COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

BACKGROUND

Apical ground-glass opacification (GGO) identified on CT angiography (CTA) performed for suspected acute stroke was developed in 2020 as a coronavirus-disease-2019 (COVID-19) diagnostic and prognostic biomarker in a retrospective study during the first wave of COVID-19.

OBJECTIVE

To prospectively validate whether GGO on CTA performed for suspected acute stroke is a reliable COVID-19 diagnostic and prognostic biomarker and whether it is reliable for COVID-19 vaccinated patients.

METHODS

In this prospective, pragmatic, national, multi-center validation study performed at 13 sites, we captured study data consecutively in patients undergoing CTA for suspected acute stroke from January-March 2021. Demographic and clinical features associated with stroke and COVID-19 were incorporated. The primary outcome was the likelihood of reverse-transcriptase-polymerase-chain-reaction swab-test-confirmed COVID-19 using the GGO biomarker. Secondary outcomes investigated were functional status at discharge and survival analyses at 30 and 90 days. Univariate and multivariable statistical analyses were employed.

RESULTS

CTAs from 1,111 patients were analyzed, with apical GGO identified in 8.5 % during a period of high COVID-19 prevalence. GGO showed good inter-rater reliability (Fleiss κ = 0.77); and high COVID-19 specificity (93.7 %, 91.8-95.2) and negative predictive value (NPV; 97.8 %, 96.5-98.6). In subgroup analysis of vaccinated patients, GGO remained a good diagnostic biomarker (specificity 93.1 %, 89.8-95.5; NPV 99.7 %, 98.3-100.0). Patients with COVID-19 were more likely to have higher stroke score (NIHSS (mean +/- SD) 6.9 +/- 6.9, COVID-19 negative, 9.7 +/- 9.0, COVID-19 positive; p = 0.01), carotid occlusions (6.2 % negative, 14.9 % positive; p = 0.02), and larger infarcts on presentation CT (ASPECTS 9.4 +/- 1.5, COVID-19 negative, 8.6 +/- 2.4, COVID-19 positive; p = 0.00). After multivariable logistic regression, GGO (odds ratio 15.7, 6.2-40.1), myalgia (8.9, 2.1-38.2) and higher core body temperature (1.9, 1.1-3.2) were independent COVID-19 predictors. GGO was associated with worse functional outcome on discharge and worse survival after univariate analysis. However, after adjustment for factors including stroke severity, GGO was not independently predictive of functional outcome or mortality.

CONCLUSION

Apical GGO on CTA performed for patients with suspected acute stroke is a reliable diagnostic biomarker for COVID-19, which in combination with clinical features may be useful in COVID-19 triage.

Cell-free DNA methylation analysis as a marker of malignancy in pleural fluid

Diagnosis of malignant pleural effusion (MPE) is made by cytological examination of pleural fluid or histological examination of pleural tissue from biopsy. Unfortunately, detection of malignancy using cytology has an overall sensitivity of 50%, and is dependent upon tumor load, volume of fluid assessed, and cytopathologist experience. The diagnostic yield of pleural fluid cytology is also compromised by low abundance of tumor cells or when morphology is obscured by inflammation or reactive mesothelial cells. A reliable molecular marker that may complement fluid cytology for the diagnosis of malignant pleural effusion is needed. The purpose of this study was to establish a molecular diagnostic approach based on pleural effusion cell-free DNA methylation analysis for the differential diagnosis of malignant pleural effusion and benign pleural effusion. This was a blind, prospective case-control biomarker study. We recruited 104 patients with pleural effusion for the study. We collected pleural fluid from patients with: MPE (n = 48), indeterminate pleural effusion in subjects with known malignancy or IPE (n = 28), and benign PE (n = 28), and performed the Sentinel-MPE liquid biopsy assay. The methylation level of Sentinel-MPE was markedly higher in the MPE samples compared to BPE control samples (p < 0.0001) and the same tendency was observed relative to IPE (p = 0.004). We also noted that the methylation signal was significantly higher in IPE relative to BPE (p < 0.001). We also assessed the diagnostic efficiency of the Sentinel-MPE test by performing receiver operating characteristic analysis (ROC). For the ROC analysis we combined the malignant and indeterminate pleural effusion groups (n = 76) and compared against the benign group (n = 28). The detection sensitivity and specificity of the Sentinel-MPE test was high (AUC = 0.912). The Sentinel-MPE appears to have better performance characteristics than cytology analysis. However, combining Sentinel-MPE with cytology analysis could be an even more effective approach for the diagnosis of MPE. The Sentinel-MPE test can discriminate between BPE and MPE. The Sentinel-MPE liquid biopsy test can detect aberrant DNA in several different tumor types. The Sentinel-MPE test can be a complementary tool to cytology in the diagnosis of MPE.

