A dairy-based, protein-rich breakfast enhances satiety and cognitive concentration before lunch in overweight to obese young females: A randomized controlled crossover study

The purpose of this study was to investigate if consumption of a high-protein, low-carbohydrate breakfast (PRO) leads to a lower subsequent ad libitum energy intake at lunch and the rest of the day compared with ingestion of an isocaloric low-protein, high-carbohydrate breakfast (CHO) or no breakfast (CON). The study was designed as a randomized controlled 3-period crossover study. Thirty young (18-30 yr) females with overweight to obesity (body mass index >25 kg/m2) in random order completed 3 separate experimental days where they consumed either a PRO, CHO, or CON breakfast test meal followed by an ad libitum lunch meal 3 h after breakfast. Participants were allocated to a sequence group by their inclusion number. The PRO and CHO breakfasts were matched in dietary fiber and fat content. Energy intake at lunch was calculated and dietary records were obtained for the rest of the day to calculate the total daily energy intake and macronutrient intake. Ratings of appetite sensations between meals and palatability of the test meals were assessed using visual analog scale sheets in intervals ranging from 10 to 30 min. In addition, blood samples were obtained at multiple time points separated by 10 to 60 min intervals between breakfast and lunch and were analyzed for appetite-regulating gut hormones, insulin, and glucose. Finally, performance in a cognitive concentration test was tested 150 min after breakfast. Compared with CHO and CON, the area under the curves for satiety, fullness, and satisfaction in the 3 h after breakfast were significantly higher after PRO, whereas the areas under the curve for hunger, desire to eat, and prospective eating were significantly lower after PRO. The appetite-regulating gut hormones cholecystokinin, glucagon-like peptide-1, and ghrelin in the hours after breakfast, energy intake during the ad libitum lunch meal, and the total daily energy intake did not differ significantly between PRO, CHO, and CON. However, the cognitive concentration test score was 3.5 percentage points higher for PRO, but not CHO, versus CON. A dairy-based high-protein, low-carbohydrate breakfast increased satiety sensation in the hours after breakfast but did not reduce total daily energy intake compared with an isocaloric low-protein, high-carbohydrate breakfast or omitting breakfast. However, performance in a cognitive concentration test before lunch was enhanced after the high-protein, low-carbohydrate breakfast, but not the low-protein, high-carbohydrate breakfast, compared with omitting breakfast.

Dynamics of magnetization at infinite temperature in a Heisenberg spin chain

Understanding universal aspects of quantum dynamics is an unresolved problem in statistical mechanics. In particular, the spin dynamics of the one-dimensional Heisenberg model were conjectured as to belong to the Kardar-Parisi-Zhang (KPZ) universality class based on the scaling of the infinite-temperature spin-spin correlation function. In a chain of 46 superconducting qubits, we studied the probability distribution of the magnetization transferred across the chain's center, [Formula: see text]. The first two moments of [Formula: see text] show superdiffusive behavior, a hallmark of KPZ universality. However, the third and fourth moments ruled out the KPZ conjecture and allow for evaluating other theories. Our results highlight the importance of studying higher moments in determining dynamic universality classes and provide insights into universal behavior in quantum systems.

Stable quantum-correlated many-body states through engineered dissipation

Engineered dissipative reservoirs have the potential to steer many-body quantum systems toward correlated steady states useful for quantum simulation of high-temperature superconductivity or quantum magnetism. Using up to 49 superconducting qubits, we prepared low-energy states of the transverse-field Ising model through coupling to dissipative auxiliary qubits. In one dimension, we observed long-range quantum correlations and a ground-state fidelity of 0.86 for 18 qubits at the critical point. In two dimensions, we found mutual information that extends beyond nearest neighbors. Lastly, by coupling the system to auxiliaries emulating reservoirs with different chemical potentials, we explored transport in the quantum Heisenberg model. Our results establish engineered dissipation as a scalable alternative to unitary evolution for preparing entangled many-body states on noisy quantum processors.

Metabolic flexibility in postmenopausal women: Hormone replacement therapy is associated with higher mitochondrial content, respiratory capacity, and lower total fat mass

AIM

To investigate effects of hormone replacement therapy in postmenopausal women on factors associated with metabolic flexibility related to whole-body parameters including fat oxidation, resting energy expenditure, body composition and plasma concentrations of fatty acids, glucose, insulin, cortisol, and lipids, and for the mitochondrial level, including mitochondrial content, respiratory capacity, efficiency, and hydrogen peroxide emission.

METHODS

22 postmenopausal women were included. 11 were undergoing estradiol and progestin treatment (HT), and 11 were matched non-treated controls (CONT). Peak oxygen consumption, maximal fat oxidation, glycated hemoglobin, body composition, and resting energy expenditure were measured. Blood samples were collected at rest and during 45 min of ergometer exercise (65% VO2 peak). Muscle biopsies were obtained at rest and immediately post-exercise. Mitochondrial respiratory capacity, efficiency, and hydrogen peroxide emission in permeabilized fibers and isolated mitochondria were measured, and citrate synthase (CS) and 3-hydroxyacyl-CoA dehydrogenase (HAD) activity were assessed.

RESULTS

HT showed higher absolute mitochondrial respiratory capacity and post-exercise hydrogen peroxide emission in permeabilized fibers and higher CS and HAD activities. All respiration normalized to CS activity showed no significant group differences in permeabilized fibers or isolated mitochondria. There were no differences in resting energy expenditure, maximal, and resting fat oxidation or plasma markers. HT had significantly lower visceral and total fat mass compared to CONT.

CONCLUSION

Use of hormone therapy is associated with higher mitochondrial content and respiratory capacity and a lower visceral and total fat mass. Resting energy expenditure and fat oxidation did not differ between HT and CONT.

Measurement-induced entanglement and teleportation on a noisy quantum processor

Measurement has a special role in quantum theory1: by collapsing the wavefunction, it can enable phenomena such as teleportation2 and thereby alter the 'arrow of time' that constrains unitary evolution. When integrated in many-body dynamics, measurements can lead to emergent patterns of quantum information in space-time3-10 that go beyond the established paradigms for characterizing phases, either in or out of equilibrium11-13. For present-day noisy intermediate-scale quantum (NISQ) processors14, the experimental realization of such physics can be problematic because of hardware limitations and the stochastic nature of quantum measurement. Here we address these experimental challenges and study measurement-induced quantum information phases on up to 70 superconducting qubits. By leveraging the interchangeability of space and time, we use a duality mapping9,15-17 to avoid mid-circuit measurement and access different manifestations of the underlying phases, from entanglement scaling3,4 to measurement-induced teleportation18. We obtain finite-sized signatures of a phase transition with a decoding protocol that correlates the experimental measurement with classical simulation data. The phases display remarkably different sensitivity to noise, and we use this disparity to turn an inherent hardware limitation into a useful diagnostic. Our work demonstrates an approach to realizing measurement-induced physics at scales that are at the limits of current NISQ processors.

Non-Abelian braiding of graph vertices in a superconducting processor

Indistinguishability of particles is a fundamental principle of quantum mechanics¹. For all elementary and quasiparticles observed to date-including fermions, bosons and Abelian anyons-this principle guarantees that the braiding of identical particles leaves the system unchanged^2,3. However, in two spatial dimensions, an intriguing possibility exists: braiding of non-Abelian anyons causes rotations in a space of topologically degenerate wavefunctions^4-8. Hence, it can change the observables of the system without violating the principle of indistinguishability. Despite the well-developed mathematical description of non-Abelian anyons and numerous theoretical proposals^9-22, the experimental observation of their exchange statistics has remained elusive for decades. Controllable many-body quantum states generated on quantum processors offer another path for exploring these fundamental phenomena. Whereas efforts on conventional solid-state platforms typically involve Hamiltonian dynamics of quasiparticles, superconducting quantum processors allow for directly manipulating the many-body wavefunction by means of unitary gates. Building on predictions that stabilizer codes can host projective non-Abelian Ising anyons^9,10, we implement a generalized stabilizer code and unitary protocol²³ to create and braid them. This allows us to experimentally verify the fusion rules of the anyons and braid them to realize their statistics. We then study the prospect of using the anyons for quantum computation and use braiding to create an entangled state of anyons encoding three logical qubits. Our work provides new insights about non-Abelian braiding and, through the future inclusion of error correction to achieve topological protection, could open a path towards fault-tolerant quantum computing.

