Trajectories of otitis media and association with health determinants among Indigenous children in Australia: the Longitudinal Study of Indigenous Children

OBJECTIVES

Indigenous children in Australia experience high burden of persistent otitis media (OM) from very early age. The aim was to identify distinct trajectories of OM in children up to age 10-12 years and examine the association with socio-economic determinants.

STUDY DESIGN

A multistage clustered national panel survey.

METHODS

The study analysed the birth cohort of the Longitudinal Study of Indigenous Children from 2008 to 2018, comprising 11 study waves. Group-based trajectory modelling was used to identify different trajectories of OM outcome. Multinomial logistic regression was applied to examine the relationship between trajectories and individual, household and community-level socio-economic determinants.

RESULTS

This analysis included 894 children with at least three responses on OM over the 11 waves, and the baseline mean age was 15.8 months. Three different trajectories of OM were identified: non-severe OM prone, early/persistent severe OM and late-onset severe OM. Overall, 11.4% of the children had early/persistent severe OM from birth to 7.5 to nine years, while late-onset severe OM consisted of 9.8% of the children who had first OM from age 3.5 to five years. Children in communities with middle and the highest socio-economic outcomes have lower relative risk of early/persistent severe OM (adjusted relative risk ratio = 0.39, 95% confidence interval = 0.22-0.70 and adjusted relative risk ratio = 0.22, 95% confidence interval = 0.09-0.52, respectively) compared to children in communities with lowest socio-economic outcomes.

CONCLUSION

Efforts to close the gap in the quality of life of Indigenous children must prioritise strategies that prevent severe ear disease (runny ears and perforation), including improved healthcare access, reduced household crowding, and better education, and more employment opportunities.

Aperiodic neural activity is a biomarker for depression severity

A reliable physiological biomarker for Major Depressive Disorder (MDD) is necessary to improve treatment success rates by shoring up variability in outcome measures. In this study, we establish a passive biomarker that tracks with changes in mood on the order of minutes to hours. We record from intracranial electrodes implanted deep in the brain - a surgical setting providing exquisite temporal and spatial sensitivity to detect this relationship in a difficult-to-measure brain area, the ventromedial prefrontal cortex (VMPFC). The aperiodic slope of the power spectral density captures the balance of activity across all frequency bands and is construed as a putative proxy for excitatory/inhibitory balance in the brain. This study demonstrates how shifts in aperiodic slope correlate with depression severity in a clinical trial of deep brain stimulation for treatment-resistant depression (TRD). The correlation between depression severity scores and aperiodic slope is significant in N=5 subjects, indicating that flatter (less negative) slopes correspond to reduced depression severity, especially in the ventromedial prefrontal cortex. This biomarker offers a new way to track patient response to MDD treatment, facilitating individualized therapies in both intracranial and non-invasive monitoring scenarios.

Green technology approach for heavy metal adsorption by agricultural and food industry solid wastes as bio-adsorbents: a review

Heavy metal discharge from various metallurgical industries has been of particular concern in India over the last few decades. Similarly, management and disposal of wastes that are generated out of agricultural commodities processing is a huge task for processors. The researchers have been focusing on a new process for remediation of heavy metals, among which biosorption is an emerging technology. Adsorption using agricultural and food industry wastes (AFW) has shown a greater absorption rate than the conventional system due to the presence of the functional groups. In addition, these reported AFW exhibited better adsorption efficiency when modified with acid, alkaline, and other chemical solvents. In this context, utilization of agricultural and food waste as bio-sorbent could simultaneously benefit both water treatment and waste management. This review seeking to address the possibilities of using biosorption as green technological approach for removal of heavy metals and also focuses on various parameters that are required to use AFW as an efficient system for biosorption. However, commercialization and implementation of this process in industrial scale is necessary for successfully utilizing AFW as low-cost adsorbents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13197-022-05486-1.

Adaptations to water stress and pastoralism in the Turkana of northwest Kenya

The Turkana people inhabit arid regions of east Africa-where temperatures are high and water is scarce-and they practice subsistence pastoralism, such that their diet is primarily composed of animal products. Working with Turkana communities, we sequenced 367 genomes and identified 8 regions putatively involved in adaptation to water stress and pastoralism. One of these regions includes a putative enhancer for STC1-a kidney-expressed gene involved in the response to dehydration and the metabolism of purine-rich foods such as red meat. We show that STC1 is induced by antidiuretic hormone in humans, is associated with urea levels in the Turkana themselves, and is under strong selection in this population (s∼0.041). This work highlights that partnerships with subsistence-level groups can lead to new models of human physiology with biomedical relevance.

