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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Risk profiles and incidence of cardiovascular events across different cancer types

BACKGROUND

Cancer survivors are at increased risk for cardiovascular (CV) disease, although additional data are needed to better understand the incidence of CV events across different malignancies. This study sought to characterize the incidence of major adverse CV events [myocardial infarction, stroke, unstable angina (MACE), or heart failure (HF)] across multiple cancer types after cancer diagnosis.

PATIENTS AND METHODS

Patients were identified from a USA-based administrative claims database who had index cancer diagnoses of breast, lung, prostate, melanoma, myeloma, kidney, colorectal, leukemia, or lymphoma between 2011 and 2019, with continuous enrollment for ≥12 months before diagnosis. Baseline CV risk factors and incidence rates of CV events post-index were identified for each cancer. Multivariable Cox hazards models assessed the cumulative incidence of MACE, accounting for baseline risk factors.

RESULTS

Among 839 934 patients across nine cancer types, CV risk factors were prevalent. The cumulative incidence of MACE was highest in lung cancer and myeloma, and lowest in breast cancer, prostate cancer, and melanoma. MACE cumulative incidence for lung cancer was 26% by 4 years (2.7-fold higher relative to breast cancer). The incidence of stroke was especially pronounced in lung cancer, while HF was highest in myeloma and lung cancer.

CONCLUSIONS

CV events were especially increased following certain cancer diagnoses, even after accounting for baseline risk factors. Understanding the variable patient characteristics and associated CV events across different cancers can help target appropriate CV risk factor modification and develop strategies to minimize adverse CV events and improve patient outcomes.

Machine learning for predicting diabetic metabolism in the Indian population using polar metabolomic and lipidomic features

AIMS

To identify metabolite and lipid biomarkers of diabetes in the Indian subpopulation in newly diagnosed diabetic and long-term diabetic individuals. To utilize the global polar metabolomic and lipidomic profiles to predict the susceptibility of an individual to diabetes using machine learning algorithms.

MATERIALS AND METHODS

87 individuals, including healthy, newly diabetic, and long-term diabetics on medication, were included in the study. Post consent, their serum was used to isolate polar metabolome and lipidome. NMR and LCMS were used to identify the polar metabolites and lipids, respectively. Statistical analysis was done to determine significantly altered molecules. NMR and LCMS comprehensive data were utilized to generate diabetic models using machine learning algorithms. 10 more individuals (pre-diabetic) were recruited, and their polar metabolomic and lipidomic profiles were generated. Pre-diabetic metabolic profiles were then utilized to predict the diabetic status of the metabolome and lipidome beyond glucose levels.

RESULTS

Mannose, Betaine, Xanthine, Triglyceride (38:1), Sphingomyelin (d63:7), and Phosphatidic acid (37:2) are some of the top key biomarkers of diabetes. The predictive model generated showed the receiver operating characteristic area under the curve (ROC-AUC) as 1 on both test and validation data indicating excellent accuracy. This model then predicted the diabetic closeness of the metabolism of pre-diabetic individuals based on probability scores.

CONCLUSION

Polar metabolic and lipid profile of diabetic individuals is very different from that of healthy individuals. Lipid profile alters before the polar metabolic profile in diabetes-susceptible individuals. Without regard to glucose, the diabetic closeness of the metabolism of any individual can be determined.

AN IN-DEPTH ASSESSMENT OF THE TUMOR'S IMPACT ON SARCOPENIA

Loss of muscle mass is a typical symptom of cancer and it is strongly correlated with poor prognosis. Cancer-related Sarcopenia is unresponsive to conventional dietary changes and exercise, in contrast to age-associated muscle atrophy. This particular type of weakness differs from different kinds of muscle loss in that it is triggered by a number of interrelated mechanisms, notably inflammatory processes, abnormal metabolic processes, proteolysis, and autophagy. This research is to examine evidence supporting the theory that tumors have a causal role in causing muscular atrophy. It seeks to investigate the precise regulators that the tumour generates and how they affect the processes that result in muscle waste. The evaluation looks for new directions for further studies and medical treatments. The analysis is based on a thorough examination of the scientific literature and research that shows how tumor and muscle atrophy are related. It concentrates on studies that clarify the numerous strategies by which malignancies cause the loss of muscle. This article highlights particular mechanisms by which these tumor-derived substances affect the development of muscle loss, including inflammatory processes, metabolic disturbance, proteolysis, and autophagy. The discovery of such targets offers hope for the creation of efficient treatment strategies that can enhance the long-term outlook and quality of life of cancer sufferers who are experiencing muscle loss.

Dorsal Column Myelopathy Following Intrathecal Chemotherapy for Leukemia

PURPOSE/OBJECTIVE(S)

Intrathecal (IT) methotrexate (Mtx) and/or cytarabine (AraC) improve CNS disease control in patients (pts) with hematologic malignancies. There are increasing number of case reports of irreversible, primarily dorsal column myelopathy in pts treated with IT chemotherapy. By describing the largest case series of myelopathy following IT chemotherapy, we aim to raise awareness about this devastating albeit rare complication.

MATERIALS/METHODS

We retrospectively reviewed 25 pts with leukemia who developed paraplegia following IT chemotherapy between 2/2006 and 9/2021. Clinical/treatment characteristics, response, and toxicity were extracted from the medical records.