The hemodynamic and prognostic impact of systolic pressure change during right ventricular ejection in patients with HFREF

Background and purpose

The gold-standard method to evaluate right ventricular (RV) function in pulmonary hypertension (PH) relies on invasive pressure-volume loop (PV-loop) measurement of RV-pulmonary artery (PA) coupling defined as the ratio of end-systolic RV elastance to pulmonary arterial elastance (Ees/Ea). The normal RV PV-loop has a triangular shape with a peaking early systolic pressure (early-SP). With progression of PH the PV-loop changes from trapezoid to a rectangular and ultimately to a trapezoid shape. Along with these geometric changes, the ratio between early-SP and end-systolic pressure (ESP) decreases from >1 to <1 with a late systolic peaking of RV pressure. How all these changes relate to RV afterload, RV-PA coupling, non-invasive RV function, and prognosis in PH due to left heart disease is incomplete understood.

Methods

We analyzed and categorized the conductance catheter-derived single-beat RV PV-loops in 133 patients with HFREF (110 patients: a post-hoc analysis of the Magdeburg CRT Responder Trial, 23 from a local PV-L-derived CRT-optimization trial) according their shape (triangular, rectangular, trapezoid), and determined the early-SP/ESP ratio.

Results

Using multivariate linear regression analysis (adjusted for afterload parameter PVR, PA-compliance, PCWP, PAmean), only PCWP (beta=−0.17) and PA-compliance (beta=0.61) remained significant determinants of the early-SP/ESP ratio and PV-loop shape. In turn, early-SP/ESP ratio seems to be an important determinant of RV-PA coupling efficiency (Ees/Ea) of the RV to afterload (r=0.8, p<0.001). The association between early-SP/ESP ratio and Ees/Ea ratio was closer than Ees/Ea ratio to the other afterload parameters Ea (r=−0.7), PVR (r=−0.41), and PA-compliance (r=0.62). Furthermore, the early-SP/ESP ratio was significantly associated with parameters of non-invasive RV function such as TAPSE (r=0.67), FAC (r=0.76), RVEF (r=0.7), and the non-invasive RV-PA coupling parameter TAPSE/PASP (r=0.8) (all p<0.001). In cox regression analysis, the early-SP/ESP ratio was a strong indicator for long-term survival (median FU 4.2 years) (OR 0.025, CI 95% 0.007–0.09). Simple categorization of the RV PV-loop shapes into “triangular” (early-SP/ESP ratio >1.1, mean survival 7.7 years), “rectangular” (0.9–1.1, 6.4 years) and “trapezoid” (<0.9, 3.2 years) clearly differentiated long-term survival of HFREF patients (log rank, Chi square 50.1, p<0.001).

Conclusion

The early-SP/ESP ratio determines the shape of RV-PV-loops and is closely associated with predominately pulsatile PA load, RV-PA coupling capacity, RV function, and long-term prognosis of patients with HFREF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boston Scientific

Novel echocardiographic measures of myocardial work predicts physical performance during prolonged strenuous exercise

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The North Sea Race, Laerdal Foundation

Background

Cardiac function is a major determinant of physical performance. Cardiac function at rest can be assessed by novel echocardiographic parameters of myocardial work. Physical performance can be accurately measured using sensors recording the power output during exercise. There is limited data on the relationship between resting echocardiographic parameters and power measurements during strenuous endurance exercise. The aim of this work was to study the relationship between power output during exercise and echocardiographic parameters of cardiac structure and function at rest, including echocardiographic parameters of myocardial work.

Method

Resting echocardiographic parameters of 40 healthy, middle aged, recreational athletes, were compared with power output recordings during two episodes of endurance exercise of different duration and intensity. The first exercise was a cardiopulmonary exercise (CPX) test, which included both a lactate threshold- and a maximal oxygen uptake test. The second exercise was a 91-km mountain bike leisure sport cycling race. Power output was measured on the bikes using power meters. All study subjects were assessed by echocardiography prior to the CPX test. Coronary Computed Tomography Angiography was performed 1-2 weeks after the race to exclude obstructive coronary artery disease.

Results

Study participants were 51.1 ±9.7 years old (73 % men), median 10.0 (7.0-21.3) years of endurance training, and a median of 10.0 (5.0-20.0) endurance exercise competitions during the past five years. Both left ventricular mass and left atrial volume were in the upper reference range: 84.0 (77.0-96.0) gram/m2, 32.0 ±8.5 mL/m2, and the left ventricles were mildly dilated; 81.6 (69.1-96.5) mL/m2 (end-diastole). Median exercise duration: CPX: 43 (IQR 40-45) minutes, race: 236 (214-268) minutes. Mean heart rate; CPX: 145 ±11 bpm, race: 154 ± 10 bpm. Maximal oxygen uptake (Vo2 max): 41.6 ±9 ml/min/kg. Mean power output: CPX: 2.9 ±0.5 watt/kg, race: 2.1 ±0.5 watt/kg. There were strong bivariate correlations between left atrial and ventricular volumes and performance parameters (Table 1). Left ventricular global longitudinal strain (LV GLS) was correlated with Vo2 max. The myocardial work parameters global wasted work (GWW) and global work efficiency (GWE) were correlated with all performance parameters except Vo2 max. In multivariable linear regression models, except for VO2 max, GWW was the most consistent and strongest predictor of physical performance in all models (Table 2).

Conclusion

The novel echocardiographic parameter of global wasted work (GWW), assessed at rest, was the strongest and most consistent predictor of physical work measured by power meters during prolonged strenuous exercise.

The Effects of Leadership Curricula With and Without Implicit Bias Training on Graduate Medical Education: A Multicenter Randomized Trial

PURPOSE

To determine whether a brief leadership curriculum including high-fidelity simulation can improve leadership skills among resident physicians.

METHOD

This was a double-blind, randomized controlled trial among obstetrics-gynecology and emergency medicine (EM) residents across 5 academic medical centers from different geographic areas of the United States, 2015-2017. Participants were assigned to 1 of 3 study arms: the Leadership Education Advanced During Simulation (LEADS) curriculum, a shortened Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum, or as active controls (no leadership curriculum). Active controls were recruited from a separate site and not randomized to limit any unintentional introduction of materials from leadership curricula. The LEADS curriculum was developed in partnership with the Council on Resident Education in Obstetrics and Gynecology and Council of Residency Directors in Emergency Medicine as a novel way to provide a leadership toolkit. Both LEADS and the abbreviated TeamSTEPPS were designed as six 10-minute interactive web-based modules.The primary outcome of interest was the leadership performance score from the validated Clinical Teamwork Scale instrument measured during standardized high-fidelity simulation scenarios. Secondary outcomes were 9 key components of leadership from the detailed leadership evaluation measured on 5-point Likert scales. Both outcomes were rated by a blinded clinical video reviewer.

RESULTS

One hundred ten obstetrics-gynecology and EM residents participated in this 2-year trial. Participants in both LEADS and TeamSTEPPS had statistically significant improvement in leadership scores from "average" to "good" ranges both immediately and at the 6-month follow-up, while controls remained unchanged in the "average" category throughout the study. There were no differences between LEADS and TeamSTEPPS curricula with respect to the primary outcome.

