Real-world EGFR testing practices for non-small-cell lung cancer by thoracic pathology laboratories across Europe

BACKGROUND

Testing for epidermal growth factor receptor (EGFR) mutations is an essential recommendation in guidelines for metastatic non-squamous non-small-cell lung cancer, and is considered mandatory in European countries. However, in practice, challenges are often faced when carrying out routine biomarker testing, including access to testing, inadequate tissue samples and long turnaround times (TATs).

MATERIALS AND METHODS

To evaluate the real-world EGFR testing practices of European pathology laboratories, an online survey was set up and validated by the Pulmonary Pathology Working Group of the European Society of Pathology and distributed to 64 expert testing laboratories. The retrospective survey focussed on laboratory organisation and daily EGFR testing practice of pathologists and molecular biologists between 2018 and 2021.

RESULTS

TATs varied greatly both between and within countries. These discrepancies may be partly due to reflex testing practices, as 20.8% of laboratories carried out EGFR testing only at the request of the clinician. Many laboratories across Europe still favour single-test sequencing as a primary method of EGFR mutation identification; 32.7% indicated that they only used targeted techniques and 45.1% used single-gene testing followed by next-generation sequencing (NGS), depending on the case. Reported testing rates were consistent over time with no significant decrease in the number of EGFR tests carried out in 2020, despite the increased pressure faced by testing facilities during the COVID-19 pandemic. ISO 15189 accreditation was reported by 42.0% of molecular biology laboratories for single-test sequencing, and by 42.3% for NGS. 92.5% of laboratories indicated they regularly participate in an external quality assessment scheme.

CONCLUSIONS

These results highlight the strong heterogeneity of EGFR testing that still occurs within thoracic pathology and molecular biology laboratories across Europe. Even among expert testing facilities there is variability in testing capabilities, TAT, reflex testing practice and laboratory accreditation, stressing the need to harmonise reimbursement technologies and decision-making algorithms in Europe.

Discovery of Gamma Rays from the Quiescent Sun with HAWC

We report the first detection of a TeV γ-ray flux from the solar disk (6.3σ), based on 6.1 years of data from the High Altitude Water Cherenkov (HAWC) observatory. The 0.5-2.6 TeV spectrum is well fit by a power law, dN/dE=A(E/1  TeV)^{-γ}, with A=(1.6±0.3)×10^{-12}  TeV^{-1} cm^{-2} s^{-1} and γ=3.62±0.14. The flux shows a strong indication of anticorrelation with solar activity. These results extend the bright, hard GeV emission from the disk observed with Fermi-LAT, seemingly due to hadronic Galactic cosmic rays showering on nuclei in the solar atmosphere. However, current theoretical models are unable to explain the details of how solar magnetic fields shape these interactions. HAWC's TeV detection thus deepens the mysteries of the solar-disk emission.

The Association of Limited English Proficiency With Morbidity and Mortality After Trauma

INTRODUCTION

Disparities following traumatic injury by race/ethnicity and insurance status are well-documented. However, the relationship between limited English proficiency (LEP) and outcomes after trauma is poorly understood. This study describes the association between LEP and morbidity and mortality after traumatic injury.

METHODS

A retrospective cohort study was conducted of adult trauma patients admitted to a level 1 trauma center from 2012 to 2018. Morbidity (length of stay [LOS], intensive care unit admission, intensive care unit LOS, discharge destination) and in-hospital mortality for LEP and English proficient (EP) patients were compared using univariate and multivariable logistic and generalized linear models controlling for patient demographics (age, sex, race/ethnicity, insurance) and clinical characteristics (mechanism, activation level, Glasgow Coma Scale, Injury Severity Score, traumatic brain injury).

RESULTS

Of the 13,104 patients, 16% were LEP patients. LEP languages included Chinese (44%) and Spanish (38%), and 18% categorized as "Other," including 33 languages. In multivariable models, LEP was statistically significantly associated with increased hospital LOS (P = 0.003) and increased discharge to home with home health services (P = 0.042) or to skilled nursing facility/rehabilitation (P = 0.006). Mortality rate was 7% for LEP versus 4% for EP patients (P < 0.0001). In multivariable analysis, speaking an LEP language other than Chinese or Spanish was statistically significantly associated with increased mortality compared to EP (P = 0.006).

CONCLUSIONS

Following traumatic injury, LEP patients experience increased hospital LOS and are more frequently discharged to home with home health services or to skilled nursing facilities/rehabilitation. LEP patients speaking languages other than Chinese or Spanish experience increased mortality compared to EP patients.

