Persistence of effort in apathy

The syndrome of apathy has generated increasing interest in recent years as systematic evaluations have revealed its high prevalence and strong negative impact on quality of life across a wide range of neurological and psychiatric conditions. However, although several theoretical models have been proposed to account for various aspects of the condition, understanding of this syndrome is still incomplete. One influential model has proposed that apathy might be described as a quantitative reduction of goal-directed behaviour in comparison to an individual's prior level of functioning. Persistence of activity defined as the capacity to continue with a task - sometimes in the face of setbacks, high levels of difficulty or fatigue - is a crucial but understudied aspect of goal-directed behaviour. Surprisingly, it has not been investigated yet in the context of apathy. Here, we provide an overview of theoretical and experimental aspects of persistence in effort that might assist to develop methods for the investigation of persistence in human behaviour, particularly within the pathologic context of apathy.

Negative symptoms and cognitive impairment are associated with distinct motivational deficits in treatment resistant schizophrenia

BACKGROUND

Motivational deficits are a central feature of the negative syndrome in schizophrenia. They have consistently been associated with reduced willingness to expend physical effort in return for monetary rewards on effort based decision making (EBDM) paradigms. Nevertheless, the mechanisms underlying such altered performance are not well characterised, and it remains unclear if they are driven purely by negative symptoms, or also in part by cognitive impairment, antipsychotic treatment or even positive symptoms. Here we investigated the impact of all these factors using a paradigm that has not previously been used to measure EBDM in schizophrenia.

METHODS

Forty treatment resistant schizophrenia (TRS) patients on clozapine and matched controls (N = 80) completed a well validated EBDM task which offers monetary rewards in return for physical effort. Choice and reaction time data was analysed using logistic regressions, as well as Bayesian hierarchical drift diffusion modelling (HDDM). Behavioural parameters were compared between groups and their association with negative symptoms, cognitive function and serum clozapine levels were assessed.

RESULTS

Overall, TRS patients accepted significantly less offers than controls during effort-based decision making, suggesting they were less motivated. They demonstrated reduced sensitivity to increasing rewards, but surprisingly were also less averse to increasing effort. Despite a positive correlation between negative symptoms and cognitive function in TRS, reward sensitivity was associated only with cognitive performance. In contrast, reduced effort aversion correlated with negative symptom severity. Clozapine levels and positive symptoms were not associated with either behavioural parameter.

CONCLUSION

Motivational deficits in TRS are characterised by both diminished reward sensitivity and reduced effort aversion during EBDM. Cognitive dysfunction and negative symptom severity account for distinct aspects of these behavioural changes, despite positive associations between themselves. Overall, these findings demonstrate that negative symptoms and cognitive impairment have significant independent contributions to EBDM in TRS, thereby opening the possibility of individualised treatment targeting these mechanisms to improve motivation.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Risk of stroke in patients with type 2 diabetes receiving semaglutide or a dipeptidyl peptidase-4 inhibitor: a real-world US claims database analysis

Introduction

People with type 2 diabetes (T2D) have a higher risk of stroke than those without, are likely to experience stroke at a younger age, and have worse outcomes. The cardiovascular benefits of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in T2D have been demonstrated in randomized controlled trials. A meta-analysis of these data has shown that GLP-1 RAs are associated with a significant reduction in the risk of stroke; however, there remains an evidence gap for the real-world effect of semaglutide specifically on stroke risk.

Purpose

To compare real-world risk of stroke in patients with T2D or T2D + atherosclerotic cardiovascular disease (ASCVD) initiating either semaglutide or a dipeptidyl peptidase-4 inhibitor (DPP-4i).

Methods

For inclusion, adults (≥18 years) in a US claims database required a claim indicating initiation of either semaglutide or a DPP-4i (index date) during the index period (1/1/18–30/9/20), a diagnosis code for T2D on or before the index date, and 12 months' continuous enrolment pre-index. Exclusion criteria were a claim for semaglutide, DPP-4i or injectable glucose-lowering medication, or diagnosis code for type 1 or secondary diabetes in the 12 months pre-index; or a claim associated with pregnancy or gestational diabetes any time during the study period. Patients were propensity score matched 1:1 on 27 baseline demographic and clinical characteristics. Patients who also had a diagnosis code for ASCVD pre-index were matched separately on 26 variables. Primary outcome was time to first stroke event during follow-up, defined as a medical claim with stroke as primary diagnosis during inpatient or emergency room visit. Patients with no event were censored at end of enrolment or end of study period (30/9/20), whichever was earliest.

Results

Post-matching, there were 17,920 pairs with T2D and 4234 pairs with T2D+ASCVD. The groups were well matched on baseline characteristics (Table). For T2D, patients initiating semaglutide had a lower risk of stroke than those initiating a DPP-4i (hazard ratio [HR], 0.63; 95% confidence interval [CI]: 0.41–0.95; p=0.029). This trend was more pronounced for T2D+ASCVD (HR, 0.45 [0.24–0.86]; p=0.015). Overall, 34 patients with T2D receiving semaglutide (0.2%) experienced a stroke event (incidence rate [IR] per 100 person-years, 0.25), compared with 60 patients receiving a DPP-4i (0.3%; IR, 0.40; IR ratio [IRR], 0.62; 95% CI: 0.40–0.95). For the groups with T2D+ASCVD, 13 patients receiving semaglutide (0.3%; IR, 0.40) and 32 receiving a DPP-4i (0.8%; IR, 0.90) experienced a stroke event (IRR, 0.44 [0.23–0.85]). The Figure shows cumulative incidence of stroke over follow-up (median 237–258 days).