CONCLUSIONS

Residents who participated in a brief structured leadership training intervention had improved leadership skills that were maintained at 6-month follow-up.

Analysis of an Intervention for Emergency Medical Services Personnel to Reduce Epinephrine Dosing Errors in Infants

This quality improvement study investigates whether a simulation-driven emergency medical services protocol of using a 1-mL syringe to administer small epinephrine doses could reduce dosing errors in infants.

Predictors and prognosis of RV function in pulmonary hypertension due to heart failure with reduced ejection fraction

Background and aims

Failure of right ventricular (RV) function worsens outcome in pulmonary hypertension (PH). The adaptation of RV contractility to afterload, the RV-pulmonary artery (PA) coupling, is defined by the ratio of RV end-systolic to PA elastances (Ees/Ea). Using pressure volume loop (PV-L) technique we aimed to identify an Ees/Ea cutoff predictive for overall survival and to assess hemodynamic and morphologic conditions for adapted RV function in secondary PH due to Heart Failure with Reduced Ejection Fraction (HFREF).

Methods

This post hoc analysis is based on 112 patients of the prospective Magdeburger Resynchronization Responder Trial. All patients underwent right and left heart echocardiography, and a baseline PV-L and RV catheter measurement. A subgroup of patients (n=50) without a pre-implanted cardiac device underwent MRI at baseline.

Results

The analysis revealed that 0.68 is an optimal Ees/Ea cutoff (area under the curve: 0.697, p<0.001) predictive for overall survival (median follow up = 4.7 years, Ees/Ea ≥0.68 vs. <0.68, log-rank 8.9, p=0.003. In patients with PH (n=76, 68%) Multivariate Cox-regression demonstrated the independent prognostic value of RV-Ees/Ea in PH patients (HR 0.2, p<0.038). Patients without PH (n=36, 32%) and those with PH but RV-Ees/Ea ≥0.68 showed comparable RV-Ees/Ea ratios (0.88 vs. 0.9, p=0.39), RV size/function, and survival. In contrast, secondary PH with RV-PA coupling ratio Ees/Ea <0.68 corresponded extremely close to cut-off values that define RV dilatation/remodeling (RVEDV >160ml, RV-mass/volume-ratio <0.37 g/ml) and dysfunction (RVEF <38%, TAPSE <16mm, FAC <42%, and stroke-volume/end-systolic volume ratio <0.59) and is associated with a dramatically increased short and medium-term all-cause mortality. Independent predictors of prognostically unfavorable RV-PA coupling (Ees/Ea <0.68) in secondary PH were a preexistent dilated RV (end-diastolic volume >171ml, odds ratio, OR 0.96, p=0.021), high pulsatile load (PA compliance <2.3 ml/mmHg, OR 8.6, p=0.003), and advanced systolic left heart failure (left ventricular (LV) ejection fraction <30%, OR 1.23, p=0.028).

Conclusions

The RV-PA coupling ratio Ees/Ea predicts overall survival in PH due to HFREF and is mainly affected by pulsatile load, RV remodeling and LV dysfunction. Prognostically favorable coupling (RV-Ees/Ea ≥0.68) in PH was associated with preserved RV size/function and mid-term survival, comparable to HFREF without PH.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific

Echocardiographic parameters of myocardial work in relation to prolonged strenuous physical exercise

Background

Myocardial work (MW) assessed by echocardiography is a novel measure of left ventricular (LV) function. This measure is load-independent, and therefore a more accurate method for assessing LV function when there are changes in loading conditions. The purpose of this study was to examine alterations in MW parameters, blood pressure (BP) and LV global longitudinal strain (LV GLS) in relation to strenuous exercise, and to compare the response between two different physical stress situations.

Methods

59 healthy recreational athletes were assessed by echocardiography before-, immediately- and 24 hours after two episodes of high-intensity endurance exercise. The first exercise was a cardiopulmonary exercise (CPX) test, which included both a stepwise lactate threshold- and a maximal oxygen uptake test. The second exercise was a 91-km mountain bike leisure sport cycling competition. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were estimated from LV pressure-strain loops, constructed from a combination of LV GLS and non-invasive BP, using commercially available software package (Echopac V.202, GE).

Results

Subjects were 52 (43–59) years old (73% men). The duration of the CPX-test was 43 (40–45) minutes, and the race was 230 (210–245) minutes. The average heart rate during the CPX-test and the race was 144 (140–153) and 154 (148–161) beats per minute (bpm), respectively. The relative changes (percent) in systolic blood pressure (SBP) and LV GLS compared with pre-exercise values are demonstrated in Figure 1a, and GWI and GCW compared with pre-exercise values in Figure 1b. GWI at baseline was 2156 (1899–2400) mmHg% and GCW 2383 (2152–2668) mmHg%. There was a significant reduction in LV GLS (p=0.015), SBP, GWI and GCW following the CPX-test and the race (p<0.001), while there was an increase in heart rate and cardiac output (p<0.001). After the race, there was a significant (p=0.001) increase in GWW, and a reduction (p=0.006) in GWE.

Conclusion

There was a significant reduction in GWI and GCW after both the CPX-test and the race, suggesting that these markers reflect increased myocardial exhaustion following strenuous physical exercise.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by ConocoPhillips and the Simon Fougner Hartmann Trust Figure 1aFigure 1b

Factors associated with parents' willingness to enroll their children in trials for COVID-19 vaccination

The coronavirus disease 2019 (COVID-19) pandemic has taken an unprecedented global toll and vaccination is needed to restore healthy living. Timely inclusion of children in vaccination trials is critical. We surveyed caregivers of children seeking care in 17 Emergency Departments (ED) across 6 countries during the peak of the pandemic to identify factors associated with intent to participate in COVID-19 vaccine trials. Questions about child and parent characteristics, COVID-19 expressed concerns and parental attitudes toward participation in a trial were asked.Of 2768 completed surveys, 18.4% parents stated they would enroll their child in a clinical trial for a COVID-19 vaccine and 14.4% would agree to a randomized placebo-controlled study. Factors associated with willingness to participate were parents agreeing to enroll in a COVID-19 vaccine trial themselves (Odds Ratio (OR) 32.9, 95% Confidence Interval (CI) (21.9-51.2)) having an older child (OR 1.0 (1.0-1.01)), having children who received all vaccinations based on their country schedule (OR 2.67 (1.35-5.71)) and parents with high school education or lower (OR 1.79 (1.18-2.74)). Mothers were less likely to enroll their child in a trial (OR 0.68 (0.47-0.97)). Only one fifth of families surveyed will consider enrolling their child in a vaccine trial. Parental interest in participation, history of vaccinating their child, and the child being older all are associated with parents allowing their child to participate in a COVID vaccine trial. This information may help decision-makers and researchers shape their strategies for trial design and participation engagement in upcoming COVID19 vaccination trials.

Critical Factors in Planning a Pediatric Prehospital Airway Trial

Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

An international survey of healthcare workers use of personal protective equipment during the early stages of the COVID-19 pandemic

OBJECTIVE

Little is known regarding the specific ways personal protective equipment (PPE) has been used and reused during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate the patterns of PPE use and the impact of PPE availability on the attitudes and well-being of an international population of healthcare workers.

METHODS

This was an online, cross-sectional survey of healthcare workers. The survey was disseminated internationally using social media, specialty society list-serves, and email augmented by snowball sampling to healthcare workers who provided direct care to patients with suspected or confirmed COVID-19. The survey was conducted between April 13 and May 1, 2020. The primary outcome was self-reported PPE use during aerosol-generating medical procedures. Other outcomes included PPE use during care for respiratory patients in general, PPE reuse, PPE decontamination, and healthcare worker impressions related to their work and the pandemic.

