILD) diagnosis and comprise inter-disciplinary discussion of multiple forms of information to provide diagnostic and management outputs. Although bias could be potentially inserted at any step in the discussion process, to date there has been no consensus regarding the appropriate constitution and governance of MDM. We sought to determine the features of ILD MDMs based within ILD centres of excellence around the world.

METHODS

An internet based questionnaire was sent to twelve expert centres in Europe, North America, and Australia seeking information regarding the structure and governance of their MDM. Data was analysed for consistent themes and points of contrast.

RESULTS

Responses were received from 10 out of 12 centres. Similarities were demonstrated with regards to contributing attendees, meeting frequency and case numbers reviewed. Significant heterogeneity in attendee speciality group type, quantity and method of data presentation, approach to diagnosis formulation and documentation, and information provision was apparent.

CONCLUSIONS

The constitution of ILD MDMs differs considerably between expert centres. Such differences may result in discordant outcomes, and emphasise the need for further evidence regarding the appropriate constitution and governance of ILD MDMs.

Quasicondensation in Two-Dimensional Fermi Gases

In this paper we follow the analysis and protocols of recent experiments, combined with simple theory, to arrive at a physical understanding of quasi-condensation in two dimensional Fermi gases. A key signature of quasi-condensation, which contains aspects of Berezinskiĭ-Kosterlitz-Thouless behavior, is a strong zero momentum peak in the pair momentum distribution. Importantly, this peak emerges at a reasonably well defined onset temperature. The resulting phase diagram, pair momentum distribution, and algebraic power law decay are compatible with recent experiments throughout the continuum from BEC to BCS.

Structural and luminescence studies of the new nitridomagnesoaluminate CaMg2AlN3

The luminescent nitridomagnesoaluminate, CaMg₂AlN₃, was synthesized in a closed system by solid-state reaction from binary nitrides. Structure solution was aided by ultrahigh-field solid-state NMR spectroscopy and DFT calculations.

Phase imprinting in equilibrating Fermi gases: the transience of vortex rings and other defects

We present numerical simulations of phase imprinting experiments in ultracold trapped Fermi gases, which were obtained independently and are in good agreement with recent experimental results. Our focus is on the sequence and evolution of defects using the fermionic time-dependent Ginzburg-Landau equation, which contains dissipation necessary for equilibration. In contrast to other simulations, we introduce small, experimentally unavoidable symmetry breaking, particularly that associated with thermal fluctuations and with the phase-imprinting tilt angle, and we illustrate their dramatic effects. As appears consistent with experiment, the former causes vortex rings in confined geometries to move to the trap surface and rapidly decay into more stable vortex lines. The latter aligns the precessing and relatively long-lived vortex filaments, rendering them difficult to distinguish from solitons.

Self-reported recurrent pain and medicine use behaviours among 15-year olds: results from the international study

BACKGROUND

There is considerable variation in adolescent pain prevalence across epidemiological studies, with limited information on pain-related behaviours among adolescents, including medicine use. The aims of this study were (1) to examine the prevalence of recurrent pain among 15-year-old adolescents internationally; (2) to investigate the association between recurrent pain and medicine use behaviours among boys and girls; and (3) to evaluate the consistency of these associations across countries.

METHODS

The World Health Organization (WHO) collaborative international Health Behaviour in School-aged Children 2009/2010 study collects data about self-reported aches and medicine use from 36,762 15-year-old adolescents from 22 countries/regions in Europe and the United States. Multi-level multivariate logistic regression, stratified by gender, was used to analyse the association between recurrent pain and medicine use for headache, stomachache, nervousness and difficulties in getting to sleep.

RESULTS

More than 30% of adolescents reported recurrent headache, almost 30% recurrent backache and approximately 20% recurrent stomachache. Although pain prevalence and medicine use for aches were much higher for girls, the association between pain and medicine use was similarly strong for both genders. Adolescents with recurrent pain are more likely to use medicines also for non-corresponding pain, nervousness and difficulties in getting to sleep. The association between recurrent pain and medicine use was consistent across countries despite large-country differences in the prevalence of recurrent pain and medicine use.

CONCLUSIONS

Recurrent pain in adolescence is common cross-nationally. Adolescents with recurrent pain are more likely to use medicine in general. Recurrent pain and medicine use should be addressed in adolescent health policies.

Glucose effectiveness in nondiabetic relatives: dysglycemia and β-cell function at 10 years

AIMS

Reduced glucose effectiveness is a predictor of future glucose tolerance in individuals with a family history of type 2 diabetes. We examined retrospectively at 10 years in normoglycemic relatives of diabetic subjects (RELs) the pathophysiological role of glucose effectiveness in the development of isolated impaired fasting glucose, glucose intolerance, and acute insulin release.

METHODS

At 0 years, 19 RELs and 18 matched control subjects had glucose effectiveness (GE), insulin sensitivity, acute insulin release (AIR)IVGTT, and disposition index measured during an iv glucose tolerance test (IVGTT), using the minimal model analysis. At 0 and 10 years, oral glucose tolerance (OGTT) and AIROGTT were determined.