RESULTS

Seventeen pts (68%) were male, 16 had B-cell ALL (64%), 4 had AML (16%), 2 had CML (8%), 2 had T-ALL (8%), and 1 had BPDCN (4%). The median age at diagnosis was 38 years (IQR 30-59). All pts required systemic salvage treatment after induction chemotherapy with a median number of 3 regimens received (IQR 2-5.5). In total, the median number of IT treatments was 19 per pt (IQR 14-27). Most pts (84%, n = 21) received single agent IT Mtx alternating with single agent AraC. Fifteen pts (60%) received triple IT therapy with a median of 3 treatments (IQR 0-8). Prior to the onset of myelopathy, 10 pts (40%) received allogeneic SCT and 9 pts (36%) were treated with radiation therapy. Median follow-up from diagnosis was 1.9 yrs (IQR 1.3-4.1). Myelopathy was progressive and irreversible in all pts (n = 25); 84% (n = 21) experienced sensory loss, and all pts had extremity weakness. Symptoms were ascending in 11 pts (44%) and descending in 4 pts (16%). Irreversible bowel/bladder incontinence developed in 12 pts (48%). CSF analysis at the time of symptom onset was negative for leukemia cells in most pts (n = 21, 84%) and showed malignant cells in 4 pts (16%). CSF studies showed elevated protein in 21 pts (84%). Myelin basic protein was elevated in all 13 assessed pts. On T2 weighted spinal MRI, all pts had enhancement of the dorsal columns, including 80% of pts with this dorsal column abnormality reported at the time of the study and 20% of pts (n = 5) with the dorsal enhancement noted retrospectively. Due to concern for occult disease, 20 pts (80%) received additional CNS-directed therapy after symptom onset. Twenty-two pts (88%) died at last follow-up. The time between neurological symptom onset and death was a median 3.5 months (IQR 2.6 and 5). Three pts (12%) are alive with paraplegia at a median of 4.4 years from symptom onset.

CONCLUSION

Dorsal column myelopathy is a rare but devastating condition that can occur after IT chemotherapy in heavily pre-treated leukemia pts. T2 weighted spinal MRI can be helpful in the evaluation of pts that present with unexplained weakness and sensory changes. We recommend delaying additional CNS-directed therapy until work-up to rule out alternative etiologies is complete. Future strategies are desperately needed to address this irreversible treatment complication.

Abstract 4066: Lipid nanoparticle library towards development next generation genomic medicines

Ionizable amino lipids are a major constituent of the lipid nanoparticles for delivering nucleic acid therapeutics (e.g., DLin-MC3-DMA in ONPATTRO®, ALC-0315 in Comirnaty®, SM-102 in Spikevax®). Scarcity of lipids that are suitable for cell therapy, vaccination, and gene therapies continue to be a problem in advancing many potential diagnostic/therapeutic/vaccine candidates to the clinic.

Herein, we describe the development of novel ionizable lipids to be used as functional excipients for designing vehicles for nucleic acid therapeutics/vaccines in vivo or ex vivo use in cell therapy applications. We first studied the transfection efficiency (TE) of LNP-based mRNA formulations of these ionizable lipid candidates in primary human T cells and established a workflow for engineering of primary immune T cells. We then adapted this workflow towards bioengineering of CAR constructs to T cells towards non-viral CAR T therapy. Lipids were also tested in rodents for vaccine applications using self-amplifying RNA (saRNA) encoding various antigens. We have then evaluated various ionizable lipid candidates and their biodistribution along with the mRNA/DNA translation exploration using various LNP compositions. Further, using ionizable lipids from the library, we have shown gene editing of various targets in rodents.

We believe that these studies will pave the path to the advancement in nucleic acid based therapeutics and vaccines, or cell & gene therapy agents for early diagnosis and detection of cancer, and for targeted genomic medicines towards cancer treatment and diagnosis.

Citation Format: Anitha Thomas, Nikita Jain, Sedigheh Nazaripour, Rehan Higgins, Zhengyu Chen, Suraj Abraham, Leanna Yee, Srinivas Abbina, Gayatri Mehar Namala, Helena Son, Sams Sadat, Sijo Chemmannur, Malathi Anantha, Ruchi Sharma, Kobe Tickner, Eve Boyer, Shannon Tsai, Seetalakshmi Thambatti, Vinay Mayya, Emily Soon, Jay Paquette. Lipid nanoparticle library towards development next generation genomic medicines. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4066.

Abstract 1785: Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles

Autologous chimeric antigen receptor (CAR) T therapies utilize patient cells and can be limited by cell quality, and the high manufacturing burden of viral vectors. As such, there is a need for allogeneic, “off-the-shelf” CAR T cells to make these transformative treatments widely available. However, allogeneic therapies require multiple genetic engineering steps to express CAR and to delete proteins responsible for graft-versus-host disease. Messenger RNA (mRNA) is a promising approach for expression of therapeutic proteins and gene editing nucleases. In this work, we demonstrate a new method for multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles (LNPs).

LNPs encapsulating Spy-Cas9 mRNA, TCR and CD52 guide RNA (sgRNA), and CAR mRNA were produced using microfluidics. The CAR construct contained an anti-CD19 scFv binding domain and CD3ζ/4-1BB co-stimulatory domains. Microgram quantities of RNA LNPs were produced to optimize LNP packaging, cargo ratios, and sgRNA combinations. Lead candidates were scaled to milligrams. Purified human primary T cells were cultured, activated, and expanded in serum-free media in plates, flasks and bioreactors. CAR+, TCR− or CD52− cells were generated by addition of the corresponding LNP to activated cells. Cytotoxic killing was determined by co-culture assays with leukemia cells. Gene knockout, CAR expression, viability and cell killing were measured using flow-cytometry.