RESULTS

A total of 2227 healthcare workers from 23 countries completed the survey. The N95 was the most common respirator among the 1451 respondents who performed aerosol-generating procedures (n = 1050, 72.3%). Overall, 1783 (80.1%) of providers reported general reuse of PPE, which was similar across US regions but less common in Canada, Italy, and Spain. The most commonly reused item of PPE was the N95 respirator, with the majority of respondents who reused PPE reporting N95 reuse (n = 1157, 64.9%). Of the 1050 individuals who wore an N95 mask while performing an aerosol-generating medical procedure, 756 (72%) reported re-using an N95, and 344 (45.5%) reported reuse for >3 days. Qualitative results identified several common themes, including (1) lack of availability of PPE, (2) fear and anxiety as a result of inadequate PPE, (3) potential exposure to family members, and (4) concerns regarding workload and pay.

CONCLUSIONS

This international survey of healthcare workers found that N95 respirators were commonly used to care for patients with respiratory symptoms with and without aerosol-generating medical procedures. Healthcare workers reported an unprecedented need to reuse PPE that was designed for single-use, specifically the N95 respirator. The reuse of PPE increased the perceived risk for COVID-19 infection and harmed mental health.

Left atrial function assessed by speckle tracking echocardiography predicts atrial fibrillation burden after catheter ablation independently of reconduction: a RACE-AF echocardiographic sub-study

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function assessed by 2D speckle tracking echocardiography (STE) has demonstrated to be a useful predictor of recurrence of atrial fibrillation (AF) following catheter ablation (CA). Pulmonary vein reconduction (PVR) is one of the most important causes of recurrent paroxysmal AF (PAF) after ablation. The purpose of this study was to evaluate the association between AF burden (% of time in AF) following CA and LA strain measurements independently of PVR.

Methods

This prospective study included 66 patients with PAF who underwent CA (mean age 60 ± 8 years, 65% male). STE was performed during sinus rhythm prior to CA. AF burden was recorded by continuous rhythm monitoring using implantable loop recorders during a follow-up period of 4-6 months, excluding a blanking period of 3 months. After follow-up, all patients underwent an invasive assessment of pulmonary vein isolation to test for PVR. Multivariable linear regression analysis was used to assess the association between AF burden and peak atrial longitudinal reservoir strain (PALS), peak atrial contraction strain (PACS) and peak atrial conduit strain (PCS).

Results

Prior to CA, median AF burden was 3.8% (IQR: 0.5, 17). During follow-up, 37 patients (56%) were free of AF while median AF burden was 0.7% (IQR: 0.2, 1.6) in patients with an AF burden of more than 0%. A total of 35 patients (54%) were found to have PVR after ablation. Patients with AF recurrence had significantly lower PACS compared to patients with no AF during follow-up (10% ± 6% vs. 14% ± 5%, p = 0.004). No differences in PALS and PCS were observed. Increased PACS remained independently associated with low AF burden following CA after multivariable adjustments for clinical characteristics, comorbidities, and PVR (β=-0.262, p = 0.049) (Figure 1). PALS and PCS did not remain significantly associated with AF burden.

Conclusion

Increased PACS is strongly associated with low AF burden after CA even after adjusting for PVR. This suggests that an analysis of LA function could be useful to stratify patients prior to CA and improve treatment strategies.

Abstract Figure.

Vital sign monitoring during out-of-hospital pediatric advanced airway management

OBJECTIVE

To evaluate physiologic monitoring in pediatric patients undergoing out-of-hospital advanced airway management.

METHODS

Retrospective case series of pediatric patients (<18 years) with advanced airways placed in the out-of-hospital setting. Patients given cardiopulmonary resuscitation (CPR) or defibrillation before the first advanced airway attempt were excluded. Reviewers abstracted physiologic data from the patient monitor files and patient care reports. The primary outcome was the proportion of time pulse oximetry was in place during airway management. Other outcomes included the proportion of time ECG monitoring and waveform end-tidal capnography were in place as well as the incidence of oxygen desaturation events.

RESULTS

We evaluated 23 pediatric patients with a mean age of 10.7 years (SD 6.5). Eleven of 18 (61%) children with medication-facilitated intubation had pulse oximetry in place when the first medication was documented as given. Eight of 18 (44%) had ECG monitoring, 12 of 18 (66%) had waveform capnography, and 5 of 18 (28%) had a blood pressure check within the 3 minutes before receiving the first medication. In the 3-minute preoxygenation phase, pulse oximetry was in place for an average of 1.4 minutes (47%, SD 0.37) and a visible photoplethysmogram (PPG) waveform obtained from the pulse oximeter was present for 0.6 minutes (20%, SD 0.34). During airway device placement, pulse oximetry was in place 73% (SD 0.39) of the time and 30% (SD 0.41) of the time there was a visible PPG waveform.

CONCLUSIONS

Pediatric patients had critical deficits in physiologic monitoring during advanced airway management.

Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey

BACKGROUND

More than 100 COVID-19 vaccine candidates are in development since the SARS-CoV-2 genetic sequence was published in January 2020. The uptake of a COVID-19 vaccine among children will be instrumental in limiting the spread of the disease as herd immunity may require vaccine coverage of up to 80% of the population. Prior history of pandemic vaccine coverage was as low as 40% among children in the United States during the 2009 H1N1 influenza pandemic.

PURPOSE

To investigate predictors associated with global caregivers' intent to vaccinate their children against COVID-19, when the vaccine becomes available.

METHOD

An international cross sectional survey of 1541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries from March 26 to May 31, 2020.

RESULTS

65% (n = 1005) of caregivers reported that they intend to vaccinate their child against COVID-19, once a vaccine is available. A univariate and subsequent multivariate analysis found that increased intended uptake was associated with children that were older, children with no chronic illness, when fathers completed the survey, children up-to-date on their vaccination schedule, recent history of vaccination against influenza, and caregivers concerned their child had COVID-19 at the time of survey completion in the ED. The most common reason reported by caregivers intending to vaccinate was to protect their child (62%), and the most common reason reported by caregivers refusing vaccination was the vaccine's novelty (52%).

CONCLUSIONS

The majority of caregivers intend to vaccinate their children against COVID-19, though uptake will likely be associated with specific factors such as child and caregiver demographics and vaccination history. Public health strategies need to address barriers to uptake by providing evidence about an upcoming COVID-19 vaccine's safety and efficacy, highlighting the risks and consequences of infection in children, and educating caregivers on the role of vaccination.

Review of Potentially Toxic Rare Earth Elements, Thallium and Tellurium in Plant-based Foods

In the last decades, there is an increasing inclusion of various trace metals and metalloids such as thallium, tellurium and rare earth elements (REEs; lanthanides, scandium, and yttrium) in the composition and production of alloys, in agricultural and medicinal applications, as well as in the manufacturing of hi-tech products. All these activities have led to an accumulation of the aforementioned elements both in soil and water bodies and consequently in the food chain, through discharges from mining and mineral processing, liquid industrial waste or disposal of urban and industrial products. It has been demonstrated that chronic exposure to some of these elements, even at low doses, might lead to a wide range of adverse health effects, even from the early stages of life, such as neurotoxicity, neurodevelopmental toxicity and hepatic alterations. Particularly in children, there have been studies suggesting that some of these elements might negatively affect the children's spatial learning and memory ability indirectly. Such effects are triggered by processes like the production of reactive oxygen species (ROS), lipid peroxidation and modulation of antioxidant activities. Nevertheless, the limited data from toxicological studies and their so-far naturally low occurrence levels in the environment acted as a deterrent in measuring their concentrations during routine analyses of metals in foodstuff. Thus, it is important to collect information on their occurrence data both in adults and in children's daily diet. This review sumrises the current knowledge on the concentration of these elements, in plant-based food products to identify whether a potential health risk occurs. As side projects, this Fellowship provided hands-on training on the evaluation of new biocides application and participation in the given advice to the Danish Food and Veterinary Administration, Danish Environmental Protection Agency, the Danish Medical Agency and the European Chemicals Agency.