Conclusion

This analysis provides initial insights into the potential of semaglutide to reduce real-world stroke risk in patients with T2D. Analyses with additional comparison groups and longer follow-up are needed to determine the broader clinical and economic implications.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was funded by Novo Nordisk A/S. Medical writing support was provided by Oxford PharmaGenesis, Oxford, UK with funding from Novo Nordisk A/S.

National Network of Depression Centers' Recommendations on Harmonizing Clinical Documentation of Electroconvulsive Therapy

ABSTRACT

Electroconvulsive therapy (ECT) is a highly therapeutic and cost-effective treatment for severe and/or treatment-resistant major depression. However, because of the varied clinical practices, there is a great deal of heterogeneity in how ECT is delivered and documented. This represents both an opportunity to study how differences in implementation influence clinical outcomes and a challenge for carrying out coordinated quality improvement and research efforts across multiple ECT centers. The National Network of Depression Centers, a consortium of 26+ US academic medical centers of excellence providing care for patients with mood disorders, formed a task group with the goals of promoting best clinical practices for the delivery of ECT and to facilitate large-scale, multisite quality improvement and research to advance more effective and safe use of this treatment modality. The National Network of Depression Centers Task Group on ECT set out to define best practices for harmonizing the clinical documentation of ECT across treatment centers to promote clinical interoperability and facilitate a nationwide collaboration that would enable multisite quality improvement and longitudinal research in real-world settings. This article reports on the work of this effort. It focuses on the use of ECT for major depressive disorder, which accounts for the majority of ECT referrals in most countries. However, most of the recommendations on clinical documentation proposed herein will be applicable to the use of ECT for any of its indications.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Lung Transplant from a DCD Donor with a Previous Symptomatic COVID Infection

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a worldwide pandemic affecting more than 172 million confirmed cases. The likelihood of historic donor infection is increasing. Here we report a lung transplantation of a previously SARS-CoV-2 positive organ donor.

Case Report

A 49-year-old female who underwent left single lung transplantation for interstitial lung disease. The lung was obtained from a donation after cardiac death (DCD) using abdominal rerperfusion of a 23 years old female donor died of intracranial bleeding with history of covid infection 8 month prior to lung donation. According to the donor records, the symptoms were mild, and required no hospital admission. She had ongoing loss of taste and smell till time of donation. There were no respiratory symptoms. At time of retrieval, chest x ray was normal and blood gases were normal, however, bronchoscopy revealed severe inflammation of the right-side mucosa so the decision was to proceed with the left lung only as it had normal blood gases, good recruitment and no consolidation as well as non inflamed bronchial mucosa. patient had single off pump left lung transplant through left anterior thoracotomy approach. After the surgery, patient was extubated on day 1 in ICU, discharged from ICU on day 3 and discharged from the hospital after 27 days. There was no evidence for primary graft dysfunction or acute rejection. After 6 month of the surgery, FVC is 2.26 L (78.2% predicted) and FEV1 is 1.9L (70.2% predicted).

Summary

This case showed that it is possible to proceed with lung transplant from a donors who had previous mild covid infection. As DCD donation might limit preoperative invasive investigations such as bronchoscopies careful examination and proper radiological and functional assessment for the donor lung after donation including EVLP needs to be considered.

Pulmonary bacterial infections in adult patients hospitalized for COVID-19 in standard wards

OBJECTIVES

During the COVID-19 pandemic, antibiotic use was very common. However, bacterial co-/secondary infections with coronaviruses remain largely unknown in standard wards. We aimed to investigate the characteristics of pulmonary bacterial infections associated with COVID-19 in hospitalized patients.

METHODS

A retrospective monocentric observational study was conducted in Bichat hospital, France, between February 26 and April 22, 2020. All patients hospitalized in standard wards with COVID-19 (positive nasopharyngeal PCR and/or typical aspect on CT scan) and diagnosed with pulmonary bacterial infection (positive bacteriological samples) were included. Bacteriological and clinical data were collected from the microbiology laboratories and patient's medical records.

RESULTS

Twenty-three bacteriological samples from 22 patients were positive out of 2,075 screened samples (1.1%) from 784 patients (2.8%). Bacterial infection occurred within a median of 10 days after COVID-19 onset. Diagnosis of pulmonary bacterial infection was suspected on increase of oxygen requirements (20/22), productive cough or modification of sputum aspect (17/22), or fever (10/22). Positive samples included 13 sputum cultures, one FilmArray® assay on sputum samples, one bronchoalveolar lavage, six blood cultures, and two pneumococcal urinary antigen tests. The most frequent bacteria were Pseudomonas aeruginosa (6/23), Staphylococcus aureus (5/23), Streptococcus pneumoniae (4/23), Enterococcus faecalis (3/23), and Klebsiella aerogenes (3/23). No Legionella urinary antigen test was positive. Four out of 496 nasopharyngeal PCR tests (0.8%) were positive for intracellular bacteria (two Bordetella pertussis and two Mycoplasma pneumonia).

