Study protocol for the implementation of Centering Patients with Fibroids, a novel group education and empowerment program for patients with symptomatic uterine fibroids

BACKGROUND

Black women and people with uteri have utilized collectivistic and relational practices to improve health outcomes in the face of medical racism and discrimination for decades. However, there remains a need for interventions to improve outcomes of uterine fibroids, a condition that disproportionately impacts Black people with uteri. Leveraging personalized approaches alongside evidence that demonstrates the positive impact of social and peer support on health outcomes, we adapted from CenteringPregnancy, an evidence based group prenatal care intervention, for the education and empowerment of patients with uterine fibroids.

METHODS

The present report provides  an overview of the study design and planned implementation of CPWF in cohorts at Boston Medical Center and Emory University / Grady Memorial Hospital. After receiving training from the Centering Healthcare Institute (CHI), we adapted the 10-session CenteringPregnancy curriculum to an 8-session hybrid group intervention called Centering Patients with Fibroids (CPWF). The study began in 2022 with planned recruitment of six cohorts of 10-12 participants at each institution. We will conduct a mixed methods evaluation of the program using validated survey tools and qualitative methods, including focus groups and 1:1 interviews.

DISCUSSION

To date, we have successfully recruited 4 cohorts at Boston Medical Center and are actively implementing BMC Cohort 5 and the first cohort at Emory University / Grady Memorial Hospital. Evaluation of the program is forthcoming.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Safety and effectiveness of the fluocinolone acetonide intravitreal implant (ILUVIEN): 3-year results from the European IRISS registry study

BACKGROUND

The ILUVIEN Registry Safety Study was a multicentre, open-label, non-randomised, observational, phase 4 study designed to assess the safety and effectiveness of the fluocinolone acetonide (FAc) implant in all indications in real-world practices in Europe.

METHODS

The study included data collected prospectively and retrospectively. Patients receiving FAc implants between 2013 and 2017 were included and monitored until the last patient reached ≥3 years of follow-up. Mean intraocular pressure (IOP) data over the course of the study, along with IOP events, use of IOP-lowering therapy, mean change in visual acuity (VA) and information on supplemental therapy use were analysed post-FAc implantation.

RESULTS

Six hundred and ninety-five eyes from 556 patients, with a mean±SD follow-up of 1150.5±357.36 days, were treated with a FAc implant. 96.7% of eyes had chronic diabetic macular oedema (cDMO). IOP lowering was achieved in 34.5% of eyes using topical agents and 4.3% by surgery. Seventy-three eyes (64.6% of 113 phakic) required cataract surgery during follow-up. Mean VA increased from a baseline of 52.2 letters to 57.1 letters at month 36, with improvement observed up to month 48. Supplementary therapies were given in 43.7% of eyes. When classified by length of cDMO less than or greater than the median duration those with a shorter history experienced greater VA gains than those with a longer history.

CONCLUSION

This study confirms the favourable, long-term benefit-to-risk profile of the FAc implant in eyes with cDMO, with an additional benefit in patients when this therapy is administered earlier.

Baseline Diabetic Retinopathy Severity and Time to Diabetic Macular Edema Resolution with Ranibizumab Treatment: A Meta-Analysis

OBJECTIVE

Having a better understanding of how long diabetic macular edema (DME) takes to resolve in patients with diabetic retinopathy (DR) after treatment with ranibizumab, and the factors affecting this outcome, would be of benefit to physicians and patients alike. The objective of this analysis was to evaluate the time to first DME resolution and the impact of baseline DR severity on this outcome in patients treated with ranibizumab in phase III clinical trials.

DESIGN

Meta-analysis of data from the phase III trials, RIDE (NCT00473382) and RISE (NCT00473330), and DR Clinical Research Network protocols I (NCT00444600), S (NCT01489189), and T (NCT01627249).

PARTICIPANTS

Patients with DME (central subfield thickness [CST] > 250 μm) and DR with Diabetic Retinopathy Severity Scale (DRSS) score between 35 and 85.

INTERVENTION

Intravitreal injection of ranibizumab.

MAIN OUTCOME MEASURES

The time to first DME resolution (defined as CST ≤ 250 μm) within 24 months was evaluated overall and by baseline DR severity category per the DRSS (35 of 43 [mild or moderate nonproliferative DR], 47-53 [moderately severe or severe nonproliferative DR], 60 [mild proliferative DR], and 61-85 [moderately severe to severe proliferative DR]).

RESULTS

There were 777 patients included in the meta-analysis. The overall mean (95% confidence interval) time to first DME resolution, adjusted for baseline CST, was 6.0 (5.6-6.4) months. The mean (95% CI) time to first DME resolution was 7.1 (6.2-7.9), 5.9 (5.2-6.6), 6.0 (4.8-7.2), and 4.5 (3.5-5.5) months for the 35 of 43, 47 to 53, 60, and 61 to 85 baseline DRSS categories, respectively (overall P = 0.002). By month 24, the proportion of eyes with DME resolution was 74.9% (221 of 295), 77.5% (299 of 386), 69.4% (109 of 157), and 78.7% (148 of 188) for the 35 of 43, 47 to 53, 60, and 61 to 85 baseline DRSS categories, respectively (overall P = 0.17).

CONCLUSIONS

This meta-analysis of data from patients treated with ranibizumab showed that DME resolution was faster in patients with more severe DR at baseline. However, by month 24, a similar proportion of patients achieved DME resolution, regardless of baseline DR severity. These findings may guide treatment decisions and inform patient expectations in clinical practice.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Correlation of Engraftment and Time from Melphalan Administration to Stem Cell Infusion

Single-agent, high-dose melphalan continues to be the most commonly used conditioning regimen for transplantation-eligible patients with multiple myeloma undergoing autologous stem cell transplantation. The timing of melphalan administration with respect to stem cell infusion has not been clearly defined. Many institutions require a minimum of 24 hours between melphalan administration and stem cell infusion; however, some institutions have adopted shorter intervals based on melphalan's short half-life. Some studies have suggested that shortening the interval between melphalan administration and stem cell infusion may contribute to delays in engraftment, but this correlation has not been clearly evaluated or defined. This multicenter retrospective cohort study evaluated the times to neutrophil and platelet engraftment in patients who received stem cells at least 24 hours after melphalan (≥24 hours cohort) compared with those who received stem cells within 24 hours of melphalan (<24 hours cohort. The study included a total of 723 adult patients, 502 patients in the ≥24 hours cohort and 221 in the <24 hours cohort, treated at 3 transplantation centers between January 1, 2016, and September 30, 2019. Patient characteristics were summarized using descriptive statistics. The Fisher exact test was used to compare nominal categorical variables between the 2 cohorts, and the nonparametric van der Waerden test or Mood median test was used to compare ordinal or continuous variables. The median time to neutrophil engraftment was 12 days for both the ≥24 hours cohort (interquartile range [IQR], 11 to 12 days) and the <24 hours cohort (IQR, 11 to 13 days) (P = .07). The median time to platelet engraftment was 19 days for both the ≥24 hours cohort (IQR, 17 to 22 days) and <24 hours cohort (IQR, 17 to 20 days) (P = .25). The median time between melphalan administration and stem cell infusion in the <24 hours cohort was 18 hours, with a minimum time of 12 hours. The existing literature has not clearly defined the impact of the timing between melphalan administration and stem cell infusion on engraftment in autologous transplantation. The ability to safely shorten the interval between chemotherapy and transplantation could increase logistical flexibility and/or decrease the length of hospital stay. This large multicenter retrospective study did not identify a statistical or clinical impact on engraftment when melphalan was infused <24 hours or ≥24 hours before autologous stem cell infusion.

PATTERNS OF SUBRETINAL AND/OR INTRARETINAL FLUID RECURRENCE IN PATIENTS WHO RECEIVED AS-NEEDED RANIBIZUMAB THERAPY IN THE HARBOR TRIAL

PURPOSE

To evaluate subretinal (SRF) and/or intraretinal fluid (IRF) recurrence in patients with neovascular age-related macular degeneration (nAMD) who received as-needed (PRN) ranibizumab in a HARBOR (NCT00891735) post hoc analysis.

METHODS

Analyses included patients with SRF and/or IRF at baseline and fluid recurrence after a ≥3 months absence (N=222). Baseline fluid location(s) was compared with location of recurrence after a ≥3-month absence.

RESULTS

At baseline, fluid was equally distributed across all locations. On recurrence, the location was most frequently central (69%). Eyes with central fluid at baseline typically had recurrence in the same location (72% versus 47%-53% with fluid in other locations). The type of recurrent fluid was typically the same as at baseline (SRF, 64%; IRF, 75%). Overall, 37% (39/105) of eyes exhibited fluid recurrence in a new location, most frequently central (53%). There was a significant gain in best-corrected visual acuity (mean [95% CI], +2.2 [0.4, 4.0] letters) between the months of SRF resolution and recurrence.