Estimation of stature with the help of tooth length using cone beam computed tomography

Introduction and Aim: Stature is the primary tool in personal identification for forensic and physical anthropology for over a period. In the absence of full skeleton, the stature can be estimated from various skeletal components. Utilizing cranium and dentition measurements is simpler as these structures are fixed, grown and straight forward to locate. Few researches had been undertaken to establish the efficacy of teeth dimensions in height assessment. But we could not come across any such studies on tooth length. So, the present research was conducted to estimate the stature from tooth length using Cone Beam Computed Tomography (CBCT).   Materials and Methods: Tooth lengths of all 4 canines were measured on digital CBCT using inbuilt software Planmeca Romexis® Software (Helsinki, Finland). Height was considered as measurement of length, from the head to toe using standard height chart. Pearson correlation test and linear regression analysis was used as a statistical tool for co-relation co-efficient and population specific formula for height assessment.   Results: There was a very good correlation between tooth length and stature, with r value 0.12-0.81 and p value less than 0.05. The length of the mandibular right canine had better correlation with stature followed by mandibular left canine, maxillary left canine and maxillary right canine. Regression equation was developed from tooth length, to predict stature.   Conclusion: Tooth length measuring using CBCT has a very good correlation with the height of the individual, as it is closer to actual length. Combined data, without sex as a parameter provides more accurate prediction. However, predication accuracy was better in females than males, when gender considered as a parameter in the regression analysis.

Acute and long-term success of left atrial anterior line and mitral isthmus line ablation in patients after mitral valve surgery

Background

Perimitral flutter and atrial fibrillation may occur in patients with prior surgical mitral valve (MV) repair or replacement and can be challenging for percutaneous catheter ablation.

Objective

This study sought to determine the feasibility, acute success and durability of catheter ablation of atrial fibrillation or atrial tachycardia by way of a mitral isthmus line (MIL) or an anterior line (AL).

Methods

A total of 81 patients (49 males, mean age 62±11 years) with prior MV replacement (n=30) or repair (n=51) underwent creation of a MIL (n=34) and/or an AL (n=72). Control group patients without prior surgery were matched 1:1 with the valve group (MIL, n=34; AL, n=72).

Results

Acute bidirectional block of the MIL was successfully achieved in 24/34 cases and of the AL in 64/72 patients with prior MV surgery. In the control group, acute bidirectional block was achieved in 31/34 MIL patients and 65/72 AL patients. In terms of durability, the MIL valve subgroup showed the poorest results (probability of long-term failure 2.224, as opposed to 0.605 in the MIL control subgroup; hazard ratio [HR]=0.27, 95% confidence interval [CI], 0.11–0.65; p=0.004). In the AL subgroups, long-term outcomes were similar (probability of failure in AL valve subgroup 0.844 vs. AL control subgroup 1.03; HR=1.22, 95% CI, 0.66–2.26; p=0.523).

Conclusions

Percutaneous creation of MIL and AL is feasible and safe in patients with prior MV replacement/repair. Because of poor long-term outcomes, MIL creation appears not advisable in patient with prior MV surgery.

Funding Acknowledgement

Type of funding sources: None.

Electroanatomic visualization of coronary arteries: a case series to elicit safety, feasibility and diagnostic value in complex ablation procedures

Funding Acknowledgements

Type of funding sources: None.

Background

Although three dimensional (3D) electroanatomic mapping systems allow detailed assessment of anatomy and substrates, ablation still carries substantial risk when close proximity to coronary arteries is suspected. 3D integration of coronary anatomy in mapping systems is still cumbersome, highlighting the need for an option of ad hoc acquirement of coronary artery anatomy. The goal of this case series was to evaluate the feasibility of a wire-based approach to the live visualization of coronary arteries and to assess its diagnostic information regarding procedure guiding.

Methods

For this single center case series, we included procedures in which close proximity of an ablation site to an epicardial vessel had to be suspected. An uninsulated-tip wire was then introduced into the relevant coronaries via diagnostic catheters after exclusion of critical stenosis by coronary angiography. The wire was connected to an impedance based 3D mapping system using a clamp and standard pin connection. Integrating this setup in the mapping system allows for live visualization of the wire tip, as well as the assessment of local electrograms within the respective vessel.