CD19 CAR was selected as a relevant protein for expression, with TCR and CD52 proteins as gene knockout targets. Single-step addition of CAR LNPs to T cells resulted in transfection efficiencies of 95.0 ± 2.1% and high protein expression. Upon TCR or CD52 LNP addition to T cells, the onset of gene editing was within 48 hours, reaching single target knockout efficiencies of 92.3 ± 3.0% (TCR−), and double knockouts (TCR−/CD52−) of 74.5 ± 6.1%. Similar results were obtained when comparing different LNP batch sizes (microgram to milligram RNA) and cell culture vessels (125,000 to 45 million cells), demonstrating scalability of both the LNP production and cell treatment. Cell viabilities above 90% were maintained at all steps and for all RNA LNPs. Finally, as proof-of-concept for multi-step engineering, sequential addition of TCR LNPs and CAR LNPs resulted in simultaneous CAR expression and TCR gene knockout. These “off-the-shelf” gene-edited CAR T cells were functionally equivalent to non-edited cells in a B cell killing assay, efficiently clearing over 80% of leukemia target cells at a 1:1 ratio.

Our findings demonstrate the advantages of LNPs for RNA delivery to T cells. The simple and gentle nature of LNP cell treatment allows for multiple genetic engineering steps for simultaneous expression and deletion of proteins. Furthermore, LNPs can be easily manufactured using microfluidics, enabling small-scale screening of RNA libraries and rapid scale-up of lead candidates for clinical translation.

Citation Format: Samuel Clarke, R Geczy, A Balgi, S Park, R Zhao, M Swaminathan, R Tieu, N Hoang, C Webb, E Watt, M Wong, M Fujisawa, N Jain, Angela Zhang, Anitha Thomas. Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1785.

Pap Smear and Colposcopic Examination of the Cervix in Pelvic Inflammatory Disease and other Gynaecological Conditions: A Prospective Analytical Study

Introduction: Pap smear and colposcopy are commonly done procedures in gynaecology practice. The Pap test is a low-cost, straight forward, and widely used tool for detecting cervical cancer and preinvasive cervical abnormalities. Colposcopy is also widely used to detect Cervical Intraepithelial Neoplasia (CIN) to guide cervical biopsy sites with clinical symptoms of suspected cervical diseases. Aim: To evaluate the diagnostic implications of Pap smear and colposcopy in inflammatory cellular changes and to estimate the incidence of Cervical Intraepithelial Neoplasia (CIN)/invasive carcinoma in the study population through biopsy. Materials and Methods: This prospective analytical study was conducted at JNU Medical College, Jaipur, India, where Pelvic Inflammatory Disease (PID), and other gynecology Out Patient Department (OPD) patients without any previous diagnosis of cervical malignancy, were included in the study. A total of 150 study patients, underwent Pap smear and colposcopic examination with biopsy as the gold standard. Descriptive analysis of data was done using means and standard deviation for continuous variables and nominal variables as frequencies. The Chi-square test was applied to categorical variables to find out the association and Receiver Operating Characteristic (ROC) analysis was done to predict the diagnostic ability of Pap smear, and colposcopy in cervical pathology. Results: The mean age of the patient population was 36±3 years. The mean age at first coitus and marriage of all the women were 18.9±2.7 years and 19.5±3.4 years, respectively. Twenty (13.3%) and 5 (3.3%) cases were reported as CIN and carcinoma, respectively after colposcopic biopsy. Pap smear results showed a sensitivity of 87.7% and a specificity of 78.2%. The Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 72.8% and 68.7%, respectively. Sensitivity of the colposcopic report was 89.4% and the specificity was 98.8%. The PPV is 96.6% and NPV is 82.3% for colposcopic report. Conclusion: This study suggested that PID and gynaecology OPD patients can be better targeted with a good opportunity for screening the potential premalignant changes in the cervix by using Pap smear and colposcopy.

Covert Conditioning for Persistent Aggressive Behaviors: A Case Illustration

In psychotherapy practice and training, single case study design plays an indispensable role by effectively articulating the application of textbook knowledge, thereby bridging the gap between theory and practice. This article, on similar lines, illustrates one such successful example of the application of the classical behavioral technique of covert conditioning modified with a component of verbal challenging. A woman in her late-thirties reported with long-standing seemingly-resistant-to-treat symptoms of aggressive behavior of beating children. The client had a total of 10 daily sessions of 60-90 minutes each. By the end of one week, she reported not beating children in this period. She felt extremely relieved because it had happened for the first time in 10 years. The intensity of anger had decreased drastically, and she was not shouting any longer. She had to discontinue sessions abruptly due to unavoidable circumstances. Although she was suggested to follow up the intensive sessions again, she was not able to do it due to feasibility issues. The improvement was maintained on follow-up visits after two weeks, four weeks, and three months.

Long-term passive wastewater surveillance of SARS-CoV-2 for seven university dormitories in comparison to municipal surveillance

Wastewater-based surveillance (WBS) has been an effective tool for monitoring and understanding potential SARS-CoV-2 transmission across small and large-scale communities. In this study at the University of Saskatchewan, the assessment of SARS-CoV-2 was done over eight months during the 2021-2022 academic year. Wastewater samples were collected using passive samplers that were deployed in domestic sewer lines near adjacent campus residences and extracted for viral RNA, followed by Reverse Transcription quantitative Polymerase Chain Reaction (RT-qPCR). The results showed similar trends for SARS-CoV-2 detection frequencies and viral loads across university residences, the whole campus, and from related WBS at Saskatoon Wastewater Treatment Plant. The maximum daily detection frequency for seven dormitories considered was about 75 %, while maximum daily case numbers for the residences and campus-wide were about 11 and 75 people, respectively. In addition, self-reported rates of infection on campus peaked during similar time frames as increases in viral load were detected at the Saskatoon wastewater treatment plant. These similarities indicate the usefulness and cost-effectiveness of monitoring the spread of COVID-19 in small-scale communities using WBS.