Antenatal care of women who use opioids: a qualitative study of practitioners' perceptions of strengths and challenges of current service provision in Scotland

BACKGROUND

The increasing rise of women using opioids during pregnancy across the world has warranted concern over the access and quality of antenatal care received by this group. Scotland has particularly high levels of opioid use, and correspondingly, pregnancies involving women who use opioids. The purpose of this study was to investigate the different models of antenatal care for women using opioids during pregnancy in three Scottish Health Board Areas, and to explore multi-disciplinary practitioners' perceptions of the strengths and challenges of working with women who use opioids through these specialist services.

METHODS

Thirteen semi-structured interviews were conducted with health and social care workers who had experience of providing antenatal and postnatal care to women who use drugs across three Scottish Health Board Areas: NHS Greater Glasgow and Clyde, NHS Lothian, and NHS Tayside. Framework Analysis was used to analyse interview data. The five stages of framework analysis were undertaken: familiarisation, identifying the thematic framework, indexing, charting, and mapping and interpretation.

RESULTS

Each area had a specialist antenatal pathway for women who used substances. Pathways varied, with some consisting of specialist midwives, and others comprising a multidisciplinary team (e.g. midwife, mental health nurse, social workers, and an obstetrician). Referral criteria for the specialist service differed between health board areas. These specialised pathways presented several key strengths: continuity of care with one midwife and a strong patient-practitioner relationship; increased number of appointments, support and scans; and highly specialised healthcare professionals with experience of working with substance use. In spite of this, there were a number of limitations to these pathways: a lack of additional psychological support for the mother; some staff not having the skills to engage with the complexity of patients who use substances; and problems with patient engagement.

CONCLUSIONS

Across the three areas, there appears to be high-quality multi-disciplinary antenatal services for women who use opioids during pregnancy. However, referral criteria vary and some services appear more comprehensive than others. Further research is needed into the perceptions of women who use opioids on facilitators and barriers to antenatal care, and provision in rural regions of Scotland.

Cell-Free DNA Methylation Analysis as a Marker of Malignancy in Pleural Fluid

Background

Diagnosis of malignant pleural effusion (MPE) is made by cytological examination of pleural fluid or histological examination of pleural tissue from biopsy. Unfortunately, detection of malignancy using cytology has an overall sensitivity of 50%, and is dependent upon tumor load, volume of fluid assessed, and cytopathologist experience. The diagnostic yield of pleural fluid cytology is also compromised by low abundance of tumor cells or when morphology is obscured by inflammation or reactive mesothelial cells. A reliable molecular marker that may complement fluid cytology malignant pleural effusion diagnosis is needed. The purpose of this study was to establish a molecular diagnostic approach based on pleural effusion cell-free DNA methylation analysis for the differential diagnosis of malignant pleural effusion and benign pleural effusion.

Results

This was a blind, prospective case-control biomarker study. We recruited 104 patients with pleural effusion for the study. We collected pleural fluid from patients with: MPE (n = 48), PPE (n = 28), and benign PE (n = 28), and performed the Sentinel-MPE liquid biopsy assay. The methylation level of Sentinel-MPE was markedly higher in the MPE samples compared to BPE control samples (p < 0.0001) and the same tendency was observed relative to PPE (p = 0.004). We also noted that the methylation signal was significantly higher in PPE relative to BPE (p < 0.001). We also assessed the diagnostic efficiency of the Sentinel-MPE test by performing receiver operating characteristic analysis (ROC). For the ROC analysis we combined the malignant and paramalignant groups (n = 76) and compared against the benign group (n = 28). The detection sensitivity and specificity of the Sentinel-MPE test was high (AUC = 0.912). The Sentinel-MPE appears to have better performance characteristics than cytology analysis. However, combining Sentinel-MPE with cytology analysis could be an even more effective approach for the diagnosis of MPE.

Conclusions

The Sentinel-MPE test can discriminate between BPE and MPE. The Sentinel-MPE liquid biopsy test can detect aberrant DNA in several different tumor types. The Sentinel-MPE test can be a complementary tool to cytology in the diagnosis of MPE.