RESULTS

At 0 years, fasting glucose (FG) and GE were raised in RELs, but insulin sensitivity and AIROGTT were reduced (P ≤ .05) compared with controls. At 10 years, RELs developed raised fasting and 2-hour OGTT glucose. FG10y correlated significantly with FG0y and body mass index0y and negatively with √GE and 2-hour OGTT glucose10y with FG0y and negatively with AIRIVGTT0y and AIROGTT0y. Log AIROGTT10y correlated with √GE, log AIRIVGTT0y and log AIROGTT0y. Multiple regression analyses demonstrated the following: REL FG10y was predicted by combined FG0y, √GE and body mass index0y (radj(2) = 56%; P ≤ .001) and 2-hour OGTT glucose10y weakly related by FG0y,and √GE (r(adj)(2) = 25%; P = .06). Log AIROGTT10y was predicted by AIRIVGTT0y and √GE (r(adj)(2) = 46%; P ≤ .004).

CONCLUSION

In normoglycemic RELs, a relative reduction of glucose effectiveness is an important contributor over 10 years to the development of isolated impaired fasting glucose and reduced acute insulin secretion.

SU-E-T-197: A Comprehensive Variance Reporting System and an Analysis of Variances Reported at Our Institution

PURPOSE

It is essential for radiation oncology departments to have comprehensive patient safety and quality programs. Two years ago we undertook a systematic review of our safety/QA program. Existing policies were updated and new policies created where necessary. One crucial component of any safety/QA program is continually updating it based on current information, the 'check' and 'act' portions of the Deming Cycle. We accomplished this with a transparent variance reporting system and a safety/QA committee reviewing and acting on reported variances.

METHODS

With 5 radiation oncology centers in our institution, we needed to devise a system that would allow anyone to report a variance and provide our QA committee the ability to review variances system-wide. We developed the system using web-based tools. The system allows individuals to report variances, anonymously or named, specify the nature of the variance and indicate the tools used to identify the variance.

RESULTS

In 2011, 285 variances were reported, 102 were reported by physicists, 86 anonymously, 71 by therapists and 26 by dosimetrists. We realized the need to develop clear classifications for variances. We added a high priority category, defined as variances which resulted in or had the potential to result in harm to a patient or when a policy is purposely overridden. Of the 285 variances reported, 5 were high priority. We created a process variance category, defined as variances where a specific clinical process is not followed. Of the 285 reported variances 155 were process variances.

CONCLUSIONS

Reporting of variances through a centralized database is central toward developing a robust patient safety/quality assurance program. Anonymous reporting fosters a non-punitive environment, and promotes the 'safety culture'. The goal of such a system is to review trends in clinical processes and ultimately to improve safety/quality by reducing variances associated with these processes.

SU-E-J-59: Dual Imaging Guided Localization System for Spine Radiosurgery

PURPOSE

To compare localization accuracies between an ExacTrac and cone beam computed tomography (CBCT) systems for single fraction spine adiosurgery. The work also aimed to evaluate the inherent systematic deviation of both ExacTrac and CBCT systems to achieve highly accurate localization in the spine radiosurgery.

METHODS

ExacTrac and CBCT imaging systems were evaluated using the linac isocenter as the mutual reference point. First, a BB was placed in an anthropomorphic pelvic phantom. The phantom was localized with both imaging systems and the procedure was repeated 12 times. These results were used to devise a localization protocol using both imaging systems in spine radiosurgery, and employed for 51 patients (81 isocenters) prescribed for single fraction treatment. The displacement discrepancy between the isocenter and two systems were quantified in four dimensions (three translations, one rotation). A Student's two-tailed t-test was used to test for significant differences between the two imaging systems.

RESULTS

The phantom study showed 1.4±0.5, 0.6±0.5, and 0.1±0.5 mm differences between the two imaging systems in the anterior/posterior (A/P), superior/inferior (S/I) and left/right (L/R) directions, respectively. The angular difference was minimal along all three axes. The patient study revealed similar isocenter discrepancies between ExacTrac and CBCT of 1.1 ± 0.7 mm, 1.0±0.9 mm, and 0.2±0.9 mm in the A/P, S/I, and L/R directions, respectively, with the A/P and S/I directions showing statistical significance ((t(80) = 13.5 and 7.6 respectively, p = 0.000). The couch yaw discrepancy was 0 ± 0.3°. Overall, 1 mm systematic differences were observed in the A/P and S/I directions between ExacTrac and CBCT localization systems, both in phantom and patient. A procedure was developed to mitigate this systematic discrepancy.

CONCLUSIONS

These findings have justified our patient localization tolerance levels of 2 mm translation and 1 degree rotation for spine SRS treatment.

The proteomic signature of insulin-resistant human skeletal muscle reveals increased glycolytic and decreased mitochondrial enzymes

AIMS/HYPOTHESIS

The molecular mechanisms underlying insulin resistance in skeletal muscle are incompletely understood. Here, we aimed to obtain a global picture of changes in protein abundance in skeletal muscle in obesity and type 2 diabetes, and those associated with whole-body measures of insulin action.