Results

We included a total of 9 procedures (4 ventricular tachycardia (VT) ablation procedures and 5 procedures for the ablation of premature ventricular contractions (PVCs)). The left coronary arteries were mapped in 8 cases, the right coronary artery was mapped in one case. In the majority of cases, the arrhythmogenic substrate was found in the left ventricle (5/9) or left ventricular summit area and the distal coronary sinus respectively (3/9). In two cases, epicardial mapping was performed combined with visualization of the right or left coronary arteries, respectively. There were no complications attributed to coronary wiring and mapping in this case series.

In two cases, the diagnostic information from mapping of the coronary arteries could be used to rule out an epicardial origin of arrhythmia. In the majority of cases, coronary visualization was used to ascertain a proper distance between the ablation site and the vessel.

Discussion

In this case series, we could demonstrate the feasibility and safety of coronary artery visualization and its integration in a 3D mapping system. The data obtained was used for diagnostic, as well as safety aspects. The electrograms from the wire were used to quickly assess relative timing of arrhythmias, thus allowing for an estimation of possible epicardial origin.

Conclusion

Applying the same caveats as for any other wiring of coronary arteries, their electroanatomic visualization is achieved in a safe and straightforward manner, with minimal technical requirements. Mapping of the coronary arteries adds critical diagnostic information and their real-time visualization is feasible without exceeding costs or risks

The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery

Introduction and hypothesis

The objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery.

Methods

Prospective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis.

Results

A total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1–4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5–2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1–0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8–2.9), p = 0.223).

Conclusions

Levator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.

Entropy directs the self-assembly of supramolecular palladium coordination macrocycles and cages

The self-assembly of palladium-based cages is frequently rationalized via the cumulative enthalpy (ΔH) of bonds between coordination nodes (M, i.e., Pd) and ligand (L) components. This focus on enthalpic rationale limits the complete understanding of the Gibbs free energy (ΔG) for self-assembly, as entropic (ΔS) contributions are overlooked. Here, we present a study of the M₂^linL₃ intermediate species (M = dinitrato(N,N,N′,N′-tetramethylethylenediamine)palladium(ii), ^linL = 4,4′-bipyridine), formed during the synthesis of triangle-shaped (M₃^linL₃) and square-shaped (M₄^linL₄) coordination macrocycles. Thermochemical analyses by variable temperature (VT) ¹H-NMR revealed that the M₂^linL₃ intermediate exhibited an unfavorable (relative) ΔS compared to M₃^linL₃ (triangle, ΔTΔS = +5.22 kcal mol⁻¹) or M₄^linL₄ (square, ΔTΔS = +2.37 kcal mol⁻¹) macrocycles. Further analysis of these constructs with molecular dynamics (MD) identified that the self-assembly process is driven by ΔG losses facilitated by increases in solvation entropy (ΔS_solv, i.e., depletion of solvent accessible surface area) that drives the self-assembly from “open” intermediates toward “closed” macrocyclic products. Expansion of our computational approach to the analysis of self-assembly in Pd_n^benL_2n cages (^benL = 4,4'-(5-ethoxy-1,3-phenylene)dipyridine), demonstrated that ΔS_solv contributions drive the self-assembly of both thermodynamic cage products (i.e., Pd₁₂^benL₂₄) and kinetically-trapped intermediates (i.e., Pd₈^cL₁₆).

These studies demonstrate that ΔS drives the self-assembly of supramolecular palladium-based coordination macrocycles and cages. As this ΔS contribution arises from solvation, these findings broadly reflect the thermodynamic drive of self-assembly to form compact structures.

Comparison of homogeneous and heterogeneous catalysts in dye-sensitised photoelectrochemical cells for alcohol oxidation coupled to dihydrogen formation

This study examines two strategies-homo- and heterogeneous approaches for the light-driven oxidation of benzyl alcohol in dye-sensitised photoelectrochemical cells (DSPECs). The DSPEC consists of a mesoporous anatase TiO2 film on FTO (fluorine-doped tin oxide), sensitised with the thienopyrroledione-based dye AP11 as the photoanode and an FTO-Pt cathode combined with a redox-mediating catalyst. The homogeneous catalyst approach entails the addition of the soluble 2,2,6,6-tetramethylpiperidine-1-oxyl (TEMPO) to the DSPEC anolyte, while the heterogeneous strategy employs immobilisation of a TEMPO analogue with a silatrane anchor (S-TEMPO) onto the photoanode. Irradiation of the photoanode oxidises the TEMPO-moiety to TEMPO+, both in the homogeneous and the heterogeneous system, which is a chemical oxidant for benzyl alcohol oxidation. Photoanodes containing the heterogeneous S-TEMPO+ demonstrate decreased photocurrent, attributed to introducing alternative pathways for electron recombination. Moreover, the immobilised S-TEMPO demonstrates an insufficient ability to mediate electron transfer from the organic substrate to the photooxidised dye, resulting in device instability. In contrast, the homogeneous approach with TEMPO as a redox-mediating catalyst in the anolyte is efficient in the light-driven oxidation of benzyl alcohol to benzaldehyde over 32 hours, promoted by the efficient electron mediation of TEMPO between AP11 and the organic substrate. Our work demonstrates that operational limitations in DSPECs can be solved by rational device design using diffusion-mediated electron transfer steps.

