Integrated Care Models for Long Coronavirus Disease

Professional or governmental agencies and organizations have developed guidelines to define the problem and evaluate and manage patients with Post-Acute Sequelae of SARS CoV-2 (PASC). Multidisciplinary models largely exist in academic centers and larger cities; however, most care for PASC patients is provided by the primary care providers. The American Academy of Physical Medicine and Rehabilitation has been in the forefront in releasing consensus statements as a part of the long COVID collaborative.

Mid-Infrared Imaging Characterization to Differentiate Lung Cancer Subtypes

Introduction: Lung cancer is the most common malignancy worldwide. Squamous cell carcinoma (SQ) and adenocarcinoma (LUAD) are the two most frequent histological subtypes. Small cell carcinoma (SCLC) subtype has the worst prognosis. Differential diagnosis is essential for proper oncological treatment. Life science associated mid- and near-infrared based microscopic techniques have been developed exponentially, especially in the past decade. Vibrational spectroscopy is a potential non-destructive approach to investigate malignancies.

Aims: Our goal was to differentiate lung cancer subtypes by their label-free mid-infrared spectra using supervised multivariate analyses.

Material and Methods: Formalin-fixed paraffin-embedded (FFPE) samples were selected from the archives. Three subtypes were selected for each group: 10-10 cases SQ, LUAD and SCLC. 2 μm thick sections were cut and laid on aluminium coated glass slides. Transflection optical setup was applied on Perkin-Elmer infrared microscope. 250 × 600 μm areas were imaged and the so-called mid-infrared fingerprint region (1800-648cm⁻¹) was further analysed with linear discriminant analysis (LDA) and support vector machine (SVM) methods.

Results: Both “patient-based” and “pixel-based” approaches were examined. Patient-based analysis by using 3 LDA models and 2 SVM models resulted in different separations. The higher the cut-off value the lower is the accuracy. The linear C-support vector classification (C-SVC) SVM resulted in the best (100%) accuracy for the three subtypes using a 50% cut-off value. The pixel-based analysis gave, similarly, the linear C-SVC SVM model to be the most efficient in the statistical indicators (SQ sensitivity 81.65%, LUAD sensitivity 82.89% and SCLC sensitivity 88.89%). The spectra cut-off, the kernel function and the algorithm function influence the accuracy.

Conclusion: Mid-Infrared imaging could be used to differentiate FFPE lung cancer subtypes. Supervised multivariate tools are promising to accurately separate lung tumor subtypes. The long-term perspective is to develop a spectroscopy-based diagnostic tool, revolutionizing medical differential diagnostics, especially cancer identification.

O033 Video tuition of intracavernosal alprostadil injection for management of erectile dysfunction

Introduction

Intracavernosal injections (ICI) are the second line treatment of erectile dysfunction (ED). To reduce the risk of complications, primarily priapism, the first administration has traditionally required face-to-face appointments. With a move to remote working, the safety and feasibility of an instructional video for the first self-administration of ICI was assessed.

Methods

Two centres recruited patients, with participants receiving a pack comprising a written instruction leaflet and a Viridal Duo prescription, followed by an email with our instructional video. Patients were given a specific time to self-administer their ICI (Alprostadil 2.5 micrograms), when our CNS was available for support. The same CNS would follow up two hours later via telephone to assess the experience using a Likert scale semi-structured interview.

Results

Thirty-nine patients were recruited between two centres, with 35 continuing to injection. The median age was 63 years (range 34–78). The most common ED aetiology was post-prostatectomy (18/35). Thirty-four (97%) recruits found the video instructions clear, with it being watched a mean 2 (range 1–8) times. Only 1 patient (3%) required telephone support. At the 2.5mcg dose, the mean erection hardness score was 2 (range 1–4) after an average of 5 minutes. No patients reported significant bruising at the injection site and there was no priapism. Thirty-three patients (94%) were very or extremely likely to recommend this method for starting ICI therapy.