Associations of segment-specific pulse wave velocity with vascular calcification: the Atherosclerosis Risk in Communities (ARIC) Study

Background

Pulse wave velocity (PWV) is a non-invasive measure of arterial stiffness and a predictor of cardiovascular disease (CVD). Vascular calcification, especially coronary artery calcium (CAC) measured by computed tomography (CT), is one of the strongest predictors of CVD but requires radiation for measurement. PWV may be helpful to identify persons with vascular calcification who may benefit from formal assessment of vascular calcification with CT. However, the associations between PWV and vascular calcification across different vascular beds have not been fully investigated.

Purpose

The aims of this study were to quantify the association between PWV and calcification at different segments and to explore whether PWV can identify individuals with vascular calcification beyond traditional risk factors.

Methods

Among 1486 ARIC Study participants (mean age 79.3 [SD 4.2] years), we measured PWV by OMRON VP1000plus at the following segments: heart-carotid (hcPWV), heart-femoral (hfPWV), carotid-femoral (cfPWV), heart-ankle (haPWV), brachial-ankle (baPWV) and femoral-ankle (faPWV). Participants were stratified into four groups based on quartiles of each PWV measure. Dependent (i.e., outcome) variables were high calcium score (≥75th percentile of Agatston score by CT) of the following vascular beds (including valves): coronary arteries, aortic valve ring, aortic valve, mitral valve, ascending aorta, and descending aorta. We ran multivariable logistic regression models and assessed c-statistics as a measure of prediction discrimination.

Results

Only cfPWV was significantly positively associated with high CAC (adjusted odds ratio [OR] for the highest vs. lowest quartile: 1.73 [95% CI: 1.17–2.55]) (green dot in figure). The associations were overall most evident for descending aorta calcification, with significantly positive results for hfPWV (gold dot in figure), cfPWV (green dot), haPWV (emerald dot), and baPWV (blue dot). For example, adjusted OR for the highest vs. lowest quartile of cfPWV was 4.08 (2.70–6.24). hfPWV and cfPWV were significantly associated with mitral valve calcification as well. In contrast, faPWV (purple dots) was inversely associated with calcification of aortic valve ring, ascending aorta, and descending aorta. For descending aorta calcification, even the second highest quartile of the following measures demonstrated significant adjusted OR: hfPWV (3.21 [2.11–4.95]), cfPWV (2.11 [1.40–3.20]), and baPWV (1.75 [1.14–2.69]). Simultaneously adding cfPWV and hfPWV improved c-statistic for CAC (Δc-statistic 0.011 [0.0007–0.022]) and descending aorta calcification (0.035 [0.017–0.053]).

Conclusions

The associations of PWV with vascular calcification varied substantially across segments, with descending aorta calcification most closely linked to PWV measures and cfPWV most robustly associated with calcification of multiple vascular beds. cfPWV and hfPWV, together, improved discrimination of high CAC beyond traditional risk factors.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The National Heart, Lung, and Blood Institute, National Institutes of Health

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'

Background

It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care (‘provider-induced demand’). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand.

Methods

We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating ‘CMO’ configurations to develop and refine theories relating to drivers of demand.

Results

EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients’ experiences of accessing primary care, community care capacity, service design and population characteristics.

Conclusions

Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00709-2.

Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

49 Accurate Hip Reduction and SPICA Application for DDH – the Case for Intraoperative CT

Aim

Accurate reduction of the hip joint and SPICA application for treatment of developmental dysplasia of the hip (DDH) is crucial for long term success – for those undergoing surgical intervention, or closed reduction only. In Alder Hey Children’s Hospital we compared two methods of confirming reduction for patients undergoing SPICA application for DDH. Those receiving either post-operative departmental computed tomography (CT) or an intra-operative CT. Specific outcome assessed were, need for repeat CT and SPICA application, return to theatre (RTT), repeat general anaesthetic (GA) (with associated risks), as well as effect on overall length of stay (LOS).

Method

Patient lists were attained from the radiography department, information regarding RTT and LOS were derived from Meditech V6. CT scans were checked on PACS imaging system.

Results

Retrospective analysis of all SPICA application cases performed, included 102 patients from 2015–2018 undergoing a departmental CT, after GA. Of these, 6 patients required a second GA, 1 patient required 3 GA’s. Mean LOS was 6 days in those requiring repeat SPICA application.

Analysis of the second group of intra-operatively CT scanned patients, included 72 patients from 2018–2020. Of these, 0 patients required a repeat GA and RTT, despite 1 patient requiring change of SPICA. Mean LOS was 4 days for these patients.

Conclusions

Intra-operative CT is crucial for getting it right first time, reducing risks of GA and cost of theatre time. It reduced the LOS for those requiring SPICA change from 6 to 4 days and reduced mean LOS by 1 day overall.