Analysis of increased paclitaxel hypersensitivity at a single institution in setting of COVID 19 vaccination

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Background: Paclitaxel is a commonly used chemotherapy agent effective in various malignancies. It is known to cause serious and potentially life-threatening hypersensitivity reactions (HRs). Pre-medication protocols have been employed, however approximately 10% of patients will still experience these reactions (1). On an internal review at the University of Louisville, Brown Cancer Center (UofL, BCC) there has been a considerable increase in the incidence of paclitaxel HRs from 4.2% in March 2020 - March 2021 to 14.8% in March 2021 - April 2022. Identifying risk factors that may predispose patients to these reactions is an area of interest in an effort to reduce these events. In this study we investigated clinical characteristics between patients that tolerated paclitaxel versus those who had a HR within the last year with a particular focus on the COVID-19 vaccine given the recent pandemic. Methods: This is a single center retrospective case-control study done at the UofL, BCC. Data was collected on patients who received cycle one day one paclitaxel from March 2021 to April 2022 (n = 135), and patients who developed a reaction were identified. Patient characteristics including demographics, COVID vaccination status, and prior allergies were also collected (table). A T-test analysis was performed between the two groups – those who had a HR and those who did not. Results: Of the 135 patients, 20 were found to have a HR. Absolute lymphocyte count (ALC) was found to be significantly higher with an average of 1125 in the HR group versus 853 in the no reaction group (p = 0.0357). Patients in the HR group also had fewer lines of chemotherapy with an average of 1.15 versus the no reaction group of 1.4 (p = 0.039). There was no significant difference between patients who received the COVID-19 vaccine and those who did not (table). Conclusions: Patients who experienced paclitaxel HRs were found to have higher levels of ALC and tend to be earlier in their treatment course with having undergone fewer lines of chemotherapy. Of note COVID-19 vaccination status appears to have no association with those experiencing paclitaxel HRs. The clinical implications of this requires further exploration in future studies[Table: see text]

Impact of wallet cards compared to conventional chemotherapy education in patients with newly-diagnosed cancer

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Background: According to American Cancer Society, 1.9 million new cases of cancer were diagnosed in year 2021, majority of who will undergo chemotherapy (1). With these treatments, there is often an overwhelming amount of information given to patients. We will first assess the percentage of new cancer patients that can recall their cancer treatments with the current patient education format. We then aim to improve patient understanding of their treatment with the introduction of a chemotherapy wallet card. Methods: This is a single center prospective cohort study at the University of Louisville, Brown Cancer Center. In phase one 50 new patients will be recruited from various oncology clinics who will receive conventional verbal chemotherapy education. On cycle two of their treatment, we will administer a survey (figure 1) to assess their understanding of their regimen. In phase two we will recruit 50 new patients and introduce a chemotherapy wallet card filled by the pharmacist to be given during their chemotherapy education and administer the survey on cycle two. We will then compare these two populations to evaluate the impact of the chemotherapy wallet cards. Results: Preliminary results from the first phase have been obtained of 15 newly diagnosed cancer patients. Surveys obtained on cycle two revealed 100% patients correctly identified their cancer diagnosis and 60% were able to correctly name their chemotherapy regimen. 53% of patients were able to identify three correct treatment side effects. Conclusions: Preliminary results show 60% of patients have suboptimal identification of their chemotherapy regimens. Previous studies have shown many patients will visit the emergency department in their first year of treatment. This is of concern as patients may not be able to provide accurate information of their current treatment to these providers resulting in suboptimal care. Our goal will be to see if chemotherapy wallet cards will help to increase patient knowledge and improve patient quality of care.[Table: see text]

OX40 agonist stimulation increases and sustains humoral and cell-mediated responses to SARS-CoV-2 protein and saRNA vaccines

To prevent SARS-CoV-2 infections and generate long-lasting immunity, vaccines need to generate strong viral-specific B and T cell responses. Previous results from our lab and others have shown that immunizations in the presence of an OX40 agonist antibody lead to higher antibody titers and increased numbers of long-lived antigen-specific CD4 and CD8 T cells. Using a similar strategy, we explored the effect of OX40 co-stimulation in a prime and boost vaccination scheme using an adjuvanted SARS-CoV-2 spike protein vaccine in C57BL/6 mice. Our results show that OX40 engagement during vaccination significantly increases long-lived antibody responses to the spike protein. In addition, after immunization spike protein-specific proliferation was greatly increased for both CD4 and CD8 T cells, with enhanced, spike-specific secretion of IFN-γ and IL-2. Booster (3^rd injection) immunizations combined with an OX40 agonist (7 months post-prime) further increased vaccine-specific antibody and T cell responses. Initial experiments assessing a self-amplifying mRNA (saRNA) vaccine encoding the spike protein antigen show a robust antigen-specific CD8 T cell response. The saRNA spike-specific CD8 T cells express high levels of GrzmB, IFN-γ and TNF-α which was not observed with protein immunization and this response was further increased by the OX40 agonist. Similar to protein immunizations the OX40 agonist also increased vaccine-specific CD4 T cell responses. In summary, this study compares and contrasts the effects and benefits of both protein and saRNA vaccination and the extent to which an OX40 agonist enhances and sustains the immune response against the SARS-CoV-2 spike protein.

Periapical dental X-ray image classification using deep neural networks

This paper studies the problem of detection of dental diseases. Dental problems affect the vast majority of the world's population. Caries, RCT (Root Canal Treatment), Abscess, Bone Loss, and missing teeth are some of the most common dental conditions that affect people of all ages all over the world. Delayed or incorrect diagnosis may result in mistreatment, affecting not only an individual's oral health but also his or her overall health, thereby making it an important research area in medicine and engineering. We propose a pipelined Deep Neural Network (DNN) approach to detect healthy and non-healthy periapical dental X-ray images. Even a minor enhancement or improvement in existing techniques can go a long way in providing significant health benefits in the medical field. This paper has made a successful attempt to contribute a different type of pipelined approach using AlexNet in this regard. The approach is trained on a large dataset of 16,000 dental X-ray images, correctly identifying healthy and non-healthy X-ray images. We use an optimized Convolutional Neural Networks and three state-of-the-art DNN models, namely Res-Net-18, ResNet-34, and AlexNet for disease classification. In our study, the AlexNet model outperforms the other models with an accuracy of 0.852. The precision, recall and F1 scores of AlexNet also surpass the other models with a score of 0.850 across all metrics. The area under ROC curve also signifies that both the false-positive rate and false-negative rate are low. We conclude that even with a big data set and raw X-ray pictures, the AlexNet model generalizes effectively to previously unseen data and can aid in the diagnosis of a variety of dental diseases.