CONCLUSIONS

Pulmonary bacterial secondary infections and co-infections with SARS-CoV-2 are uncommon. Antibiotic use should remain limited in the management of COVID-19.

Medical check-up of newly arrived unaccompanied minors: A dedicated pediatric consultation service in a hospital

BACKGROUND AND AIMS

Healthcare for the increasing number of migrants in Europe, and particularly of unaccompanied minors (UMs) seeking asylum, has become a major challenge. We aimed to describe the health issues of UMs managed in a dedicated pediatric consultation service in a care center in Paris.

METHODS

All UMs attending a dedicated migrant medical consultation service in Robert Debré Hospital, Paris, France, were included in a single-center retrospective observational study from September 1, 2017, to September 30, 2018.

RESULTS

Out of the 107 UMs who were included, 87% had a health problem (n=93) and 52% had an infectious disease (n=56). The main infectious diagnoses were schistosomiasis (22%), latent tuberculosis (22%), intestinal parasitosis (16%), and chronic hepatitis B (8%). Posttraumatic stress disorder (PTSD) and overweight were common (35% and 20%, respectively). The median age was 15 years old (IQR, 14-16), the male/female ratio was 95/12. Most of the children were from sub-Saharan Africa (n=67), 46% had crossed Libya (n=49) and, when compared to the other migration routes, faced an increasing risk of violence (69%, p=0.04), imprisonment (53%, p=0.03), and forced labor (48%, p=0.02). The median duration of the trip before reaching France was 6 months (IQR, 2-13), the median time to consultation was 2 months (0-5) and was not associated with an increased risk of health problems. A total of 43 UMs were lost to follow-up.

CONCLUSION

Health problems, particularly infectious diseases and PTSD, are common among UMs and should prompt an early medical consultation with psychiatric evaluation. Follow-up is problematic and could be improved by an on-line health book.

Neutrophil-to-lymphocyte ratio predicts cardiovascular events in patients with type 2 diabetes: post hoc analysis of SUSTAIN 6 and PIONEER 6

Background

Inflammation plays an important role in atherosclerosis. The neutrophil-to-lymphocyte ratio (NLR) may serve as a clinically useful biomarker of inflammation and cardiovascular (CV) disease, although this relationship has not been studied in people with type 2 diabetes (T2D).

Purpose

This post hoc analysis investigated the relationship between NLRs and CV outcomes in T2D CV outcomes trials for two formulations of semaglutide, a glucagon-like peptide-1 receptor agonist.

Methods

In pooled analyses of the SUSTAIN 6 and PIONEER 6 trials, 6,480 patients with T2D at high CV risk received placebo or semaglutide (once-weekly subcutaneously up to 1.0 mg, or once-daily orally up to 14 mg). NLRs were calculated from complete blood counts at randomisation. Adjudicated outcomes included 3-point major adverse CV events (MACE: composite of CV death, non-fatal myocardial infarction [MI] or non-fatal stroke; primary outcome), expanded MACE, CV death and all-cause death (secondary outcomes). Patient characteristics and CV outcomes were analysed according to baseline NLR tertiles using pooled trial data. Estimation of hazard ratios (HRs) for all outcomes across NLR tertiles used a Cox proportional hazards model. A Cox spline regression with continuous NLR as covariate adjusted for treatment was used to predict the event rate of first MACE at 2 years.

Results

Overall, baseline NLR was recorded in 6,364 patients. Mean baseline NLRs were 1.5, 2.2 and 3.6 in the low, middle and high tertiles, respectively. Patients in the high NLR tertile were older (66.6 years), more likely to be male (70.0%), had longer duration of diabetes (15.3 years), higher body weight (93.3 kg), lower diastolic blood pressure (75.5 mmHg) and estimated glomerular filtration rate (70.4 mL/min/1.73m2) vs those in the lower NLR tertiles (all p&lt;0.0001). Higher NLR was associated with an increased risk of MACE (HR [95% confidence interval (CI)]: 1.37 [1.05; 1.80; p=0.02] and 1.86 [1.45; 2.41; p&lt;0.0001] for the middle and high tertiles, respectively, vs the low tertile). The high NLR tertile was also associated with a 74% increased risk of expanded MACE and twofold risk for CV death and all-cause death vs the low NLR tertile (Figure 1). Spline regression indicated that NLR values &gt;5 increased the risk of first MACE substantially (Figure 2). Further analysis of NLR and MACE by tertiles showed a more pronounced association in patients without prior MI and/or stroke (HR [95% CI]: 1.64 [1.07; 2.56]; p=0.03 and 2.09 [1.38; 3.21]; p=0.0006 in the middle and high tertiles, respectively, vs the low tertile).