Utilising clinical data to personlaise boundary conditions significantly improves the accuracy of angiography based virtual FFR

Background

Angiography-derived computed (virtual) fractional flow reserve (vFFR) permits the assessment of coronary physiology without the need for a pressure wire or hyperaemia. However, accuracy is limited by assumptions made about coronary microvascular resistance (CMVR) [1]. We hypothesised that machine learning may allow us to “tune” our estimate of the CMVR to increase the accuracy of vFFR.

Purpose

To determine whether routine clinical data can personalise CMVR and improve the accuracy of vFFR on an individual case basis.

Methods

Patients with chronic coronary syndromes underwent coronary angiography with FFR assessment. Vessel-specific CMVR was computed using a 3D- computational fluid dynamics simulation with invasively measured proximal and distal pressures. Predictive models were created using non-linear autoregressing moving average with exogenous inputs (NARMAX) modelling with computed CMVR as the dependent variable. vFFR was computed using previously described methods [2]. Three simulations were run, using: 1) a generic CMVR value (Model A); 2) a NARMAX-predicted CMVR based upon a panel of simple clinical data (Model B); and 3) a NARMAX-predicted CMVR incorporating echocardiographic data (Model C). The diagnostic and quantitative accuracy of each model was compared with directly measured FFR.

Results

Eighty four patients underwent coronary angiography with FFR assessment in 157 vessels. Mean age was 64 (±0.1) years and 64 (76%) were male. Mean FFR was 0.79 (±0.15). Mean CMVR was 1.01e+10 Pa/m3 s–1. vFFR error with Model A was ±0.10, with Model B was ±0.07 (p&lt;0.001) and with Model C was ±0.05 (p&lt;0.001) (Table 1).

Conclusion

vFFR is dependent upon not only the epicardial stenosis, but also the CMVR, estimation of which can be personalised based upon clinical and echocardiographic data. This can be used to increase the accuracy of vFFR.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): British Heart Foundation Clinial Research Training FellowshipNIHR i4i grant Table 1

SURPRISINGLY FEW WOMEN WITH SEVERE OSTEOPOROSIS BY BONE DENSITOMETRY UNDERGO WORKUP FOR SECONDARY CAUSES - A RETROSPECTIVE EVALUATION

We describe clinical features of women with extremely low bone density, and investigate secondary causes of osteoporosis. Our hypothesis was that this population would be enriched in identifiable causes of osteoporosis. We performed a retrospective review of medical records of all women seen at our university over 4 years with T-score on bone densitometry at/below -4 at any site. Historical and fracture details were abstracted. We considered a thorough work up to include Vitamin D, PTH, CBC, chemistry panel, cortisol, transglutaminase, myeloma screen, tryptase and 24-hour urine calcium.

RESULTS

137 women were identified with T-score at/below -4. Percent identified as Asian was 26% (higher than local prevalence of 8%). Average BMI was 21.6 kg/m². Clearly identifiable causes of osteoporosis were noted in 57% (inflammatory disorder, glucocorticoid or antacid exposure, prolonged immobilization and alcoholism were most prevalent). Of the remainder, full work up was performed only in 8%. Endocrine consultation and white race predicted thoroughness of secondary work-up.

CONCLUSION

Fragility fractures, leanness and Asian race were common in women with very low T-score. However, few new causes were identified. Underlying etiology was either immediately evident or inadequately studied, especially in minorities.

Physiotherapy rehabilitation for osteoporotic vertebral fracture-a randomised controlled trial and economic evaluation (PROVE trial)

The trial compared three physiotherapy approaches: manual or exercise therapy compared with a single session of physiotherapy education (SSPT) for people with osteoporotic vertebral fracture(s). At 1 year, there were no statistically significant differences between the groups meaning there is inadequate evidence to support manual or exercise therapy.

INTRODUCTION

To evaluate the clinical and cost-effectiveness of different physiotherapy approaches for people with osteoporotic vertebral fracture(s) (OVF).

METHODS

>Prospective, multicentre, adaptive, three-arm randomised controlled trial. Six hundred fifteen adults with back pain, osteoporosis, and at least 1 OVF participated.

INTERVENTIONS

7 individual physiotherapy sessions over 12 weeks focused on either manual therapy or home exercise compared with a single session of physiotherapy education (SSPT). The co-primary outcomes were quality of life and back muscle endurance measured by the QUALEFFO-41 and timed loaded standing (TLS) test at 12 months.

