Mediation analysis of chronic kidney disease risk factors using kidney biomarkers in women living with HIV

OBJECTIVE

Novel urinary biomarkers reflecting kidney tubule health are associated with chronic kidney disease (CKD) risk in persons living with HIV. However, it is unknown whether these biomarkers provide mechanistic insight into the associations between clinical risk factors for CKD and subsequent CKD risk.

METHODS

Among 636 women living with HIV in the Women's Interagency HIV Study with estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m 2 , we used a counterfactual approach to causal mediation analysis to evaluate the extent to which systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin a1c (Hba1c) and serum albumin associations with incident CKD were mediated by eight urine proteins. These biomarkers reflect proximal tubular reabsorptive dysfunction (α1-microglobulin [a1m], β2-microglobulin, trefoil factor 3); tubular injury (interleukin 18 [IL-18], kidney injury molecule 1 [KIM-1]); kidney repair (epidermal growth factor); tubular reserve (uromodulin); and glomerular injury (urinary albumin). Incident CKD was defined as eGFR <60 ml/min/1.73 m 2 measured at two consecutive 6-month visits with an average annual eGFR decline ≥3% per year.

RESULTS

During a median follow-up of 7 years, 11% developed CKD. Urinary albumin and KIM-1 mediated 32% (95% CI: 13.4%, 76.6%) and 23% (6.9%, 60.7%) of the association between SBP and incident CKD, respectively; and 19% (5.1%, 42.3%) and 22% (8.1%, 45.7%) of the association between DBP and incident CKD, respectively. Urinary albumin, α1m, and IL-18 were significant mediators of the association between Hba1c and incident CKD. None of the eight biomarkers mediated the association between serum albumin and incident CKD.

CONCLUSIONS

Among women living with HIV, several urinary biomarkers reflecting distinct dimensions of kidney health may partially explain the associations between SBP, DBP, and Hba1c and subsequent CKD risk.

Association of Higher Intake of Plant-Based Foods and Protein With Slower Kidney Function Decline in Women With HIV

BACKGROUND

We investigated whether there exists an association between dietary acid load and kidney function decline in women living with HIV (WLWH) receiving antiretroviral therapy (ART).

SETTING

One thousand six hundred eight WLWH receiving ART in the WIHS cohort with available diet data and a baseline estimated glomerular filtration rate (eGFR) ≥15 mL/minute/1.73 m2.

METHODS

A brief dietary instrument conducted from 2013 to 2016 under the Food Insecurity Sub-Study was used for assessing fruits and vegetables (FV) and protein intake. A mixed-effects model with random intercept and slope was used to estimate subjects' annual decline rate in eGFR and the association between FV intake and eGFR decline, adjusting for sociodemographics, serum albumin, comorbidities, time on ART, ART drugs, HIV markers, and baseline eGFR. We evaluated whether markers of inflammation mediated the effect of FV intake on decline in eGFR, using causal mediation analysis.

RESULTS

We found a dose-response relationship for the association of FV intake and eGFR decline, with lesser annual decline in eGFR in the middle and highest tertiles of FV intake. An increase of 5 servings of FV intake per day was associated with a lower annual eGFR decline (-1.18 [-1.43, -0.94]). On average, 39% of the association between higher FV intake and slower eGFR decline was explained by decreased levels of inflammation.

CONCLUSIONS

Plant-rich diet was associated with slower decline in kidney function. Inflammation is a potential path through which diet may affect kidney function. The findings support an emerging body of literature on the potential benefits of plant-rich diets for prevention of chronic kidney disease.

Incidence of New-Onset Hypertension Post-COVID-19: Comparison With Influenza

BACKGROUND

SARS-CoV-2 may trigger new-onset persistent hypertension. This study investigated the incidence and risk factors associated with new-onset persistent hypertension during COVID-19 hospitalization and at ≈6-month follow-up compared with influenza.

METHODS

This retrospective observational study was conducted in a major academic health system in New York City. Participants included 45 398 patients with COVID-19 (March 2020 to August 2022) and 13 864 influenza patients (January 2018 to August 2022) without a history of hypertension.

RESULTS

At 6-month follow-up, new-onset persistent hypertension was seen in 20.6% of hospitalized patients with COVID-19 and 10.85% of nonhospitalized patients with COVID-19. Persistent hypertension incidence among hospitalized patients did not vary across the pandemic, whereas that of hospitalized patients decreased from 20% in March 2020 to ≈10% in October 2020 (R2=0.79, P=0.003) and then plateaued thereafter. Hospitalized patients with COVID-19 were 2.23 ([95% CI, 1.48-3.54]; P<0.001) times and nonhospitalized patients with COVID-19 were 1.52 ([95% CI, 1.22-1.90]; P<0.01) times more likely to develop persistent hypertension than influenza counterparts. Persistent hypertension was more common among older adults, males, Black, patients with preexisting comorbidities (chronic obstructive pulmonary disease, coronary artery disease, chronic kidney disease), and those who were treated with pressor and corticosteroid medications. Mathematical models predicted persistent hypertension with 79% to 86% accuracy. In addition, 21.0% of hospitalized patients with COVID-19 with no prior hypertension developed hypertension during COVID-19 hospitalization.

CONCLUSIONS

Incidence of new-onset persistent hypertension in patients with COVID-19 is higher than those with influenza, likely constituting a major health burden given the sheer number of patients with COVID-19. Screening at-risk patients for hypertension following COVID-19 illness may be warranted.

A descriptive analysis of first trimester urinary concentrations of 14 bisphenol analogues in the MIREC Canadian pregnancy cohort

BACKGROUND

Concern over the health effects of BPA, particularly for the developing fetus, has led to an increasing use of bisphenol analogues in industrial and consumer products, which may be as hormonally active as BPA. Biomonitoring data for many bisphenol analogues, especially in pregnant populations, are limited.

METHODS

We measured concentrations of 14 bisphenol analogues in 1st trimester urine samples (n = 1851) from the Maternal-Infant Research on Environmental Chemicals (MIREC) Canadian pregnancy cohort (2008-2011). We examined patterns of exposure according to sociodemographic and sampling characteristics as well as occupation and frequency of consumption of canned fish within the previous 3 months.

RESULTS

BPA was detected in 89% of participants with a specific gravity standardized geometric mean concentration of 0.990 μg/L. Biphenol 4,4' (BP 4,4'), 4,4'-dihydroxydiphenyl ether (DHDPE), and bisphenol E (BPE) were detected in >97% of participants. Bisphenol F (BPF) and bisphenol S (BPS) were detected in >60% of participants. Specific gravity standardized geometric mean concentrations of these 5 compounds ranged from 0.024 to 0.564 μg/L. Nine bisphenol analogues were detected in <9% of participants. Concentrations of BP 4,4', DHDPE, and BPE were higher in younger women and those with higher pre-pregnancy BMI, lower household income, lower education, and among smokers. We found a similar pattern of differences in BPF for age, education, and smoking status while BPS similarly differed across categories of pre-pregnancy BMI. Participants who were unemployed or working in the service industry had higher molar sum of 7 bisphenol analogues than those working in healthcare, education, or an office setting. Canned fish consumption was not related to bisphenol analogue concentrations.

CONCLUSION

BP 4,4', DHDPE, BPE, BPF, and BPS were highly detected in 1st trimester urine samples in this large pan-Canadian pregnancy cohort. This suggests widespread exposure to these analogues around 2008-2011 and warrants further investigation into associations with health outcomes.

Associations of Dysnatremia with COVID-19 Status and Mortality

Background

In patients without COVID-19, dysnatremia is associated with mortality. These relationships are not well established in patients with COVID-19. We tested the hypotheses that patients with COVID-19 were more likely to have dysnatremia than those without COVID-19 and that, among those with COVID-19, dysnatremia is associated with mortality.

Methods

We conducted a retrospective observational study of patients admitted to a tertiary care center in the Bronx, New York, during the COVID-19 surge from March 11 to April 26, 2020. Using multinomial logistic regression models, we compared the prevalence of hypernatremia (serum sodium ≥150 mEq/L) and hyponatremia (serum sodium <130 mEq/L) on admission between patients with and without COVID-19. Among patients with COVID-19, we used Cox proportional hazards models to examine the association of dysnatremia with mortality.