Conclusion

Baseline NLR predicts MACE, CV death and all-cause death in patients with T2D and high CV risk. NLR is readily accessible from routinely obtained and inexpensive blood counts; it could offer a convenient, clinically useful inflammatory biomarker for CV risk prediction in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novo Nordisk A/S Figure 1Figure 2

Impact de la pandémie de COVID-19 sur les populations sans domicile fixe : résultats d’une cohorte fermée rétrospective (mars–mai 2020)

Introduction

Les populations de sans domicile fixe ont un taux de mortalité supérieur à celui de la population générale. Ceci est en partie en lien avec des maladies chroniques non suivis, des problèmes d’addiction ainsi qu’une exposition plus forte aux maladies transmissibles, en particulier respiratoires. Nous avons réalisé une étude pour évaluer les taux d’attaque, d’hospitalisation et de mortalité liés à l’infection par le SARS-CoV-2 dans une population de résidents de centres d’hébergement pour sans-abri et du personnel à leur contact.

Matériels et méthodes

Une étude sérologique rétrospective a été réalisée sur l’ensemble des résidents et des membres du personnel de trois centres d’hébergement pour sans-abri entre mars et mai 2020 : 2 centres de lits halte soins santé (LHSS) et un dortoir de femmes. Nous avons inclus tous les adultes présents dans les centres d’hébergement ou décédés d’une infection avérée par le SARS-CoV-2. Les IgG anti-SARS-CoV-2 étaient détectés par le test ELISA « SARS-CoV-2 IgG Architect (Abbott) ». Un cas confirmé de SARS-CoV-2 était défini comme tout participant présentant une PCR ou une sérologie positive. Des sérologies de contrôle ont été prélevées quatre mois après la première sérologie positive.

Résultats

Nous avons inclus 100 résidents et 83 membres du personnel. Le taux de SARS-CoV-2 confirmé par PCR ou sérologie était de 72/100 (72,0 %) pour les résidents et de 17/83 (20,5 %) pour le personnel. Le taux d’hospitalisation chez les résidents était de 17/72 (25 %) et le taux de décès de 4/72 (5,6 %). Toutes les hospitalisations sauf une et tous les décès sont survenus chez des résidents des LHSS. Trente-quatre sur 68 (50 %) des résidents des LHSS présentaient au moins deux facteurs de risque de forme grave d’infection par le SARS-CoV-2. Les femmes hébergées dans le dortoir étaient plus jeunes, présentaient moins de comorbidité, avaient le taux d’attaque le plus élevé (90,6 %) et une morbidité-mortalité quasi nulle. Cinquante-deux sur 80 (63,4 %) des personnes ayant une première sérologie positive ont eu une sérologie de contrôle à 4 mois de la première sérologie et 8 mois environ de leur infection. Parmi eux, 44 (84,6 %) avaient conservé des sérologies positives.

Conclusion

Le taux d’attaque du SARS-CoV-2 était extrêmement élevé chez les résidents des centres d’hébergement pour sans-abri par rapport à la population générale. Le risque d’infection grave par le SARS-CoV-2 était fortement associé à la présence de comorbidités à un plus jeune âge. Cette population à risqué doit être considérée comme prioritaire dans les campagnes de vaccination dans l’accès aux logements individuels pour les plus vulnérables.

International Consortium on the Genetics of Electroconvulsive Therapy and Severe Depressive Disorders (Gen-ECT-ic)

Recent genome-wide association studies have demonstrated that the genetic burden associated with depression correlates with depression severity. Therefore, conducting genetic studies of patients at the most severe end of the depressive disorder spectrum, those with treatment-resistant depression and who are prescribed electroconvulsive therapy (ECT), could lead to a better understanding of the genetic underpinnings of depression. Despite ECT being one of the most effective forms of treatment for severe depressive disorders, it is usually placed at the end of treatment algorithms of current guidelines. This is perhaps because ECT has controlled risk and logistical demands including use of general anaesthesia and muscle relaxants and side-effects such as short-term memory impairment. Better understanding of the genetics and biology of ECT response and of cognitive side-effects could lead to more personalized treatment decisions. To enhance the understanding of the genomics of severe depression and ECT response, researchers and ECT providers from around the world and from various depression or ECT networks, but not limited to, such as the Psychiatric Genomics Consortium, the Clinical Alliance and Research in ECT, and the National Network of Depression Centers have formed the Genetics of ECT International Consortium (Gen-ECT-ic). Gen-ECT-ic will organize the largest clinical and genetic collection to date to study the genomics of severe depressive disorders and response to ECT, aiming for 30,000 patients worldwide using a GWAS approach. At this stage it will be the largest genomic study on treatment response in depression. Retrospective data abstraction and prospective data collection will be facilitated by a uniform data collection approach that is flexible and will incorporate data from many clinical practices. Gen-ECT-ic invites all ECT providers and researchers to join its efforts.

Co-infection et surinfection bactérienne chez les patients hospitalisés pour COVID-19: une étude rétrospective monocentrique

Introduction

Durant la pandémie de COVID-19, la prescription d’antibiotique a été importante. Cependant, les surinfections et co-infections bactériennes associées aux coronavirus sont peu décrites, et concernent principalement les patients de soins intensifs.