RESULTS

At 12 months, there were no statistically significant differences between groups. Mean QUALEFFO-41: - 1.3 (exercise), - 0.15 (manual), and - 1.2 (SSPT), a mean difference of - 0.2 (95% CI, - 3.2 to 1.6) for exercise and 1.3 (95% CI, - 1.8 to 2.9) for manual therapy. Mean TLS: 9.8 s (exercise), 13.6 s (manual), and 4.2 s (SSPT), a mean increase of 5.8 s (95% CI, - 4.8 to 20.5) for exercise and 9.7 s (95% CI, 0.1 to 24.9) for manual therapy. Exercise provided more quality-adjusted life years than SSPT but was more expensive. At 4 months, significant changes above SSPT occurred in endurance and balance in manual therapy, and in endurance for those ≤ 70 years, in balance, mobility, and walking in exercise.

CONCLUSIONS

Adherence was problematic. Benefits at 4 months did not persist and at 12 months, we found no significant differences between treatments. There is inadequate evidence a short physiotherapy intervention of either manual therapy or home exercise provides long-term benefits, but arguably short-term benefits are valuable.

TRIAL REGISTRATION

ISRCTN 49117867.

4325Change in left atrial function predicts incident atrial fibrillation: the multi-ethnic study of atherosclerosis

Background

Longitudinal change in left atrial (LA) structure and function could be helpful in predicting risk for incident AF. We used cardiac magnetic resonance (CMR) imaging to explore the relationship between change in LA structure and function and incident AF in a multi-ethnic population free of clinical cardiovascular disease at baseline.

Methods and results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2338 participants, free at baseline of clinically recognized AF and cardiovascular disease, had LA volume and function assessed with CMR imaging, at baseline (2000–02), and at Exam 4 (2005–07) or 5 (2010–12). Free of AF, 124 participants developed AF over 3.8±0.9 years (to 2015) following the second imaging. In adjusted Cox regression models, an average annualized change in all LA parameters were significantly associated with an increased risk of AF. An annual decrease of 1–SD unit in total LA emptying fractions (LAEF) was most strongly associated with risk of AF after adjusting for AF clinical risk factors, baseline LA parameters and left ventricular mass-to-volume ratio (hazard ratio per SD=1.91,95% confidence interval=1.53–2.38, P<0.001). The addition of change in total LAEF to an AF risk score improved model discrimination and reclassification (net reclassification improvement=0.107, P=0.017; integrative discrimination index=0.049, P<0.001).

Model discrimination, NRI and IDI Model: CHARGE-AF risk factors# + Baseline LA variable + ΔLA variable CHARGE-AF ΔLAVImin (mL/m2/y) ΔTotal LAEF (%/y) ΔPeak LA Strain (%/y) C-statistic (95% CI) 0.757 (0.721–0.794) 0.787 (0.749–0.824) 0.779 (0.737–0.820) 0.770 (0.732–0.808) NRI† (p-value) – 0.000 (0.991) 0.107 (0.017) 0.017 (0.634) IDI (p-value) – 0.049 (<0.001) 0.049 (<0.001) 0.018 (<0.001) Calibration chi2* (p-value) 19.3 (0.02) 11.68 (0.232) 5.751 (0.765) 3.673 (0.932) AF: atrial fibrillation; LA: left atrium; EF: emptying fractions; Δ: annual change; VImin: minimum indexed volume; CI: confidence interval; NRI: net reclassification improvement; IDI: integrative discrimination index #CHARGE-AF risk factors: age, race, height, weight, systolic and diastolic blood pressure, use of antihypertensive medication, smoking status, diabetes, MI and CHF by the second imaging. † Categories for NRI: <2.5%, 2.5%-5% and >5%. *Model calibration: Grønnesby and Borgan's modified Hosmer-Lemeshow chi-square statistic for survival analysis.

Kaplan-Meier curves of ΔTotal LAEF

Conclusion

In this multi-ethnic study population free of clinical cardiovascular disease at baseline, a greater increase in LA volumes and decrease in LA function were associated with incident AF. The addition of change in total LAEF to risk prediction models for AF improved model discrimination and reclassification of AF risk.

Acknowledgement/Funding

This research was supported by contracts HHSN2682015ehz745.01623I,N01-HC-95159-69 from the NHLBI and UL1-TR-ehz745.016240,UL1-TR-001079,R01-HL-127659 from NIH

Abstract P3-06-19: MUC17 and PCNX1 as mediators of chemotherapy response in breast cancer

Breast cancer is a heterogeneous disease and accumulating evidence suggests that treatment failure may be driven by intra-tumour heterogeneity (ITH). Utilising the current protocol for neoadjuvant (pre-surgery) chemotherapy (NAC) provides the opportunity to study molecular genetic changes between pre- and post-therapy by assessing pre-therapy biopsies and post-therapy surgical resections.