P14.32 Patterns of invasion in Glioblastoma have unique radiological features, varied response to radiotherapy and long term outcomes

BACKGROUND

To assess the correlation of the three patterns of invasion of Glioblastoma (GB) with the respective MRI features, response to radiotherapy and disease free survival

MATERIAL AND METHODS

Histopathology of 62 patients with Glioblastoma who had undergone maximal safe resection (MSR)/ stereotactic biopsy (STB) & referred for adjuvant therapy was reviewed to assess the pattern of invasion. Three patterns were observed- single cell infiltration (pattern 1), perineuronal satellitosis (pattern 2) and vessel cooption (or perivascular spread, pattern 3), majority also had diffuse infiltration pattern in the background. The pre and post operative MRI scans were utilized for RT planning of 3DCRT/ IMRT/ VMAT, the modality decided by the treating oncologist. RT volumes were as per ESTRO-ACROP guidelines. Duration of radiotherapy- the Stupp regimen or a short course of hypofractionated radiotherapy (HFRT) (35Gy/10Fr- planned gap- completion of total dose) was based on the extent of resection (EOR) and KPS at the time of RT. Correlation of the pattern of invasion, MRI characteristics of each on the response to radiotherapy as assessed by RANO criteria and survival was analysed with the help of SPSS V21.

RESULTS

MRI findings after stratification of 62 patients, median age 43 years(18–70), M:F::42:20) into type 1:17, type 2:21 and type 3:24- patterns of invasion, were cortical tumours (subtle enhancement) close to SVZ, solid (+/- cystic) lesion in the eloquent cortex or large mass effect crossing the barriers respectively. OS of entire cohort at 1 year was 75%, with significant differences among groups (82% vs. 85% vs. 50%). Among pattern 1, those patients with IDH mutant (20%) & mean dose to C/L SVZ of 30Gy or more had longer DFS at 1 year (89% Vs. 38% & 85% vs. 0%, p<0.05). In pattern 2, EOR (gross total or near total resection Vs. only STB) showed a better DFS at 1 year (90% vs. 40%, p=0.095). In patients with pattern 3, 40% had post op KPS of <80 and 20% of them underwent HFRT who showed higher CR/PR rates compared to the conventional RT. HFRT in low KPS with m-MGMT showed higher local control at 6 months (100% Vs. 66%, p= 0.02).

CONCLUSION

Glioblastoma has three patterns of invasion with unique MRI features and aggressiveness for each. Identification of this may guide choice of adjuvant therapy, patterns of failure and therapy resistance

Concomitant utilization of radiofrequency ablation during atrial fibrillation cryoballoon ablation procedures

Funding Acknowledgements

Type of funding sources: None.

Background

Use of cryoballoon ablation (CBA) for the treatment of atrial fibrillation (AF) has become increasingly common in recent years. While various techniques have been described for use of the cryoballoon to achieve PVI and create selective additional lesion sets, the need for concomitant radiofrequency (RF) ablation in delivering touch-up ablation or non-PVI lesion sets has not been quantified.

Purpose

To quantify the rate of RF ablation catheter use in AF CBA procedures, and to evaluate whether indication for ablation can be used as a predictor of the need for supplementary RF ablation.

Methods

Self-reported data was prospectively collected in AF CBA procedures. Procedural characteristics including concomitant utilization of RF ablation catheters and lesion set delivery were recorded and analyzed. Post-hoc statistical analysis was completed utilizing a two-sample t-test of significance.