Right ventricular pulmonary vascular coupling in secondary tricuspid regurgitation: a pressure volume loop study

Introduction

The severity of secondary tricuspid regurgitation (sTR) predicts outcome of patients with left heart failure with reduced ejection fraction (HFrEF). In these patients sTR predominantly occurs as a result of secondary pulmonary hypertension (PH). However, more than 46% of patients with severe PH have only mild or none sTR. In this study we tested the hypothesis that intrinsic right ventricular (RV) contractility adaptation to the pulmonary arterial (PA) vascular load (RV-PA-coupling) is associated with the presence and severity of sTR.

Methods

In 110 patients with HFrEF (a post-hoc analysis of the Magdeburger CRT Responder Trial, DRKS00011133) we quantified the RV intrinsic contractility response (end-systolic elastance, Ees) to pulmonary vascular afterload (arterial elastance, Ea) and its coupling ratio (RV-PA coupling ratio: Ees/Ea) by the RV pressure-volume loop catheter technique at baseline, and combined it with echocardiography-derived parameter of sTR presence and severity and RV function.

Results

Echocardiography at baseline demonstrated no or trace TR (TR0) in 67 patients (61%), mild TR (TR1) in 23 (21%), moderate TR (TR2) in 11 (10%), and severe TR (TR3) in 9 (8%). The transition from TR0 to TR1 was characterized by a pronounced drop of the RV-PA coupling ratio (TR0: Ees/Ea= 0.88, 0.67–1.1 vs. TR1: Ees/Ea= 0.48, 0.3–0.83, p&lt;0.001), caused by a non-adaptive, non-rising Ees (0.24 mmHg/ml, 0.34–0.44 vs. 0.3 mmHg/ml, 0.21–0.46, p=0.8, respectively, p&lt;0.001). We observed a further but only marginal drop of Ees/Ea from TR1 to TR3 (p=0.008) caused by an additional small non-significant decrease of Ees and increase of Ea. Interestingly, other afterload parameter, such as PA-pressure, wedge pressure (PCWP), PA compliance, and PA resistance (PVR), and parameters of RV function, such as tricuspid annular plane systolic excursion (TAPSE) and fractional area shortening (FAC) followed the same course of a pronounced drop from TR0 to TR1, succeeded by an only marginal change from TR1 to TR3. In contrast, the progressive RV-PA un-coupling from TR0 to TR3 was accompanied by a more or less continuously increase of RV size and volume load (end-diastolic (ED) area in 4 chamber view, ED-RV outflow tract diameter, size of tricuspid annulus). In the binary logistic regression analysis, the decrease of RV-PA coupling ratio Ees/Ea (OR 0.14, CI 0.001–0.165) and PA compliance (OR 0.44, CI 0.25–0.79) were independently associated with the transition from TR0 to TR1–3.

Conclusion

The presence and severity of secondary TR in patients with HFREF is independently associated with a progressive RV-PA uncoupling. Most importantly, already the transition from none TR to mild TR is characterized by a significant and pronounced increase of pulmonary vascular afterload, a non-adaptive RV contractility response, and resulting RV-PA un-coupling.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific

Retrospective chart review and survey to identify adverse safety events in the emergency medical services care of children with out-of-hospital cardiac arrest in the USA: a study protocol

INTRODUCTION

Efforts to improve the quality of emergency medical services (EMS) care for adults with out-of-hospital cardiac arrest (OHCA) have led to improved survival over time. Similar improvements have not been observed for children with OHCA, who may be at increased risk for preventable adverse safety events during prehospital care. The purpose of this study is to identify patient and organisational factors that are associated with adverse safety events during the EMS care of paediatric OHCA.

METHODS AND ANALYSIS

This is a large multisite EMS study in the USA consisting of chart reviews and agency surveys to measure, characterise and evaluate predictors of our primary outcome severe adverse safety events in paediatric OHCA. Using the previously validated Paediatric prehospital adverse Event Detection System tool, we will review EMS charts for 1500 children with OHCA from 2013 to 2019 to collect details of each case and identify severe adverse safety events (ASEs). Cases will be drawn from over 40 EMS agencies in at least five states in geographically diverse areas of the USA. EMS agencies providing charts will also be invited to complete an agency survey to capture organisational characteristics. We will describe the frequency and proportion of severe ASEs in paediatric OHCA across geographic regions and clinical domains, and identify patient and EMS organisational characteristics associated with severe ASEs using logistic regression.

ETHICS AND DISSEMINATION

This study has been approved by the Oregon Health & Science University Institutional Review Board (IRB Approval# 00018748). Study results will be disseminated through scientific publications and presentations, and to EMS leaders and staff through local EMS medical directors, quality and training officers and community engagement activities.

Racial disparities in out-of-hospital cardiac arrest interventions and survival in the Pragmatic Airway Resuscitation Trial

BACKGROUND

Prior studies have reported racial disparities in survival from out-of-hospital cardiac arrest (OHCA). However, these studies did not evaluate the association of race with OHCA course of care and outcomes. The purpose of this study was to evaluate racial disparities in OHCA airway placement success and patient outcomes in the multicenter Pragmatic Airway Resuscitation Trial (PART).

METHOD

We conducted a secondary analysis of adult OHCA patients enrolled in PART. The parent trial randomized subjects to initial advanced airway management with laryngeal tube or endotracheal intubation. For this analysis, the primary independent variable was patient race categorized by emergency medical services (EMS) as white, black, Hispanic, other, and unknown. We used general estimating equations to examine the association of race with airway attempt success, 72-h survival, and survival to hospital discharge, adjusting for sex, age, witness status, bystander cardiopulmonary resuscitation (CPR), initial rhythm, arrest location, and PART randomization cluster.

RESULTS

Of 3002 patients, EMS-assessed race as 1537 white, 860 black, 163 Hispanic, 90 other, and 352 unknown. Initial shockable rhythms (13.8% vs. 21.5%, p < 0.001), bystander CPR (35.6% vs. 51.4%, p < 0.001), and survival to hospital discharge (7.6% vs. 10.8%, p = 0.011) were lower for black compared to white patients. After adjustment for confounders, no difference was seen in airway success, 72-h survival, and survival to hospital discharge by race.

CONCLUSIONS

In one of the largest studies evaluating differences in prehospital airway interventions and outcomes by EMS-assessed race for OHCA patients, we found no significant adjusted differences between airway success or survival outcomes.

Outcomes With the Use of Bag-Valve-Mask Ventilation During Out-of-hospital Cardiac Arrest in the Pragmatic Airway Resuscitation Trial

BACKGROUND

While emergency medical services (EMS) often use endotracheal intubation (ETI) or supraglottic airways (SGA), some patients receive only bag-valve-mask (BVM) ventilation during out-of-hospital cardiac arrests (OHCA). Our objective was to compare patient characteristics and outcomes for BVM ventilation to advanced airway management (AAM) in adults with OHCA.

METHODS

Using data from the Pragmatic Airway Resuscitation Trial, we identified patients receiving AAM (ETI or a SGA), BVM ventilation only (BVM-only), and BVM ventilation as a rescue after at least one failed attempt at advanced airway placement (BVM-rescue). The outcomes were return of spontaneous circulation (ROSC), 72-hour survival, survival to hospital discharge, neurologically intact survival (Modified Rankin Scale ≤ 3), and the presence of aspiration on a chest radiograph. Comparisons were made using generalized mixed-effects models while adjusting for age, sex, initial rhythm, EMS-witnessed status, bystander cardiopulmonary resuscitation, response time, study cluster, and advanced life support first on scene.