Whole exome sequencing was performed on matched pre- and post-treatment cancer cells from 6 patients with oestrogen receptor positive breast cancers that showed partial responses to the chemotherapeutic epirubicin. Data analysis was performed to determine differences in genetic aberrations between pre- and post-NAC, and in particular to identify evidence of consistent selection by therapy of aberrations that therefore may define chemotherapy resistance or sensitivity.

There were extensive differences in the range of genetic aberrations between pre- and post-NAC. 48 genes were identified for further study based on evidence of mutations conferring a selective advantage or disadvantage during chemotherapeutic response. The relevance of these was screened using siRNA knock-down and assessment of response to chemotherapeutic drug using cell viability assays in vitro. Two genes were taken forward. Potential loss-of-function mutations in the MUC17 gene were selected against during therapy in patients, and in accordance with this MUC17 knock-down was associated with increased sensitivity in vitro. Potential loss-of-function mutations in the PCNX1 gene were selected for during therapy in patients, and in accordance with this PCNX1 knock-down was associated with resistance. Further work was done to investigate mechanisms by which these genes modify cellular chemotherapy response, by examining drug loading and ABC transporter expression levels. Data indicate that both genes impact on drug loading, potentially through modulating ABC transporter activities. Using available transcriptomic datasets, expression of neither gene correlated with breast cancer outcomes in mixed cohorts that received a wide-range of therapies, however, analysis of correlations between protein expression and outcomes specifically after chemotherapy are on-going. We conclude that MUC17 and PCNX1 are potential markers of response to chemotherapy in breast cancer, and therapeutic modulation of their activities could enhance chemotherapy responses.

Citation Format: Al Amri W, Verghese E, Stead L, Hanby A, Sharma N, Hughes T. MUC17 and PCNX1 as mediators of chemotherapy response in breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-06-19.

Photocuring of 4-arm coumarin-functionalised monomers to form highly photoreversible crosslinked epoxy coatings

Highly photoreversible photocurable crosslinked epoxy coatings that can heal substantial surface damage were formed by the synthesis of unique monomers.

Is the timed loaded standing test a valid measure of back muscle endurance in people with vertebral osteoporosis?

Timed loaded standing (TLS) is a suggested measure of back muscle endurance for people with vertebral osteoporosis. Surface electromyography revealed back muscles work harder and fatigue during TLS. The test end-point and total time were associated with back fatigue. The findings help demonstrate the concurrent validity of the TLS test.

INTRODUCTION

The TLS test is suggested as a measure of back muscle endurance for patients with vertebral osteoporosis. However, to date, no study has demonstrated that TLS does measure back extensor or erector spinae (ES) muscle endurance. We used surface electromyography (sEMG) to investigate the performance of the thoracic ES muscles during TLS.

METHODS

Thirty-six people with vertebral osteoporosis with a mean age of 71.6 (range 45-86) years participated. sEMG recordings were made of the ES at T3 and T12 bilaterally during quiet standing (QS) and TLS. The relative (%) change in sEMG amplitude between conditions was compared. Fatigue was evaluated by analysing the change in median frequency (MF) of the sEMG signal during TLS, and the correlation between maximal TLS time and rate of MF decline was examined.

RESULTS

Activity in the ES increased significantly during TLS at all electrode locations. During TLS, the MF declined at a mean rate of -24.2% per minute (95% C.I. -26.5 to -21.9%). The MF slope and test time were strongly correlated (r² = 0.71), and at test end, the final MF dropped to an average 89% (95% C.I. 85 to 93%) of initial MF. Twenty-eight participants (78%) reported fatigue was the main reason for stopping, and for eight (22%), it was pain.

CONCLUSIONS

This study demonstrates that TLS challenges the ES muscles in the thoracic region and results in ES fatigue. Endurance time and the point at which the TLS test ends are strongly related to ES fatigue.

Improvement and tuning of the performance of light-healable polymers by variation of the monomer content

High-performing crosslinked epoxy coatings that possess room temperature self-healing ability by the use of a newly synthesised dynamic diamine crosslinker.