Results

Compared with those without COVID-19 (n=1265), patients with COVID-19 (n=3345) had a higher prevalence of hypernatremia (7% versus 4%, P<0.001) and hyponatremia (7% versus 6%, P=0.04). In adjusted models, COVID-19-positive patients had a higher likelihood of having hypernatremia (adjusted odds ratio=1.87, 95% CI, 1.3 to 2.57, P=0.001) compared with COVID-19-negative patients, whereas the association between hyponatremia and COVID-19 status was no longer significant (P=0.06). Among patients with COVID-19, 775 (23%) died after a median follow-up of 17 days (IQR 7-27 days). Among nonsurvivors, 15% had hypernatremia and 8% had hyponatremia on admission. Hypernatremia was associated with a higher risk of mortality (adjusted hazard ratio=1.28, 95% CI, 1.01 to 1.63, P=0.04) compared with patients with eunatremia.

Conclusions

In patients hospitalized during the spring 2020 COVID-19 surge, COVID-19 status was associated with hypernatremia on admission. Among patients with COVID-19, hypernatremia was associated with higher mortality. Hypernatremia may be a potential prognostic marker for mortality in COVID-19 patients.

AB0093 MODELING OF ANTIGEN-COLLAGEN-INDUCED ARTHRITIS IN BALB/c MICE

Background

Rheumatoid arthritis (RA) is one of the most common autoimmune diseases. Currently, disease-modifying drugs and biological agents are used to treat RA [1]. The available drugs are not perfect: they have serious side effects and do not always cause a stable improvement or remission [2]. The above sets the task of finding new approaches to treatment that will be effective, more specific and safe. In this connection, it is necessary to develop and apply experimental models as close as possible in pathogenesis to rheumatoid arthritis. One such model, rarely used at present, is the combined antigen-collagen-induced arthritis [3].

Objectives

To show immunological and histological changes similar to RA in the AIA/CIA model and the validity of its application in research activities.

Methods

Experimental AIA/CIA was induced according to 2 different protocols in 50 BALB/c mice. Clinical assessment of arthritis was made by measuring the swelling of the paws with a caliper at different times. The assessment of immunological changes included the analysis of the content of antibodies to type II collagen by ELISA, the content of T-regulatory cells by flow cytometry. Also, a histological analysis of the obtained data was carried out.

Results

On the 10th day, a significant increase in paw thickness was recorded in animals induced both according to the first and second protocols. The intensity of swelling subsided by the 23rd day. A significant increase in the content of antibodies to type II collagen was observed in all experimental groups, but in animals from Protocol No. 1, the amount of antibodies to type II collagen was significantly higher. A high level of T-regulatory cells was registered only in mice induced according to the first protocol on the 10th day. Histological changes in the form of synovial hyperplasia, pannus, usurations were observed to varying degrees in all experimental groups, but the most pronounced changes were in animals from the first protocol.

Conclusion

In experimental animals, in all the presented protocols, changes were observed that were closest to RA, when compared with classical models of experimental arthritis induction. Based on the fact that protocol 1 animals showed an increase in the content of T-regulatory cells, the levels of antibodies to type 2 collagen were consistently high, and the histological changes were the most pronounced, it can be assumed that protocol 1 of the combined AIA/CIA model on the line of Balb/c mice, is the most suitable for testing and developing new methods of RA therapy.

References

[1]Abbasi M, Mousavi MJ, Jamalzehi S, Alimohammadi R, Bezvan MH, Mohammadi H, Aslani S. Strategies toward rheumatoid arthritis therapy; the old and the new. J Cell Physiol. 2019 Jul;234(7):10018-10031. doi: 10.1002/jcp.27860. Epub 2018 Dec 7. PMID: 30536757.

[2]Greenberg JD, Reed G, Kremer JM, Tindall E, Kavanaugh A, Zheng C, Bishai W, Hochberg MC; CORRONA Investigators. Association of methotrexate and tumour necrosis factor antagonists with risk of infectious outcomes including opportunistic infections in the CORRONA registry. Ann Rheum Dis. 2010 Feb;69(2):380-6. doi: 10.1136/ard.2008.089276. Epub 2009 Apr 8. PMID: 19359261; PMCID: PMC2861900.

[3]Baddack U, Hartmann S, Bang H, Grobe J, Loddenkemper C, Lipp M, Müller G. A chronic model of arthritis supported by a strain-specific periarticular lymph node in BALB/c mice. Nat Commun. 2013;4:1644. doi: 10.1038/ncomms2625. PMID: 23552059; PMCID: PMC3644064

Disclosure of Interests

None declared

Examining the trajectory and predictors of post-concussion sleep quality in children and adolescents

OBJECTIVES

This study aimed to 1) determine if post-concussion sleep quality of children and adolescents differed from healthy sleep estimates; 2) describe the trajectory of parameters of sleep quality; 3) determine factors that predict sleep quality outcomes; and 4) compare sleep parameter outcomes between asymptomatic and symptomatic participants at 4 weeks post-concussion.

METHODS

Nightly actigraphy estimates of sleep in 79 children and adolescents were measured throughout 4 weeks post-concussion. Total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), number of arousals (NOA), and average arousal length (AAL) were measured.

RESULTS

Child and adolescent participants experienced significantly poorer SE and longer WASO duration throughout 4 weeks of recovery and adolescents experienced significantly longer TST. SE significantly improved with time post-injury (p = .047). Older age was associated with longer TST (p = .003) and female sex was associated with longer WASO (p = .025) and AAL duration (p = .044). Week 4 sleep parameter outcomes were not significantly different between asymptomatic and symptomatic participants.

CONCLUSIONS

The sleep quality of youth is adversely affected by concussion, particularly in females. Sleep quality appears to improve with time but may require more than 4 weeks to return to normal.

A comprehensive, contemporary assessment of the association between hepatosteatosis and coronary artery calcium scoring

Funding Acknowledgements

Type of funding sources: None.

onbehalf

Liverpool Multiparametric Imaging Collaboration

Background

Coronary artery calcium (CAC) score is a well-established technique for stratifying an individual’s cardiovascular disease (CVD) risk. Several well-established registries have incorporated CAC scoring into CVD risk prediction models to enhance accuracy. Hepatosteatosis (HS) has been shown to be an independent predictor of CVD events and can be measured on non-contrast computed tomography (CT). We sought to undertake a contemporary, comprehensive assessment of the influence of HS on CAC score alongside traditional CVD risk factors. In patients with HS it may be beneficial to offer routine CAC screening to evaluate CVD risk to enhance opportunities for earlier primary prevention strategies.

Methods

We performed a retrospective, observational analysis at a high-volume cardiac CT centre analysing consecutive CT coronary angiography (CTCA) studies. All patients referred for investigation of chest pain over a 28-month period (June 2014 to November 2016) were included. Patients with established CVD were excluded. The cardiac findings were reported by a cardiologist and retrospectively analysed by two independent radiologists for the presence of HS. Those with CAC of zero and those with CAC greater than zero were compared for demographic and cardiac risks. A multivariate analysis comparing the risk factors was performed to adjust for the presence of established risk factors. A binomial logistic regression model was developed to assess the association between the presence of HS and increasing strata of CAC.

Results

In total there were 1499 patients referred for CTCA without prior evidence of CVD. The assessment of HS was completed in 1195 (79.7%) and CAC score was performed in 1103 (92.3%). There were 466 with CVD and 637 without CVD. The prevalence of HS was significantly higher in those with CVD versus those without CVD on CTCA (51.3% versus 39.9%, p = 0.007). Male sex (50.7% versus 36.1% p= &lt;0.001), age (59.4 ± 13.7 versus 48.1 ± 13.6, p= &lt;0.001) and diabetes (12.4% versus 6.9%, p = 0.04) were also significantly higher in the CAC group compared to the CAC score of zero.