Conclusion

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Take-home message

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

Mid-Infrared Imaging Is Able to Characterize and Separate Cancer Cell Lines

Malignancies are still responsible for a large share of lethalities. Macroscopical evaluation of the surgical resection margins is uncertain. Big data based imaging approaches have emerged in the recent decade (mass spectrometry, two-photon microscopy, infrared and Raman spectroscopy). Indocianine green labelled MS is the most common approach, however, label free mid-infrared imaging is more promising for future practical application. We aimed to identify and separate different transformed (A-375, HT-29) and non-transformed (CCD986SK) cell lines by a label-free infrared spectroscopy method. Our approach applied a novel set-up for label-free mid-infrared range classification method. Transflection spectroscopy was used on aluminium coated glass slides. Both whole range spectra (4000-648 cm^-1) and hypersensitive fingerprint regions (1800-648 cm^-1) were tested on the imaged areas of cell lines fixed in ethanol. Non-cell spectra were possible to be excluded based on mean transmission values being above 90%. Feasibility of a mean transmission based spectra filtering method with principal component analysis and linear discriminant analysis was shown to separate cell lines representing different tissue types. Fingerprint region resulted the best separation of cell lines spectra with accuracy of 99.84% at 70-75 mean transmittance range. Our approach in vitro was able to separate unique cell lines representing different tissues of origin. Proper data handling and spectra processing are key steps to achieve the adaptation of this dye-free technique for intraoperative surgery. Further studies are urgently needed to test this novel, marker-free approach.

THU0335 IS CARDIOVASCULAR RISK IN INFLAMMATORY MYOPATHIES UNDERESTIMATED?

Background:

Inflammatory myopathies (IIM) comprise a heterogeneous group of rare connective tissue diseases (CTD) which can occur in any age group and in association with other autoimmune CTD. Extramuscular manifestations, including cardiac involvement, are common and may occur in the absence of muscle symptoms.

The link between inflammation and atherosclerosis has been well established in other immune-mediated diseases suggesting that atherosclerosis in these conditions is driven by disease activity rather than traditional cardiovascular (CV) risk factors. Large observational studies have identified atherosclerotic cardiovascular events (CVE) as one of the leading causes in mortality in IIM but to date there are no specific recommendations for patients with IIM beyond the general guidelines for management of CV risk in the general population.

A systematic review of the literature available was carried out, identifying six observational studies based on data collected from local or national healthcare databases. All six studies showed an increased incidence of MI and/or stroke compared to the general population, with a suggestion in some of them that this incidence was particularly high in the first few years after disease onset.

Objectives:

To establish if the incidence of atherosclerotic CVE in an IIM cohort is higher than expected when compared to QRISK2 predicted risk, and if so to determine if this risk is influenced by disease duration, gender, disease phenotype or ethnicity.

Methods:

Patients referred to the Myositis clinic at King’s College Hospital (KCH) were identified, excluding patients with Inclusion Body Myositis, overlap diagnoses with other CTD or prior atherosclerotic CVE. Only patients fulfilling ACR/EULAR criteria for IIM and under follow up at KCH (Denmark Hill site) were included in the study. Retrospective data was gathered by reviewing electronic patient records.

Results:

327 patients were identified through the Myositis Departmental database. After applying exclusion criteria the final dataset consisted of 159 patients (114 female, 71.7%), including dermatomyositis (82 patients), polymyositis (49 patients), Clinically Amyopathic Dermatomyositis (7 patients), anti-synthetase syndrome (12 patients) and necrotizing myopathy (9 patients). 81 patients were white (50.9%). Mean age of entry in the study was 49.1 years (SD 15.2) for women and 49.7 years (SD 12.2) for men. The mean follow up time was 2.61 years with a median time of 2.78 years (IQR 1.64-2.85). The mean disease duration was 6.77 years for the whole cohort with a median time of 4.61 years (IQR 2.43-9.07).