Prevalence of infraocclusion of primary molars determined using a new 2D image analysis methodology

BACKGROUND

The reported prevalence of infraocclusion varies widely, reflecting differences in definitions and measurement/scoring approaches. This study aimed to quantify the prevalence and extent of infraocclusion in singletons and twins during the late mixed dentition stage of dental development using a new diagnostic imaging method and objective criteria. The study also aimed to determine any associations between infraocclusion and gender, arch type, arch side and tooth type.

METHODS

Two samples were analysed, 1454 panoramic radiographs of singletons and 270 dental models of twins. Both samples ranged in age from 8 to 11 years. Adobe Photoshop CS5 was used to measure the extent of infraocclusion. Repeatability tests showed systematic and random errors were small.

RESULTS

The prevalence in the maxilla was low (<1%), whereas the prevalence in the mandible was 22% in the singleton sample and 32% in the twin sample. The primary mandibular first molar was affected more often than the second molar. There was no significant difference in the expression between genders or sides.

CONCLUSIONS

A new technique for measuring infraocclusion has been developed with high intra- and interoperator reproducibility. This method should enhance early diagnosis of tooth developmental abnormalities and treatment planning during the late mixed dentition stage of development.

Clinical location of the fourth and fifth intercostal spaces as a percent of the length of the sternum

OBJECTIVES

To verify accurate placement of the precordial ECG leads by identifying the 4th and 5th intercostal spaces as a function of the length of the sternum. This should decrease the percentage of lead misplacement leading to misdiagnoses.

METHODS

The population consisted of patients and healthy volunteers. The proposed method compared palpation of the 4th and 5th intercostal spaces to a percentile of the sternal length. Location of the 4th and 5th intercostal space using a simple device was evaluated to assist in proper placement of the precordial leads to obtain accurate diagnosis.

RESULTS

The location of the 4th and 5th intercostal space is related to the length of the sternum. It is 77% of the sternal length that measures 15cm for the 4th intercostal space. The position of the V1 and V2 electrodes decreases to 57% when the sternal length is 26cm. Similar data was obtained to locate the 5th intercostal space with proper position of V4-V6 electrodes. Tables are provided to facilitate this process. An instrument was designed to measure the 4th and 5th intercostal space as a function of the sternal length.

CONCLUSIONS

The location of the 4th and 5th intercostal space is identified based on the length of the sternum.

Prognostic factors for musculoskeletal injury identified through medical screening and training load monitoring in professional football (soccer): a systematic review

OBJECTIVES

To identify prognostic factors and models for spinal and lower extremity injuries in adult professional/elite football players from medical screening and training load monitoring processes.

METHODS

The MEDLINE, AMED, EMBASE, CINAHL Plus, SPORTDiscus electronic bibliographic databases and the Cochrane Database of Systematic Reviews were searched from inception to July 2016. Searches were limited to original research, published in peer reviewed journals of any language. The Quality in Prognostic Studies (QUIPS) tool was used for appraisal and the modified GRADE approach was used for synthesis. Prospective and retrospective cohort study designs of spinal and lower extremity injury incidence were found from populations of adult professional/elite football players, between 16 and 40 years. Non-football or mixed sports were excluded.

RESULTS

858 manuscripts were identified. Removing duplications left 551 studies, which were screened for eligibility by title and abstract. Of these, 531 studies were not eligible and were excluded. The full text of the remaining 20 studies were obtained; a further 10 studies were excluded. 10 studies were included for appraisal and analysis, for 3344 participants.

CONCLUSIONS

Due to the paucity and heterogeneity of the literature, and shortcomings in methodology and reporting, the evidence is of very low or low quality and therefore cannot be deemed robust enough to suggest conclusive prognostic factors for all lower limb musculoskeletal injury outcomes identified. No studies were identified that examined spinal injury outcomes or prognostic models.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

An audit of CT chest surveillance following oral cancer treatment

Computed tomography (CT) of the chest is an integral part of the staging of patients with oral cancer. It identifies metastases, synchronous pulmonary primaries, and detects small nodules of indeterminate character that require a follow-up scan. We aimed to find out how many patients with small nodules had had subsequent scans, and the outcome of those who did. Between 2010 and 2013, 413 patients with oral squamous cell carcinoma (SCC) were treated with curative intent or were actively monitored at the Merseyside and Cheshire Regional Surgical Head and Neck Unit. A total of 324 (78%) had CT at diagnosis. The scans of 246 were clear, metastases were detected in 4, and 51 showed abnormalities. Forty-nine of the patients with abnormalities were recommended for further interval scans but only 20 (41%) actually had them. Further pathological findings were found in 11 (increase in the size of the nodule n=2; metastatic disease n=5; and primary pulmonary tumour n=4). A substantial number of patients did not have the recommended follow-up scans and potentially serious disease was found in some who did. As a result of this audit we have changed the process regarding the booking of CT surveillance scans, and we now check periodically that they have been done. The audit will be repeated to include other sites in the head and neck.