HS was associated with increasing strata of CAC score compared with CAC of zero (CAC score 1-100 OR1.47, p = 0.01, CAC score 101-400 OR:1.68, p = 0.02, CAC score &gt;400 OR 1.42, p = 0.14). This association became non-significant in the highest strata of CAC score.

Conclusion

We found a significant association between the increasing age, male sex, diabetes and HS with the presence of CAC. HS was also associated with a more severe phenotype of CVD based on the multinomial logistic regression model. Although the association reduced for the highest strata of CAC (CAC score &gt;400) this likely reflects the overall low numbers of patients within this group and is likely a type II error.

Based on these findings it may be appropriate to offer routine CVD risk stratification techniques in all those diagnosed with HS.

Clinical Outcomes and Inflammatory Markers by HIV Serostatus and Viral Suppression in a Large Cohort of Patients Hospitalized With COVID-19

BACKGROUND

Limited data exist about clinical outcomes and levels of inflammatory and immune markers among people hospitalized with COVID-19 by HIV serostatus and by HIV viral suppression.

SETTING

Large tertiary care health system in the Bronx, NY, USA.

METHODS

We conducted a retrospective cohort study of 4613 SARS-CoV-2 PCR-positive patients admitted between March 10, 2020, and May 11, 2020. We examined in-hospital intubation, acute kidney injury (AKI), hospitalization length, and in-hospital mortality by HIV serostatus, and by HIV-viral suppression and CD4 counts among people living with HIV (PLWH) using adjusted competing risks regression. We also compared immune and inflammatory marker levels by HIV serostatus and viral suppression.

RESULTS

Most patients were either non-Hispanic Black (36%) or Hispanic (37%); 100/4613 (2.2%) were PLWH, among whom 15 had detectable HIV viral load. PLWH compared to patients without HIV had increased intubation rates (adjusted hazard ratio 1.73 [95% CI: 1.12 to 2.67], P = 0.01). Both groups had similar rates of AKI, length of hospitalization, and death. No (0%) virally unsuppressed PLWH were intubated or died, versus 21/81 (26%, P = 0.04) and 22/81 (27%, P = 0.02) of virally suppressed PLWH, respectively. Among PLWH, higher CD4 T-cell counts were associated with increased intubation rates. C-reactive protein, IL-6, neutrophil counts, and ferritin levels were similar between virally suppressed PLWH and patients without HIV, but significantly lower for unsuppressed PLWH (all P < 0.05).

CONCLUSIONS

PLWH had increased risk of intubation but similarly frequent rates of AKI and in-hospital death as those without HIV. Findings of no intubations or deaths among PLWH with unsuppressed HIV viral load warrant further investigation.

Modified HEART score, utilising a single high-sensitive troponin sample, allows early, safe discharge of suspected acute coronary syndrome: a prospective multicentre cohort study of 3016 patients

Background

Combining HSTnT (high sensitive troponin T) values at low levels with composite risk scores may improve early safe, discharge in suspected acute coronary syndromes (ACS). We tested this hypothesis by a prospective study of 3016 consecutive patients with suspected ACS in 2 large hospitals.

Methods

Consecutive chest pain (CP) presentations with HSTnT sampled and ECG undertaken at presentation were prospectively defined in 2 time periods (2011-12, n=1642 [derivation] 2018, n=1376 [validation]).

The HstnT input was modified: dichotomous HSTnT input was lowered to &lt;5 (limit of detection, LOD) or ≥5ng/l (mod TIMI and GRACE), HEART score was re-calibrated (&lt;5 = 0 [LOD], ≥5–14 = 1, &gt;14 = 2 [99th percentile]). All biomarker positive CP index and re-admissions to any regional hospital (catchment population 2.6 million) were independently adjudicated for MI by 2 experienced physicians. Primary outcome was MACE (adjudicated type 1 MI, unplanned coronary revascularisation and all cause death) at 6 weeks.

Results

In the 2 cohorts demographic factors were similar: median age 59 and 56, male 52% and 52%, previous MI 20% and 14% for 2011-12 and 2018 respectively. At 6 weeks 180 (11%) and 75 (5.4%) suffered type 1 MI and 211 (12.9%) and 92 (6.7%) patients suffered MACE in the 2011-12 and 2018 cohorts respectively.

Only Mod HEART ≤3 and undetectable HSTnT, with a nonischaemic ECG, achieved prespecified NPV of &gt;99.5% in both derivation and validation cohorts (table). However Modified HEART ≤3 score could discharge approximately 12% more patients as compared to undetectable HSTnT strategy.

Conclusion

Modified HEART score ≤3, with the use of a single HSTnT, appears the optimum early discharge strategy for suspected ACS

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Liverpool university Hospitals, North-West Educational Cardiac Group

Gaining political will for actions to achieve health equity: lessons from Australia for advocates

Background

There has been an accumulation of evidence on the importance of action on the social determinants of health to reduce global and national health equity. Yet there has been little effective systematic action by governments. This is commonly attributed to the absence of political will. Despite its importance, however, little research has examined how political will might be created or prevented.

Methods

This paper reports on the results of eight case studies of the extent to which Australian public policy is likely to contribute to reducing health inequities. 192 participants were interviewed including public servants, politicians and their staff, non-government organisation workers and community members. The transcripts were interrogated with the assistance of NVivo software to determine lessons about the creation or destruction of political will. The case studies were of: national primary health care policy, crucial determinants of health (work conditions, internet access, urban planning, social welfare, trade) and an automotive plant closure.

Results

We found the following factors to be important in determining the extent of political will for health equity, whether: path dependency was present; the issue would impact on staying in or winning government; political philosophies stressed collectivism or individualism; there were negative or positive social constructions of groups affected by the policies; economic and/or biomedical framings were dominant; elites (especially business interests) lobbied against the policies; and there was effective civil society and policy advocacy in favour of the policies.

Conclusions

Building on our insights from our case studies of action for political will, we conclude with a series of questions to guide the work of public health activists and policy advocates working to support existing and to create new political will in multiple contexts.

Key messages

The creation of political will is vital to the adoption of policies supportive of health equity. Analysis of 8 policy case studies points to how advocacy can most effectively create political will.

How can corporate HIA help shape regulatory environments for Trans-National Corporations?

Background

Transnational Corporations (TNCs) exercise considerable sway over population health. They now comprise 157 of the 200 largest economies in the world and shape our food choices and degree of exploitation of our natural environment. This paper will analyse data from two corporate health impact assessments exercise (food and extractive industries) to determine what government and international agency regulatory actions are required to minimize the health harm causes by the actions of TNCs.

Methods

We used a Corporate Health Impact Assessment (CHIA) framework, data sourced through document and media analyses, and semi-structured interviews to examine the practices of McDonalds in Australia and Rio Tinto in Australia and South Africa. Data were mapped against the CHIA framework's three sections which are: i) the impact of regulatory environments ii) How TNC practices and products impact on health and equity ii) the direct impact of TNCs practices on daily living conditions.

Results

The CHIA exercise indicated an absence of effective international regulation on the actions of TNCs and that national regulatory regimes can encourage more responsible behavior from TNCs, for example in occupational health and safety. We identified the need for a much higher level of global and national regulation to: i) prevent the many conflicts of interest we found ii) reduce the extent to which TNC products are unhealthy iii) enforce healthy employment practices iv) prevent externalization of the costs of TNCs v) prevent taxation minimization.

Conclusions

The study highlighted the ways in which TNCs can use their power and size to maintain a de-regulated environment. Concerted global and national action is required to regulate in favour of human health and safety and that of the environment. Our findings support the need for an enforceable international treaty.

Key messages

Transnational corporations have a massive impact on population health. A health impact assessment can identify the pathways of impact and be used to inform regulatory action to promote health.

AKI in Hospitalized Patients with and without COVID-19: A Comparison Study

BACKGROUND

Reports from centers treating patients with coronavirus disease 2019 (COVID-19) have noted that such patients frequently develop AKI. However, there have been no direct comparisons of AKI in hospitalized patients with and without COVID-19 that would reveal whether there are aspects of AKI risk, course, and outcomes unique to this infection.