The incidence rate of atherosclerotic CVE was 16.3/1000 patient-years (95% CI: 8.8-30.3), twice as high as expected by QRISK2. Analysis showed statistical difference with males (RR=6.49, p=0.002) and white patients (RR=5.04, p=0.02) although the statistical significance for white ethnicity was lost after adjusting for age and gender. Statistical analysis showed association between disease duration and higher incidence of atherosclerotic CVE, with a rate reduction of 0.7 per year from disease onset (p=0.01) after adjusting for age and gender.

Fig. 1.

Atherosclerotic risk by disease duration

Fig. 2.

Kaplan-Meier survival plot to atherosclerotic event

Conclusion:

Our results suggest that atherosclerotic cardiovascular risk in inflammatory myopathies is underestimated, particularly early on the disease. Based on our results we would recommend a low threshold for primary prevention of atherosclerosis including the use of statins particularly for the first year after diagnosis.

Disclosure of Interests:

None declared

Heart disease prevention in women: The NP's role

More women die from heart disease than any other illness. This article focuses on risk factors and their prevalence in women along with strategies for preventing this disease. Armed with this information, the NP can play a major role in preventing cardiovascular deaths in women.

Steady-state PERG adaptation: a conspicuous component of response variability with clinical significance

PURPOSE

To investigate within-test variability of the steady-state PERG (SS-PERG).

METHODS

SS-PERGs were recorded in response to black-white horizontal gratings (1.6 cycles/deg, 98% contrast, 15.63 reversals/s, LED display, 25 deg square field, 800 cd/sqm mean luminance) using skin electrodes. PERG and noise (± reference) signals were averaged over 1024 epochs (~ 2.2 min) and Fourier analyzed to retrieve SS-PERG amplitude and phase. SS-PERGs were split into 16 partial averages (samples) of 64 epochs each, and corresponding amplitudes and phases combined in polar coordinates to assess their dispersion (within-test variability). To assess time-dependent variability, samples were clustered in four successive time segments of ~ 33 s each. Amplitude adaptation was defined as amplitude difference between initial and final clusters, and PERG phase adaptation as the corresponding phase difference. To determine the dynamic range of SS-PERG adaptation, recording was performed in normal controls of different age (n = 32) and patients with different severity of optic nerve dysfunction (early manifest glaucoma, EMG, n = 7; non-arteritic ischemic optic neuropathy, NAION, n = 5).

RESULTS

Amplitude adaptation was largest in younger controls (amplitude adaptation ÷ noise, SNR = 9.5, 95% CI 13.1, 5.9) and progressively decreased with increasing age (older subjects, SNR = 5.5, 95% CI 9.2, 1.8) and presence of disease (EMG: SNR = 2.4, 95% CI 3.5, 1.4; NAION: SNR = 1.9, 95% CI 6.5,-2.2). In 11 young subjects, amplitude adaptation was repeatable (test-retest in two sessions a week apart; intraclass correlation coefficient = 0.59). Phase adaptation was not significantly different from zero in all groups.

CONCLUSIONS

SS-PERG adaptation accounts for a sizeable portion of the within-test variability. As it has robust SNR, sufficient test-retest variability, and is altered in disease, it may have physiological and clinical significance. This study suggests that SS-PERG protocols should include adaptation in addition to SS-PERG amplitude and phase/latency.

Detecting intratumoral heterogeneity of EGFR activity by liposome-based in vivo transfection of a fluorescent biosensor