Results

Data was collected in a total of 246 AF CBA cases across 44 centers in the USA, Europe, and Japan. Included in the analysis were 170 paroxysmal atrial fibrillation cases (PAF group); 70 PersAF and 6 LsPersAF cases (PersAF group). Utilization rates for RF ablation catheters did not differ between the two groups; 35.9% and 36.8% of cases in PAF and PersAF, respectively (p = 0.885). The number of patients in which non-PV lesion sets were delivered also did not differ between groups; 38.2% and 40.8% in PAF and PersAF, respectively (p = 0.706). The choice of non-PV lesion sets varied as shown in Table 1. Upon completion of ablation, more patients were in sinus rhythm in the PAF group compared to the PersAF group, but the difference did not reach statistical significance; 88.2% and 78.9%, respectively (p = 0.057).

Conclusions

RF ablation catheter utilization rates were similar between groups, suggesting that indication (PAF vs. PersAF) alone is not a good predictor of whether concomitant RF ablation catheter utilization will be required during an AF CBA procedure. Table 1 Incidence Lesion Set PAF (n = 170) PersAF (n = 76) CTI Line 26.5% (45/170) 15.8% (12/76) Isolation/Homogenization of Fibrotic Areas 2.9% (5/170) 3.9% (3/76) CFE 2.9% (5/170) 0.0% (0/76) Posterior Wall Isolation 1.8% (3/170) 21.1% (16/76) Roof Line 1.8% (3/170) 7.9% (6/76) Other 9.4% (16/170) 27.6% (21/76) Utilization rate of non-PVI lesion sets

Incidence of residual gaps identified by a high-density grid-style catheter post-cryoballoon ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Despite advances in cardiac ablation technologies and the introduction of single-shot ablation devices such as the cryoballoon, the ability to consistently achieve complete and durable PVI remains elusive. While this is often attributed to PV reconnections that develop after the index procedure, recent data has suggested that traditional diagnostic techniques and technologies may in fact fail to identify gaps that remain upon completion of the index ablation. Initial observations in a small cohort of patients suggested that these residual gaps could be detected by a high-density, grid-style mapping catheter (HD Grid) post-cryoballoon ablation (CBA). The true incidence of these residual gaps as identified in a large patient population has not been previously reported.

Purpose

To quantify in a large cohort of CBA procedures, the presence of residual gaps identified by HD Grid which are missed by standard techniques of PVI confirmation using a 3.3F circular mapping catheter (CMC).

Methods

Self-reported data was prospectively collected in CBA procedures in which PVI was first confirmed using CMC followed by assessment using the HD Grid. Procedural characteristics and acute outcomes, including the incidence and location of residual gaps were analyzed.

Results

Data was collected in 150 CBA procedures performed in 24 centers across the US, Europe and Japan. De novo and repeat ablations represented 78.7% and 12.0% of cases, respectively (9.3% NR). A left common PV was present and ablated in 5.3%; right common in 0.7%. The CMC was used to confirm isolation in all cases using a variety of techniques including voltage mapping (73.3%), exit block (54.7%), and entrance block (29.3%); note: total exceeds 100% as >1 technique may be used in a single case. PVI was then reassessed with HD Grid, enabling a direct comparison of the two technologies. The HD Wave configuration, measuring simultaneous orthogonal bipoles, was used in 94.0% of cases. HD Grid identified a total of 119 gaps in 41 (27.3%) patients, which were missed by the CMC (Figure 1).

Conclusions

Assessment of PVI using the HD Grid identified residual PV conduction gaps that were missed by the CMC and standard diagnostic techniques in over a quarter of the patients evaluated. One limitation of this analysis is that the technique(s) used for confirmation of PVI were left to the discretion of the operator. Additionally, this analysis includes only workflows in which PVI was confirmed with HD Grid after confirmation using the CMC. Considering the prevalence of residual gaps observed, it is reasonable to interpret that new diagnostic catheter technologies could be critical in the pursuit of more complete and durable PVI, potentially impacting long-term clinical outcomes. Further study on other high-density mapping catheter configurations would be warranted before extrapolating these results to different technologies. Abstract Figure.