Third year medical student knowledge gaps after a virtual surgical rotation

INTRODUCTION

This study describes perceived knowledge gaps of third-year medical students after participating in a virtual surgical didactic rotation (EMLR) and shortened in-person surgery rotation during the COVID-19 Pandemic.

METHODS

Open-ended and Likert questions were administered at the end of the virtual rotation and inperson-surgical rotation to medical students. Three blinded coders identified themes by semantic analysis.

RESULTS

82 students (51% of all MS3s) participated in the EMLR. Semantic analysis revealed gaps in perioperative management (Post-EMLR:18.4%, Post-Inpatient:26.5%), anatomy (Post-EMLR:8.2%, PostInpatient:26.5%). and surgical skills (Post-EMLR: 43.0%, Post-Inpatient: 44.1%). Students also described gaps related to OR etiquette (Post-EMLR: 12.2%, Post-Inpatient: 8.8%) and team dynamics/the hidden curriculum (Post- Inpatient:26.6%). There was a significant improvement in perceived confidence to perform inpatient tasks after completing the inpatient clinical experience (p ≤ 0.01).

CONCLUSION

Virtual interactive didactics for cognitive skills development cannot replace a full clinical surgical experience for third-year medical students. Future curricula should address perceived gaps.

Comparison of advanced techniques for local excision of rectal lesions: a case series

Background

Robotic transanal minimally invasive surgery (R-TAMIS) is an appealing alternative to transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM) for benign and early malignant rectal lesions that are not amenable to traditional open transanal excision. However, no studies to our knowledge have directly compared the three techniques. This study sought to compare peri-operative and pathologic outcomes of the three approaches.

Methods

The records of 29 consecutive patients who underwent TEM, TAMIS, or R-TAMIS at a single academic center between 2016 and 2020 were reviewed. Intra-operative details, pathological diagnosis and margins, and post-operative outcomes were recorded. The three groups were compared using chi-square and Kruskal–Wallis tests.

Results

Overall, 16/29 patients were women and the median age was 57 (interquartile range (IQR): 28–81). Thirteen patients underwent TEM, six had TAMIS, and 10 had R-TAMIS. BMI was lower in the R-TAMIS patients (24.7; IQR 23.8–28.7), than in TEM (29.3; IQR 19.9–30.2), and TAMIS (30.4; IQR 26.6–32.9) patients. High grade dysplasia and/or invasive cancer was more common in TAMIS (80%) and R-TAMIS (66.7%) patients than in TEM patients (41.7%). The three groups did not differ significantly in tumor type or distance from the anal verge. No R-TAMIS patients had a positive surgical margin compared to 23.1% in the TEM group and 16.7% in the TAMIS group. Length of stay (median 1 day for TEM and R-TAMIS patients, 0 days for TAMIS patients) and 30-day readmission rates (7.7% of TEM, 0% of TAMIS, 10% of R-TAMIS patients) also did not differ among the groups. Median operative time was 110 min for TEM, 105 min for TAMIS, and 76 min for R-TAMIS patients.

Conclusions

R-TAMIS may have several advantages over other advanced techniques for transanal excisions. R-TAMIS tended to be faster and to more often result in negative surgical margins compared to the two other techniques.

Advocating for a New Residency Application Process: A Student Perspective

OBJECTIVE

The COVID-19 pandemic provided an opportunity for surgical residency programs to rethink their methods of evaluating and recruiting candidates. However, the past year has not been seamless, with a soaring number of applications, reports of programs and applicants having difficulty evaluating each other, and an increasingly uneven distribution of interviews among applicants. Consequently, many have called for national changes to the residency application process to address these longstanding concerns.

RESULTS

Here, we review the evolving literature and advocate for the permanent adoption of visiting rotations, virtual interviews with a universal release date and data-driven attendance limits, and opportunities for in-person applicant visits.

CONCLUSIONS

We believe these changes leverage the strengths of each format, allow for satisfactory bidirectional evaluation, and promote principles of justice, equity, diversity, and inclusion.