Despite decades of research in the epidermal growth factor receptor (EGFR) signalling field, and many targeted anti-cancer drugs that have been tested clinically, the success rate for these agents in the clinic is low, particularly in terms of the improvement of overall survival. Intratumoral heterogeneity is proposed as a major mechanism underlying treatment failure of these molecule-targeted agents. Here we highlight the application of fluorescence lifetime microscopy (FLIM)-based biosensing to demonstrate intratumoral heterogeneity of EGFR activity. For sensing EGFR activity in cells, we used a genetically encoded CrkII-based biosensor which undergoes conformational changes upon tyrosine-221 phosphorylation by EGFR. We transfected this biosensor into EGFR-positive tumour cells using targeted lipopolyplexes bearing EGFR-binding peptides at their surfaces. In a murine model of basal-like breast cancer, we demonstrated a significant degree of intratumoral heterogeneity in EGFR activity, as well as the pharmacodynamic effect of a radionuclide-labeled EGFR inhibitor in situ. Furthermore, a significant correlation between high EGFR activity in tumour cells and macrophage-tumour cell proximity was found to in part account for the intratumoral heterogeneity in EGFR activity observed. The same effect of macrophage infiltrate on EGFR activation was also seen in a colorectal cancer xenograft. In contrast, a non-small cell lung cancer xenograft expressing a constitutively active EGFR conformational mutant exhibited macrophage proximity-independent EGFR activity. Our study validates the use of this methodology to monitor therapeutic response in terms of EGFR activity. In addition, we found iNOS gene induction in macrophages that are cultured in tumour cell-conditioned media as well as an iNOS activity-dependent increase in EGFR activity in tumour cells. These findings point towards an immune microenvironment-mediated regulation that gives rise to the observed intratumoral heterogeneity of EGFR signalling activity in tumour cells in vivo.

A Curriculum for Clerkship Students to Foster Professionalism Through Reflective Practice and Identity Formation

INTRODUCTION

Research suggests that students become less patient-centered and empathetic in response to both internal and external factors, including the organizational culture, or hidden curriculum, of medical school. Students often feel compelled to make compromises when they experience tension between competing values in clinical teaching environments. To address this, we implemented a modular, longitudinal professionalism curriculum for third-year medical students, based on a conceptual model that highlights a student's ideal, as well as the internal and environmental forces that can either sustain or change their ideal over time.

METHODS

As students progressed through the third year, they participated in various modules linked to different clerkships, each focusing on a different aspect of the conceptual model. Each module includes a reflective writing exercise followed by a faculty-facilitated discussion.

RESULTS

In general, students rated the group discussions and faculty facilitation as the most useful parts of each session and the writing exercises as the least useful. Written comments were mostly favorable and suggested that the session facilitated self-reflection and provided a safe environment for students to discuss stressors of third-year clerkships.

DISCUSSION

This curriculum represents a unique approach to fostering professional role formation through its broad potential applicability to multiple types and levels of learners, its adaptability to fit various course lengths and learning environments, and its incorporation of a conceptual model that allows individual learners to address different facets of the sustaining and acculturating forces that impact their personal professional identity formation for future encounters.

Cocaine-induced transmural myocardial infarction in a Yorkshire swine with normal coronary arteries: Evidence for microvascular and/or epicardial coronary artery spasm

Cocaine-induced myocardial infarction with normal coronary arteries is well documented in humans. The exact mechanism of action remains speculative. We report one case of cocaine-induced myocardial infarction with normal coronaries in one swine. Systemic hemodynamics and angiographic, electrocardiographic, echocardiographic, and histopathologic data are presented. Intravenous cocaine (1, 3, 10 mg/kg) produced significant decreases in mean arterial pressure, heart rate, stroke volume, coronary blood flow, and coronary reserve, whereas pulmonary artery diastolic pressure and coronary vascular resistances increased. Left anterior descending and left circumflex coronary artery cross-sectional area decreased by 31% and 64%, respectively, without localized vasospasm. Electrocardiographic changes occurred (3 mm ST elevation in leads II, III, AVF). Peak creatine phosphokinase was 17,220 IU/L. The echocardiogram revealed severe hypokinesis of the inferior wall and normal ventricular function. The animal survived the acute phase of the infarction and the swine was restudied 12 weeks later. Upon rechallenge, systemic and coronary hemodynamics shoved changes similar to those in the previous study. The swine developed ventricular fibrillation and expired after the 10 mg/kg cocaine dose. Macroscopic examination of the external surface of the heart revealed marked diffuse fibrosis in the posteroinferior and lateral left ventricular wall. Our data suggest that the infarct induced by cocaine may have resulted from severe vasoconstriction or spasm at the level of the microcirculation, and/or the epicardial coronary arteries, which shoved slight but significant narrowing throughout their lengths.