METHODS

In a retrospective observational study, we evaluated AKI incidence, risk factors, and outcomes for 3345 adults with COVID-19 and 1265 without COVID-19 who were hospitalized in a large New York City health system and compared them with a historical cohort of 9859 individuals hospitalized a year earlier in the same health system. We also developed a model to identify predictors of stage 2 or 3 AKI in our COVID-19.

RESULTS

We found higher AKI incidence among patients with COVID-19 compared with the historical cohort (56.9% versus 25.1%, respectively). Patients with AKI and COVID-19 were more likely than those without COVID-19 to require RRT and were less likely to recover kidney function. Development of AKI was significantly associated with male sex, Black race, and older age (>50 years). Male sex and age >50 years associated with the composite outcome of RRT or mortality, regardless of COVID-19 status. Factors that were predictive of stage 2 or 3 AKI included initial respiratory rate, white blood cell count, neutrophil/lymphocyte ratio, and lactate dehydrogenase level.

CONCLUSIONS

Patients hospitalized with COVID-19 had a higher incidence of severe AKI compared with controls. Vital signs at admission and laboratory data may be useful for risk stratification to predict severe AKI. Although male sex, Black race, and older age associated with development of AKI, these associations were not unique to COVID-19.

Chronic Hemodialysis Patients Hospitalized with COVID-19: Short-term Outcomes in the Bronx, New York

Background

Patients with ESKD who are on chronic hemodialysis have a high burden of comorbidities that may place them at increased risk for adverse outcomes when hospitalized with COVID-19. However, data in this unique patient population are limited. The aim of our study is to describe the clinical characteristics and short-term outcomes in patients on chronic hemodialysis who require hospitalization for COVID-19.

Methods

We performed a retrospective study of 114 patients on chronic hemodialysis who were hospitalized with COVID-19 at two major hospitals in the Bronx from March 9 to April 8, 2020 during the surge of SARS-CoV-2 infections in New York City. Patients were followed during their hospitalization through April 22, 2020. Comparisons in clinical characteristics and laboratory data were made between those who survived and those who experienced in-hospital death; short-term outcomes were reported.

Results

Median age was 64.5 years, 61% were men, and 89% were black or Hispanic. A total of 102 (90%) patients had hypertension, 76 (67%) had diabetes mellitus, 63 (55%) had cardiovascular disease, and 30% were nursing-home residents. Intensive care unit (ICU) admission was required in 13% of patients, and 17% required mechanical ventilation. In-hospital death occurred in 28% of the cohort, 87% of those requiring ICU, and nearly 100% of those requiring mechanical ventilation. A large number of in-hospital cardiac arrests were observed. Initial procalcitonin, ferritin, lactate dehydrogenase, C-reactive protein, and lymphocyte percentage were associated with in-hospital death.

Conclusions

Short-term mortality in patients on chronic hemodialysis who were hospitalized with COVID-19 was high. Outcomes in those requiring ICU and mechanical ventilation were poor, underscoring the importance of end-of-life discussions in patients with ESKD who are hospitalized with severe COVID-19 and the need for heightened awareness of acute cardiac events in the setting of COVID-19. Elevated inflammatory markers were associated with in-hospital death in patients with ESKD who were hospitalized with COVID-19.

The association of race and COVID-19 mortality

BACKGROUND

COVID-19 mortality disproportionately affects the Black population in the United States (US). To explore this association a cohort study was undertaken.

METHODS

We assembled a cohort of 505,992 patients receiving ambulatory care at Bronx Montefiore Health System (BMHS) between 1/1/18 and 1/1/20 to evaluate the relative risk of hospitalization and death in two time-periods, the pre-COVID time-period (1/1/20-2/15/20) and COVID time-period (3/1/20-4/15/20). COVID testing, hospitalization and mortality were determined with the Black and Hispanic patient population compared separately to the White population using logistic modeling. Evaluation of the interaction of pre-COVID and COVID time periods and race, with respect to mortality was completed.

FINDINGS

A total of 9,286/505,992 (1.8%) patients were hospitalized during either or both pre-COVID or COVID periods. Compared to Whites the relative risk of hospitalization of Black patients did not increase in the COVID period (p for interaction=0.12). In the pre- COVID period, compared to Whites, the odds of death for Blacks and Hispanics adjusted for comorbidity was statistically equivalent. In the COVID period compared to Whites the adjusted odds of death for Blacks was 1.6 (95% CI 1.2-2.0, p = 0.001). There was a significant increase in Black mortality risk from pre-COVID to COVID periods (p for interaction=0.02). Adjustment for relevant clinical and social indices attenuated but did not fully explain the observed difference in Black mortality.

INTERPRETATION

The BMHS COVID experience demonstrates that Blacks do have a higher mortality with COVID incompletely explained by age, multiple reported comorbidities and available metrics of sociodemographic disparity.

FUNDING

N/A.

1004 Smith-&lt;Magenis Syndrome (SMS) Circadian Abnormalities And Biological Rhythms

Introduction

SMS is a rare neurodevelopmental disorder that manifests with craniofacial abnormalities, behavioral disturbances, and a severe sleep disorder. It has been reported that many SMS patients have an inverted melatonin secretion pattern (peaking during the daytime) although a small minority have near normal patterns. The goal of this study was to better characterize the intra- and inter-patient variability of melatonin secretion patterns and investigate a potential relationship with sleep behavior in SMS patients.

Methods

In this observational study, sleep behaviors of patients (N=8, 1 female, ages: 7 - 35) with SMS were characterized through caretaker surveys. On 3 separate occasions, patients had hourly serum melatonin levels sampled for 36 hours. From these data, peak serum melatonin concentration and time of peak concentration were determined. Inter- and intra-patient variability was characterized by zero lag correlation of the melatonin concentration timeseries across and within patients, respectively. The relationship between peak melatonin concentration, peak time, and sleep latency was analyzed by a generalized linear model, GLM.

Results

Peak melatonin concentrations varied across SMS patients with a range of 3.55pg/ml - 49.65pg/ml (mean 14.18 ± 15.19pg/ml). Time of peak melatonin concentrations ranged from 0400h-2100h (mean 1422 ± 6h). Correlation coefficients characterizing intra-patient variability ranged from -0.0098 to 0.89 (mean 0.55 ± 0.2533). Correlation coefficients characterizing inter-patient variability ranged from -0.75 to 0.79 (mean of 0.18 ± 0.52). Sleep latency ranged from 8.4min - 36.35min (mean of 21.99 ± 9.77 min). GLM analysis demonstrated a significant, positive effect of peak time with sleep latency (p=0.022).

Conclusion

Consistent with previous findings, our study confirms that SMS patients have abnormal circadian rhythms. Our work extends this body of literature by demonstrating a significant degree of inter-patient variability with relatively stable intra-patient variability. Preliminary evidence suggests that the timing of melatonin peak may be related to sleep onset latency.

Support

This work was supported by Vanda Pharmaceuticals Inc.

1161 Tasimelteon Shows Persistence Of Efficacy In Improving Sleep Disturbances In Patients With Smith-Magenis Syndrome (SMS) In Open-Label Extension Study

Introduction

Smith-Magenis Syndrome (SMS) is a rare (1/15,000 - 25,000 births) neurodevelopmental disorder resulting from an interstitial deletion of chromosome 17p11.2, or from a point mutation in the RAI1 gene. Severe sleep disorder is almost universal in patients with SMS and poses a significant challenge to patients and their families. Tasimelteon improved sleep symptoms in a randomized, double-blind, two-period, crossover study; and here we show that this effect persists for up to four years in an open-label extension. To our knowledge, this is the largest interventional study of SMS patients to date.

Methods

Following the 4-week crossover study, all eligible participants had the option to enroll in an open-label extension. 31/39 (79.4%) of all individuals who participated in the efficacy study have continued on tasimelteon treatment. Participants in the open-label extension provided daily diary sleep quality (DDSQ), and daily diary total sleep time (DDTST) measures via parental post sleep questionnaire and characterized behavior using the Aberrant Behavior Checklist (ABC).