Bursting the Hidden Curriculum Bubble: A Surgical Near-Peer Mentorship Pilot Program for URM Medical Students

The hidden curriculum of unspoken professional expectations negatively impacts medical student interest in surgery. Medical student mentorship and early surgical exposure have been shown to demystify the hidden curriculum. Although residents and faculty play a vital role, near-peer mentorship may aid in uncovering the hidden curriculum and promoting medical student interest in surgery, especially for those learners who are underrepresented in medicine. We developed and implemented a formalized near-peer mentorship program composed of quarterly small group Surgical Peer Teacher led lessons and one-on-one Surgical Support Team mentorship meetings covering surgical curriculum topics for medical students at an academic medical school. This structured near-peer mentorship model provides a mechanism to demystify surgical culture, increase early access to surgical mentorship, and develop mentorship skills amongst students. This program aims to uncover the surgical hidden curriculum to improve surgical career support and interest among medical students with less exposure and access to physician role models. This longitudinal mentorship model is student-run and can be easily adapted to enhance existing support models at medical schools. Future studies will evaluate utilization, impact on surgical specialty interest, and efficacy in demystifying the surgical hidden curriculum.

Screening for Primary Aldosteronism is Underutilized in Patients with Obstructive Sleep Apnea

BACKGROUND

Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines' inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown.

METHODS

All hypertensive adult patients with obstructive sleep apnea (n = 4751) at one institution between 2012 and 2020 were compared with a control cohort without sleep apnea (n = 117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation.

RESULTS

Obstructive sleep apnea patients were predominantly men and had higher body mass index. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (odds ratio [OR] 2.70; P < .001) and hypokalemia (OR 1.26; P < .001) independent of body mass index, sex, and number of antihypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; P < .001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% vs 4.6%; post-guidelines 3.6% vs 4.6%; P < .01). Screening among eligible sleep apnea patients remained low prior to and after guideline publication (4.4% vs 3.4%).

CONCLUSIONS

Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.

Restoration of marine ecosystems: Understanding possible futures for optimal outcomes

Accelerating declines in the extent, quality and functioning of the world's marine ecosystems have generated an upsurge in focus on practical solutions, with ecosystem restoration becoming an increasingly attractive mitigation strategy for systems as diverse as coral reefs, mangroves and tidal flats. While restoration is popular because it promises positive outcomes and a return to something approaching unimpacted condition and functioning, it involves substantial public and private investment, both for the initial restoration activity and for on-going maintenance of the restored asset. This investment often affords one big chance to get things right before irretrievable damage is done. As a result, precise, well considered and accountable decision-making is needed to determine the specific focus for restoration, the scale of restoration, the location for deploying restoration activities, and indeed whether or not restoration is necessary or even possible. We explore the environmental/ecological considerations and constraints governing optimal decisions about the nature, location and prioritisation of restoration activities in marine ecosystems, and in particular the constraints on achieving understanding of possible futures and the likelihood of achieving them. We conclude that action must be informed by a context-specific understanding of the historical situation, the current situation, the constraints on change, the range of potential outcome scenarios, and the potential futures envisioned.

Where Do We Go From Here? Assessing Medical Students' Surgery Clerkship Preparedness During COVID-19

INTRODUCTION

The impact of COVID-19 on surgical education has been profound, and clinical learning experiences transitioned to virtual formats. This study investigated the impact of virtual experiences created to facilitate learning during the pandemic for medical students.

METHODS

We performed a cohort study to determine the perceived clinical preparedness for medical students enrolled in the preclinical surgery pilot course, surgical Extended Mastery Learning Rotation (EMLR), and longitudinal surgical clerkship (LC). The preclinical surgery pilot course took place before COVID-19 disruptions, and the EMLR and LC experiences took place virtually. Specialty choice was examined in the EMLR and LC cohorts. Performance on the NBME surgical assessments was analyzed among students enrolled in the traditional clerkship and pandemic-disrupted courses and compared to national data using a two-sample t-test.

RESULTS

Compared to preclinical students, EMLR and LC students demonstrated improvements in their perceived surgical clerkship readiness. After the 3-week EMLR course, in the setting of completing only one-third of the clerkship year, students had an average NBME Surgical Self-Assessment Exam score of 72 (SD 12), comparable to the national average of 71 (SD 9) p = 0.33. The average shelf exam score for students (N = 24) enrolled in the traditional clerkship (block 1), prior to COVID-19, disruptions was 66 (SD 9) compared to an average score of 69 (SD 9) for the longitudinal clerkship students (N = 20) that took the shelf exam later in the year (p = 0.36). COVID-19 disruptions did not affect specialty choice. All LC students have decided on a specialty; 50% nonsurgical and 50% surgical. From the EMLR cohort, 36% and 38% plan to pursue surgical and nonsurgical specialties, respectively, with 26% still undecided.