An in vitro study of Ocimum sanctum as a chemotherapeutic agent on oral cancer cell-line

Oral squamous cell carcinoma (OSCC) is the most commom cancer in the world. If remain untreated for several years, it may be fatal. Hence, it is important to prevent and treat OSCC at an early stage. In this study the effect of aqueous and dry leaves extract of Ocimum sanctum was observed on Ca9-22 cell line, which is an OSCC cell line. For this, Ca9-22 cell line was cultured and maintained. After 24 h, the cells were treated with aqueous and dry leaves extract of Ocimum sanctum plant. Viability of the cancerous cells were studied by 3-(4, 5-dimethythiazol-2-yl)-2, 5-diphenyl tetrazolium bromide (MTT) assay and neutral red uptake (NRU) assay. Minimum inhibitory concentrations (MIC), lethal concentration₂₅ (LC₂₅), lethal concentration₅₀ (LC₅₀) and highest permissive concentration (HPC) was calculated by probit computational method. Experimentally, the MIC value was 5 mg/L, whereas the HPC was 30 mg/L of the plant extract in aqueous state. For the dry extract the MIC was 5 mg/L whereas the HPC was 35 mg/L for both MTT and NRU assays. For MTT assay LC values: 7.41 (LC₂₅), 14.79 (LC₅₀) and 26.91 mg/L (LC₇₅) for aqueous extract and 12.58 (LC₂₅), 20.89 (LC₅₀), 29.51 mg/L (LC₇₅) for dry extract. For NRU assay LC values were 10.23 (LC₂₅), 14.79 (LC₅₀) and 20.89 mg/L (LC₇₅) aqueous extract, and 16.59 (LC₂₅), 23.44 (LC₅₀), 30.19 mg/L (LC₇₅) dry extract of the plant. From the above study it was concluded that, Ocimum sanctum have anti-cancerous activity. It can further be used for therapeutic purposes.

Safety and feasibility of carotid revascularization in patients with cerebral embolic strokes associated with carotid webs and histopathology revisited

INTRODUCTION

Carotid web is increasingly recognized as the cause of ischemic embolic strokes in younger patients. The best way to treat carotid web is debatable and carotid artery stenting (CAS) has been reported as a treatment for the carotid web in only a few case series. In this study we evaluate the safety and feasibility of CAS in symptomatic carotid webs and examined the histopathology of a carotid web.

MATERIALS AND METHODS

At our institution between 2017 and 2019, 10 consecutive patients with symptomatic carotid webs were treated. We retrospectively analyzed the data for patient demographics, clinical presentation, imaging, treatment methodology and follow up.

RESULTS

All the patients had presented with ipsilateral embolic stroke. The mean age at presentation was 50 years (range 37-71) with seven female and three male patients. All patients underwent CAS except one patient who underwent carotid endarterectomy (CEA). In one stented patient, there was significant hypotension in the post-procedural period lasting a week. The patients were followed for a mean of 5.5 months (range one day-12 months). No recurrent stroke or transient ischemic attack (TIA) occurred. Surgical pathological studies confirmed fibromuscular dysplasia in one specimen.

CONCLUSION

In our experience CAS for carotid web is feasible and safe in patients presenting with ischemic embolic strokes.

The effect of SGLT2 inhibitors on silent myocardial ischemia

Background

In large cardiovascular (CV) outcome trials, sodium-glucose co-transporter 2 (SGLT2) inhibitors reduced the development of heart failure (HF) in patients with type 2 diabetes (T2DM). Also it reduced CV death and worsening HF events in HFrEF patients. It is unknown whether SGLT2 inhibitors work through glucose-dependent mechanism or it could have other effects not related to glucose on cardiovascular morbidity and mortality in diabetic patients. Its effect on silent ambulatory myocardial ischemia (SAMI) has not been reported yet. In this study we report the effect of SGLT2 inhibitors on (SAMI). Treating silent myocardial ischemia has a prognostic effect and may improve long term mortality of chronic ischemic heart disease (CIHD).

Methods

We enrolled 44 type 2 diabetic patients with proven stable coronary artery disease (CAD) and at least one episode of on silent ambulatory myocardial ischemia (SAMI) on ambulatory ECG monitoring. All of them were receiving optimal therapy for CIHD and type 2 DM. 22 patients were randomized to receive Dapagliflozin 5mg qd and the other 22 patients received placebo. Ambulatory monitoring was repeated after 4 to 6 months of therapy. The two groups were comparable with respect to baseline characteristics, number of episodes of ST-segment depression, HgbA1c level, and baseline serum cholesterol levels. Holters were read by a blinded cardiologist.

Results

The Dapagliflozin group experienced a significant reduction in the number of episodes of ST-segment depression compared with the placebo group. ST-segment depression completely resolved in 8 of 22 patients (36%) in the Dapagliflozin group versus 3 of 22 (13%) in the placebo group and the Dapagliflozin group exhibited a highly significant reduction in (SAMI) (P<0.001). By logistic regression, treatment with Dapagliflozin was an independent predictor of (SAMI) resolution.