Matériels et méthodes

Une étude observationnelle rétrospective monocentrique a été menée dans notre CHU du 26/02/2020 au 22/04/2020. Ont été inclus tous les patients hospitalisés pour une COVID-19 (PCR respiratoire positive à SARS-CoV-2 ou atteinte scannographique compatible) hors service de réanimation et présentant une infection bactérienne documentée par un prélèvement bactériologique positif parmi: prélèvement respiratoire (ECBC, aspiration bronchique, LBA), hémoculture, antigénurie légionnelle ou pneumocoque, ou PCR nasopharyngée (Bordetella pertussis, Mycoplasma pneumoniae et légionnelle). Les données bactériologiques ont été obtenues par les laboratoires de bactériologie et virologie et les données cliniques recueillies à partir du dossier médical des patients.

Résultats

Au total, 2710 prélèvements ont été réalisés chez 778 patients hospitalisés: 957 hémocultures, 169 ECBC, 3 aspirations bronchiques, 2 LBA, 537 PCR nasopharyngées, 517 antigénuries légionnelle et 525 antigénuries pneumocoque. Quarante et un prélèvements étaient positifs (1,5 %) dont quatorze ont été considérés comme une colonisation par les cliniciens. Vingt neuf prélèvements positifs (1,1 %) ont été considérés comme pathogènes chez 27 patients (3,5 %): 15 ECBC, 2 aspirations bronchiques, 1 LBA, 7 hémocultures, 2 antigénuries et 4 PCR nasopharyngées. Parmi les 27 patients, 18 (66,7 %) avaient des comorbidités dont 10 (37 %) une pathologie respiratoire chronique. Huit patients (29,6 %) étaient sous traitement immunosuppresseur au long cours et 15 (55,6 %) ont reçu des corticoïdes ou autres traitements immunomodulateurs pour la COVID-19. Le delais entre l’apparition des symptômes de COVID-19 et la survenue de la surinfection bactérienne était en moyenne de 11 jours. Les arguments en faveur d’une surinfection étaient l’augmentation des besoins en oxygène (n = 22, 81,5 %), la toux expectorante (n= 20, 74,0 %) ou la modification de la toux (n = 5, 18,5 %) et la présence de fièvre (n= 5, 18,5 %). Un patient avait un tableau de sepsis. Les pathogènes les plus fréquemment retrouvés nétaient: Pseudomonas aeruginosa (n = 8, 29,6 %), Staphylococcus aureus (n = 5, 18,5 %), Streptococcus pneumoniae (n = 4, 14,8 %) et Enterococcus faecalis (n = 3, 11,1 %). Quatre patients (0,5 %) avaient une co-infection à bactérie intracellulaire: 2 à Bordetella pertussis et 2 à Mycoplasma pneumoniae. Aucune antigénurie légionnelle n’est revenue positive.

Conclusion

Le taux de surinfections et de co-infections bactériennes dans la COVID-19 semble faible. Ce faible taux est en faveur d’une utilisation limitée des antibiotiques dans la prise en charge de la COVID-19.

Molecular characterization, expression pattern and RNAi-mediated silencing of vitellogenin receptor gene in almond moth, Cadra cautella

The almond moth is an important pest of date fruits worldwide. The females produce several eggs; however, role of vitellogenin receptor (VgR) in oocyte development by mediating endocytosis of major yolk protein precursor Vg remains yet unexplored. To investigate the role of vitellogenin receptor (VgR) in reproduction, Cadra cautella vitellogenin receptor (CcVgR) transcript was obtained using rapid amplification of cDNA ends-polymerase chain reaction. Expression analysis of CcVgR was performed using reverse transcriptase and quantitative polymerase chain reaction (qPCR) in different developmental stages. RNA interference was performed by injecting CcVgR-based double-stranded (ds)RNA at different exposure times. The results revealed that CcVgR is 5421 bp long, encoded 1807 amino acid, belongs to low-density lipoprotein receptor superfamily and contains all conserved domains. Expression analysis confirmed that CcVgR is sex-specific and starts to express in female larvae on day 19. Additionally, RNA interference (RNAi) of CcVgR-based dsRNA inhibited CcVgR expression up to 83% after 72 h, reduced fecundity and hatchability, and confirmed involvement of CcVgR in C. cautella reproduction. This report provides a basis for gene silencing in this species, and proposes RNAi technology potential for pest management.

Social Stress and Depression During Pregnancy in Women of a Low Income Country

There has been considerable research on postnatal depression (PND), in comparison to antenatal depression (AND). We aimed to study the Prevalence of AND, testing the following hypotheses:a.

Methods:

Using a cross sectional study design 1366/1401 women in their 3rd trimester of pregnancy were screened for depression using the Self-Rating Questionnaire (SRQ) and the Edinburgh Postnatal Depression Scale (EPDS). These instruments are validated, available in Urdu and have been used in the pre and postnatal period in Pakistan. The life events checklist was used to measure social stress and the Brief Disability Questionnaire (BDQ) for disability.

Results:

342 women scored ≥ 12 on the EPDS giving an estimated AND prevalence of 25.6 %. The EPDS and SRQ scores showed a high positive correlation. A significantly higher percentage of depressed women experienced problems in marital relations, work, finances, housing and domestic violence. Depressed women had higher disability scores. 32% of the depressed and 14% of non depressed were unable to perform usual daily activities. 35% of depressed women stayed in bed due to illness as compared to only 16 % of non-depressed.