CONCLUSION

Although the location of SRF and/or IRF were equally distributed at baseline, recurrent fluid was typically centrally located. We identified a subgroup of eyes exhibiting fluid recurrence in a different location than at baseline, potentially indicating new choroidal neovascularization.

Characteristics that Correlate with Macular Atrophy in Ranibizumab-Treated Patients with Neovascular Age-Related Macular Degeneration

OBJECTIVE

To use multimodal assessment (fluorescein angiography [FA], color fundus photography [CFP], and spectral-domain-OCT [SD-OCT]) to reevaluate macular atrophy (MA) and macular neovascularization (MNV) type in the HARBOR trial according to the consensus on neovascular age-related macular degeneration (nAMD) Nomenclature criteria; and to determine if there are any associations between baseline demographic factors, ocular characteristics, and treatment for nAMD and the development of MA by month 24.

DESIGN

Post hoc analysis of the phase III, randomized, multicenter, double-masked, controlled HARBOR trial (NCT00891735).

SUBJECTS

Nine-hundred and twenty-two study eyes and 919 fellow eyes from the HARBOR trial.

METHODS

This post hoc analysis included patients with multimodal assessments on FA, CFP, and SD-OCT at baseline. A risk analysis for the development of MA was performed by multimodal assessment and SD-OCT on study eyes without MA at baseline that had completed SD-OCT assessments for MA at month 24.

MAIN OUTCOME MEASURES

Development of MA in study eyes at month 24 and a risk analysis for developing MA at month 24 in study eyes that had no MA at baseline, as assessed by multimodal assessment.

RESULTS

Of 1097 patients in the HARBOR trial with nAMD and active subfoveal MNV, a total of 922 study eyes and 919 fellow eyes were included in the multimodal analysis of MNV. Macular atrophy assessment was performed on SD-OCT. Of these, 593 had no baseline MA and were included in the risk analysis for developing MA. In eyes with no detectable MA at baseline, a larger proportion of eyes with any MNV type 3 (including mixed type) at baseline developed new MA at month 24 (49.2%) than eyes with MNV type 1 (26.5%), type 2 (29.1%), or mixed type 1 and 2 (34.6%). Macular neovascularization type 3 and fellow eye MA were identified as risk factors for new MA development at month 24.

CONCLUSIONS

Macular neovascularization type 3 was a strong risk factor for new MA development at month 24, with fellow eye MA also being identified as a predictor. No other variables, including ranibizumab treatment, were identified as risk factors for new MA development.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Performance improvement in sport through vitamin D - a narrative review

OBJECTIVE

It is well known that vitamin D deficiency can lead to various health problems. However, it is not common knowledge among athletes and doctors that vitamin D deficiency is prevalent in sports. This deficiency can severely impact performance, while vitamin D supplementation can alleviate this effect and potentially improve performance.

MATERIALS AND METHODS

This narrative review aims to compile the current state of knowledge about the importance of vitamin D in increasing performance for active people. To this end, we searched the 'Scopus' and 'PubMed' databases for the terms 'vitamin D - athlete - performance' with an end date of 30 June 2022.

RESULTS

Study results indicated that the therapeutic impact of vitamin D on aerobic capacity, recovery, strength and sprint performance remains controversial.

CONCLUSIONS

Based on the previous findings on recovery, strength and performance, 4,000-5,000 IU of vitamin D per day may be a safe dose that can improve athletic performance.

Subretinal Fluid Resolution and Visual Acuity in Patients with Neovascular Age-Related Macular Degeneration: A HARBOR Post Hoc Analysis

OBJECTIVE

To determine the effect of subretinal fluid (SRF) resolution on visual acuity in patients with neovascular age-related macular degeneration (nAMD) from the HARBOR trial.

DESIGN

Post hoc analysis of the HARBOR trial (a phase 3, double-masked, randomized, active treatment-controlled trial of ranibizumab conducted between July 2009 and August 2012 [NCT00891735]) was carried out from January 2020 to July 2021.

PARTICIPANTS

Treatment-naive patients with nAMD and active subfoveal choroidal neovascularization (N = 1097). Multiple intervention arms were pooled for this analysis if SRF was present at baseline and intraretinal fluid/SRF resolved during the study, based on spectral-domain OCT (n = 349).

INTERVENTION

Three monthly loading doses followed by intravitreal injections of 0.5-mg or 2.0-mg ranibizumab were administered monthly or pro re nata over 24 months.

MAIN OUTCOME MEASURES

Mean change in ETDRS best-corrected visual acuity (BCVA) between the month before SRF resolution and the month of SRF resolution detection. Visual outcomes at months 12 and 24 were analyzed in eyes without SRF recurrence after SRF resolution. The proportion of patients who lost ≤ 4 letters were considered as vision gainers/maintainers and those who lost ≥ 5 were considered as vision losers.

RESULTS

Of 349 patients, 32 patients (9%) lost ≥ 5 ETDRS letters (mean [95% confidence interval (CI)], -9.9 letters [-12.0, -7.9]) and 317 (91%) of the eyes gained/maintained BCVA (mean, 6.1 letters [95% CI, 5.3, 6.8]) between the month before SRF resolution and the month of SRF resolution. There were no differences in baseline ocular characteristics between patient groups. Among eyes without SRF recurrence after SRF resolution (64%; 224/349), eyes that lost ≥ 5 ETDRS letters compared with those that gained/maintained letters at the time of SRF resolution had reduced visual outcome gains from baseline to month 12 (1.4 vs. 12.9 letters) and month 24 (0.0 vs. 12.6 letters).

CONCLUSIONS

A greater proportion of ranibizumab-treated eyes with nAMD gained/maintained visual acuity at SRF resolution. Approximately 9% of eyes lost vision during SRF resolution; these eyes had reduced final visual acuity gains at 12 and 24 months. Further analyses are warranted to investigate potential underlying factors and discuss the treatment implications if confirmed.

Postoperative symptom monitoring with ePROs in an academic public hospital

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Background: Postoperative symptom burden is high in surgical oncology patients. Electronic patient-reported outcome (ePRO) remote monitoring systems are rapidly proliferating and have the promise of improving care. However, implementation in diverse practice settings is understudied. More information on ePRO participation may determine addressable barriers. Methods: Patients presenting to the Multidisciplinary Thoracic Oncology Program for surgery were prospectively enrolled. ePROs assessing common postop symptoms and functional impairments were administered via a web-based platform daily for 14 days and then weekly until 3 months post-discharge. Automated reminders were provided by email. Phone calls were made for 2 consecutive missed ePROs. ePRO participation levels were categorized as high (> 80%), medium (50-80%), low (1-49%), and none. Patient characteristics were examined by participation level via Fisher’s exact and Kruskal-Wallis tests. Results: From 2020-2022, 202 patients were recruited to participate, and 113 (56%) agreed. There were no differences in demographics of agreed vs. declined. 99 patients initiated ePROs after discharge. Mean age was 60.5 years (sd 13.4), 37.8% were male, 72.5% were White, and the majority (64%) had lung resection. Patients participated in ePROs for an average of 82 days (sd 24) before discontinuing. Overall, 57.7% (1383/2397) of delivered surveys were completed; response rates were lowest in week 1 (48%) and highest in week 7 (71%). Participation levels are described in Table. Married/partnered patients were significantly more likely to have high levels of participation (p = 0.003), and those who regularly used a computing device almost reached significance (p = 0.057). Age, gender, race, employment, email/internet use, financial status, and quality of life did not vary across ePRO participation levels. Conclusions: Monitoring symptoms with ePROs after discharge from thoracic surgery is feasible in a large academic public hospital. Participation levels in ePROs are lower immediately after discharge, when symptomatic complications drive the highest rates of readmissions. This suggests an opportunity to improve ePRO implementation during the post-acute period when intensive monitoring is desired and in patients who are not partnered or are less frequent device users. As length of stay and readmissions are increasingly targeted for expenditure reduction in academic inpatient settings, it is paramount to design and implement systems to effectively monitor at-risk patients. Clinical trial information: NCT04342260. [Table: see text]

Establishing Novel Antiretroviral Imaging for Hair to Elucidate Non-Adherence (ENLIGHTEN): Study Design (Preprint)

BACKGROUND

Adherence to antiretroviral (ARV) therapy is critical for achieving HIV RNA suppression in people living with HIV and for preventing HIV infection in uninfected individuals using preexposure prophylaxis. However, a high level of adherence can be challenging to achieve for people living with HIV on lifelong ARVs and for HIV-negative individuals using daily preexposure prophylaxis who are not at daily risk for HIV infection. Current biological measures of adherence are invasive and use bioanalytical methods that do not allow for real-time feedback during a clinic visit. This study was designed to test the feasibility and acceptability of using MedViewer, a novel, minimally invasive, hair-based assay that measures longitudinal ARV drug adherence in real time and provides an output for provider-patient discussion.