CONCLUSIONS

Courses were well-liked and will be implemented in future clerkships. Surgical educators demonstrated flexibility and creativity in the development of the EMLR. Despite COVID-19 disruptions, medical students made progress in their clinical skills and foundational science knowledge. COVID-19 disruptions did not appear to impact specialty choice.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic

BACKGROUND

The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic.

METHODS

We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted.

RESULTS

One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns.

CONCLUSIONS

Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

usefulness of the electrocardiogram and cardiac magnetic resonance to differentiate tachycardia induced cardiomyopathy from dilated cardiomyopathy in patients admitted for heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

In patients admitted for heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and a concomitant high-rate supraventricular tachyarrhythmia (SVT) it is challenging to predict LVEF recovery after heart rate control and distinguish tachycardia-induced cardiomyopathy (TIC) from dilated cardiomyopathy (DC). The role of cardiac magnetic resonance (CMR) and the electrocardiogram (ECG) in this setting remains unsettled.

Methods

Forty-three consecutive patients admitted for HF due to high-rate SVT and LVEF &lt;50% undergoing CMR in the acute phase were retrospectively included. Those who had LVEF &gt;50% at follow up were classified as TIC and those with LVEF &lt;50% were classified as DC. Clinical, laboratory, CMR and ECG findings were analyzed to predict LVEF recovery.

Results

Twenty-five (58%) patients were classified as TIC. Patients with DC had wider QRS (121.2 ± 26 vs 97.7 ± 17.35 ms; p = 0.003). On CRM the TIC group presented with higher LVEF (33.4 ± 11 vs 26.9 ± 6.4% p = 0.019) whereas late gadolinium enhancement (LGE) was more frequent in DC group (61 vs 16% p = 0.004). On multivariate analysis, QRS duration ≥100 ms (p = 0.027), LVEF &lt; 40% on CMR (p = 0.047) and presence of LGE (p = 0.03) were identified as independent predictors of lack of LVEF recovery. Furthermore, during clinical follow-up (median 60 months) DC patients were admitted more frequently for HF (44% vs 0%; p &lt; 0.001) than TIC patients (Figure 1).

Conclusion

In patients with reduced LVEF admitted for HF due to high-rate SVT, QRS duration ≥100 ms, LVEF &lt;40% on CMR and presence of LGE are independently associated with lack of LVEF recovery and worse clinical outcome.

Near-Peer Learning During the Surgical Clerkship: A Way to Facilitate Learning After a 15-Month Preclinical Curriculum

OBJECTIVES

To investigate the performance and perspectives of third-year medical students (MS3s) participating in near-peer learning (NPL) sessions during their core surgical clerkship following a 15-month preclerkship curriculum.

DESIGN

An evaluation study of 7 NPL sessions developed and implemented by fourth-year medical students (MS4s) held from March 2019 to February 2020. MS4s taught 1-2 sessions per rotation that included test taking strategies, illness script development, radiology review, case-based multiple-choice questions, and rapid review. Participants completed a questionnaire with 11 seven-point Likert and open-ended questions after each session. Analyses included quantitative comparison of shelf score averages between NPL participants and nonparticipants and qualitative content analysis for open-ended questions.

SETTING

Surgical clerkship at the University of California, San Francisco.

PARTICIPANTS

Forty-eight (32%) MS3s participated, with an average attendance of 10 students per rotation. Thirty-three (69%) participants completed the questionnaire.

RESULTS

MS3s enjoyed the session (6.9 ± 0.4), improved their knowledge (6.8 ± 0.5), and felt more prepared for the surgery shelf examination (6.5 ± 0.6). MS4 leaders found that MS3s always wanted radiology review, and their interest in test taking strategies and illness script development declined across the clerkship year. Participants had lower shelf exam scores compared to nonparticipants (68.1 vs 71.4, respectively; p = 0.04, ES = 0.03). Shelf exam scores increased over time in both cohorts. Each group had 2 shelf exam failures. Qualitative analysis suggests that MS3s appreciated the NPL's tailored approach and exam demystification, with a desire for increased NPL integration into the clerkship.

CONCLUSION

Students participating in NPL were satisfied with the sessions. Participants may have been students who struggled as indicated by shelf exam scores and appreciated the support. The shift in preferred topics across the blocks reflects the students' development during clerkships. Near-peer teachers should adjust sessions over time to fit students' evolving needs.

Surviving traumatic injury, only to die of acute drug poisoning: Should trauma centers be a path for intervention?