Results

In the open-label extension, tasimelteon continued to show improvement in the primary endpoints of 50% worst sleep quality (mean = 0.7, SD = 0.94) and 50% worst total nighttime sleep duration (mean = 53.3, SD = 59.01) when compared to baseline. Tasimelteon also improved overall sleep quality (mean=0.7, SD=0.83) and overall total nighttime sleep duration (mean = 51.9, SD=53.03). ABC scores also improved with tasimelteon (mean= -16.3, SD = 15.82).

Conclusion

Tasimelteon continues to demonstrate persistence in efficacy (longest approximately 4 years) with similar magnitudes observed in the 4-week crossover study for sleep quality and total sleep time. Interestingly, daytime behavior also demonstrates long-term improvement in patients with SMS treated with tasimelteon. These results further confirm tasimelteon as a novel therapy for the treatment of sleep disorders in patients with SMS and may provide benefit for behavioral symptoms.

Support

This work was supported by Vanda Pharmaceuticals Inc.

Involving Service Users in Professional Nurse Education in Wales

A small scale survey was conducted among nurse educationalists within Wales as part of the ongoing monitoring of Welsh Office targets for learning disability nursing. This survey showed that there has been very little service user involvement in professional nurse education in Wales. The authors discuss the possible reasons for such low level involvement. Examples of involvement of people with learning disabilities are compared to the much more favourable situation within the mental health field. Possible reasons for the barriers to progress in this area are discussed. The history of service user involvement and the development of advocacy both within the UK and other countries is also highlighted. The impact of various government initiatives on this situation is considered.

A review of the NG17 recommendations for the use of basal insulin in type 1 diabetes

AIMS

To revisit the data analysis used to inform National Institute of Health and Care Excellence (NICE) NG17 guidance for initiating basal insulin in adults with type 1 diabetes mellitus (diabetes).

METHODS

We replicated the data, methodology and analysis used by NICE diabetes in the NG17 network meta-analysis (NMA). We expanded this data cohort to a more contemporary data set (extended 2017 NMA) and restricted the studies included to improve the robustness of the data set (restricted 2017 NMA) and in a post hoc analysis, changed the index comparator from neutral protamine Hagedorn (NPH) insulin twice daily to insulin detemir twice daily.

RESULTS

The absolute changes in HbA_1c were similar to those reported in the NG17. However, all 95% credible intervals for change in HbA_1c point estimates crossed the line of null effect, except for detemir twice daily (in the NICE and extended 2017 NMAs) and NPH four times daily. In the detemir twice-daily centred post hoc analysis, the 95% credible intervals for change in HbA_1c crossed the line of null effect for all basal therapies, except NPH.

CONCLUSIONS

In NG17, comparisons of basal insulins were based solely on efficacy of glycaemic control. Many of the trials used in this analysis were treat-to-target, which minimize differences in HbA_1c . In the NMAs, statistical significance was severely undermined by the wide credible intervals. Despite these limitations, point estimates of HbA_1c were used to rank the insulins and formed the basis of NG17 guidance. This study queries whether such analyses should be used to make specific clinical recommendations.

Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis

Bloodstream infections are an important cause of hospitalizations, morbidity, and mortality in patients receiving hemodialysis. Eliminating bloodstream infections in the hemodialysis setting has been the focus of the Centers for Disease Control and Prevention (CDC) Making Dialysis Safer for Patients Coalition and, more recently, the CDC's partnership with the American Society of Nephrology's Nephrologists Transforming Dialysis Safety Initiative. The majority of vascular access-associated bloodstream infections occur in patients dialyzing with central vein catheters. The CDC's core interventions for bloodstream infection prevention are the gold standard for catheter care in the hemodialysis setting and have been proven to be effective in reducing catheter-associated bloodstream infection. However, in the United States hemodialysis catheter-associated bloodstream infections continue to occur at unacceptable rates, possibly because of lapses in adherence to strict aseptic technique, or additional factors not addressed by the CDC's core interventions. There is a clear need for novel prophylactic therapies. This review highlights the recent advances and includes a discussion about the potential limitations and adverse effects associated with each option.

Identifying critical source areas using multiple methods for effective diffuse pollution mitigation

Diffuse pollution from agriculture constitutes a key pressure on the water quality of freshwaters and is frequently the cause of ecological degradation. The problem of diffuse pollution can be conceptualised with a source-mobilisation-pathway (or delivery)-impact model, whereby the combination of high source risk and strong connected pathways leads to 'critical source areas' (CSAs). These areas are where most diffuse pollution will originate, and hence are the optimal places to implement mitigation measures. However, identifying the locations of these areas is a key problem across different spatial scales within catchments. A number of approaches are frequently used for this assessment, although comparisons of these assessments are rarely carried out. We evaluate the CSAs identified via traditional walkover surveys supported by three different approaches, highlighting their benefits and disadvantages. These include a custom designed smartphone app; a desktop geographic information system (GIS) and terrain analysis-based SCIMAP (Sensitive Catchment Integrated Modelling and Analysis Platform) approach; and the use of a high spatial resolution drone dataset as an improved input data for SCIMAP modelling. Each of these methods captures the locations of the CSAs, revealing similarities and differences in the prioritisation of CSA features. The differences are due to the temporal and spatial resolution of the three methods such as the use of static land cover information, the ability to capture small scale features, such as gateways and the incomplete catchment coverage of the walkover survey. The relative costs and output resolutions of the three methods indicate that they are suitable for application at different catchment scales in conjunction with other methods. Based on the results in this paper, it is recommended that a multi-evidence-based approach to diffuse pollution management is taken across catchment spatial scales, incorporating local knowledge from the walkover with the different data resolutions of the SCIMAP approach.

Energy policy as a social determinant of Australian health equity

Background

Intersectoral action on social determinants of health to reduce health inequities requires policy research beyond the usual social and human services. We ask how Australian energy policy affects health equity.

Methods

Document analysis and policy case studies on how goals, objectives and strategies of all Australian energy policies address equity.

Results

Energy policy affects health via risk from unreliable energy; difficult transitions to renewables; disproportionate effects on poorer people faced with high energy bills versus other basics; ecological degradation; cost pressures on businesses and governments; job losses and policy paralysis about renewable energy and climate change. Policy features subsidies for the disadvantaged; privatisation and artificial markets; differing geographical distribution of resources and high level political conflict about whether it can deliver on 3, or only 2, of the ’energy trilemma’ of reliability, affordability and ecological sustainability. Mining, industrial and political interests, powerful enough to orchestrate the downfall of Australian prime ministers, actively close policy links between health, climate change and energy. Bridging energy and health policy requires political support for market solutions involving renewables; community generation of renewable energy; solutions for rural and remote areas; and global treaties. Intergenerational equity is a strong policy lever.

Conclusions

Health in All Policies approaches can creatively engage with the language and concepts of energy policy via the daily conditions of living, inequity and climate change. When it is difficult to engage, researchers can connect with non-government organisations who bridge sectors through simultaneous advocacy for equitable health, climate and energy policies.

Key messages

Powerful interests burn bridges between health equity and energy policy. Local and global policy levers harmonising terminology differences build bridges between energy, climate change and health equity.

Reducing peak pressures under the saddle at thoracic vertebrae 10-13 is associated with alteration in jump kinematics

There is little information about horse-saddle interaction at take-off for a fence, although there is potential that this could have an influence on performance. It was hypothesised that (1) maximum peak pressure under the saddle would occur in the phase of maximum thoracolumbar flexion prior to hindlimb take-off; and (2) limb and trunk kinematics at take-off over the fence would be affected by reducing peak pressure at Thoracic vertebrae (T)10-13 at the point in the stride where peak pressures occur. The peak pressures under the usual saddle (Saddle S) and a saddle modified to reduce peak pressures at T10-13 (Saddle F) were measured during approach and take-off over a 1.30 m upright fence in 12 elite jumping horses. The timing of peak pressures was determined by comparison with simultaneous video data. Shoulder, carpal flexion angle and trunk angle to the horizontal at hindlimb take-off, take-off distance from the fence and fetlock height above the fence were determined using high speed motion analysis. Peak pressures under the saddle at T10-13 and kinematic data were compared between Saddles S and F. Maximum peak pressures occurred at forelimb vertical, during hindlimb protraction, consistent with thoracolumbar ventroflexion. Saddle F was associated with significantly lower peak pressures at T10-13, greater shoulder and carpal flexion, a steeper trunk angle, and higher fetlock height above the fence than Saddle S. Forelimb take-off distance from the fence was not different between saddles, but hindlimbs were significantly closer to the fence with Saddle F, indicating potential increase in ventroflexion through the thoracolumbosacral region. These findings suggest that reducing peak pressures under the saddle at T10-13 are associated with altered kinematics during the approach and take-off over a fence, which may have a positive effect on jumping performance.