OBJECTIVE

The primary objectives were to investigate the feasibility of delivering the MedViewer results as planned, the acceptability of participation in a discussion of the MedViewer results, and the appropriateness of using MedViewer for adherence counseling. The secondary objectives were to investigate additional dimensions of feasibility, acceptability, and appropriateness of using the MedViewer test during a routine clinic visit for people with HIV.

METHODS

The proposed study was a single-arm cross-sectional study among patients receiving HIV care and providers of HIV care in a southeastern infectious disease clinic. The study originally planned to implement the MedViewer test with 50 eligible patients who were living with HIV across 2 viral load strata (undetectable or detectable plasma HIV RNA over the previous 2 years), administer brief visit-specific questionnaires to all patient and provider participants, and conduct qualitative in-depth interviews and quantitative end-line questionnaires with a subsample of patient participants (n=30) and all provider participants.

RESULTS

The Establishing Novel Antiretroviral Imaging for Hair to Elucidate Nonadherence study was funded by the National Institute of Allergy and Infectious Diseases and approved by the local institutional review board on November 4, 2019. Provider participant enrollment began on January 17, 2020, and patient participant enrollment began on January 22, 2020. Participant enrollment was halted on March 16, 2020, because of the COVID-19 pandemic (16 providers and 10 patients on study). Study activities resumed on February 2, 2021, with COVID-19 modifications approved by the local institutional review board. Participant enrollment closed on October 8, 2021, and data collection closed on November 15, 2021. In total, 36 unique patient participants, representing 37 samples, and 20 provider participants were enrolled. Data analysis and manuscript writing will take place throughout 2023.

CONCLUSIONS

We anticipate that the data collected through this study will provide important insights regarding the feasibility, acceptability, and appropriateness of incorporating new real-time longitudinal, minimally invasive adherence tests into routine clinical care and identify potential barriers to medication adherence among patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04232540; https://clinicaltrials.gov/ct2/show/NCT04232540.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/41188.

The impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Northern Ireland Chest Heart & Stroke

Background

Cardiac cachexia is a multifactorial wasting syndrome, which is characterised by unintentional weight loss, a reduction in skeletal muscle mass, and reduced quality of life. There is a paucity of qualitative research outlining the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers. Research in this area may promote a better understanding of the syndrome, enhance current treatment strategies, and highlight priorities for patient care.

Purpose

To qualitatively investigate the impact and experience of cardiac cachexia in advanced heart failure patients and their caregivers.

Methods

Semi-structured interviews were performed with advanced heart failure (NYHA functional class III-IV) patients meeting diagnostic criteria for cardiac cachexia (number (n) = 8) and their caregivers (n = 5). Interview questions followed a "laddered style approach", with a focus on determining the experience of cachexia for patients and carers, and its impact on their daily lives. Interviews were digitally recorded and transcribed verbatim. Average interview duration was 43 (15-64) minutes. Data were thematically analysed, using the 6-step approach of Braun & Clarke. Themes were developed and refined by several members of the research team to ensure rigor.

Results

Four key themes were developed from the data. 1) "Changed relationship with food and eating": patients with cachexia referred to eating as something they now ‘make’ themselves do without enjoyment, often just to placate their caregiver. Caregivers noted this change in habit and were concerned about inadequate nutritional intake due to the patient’s lack of interest in food. 2) "Not me in the mirror": patients struggled with their appearance and had a negative perception of themselves, linked to their weight loss. Caregivers were similarly aware of the physical changes in their loved ones and emotionally impacted. 3) "Lack of understanding regarding cachexia": despite the patient and caregivers’ concerns, they had a perception that healthcare professionals were just ‘fobbing you off’. Even though weight loss was noted and distressing to patients and caregivers, there was little clinical recognition of it, nor any advice or support from the clinical team regarding management. 4) "Uncertainty regarding the future": patients and caregivers recognised cachexia as a bad sign, and many expressed concerns about their future health and prognosis.

Conclusion

These novel qualitative findings highlight the severe impact of cardiac cachexia on the daily lives of patients and caregivers, and demonstrate their limited understanding of the syndrome. To improve care, professionals need to recognise and discuss cachexia with heart failure patients and caregivers, supporting them to cope with prognostic implications and develop more effective management strategies.

Effect of less aggressive treatment on diabetic retinopathy severity scale scores: analyses of the RIDE and RISE open-label extension

Objective

To evaluate factors associated with Diabetic Retinopathy Severity Scale (DRSS) changes with less frequent ranibizumab after induction therapy.

Methods and analysis

Post hoc analyses of RIDE/RISE and their open-label extension (OLE). Analyses included patients with diabetic retinopathy (DR)/diabetic macular oedema who completed the OLE. Comparisons were made between patients with improved/maintained (≥0 step decrease from OLE baseline (month 36) to month 48) versus worsened (≥1 step increase) DRSS during the OLE. DRSS changes over 12 months were compared between patients randomised to ranibizumab at RIDE/RISE baseline who improved to DRSS score ≤43 at OLE baseline (induced) versus those randomised to sham with DRSS score ≤43 at RIDE/RISE baseline (native).

Results

From OLE baseline to month 48, 72% (263/367) of patients improved/maintained DRSS scores. These patients had similar mean best-corrected visual acuity at RIDE/RISE (56.4 letters) and OLE baseline (68.6 letters) versus patients with worsened scores (58.2 and 70.8 letters). Patients who improved/maintained DRSS scores had similar mean central foveal thickness at RIDE/RISE (492 µm) and OLE baseline (196 µm) versus patients with worsened scores (441 and 167 µm). Patients who improved/maintained DRSS scores received a significantly higher (p<0.0001) mean number of pro re nata (PRN) injections (4.4) between OLE baseline and month 48 versus those with worsened scores (2.3). Patients with more severe DR at baseline who achieved mild-to-moderate non-proliferative DR (NPDR) induced by monthly ranibizumab injections were significantly more likely to worsen (p<0.0001) than those with mild-to-moderate NPDR at baseline randomised to sham injections (1.0-step versus 0.1-step worsening).

Conclusions

Most patients improved/maintained DRSS scores with less-than-monthly PRN ranibizumab. Some minimum treatment/monitoring may be necessary to maintain improvements after induction therapy.

Trial registration numbers

NCT00473382/NCT00473330.

MAIT and Vδ2 unconventional T cells are supported by a diverse intestinal microbiome and correlate with favorable patient outcome after allogeneic HCT

Microbial diversity is associated with improved outcomes in recipients of allogeneic hematopoietic cell transplantation (allo-HCT), but the mechanism underlying this observation is unclear. In a cohort of 174 patients who underwent allo-HCT, we demonstrate that a diverse intestinal microbiome early after allo-HCT is associated with an increased number of innate-like mucosal-associated invariant T (MAIT) cells, which are in turn associated with improved overall survival and less acute graft-versus-host disease (aGVHD). Immune profiling of conventional and unconventional immune cell subsets revealed that the prevalence of Vδ2 cells, the major circulating subpopulation of γδ T cells, closely correlated with the frequency of MAIT cells and was associated with less aGVHD. Analysis of these populations using both single-cell transcriptomics and flow cytometry suggested a shift toward activated phenotypes and a gain of cytotoxic and effector functions after transplantation. A diverse intestinal microbiome with the capacity to produce activating ligands for MAIT and Vδ2 cells appeared to be necessary for the maintenance of these populations after allo-HCT. These data suggest an immunological link between intestinal microbial diversity, microbe-derived ligands, and maintenance of unconventional T cells.

The aspects of sex, age and nationality in winter swimming performance

OBJECTIVE

Winter swimming is a new sport discipline. Very little is known, however, about the sex differences, origin, participation and performance of the world's best winter swimmers. Therefore, the study aimed to investigate sex differences in performance and age. Furthermore, it should be determined which country has the fastest swimmers, the highest numbers of participants and the most successful age group athletes in winter swimming.

SUBJECTS AND METHODS

A total of 6,477 results from the 25 m events of the IWSA (International Winter Swimming Association) World Cups from 2016-2020 was collected from the official website of IWSA. Data were analyzed using a generalized linear model (GLM) with a gamma probability distribution and identity link function. The 25 m events were carried out in head-up breaststroke style, freestyle and butterfly. The nationalities were grouped into six groups, the five nationalities with the highest number of participants in the 25 m competitions and one group with the other nationalities. The mean time of 25 m races by sex and country of the total sample was compared. For the top 10 comparisons, the best ten athletes from the six groups were selected. The mean time of each top 10 groups was compared by sex and nationality.