BACKGROUND

Although death from drug overdose is a leading cause of injury-related death in the United States, its incidence after traumatic incident is unknown. Moreover, little is known about related risk factors. We sought to determine the incidence and characteristics of and risk factors for trauma patients suffering death by acute drug poisoning ("overdose") after hospitalization for a traumatic incident.

METHODS

We conducted a retrospective chart review of all admitted trauma patients ≥18 y of age at the only level-1 trauma center in our region from 2012 to 2019, matched with unintentional overdose decedents from the California death registry. We assessed associations between demographic and clinical characteristics with risk of overdose death, using cumulative incidence functions and Fine-Gray subdistribution hazard models.

RESULTS

Of 9,860 patients residing in San Francisco, CA, USA, at the time of their trauma activation or admission during the study period, 1,418 died (4.3 per 100 person-years), 107 from unintentional overdose (0.3 per 100 person-years). Overdose decedents were 84% male, 50% white, with a mean age of 48 years at the time of presentation; 20% of deaths occurred within 3 months of hospitalization, and 40% were attributed to a prescription opioid. In multivariate analysis, younger age, male sex, white race, and having undergone a urine drug screening were all associated with subsequent death from overdose.

CONCLUSION

During a mean 3.4-year follow-up, the mortality rate from overdose among adult patients with traumatic incidents was 0.3/100 person-years. Trauma hospitalization may serve as an opportunity to screen and initiate prevention, harm reduction, and treatment interventions.

Practical strategies for reducing suicide risk among depressed adults

Introduction

Suicide remains a major problem throughout society. Unfortunately, recommendations for the treatment of suicidal clients are often presented at a general level, without providing adequate detail that could guide the practicing clinician.

Objectives

The review explains three main strategies that can be used to helpr educe the risk of suicide among depressed adults.

Methods

Method: The review identified three themes derives from an integration of 30+ years of clinical experience working with depressed outpatients combined with a comprehensive review of recent journal articles on depression and suicide.

Results

First, clients may become suicidal when they focus on unfortunate events from their recent or distant past, resulting in tendencies for rumination and guilt. Therapy can help clients cultivate an attitude of contentment, promoting self-forgiveness and a sense of accomplishment. Second, suicidal clients often focus on their current struggles, frequently involving financial problems, interpersonal conflict, and social isolation. Therapy can help clients to embrace life through planned activities, reconnecting with loved ones, and repairing damaged relationships. Third, clients may struggle because of hopeless views of their future, feeling trapped in a desperate situation with no possible solution. Therapy can help clients look to the future with a more optimist attitude and a sense of control.

Conclusions

Clients can learn to search for realistic solutions to their problems, developing a renewed sense of optimism and empowerment. The risk of suicide can be reduced when therapy helps clients reduce guilt and worthlessness, increase meaningful social bonds, and instill realistic hope for the future.

Conflict of interest

No significant relationships.

Surgery Clerkship Curriculum Changes at an Academic Institution during the COVID-19 Pandemic

PROBLEM

The COVID-19 pandemic has suspended the surgery clinical clerkship for third-year medical students at numerous institutions across the world. As a result, educators and students have adapted rapidly. There is a paucity of precedents regarding urgent and brusque formal curricular changes for medical students enrolled in surgical clinical rotations.

APPROACH

The University of California, San Francisco Department of Surgery created a surgically focused extended mastery learning rotation (EMLR). The surgery clerkship leadership designed a curriculum consisting of multiple learning strategies compatible with virtual learning environments. The primary aims of the newly developed EMLR were to help students consolidate their foundational science knowledge before their return to clinical medicine in an altered learning environment. The EMLR is currently underway, and further studies are necessary to evaluate its effectiveness.

Added prognostic value of longitudinal changes of angiogenic factors in early-onset severe pre-eclampsia: a prospective cohort study

OBJECTIVE

To assess in women with early-onset severe pre-eclampsia whether longitudinal changes in angiogenic factors improve the prediction of adverse outcome.

DESIGN

Prospective cohort study.

SETTING

Maternity units in two Spanish hospitals.

POPULATION

Women with diagnosis of early-onset severe pre-eclampsia.

METHODS

Levels of placental growth factor (PlGF), soluble fms-like tyrosine kinase (sFlt-) and sFlt-1/PlGF ratio were measured at admission and before delivery, and average daily change calculated. The association of longitudinal changes of angiogenic factors with the time interval to delivery and with complications was evaluated by logistic and Cox regression.

MAIN OUTCOME MEASURES

Interval to delivery and composite of adverse outcomes.