RESULTS

Of 3,004 patients enrolled, there were 282 BVM-only, 2,129 AAM, and 156 BVM-rescue patients with complete covariates. Shockable initial rhythms (34% vs. 18.6%) and EMS-witnessed arrests (21.6% vs. 11.3%) were more likely in BVM-only than AAM but similar between BVM-rescue and AAM. Compared to AAM, BVM-only patients had similar ROSC (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 0.96 to 1.73), but higher 72-hour survival (OR = 1.96, 95% CI = 1.42 to 2.69), survival to discharge (OR = 4.47, 95% CI = 3.03 to 6.59), and neurologically intact survival (OR = 7.05, 95% CI = 4.40 to 11.3). Compared to AAM, BVM-rescue patients had similar ROSC (OR = 0.73, 95% CI = 0.47 to 1.12) and 72-hour survival (OR = 1.08, 95% CI = 0.66 to 1.77) but higher survival to discharge (OR = 2.15, 95% CI = 1.17 to 3.95) and neurologically intact survival (OR = 2.64, 95% CI = 1.20 to 5.81). Aspiration incidence was similar.

CONCLUSIONS

Bag-valve-mask-only ventilation is associated with improved OHCA outcomes. Despite similar rates of ROSC and 72-hour survival, BVM-rescue ventilation was associated with improved survival to discharge and neurologically intact survival compared to successful AAM.

Lexical analysis of emotional responses to "real-world" experiences in individuals with schizophrenia

Abnormalities in emotion perception, expression, and experience are considered a core component of schizophrenia. Previous laboratory studies have demonstrated that while individuals with schizophrenia report levels of positive emotions comparable to healthy individuals in response to positive stimuli, they also report co-occurring negative emotions in response to such stimuli. However, it is unknown whether this response pattern extends to "real world" naturalistic environments. To examine this question, we employed an experience sampling method (ESM) approach using mobile electronic devices to collect information up to 10 times/day over a two-day period from 53 individuals with schizophrenia and 19 non-clinical controls. As part of each experience sample, participants completed brief open-ended responses and answered questions about their emotional responses to three recent events (neutral, positive, and negative). Additionally, participants completed diagnostic and clinical measures. Lexical analyses were used to analyze ESM-based word production and characterize emotion word use. Compared to non-clinical controls, individuals with schizophrenia reported similar levels of positive emotion, but significantly higher negative emotion, which was associated with increased negative symptoms. The schizophrenia group used more anxiety words in response to negative and neutral events, and more anger words in response to positive events. Increased use of anger words was linked with elevations in positive symptoms as well as symptoms of depression, while use of sadness words was linked with anhedonia. Our findings support the co-activation of negative emotion hypothesis documented in laboratory settings and provide evidence of its ecological validity. Implications for functioning and future directions are discussed.

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (&lt;10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Secondary traumatisation, burn-out and functional impairment: findings from a study of Danish child protection workers

Background: Child-protection workers are at elevated risk for secondary traumatization. However, research in the area of secondary traumatization has been hampered by two major obstacles: the use of measures that have unclear or inadequate psychometric properties and equivocal findings on the degree of associated functional impairment. Objective: To assess the relationship between secondary traumatization and burnout using exploratory structural equation modelling (ESEM) and to assess the relationship between secondary traumatization and functional impairment. Methods: A survey of Danish child-protection workers was conducted through the Danish Children Centres (N = 667). Secondary traumatization was measured using the Professional Quality of Life-5 (ProQoL-5) and burnout using the Oldenburg Burnout Inventory. Results: A three-factor ESEM model provided the best fit to the data, reflecting factors consistent with the structure of secondary traumatization and burnout. The factors were differentially related to trauma-related and organizational variables in ways consistent with existing evidence. All factors were significantly related to functional impairment. Conclusion: The findings supported the discriminant validity of secondary traumatization and burnout while highlighting methodological issues around the current use of sum-score approaches to investigating secondary traumatization. The current study supported the clinical relevance of secondary traumatization by linking it explicitly to social and cognitive functional impairment.

Association between measured teamwork and medical errors: an observational study of prehospital care in the USA

OBJECTIVES

The goal of this study was to examine the relationship between measured teamwork and adverse safety events in the prehospital emergency care of children using high-fidelity simulation. We posit that non-technical skills such as leadership, teamwork, situation awareness and decision-making are associated with the clinical success of teams.

DESIGN

Observational study.

SETTING

Emergency medical services (EMS) responders were recruited from public fire and private transport agencies in Oregon State to participate in four simulations of paediatric emergencies using high-fidelity patient simulators, scene design, and professional actors playing parents and bystanders.

PARTICIPANTS

Forty-four fire/transport teams consisting of 259 EMS professionals consented to participate and completed simulations.

PRIMARY AND SECONDARY OUTCOME MEASURES

Teams were assessed using the Clinical Teamwork Scale (CTS), a validated instrument that measures overall teamwork and 15 specific elements in five overarching domains: communication, decision-making, role responsibility (leadership and followership), situational awareness/resource management and patient-friendliness. We used generalised estimating equations to estimate the odds of error with increasing overall CTS teamwork score while adjusting for clinical scenario and potential clustering by team.

RESULTS

Across 176 simulations, the mean overall score on the CTS was 6.04 (SD 2.10; range 1=poor to 10=perfect) and was normally distributed. The distribution of scores was similar across the four clinical scenarios. At least one error was observed in 82% of the simulations. In simulations with at least one observed error, the mean CTS score was 5.76 (SD 2.04) compared with 7.16 (SD 1.95) in scenarios with no observed error. Logistic regression analysis accounting for clustering at the team level revealed that the odds of an error decreased 28% with each unit increase in CTS (OR 0.72, 95% CI 0.59 to 0.88).

CONCLUSIONS

This study found that overall teamwork among care delivery teams was strongly associated with the risk of serious adverse events in simulated scenarios of caring for critically ill and injured children.

Implicit gender bias among US resident physicians

BACKGROUND

The purpose of this study was to characterize implicit gender bias among residents in US Emergency Medicine and OB/GYN residencies.

METHODS

We conducted a survey of all allopathic Emergency Medicine and OB/GYN residency programs including questions about leadership as well as an implicit association test (IAT) for unconscious gender bias. We used descriptive statistics to analyze the Likert-type survey responses and used standard IAT analysis methods. We conducted univariate and multivariate analyses to identify factors that were associated with implicit bias. We conducted a subgroup analysis of study sites involved in a multi-site intervention study to determine if responses were different in this group.

RESULTS

Overall, 74% of the programs had at least one respondent. Out of 14,234 eligible, 1634 respondents completed the survey (11.5%). Of the five sites enrolled in the intervention study, 244 of 359 eligible residents completed the survey (68%). Male residents had a mean IAT score of 0.31 (SD 0.23) and females 0.14 (SD 0.24), both favoring males in leadership roles and the difference was statistically significant (p < 0.01). IAT scores did not differ by postgraduate year (PGY). Multivariable analysis of IAT score and participant demographics confirmed a significant association between female gender and lower IAT score. Explicit bias favoring males in leadership roles was associated with increased implicit bias favoring males in leadership roles (r = 0.1 p < 0.001).

CONCLUSIONS

We found that gender bias is present among US residents favoring men in leadership positions, this bias differs between male and female residents, and is associated with discipline. Implicit bias did not differ across training years, and is associated with explicit bias.