RESULTS

Men were faster than women for all categories. Swimmers in age group 15-29 years were the fastest, where females were the fastest in age group 15-19 years and males in age group 20-29 years. Women from both Russia and Estonia and men from both Russia and China were the fastest. Both Russian and Chinese males were the fastest in all water categories in the top 10 section in the 25 m events.

CONCLUSIONS

In summary, males were faster than females in the IWSA World Cups between 2016 and 2020. The age group of 15-29 years old athletes was the most successful while females had their age of peak performance earlier than males. Russian and Estonian males and Russian females were the overall fastest in the 25 m events in all water categories. Future studies should investigate the optimal anthropometric characteristics of male and female winter swimming sprint athletes and whether there are distinct areas in Russia, Estonia and China, where many international winter swimming athletes originate.

Effect of two incremental intensity field tests on wellness indices, recovery state, and physical enjoyment in soccer players

OBJECTIVE

Competitive athletes must undergo fitness testing to monitor athlete progress and to create appropriate, progressive training programs. However, fitness testing adds to training stress; therefore, impacts of testing on wellness and recovery must be considered in test selection. This study investigated the effects of two incremental field tests [VAMEVAL test (T-VAM) and 20-m maximum shuttle test (20-m MST)] on wellness, total quality of recovery (TQR) and physical enjoyment (PE) in competitive soccer players.

SUBJECTS AND METHODS

Twenty-two soccer players (20.9±1.5 years) completed two T-VAM and two 20-m MST in a randomized order on separate days with a 1-week interval between tests. TQR and wellness indices (sleep, fatigue, stress and muscle soreness) measures were collected before and 24 hours after each test. Heart rate (HR) was continuously monitored during each test. Rating of perceived exertion (RPE) and PE were assessed after each test.

RESULTS

T-VAM resulted in higher PE, TQR and wellness scores than 20-m MST (p<0.05). T-VAM and 20-m MST resulted in similar HR and maximal aerobic speed. For T-VAM, TQR was correlated (p<0.01) with RPE and wellness indices. For 20-m MST, TQR was correlated (p<0.01) with wellness indices. HRmax and RPE were not correlated with wellness indices, TQR or PE.

CONCLUSIONS

Overall, T-VAM and 20-m MST produced similar aerobic fitness testing results, but athletes responded more favorably to T-VAM. Coaches can use T-VAM for evaluating aerobic fitness while maximizing well-being and physical enjoyment among soccer players.

Macular neovascularization lesion type and vision outcomes in neovascular age-related macular degeneration: post hoc analysis of HARBOR

Purpose

To characterize relationships between Consensus on Neovascular Age-Related Macular Degeneration Nomenclature (CONAN) Study Group classifications of macular neovascularization (MNV) and visual responses to ranibizumab in patients with neovascular age-related macular degeneration (nAMD).

Methods

This was a post hoc analysis of the phase 3 HARBOR trial of ranibizumab in nAMD. Analyses included ranibizumab-treated eyes with baseline multimodal imaging data; baseline MNV; subretinal and/or intraretinal fluid at screening, baseline, or week 1; and spectral-domain optical coherence tomography images through month 24 (n = 700). Mean best-corrected visual acuity (BCVA) over time and mean BCVA change at months 12 and 24 were compared between eyes with type 1, type 2/mixed type 1 and 2 (type 2/M), and any type 3 MNV at baseline.

Results

At baseline, 263 (37.6%), 287 (41.0%), and 150 (21.4%) eyes had type 1, type 2/M, and any type 3 lesions, respectively. Type 1 eyes had the best mean BCVA at baseline (59.0 [95% CI: 57.7–60.3] letters) and month 24 (67.7 [65.8–69.6] letters), whereas type 2/M eyes had the worst (50.0 [48.6–51.4] letters and 60.8 [58.7–62.9] letters, respectively). Mean BCVA gains at month 24 were most pronounced for type 2/M eyes (10.8 [8.9–12.7] letters) and similar for type 1 (8.7 [6.9–10.5] letters) and any type 3 eyes (8.3 [6.3–10.3] letters).

Conclusion

Differences in BCVA outcomes between CONAN lesion type subgroups support the use of an anatomic classification system to characterize MNV and prognosticate visual responses to anti-vascular endothelial growth factor therapy for nAMD.

Trial registration

ClinicalTrials.gov identifier: NCT00891735. Date of registration: April 29, 2009.

A Kerr polarization controller

Kerr-effect-induced changes of the polarization state of light are well known in pulsed laser systems. An example is nonlinear polarization rotation, which is critical to the operation of many types of mode-locked lasers. Here, we demonstrate that the Kerr effect in a high-finesse Fabry-Pérot resonator can be utilized to control the polarization of a continuous wave laser. It is shown that a linearly-polarized input field is converted into a left- or right-circularly-polarized field, controlled via the optical power. The observations are explained by Kerr-nonlinearity induced symmetry breaking, which splits the resonance frequencies of degenerate modes with opposite polarization handedness in an otherwise symmetric resonator. The all-optical polarization control is demonstrated at threshold powers down to 7 mW. The physical principle of such Kerr effect-based polarization controllers is generic to high-Q Kerr-nonlinear resonators and could also be implemented in photonic integrated circuits. Beyond polarization control, the spontaneous symmetry breaking of polarization states could be used for polarization filters or highly sensitive polarization sensors when operating close to the symmetry-breaking point.

Effect of Residual Retinal Fluid on Visual Function in Ranibizumab-Treated Neovascular Age-Related Macular Degeneration

PURPOSE

To investigate the relationship between retinal fluid and vision in ranibizumab-treated patients with neovascular age-related macular degeneration (nAMD).

DESIGN

Clinical cohort study using post hoc analysis of clinical trial data.

METHODS

We assessed data from HARBOR (NCT00891735), a phase III, randomized, controlled trial. We reviewed 917 patients ≥50 years of age with subfoveal nAMD associated with subretinal (SRF) and/or intraretinal fluid (IRF) at baseline, screening, or week 1. The intervention was intravitreal ranibizumab 0.5 or 2.0 mg (all treatment arms pooled). Outcomes included mean best-corrected visual acuity (BCVA) and BCVA change from baseline at months (M) 12 and 24 evaluated by the presence/absence of SRF and/or IRF.

RESULTS

Baseline BCVA was higher with residual vs resolved SRF at M12 (mean [95% confidence interval {CI}] 58.8 letters [57.2-60.4] vs 53.5 [52.4-54.5]) and M24 (59.3 letters [57.8-60.8] vs 53.5 [52.5-54.5]). Mean BCVA change (adjusted for baseline) to M12 was greater with residual vs resolved SRF (mean difference [95% CI], +2.4 letters [+0.1 to +4.7]), but lower with residual vs resolved IRF (-3.5 letters [-5.8 to -1.2]). Eyes with residual SRF (no IRF) exhibited the largest mean BCVA gains (M12, +14.1 letters; M24, +13.2 letters), followed by resolved SRF/IRF (M12, +10.6 letters; M24, +10.0 letters), residual SRF/IRF (M12, +7.2 letters; M24, +8.5 letters), and residual IRF only (M12, +5.5 letters; M24, +3.6 letters).

CONCLUSIONS

Vision outcomes (adjusted for baseline BCVA) through M24 were better in ranibizumab-treated eyes with residual vs resolved SRF, and worse with residual vs resolved IRF. Presence of residual retinal fluid requires a more complex and nuanced assessment and interpretation in the context of nAMD management.

Enterococcus Intestinal Domination is Associated with Increased Mortality in the Acute Leukemia Chemotherapy Population

BACKGROUND

Enterococcus intestinal domination (EID), a state of dysbiosis wherein enterococci comprise ≥30% abundance within the microbiota, has been associated with Enterococcus bacteremia, graft-versus-host disease, and mortality in the allogeneic hematopoietic stem cell transplant (allo HCT) population. The acute leukemia (AL) chemotherapy population includes patients receiving intensive chemotherapy but do not all go on to have an allo HCT. The impact of EID on outcomes including mortality in the AL chemotherapy population is unknown.

METHODS

Microbiota composition from weekly stool samples was analyzed by 16S ribosomal RNA gene sequencing. Patients were analyzed in 2 cohorts: AL chemotherapy cohort and allo HCT cohort. Alpha-diversity and richness were calculated. Kaplan Meier Analysis was used to analyze mortality.

RESULTS

929 stool samples were collected from 139 patients. Both allo HCT and AL cohorts had a decline in α-diversity and richness over the course of treatment that tends not to return to baseline months later. EID was observed in at least one sample in 36% of allo HCT patients and 49% of AL patients. Patients with observed EID had lower alpha-diversity over time. Similar to the HCT cohort, AL patients with EID had reduced overall survival. We identified 4 other genera that were commonly found in ≥30% relative abundance within the microbiota, but none were associated with mortality. In fact, in allo HCT, Bacteroides abundance ≥30% was associated with improved survival.