RESULTS

We included 63 women, of which 26 (41.3%) had a complication. Longitudinal changes of sFlt-1 were more pronounced in complicated pregnancies (median: 1047 versus 342 pg/ml/day; P = 0.04). On the multivariate analysis, the clinical risk score and sFlt-1 at admission explained 6.2% of the uncertainty for complication; the addition of sFlt-1 longitudinal changes improved this to 25.3% (P = 0.002). The median time from admission to delivery was 4 days (95% CI 1.6-6.04) in those in the highest quartile of sFlt-1 longitudinal changes versus 16 days (95% CI 12.4-19.6) in the remaining women (Log-rank test P < 0.001).

CONCLUSIONS

Longitudinal changes in sFlt-1 maternal levels from admission for confirmed early-onset severe pre-eclampsia add to baseline characteristics in the prediction of adverse outcome and interval to delivery.

TWEETABLE ABSTRACT

In early-onset severe pre-eclampsia, longitudinal changes in sFlt-1 levels improve the prediction of complications and interval to delivery.

Modulation instability in waveguides with an arbitrary frequency-dependent nonlinear coefficient

In this Letter, we present, for the first time, to the best of our knowledge, the modulation instability (MI) gain spectrum of waveguides with an arbitrary frequency-dependent nonlinear coefficient ensuring strict energy and photon-number conservation of the parametric process. This is achieved by starting from a linear stability analysis of the recently introduced photon-conserving nonlinear Schrödinger equation. The derived MI gain is shown to predict some unique features, such as a nonzero gain extending beyond a zero-nonlinearity wavelength and a complex structure of the MI gain spectrum. Analytical results are shown to be in excellent agreement with numerical simulations.

Constraints on Lorentz Invariance Violation from HAWC Observations of Gamma Rays above 100 TeV

Because of the high energies and long distances to the sources, astrophysical observations provide a unique opportunity to test possible signatures of Lorentz invariance violation (LIV). Superluminal LIV enables the decay of photons at high energy. The high altitude water Cherenkov (HAWC) observatory is among the most sensitive gamma-ray instruments currently operating above 10 TeV. HAWC finds evidence of 100 TeV photon emission from at least four astrophysical sources. These observations exclude, for the strongest of the limits set, the LIV energy scale to 2.2×10^{31}  eV, over 1800 times the Planck energy and an improvement of 1 to 2 orders of magnitude over previous limits.

Multiple Galactic Sources with Emission Above 56 TeV Detected by HAWC

We present the first catalog of gamma-ray sources emitting above 56 and 100 TeV with data from the High Altitude Water Cherenkov Observatory, a wide field-of-view observatory capable of detecting gamma rays up to a few hundred TeV. Nine sources are observed above 56 TeV, all of which are likely galactic in origin. Three sources continue emitting past 100 TeV, making this the highest-energy gamma-ray source catalog to date. We report the integral flux of each of these objects. We also report spectra for three highest-energy sources and discuss the possibility that they are PeVatrons.

616 Aortic stenosis: changing with age?

Introduction and aim

Aortic stenosis (AS) represents the main valve disease, thus, addressing its epidemiology and natural history becomes crucial. The aim of the present study is to shed light in the differences appearing with age in severe AS.

Methods

Observational, multicentre and prospective study of consecutive cases. Patients with severe AS, defined as aortic valve area (AVA) &lt;1.0 cm2, and preserved left ventricle ejection fraction (LVEF≥50%) were included. Subjects under and above 85 years were compared. Low gradient (LG) was defined by mean transaortic gradient (MG) &lt;40 mmHg and low flow (LF) by indexed stroke

volume (iSV) &lt;35 mL/m2. LV geometry was defined according to current chamber quantification guidelines.

A p-value &lt;0.05 was considered significant.

Results

A total of 636 patients were included, with slight predominance of females (53.9%; n = 343). No differences were found in AVA, LVEF, end-diastolic indexed values, LV mass or LV geometry between both age groups. MG and SVi were significantly lower in people over 85, who also presented more frequently with atrial fibrillation (AF) and significant mitral (MR) and tricuspid regurgitation (TR). Flow and gradient pattern vary significantly as shown in the graphic.

Conclusions

In our cohort, flow and gradient pattern in severe AS varies with age, despite no differences in LV geometry. This contrasts with previously assumed, relating LF and LG to more severe concentric hypertrophy. LF and LG can be explained by AF, significant MR and TR affecting more frequently those over 85.