Driving Change: Do Nurse-Led Clinics Make a Difference for the Patient?

Background and context: The number of people living with breast cancer and beyond is increasing. The nurse led clinics prioritise the patient as the center of care, providing the opportunity to address the serious medical, functional and psychosocial consequences of cancer and its treatments. Aim: To evaluate a model of survivorship care from the patient´s perspective. Strategy/Tactics: Eligible patients were identified through the multidisciplinary team breast meeting. Consultation with the breast care nurse at approximately 10 months postdiagnosis. Prior to this appointment, validated screening tools were sent to attendees and completed. Through assessment and discussion, issues were identified and addressed, with onward referral to internal and community based organizations. Resource packs provided together with a care plan. Program/Policy process: Having offered the nurse led clinics for 18 months Western Health conducted a patient satisfaction survey. Data were collected in the form of a questionnaire to ascertain the effect of the clinic in providing optimal and supportive survivorship care. Outcomes: 208 patients seen, 134 were born in a country other than Australia. 208 surveys sent to both English and non-English speaking patients. 91 respondents. 72% made changes to their lifestyles and relationships following the nurse led clinic. 93% of respondents felt they had more time to talk about their concerns and ask questions. 92% felt the BCN provided helpful information about support services and programs that they would otherwise not be aware of. What was learned: Patients may experience significant burden of symptoms following definitive treatment of early breast cancer. The nurse led clinic allows patients space to reflect and explore their disease experience to date, which for many has resulted in positive lifestyle changes.

Bridge of Support: A Collaborative Approach to a Peer Support Program

Background and context: The Bridge of Support Program (BOS) is adapting a successful community based model of peer support to an acute setting, at the Sunshine Hospital Breast Clinic, to meet the cultural and socioeconomic diverse needs of women with breast cancer. This two year project was funded by LUCRF Community Partnership Trust. Aim: To improve the experience of women undergoing treatment of breast cancer at Western Health. To improve access to psych-social, emotional and practical support for women by extending the reach of CounterPart- a state-wide service of women´s Health Victoria, funded by the Victorian Department of Health and Human Services to provide peer support and information to people affected by breast or a gynecologic cancer. Program/Policy process: Peer support volunteers actively guided women to current and credible evidence-based information, support decision making and provide emotional support. Peer support volunteers are rostered once a week at Sunshine Hospital to coincide with breast clinic and include access to the day oncology unit and radiotherapy center. Detailed contact information is recorded and women receive follow-up contact (with consent) from the peer support volunteers at the CounterPart Resource Centre in Melbourne. A CounterPart staff member oversees the project and provides direct support and supervision to the volunteers on site at the hospital. Women can self refer. Outcomes: Between February and December 2016 the BOS program had 159 separate contacts with patients and their families. 82 contacts were with men and women who were new to CounterPart and 77 were follow-up contacts. 90 individuals treated for breast cancer at Western Health accessed the program, which represent 53% of the women seen by the breast service. 48% of the contacts were follow-up contacts with the CounterPart volunteers indicating that once engaged with the service many men and women continue to make contact. 38% of contacts were with women diagnosed with metastatic disease, a group who often have higher levels of unmet or more complex needs. 49% were born in a nonmain English speaking country (compared with the overall state of Victoria average of 19.6%) thus reflecting an accessible service to the non-English speaking community. What was learned: At a time when peer support is being increasingly recognized as a key part of effective supportive care in cancer services, the BOS program offers a model of integrated peer support that is respected, reliable, well supported and safe within the acute setting. This acute-community sector partnership demonstrates how the medical and social models of health care can work together to provide a connected and quality service for men and women diagnosed with breast cancer. An active research approach is enabling the project to be responsive to issues and challenges as they arise including the ongoing recruitment of women as volunteers from the local community to work within the acute setting.

The Impact of a Breast Cancer Diagnosis on Women´s Work Status

Background: Many women diagnosed with breast cancer are of working age at the time of diagnosis, so the impact of a diagnosis and treatment regimen on their lives can cause financial stress-partly by impacting on their ability to continue in paid employment. The financial fallout from not working, changes in employment status and the hidden costs associated with cancer treatment can add to financial toxicity. Aim: Our aim was to identify changes in work status after a diagnosis of breast cancer. Our secondary aim was to determine if there was a correlation between different treatment modalities and work status at 12 month follow-up. Finally, we wanted to consider the role of treatment and change in work status on the financial stress experienced by patients after their diagnosis and treatment. Methods: An audit of the medical record of women who present to Western Health with a diagnosis of early breast cancer and consequently attended the nurse led breast cancer survivorship clinic (SC) between October 2015 and October 2016 was performed to identify employment status at diagnosis and at review in SC 12 months later. Results: 114 patients attended the SC in a 1 year period- 2 were males and both retired at diagnosis. The records of 111 women were reviewed. 46 of the 84 women < 65 years, were in paid employment at diagnosis. 38 of these 46 women were working in some capacity at 12 month review though only 28 were working the same, having decreased hours since diagnosis. 17 of the 111 (15%) women reported financial stress at the 12 month review. 9 of the 19 (42%) women with changed work status reported financial stress. 2 of the 28 (7%) women working the same hours reported financial stress. 14 of the 19 (74%) women who had changed work status had chemotherapy. 65% of those who reported financial stress (11/17) had chemotherapy as part of their treatment. 10/19 (53%) had changed or stop working since axillary dissection. Conclusion: Our data suggest that 83% of women returned to work in some capacity- most at the same level, and these women were unlikely to report financial stress. Women who returned to work at reduced hours, increased hours, or did not return to work at all were more likely to report significant financial concerns at one year postdiagnosis. Health care professionals as part of ongoing care should be aware of the financial impact a cancer diagnosis and its treatments, and should aim to refer appropriately.

Data on items of AKUSSI in Alkaptonuria collected over three years from the United Kingdom National Alkaptonuria Centre and the impact of nitisinone

Alkaptonuria is a rare genetic disorder characterized by a high level of circulating (and urine) homogentisic acid (HGA), which contributes to ochronosis when it is deposited in connective tissue as a pigmented polymer. In an observational study carried out by National AKU Centre (NAC) in Liverpool, a total of thirty-nine AKU patients attended yearly visits in varying numbers. At each visit a mixture of clinical, joint and spinal assessments were carried out and the results calculated to yield an AKUSSI (Alkaptonuria Severity Score Index), see "Nitisinone arrests ochronosis and decreases rate of progression of Alkaptonuria: evaluation of the effect of nitisinone in the United Kingdom National Alkaptonuria Centre" (Ranganath at el., 2018). The aim of this data article is to produce visual representation of the change in the components of AKUSSI over 3 years, through radar charts. The metabolic effect of nitisinone is shown through box plots.

Nitisinone arrests ochronosis and decreases rate of progression of Alkaptonuria: Evaluation of the effect of nitisinone in the United Kingdom National Alkaptonuria Centre

QUESTION

Does Nitisinone prevent the clinical progression of the Alkaptonuria?

FINDINGS

In this observational study on 39 patients, 2 mg of daily nitisinone inhibited ochronosis and significantly slowed the progression of AKU over a three-year period.

MEANING

Nitisinone is a beneficial therapy in Alkaptonuria.

BACKGROUND

Nitisinone decreases homogentisic acid (HGA), but has not been shown to modify progression of Alkaptonuria (AKU).