CONCLUSIONS

EID is associated with increased all-cause mortality in HCT and AL cohorts. UnlikeEID, relative abundance ≥30% by other genera is not associated with increased all-cause mortality.

Hydrogel matrix presence and composition influence drug responses of encapsulated glioblastoma spheroids

Glioblastoma multiforme (GBM) is the most aggressive brain tumor with median patient survival of 12-15 months. To facilitate treatment development, bioengineered GBM models that adequately recapitulate the in vivo tumor microenvironment are needed. Matrix-encapsulated multicellular spheroids represent such model because they recapitulate solid tumor characteristics, such as dimensionality, cell-cell, and cell-matrix interactions. Yet, there is no consensus as to which matrix properties are key to improving the predictive capacity of spheroid-based drug screening platforms. We used a hydrogel-encapsulated GBM spheroid model, where matrix properties were independently altered to investigate their effect on GBM spheroid characteristics and drug responsiveness. We focused on hydrogel degradability, tuned via enzymatically degradable crosslinkers, and hydrogel adhesiveness, tuned via integrin ligands. We observed increased cellular infiltration of GBM spheroids and increased resistance to temozolomide in degradable, adhesive hydrogels compared to spheroids in non-degradable, non-adhesive hydrogels or to free-floating spheroids. Further, a higher infiltration index was noted for spheroids in adhesive compared to non-adhesive degradable hydrogels. For spheroids in degradable hydrogels, we determined that infiltrating cells were more susceptible to temozolomide compared to cells in the spheroid core. The temozolomide susceptibility of the infiltrating cells was independent of integrin adhesion. We could not attribute differential drug responses to differential cellular proliferation or to limited drug penetration into the hydrogel matrix. Our results suggest that cell-matrix interactions guide GBM spheroid drug responsiveness and that further elucidation of these interactions could enable the engineering of more predictive drug screening platforms. STATEMENT OF SIGNIFICANCE: Glioblastoma multiforme (GBM) multicellular spheroids hold promise for drug screening and development as they better mimic in vivo cellular responses to therapeutics compared to monolayer cultures. Traditional spheroid models lack an external extracellular matrix (ECM) and fail to mimic the mechanical, physical, and biochemical cues seen in the GBM microenvironment. While embedding spheroids in hydrogel matrices has been shown to better recapitulate the tumor microenvironment, there is still limited understanding as to the key matrix properties that govern spheroid responsiveness to drugs. Here we decoupled and independently altered matrix properties such as degradability, via an enzymatically degradable peptide crosslinker, and cell adhesion, via an adhesive ligand, giving further insight into what matrix properties contribute to GBM chemoresistance.

The feasibility and acceptability of a virtual six-week psychoeducational intervention for carers of patients with heart failure

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Northern Ireland Chest Heart and Stroke Queen"s University Belfast

Background

Globally, the number of individuals living with heart failure (HF) is increasing, with many living with additional comorbidities and complex health needs. Carers play an invaluable role in helping the patient with self-care at home, taking on the key responsibility for tasks critical in the management and monitoring of HF symptoms. As a result, carers can frequently experience poor quality of life attributed to this caring role, whilst simultaneously managing health problems of their own. Evidence has shown that many of these carers have unmet educational, social and emotional needs, that require urgent support and information.

Purpose

To assess the feasibility and acceptability of a six-week psychoeducational intervention tailored towards carers of patients with HF.

Methods

  The psychoeducational intervention was co-produced with involvement of carers, HF professionals and researchers. It was delivered over six weeks, with four support group sessions and an information booklet tailored specifically to the needs of carers. Carers were identified by the clinical HF team or through social media, with informed consent obtained before inclusion. Due to COVID-19 regulations, the support group sessions were delivered virtually via a secure online app (Zoom). Each session involved a member of the interdisciplinary research team and covered topics including: 1. Understanding HF, 2. Personal wellbeing, 3. Communication and Support, and 4. Practical skills to help manage HF. Validated questionnaires (SF-12, HADS,ZBI,PSS,MSPSS,CPS) measuring carer related outcomes were completed at baseline, at 6 weeks and 3 months post intervention. Qualitative data from focus group post-intervention explored the acceptability of the intervention. Data was analysed using SPSS (version 27) and NVivo (version 11).

Results

 Nine participants consented to participate, six of which were recruited from heart failure clinics, and three volunteered in response to social media advertisements. Two participants, due to personal health reasons, withdrew consent and did not attend the support group sessions. All carers were female, mean age 61 years, four spouses and three adult children. Preliminary qualitative findings show carers recalled information and advice included in the intervention as useful and easy to understand. With the intervention being described as, "a dimension that doesn’t already exist". The majority of participants (n = 5) preferred the convenience and flexibility of the online approach to the intervention, however some participants (n = 2) felt that they would have benefitted more from an in-person approach. A second  support group is currently underway. 

Conclusions

Preliminary results are promising and indicate that carers responded well to an online psychoeducational intervention.

Understanding needs and expectations of heart failure patients and their caregivers regarding digital health - the PASSION-HF project

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE

Background/Introduction

Current heart failure (HF) healthcare provision is not sufficient. Due to demographic changes and subsequent increases in comorbidities, along with unequal distribution of medical care in rural areas, alternative approaches need be sought. The use of eHealth applications has potential to enable patients to become more self-sufficient. The "PASSION-HF" project aims to develop an interactive decision-making system – a virtual doctor – that provides solutions based on current guidelines and artificial intelligence. Patient independence is maximized through 24/7 access to personalized HF-management. Furthermore, the application defines decision points, where medical professionals need to be included.

Purpose

To understand needs and expectations of HF patients and their informal caregivers in regard to a virtual doctor.

Methods

We conducted an exploratory mixed-methods study within the Netherlands, UK, Ireland and Germany. Semi-structured qualitative interviews were supplemented by a standardized questionnaire. The interviews focused on i) acceptance and motivation to use a virtual doctor and ii) experience and perception of current health care provision. The interviews were analysed using the content analysis according to Mayring (2010) with the help of "ATLAS.TI" software. Additional information about the role of informal caregivers, technology acceptance and decision-making processes was collected via questionnaires.

Results

A total of 49 patients and 33 informal caregivers were interviewed. Most patients were male (76%), aged between 60 and 69 years (43%). Three key themes were identified in regard to an interactive decision-making system: 1) Reassurance, because patients felt uncertain about their condition and their symptoms, they had a strong desire for an application that could monitor their health 24/7, was able to spot deteriorations, before they occured and gave them instant feedback about their current health status; 2) Personalized advice, e.g. patients wanted the virtual doctor to adapt medication, sport activities and food recommendations to their current health status; and 3) Transparency, e.g. patients wanted to know, where the recommendations are coming from and justifications for management modifications. Interview findings also identified that the HF-nurses play a significant role in the care and management of the condition. Across all countries with HF-nurses, they were the primary point of contact, when patients had any HF related concerns. 

Conclusion

The findings provide valuable information for the development and implementation of eHealth solutions. Patients want reassurance, independently of the availability of healthcare services, combined with personalized advice regarding day-to-day management of their HF. For the next step, we are planning a multicentre clinical trial to test the prototype of the application. Here all decisions are examined by a clinical committee and benefits are evaluated.

Prevalence and effect of cardiac cachexia in advanced heart failure patients living in northern ireland

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Northern Ireland Chest Heart and Stroke

Background/Introduction: Cardiac cachexia (CC) is a multifactorial wasting syndrome, resulting in significant weight loss and reduction in muscle mass. This is reflected in a detrimental effect on the patients’ physical condition, quality of life and increases the patient’s risk of premature death. Nonetheless, cardiac cachexia remains frequently unrecognised in clinical practice and therefore understudied.

Purpose

To determine the prevalence and effect of cardiac cachexia in 200 patients with advanced heart failure (NYHA class III-IV) living in Northern Ireland.

Methods

A mixed methods cross sectional study of patients recruited from a regional heart failure centre. A total of 200 patients with NYHA class III-IV heart failure were consented, enrolled and detailed data collected from their records. Anthropometric measures were taken (i.e. measures of lean muscle mass and fat tissue) and each individual completed three validated questionnaires - EQ-5D-5L (quality of life), FACIT-Fatigue and FAACT (various wellbeing subscales).