Improved COVID-19 detection with chest x-ray images using deep learning

The novel coronavirus disease, which originated in Wuhan, developed into a severe public health problem worldwide. Immense stress in the society and health department was advanced due to the multiplying numbers of COVID carriers and deaths. This stress can be lowered by performing a high-speed diagnosis for the disease, which can be a crucial stride for opposing the deadly virus. A good large amount of time is consumed in the diagnosis. Some applications that use medical images like X-Rays or CT-Scans can pace up the time used in diagnosis. Hence, this paper aims to create a computer-aided-design system that will use the chest X-Ray as input and further classify it into one of the three classes, namely COVID-19, viral Pneumonia, and healthy. Since the COVID-19 positive chest X-Rays dataset was low, we have exploited four pre-trained deep neural networks (DNNs) to find the best for this system. The dataset consisted of 2905 images with 219 COVID-19 cases, 1341 healthy cases, and 1345 viral pneumonia cases. Out of these images, the models were evaluated on 30 images of each class for the testing, while the rest of them were used for training. It is observed that AlexNet attained an accuracy of 97.6% with an average precision, recall, and F1 score of 0.98, 0.97, and 0.98, respectively.

Code status discussions in outpatient setting

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Background: In the face of the COVID 19 pandemic, goal-concordant care has been gaining further significance. Discussions about the care goals are best when they are exploratory, conversational, and longitudinal. Complex information processing is best done outside of a crisis. Ideally, these conversations should start with the primary care clinician who has a longitudinal clinical relationship with the patient. Methods: A quality initiative project was conducted at the Internal Medicine Residency Clinic located in Northwestern Medicine Woodstock Hospital. Review of order entry in electronic medical records and charts for code status was assessed for data gathering. Patients above the age of 65 years presenting for their annual physical visit were included in the study. Various interventions were done, including educating residents through didactic lectures, sending electronic reminders to the residents and formatting a template note including code status documentation. Pre and post-intervention data was gathered. Results: A total of 104 patients were in the pre-intervention group and 94 patients in the post-intervention group. Pre-intervention, code status was addressed in 33% of total patients interviewed during their annual physical visit. Post intervention, code status was addressed in 48% of the patients. Conclusions: This project was undertaken to increase awareness on a crucial aspect of the addressing code status in outpatient setting. Post intervention studies showed that addressing code status significantly increased. In order to fill the gap, we propose that addressing code status be a mandatory process or a reminder be generated in electronic health records.

Melanoma of unknown primary: Favorable survival persists in the immunotherapy era

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Background: Patients with advanced melanoma have historically had better survival in those with unknown primary (MUP) than known primary (MKP). Trends in survival since the introduction of immunotherapy have not been established. Methods: We conducted a retrospective cohort study of patients with advanced/metastatic melanoma (Stage IIIC/IV disease) treated during the period 2014-2020 at the University of Louisville. The primary outcome was overall survival in MUP compared with MKP. Differences in clinical characteristics, BRAF status, tumor mutational burden and PD-L1 tumor proportion score (Dako 22C3 assay) were examined. Differences between numerical variables were calculated based on parametric or non-parametric comparisons accordingly and categorical data analyzed using chi-squared testing. Kaplan-Meier survival analyses were performed with log-rank testing to evaluate differences. Alpha was set at 0.05 for significance. Results: Of the 79 patients with advanced/metastatic melanoma included, 12 had MUP and 67 had MKP. Of those with MKP, the primary site was cutaneous melanoma in 65 and anal melanoma in 2. Clinical characteristics showed the majority were male, with median age of 61 years. There were no significant differences in demographics, distribution of stage, BRAF status, TMB, PDL-1 score or treatment modality between MUP and MKP groups (Table). The median follow-up time overall was 50 months. The MUP group demonstrated significantly better survival with 3-year OS of 92% vs. 62% in MKP, and 5-year OS of 83% vs 44% in MKP. Median survival was 54 months for MKP and not reached for MUP. For MKP, the 5-year OS of 44% compares similarly to other cohorts. The Keynote-001 trial of advanced/metastatic melanoma treated with pembrolizumab reported 5-year OS of 41%. This is approximately a 4-fold improvement compared to cohorts treated before the approval of immunotherapy, where the 5-year OS was in the range of 10% [Lee et al, 2009]. The 5-year OS for metastatic MUP was previously in the range of 18%, also suggesting improvement by about 4-fold with the use of immunotherapy. Conclusions: Melanomas of unknown primary continue to have better survival with durable response on immunotherapy even in the advanced/metastatic setting. The exact mechanisms for this survival advantage remain unknown but are likely immune-mediated.[Table: see text]

Pulmonary Endothelial Activation with COVID‐19: Possible Role of Reactive Oxygen Species

Introduction

Recent research suggests that endothelial activation plays a role in COVID‐19 pathogenesis by promoting a pro‐coagulative and pro‐inflammatory state. However, the mechanism by which the endothelium is activated in COVID‐19 is unclear.

Objective

To investigate the mechanism by which COVID‐19 activates the pulmonary endothelium.