METHODS

Thirty-nine AKU patients attended the National AKU Centre (NAC) in Liverpool for assessments and treatment. Nitisinone was commenced at V1 or baseline. Thirty nine, 34 and 22 AKU patients completed 1, 2 and 3 years of monitoring respectively (V2, V3 and V4) in the VAR group. Seventeen patients also attended a pre-baseline visit (V0) in the VAR group. Within the 39 patients, a subgroup of the same ten patients attended V0, V1, V2, V3 and V4 visits constituting the SAME Group. Severity of AKU was assessed by calculation of the AKU Severity Score Index (AKUSSI) allowing comparison between the pre-nitisinone and the nitisinone treatment phases.

RESULTS

The ALL (sum of clinical, joint and spine AKUSSI features) AKUSSI rate of change of scores/patient/month, in the SAME group, was significantly lower at two (0.32 ± 0.19) and three (0.15 ± 0.13) years post-nitisinone when compared to pre-nitisinone (0.65 ± 0.15) (p < .01 for both comparisons). Similarly, the ALL AKUSSI rate of change of scores/patient/month, in the VAR group, was significantly lower at one (0.16 ± 0.08) and three (0.19 ± 0.06) years post-nitisinone when compared to pre-nitisinone (0.59 ± 0.13) (p < .01 for both comparisons). Combined ear and ocular ochronosis rate of change of scores/patient/month was significantly lower at one, two and three year's post-nitisinone in both VAR and SAME groups compared with pre-nitisinone (p < .05).

CONCLUSION

This is the first indication that a 2 mg dose of nitisinone slows down the clinical progression of AKU. Combined ocular and ear ochronosis progression was arrested by nitisinone.

A multiplex reverse transcription PCR and automated electronic microarray assay for detection and differentiation of seven viruses affecting swine

Microarray technology can be useful for pathogen detection as it allows simultaneous interrogation of the presence or absence of a large number of genetic signatures. However, most microarray assays are labour-intensive and time-consuming to perform. This study describes the development and initial evaluation of a multiplex reverse transcription (RT)-PCR and novel accompanying automated electronic microarray assay for simultaneous detection and differentiation of seven important viruses that affect swine (foot-and-mouth disease virus [FMDV], swine vesicular disease virus [SVDV], vesicular exanthema of swine virus [VESV], African swine fever virus [ASFV], classical swine fever virus [CSFV], porcine respiratory and reproductive syndrome virus [PRRSV] and porcine circovirus type 2 [PCV2]). The novel electronic microarray assay utilizes a single, user-friendly instrument that integrates and automates capture probe printing, hybridization, washing and reporting on a disposable electronic microarray cartridge with 400 features. This assay accurately detected and identified a total of 68 isolates of the seven targeted virus species including 23 samples of FMDV, representing all seven serotypes, and 10 CSFV strains, representing all three genotypes. The assay successfully detected viruses in clinical samples from the field, experimentally infected animals (as early as 1 day post-infection (dpi) for FMDV and SVDV, 4 dpi for ASFV, 5 dpi for CSFV), as well as in biological material that were spiked with target viruses. The limit of detection was 10 copies/μl for ASFV, PCV2 and PRRSV, 100 copies/μl for SVDV, CSFV, VESV and 1,000 copies/μl for FMDV. The electronic microarray component had reduced analytical sensitivity for several of the target viruses when compared with the multiplex RT-PCR. The integration of capture probe printing allows custom onsite array printing as needed, while electrophoretically driven hybridization generates results faster than conventional microarrays that rely on passive hybridization. With further refinement, this novel, rapid, highly automated microarray technology has potential applications in multipathogen surveillance of livestock diseases.

The decrease in population bone lead levels in Canada between 1993 and 2010 as assessed by in vivo XRF

Objective and Approach: A study, conducted in Toronto, Canada, between 2009 and 2011, measured the bone lead concentrations of volunteers aged 1-82 years using in vivo x-ray fluorescence (XRF) technology.

MAIN RESULTS

Bone lead levels were lower compared to Ontario in vivo XRF studies from the early 1990s. In adults, the slope of tibia lead content versus age was reduced by 36-56%, i.e. bone lead levels for a given age group were approximately half compared to the same age group 17 years prior. Further, bone lead levels of individuals fell over that time period. In 2010, an average person aged 57 years had a bone lead level approximately 1/3 less than their bone lead level age 40 years in 1993. Using this data, the half-lives of lead in the tibia were estimated as 7-26 years. Tibia lead levels were found to be low in children. The reduction in bone tibia content in children was not significant (p  =  0.07), but using data from additional north eastern US studies, there is evidence that childhood tibia stores are lower than in the 1990s.

SIGNIFICANCE

In vivo XRF analysis shows that there has been a reduction in the level of lead in bone in Canada over the last two decades. Public health measures have been very successful in reducing ongoing exposure to lead and in reducing bone lead stores.

Comparison of Post-Liver Transplantation Outcomes in Portopulmonary Hypertension and Pulmonary Venous Hypertension: A Single-Center Experience

BACKGROUND

In potential liver transplant candidates, pulmonary vascular diseases, including portopulmonary hypertension (PoPH) and pulmonary venous hypertension (PVH), can be associated with high morbidity and mortality. Although there are clear guidelines regarding management and transplant listing criteria for patients with PoPH, the listing criteria for PVH are not well defined.

OBJECTIVE

The aim of this study was to describe and compare the perioperative and postoperative morbidity and mortality associated with PoPH and PVH in patients undergoing liver transplantation.

METHODS

We conducted a retrospective observational study of all patients referred for liver transplantation to our center between 2005 and 2015 who underwent a right heart catheterization (RHC) for screening for pulmonary hypertension as suggested by initial echocardiography. Based on the RHC data, the patients were grouped into no pulmonary hypertension (No PH), PoPH, and PVH categories. In patients who underwent liver transplantation, we recorded vital status intraoperatively and at 30 days and 1-year post-transplant, and we recorded the incidence of postoperative cardiopulmonary and renal complications.

RESULTS

Of the 134 patients who underwent RHC as part of the initial transplant evaluation, 50 patients were successfully transplanted. There was 1 intraoperative death in the PoPH group. No significant difference in mortality was noted between the No PH, PoPH, and PVH groups intraoperatively and 30 days after liver transplantation. At 1 year, the survival rates were 100%, 69.2%, and 94.1% in the No PH, PoPH, and PVH groups, respectively. With respect to cardiopulmonary and renal complications, no statistically significant difference was noted among the groups, though there was a trend toward increased post-transplant reversible pulmonary complications in the PVH group.

CONCLUSION

Our findings suggest that the post-transplant outcomes of patients with PoPH and PVH are similar. In light of the growing recognition of diastolic dysfunction and cirrhotic cardiomyopathy in decompensated cirrhotic patients at the time of transplant, the issue of pulmonary hypertension related to PVH will gain increasing importance as we assess these patients for transplantation. Therefore, future studies are needed to define evidence based guidelines to determine candidacy for liver transplantation in the context of PVH.

RGD Conjugated Dendritic Polylysine for Cellular Delivery of Antisense Oligonucleotide

Dendritic polylysines (DPL) are highly branched nano-sized spherical polymer with positively charged primary amino groups on surface. This structural feature is useful for a delivery of antisense oligonucleotide or siRNA. In this study, we modified the surface of DPL with cyclic RGD (and iRGD) peptide by conjugation reaction generating RGD (and iRGD) peptide conjugated dendritic poly-lysines, RGD-DPL or iRGD-DPL. The prepared conjugates were evaluated for integrin receptor-mediated cellular delivery of antisense oligonucleotide. The conjugation of RGD or iRGD peptide on DPL was monitored by measuring the retention time in capillary zone electrophoresis and the absorbance at UV-Vis spectroscopy. Cellular delivery by DPL-RGD (or -iRGD)/antisense oligonucleotide complex was examined by antisense splicing correction assay on integrin alpha v/beta 3 positive A375B3-Luc cells, which were stably transfected with plasmid pLuc/705. DPL-RGD (or -iRGD)/antisense oligonucleotide complexes exhibited integrin receptor mediated uptake on A375B3 cells without inducing cellular toxicity. In addition, the delivery of antisense oligonucleotide was integrin receptor-dependent with moderate efficiency.