The LIM and POU homeobox genes ttx-3 and unc-86 act as terminal selectors in distinct cholinergic and serotonergic neuron types

Transcription factors that drive neuron type-specific terminal differentiation programs in the developing nervous system are often expressed in several distinct neuronal cell types, but to what extent they have similar or distinct activities in individual neuronal cell types is generally not well explored. We investigate this problem using, as a starting point, the C. elegans LIM homeodomain transcription factor ttx-3, which acts as a terminal selector to drive the terminal differentiation program of the cholinergic AIY interneuron class. Using a panel of different terminal differentiation markers, including neurotransmitter synthesizing enzymes, neurotransmitter receptors and neuropeptides, we show that ttx-3 also controls the terminal differentiation program of two additional, distinct neuron types, namely the cholinergic AIA interneurons and the serotonergic NSM neurons. We show that the type of differentiation program that is controlled by ttx-3 in different neuron types is specified by a distinct set of collaborating transcription factors. One of the collaborating transcription factors is the POU homeobox gene unc-86, which collaborates with ttx-3 to determine the identity of the serotonergic NSM neurons. unc-86 in turn operates independently of ttx-3 in the anterior ganglion where it collaborates with the ARID-type transcription factor cfi-1 to determine the cholinergic identity of the IL2 sensory and URA motor neurons. In conclusion, transcription factors operate as terminal selectors in distinct combinations in different neuron types, defining neuron type-specific identity features.

Results of a two-center, before and after study of piperacillin-tazobactam versus ampicillin and gentamicin as empiric therapy for suspected sepsis at birth in neonates ≤ 1500 g

OBJECTIVE

We changed from ampicillin and gentamicin (AG) to piperacillin-tazobactam (PT) for routine treatment of suspected early-onset sepsis. The rationale for this change included ototoxic and renal toxic effects of gentamicin, resistance to gentamicin in late-onset infections and emergence of ampicillin resistant Escherichia coli. A before and after study was designed before the start of PT administration to monitor whether PT was associated with altered outcomes within the 501 to 1500 g birth weight (Very Low Birth Weight) population.

METHOD

Both unmatched and matched comparisons of AG (2007 to 2009) and PT (2010 to 2011) exposed infants are reported. Cohorts were evaluated for initial effectiveness for congenital infections, subsequent morbidities and mortality.

RESULTS

Data from 714 patients were collected (499 AG and 215 PT in the unmatched and 301 AG and 183 PT in the matched cohorts). No significant differences in demographics or initial Apgar scores were noted in the unmatched or matched comparisons. There were significant differences in many of the outcomes of interest in both the matched and unmatched comparisons including less necrotizing enterocolitis (NEC) and less diaper rash with PT versus AG. The only adverse finding with PT was a small, but statistically significant elevation in alkaline phosphatase.

CONCLUSIONS

Use of PT as the initial empiric antibiotic for very low birth weight infants was not associated with adverse microbiological outcomes. There was no increase in major morbidities. Although outcomes were superior in ≤ 1500 g infants treated with PT when compared with AG, the study design does not allow us to conclude that others will see a reduction in NEC or diaper rash if they implement this alternative.

Understanding the implications of the breast cancer pathology report: a case study