Results

This population was predominately male (65.5%), with an average age of 74.4 years. Of the 200 NYHA class III-IV patients recruited, 30 were identified as cachectic (15%) Physically, cachectic patients were approximately 25 kg lighter than non-cachectic patients (p &lt; 0.01) with an average BMI of 21.8 ± 4.4. The cachectic group showed significant reductions in mid-upper arm circumference (p &lt; 0.01), skinfold thickness (p &lt; 0.01) and upper arm fat area (p &lt; 0.01), in comparison to the non-cachectic group. Measures of muscle mass were reduced, for example upper arm muscle circumference and area (p &lt; 0.01), as well as grip strength (p &lt; 0.01 for both right and left hands). Quality of life results from the EQ-5D-5L [see figure part b)] indicated an overall reduction for the cachectic group (p = 0.047). Of the EQ-5D-5L subscales, mobility and ‘usual activities’ were significantly reduced (p = 0.02 and p &lt; 0.01 respectively), highlighting a significant change in the daily routine and ability of these patients. The FACIT-Fatigue questionnaire showed cachectic patients to be significantly more fatigued (p &lt; 0.01) [see figure part a)], whilst the FAACT demonstrated reduced physical wellbeing (p = 0.02) and greater issues with diet and appetite (p &lt; 0.01).

Conclusions

This is the first prevalence study of cardiac cachexia within Northern Ireland. The 15% prevalence rate shows that the syndrome is relatively common in the advanced heart failure population. Cardiac Cachexia has severe physical consequences, attributed to an individual’s weight loss in both fat and muscle tissue. Such changes may explain the subsequent decrease in mobility and the ability of these patients to conduct their ‘usual activities’. Increased fatigue, reduced physical wellbeing and issues with diet and appetite only intensify these dire physical effects. It is hoped that these results will highlight the impact of this syndrome and promote targeted interventions.

Anti-VEGF-resistant subretinal fluid is associated with better vision and reduced risk of macular atrophy

BACKGROUND/AIM

To evaluate relationships between subretinal fluid (SRF), macular atrophy (MA) and visual outcomes in ranibizumab-treated neovascular age-related macular degeneration (nAMD).

METHODS

This post hoc HARBOR trial (NCT00891735) analysis included ranibizumab-treated (0.5 or 2.0 mg, monthly or as-needed, all treatment arms pooled) eyes with nAMD and baseline (screening, baseline and week 1) SRF. SRF presence, SRF thickness (0, >0-50, >50-100 and >100 µm) and subretinal fluid volume (SRFV) were determined by spectral domain optical coherence tomography (SD-OCT). Best-corrected visual acuity (BCVA) was assessed. MA was identified using fluorescein angiograms and colour fundus photographs, as well as SD-OCT.

RESULTS

Seven hundred eighty-five of 1097 eyes met analysis criteria. In eyes without baseline MA, residual versus no SRF at month (M) 3 was associated with lower MA rates at M12 (5.1% vs 22.1%) and M24 (13.3% vs 31.2%) (both p<0.0001); MA percentages at M12/M24 were similar among patients with residual SRF at M6. Higher baseline SRFV was associated with a lower MA rate. Greater mean BCVA was observed with residual SRF of any thickness (>0-50 µm, 71.2 letters; >50-100 µm, 71.3 letters; >100 µm, 69.2 letters) versus no SRF (63.6 letters), but the change in BCVA from baseline to M12 or M24 was the same for eyes with or without treatment-resistant subretinal fluid (TR-SRF) at M3 or M6.

CONCLUSION

TR-SRF was not detrimental to vision outcomes over 2 years, regardless of thickness. MA rates were significantly higher without TR-SRF.

Changes in Treatment-Naive Pigment Epithelial Detachments Associated With the Initial Anti-Vascular Endothelial Growth Factor Injection: A Post Hoc Analysis From the HARBOR Trial

Importance

Pigment epithelial detachment (PED) is a feature commonly associated with neovascular age-related macular degeneration (nAMD) and may be perceived as being difficult to treat. Therefore, this investigation explored changes in PEDs and visual acuity outcomes following an initial anti-vascular endothelial growth factor (VEGF) injection and identified factors associated with positive response.

Objective

To describe changes in treatment-naive pigment epithelial detachments associated with the initial anti-VEGF injection.

Design, Setting, and Participants

Post hoc analysis of patients from the Phase III, Double-masked, Multicenter, Randomized, Active Treatment-controlled Study of the Efficacy and Safety of 0.5 mg and 2.0 mg Ranibizumab Administered Monthly or on an As-needed Basis in Patients With Subfoveal Neovascular Age-Related Macular Degeneration (HARBOR) trial (NCT00891735) with PED at baseline. The HARBOR trial was a phase 3, randomized, multicenter, double-masked, active treatment-controlled trial. Participants included treatment-naive patients with subfoveal nAMD and PEDs at baseline; intervention arms were pooled for analysis (n = 586). The HARBOR study began in July 2009 and was completed in August 2012, and the post hoc analyses were conducted between October 2016 and May 2018.

Interventions

Intravitreal injections of ranibizumab, 0.5 mg and 2.0 mg, administered monthly or on an as-needed basis over 24 months.

Main Outcomes and Measures

Post hoc analyses of flattened PED frequency at month 1, univariate and multivariable analysis of patient and ocular characteristics at baseline and PED status at month 1, and total number of ranibizumab injections received stratified by PED status at month 1.

Results

A total of 35.5% of patients (208 of 586) with PED at baseline achieved a flattened PED after a single ranibizumab injection. An additional 17.3% subsequently achieved a flattened PED at month 2. Univariate analysis identified an association between older age, lower PED height, and lower subretinal fluid thickness with PED flattening after a single injection. Multivariable analysis identified PED height as a factor associated with this anatomical outcome. Best-corrected visual acuity scores were not superior based on PED flattening at month 1. On average, patients in the as-needed arm who achieved a flattened PED after a single ranibizumab injection required fewer injections by month 24 vs patients whose PED remained present at month 1 (11.0 vs 14.2; difference, 3.3; 95% CI, 1.9-4.6; P < .001).

Conclusions and Relevance

In this group of treatment-naive patients with PED from nAMD, after the initial ranibizumab injection approximately one-third and after the second injection approximately one-half had flattened PEDS, although visual outcomes were not superior among those that did vs did not have flattening. The findings suggest flattening may serve as a marker for less intensive as-needed injection frequencies.

Trial Registration

ClinicalTrials.gov Identifier: NCT00891735.

Ultra-Response to Ranibizumab: Improvement by 4 or More Steps in Diabetic Retinopathy Severity in Diabetic Retinopathy Clinical Research Network Protocol S

PURPOSE

To quantify and evaluate patients with diabetic retinopathy (DR) who had at least a 4-step improvement on the Early Treatment Diabetic Retinopathy Study (ETDRS) Diabetic Retinopathy Severity Scale (DRSS) in response to treatment with ranibizumab in the Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol S study, and factors predictive of such improvements.

DESIGN

Post hoc retrospective analysis of 2-year outcomes in the phase 3 Protocol S study.

PARTICIPANTS

Patients randomized to treatment with ranibizumab 0.5 mg with sufficient baseline DRSS severity (≥47) to allow for an at least 4-step improvement (n = 181).

METHODS

Study eyes received a ranibizumab 0.5 mg injection at baseline and every 4 weeks for 12 weeks, with subsequent as-needed injections. Fundus photographs graded at baseline and years 1 and 2 using DRSS were used for this analysis. The data source is DRCR.net, but analyses, content, and conclusions of this report are solely the responsibility of the authors.

MAIN OUTCOME MEASURES

Proportion of eyes achieving at least a 4-step DRSS improvement (DR ultra-response) at years 1 and 2; treatment course for eyes achieving ultra-response; mean change in best-corrected visual acuity (BCVA) in eyes with and without ultra-response; factors associated with ultra-response (identified by univariate and multivariable analyses).

RESULTS

Approximately 30% of ranibizumab-treated eyes achieved DR ultra-response at year 1 (43/148; 29.1%) and year 2 (38/136; 27.9%); 74% of eyes with ultra-response at year 1 maintained their response at year 2. At year 2, patients with DR ultra-response had gained more than 5 additional ETDRS letters compared with those without DR ultra-response. Multivariable analyses identified presence of vitreous hemorrhage at baseline, increasing age, absence of epiretinal membrane, and glycated hemoglobin below 9 as predictive of DR ultra-response. Mean number of injections received was similar for eyes with versus without DR ultra-response to ranibizumab (mean, 7.4 vs. 7.6 in year 1; mean, 4.2 vs. 3.9 in year 2).

CONCLUSIONS

Approximately 30% of eyes with a DRSS score of at least 47 receiving ranibizumab 0.5 mg per study protocol experienced at least a 4-step DR severity improvement on the DRSS, accompanied by meaningful improvements in BCVA.

Mobile Lung Screening: Should We All Get on the Bus?

BACKGROUND

Despite favorable recommendations, national lung screening adoption remains low (2% to 3%). Patients living in rural areas have additional challenges, including access to lung screening programs. We initiated a mobile lung screening program to serve the rural patients at risk. This is what we learned from this 12-month feasibility project.