Riders’ perception of symmetrical pressure on their ischial tuberosities and rein contact tension whilst sitting on a static object

The horse-rider system is of great interest in understanding the mechanics involved in optimising locomotor function and performance in the ridden horse. Adult riders (n=30) attending a rider conference volunteered to take part in the study. Riders were asked to mimic riding position by positioning themselves symmetrically on their seat bones (ischial tuberosities) sitting on a (Pliance) pressure mat which was placed on a static platform. Riders were also asked to mimic even rein contact using reins with gauges which were attached to a solid wall. When satisfied that they were sitting symmetrically and had an even rein contact, pressure and rein measurements were captured for 5 s and repeated three times. A paired T Test was carried out to determine differences between left and right ischial tuberosities and rein pressures. Using a static model, this study found that the riders had significantly more pressure beneath the left ischial tuberosity (mean ± standard deviation, 3.22±1.43 N/cm2) compared to the right (2.65±1.49 N/cm2) (P=0.04) and no significant differences were observed between left (6.37±2.42 N) and right rein pressure (6.38±2.66 N) (P=0.95). Whilst sitting on a static platform, differences in ischial tuberosity pressure in adult riders were observed despite these riders’ perception that their seat was symmetrically weighted. These differences observed need to be investigated further, dynamically, to determine if there is a similar trend in the ridden situation.

Sex and Stroke in Thrombolyzed Patients and Controls

Background and Purpose—

We hypothesized that any sex-related difference in outcome poststroke is explained by other prognostic factors and that the response to intravenous recombinant tissue-type plasminogen activator (r-tPA) is equal in males and females after adjustment for such factors.

Methods—

We accessed an independent collection of randomized clinical trials—the VISTA (Virtual International Stroke Trials Archive). Data were preprocessed by selecting complete cases (n=8028) and matching females to males (coarsened exact matching, n=4575, 24.3% r-tPA). Outcome was assessed by the 7-point modified Rankin Scale (mRS) measured at 90 days after ischemic stroke. Relationship among variables was estimated by adjusted regression analysis.

Results—

In nonthrombolyzed patients, ordinal analysis of mRS adjusting for stroke- and sex-related prognostic factors suggested comparable outcomes for females and males (odds ratio, 0.96; 95% confidence interval, 0.85–1.06). Females responded comparably to r-tPA as did males, irrespective of the outcome definition of mRS (ordinal: P Interaction =0.46, relative excess risk because of interaction=0). The number needed to treat was 6.8 and 11.2 for 1 female to achieve mRS score of 0 to 2 and 0 to 1, which was highly congruent with males. Analysis for a nonlinear variation of age-by-sex revealed a good outcome for females <45 years with significant disadvantage thereafter (mRS score of 0–2: P Interaction =0.004). No relationship between sex, r-tPA, and bleeding complications was evident.

Conclusions—

Functional outcome (mRS) without r-tPA was overall similar between the sexes, as was the response to r-tPA. Nonlinear sex-by-age interaction improved estimates of functional independence; this should be considered in sex-related studies in stroke.

Ischemic stroke subtype is associated with outcome in thrombolyzed patients

OBJECTIVES

The impact of ischemic stroke subtype on clinical outcome in patients treated with intravenous tissue-type plasminogen activator (IV-tPA) is sparsely examined. We studied the association between stroke subtype and clinical outcome in magnetic resonance imaging (MRI)-evaluated patients treated with IV-tPA.

MATERIAL AND METHODS

We conducted a single-center retrospective analysis of MRI-selected stroke patients treated with IV-tPA between 2004 and 2010. The Trial of ORG 10172 in Acute Stroke Treatment criteria were used to establish the stroke subtype by 3 months. The outcomes of interest were a 3-month modified Rankin Scale score of 0-1 (favorable outcome), and early neurological improvement defined as complete remission of neurological deficit or improvement of ≥4 on the National Institute of Health Stroke Scale at 24 h. The outcomes among stroke subtypes were compared with multivariable logistic regression.

RESULTS

Among 557 patients, 202 (36%) had large vessel disease (LVD), 153 (27%) cardioembolic stroke (CE), 109 (20%) small vessel disease, and 93 (17%) were of other or undetermined etiology. Early neurological improvement was present in 313 (56.4%) patients, and 361 (64.8%) patients achieved a favorable outcome. Early neurological improvement and favorable outcome were more likely in CE patients compared with LVD patients (odds ratio (OR), 2.1 (95% confidence interval, 1.4-3.3), and 2.0 (95% confidence interval, 1.2-3.3), respectively).

CONCLUSIONS

Cardioembolic stroke patients were more likely to achieve early neurological improvement and favorable outcome compared with LVD stroke following MRI-based IV-tPA treatment. This finding may reflect a difference in the effect of IV-tPA among stroke subtypes.

Age, time living with diagnosed HIV infection, and self-rated health

OBJECTIVES

An increasing proportion of people living with HIV are older adults, who may require specialized care. Adverse physical and psychological effects of HIV infection may be greatest among older people or those who have lived longer with HIV.

METHODS

The ASTRA study is a cross-sectional questionnaire study of 3258 HIV-diagnosed adults (2248 men who have sex with men, 373 heterosexual men and 637 women) recruited from UK clinics in 2011-2012. Associations of age group with physical symptom distress (significant distress for at least one of 26 symptoms), depression and anxiety symptoms (scores ≥ 10 on PHQ-9 and GAD-7, respectively), and health-related functional problems (problems on at least one of three domains of the Euroqol 5D-3L)) were assessed, adjusting for time with diagnosed HIV infection, gender/sexual orientation and ethnicity.

RESULTS

The age distribution of participants was: < 30 years, 5%; 30-39 years, 23%; 40-49 years, 43%; 50-59 years, 22%; and ≥ 60 years, 7%. Overall prevalences were: physical symptom distress, 56%; depression symptoms, 27%; anxiety symptoms, 22%; functional problems, 38%. No trend was found in the prevalence of physical symptom distress with age [adjusted odds ratio (OR) for trend across age groups, 0.96; 95% confidence interval (CI) 0.89, 1.04; P = 0.36]. The prevalence of depression and anxiety symptoms decreased with age [adjusted OR 0.86 (95% CI 0.79, 0.94; P = 0.001) and adjusted OR 0.85 (95% CI 0.77, 0.94; P = 0.001), respectively], while that of functional problems increased (adjusted OR 1.28; 95% CI 1.17, 1.39; P < 0.001). In contrast, a longer time with diagnosed HIV infection was strongly and independently associated with a higher prevalence of symptom distress, depression symptoms, anxiety symptoms, and functional problems (P < 0.001 for trends, adjusted analysis).

CONCLUSIONS

Among people living with HIV, although health-related functional problems were more common with older age, physical symptom distress was not, and mental health was more favourable. These results suggest that a longer time with diagnosed HIV infection, rather than age, is the dominating factor contributing to psychological morbidity and lower quality of life.

Age and sex influence on bone and blood lead concentrations in a cohort of the general population living in Toronto

OBJECTIVE

To study the age and sex influence on bone and blood lead concentrations in a cohort of the general population living in Toronto.

APPROACH

A ¹⁰⁹Cd K x-ray fluorescence (KXRF) measurement system was used from 2009 to 2011 in a study that measured the bone lead (Pb) concentration of 263 environmentally exposed individuals residing in Toronto, Ontario, Canada. Tibia (cortical bone) and calcaneus (trabecular bone) lead contents were measured in 134 males and 129 females between 1 and 82 years of age. Whole blood Pb concentration was measured by TIMS (thermal ionization mass spectrometer). Tibia (Ti) and calcaneus (Cal) Pb were examined versus the age of participants, taking into account uncertainties in bone Pb measurement values.

MAIN RESULTS

No significant sex differences were observed in any of the age categories. Participants older than 50 years of age demonstrated the highest concentrations of Pb in their blood, tibia, and calcaneus bones.

SIGNIFICANCE

In most of the previous publications, uncertainty was not considered in the regression model of bone Pb and age. However, in this paper, we adjusted the bone Pb values for the uncertainty level. This had a significant influence in regression models of bone Pb and thus we recommend that uncertainty be considered in future studies.