Age-related differences in severe AS Less than 85 y.o. ≥85 y.o. p-value AVA (cm2) 0.73 (± 0.16) 0.72 (±0.18) 0.46 LVEF (%) 65 (±7.9) 64 (±7.8) 0.21 MG (mmHg) 41 (±14.2) 37 (±13) 0.04 iSV (mL/m2) 40 (±11) 36 (±11) 0.01 iLVEDV (mL/m2) 47 (±16) 45 (±16) 0.07 iLVMass (g/m2) 126 (±36) 127 (±36) 0.66 Normal geometry (%) 3.9 2.5 0.64 Concentric remodelling (%) 24.3 24.4 Concentric hypertrophy (%) 64.2 66.4 Eccentric hypertrophy (%) 7.6 6.7 AF (%) 12.3 19.3 0.04 Significant MR (%) 11.3 18.7 0.02 Significant TR (%) 50.4 65.7 &lt;0.01 iLVEDV indexed LV end-diastolic volume iLVMass: indexed LV mass

Abstract 616 Figure. Age-related flow and gradient pattern

619 Left ventricle remodelling in severe aortic stenosis: analysis of a large cohort of patients

Introduction

Aortic stenosis (AS) is the most prevalent valve disease. It involves increased left ventricle (LV) postcharge leading to LV hypertrophy. The aim of the study was to assess the burden of LV hypertrophy and its different patterns among a large cohort of patients with severe AS.

Methods

Observational, multicentre and prospective study of consecutive cases. Patients with severe AS defined as aortic valve area (AVA) &lt;1.0 cm2, and preserved LV ejection fraction (LVEF≥50%) were included. LV hypertrophy was diagnosed in case of LV indexed mass &gt;95 g/m2 in females or &gt;115 g/m2 in males. LV geometry was assessed by relative wall thickness ratio, considering a cut-off value of 0.42. A p value &lt;0.05 was considered statistically significant.

Results

A total of 805 patients with severe AS were included, 49.7% (n = 400) of them females and 50.3% (n = 405) males. LV indexed mass was available in 665 subjects, most of them (74.9%, n = 498) presenting LV hypertrophy. Females showed higher prevalence of LV hypertrophy than males (82.7% vs. 60.5%; p &lt; 0.01). Concentric hypertrophy was the most frequently encountered phenotype (63.9%; n = 420), being significantly more prevalent among women (74.3% vs 53.4%; p &lt; 0.01). Despite that increased hypertrophy, females showed less severe AS when comparing mean transaortic gradient (39 mmHg vs 42 mmHg; p = 0.04) and indexed AVA (0.42 cm/m2 vs 0.40 cm/m2; p = 0.02). LV hypertrophy was associated with enlarged atria and higher pulmonary systolic pressure.

Conclusions

LV hypertrophy affects most of patients with severe AS. LV remodelling is different between gender, with women developing higher grade of hypertrophy despite lesser AS severity. LV hypertrophy is associated with poor prognosis echocardiographic signs (increased PSAP and indexed LAV).

Differences related to LV mass Normal LV mass LV hypertrophy P value Indexed AVA (cm/m2) 0.42 ± 0.01 0.41 ± 0.01 0.52 Mean gradient (mmHg) 42 ± 0.7 36 ± 1.1 &lt;0.01 Indexed stroke volumen (mL/m2) 41 ± 1 37 ± 1 &lt;0.01 Indexed LAV (mL/m2) 46 ± 1 38 ± 1 &lt;0.01 PSAP (mmHg) 30 ± 2 41 ± 1 0.01 LAV left atrial volume PSAP: pulmonary systolic arterial pressure

Abstract 619 Figure. Sex related LV geometry patterns

P729 A shocking tumor

Introduction

Primary cardiac tumors are a relatively uncommon condition, which may appear both in asymptomatic patients or in a myriad of clinical presentations. Imaging techniques are crucial for its diagnosis, and a multi-modality approach may be useful in the evaluation of this masses.

Case description

A 57 year-old man with history of hypertension presented in the emergency department with acute pulmonary edema and cardiogenic shock. He was admitted to the coronary care unit, and on bedside echocardiography a mass on the tricuspid valve was observed.

Upon clinical improvement, a cardiac CT and cardiac MRI was performed (figure 1). A solid mass with no calcium content and dependent exclusively on the anterior leaflet of the tricuspid valve was seen on CT-scan (fig 1, A and B). Thrombus on the right atrial appendage could also be appreciated.