Conclusion:

This study confirms a high prevalence of AND in less educated women, experiencing a large number of social difficulties.

P6175Prediction of coronary revascularization by coronary computed tomography angiography derived fractional flow reserve - different algorithms for interpretation

Introduction

Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly used for guiding referral to invasive procedures in patients with stable chest pain. However, optimal interpretation of FFRct-analysis in terms of location and threshold of applied FFRct-values is unclear.

Purpose

To evaluate the clinical performance of various vessel-specific physiological FFRct derived measures of ischemia for prediction of standard of care guided coronary revascularization in patients with stable chest pain and coronary artery disease as determined by coronary CTA.

Methods

Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Any FFRct value in the major coronary arteries ≥1.8 mm in diameter, including side branches, were registered. Lesions were categorized as positive for ischemia using 6 different algorithms: Lowest in vessel FFRct-value (1) ≤0.75 or (2) ≤0.80; 2 cm distal-to-lesion FFRct-value (3) ≤0.75 or (4) ≤0.80; ΔFFRct (5) ≥0.06 or a combination of 2 and 5. The personnel responsible for downstream patient management had no information regarding FFRct test results.

Results

A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. The diagnostic performance of different FFRct algorithms for predicting standard of care guided coronary revascularization is shown in the Table.

Revascularization Predictions by FFRct N=172 Diagnostic performance FFRCT false negative FFRCT false positive Values given as (%) No. of revasc vessels No. of abnormal vessels FFRCT Algorithm Sens Spec PPV NPV Acc 1 2 3 1 2 3 Distal FFRCT ≤0.75 77 68 58 84 72 12 2 0 29 5 1 Distal FFRCT ≤0.80 92 43 48 90 61 5 0 0 40 20 3 Lesion-specific FFRCT ≤0.75 68 86 74 83 80 17 3 0 12 3 0 Lesion-specific FFRCT ≤0.80 82 78 68 89 80 10 2 0 21 3 1 ΔFFRCT ≥0.06 98 36 47 98 59 1 0 0 51 19 0 Combinationa 92 54 53 92 67 5 0 0 39 12 0 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. Sens = sensitivity; Spec = specificity; PPV = positive predictive value; NPV = negative predictive value; Acc = accuracy; FFRCT = fractional flow reserve derived from coronary CTA; ΔFFRCT = difference between FFRCT-value immediately proximal and distal to lesion; Revasc = revascularized.

Conclusion

The diagnostic performance of FFRct in terms of predicting standard of care guided coronary revascularization is dependent on the applied algorithm for interpretation of the FFRct-analysis.

P6186Symptomatic effect of coronary revascularization at 1-year follow-up in stable chest pain - prediction by coronary computed tomography angiography derived fractional flow reserve

Introduction

Coronary CT angiography (CTA) derived fractional flow reserve (FFRct) is increasingly being used for guiding referral to invasive procedures in patients with stable chest pain. However, the ability of FFRct to predict the symptomatic effect of revascularization remains unclear.

Purpose

To evaluate the ability of different vessel-specific physiological FFRct derived measures of ischemia for predicting the occurrence of chest pain one year after coronary revascularization in stable patients.

Methods

Retrospective study in patients with stable chest pain referred for coronary angiography based on coronary CTA. Standard acquired coronary CTA data sets were transmitted for core-laboratory analysis at HeartFlow. Patients were categorized as positive for ischemia using 3 different algorithms: Lowest in vessel FFRct-value ≤0.80; ΔFFRct ≥0.06 or a combination of the two. Personnel responsible for downstream patient management had no information on FFRct test results. Classification of revascularization was performed based on the applied FFRct algorithm: complete if all FFRct positive lesions were revascularized; incomplete if ≥1 FFRct positive lesion was not revascularized. Symptomatic status at 1-year follow-up was obtained by a visit in the outpatient clinic or by telephone.

Results

A total of 172 patients were included. Revascularization was performed in 62 (35%) patients. At 1-year follow-up 48 (28%) patients had chest pain; 15 (24%) revascularized vs 33 (30%) non-vascularized patients, p=0.415. No difference in utilization of anti-anginal medicine for patients with and without chest pain was registered at 1-year follow-up. The association between the chosen FFRct algorithm, revascularization and occurrence of chest pain at 1-year follow-up are shown in the Table.

FFRct, Revascularization and Chest pain FFRCT, Algorithm Revascularizationb Patients with chest pain 1-year risk of chest pain p-valuec N (%) OR (95%-CI) Distal FFRCT ≤0.80 Incomplete 32 (34) Ref. Distal FFRCT ≤0.80 Complete 4 (15) 0.34 (0.11, 1.06) Distal FFRCT >0.80 No 11 (24) 0.61 (0.27, 1.35) 0.097 ΔFFRCT ≥0.06 Incomplete 34 (35) Ref. ΔFFRCT ≥0.06 Complete 7 (21) 0.49 (0.19, 1.24) ΔFFRCT <0.06 No 7 (18) 0.41 (0.16, 1.03) 0.074 Combinationa abnormal Incomplete 30 (40) Ref. Combination abnormal Complete 6 (18) 0.32 (0.12, 0.87) Combination normal No 11 (19) 0.35 (0.16, 0.78) 0.009 aDistal FFRCT ≤0.80 and ΔFFRCT ≥0.06. bIncomplete (≥1 FFRCT positive lesion not revascularized); complete (All FFRCT positive lesions revascularized); No (No FFRCT positive lesions and revascularization not performed). cBetween group comparison performed using logistic regression.