METHODS

Utilizing a multidisciplinary approach, we began an 8-month design and build schedule. This was the first build of this type. The operational team included a radiology technician, nurse practitioner, driver with a commercial driver's license, and program developer. Specialized software was used for data mining. Downstream revenue projections were based on previously published Medicare claims data. Generally accepted accounting principles were used.

RESULTS

The prototype bus was delivered January 2018. During the 12-month feasibility period, we performed 548 low-dose lung screenings at 104 sites. Mean patient age was 62 years, mean pack-years of smoking was 41; 258 (47%) were male. Five lung cancers were found in addition to a type B thymoma. Financially, we exceeded the break-even analysis by 28%. The 5-year pro forma using 1 year of actual data and 4 additional years of projected data demonstrated a net present value of 1 million, internal rate of return of 34.6%, and profitability index of 2.2-all highly dependent on downstream revenue.

CONCLUSIONS

Although challenges exist, a commercially viable bus and a financially sound mobile program can be developed. However, without a centralized approach for incidental findings, the downstream revenue may be at risk as well as the financial viability of the project.

<p>Predictors of Early Diabetic Retinopathy Regression with Ranibizumab in the RIDE and RISE Clinical Trials</p>

Purpose

To investigate the predictors of early diabetic retinopathy (DR) improvement in the RIDE/RISE (NCT00473382/NCT00473330) clinical trials.

Patients and Methods

In RIDE/RISE, adult patients with vision loss due to diabetic macular edema (DME) were randomized to monthly intravitreal ranibizumab 0.3 or 0.5 mg (n=502 total) or sham (n=257). DR severity was graded (using the Early Treatment Diabetic Retinopathy Study Diabetic Retinopathy Severity Scale). In this post hoc analysis of RIDE/RISE, eyes with baseline DR score ≥35 were evaluated for ≥2-step improvements, and eyes with baseline DR score ≥43 were evaluated for ≥3-step improvements. The characteristics associated with ≥2- or ≥3-step DR improvement at months 3 or 6 were assessed using univariate and/or multivariable analyses.

Results

The percentage of eyes with a ≥2- or ≥3-step DR improvement was 20.1% and 3.7% at month 3 and 31.2% and 5.8% at month 6. Odds of ≥2-step DR improvement at months 3 or 6 were significantly greater in eyes with moderately severe to severe nonproliferative DR (NPDR) at baseline versus less severe or more severe DR (both P<0.0001). At month 6, odds of ≥2-step DR improvement were significantly greater in eyes with no DME at month 3 (P=0.008). Most patients with ≥3-step DR improvement at months 3 or 6 had proliferative DR (PDR) at baseline (83.3% and 66.7%).

Conclusion

The strongest predictors of DR response to ranibizumab at month 6 were baseline DR severity and DME quiescence at month 3. Eyes with the most robust early improvements had moderately severe or severe NPDR or PDR at baseline.

Agreement of Spectral-Domain OCT with Fluorescein Leakage in Neovascular Age-Related Macular Degeneration: Post Hoc Analysis of the HARBOR Study

PURPOSE

To evaluate the agreement between detection of activity of choroidal neovascularization (CNV) in neovascular age-related macular degeneration (AMD) by fundus fluorescein angiography (FFA) and spectral-domain (SD) OCT in the HARBOR study. Most retina specialists rely on OCT to guide treatment decisions in neovascular AMD. However, OCT may not always detect exudative activity. Traditionally, FFA was frequently performed in clinical practice, but its use has diminished due to reliance on OCT.

DESIGN

Retrospective post hoc analysis of prospective clinical trial (HARBOR; ClinicalTrials.gov identifier, NCT00891735).

PARTICIPANTS

Patients with neovascular AMD in the HARBOR Trial.

METHODS

Baseline to month 24 data from all randomized study eyes in HARBOR with both FFA and SD OCT data were analyzed for (1) evidence of CNV activity on SD OCT (presence of subretinal fluid, intraretinal fluid, and/or cystoid spaces); (2) evidence of CNV activity on FFA identified by the presence of leakage, and (3) cross-tabulation of CNV activity identified by FFA and SD OCT by office visit.

MAIN OUTCOME MEASURES

The percent agreement between FFA and SD OCT in detecting CNV activity and sensitivity and specificity of SD OCT to detect fluorescein leakage in neovascular AMD using FFA as the reference standard.

RESULTS

At baseline, 1094 patients (99.9%) had agreement between SD OCT and FFA in detecting CNV activity. By month 24, of the 779 total active cases, the agreement was only 36% (277 cases). By month 24, most cases (n = 452 [58%]) had evidence of CNV activity on SD OCT only, whereas 6% of cases (n = 50) had CNV activity identified by FFA only. At screening and months 3, 6, 12, and 24, 92% to 100% of cases identified by FFA only were occult CNV lesions. Using FFA as the reference standard, the sensitivity and specificity of SD OCT in detecting CNV activity was 91% (95% confidence interval [CI], 84%-99%) and 13% (95% CI, 4%-22%).

CONCLUSIONS

Spectral-domain OCT alone can be relied upon for detecting CNV activity while monitoring eyes with neovascular AMD. However, FFA may still be of value in those with occult lesions that appear quiescent on SD OCT, as this type of lesion may show leakage on FFA.

A226 CHILD AND PARENT PERCEPTIONS OF FAECAL MICROBIOTA TRANSPLANT (FMT): QUALITATIVE PERSPECTIVES FROM PARTICIPANTS IN A TRIAL OF FMT FOR PEDIATRIC ULCERATIVE COLITIS

Background

Fecal microbiota transplant (FMT) is being increasingly studied across a range of therapeutic indications, including ulcerative colitis (UC). Pediatric patients may have unique responses to microbiome-based therapeutics, given their younger age, fewer comorbidities, and greater susceptibility to medication-related side effects.

Aims

We recently conducted the first pilot RCT of FMT in Canada for the treatment of pediatric ulcerative colitis (PediFETCh Trial) and conducted qualitative interviews post-study of participants and their parents. This study aims to describe the experience and perceptions of children who received FMT, and their parents.

Methods

Patients enrolled in the PediFETCh Trial (ClinicalTrials.gov: NCT02487238) and their parents were invited to participate in face-to-face, semi-structured interviews. Interviews were audiotaped, transcribed, and analyzed using open coding (NVivo 12 Pro).

Results

8 patients and 8 parents were interviewed. Our data has been summarized into 4 domains and 11 composite themes (Table 1). Most patients and parents saw FMT as a natural treatment. Pre-treatment, patients were concerned with receiving “someone else’s poo” and physical discomfort, while parents were concerned with transmission of enteric infections or psychiatric diseases. Both felt their decision to pursue FMT was influenced by frustration with previous lack of response to medications and a fear of medication side effects. Post-treatment, most patients and families expressed no concerns over potential future side effects as a result of the FMT, and all patients reported feeling “completely normal”. Patients were split between preferring FMT or medication, with convenience of medication being an important factor, while others favored FMT for its perceived naturality and symptomatic improvements. For most families, natural therapies and diet played an important role in influencing their decision to pursue FMT; however, several parents reported that alternative healthcare practitioners did not support their desire to pursue FMT.

Conclusions

The study offers valuable insights into pediatric patients’ and parents’ experiences receiving FMT across several themes. Our results suggest a high rate of acceptance and interest in FMT research by pediatric patients and their parents. These findings suggest strategies to improve future delivery of FMT in clinical trials, and should support inclusion of children in FMT-based studies.

Funding Agencies

Hamilton Health Sciences New Investigator Fund (2015, Spring); Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario (HAH-17-002)

A242 EXERCISE AND PHYSICAL ACTIVITY IN PEDIATRIC INFLAMMATORY BOWEL DISEASE: A SYSTEMATIC REVIEW AND RECOMMENDATIONS

Background

Inflammatory bowel disease (IBD) is a chronic life-long condition affecting 0.25% of the North American population. Childhood onset IBD is particularly aggressive, with disease often characterised by poor growth, severe unpredictable abdominal pain and frequent school absences. Treatment involves lifelong medications, which do not always resolve symptoms and carry increased cumulative risks of infections, malignancy, or other adverse effects. Exercise has been suggested as a method of ameliorating some of the symptoms associated with IBD. To date, few studies have investigated the role of exercise and physical activity in paediatric IBD patients.

Aims

We conducted a systematic review assessing the role of exercise and physical activity in paediatric IBD.

Methods

This Level III systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. An electronic database search of Pubmed, Google Scholar, and Cochrane used the search terms “(physical activity or exercise), (Inflammatory Bowel Disease), and (children or paediatric)”. Of the 1458 articles identified during the two rounds of review, only 21 articles met final inclusion criteria.