Hypothesis

The pulmonary endothelium generates reactive oxygen species (ROS) upon exposure to the “inflammatory load” of the systemic circulation.

Methods

COVID‐19 was recreated in vitro and ex vivo, by exposing human lung endothelial cells (EC) or donor human lung slices (human precision‐cut lung slices or huPCLS) to medium supplemented with serum from COVID‐19 affected subjects. Sera were acquired from patients with COVID‐19 infection admitted to the Intensive Care Unit of the Hospital at the University of Pennsylvania. ROS (fluorescent dye, CellROX) and intercellular adhesion molecule (ICAM‐1) levels were assessed by fluorescence labeling and imaging.

Results

Both EC activation (as monitored by ROS production) and pro‐inflammatory phenotype (as assessed by ICAM‐1), were significantly higher with COVID‐19 as compared to normal subjects.

Conclusions

The endothelium is activated with COVID‐19 via ROS production; thus, the ROS produced drive a pro‐inflammatory phenotype by inducing the expression of ICAM‐1, a pivotal marker of endothelium inflammation. As ROS mediates EC activation and inflammation during COVID‐19, ROS blockade could be a therapeutic target in maintaining vascular health.

Computational structural assessment of BReast CAncer type 1 susceptibility protein (BRCA1) and BRCA1-Associated Ring Domain protein 1 (BARD1) mutations on the protein-protein interface

Breast cancer type 1 susceptibility protein (BRCA1) is closely related to the BRCA2 (breast cancer type 2 susceptibility protein) and BARD1 (BRCA1-associated RING domain-1) proteins. The homodimers were formed through their RING fingers; however they form more compact heterodimers preferentially, influencing BRCA1 residues 1-109 and BARD1 residues 26-119. We implemented an integrative computational pipeline to screen all the mutations in BRCA1 and identify the most significant mutations influencing the Protein-Protein Interactions (PPI) in the BRCA1-BARD1 protein complex. The amino acids involved in the PPI regions were identified from the PDBsum database with the PDB ID: 1JM7. We screened 2118 missense mutations in BRCA1 and none in BARD1 for pathogenicity and stability and analyzed the amino acid sequences for conserved residues. We identified the most significant mutations from these screenings as V11G, M18K, L22S, and T97R positioned in the PPI regions of the BRCA1-BARD1 protein complex. We further performed protein-protein docking using the ZDOCK server. The native protein-protein complex showed the highest binding score of 2118.613, and the V11G mutant protein complex showed the least binding score of 1992.949. The other three mutation protein complexes had binding scores between the native and V11G protein complexes. Finally, a molecular dynamics simulation study using GROMACS was performed to comprehend changes in the BRCA1-BARD1 complex's binding pattern due to the mutation. From the analysis, we observed the highest deviation with lowest compactness and a decrease in the intramolecular h-bonds in the BRCA1-BARD1 protein complex with the V11G mutation compared to the native complex or the complexes with other mutations.

A study of the association between Vitamin D deficiency and Dry Eye Syndrome (DES) in the Indian population

Purpose

A study of the association between vitamin D deficiency and dry eye syndrome (DES) in the Indian population.

Methods

This was a cross-sectional, hospital-based observational study. Sixty patients diagnosed with vitamin D deficiency (<20 ng/dl) who met the inclusion criteria were sent to the Eye OPD from the Endocrinology OPD (case) were compared to 60 subjects with normal vitamin D levels (≥20 ng/dl) who attended the Eye OPD (controls). The examination of the tear film was done using Whatman filter paper in Schirmer test I and Schirmer test I (with anesthesia). The tear film break-up time (TFBUT) was determined by slit-lamp examination using the fluorescein stain, and scoring using the ocular surface disease index (OSDI) was done.

Results

A significant difference in the mean values of Schirmer I and Schirmer I test (with anesthesia) (P < 0.001) was seen between the case and control groups. A significant difference in the mean values of TFBUT (P < 0.001) and OSDI scores (P < 0.01) was also seen between the two groups.

Conclusion

A positive association was found between vitamin D deficiency and dry eye on comparing the above parameters.

COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

A deep learning approach based hardware solution to categorise garbage in environment

Garbage detection and disposal have become one of the major hassles in urban planning. Due to population influx in urban areas, the rate of garbage generation has increased exponentially along with garbage diversity. In this paper, we propose a hardware solution for garbage segregation at the base level based on deep learning architecture. The proposed deep-learning-based hardware solution SmartBin can segregate the garbage into biodegradable and non-biodegradable using Image classification through a Convolutional Neural Network System Architecture using a Real-time embedded system. Garbage detection via image classification aims for quick and efficient categorization of garbage present in the bin. However, this is an arduous task as garbage can be of any dimension, object, color, texture, unlike object detection of a particular entity where images of objects of that entity do share some similar characteristics and traits. The objective of this work is to compare the performance of various pre-trained Convolution Neural Network namely AlexNet, ResNet, VGG-16, and InceptionNet for garbage classification and test their working along with hardware components (PiCam, raspberry pi, infrared sensors, etc.) used for garbage detection in the bin. The InceptionNet Neural Network showed the best performance measure for the proposed model with an accuracy of 98.15% and a loss of 0.10 for the training set while it was 96.23% and 0.13 for the validation set.

Diagnosis and Treatment Planning for Dental Implants – A Review

Establishing and arriving at a diagnosis is the key to treatment planning and often practitioners tend to create a treatment plan overlooking the fundamental principles that must be taken into consideration prior to performing implant surgeries. The sequential process of clinical examination, laboratory tests, radiographic analysis, diagnostic protocols, casts wax ups, along with the treatment needs and desires of the patient have to be factored in for the overall diagnosis and prognosis of implant therapy. A step-by-step methodology has been created to help the implant practitioner with a checklist that aims to create the optimal treatment plan for each case.