Conclusion

Revascularization based on classification by FFRct is associated with symptomatic relief at 1-year follow-up in patients with stable chest pain.

P5997GLP-1(28-36) prevents progression of ischemic heart failure in mice

Background

Glucagon-like peptide-1 (GLP-1), its metabolites and related drugs have demonstrated cardioprotective benefits in several animal models of cardiovascular disease (CVD) and select clinical trials. Indeed, large cardiovascular outcome trials (CVOT) of GLP-1 analogs showed significant reductions in major adverse cardiovascular events (MACE). However, smaller studies in patients with heart failure (HF) (e.g. FIGHT), and secondary analyses of some CVOT (e.g. LEADER), have suggested that the cardiovascular benefits of GLP-1 analogs may be muted in select patients. Speculating on how this may be due to undesirable increases in heart rate caused by activation of sinoatrial GLP-1 receptors (Glp1r), we have explored the Glp1r-independent cardioprotective actions of GLP-1(28–36), a neutral endopeptidase (NEP)-derived metabolite of GLP-1. We have shown that the cardioprotective effects of GLP-1(28–36) are mediated by mitochondrial trifunctional protein-α (MTPα)-dependent metabolic shift from fatty acid- to glucose oxidation in coronary vascular cells. As metabolic perturbations are believed to contribute to the pathophysiology of HF, we hypothesized that treatment with GLP-1(28–36) may have beneficial effects on this condition.

Purpose

To evaluate if treatment with GLP-1(28–36) can prevent onset of HF and/or reverse established HF in a post-MI mouse model.

Methods and results

Permanent LAD ligation was performed in 10–12wk old male C57BL/6J wild-type mice (wt). Immediately post-MI, mice were assigned to receive either GLP-1(28–36) or scrambled peptide [Scram(28–36)] at 18.5nmol/kg/d (N=30/group) subcutaneously (s.c.) via osmotic mini-pumps for 4wk. Although, treatment with GLP-1(28–36) did not improve post-MI survival, triphenyltetrazolium chloride (TTC)-stained hearts 28d post-MI reveal smaller infarct size in GLP-1(28–36)- vs. Scram(28–36)-treated mice (35.3±1.9% vs. 41.2±1.7%, N=12–15/group, P<0.05). Echocardiography at 28d post-MI showed improved LVEF in mice treated with GLP-1(2–36) (30.1±2.3% vs. 24.2±3.7%, N=12–15/group, P<0.05). Similarly, treatment with GLP-1(28–36) reduced heart/body weight ratio (7.9±0.3 vs. 8.8±0.4 mg/g, N=12–15/group, P<0.05). Next, we tested if GLP-1(28–36) might reverse ischemic HF in this model. After permanent LAD ligation of 10–12wk old male wt mice, only those with echocardiography-defined LVEF between 20–35% at 28d post-MI were randomized to treatment with GLP-1(28–36) or Scram(28–36) [18.5nmol/kg/d (N=15/group)] via s.c. mini-pumps for 4wk. Echocardiography at 56d post-MI (i.e. 28d post-treatment start) revealed that GLP-1(28–36) preserved LV function with no deterioration in LVEF vs. Scram(28–36)-treated controls [−3.1±4.9% vs. −22.8±4%, relative change, N=15/group, P<0.001].

Conclusion

In a post-MI mouse model of HF, treatment with GLP-1(28–36) prevents progression to HF, and preserves LV function after the development of established HF.

Acknowledgement/Funding

This study was funded by a Fellowship from Ted Rogers Centre for Heart Research and a Project Grant from Heart and Stroke Foundation, Canada

Transcranial photobiomodulation with 1064-nm laser modulates brain electroencephalogram rhythms

Noninvasive transcranial photobiomodulation (tPBM) with a 1064-nm laser has been reported to improve human performance on cognitive tasks as well as locally upregulate cerebral oxygen metabolism and hemodynamics. However, it is unknown whether 1064-nm tPBM also modulates electrophysiology, and specifically neural oscillations, in the human brain. The hypothesis guiding our study is that applying 1064-nm tPBM of the right prefrontal cortex enhances neurophysiological rhythms at specific frequency bands in the human brain under resting conditions. To test this hypothesis, we recorded the 64-channel scalp electroencephalogram (EEG) before, during, and after the application of 11 min of 4-cm-diameter tPBM (CW 1064-nm laser with 162    mW / cm 2 and 107    J / cm 2 ) to the right forehead of human subjects ( n = 20 ) using a within-subject, sham-controlled design. Time-resolved scalp topographies of EEG power at five frequency bands were computed to examine the tPBM-induced EEG power changes across the scalp. The results show time-dependent, significant increases of EEG spectral powers at the alpha (8 to 13 Hz) and beta (13 to 30 Hz) bands at broad scalp regions, exhibiting a front-to-back pattern. The findings provide the first sham-controlled topographic mapping that tPBM increases the strength of electrophysiological oscillations (alpha and beta bands) while also shedding light on the mechanisms of tPBM in the human brain.