Global humid tropics forest structural condition and forest structural integrity maps

Remotely sensed maps of global forest extent are widely used for conservation assessment and planning. Yet, there is increasing recognition that these efforts must now include elements of forest quality for biodiversity and ecosystem services. Such data are not yet available globally. Here we introduce two data products, the Forest Structural Condition Index (SCI) and the Forest Structural Integrity Index (FSII), to meet this need for the humid tropics. The SCI integrates canopy height, tree cover, and time since disturbance to distinguish short, open-canopy, or recently deforested stands from tall, closed-canopy, older stands typical of primary forest. The SCI was validated against estimates of foliage height diversity derived from airborne lidar. The FSII overlays a global index of human pressure on SCI to identify structurally complex forests with low human pressure, likely the most valuable for maintaining biodiversity and ecosystem services. These products represent an important step in maturation from conservation focus on forest extent to forest stands that should be considered "best of the last" in international policy settings.

P4687Relevance of TAPSE and FAC, and their relationship to PASP as echo-derived measures for RV-PA coupling in heart failure: a comparative analysis with invasive RV-pressure volume loop data

Background

Right ventricular (RV) to pulmonary artery (PA) coupling (C), quantified by pressure volume (PV) loop analysis, predicts RV function, and is independently associated with long term survival in systolic heart failure (HFrEF). However, the PV loop technique is invasive and complex to carry out, especially when used to do RV functional analyses. Different echo-surrogate parameters are proposed to measure RV-PA-C, such as the tricuspid annular plane systolic excursion, TAPSE/PAsystolic pressure (SP) and FAC (fractional area change)/PASP as the most promising parameters. However, up to now, no validation of these non-invasive coupling indices with the invasive gold standard method of RV-PV-loops has been done.

Methods

In 111 patients with advanced HFrEF (Post-hoc analysis of Magdeburger CRT Responder Trial, DRKS00011133), echo-derived TAPSE and FAC, and their relationship to PASP were related to the RV PV-loop-derived parameters of intrinsic RV contractility (Ees), pulmonary load (Ea), and the RV-PA-C efficiency (Ees/Ea) by linear regression analysis. Within a MRI substudy (n=49 patients) we examined the relationship of pure longitudinal contraction (MRI-TAPSE) and radial free wall to septum contraction (area change of 5 RV segments from tricuspid valve to apex in the short axis view) to the invasive RV-PA-C.

Results

The MRI analysis demonstrated that radial RV contraction (R2=0.77, p<0.001) correlated better to invasive RV-PA-C than pure longitudinal shortening (R2=0.37, p<0.001) (radial vs. longitudinal: p<0.00). Echo data for the entire patient cohort confirmed the MRI data. The FAC (R2=0.8, p<0.001) was significantly better associated with RV-PA-C than TAPSE (R2=0.57, p<0.001) (TAPSE vs FAC, p<0.001). Placing TAPSE or FAC into a quotient with PASP did not at all (TAPSE vs. TAPSE/PASP, p=0.1) or significantly attenuated (FAC vs. FAC/PASP R2=0.8 vs 0.58, p<0.001) their association to RV-PA-C. However, FAC/PASP and TAPSE/PASP correlated significantly better with global afterload (Eea), PA compliance, and pressure volume area (PVA), (p<0.001). In ROC analysis for all-cause mortality, all 4 tested parameters were prognostic relevant, however, with higher AUC values for FAC/PASP (AUC=0.74, p<0.001) and TAPSE/PASP (AUC=0.74, p<0.001) than for single TAPSE (AUC= 0.71, p=0.001) or FAC (AUC=0.7, p=0.001). Within a multivariate Cox regression analysis, only the FAC/PASP remained an independent predictor for long term survival.

Conclusion

FAC, an echo parameter that includes a predominant radial with a smaller part of longitudinal contraction, correlated significantly better to the invasively derived RV-PA-C-ratio than pure longitudinal RV shortening (TAPSE). Combining FAC or TAPSE with PASP did not improve the non-invasive RV-PA coupling information. However, it provided more comprehensive information on pulmonary vascular load and RV oxygen consumption, which seems to be translated into a higher prognostic power.

Acknowledgement/Funding

scientific grant from Boston Scientific

Are vitamins A and E associated with persistent organic pollutants and fatty acids in the blubber of highly contaminated killer whales (Orcinus orca) from Greenland?

We quantified blubber concentrations of vitamins A (retinol) and E (α-tocopherol) and evaluated associations with persistent organic pollutants (ΣPOPs) in 14 highly-contaminated killer whales (Orcinus orca) sampled in Greenland from 2012 to 2014. We considered the influence of blubber depth, sex/age class and diet (based on biomass % of major fatty acids) in these relationships. Blubber concentrations of vitamin A averaged 34.1 ± 4.7 μg g^-1 wet weight (ww) and vitamin E averaged 35.6 ± 4.4 μg g^-1 ww. Although overall vitamin A concentrations did not vary between inner (closer to the muscle) and outer (closer to the skin) blubber layer or between sub-adults and adult females, concentrations in the outer layer of sub-adults were lower compared to the outer layer of adult females (p = 0.03). Outer layer may therefore reflect age accumulation of vitamin A, while in the more active inner layer, age effects might be masked by metabolic needs such as lactation. Neither diet nor ΣPOPs affected vitamin A variation, suggesting this vitamin is highly regulated in the body. Given the high exposures in these killer whales, vitamin A might not be a sensitive biomarker for POPs adverse effects. Vitamin E concentrations were significantly higher in inner compared to outer layer (p < 0.001), likely associated with blubber composition, suggesting that biopsies may not fully represent vitamin E concentrations in blubber. Age-accumulation of vitamin E also occurred with higher concentrations in adult females compared to sub-adults, independent of blubber depth (p < 0.01). Diet, ΣPOPs, and an interaction between these two variables significantly affected vitamin E variation in inner blubber, explaining 91% of this variation. The negative relationship between ΣPOPs (especially Σdichlorodiphenyltrichloroethane (DDT) and Σchlordanes in outer layers) and vitamin E was observed only in killer whales with a diet poorer in polyunsaturated fatty acids, suggested that killer whales feeding more consistently on marine mammals in Arctic environments over a fish-based diet, may be at higher risk of POP-induced disruption in vitamin E homeostasis. Considering diet is therefore important to understand the potential effects of elevated contaminant exposures on levels of certain essential nutrients, i.e., vitamin E, in killer whales.

Analysis and Risk Assessment of Seaweed

During the last decade, the interest on the use of seaweed as food or feed, which was before limited to certain European regional subpopulations, has experienced a significant increase in other regions of the EU. In fact, the growing awareness and interest on sustainable and alternative food sources, healthier lifestyles and changes on dietary patterns brought seaweed to the spotlight for the general worldwide cuisine. Due to their high biosorption and accumulation capacity, seaweed can be an important source of increased exposure to persistent and potential harmful elements, such as cadmium (Cd), lead (Pb), mercury (Hg) and inorganic arsenic (iAs), or even some micronutrients, particularly iodine (I), to which an antioxidant role as been described in seaweed. This concentration potential has raised the interest of several Food Authorities regarding the risk of increased exposure to these elements. Moreover, the European Commission requested the collection of monitoring data on their levels aiming to aid the performance of better risk assessments and potentially set maximum levels on the European Legislation. This work aimed to obtain levels of these elements in species of seaweed (Fucus vesiculosus, Fucus serratus, Fucus spiralis, Fucus evanescens, Saccharina latissima, ulva lactuca and Ccladophora sp.) cultivated and harvested in Denmark, following European Commission's request. Additionally, a collaboration between Denmark, Ireland, France and the Netherlands was initiated to review and collect all the data available on scientific papers regarding the levels of these contaminants in seaweed worldwide. The final result of this work would be the publication of a review article. This Fellowship also provided on‐the‐job training on the evaluation of applications of new biocides and participation in the science based advises given to the Danish Food and Veterinary Administration, Danish EPA, the Danish Medical Agency and ECHA.