Conclusions

Therapy with SGLT2 inhibitors in type2 DM patients results in reduction or resolution of (SAMI) recorded as episodes of ST-segment depression in ambulatory monitoring of the ECG. A larger study is required to confirm this theory and to see the effect of SAMI reduction on long term mortality of CIHD in diabetics. Possible mechanisms for this beneficial effects of SGLT2i includes: Reduction in oxygen supply-demand mismatch, improvement in cardiac microvascular function, modulation of cardiac energy metabolism, reduction in glucotoxicity, reduction in sympathetic nervous system activation and reduction in blood pressure.

Funding Acknowledgement

Type of funding source: None

Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial

OBJECTIVES

To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery.

METHODS

This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables.

RESULTS

Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH₂ O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced.

CONCLUSIONS

We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

P1361Impact of radiation/chemotherapy for breast cancer on the electroanatomic features in patients receiving catheter ablation for left atrial arrhythmia

Background

Atrial fibrillation (AF) is a common cardiac arrhythmia and catheter ablation a viable treatment option for patients with AF. Extensive left atrial (LA) scars, frequently seen in patients with persistent AF, can limit its efficacy. Radiation for breast cancer treatment is known to have serious long-term effects (e.g. fibrosis) on the targeted tissue. At the same time, chemotherapy often leads to organ dysfunction. We sought to examine the effects of radiation and chemotherapy on the electroanatomic features of the LA in patients who received catheter ablation for left atrial arrhythmias with prior breast cancer treatment.

Methods and Results

We compared 38 patients (mean age 68.4 ± 7.1 years) who underwent catheter ablation for LA arrhythmia and had a previous diagnosis of breast cancer with 38 patients (mean age 65.4 ± 7.3 years) without breast cancer who formed our control group. LA scar area, as well as its distribution was measured during the electrophysiology (EP) study and graded according to the Utah classification.

The existence of LA scarring did not differ significantly between both groups (71.1% vs. 76.3%, p = 0.602). LA scar area (excluding PVs) was 107.5cm2 ± 19.0cm2 in the breast cancer group compared to 110.1cm2 ± 18.5cm2 in the control group (p = 0.536). The distribution of the scar area revealed no significant difference between both groups, however an involvement of the anterior wall was common (65.8% vs. 73.7%; p = 0.454). We further investigated whether the location of breast cancer had an impact on the LA scar development of the patients in our study cohort. Here, we found no significant difference in the amount of LA scarring when comparing patients with left-sided breast cancer to patients with right-sided breast cancer (66.7% vs. 73.9%). In a sub-analysis patients with breast cancer and persistent AF showed a non-significant trend towards greater LA scar areas (17.4cm2 vs. 6.8cm2) in comparison to patients of the control group with similar LA volumes.

The patient’s age (&gt;65 years) was the only independent predictor for greater LA scarring we could identify. Neither former radiotherapy, nor chemotherapy showed a positive correlation with greater LA scarring.

Conclusion

There is no change in the distribution as well as an increase of the extent of LA scars after thoracic irradiation and/or chemotherapy. A trend towards greater LA scar areas was seen in patients with breast cancer and persistent AF. The patient’s age was identified as an independent predictor for LA scar development.

P1061Incidence and location of PVI gaps identified post-cryoballoon ablation for atrial fibrillation

Background

 Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported.

Purpose

 To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes.

Methods

 Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed.

Results

 Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case.

Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study.

Abstract Figure.

Ultrasound assessment of pelvic floor muscle contraction: reliability and development of an ultrasound-based contraction scale

OBJECTIVES

To determine intra- and interrater reliability and agreement for ultrasound measurements of pelvic floor muscle contraction and to assess the correlation between ultrasound and vaginal palpation. We also aimed to develop an ultrasound scale for assessment of pelvic floor muscle contraction.

METHODS

This was a cross-sectional study of 195 women scheduled for stress urinary incontinence (n = 65) or prolapse (n = 65) surgery or who were primigravid (n = 65). Pelvic floor muscle contraction was assessed by vaginal palpation using the Modified Oxford Scale (MOS) and by two- and three-dimensional (2D/3D) transperineal ultrasound. Proportional change in 2D and 3D levator hiatal anteroposterior (AP) diameter and 3D levator hiatal area between rest and contraction were used as measures of pelvic floor muscle contraction. One rater repeated all ultrasound measurements on stored volumes, which were used for intrarater reliability and agreement analysis, and three independent raters analyzed 60 ultrasound volumes for interrater reliability and agreement analysis. Reliability was assessed using the intraclass correlation coefficient (ICC) and agreement using Bland-Altman analysis. Tomographic ultrasound was used to identify women with major levator injury. Spearman's rank correlation coefficient (r_S ) was used to assess the correlation between ultrasound measurements of pelvic floor muscle contraction and MOS score. The proportion of women allocated to each category of muscle contraction (absent, weak, moderate or strong) by palpation was used to determine the cut-offs for the ultrasound scale.