Physiologic Status Monitoring via the Gastrointestinal Tract

Reliable, real-time heart and respiratory rates are key vital signs used in evaluating the physiological status in many clinical and non-clinical settings. Measuring these vital signs generally requires superficial attachment of physically or logistically obtrusive sensors to subjects that may result in skin irritation or adversely influence subject performance. Given the broad acceptance of ingestible electronics, we developed an approach that enables vital sign monitoring internally from the gastrointestinal tract. Here we report initial proof-of-concept large animal (porcine) experiments and a robust processing algorithm that demonstrates the feasibility of this approach. Implementing vital sign monitoring as a stand-alone technology or in conjunction with other ingestible devices has the capacity to significantly aid telemedicine, optimize performance monitoring of athletes, military service members, and first-responders, as well as provide a facile method for rapid clinical evaluation and triage.

A phase 2 trial of ponatinib in Philadelphia chromosome-positive leukemias

BACKGROUND

Ponatinib is a potent oral tyrosine kinase inhibitor of unmutated and mutated BCR-ABL, including BCR-ABL with the tyrosine kinase inhibitor-refractory threonine-to-isoleucine mutation at position 315 (T315I). We conducted a phase 2 trial of ponatinib in patients with chronic myeloid leukemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-positive ALL).

METHODS

We enrolled 449 heavily pretreated patients who had CML or Ph-positive ALL with resistance to or unacceptable side effects from dasatinib or nilotinib or who had the BCR-ABL T315I mutation. Ponatinib was administered at an initial dose of 45 mg once daily. The median follow-up was 15 months.

RESULTS

Among 267 patients with chronic-phase CML, 56% had a major cytogenetic response (51% of patients with resistance to or unacceptable side effects from dasatinib or nilotinib and 70% of patients with the T315I mutation), 46% had a complete cytogenetic response (40% and 66% in the two subgroups, respectively), and 34% had a major molecular response (27% and 56% in the two subgroups, respectively). Responses were observed regardless of the baseline BCR-ABL kinase domain mutation status and were durable; the estimated rate of a sustained major cytogenetic response of at least 12 months was 91%. No single BCR-ABL mutation conferring resistance to ponatinib was detected. Among 83 patients with accelerated-phase CML, 55% had a major hematologic response and 39% had a major cytogenetic response. Among 62 patients with blast-phase CML, 31% had a major hematologic response and 23% had a major cytogenetic response. Among 32 patients with Ph-positive ALL, 41% had a major hematologic response and 47% had a major cytogenetic response. Common adverse events were thrombocytopenia (in 37% of patients), rash (in 34%), dry skin (in 32%), and abdominal pain (in 22%). Serious arterial thrombotic events were observed in 9% of patients; these events were considered to be treatment-related in 3%. A total of 12% of patients discontinued treatment because of an adverse event.

CONCLUSIONS

Ponatinib had significant antileukemic activity across categories of disease stage and mutation status. (Funded by Ariad Pharmaceuticals and others; PACE ClinicalTrials.gov number, NCT01207440 .).

Second hematopoietic SCT for leukemia relapsing after myeloablative T cell-depleted transplants does not prolong survival

Patients with leukemia relapsing after allogeneic hematopoietic stem cell transplantation (SCT) have a dismal prognosis. A second SCT offers a further opportunity for cure, but has a high rate of treatment failure. To determine the utility of this option, we analyzed 59 consecutive patients relapsing after a myeloablative HLA-matched sibling T cell depleted SCT. Twenty five patients (13 relapsing within 6 months and 12 relapsing between 6 – 170 months after the first SCT) received a T-replete second SCT. Thirty-eight patients relapsing early had a shorter survival than the 21 patients relapsing later (median 96 vs 298 days, p = 0.0002). In patients relapsing early, the second SCT did not improve overall survival compared to patients receiving non-SCT treatments (median survival 109 vs 80 days, p = 0.41). In patients relapsing late, despite an early trend in favor of second SCT, overall survival was comparable for patients receiving a second SCT compared with patients not retransplanted (median survival 363.5 vs 162 days, p = 0.49). Disappointingly our results do not demonstrate an important survival benefit for a second T-replete allogeneic SCT to treat relapse following a T cell depleted SCT.