Modeling variation of clinical team processes with multiple sequence alignment

Our objective was to model process variation of Emergency Medical Service teams responding to simulated pediatric emergencies and determine if sequence alignment distinguishes performance quality. We performed a retrospective process analysis by watching and coding activities in videos from standardized simulations of 42 Emergency Medical Service teams. Teams were classified into high- or low-performing groups based on the Clinical Teamwork Scale™. Activities were coded according to resuscitation tasks, performer, and times. We used ClustalG to align task sequences within and between groups, and measured similarity. Teams within and between performance levels had an average sequence similarity of 52 ± 7% and 50 ± 7%. Teams performed clinically appropriate tasks that varied in prioritization, for example, performing compressions or connecting the EKG monitor early. There was no statistical difference in gross similarity between groups but specific differences in prioritization may have had clinically meaningful implications. Alignment could improve by accounting for task duration and concurrency.

Effect of initial airway strategy on time to epinephrine administration in patients with out-of-hospital cardiac arrest

INTRODUCTION

Epinephrine and advanced airway management are commonly used during treatment of out-of-hospital cardiac arrest (OHCA). Recent studies suggest that early but not late administration of epinephrine is associated with improved survival. The purpose of this study was to evaluate the effect of initial airway strategy on timing to the first epinephrine dose in OHCA.

METHODS

This is a secondary analysis of patients enrolled in the Pragmatic Airway Resuscitation Trial who had an advanced airway attempted. We examined differences in time to epinephrine administration by randomly assigned airway strategy, laryngeal tube (LT) or endotracheal tube (ETI); by the duration of airway attempt; and by number of attempts. We used survival methods to account for interval censoring due to unknown administration time. We also examined the association of epinephrine administration timing with survival to hospital discharge.

RESULTS

Among 2652 subjects (1299 ETI and 1353 LT), 2579 received epinephrine.There were no significant differences between ETI and LT in median time to initial epinephrine administration (min) (ETI - 9.0 vs. LT - 8.6, p = 0.55). There was no significant association between the duration of airway attempt or number of attempts and time to initial epinephrine administration (p = 0.12 and 0.66, respectively). Early administration of epinephrine (<10 min from EMS arrival) was significantly associated with survival compared to administration ≥10 min (OR 1.36, 95% CI: 1.05, 1.77).

CONCLUSIONS

There was no significant association between airway strategy and time to initial epinephrine administration. Earlier administration of epinephrine (< 10 min from EMS arrival) was associated with improved survival.

Obesity leads to impairments in the morphology and organization of human skeletal muscle lipid droplets and mitochondrial networks, which are resolved with gastric bypass surgery-induced improvements in insulin sensitivity

AIMS

Skeletal muscle lipid stores and mitochondrial function have been appointed as key players in obesity-induced insulin resistance. However, there are conflicting reports in the literature based on in vitro quantitative measurements. Here, we test the hypothesis that it is not the quantity but the quality that matters.

METHODS

This study combines quantitative and qualitative structural measurements of lipid stores and mitochondrial dynamics in skeletal muscle from lean subjects, and subjects with morbid obesity, with and without type 2 diabetes, before and after gastric bypass surgery.

RESULTS

The structural organization of muscle mitochondrial networks in type II muscle fibres from subjects with morbid obesity is impaired. In addition, the amount of skeletal muscle perilipin 2 protein per intramyocellular lipid is reduced in subjects with morbid obesity, resulting in qualitative alterations in perilipin 2 coat around some lipid droplets. Gastric bypass surgery-induced weight loss and insulin resistance remission were associated with decreases in intramyocellular lipid stores and, qualitative improvements in lipid droplets' morphology, perilipin 2 coat and mitochondrial dynamics.

CONCLUSION

Morbid obesity leads to severe qualitative alterations of both skeletal muscle lipid stores and mitochondrial networks. The degree of structural improvements after gastric bypass surgery was proportional to the improvements in whole body insulin sensitivity, suggesting an association between these events.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Mood disorder in the personal correspondence of Robert Burns: testing a novel interdisciplinary approach

Robert Burns has long been recognised as someone who experienced episodes of melancholia, but no detailed, systematic and objective assessment of his mental health has been undertaken. We tested a novel methodology, combining psychiatric and literary approaches, to assess the feasibility of using Burns's extensive personal correspondence as a source of evidence for assessing the presence of symptoms of a clinically significant mood disorder. We confirmed the potential of this approach and identified putative evidence of episodes of depression and hypomania within the correspondence. While not conclusive of a formal diagnosis of bipolar disorder, this work highlights a need for further systematic examination of Burns's mental health and how this may have influenced his work.

Endothelial dysfunction following coronary artery bypass grafting : Influence of patient and procedural factors

BACKGROUND

Angiopoietin-2 (Angpt2) mediates endothelial dysfunction (ED) following coronary artery bypass grafting (CABG). Its triggers are, however, poorly understood.

METHODS

We examined the time course of ED beyond the early phase of postoperative recovery in 75 patients following CABG with a special focus on different cardiopulmonary bypass (CPB) modes as potential triggers of Angpt2 release.

RESULTS

Nine patients (12.0%) underwent off-pump coronary artery bypass (OPCAB), 31 patients (41.3%) received minimized extracorporeal circulation (MECC), and 35 patients (46.6%) were operated on with (conventional) CPB. Angpt2 levels steadily increased across the observation period (1.7 [1.4-2.1] to 3.4 [2.5-6.1] ng/ml, p < 0.001). Angpt2 levels did not differ between the MECC and CPB groups (p = 0.564). There was no difference between MECC and CPB patients regarding net fluid balance (p = 0.821) and other surrogate markers of postoperative ED. The magnitude of Angpt-2 increase correlated more strongly with baseline C‑reactive protein (r = 0.459, p < 0.001) than with any other parameter. Hospital length of stay correlated more strongly with baseline Angpt2 levels (r = 0.512, p = 0.005) than with follow-up Angpt2 levels and appeared not to be influenced by CPB mode (p = 0.428).

CONCLUSION

CABG is associated with prolonged ED, which is determined by the patient's preoperative inflammatory state rather than by CPB modifications.

Mitochondrial respiratory capacity remains stable despite a comprehensive and sustained increase in insulin sensitivity in obese patients undergoing gastric bypass surgery

AIM

It has been proposed, but not yet demonstrated by convincing evidence in published articles, that insulin resistance and mitochondrial respiratory function are causally related physiological phenomena. Here, we tested the prediction that weight loss-induced increase in insulin sensitivity will correlate with a corresponding change in mitochondrial respiratory capacity over the same time period.

METHODS

Insulin sensitivity was evaluated using the hyperinsulinaemic-euglycaemic clamp technique, and skeletal muscle mitochondrial respiratory capacity was evaluated by high-resolution respirometry in 26 patients with obesity. Each experiment was performed ~2 months and 1-2 weeks before, and ~4 and ~19 months after Roux-en-Y gastric bypass (RYGB) surgery.

RESULTS

A substantial weight loss was observed in all patients, and insulin sensitivity increased in all patients over the 21-months time period of the study. In contrast, skeletal muscle mitochondrial respiratory capacity, intrinsic mitochondrial respiratory capacity and mitochondrial content remained unchanged over the same time period.

CONCLUSION

Among obese patients with and without type 2 diabetes undergoing RYGB surgery, intrinsic mitochondrial respiratory capacity in skeletal muscle is not correlated with insulin sensitivity before or after the surgical intervention. Mitochondrial respiratory function may not be germane to the pathophysiology and/or aetiology of obesity and/or type 2 diabetes.