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BACKGROUND

Very few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.

METHOD

Endothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.

RESULTS

There was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.

CONCLUSION

Study found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.

Polymeric and lipid nanoparticles for delivery of self-amplifying RNA vaccines

Self-amplifying RNA (saRNA) is a next-generation vaccine platform, but like all nucleic acids, requires a delivery vehicle to promote cellular uptake and protect the saRNA from degradation. To date, delivery platforms for saRNA have included lipid nanoparticles (LNP), polyplexes and cationic nanoemulsions; of these LNP are the most clinically advanced with the recent FDA approval of COVID-19 based-modified mRNA vaccines. While the effect of RNA on vaccine immunogenicity is well studied, the role of biomaterials in saRNA vaccine effectiveness is under investigated. Here, we tested saRNA formulated with either pABOL, a bioreducible polymer, or LNP, and characterized the protein expression and vaccine immunogenicity of both platforms. We observed that pABOL-formulated saRNA resulted in a higher magnitude of protein expression, but that the LNP formulations were overall more immunogenic. Furthermore, we observed that both the helper phospholipid and route of administration (intramuscular versus intranasal) of LNP impacted the vaccine immunogenicity of two model antigens (influenza hemagglutinin and SARS-CoV-2 spike protein). We observed that LNP administered intramuscularly, but not pABOL or LNP administered intranasally, resulted in increased acute interleukin-6 expression after vaccination. Overall, these results indicate that delivery systems and routes of administration may fulfill different delivery niches within the field of saRNA genetic medicines.

Toward Integrated CNN-based Sentiment Analysis of Tweets for Scarce-resource Language—Hindi

Linguistic resources for commonly used languages such as English and Mandarin Chinese are available in abundance, hence the existing research in these languages. However, there are languages for which linguistic resources are scarcely available. One of these languages is the Hindi language. Hindi, being the fourth-most popular language, still lacks in richly populated linguistic resources, owing to the challenges involved in dealing with the Hindi language. This article first explores the machine learning-based approaches—Naïve Bayes, Support Vector Machine, Decision Tree, and Logistic Regression—to analyze the sentiment contained in Hindi language text derived from Twitter.

Further, the article presents lexicon-based approaches (Hindi Senti-WordNet, NRC Emotion Lexicon) for sentiment analysis in Hindi while also proposing a Domain-specific Sentiment Dictionary. Finally, an integrated convolutional neural network (CNN)—Recurrent Neural Network and Long Short-term Memory—is proposed to analyze sentiment from Hindi language tweets, a total of 23,767 tweets classified into positive, negative, and neutral. The proposed CNN approach gives an accuracy of 85%.

Syncope as the Initial Manifestation of a Late-Stage Renal Cell Carcinoma With Metastasis to the Brain

Renal cell carcinoma (RCC) is the most common neoplasm that arises from renal parenchyma. About one-third of patients with RCC develop metastatic spread, with common sites including the lung, liver, bone, adrenal gland, and brain. Distant metastases can be difficult to detect unless symptoms appear. We report a case of a 56-year-old female who presented to the emergency department with the unresponsiveness of unknown duration. She underwent a thorough laboratory workup, and the computed tomography (CT) scan revealed a retroperitoneal mass originating from the right kidney and a large hemorrhagic brain mass in the left frontal lobe. The patient underwent emergent full craniotomy for tumor removal, and histology confirmed metastatic RCC. Since several patients with RCC are asymptomatic, the slow growth of tumors leading to distant metastasis can be overlooked. Thus, this case demonstrates the importance of early detection of RCC to help prevent or delay further disease progression.

952 In-Patient Trauma Surgery in COVID-19 Positive Patients Carries A Significantly Higher Mortality Risk When Compared to In-Patient Covid-19 Negative Patients and Day Case Trauma Patients

Introduction

Covid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19.

Method

We reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23^rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups.

Results

In total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p < 0.001). A higher mortality rate was observed in patients with symptoms but a negative Covid-19 test (6.7%) than patients in whom a test was never indicated (2.3%).

Conclusion

Covid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

866 A Lateral Approach Is More Likely to Be Successful Than A Posterior Approach for An Injection to Reach the Subacromial Space

Background

Subacromial injections are common for diagnosis and therapy of shoulder impingement secondary to subacromial bursitis. We evaluated the likelihood of a successful subacromial injection from both the posterior and lateral injection sites.

Method

We reviewed 100 MRI scans of the shoulder and recorded measurements in both the sagittal (representative of posterior injection) and coronal (representative of lateral injection) orientations. We compared these to the lengths of standard needles.

Multiple measurements were taken:

Results

Measuring along the angle of the acromion demonstrated shorter mean distances from the lateral injection site. The distance from skin to mid-point of the acromion) provided mean values of 51.4mm for posterior and 40.1mm for lateral. A standard 40mm (green) needle would reach the midpoint of the acromion in 58% of lateral measurements and 23% from posterior.

Conclusions

Injections are more likely to enter the subacromial space from a lateral rather than a posterior entry point.

384 Use of A Dry Swab During ACL Hamstring Tendon Graft Preparation May Lead to Decreased Graft Diameter at Implantation with Subsequent Rebound in Graft Diameter When Exposed to Haemarthrosis – A Porcine Tendon Study

Introduction

ACL reconstruction surgery commonly utilises a hamstring tendon graft. Grafts are normally covered with a wet swab prior to implantation. The aim of this study was to determine the variance in graft diameter when comparing the traditional wet swab to a dry swab.