Case Study A.K. is a 50-year-old Caucasian female who was recently diagnosed with breast cancer and is presenting for an opinion regarding adjuvant therapy following a right segmental mastectomy and sentinel lymph node biopsy. The advanced practitioner (AP) in the outpatient oncology treatment center will be expected to participate in the discussion regarding the patient's care plan. In her review of the final pathology, the AP notes that the breast tumor is infiltrating ductal carcinoma, the most common type of invasive breast cancer. It starts in the cells that line the milk ducts in the breast, grows outside the ducts, and often spreads to the lymph nodes. Infiltrating ductal carcinoma represents 65% to 85% of all breast cancer cases (College of American Pathologists, 2011). The breast tumor measures 1.2 × 0.9 × 1.0 cm(3) (T1), is estrogen receptor positive with an H score of 280, is progesterone receptor negative with an H score of 0, and is HER2 equivocal 2+ by immunohistochemistry with a fluorescence in situ hybridization ratio of 1.9 with a copy number of 5. The Ki-67 proliferation rate is 60%, and the nuclear grade is 2/3, with a Nottingham score of 5/9. The surgical margins from the segmental mastectomy are clear by 0.4 mm. There is lymphovascular invasion present. Of two sentinel lymph nodes, none is positive (N0). There has been no workup for metastatic disease. Additionally, the AP notes that the patient is premenopausal and that A.K.'s family history is positive for a maternal aunt diagnosed with a stage I breast cancer at age 75. What is the recommended plan of care for A.K.?

Evolving patient selection and clinical benefit criteria for sapropterin dihydrochloride (Kuvan®) treatment of PKU patients

PURPOSE

To understand current patient selection, dosing, and response criteria used for sapropterin dihydrochloride (sapropterin, Kuvan®) to treat phenylketonuria (PKU).

METHODS

Results of a 2010 survey of twenty-nine academic medical centers are reported to describe practice patterns in comparison to results of a survey done in 2008 and to what is reported in the literature.

RESULTS/CONCLUSIONS

In addition to reduction in blood phenylalanine (Phe) levels, clinicians report using broader disease-management approaches when evaluating clinical benefit of sapropterin, including consideration of increased Phe tolerance and behavioral changes. Similar approaches are reported in the literature.

Characteristics of patients who die of necrotizing enterocolitis

OBJECTIVE

Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality among infants admitted for intensive care. The factors associated with mortality and catastrophic presentation remain poorly understood. Our objective was to describe the factors associated with mortality in infants with NEC and to quantify the degree to which catastrophic presentation contributes to mortality in infants with NEC. Catastrophic NEC was defined before data analysis as NEC that led to death within 7 days of diagnosis.

STUDY DESIGN

We performed a retrospective review of the Pediatrix's Clinical Data Warehouse (1997 to 2009, n=560,227) to compare the demographic, therapeutic and outcome characteristics of infants who survived NEC vs those who died. Associations were tested by bivariate and multivariate analysis.

RESULT

We compared the 5594 infants diagnosed with NEC and who were discharged home with 1505 infants diagnosed with NEC who died. In multivariate analysis, the factors associated with death (P<0.01 in analysis) were lower estimated gestational age, lower birth weight, treatment with assisted ventilation on the day of diagnosis of NEC, treatment with vasopressors at the time of diagnosis, and Black race. Patients who received only ampicillin and gentamicin on the day of diagnosis were less likely to die. Two-thirds of NEC deaths occurred quickly (<7 days from diagnosis), with a median time of death of one day from time of diagnosis. Infants who died within 7 days of diagnosis had a higher birth weight, more often were on vasopressors and high frequency ventilation at the time of diagnosis compared with patients who died at 7 or more days. Although mortality decreased with increasing gestational age, the proportion of deaths that occurred within 7 days was relatively consistent (65 to 75% of the patients who died) across all gestational ages.

CONCLUSION

Mortality among infants who have NEC remains high and infants who die of NEC commonly (66%) die quickly. Most of the factors associated with mortality are related to immaturity, low birth weight and severity of illness.

Recurrent posterior circulatory emboli from a mildly stenosed bicuspid aortic valve

Bicuspid aortic valve (BAV) is a common condition but is only rarely associated with embolic complications. We describe a 42-year-old man with recurrent posterior circulatory ischemic strokes that resulted in ataxia and cognitive impairment. Transesophageal echocardiography demonstrated a BAV with mild stenosis, moderate calcification, and a dilated ascending aorta. The degree of calcification and the valve phenotype might be important factors implicating the BAV as a rare cause of ischemic stroke.