METHODS

Skeletal muscle biopsies were obtained from ten healthy lean (LE), 11 obese non-diabetic (OB), and ten obese type 2 diabetic participants before and after hyperinsulinaemic-euglycaemic clamps. Quantitative proteome analysis was performed by two-dimensional differential-gel electrophoresis and tandem-mass-spectrometry-based protein identification.

RESULTS

Forty-four protein spots displayed significant (p < 0.05) changes in abundance by at least a factor of 1.5 between groups. Several proteins were identified in multiple spots, suggesting post-translational modifications. Multiple spots containing glycolytic and fast-muscle proteins showed increased abundance, whereas spots with mitochondrial and slow-muscle proteins were downregulated in the OB and obese type 2 diabetic groups compared with the LE group. No differences in basal levels of myosin heavy chains were observed. The abundance of multiple spots representing glycolytic and fast-muscle proteins correlated negatively with insulin action on glucose disposal, glucose oxidation and lipid oxidation, while several spots with proteins involved in oxidative metabolism and mitochondrial function correlated positively with these whole-body measures of insulin action.

CONCLUSIONS/INTERPRETATION

Our data suggest that increased glycolytic and decreased mitochondrial protein abundance together with a shift in muscle properties towards a fast-twitch pattern in the absence of marked changes in fibre-type distribution contribute to insulin resistance in obesity with and without type 2 diabetes. The roles of several differentially expressed or post-translationally modified proteins remain to be elucidated.

Microscopic approach to shear viscosities of unitary Fermi gases above and below the superfluid transition

Recent experiments on the shear viscosity η in a unitary Fermi gas fail to see the theoretically predicted upturn in η at the lower T. In this Letter, we compute η in a fashion which is demonstrably consistent with conservation laws and, in the process, provide an understanding of recent experiments. We show that this disagreement with prior theories cannot be readily attributed to the trap, since (via edge effects) trap-averaged viscosities will be larger than their homogeneous counterparts. The small values of η we find can be simply understood; they reflect the fact that the Goldstone bosons (phonons) do not couple to transverse probes such as η, and fermionic excitations, which determine the viscosity, are necessarily absent in the ground state.

Establishing the presence of coherence in atomic fermi superfluids: spin-flip and spin-preserving Bragg scattering at finite temperatures

We show how in ultracold Fermi gases the difference between the finite temperature T structure factors, called S_(ω,q), associated with spin and density, reflects coherent order at all ω, q, k(F)a, and T. This observation can be exploited in two photon Bragg scattering experiments on gases which are subject to variable attractive interactions. Our calculations incorporate spin and particle number conservation laws which lead to compatibility at general T with two f-sum rules. Because of its generality a measurement of S_(ω,q) can be a qualitative, direct, in situ approach for establishing superfluid order.

Human ATP synthase beta is phosphorylated at multiple sites and shows abnormal phosphorylation at specific sites in insulin-resistant muscle

AIMS/HYPOTHESIS

Insulin resistance in skeletal muscle is linked to mitochondrial dysfunction in obesity and type 2 diabetes. Emerging evidence indicates that reversible phosphorylation regulates oxidative phosphorylation (OxPhos) proteins. The aim of this study was to identify and quantify site-specific phosphorylation of the catalytic beta subunit of ATP synthase (ATPsyn-beta) and determine protein abundance of ATPsyn-beta and other OxPhos components in skeletal muscle from healthy and insulin-resistant individuals.

METHODS

Skeletal muscle biopsies were obtained from lean, healthy, obese, non-diabetic and type 2 diabetic volunteers (each group n = 10) for immunoblotting of proteins, and hypothesis-driven identification and quantification of phosphorylation sites on ATPsyn-beta using targeted nanospray tandem mass spectrometry. Volunteers were metabolically characterised by euglycaemic-hyperinsulinaemic clamps.

RESULTS

Seven phosphorylation sites were identified on ATPsyn-beta purified from human skeletal muscle. Obese individuals with and without type 2 diabetes were characterised by impaired insulin-stimulated glucose disposal rates, and showed a approximately 30% higher phosphorylation of ATPsyn-beta at Tyr361 and Thr213 (within the nucleotide-binding region of ATP synthase) as well as a coordinated downregulation of ATPsyn-beta protein and other OxPhos components. Insulin increased Tyr361 phosphorylation of ATPsyn-beta by approximately 50% in lean and healthy, but not insulin-resistant, individuals.

CONCLUSIONS/INTERPRETATION

These data demonstrate that ATPsyn-beta is phosphorylated at multiple sites in human skeletal muscle, and suggest that abnormal site-specific phosphorylation of ATPsyn-beta together with reduced content of OxPhos proteins contributes to mitochondrial dysfunction in insulin resistance. Further characterisation of phosphorylation of ATPsyn-beta may offer novel targets of treatment in human diseases with mitochondrial dysfunction, such as diabetes.