Results

Three main themes emerged from the review: 1) prescriptive exercise and physical activity ameliorated symptoms IBD and improved physical well-being, 2) patients who actively engage in exercise and physical activity show improved markers of inflammation and decreased future risk of disease, 3) exercise and physical activity improves the mental health and well-being of paediatric IBD patients. The results recommended 30–60 minutes, 6 times per week of mild to moderate aerobic exercise activity. It was noted that vigorous and high intensity exercise was well-tolerated by most IBD patients. Further, exercise prescription should be tailored to individual needs.

Conclusions

Exercise and physical activity improves mental and physical health and well-being of paediatric IBD patients, including decreasing the risk of future disease exacerbation in patients with mild to moderate disease activity. Clinicians and practitioners should consider actively prescribing exercise and physical activity to IBD patients as part of a standard treatment algorithm.

Funding Agencies

None

MACULAR ATROPHY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION: A Pilot Post Hoc Analysis of Patients With Pigment Epithelial Detachments

PURPOSE

To determine optical coherence tomography signs associated with macular atrophy (MA) in eyes with neovascular age-related macular degeneration and pigment epithelial detachments treated with vascular endothelial growth factor inhibitors.

METHODS

Optical coherence tomography scans from a subgroup of the pigment epithelial detachment cohort of the HARBOR study were analyzed for MA. Two groups were formed based on MA presence/absence at Month 24. Then, optical coherence tomography scans from each baseline visit were graded with standard reading center grading parameters including ellipsoid zone disruption, intraretinal cysts, subretinal fluid, and MA or nascent MA in the study and fellow eyes.

RESULTS

Twenty-eight eyes from 28 patients were included in the analysis. Fourteen eyes had optical coherence tomography-based MA at Month 24 and 14 did not. Macular atrophy at Month 24 was significantly associated with 1) MA/nascent MA at baseline (P = 0.0136), 2) intraretinal cysts at baseline (P = 0.0048), and 3) collapse of pigment epithelial detachments in the study eye (P = 0.0025). Macular atrophy was not associated with ellipsoid zone disruption or subretinal fluid in the study eye at baseline.

CONCLUSION

This study suggests that some optical coherence tomography findings in eyes of patients with neovascular age-related macular degeneration were present before the start of anti-vascular endothelial growth factor therapy and may predict the development of MA.

Swimming during COVID-19: Operational recommendations and considerations for South African swimming venues

Swimming is one of the most popular recreational activities in South Africa. Since the emergence of the Coronavirus disease 2019 (COVID-19), South Africa imposed one of the strictest lockdown measures to contain and control the spread of the virus. These measures included the closure of gyms, fitness centres and swimming pools across the country. However, as the restrictions begin to ease, it is important to consider how swimming facilities can reopen whilst simultaneously ensuring appropriate measures are in place to reduce COVID-19 infections. Outlined are recommendations and considerations for swimming facilities in South Africa. Currently there is no evidence to suggest that COVID-19 transmission to humans is possible through water, making swimming one of the safer options for physical activity indoors. However, participation is still not without risk and compliance with government mandates and public health officials take precedent over the recommendations outlined in this article.

TECRA® Unique™ Test for Rapid Detection of Salmonella in Food: Collaborative Study

The TECRA® Unique™ Salmonella test uses the principle of immunoenrichment to allow rapid detection of Salmonellae in food. A collaborative study was conducted to compare the TECRA Salmonella Unique test with the reference culture method given in the U.S. Food and Drug Administration's Bacteriological Analytical Manual. Three food types (milk powder, pepper, and soy flour) were analyzed in Australia and 2 food types (milk chocolate and dried egg) were analyzed in the United States. Forty-one collaborators participated in the study. For each of the 5 foods at each of the 3 levels, a comparison showed no significant differences (p ≥ 0.05) in the proportion of positive test samples for Unique and that for the reference method using the Chi-square test for independence with continuity correction.

Development of a biochemical marker to detect current breast milk intake

The WHO recommends exclusive breastfeeding for 6 months, but despite interventions, breastfeeding rates remain stubbornly low. Financial voucher incentives have shown promise but require a biomarker for validation of intake. This study aimed to develop a simple biochemical assay of infant urine that would tell if an infant was receiving any breast milk to validate maternal report. Urine samples were collected and snap frozen from 34 infants attending with minor illness or feeding problems, of whom 12 infants were exclusively breastfed, nine exclusively formula fed, and 11 mixed breast/formula fed. High‐performance anion exchange chromatography was used to identify discriminating patterns of monosaccharide composition of unconjugated glycans in a sequence of three experiments. The absolute concentration of all human milk oligosaccharides measured blind could detect “any breastfeeding” only with a sensitivity of 48% and specificity of 78%. Unblinded examination of N‐acetylglucosamine (GlcNAc) measured as GlcNH₂ after hydrolysis of GlcNAc improved sensitivity to 75% at the expense of a specificity of 28%. Estimation of the relative abundance of GlcNH2 (GlcNH2[%]) or the ratio of GlcNH2 to endogenous mannose (Man) improved accuracy. In a further blind experiment, the GlcNH2/Man ratio with a cut‐off of 1.5 correctly identified all those receiving “any breast milk,” while excluding exclusively formula fed infants. The GlcNH2/Man ratio in infant urine is a promising test to provide biochemical confirmation of any breastfeeding for trials of breastfeeding promotion.

Towards a rapid assessment protocol for identifying pit lakes worthy of restoration

Before the introduction of reclamation legislation in South Africa, final cut lakes in mining areas were left without any restoration while the final excavation was not back filled. Characteristics of these lacustrine water bodies vary considerably, but they are often linear in shape, large (1-30 ha), deep (2-30 m) and have poorly developed littoral zones. With water tables often near the surface; a variety of vascular hydrophytes can colonize these bodies, thus establishing emerging wetland type ecosystems. These, man-made aquatic structures that are (unintentionally) created potentially offers some realistic and inexpensive mitigation options for some of the negative impacts associated with mining, i.e. these water bodies can become useful by yielding potentially valuable services. However, no method currently exists to compare and rank these water bodies according ecological integrity and the expected monetary value to be derived from them in order to select sites for restoration. To answer this need, we applied an index to determine the ability of these water bodies to provide useful services in their current state. The index was then used to derive estimates of the monetary value of potential services in order to allow comparison with the cost of restoring the water body in question or to compare with other pit lakes. We present a South African case study to illustrate the method. As far as could be established, this is the first attempt towards creating a rapid assessment tool as standardised way of comparing pit lakes that allows for the ranking and identification of those pit lakes worthy of restoration.

A mutation in Ccdc39 causes neonatal hydrocephalus with abnormal motile cilia development in mice

Pediatric hydrocephalus is characterized by an abnormal accumulation of cerebrospinal fluid (CSF) and is one of the most common congenital brain abnormalities. However, little is known about the molecular and cellular mechanisms regulating CSF flow in the developing brain. Through whole-genome sequencing analysis, we report that a homozygous splice site mutation in coiled-coil domain containing 39 (Ccdc39) is responsible for early postnatal hydrocephalus in the progressive hydrocephalus (prh) mouse mutant. Ccdc39 is selectively expressed in embryonic choroid plexus and ependymal cells on the medial wall of the forebrain ventricle, and the protein is localized to the axoneme of motile cilia. The Ccdc39^prh/prh ependymal cells develop shorter cilia with disorganized microtubules lacking the axonemal inner arm dynein. Using high-speed video microscopy, we show that an orchestrated ependymal ciliary beating pattern controls unidirectional CSF flow on the ventricular surface, which generates bulk CSF flow in the developing brain. Collectively, our data provide the first evidence for involvement of Ccdc39 in hydrocephalus and suggest that the proper development of medial wall ependymal cilia is crucial for normal mouse brain development.

A Desire for Social Media Is Associated With a Desire for Solitary but Not Social Activities

While social media is an aspect of life for many, it brings to light the lack of interpersonal connection when browsing activity occurs. The displacement theory suggests that the quality of one's offline interactions is affected by how much time an individual allots to those exchanges. Depending on the amount of time spent online, interpersonal connections may suffer and lead to negative psychological consequences. Our study aimed to explore the relationship between the desirability of social media and socialization preferences through a cue-based perceptual judgment task where participants ( N = 136) rated 40 gray-scale images in terms of their desirability. The image categories included social media icons, singular scenes depicting an isolated activity, social scenes representing an interactive activity, and traffic signs as the control. We also included questionnaires to assess depressiveness and aspects of social media usage. Our findings suggest that the immediate desire for social media is potentially linked to one's desire for social isolation as represented by the singular scene category, the intensity of participant's reported daily usage, and the extent to which social media is perceived to impact real social life. To our knowledge, this is the first report on the initial desirability judgment of social media and its association with other factors. Further research is needed to distinguish the variability in users' aim of using social media and if that is related to one's perceived feelings of social connectedness and solitude.