Method

Flexor tendons from a selection of fresh pig trotters were isolated and prepared with a standard ACL graft preparation technique. Half of the grafts were covered with a wet swab; the other half were covered with a dry swab. Graft diameters were measured at 10-minute intervals. After 30 minutes the grafts were submerged in Hartmann’s solution to simulate the post-operative haemarthrosis, diameters were checked again after 1 hour in the solution.

Results

Use of a dry swab resulted in a 0.5mm greater reduction in diameter than the wet swab group. The dry swab group also showed an increase in diameter by 0.5mm when soaked in Hartmann’s solution, this was not seen in the wet swab group.

Conclusions

Using a dry swab produces a smaller graft diameter, this would allow smaller bone tunnels, retaining bone stock. The subsequent rebound in diameter when in solution may increase the press fit mechanism and facilitate improved integration into the bone tunnel.

890 Predictive Factors for Mortality Following Trauma & Orthopaedic Surgery in The Covid-19 Pandemic. The Manchester Equation

Introduction

Covid-19 caused many service changes including limitations on operations due to potential increased mortality risk to patients. We report our findings from Trauma & Orthopaedic (T&O) surgical mortality through this period and the effectiveness of using a scoring system (The Manchester Equation) to predict likelihood of mortality.

Method

We reviewed all T&O admissions that underwent surgical intervention during the height of the pandemic. We recorded numerous factors for each patient including mortality and Covid status. From this we created a scoring system which is the product of Covid status, Anaesthetic type, Medical co-morbidities and other medical factors and ASA Score. We then analysed the findings to determine whether the score could be predictive of mortality rate.

Results

Of 123 patients undergoing surgery 6 deaths were observed (mean score of 51.3) compared to 117 patients surviving (mean score 31.9), p = 0.001. A score of less than 32 carried a 0% chance of death whereas a score of 32 or more resulted in a 14.6% mortality rate (p = 0.01).

Conclusion

The Manchester Equation can be used to help predict the mortality rate of T&O surgery in the presence of Covid-19 and may be useful for clinical decision making and consent purposes.

Leptomeningeal Carcinomatosis in Epithelial Ovarian Cancer: A Diagnostic Challenge

Leptomeningeal carcinomatosis (LCM), also known as neoplastic meningitis, is a rare entity. It is generally seen in solid tumors. Ovarian cancers can infrequently cause LCM. The clinical presentation is variable. Diagnosis is made by a lumbar puncture that shows malignant cells in the cerebrospinal fluid (CSF) and usually correlates with imaging findings. Given the low individual sensitivities of lumbar puncture (55%) and magnetic resonance imaging (70%), it is recommended to combine both modalities for optimal diagnostic results. Treatment options vary depending on the type of primary carcinoma, however, the prognosis is guarded. We report a case of LCM in a patient with stage IV epithelial ovarian cancer in remission, which became a diagnostic challenge due to a lack of imaging findings.

A review of novel coronavirus disease (COVID-19): based on genomic structure, phylogeny, current shreds of evidence, candidate vaccines, and drug repurposing

Coronavirus disease (COVID-19) pandemic is instigated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of March 13, 2021, more than 118.9 million cases were infected with COVID-19 worldwide. SARS-CoV-2 is a positive-sense single-stranded RNA beta-CoV. Most COVID-19 infected individuals recover within 1-3 weeks. Nevertheless, approximately 5% of patients develop acute respiratory distress syndrome and other systemic complications, leading to death. Structural genetic analyses of SARS-CoV-2 have shown genomic resemblances but a low evolutionary correlation to SARS-CoV-1 responsible for the 2002-2004 outbreak. The S glycoprotein is critical for cell adhesion and the entrance of the virus into the host. The process of cell entry uses the cellular receptor named angiotensin-converting enzyme 2. Recent evidence proposed that the CD147 as a SARS-CoV-2's potential receptor. The viral genome is mainly held by two non-structural proteins (NSPs), ORF1a and ORF1ab, along with structural proteins. Although NSPs are conserved among the βCoVs, mutations in NSP2 and NSP3 may play critical roles in transmitting the virus and cell tropism. To date, no specific/targeted anti-viral treatments exist. Notably, more than 50 COVID-19 candidate vaccines in clinical trials, and a few being administered. Preventive precautions are the primary strategy to limit the viral load transmission and spread, emphasizing the urgent need for developing significant drug targets and vaccines against COVID-19. This review provides a cumulative overview of the genomic structure, transmission, phylogeny of SARS-CoV-2 from Indian clusters, treatment options, updated discoveries, and future standpoints for COVID-19.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s13205-021-02749-0.

Metastatic renal cell carcinoma complicated by right atrial thrombus

Metastasis of renal cell carcinoma to the heart is a rare event. Herein we present a case of renal cell carcinoma presenting with progressive fatigue, abdominal pain, and weight loss. Imaging studies revealed complex renal mass with extension to right atrium and histopathology confirmed the metastatic renal cell carcinoma.

Acute Pancreatitis Induced by Linagliptin: A Rare but Dangerous Side Effect

Diabetes mellitus type 2 (DMT2) is a highly prevalent disease both in the United States and worldwide. Multiple treatment options are currently available, and several new groups of medications have been introduced over the last couple of decades. One of these groups is dipeptidyl peptidase-4 (DPP-4) inhibitors. These medications have side effects, some of which are severe and potentially life-threatening; however, some of their side effects have been underreported since they are relatively new. When prescribing these medications, it is essential to be cautious, especially with patients at an increased risk of developing an adverse effect. We present the case of a 57-year-old male who developed DPP-4 inhibitor-induced acute pancreatitis after the initiation of linagliptin. The patient did not have any apparent risk factors for pancreatitis as he did not drink alcohol or smoke cigarettes, his lipid panel was within normal limits, and he had a cholecystectomy five years prior. His linagliptin was held in the hospital and discontinued post-discharge, which led to the resolution of his symptoms.