Analytical and computational studies of the nonlinear vibrations of SWCNTs embedded in viscous elastic matrix using KBM method

The forced vibration analysis of single wall carbon nanotubes (SWCNTs) embedded in the viscous elastic matrix subjected to axial parametric excitation has been investigated. The Euler Bernoulli beam model of the non-local continuum theory is used. The resonant and non-resonant solutions are analytically studied using the Krylov Bogoliubov and Mitropolsky method. It has been seen that the amplitude remains constant up to the second order of approximation. The resonant solutions are also found to analyze the possibility of chaos in the neighborhood of resonance. The computational techniques are used, and plots of time series, phase plot, and Poincaré surface of section are also drawn to confirm the chaotic behavior for certain values of parameters of SWCNTs, which may lead the aging process in the SWCNTs after a long time.

The anatomy of apathy: A neurocognitive framework for amotivated behaviour

Apathy is a debilitating syndrome associated with many neurological disorders, including several common neurodegenerative diseases such as Parkinson's disease and Alzheimer's disease, and focal lesion syndromes such as stroke. Here, we review neuroimaging studies to identify anatomical correlates of apathy, across brain disorders. Our analysis reveals that apathy is strongly associated with disruption particularly of dorsal anterior cingulate cortex (dACC), ventral striatum (VS) and connected brain regions. Remarkably, these changes are consistent across clinical disorders and imaging modalities. Review of the neuroimaging findings allows us to develop a neurocognitive framework to consider potential mechanisms underlying apathy. According to this perspective, an interconnected group of brain regions - with dACC and VS at its core - plays a crucial role in normal motivated behaviour. Specifically we argue that motivated behaviour requires a willingness to work, to keep working, and to learn what is worth working for. We propose that deficits in any one or more of these processes can lead to the clinical syndrome of apathy, and outline specific approaches to test this hypothesis. A richer neurobiological understanding of the mechanisms underlying apathy should ultimately facilitate development of effective therapies for this disabling condition.

Apathy in rapid eye movement sleep behaviour disorder is common and under-recognized

BACKGROUND AND PURPOSE

Apathy is an important neuropsychiatric feature of Parkinson's disease (PD), which often emerges before the onset of motor symptoms. Patients with rapid eye movement sleep behaviour disorder (RBD) have a high probability of developing PD in future. Neuropsychiatric problems are common in RBD, but apathy has not previously been detailed in this key prodromal population.

METHODS

Eighty-eight patients with polysomnographically proven RBD, 65 patients with PD and 33 controls were assessed for apathy using the Lille Apathy Rating Scale. Cognition and depression were also quantified. The sensitivity of the Unified Parkinson's Disease Rating Scale screening questions for apathy and depression was calculated.

RESULTS

A total of 46% of patients with RBD were apathetic, compared with 31% of patients with PD in our sample. Most patients with RBD with depression were apathetic but more than half of apathetic patients were not depressed. The sensitivity of the single Unified Parkinson's Disease Rating Scale screening question was only 33% for mild apathy and 50% for severe apathy.

CONCLUSIONS

Apathy is common in RBD and is underestimated by a single self-report question. Recognition of apathy as a distinct neuropsychiatric feature in RBD could aid targeted treatment interventions and might contribute to the understanding of prodromal PD.

Cold Wall CVD (CWCVD) in the Synthesis of Few Layered Graphene on Ni.. [DOI: 10.20944/preprints201705.0217.v1]

We report the growth of graphene at a low temperature using the cold wall chemical vapor deposition technique (CWCVD). Few layered (~6-8 layers) graphene were grown on nickel-coated silicon with acetylene as the precursor gas. The advantage of the combination of the acetylene (as a carbon feedstock) and the nickel catalyst was the lowering of the graphene growth temperature. Nickel coated silicon samples were pre-treated (heat treatment in inert atmosphere) before the growth and the effect of the pre-treatment on the catalyst as well as on the grown film was studied. The final samples were characterized with scanning electron microscopy and Raman spectroscopy. In CWCVD route, the heating of only the substrate holder enabled high heating and cooling rates, which, along with the control over partial pressure of the precursor gas had profound effect on the formation of graphene. In the best sample we have achieved almost equal intensity of the G and 2D peaks in Raman spectrum, which implied about ~6-8 layers of Graphene. The defect peak (the D band) was extremely small in the sample and it was attributed to the ripples and the underlying roughness of the nickel film. We analyzed that a proper choice of the thickness of catalyst layer and a higher cooling rate after graphene growth it would be possible to obtain monolayered graphene. Similar samples grown in a normal atmospheric CVD (with some engineered design to promote fast cooling) were also compared with the cold wall CVD grown samples and plasma assisted CWCVD, and cold-wall CVD demonstrated a better control over the quality of graphene film through the fast cooling and a controlled partial pressure of the precursor gas.