MRI confirmed the presence of a 18x19 mm mass with isointense signal on T1-turbo spin echo black-blood (fig 1, C) and cine steady-state free precession sequences, whereas an hyperintense signal was evident on T2 weighted images (T2-STIR; fig 1 D). In first pass sequences the central core was hypointense and late gadolinium enhancement showed peripheral enhancement with a non captating central core (fig 1, E).

The patient underwent surgery and the anatomopathological results showed a tumor constituted by dense connective tissue, scarce cellular content and an avascular matrix of mucopolysaccharides, elastic fibers and fusiform cells consistent with the diagnosis of papillary fibroelastoma.

Discussion

The imaging characteristics of papillary fibroelastoma are not commonly reported on MRI. We present an unusually large right-sided fibroelastoma with a characteristic distribution of late gadolinium enhancement, which has not been consistently described on a fibroelastoma.

Cardiac tumors are rare, and a non-invasive differential diagnosis is always a challenge. A multi-modality approach (echocardiography, cardiac-CT and cardiac MRI) as well as integration of relevant morphological information, including the location of the lesion and tissue characteristics was essential to the orientate the most plausible diagnosis. The distinctive images are presented.

Abstract P729 Figure 1.

Phage cocktail SalmoFREE® reduces Salmonella on a commercial broiler farm

According to the World Health Organization, Salmonella is one of the most important zoonotic foodborne pathogens. Poultry products are thought to be the main source of Salmonella, which means that it is necessary to control Salmonella at the pre-harvest stage. Bacteriophages, acting as host-specific parasites of bacterial cells, represent one of the alternatives to antibiotics that can contribute to food safety and security. The present study evaluated the effectiveness of the bacteriophage cocktail SalmoFREE^® to control Salmonella on a commercial broiler farm. We assessed the relationship between the use of SalmoFREE^® and productivity parameters (feed conversion, weight gain, homogeneity). Two field trials (trial 1 n = 34,986; trial 2 n = 34,680) were carried out under commercial rearing conditions on a Colombian broiler farm with a record of Salmonella presence. Each trial comprised 2 control chicken houses and 2 experimental ones. SalmoFREE^® and a control suspension were delivered in the drinking water at 3 time points in the production cycle, and the presence of Salmonella was assessed in cloacal swabs the day before and after the treatments. Results revealed that SalmoFREE^® controls the incidence of Salmonella and does not affect the animals nor the production parameters, demonstrating its efficacy and innocuity at the production scale. We detected phage-specific genes in samples of total DNA extracted from ceca after the treatment with SalmoFREE^®, and tested for the appearance of cocktail-resistant Salmonella, which showed to be an uncommon event. These results contribute relevant information to the adoption of phage therapy as an alternative to growth-promoter antibiotics on poultry farms.

P3370Prevalence of right ventricular dysfunction according to different parameters: basal and one year after transcatheter aortic valve implantation

Background

Right ventricle (RV) is not often specifically studied in patients with severe aortic stenosis (AS). It's difficult to find the correct tool to assess RV function with echocardiographic parameters, and the percentage of patients with dysfunction may vary depending on the parameter that we use.

The aim of the study was to evaluate the prevalence of RV dysfunction basal and one year after transcatheter aortic valve implantation (TAVI), according to different parameters.

Methods

Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed according to ESC and ASE guidelines. RV dysfunction was assessed using tricuspid annular plane systolic excursion (TAPSE) <17 mm, fractional area change <35%, systolic movement of the RV lateral wall by tissue Doppler imaging (RV-S'TDI) <9.5 cm/s, global longitudinal (RV-GLS) and free wall strain (RV-FWS) using as cutting point [20]. Pre procedure echo, immediate post procedure and 1 year echo were analyzed. Statistical analysis was performed using SSPS version 22.

Results

The final study population consisted of 78 patients (115 patients were included, 37 were excluded due to suboptimal acoustic window for RV anatomical and functional evaluation), mean age 83.73±6.31 year-old, 38.2% females. We analyzed the percentages of RV dysfunction according to the different parameters evaluated before and in the control one year after. They are shown in Figure 1.

Prevalence of RV dysfunction

Conclusions

The presence of RV dysfunction in patients with severe AS is higher than expected Our data suggest that RV function improve one year after TAVI, in terms of a reduction in the number of patients with dysfunction. The assessment of RV function is difficult, and there is no agreement on what tools are more accurate and useful. RV strain seems to be the most sensible parameter to assess RV function in patients with AS undergoing TAVI. Impact of these measurements in patients management needs further evaluation.

Publisher Correction: Very-high-energy particle acceleration powered by the jets of the microquasar SS 433

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