RESULTS

Intrarater ICC was 0.81 (95% CI, 0.74-0.85) for proportional change in 2D levator hiatal AP diameter. Interrater ICC was 0.82 (95% CI, 0.72-0.89) for proportional change in 2D AP diameter, 0.80 (95% CI, 0.69-0.88) for proportional change in 3D AP diameter and 0.72 (95% CI, 0.56-0.83) for proportional change in hiatal area. The prevalence of major levator injury was 22.6%. The strength of correlation (r_S ) between ultrasound measurements and MOS score was 0.52 for 2D AP diameter, 0.62 for 3D AP diameter and 0.47 for hiatal area (P < 0.001 for all). On the ultrasound contraction scale, proportional change in 2D levator hiatal AP diameter of < 1% corresponds to absent, 2-14% to weak, 15-29% to normal and > 30% to strong contraction.

CONCLUSIONS

Ultrasound seems to be an objective and reliable method for evaluation of pelvic floor muscle contraction. Proportional change in 2D levator hiatal AP diameter had the highest ICC and moderate correlation with MOS score assessed by vaginal palpation, and we constructed an ultrasound scale for assessment of pelvic floor muscle contraction based on this measure. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Merkel Cells: A Collective Review of Current Concepts

Merkel cells (MCs) constitute a very unique population of postmitotic cells scattered along the dermo-epidermal junction. These cells that have synaptic contacts with somatosensory afferents are regarded to have a pivotal role in sensory discernment. Several concerns exist till date as to their origin, multiplication, and relevance in skin biology. The article, a collective review of literature extracted from PubMed search and dermatology books, provides novel insights into the physiology of MCs and their recent advances.

Systematic Review on Effectiveness of Patient/Nurse Navigation on Health Outcomes of Breast Cancer Patients

Background: Continued advances in technology and cancer treatment have made cancer care more complex. A wide range of healthcare professionals are involved in the care and there is a potential for poor coordination and miscommunication. Hence there is a need to integrate and coordinate care to enhance quality care and improved health outcomes patient navigation approach was introduced by Dr Harold Freeman at Harlem Hospital Centre, the USA in 1990. Some literature identified nurses as a suitable candidate to assume this role. But there is a need to further explore the effectiveness of patient/nurse navigation program for its effectiveness on health outcomes such as anxiety, psychological distress, mood states, quality of life, symptom distress (nausea, vomiting, sleep disturbances) physical well being, psychological well being, coping, support and patient satisfaction. Aim: To synthesize the best available evidence on the effectiveness of patient/nurse navigation program in the care of women with breast cancer. Methods: This review was conducted according to Cochrane guidelines. An extensive literature search was conducted in PubMed, CINAHL, Proquest, Cochrane Library, IndMed (Indian database of studies) and Shodhganga, a reservoir of Indian theses from January 1990-January 2017 for relevant studies published in the English language. The search criteria were limited to randomized controlled trials with patient or nurse navigation interventions compared with routine/usual care interventions without patient/nurse navigator in women with diagnosis of breast cancer aged 18 years and above, at any stage of illness undergoing any treatment in a hospital setting, including inpatient and outpatient/ambulatory care and studies. Results: Out of 238 studies assessed for eligibility only 6 studies were assessed for methodological quality. Quality assessment was done by using Delphi checklist by two independent reviewers. The risks of bias in RCTs were assessed using Cochrane risk of bias tool. Due to the methodological heterogeneity of the studies, a meta-analysis was not performed. The reviewers categorized the main outcomes as quality of life, patient satisfaction with care, anxiety, psychological distress and physical problems and other outcomes (treatment adherence, barriers to care, diagnostic interval, timely access to care, time to completion of treatment, use of health care resources) and presented it in narrative form. Conclusion: This review provides evidence that navigation programs have some benefit on breast cancer patients' health outcomes. The findings from this review show that there are a limited number of studies reporting health outcomes of breast cancer patients from inpatient settings and especially no studies from Asian countries. This warrants the need for developing navigation programs in developing countries especially in Indian setting where no navigation programs are being reported in cancer care.