A quantitative evaluation of aerosol generation during cardiopulmonary resuscitation

It is unclear if cardiopulmonary resuscitation is an aerosol-generating procedure and whether this poses a risk of airborne disease transmission to healthcare workers and bystanders. Use of airborne transmission precautions during cardiopulmonary resuscitation may confer rescuer protection but risks patient harm due to delays in commencing treatment. To quantify the risk of respiratory aerosol generation during cardiopulmonary resuscitation in humans, we conducted an aerosol monitoring study during out-of-hospital cardiac arrests. Exhaled aerosol was recorded using an optical particle sizer spectrometer connected to the breathing system. Aerosol produced during resuscitation was compared with that produced by control participants under general anaesthesia ventilated with an equivalent respiratory pattern to cardiopulmonary resuscitation. A porcine cardiac arrest model was used to determine the independent contributions of ventilatory breaths, chest compressions and external cardiac defibrillation to aerosol generation. Time-series analysis of participants with cardiac arrest (n = 18) demonstrated a repeating waveform of respiratory aerosol that mapped to specific components of resuscitation. Very high peak aerosol concentrations were generated during ventilation of participants with cardiac arrest with median (IQR [range]) 17,926 (5546-59,209 [1523-242,648]) particles.l-1 , which were 24-fold greater than in control participants under general anaesthesia (744 (309-2106 [23-9099]) particles.l-1 , p < 0.001, n = 16). A substantial rise in aerosol also occurred with cardiac defibrillation and chest compressions. In a complimentary porcine model of cardiac arrest, aerosol recordings showed a strikingly similar profile to the human data. Time-averaged aerosol concentrations during ventilation were approximately 270-fold higher than before cardiac arrest (19,410 (2307-41,017 [104-136,025]) vs. 72 (41-136 [23-268]) particles.l-1 , p = 0.008). The porcine model also confirmed that both defibrillation and chest compressions generate high concentrations of aerosol independent of, but synergistic with, ventilation. In conclusion, multiple components of cardiopulmonary resuscitation generate high concentrations of respiratory aerosol. We recommend that airborne transmission precautions are warranted in the setting of high-risk pathogens, until the airway is secured with an airway device and breathing system with a filter.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Concordance between a gastrointestinal consultant radiologist, a consultant radiologist and qualified reporting radiographers interpreting abdominal radiographs

INTRODUCTION

Radiographers can accurately report musculoskeletal and chest radiographs, but there is paucity of research comparing the performance of reporting radiographers (RRs) with consultant radiologists when interpreting and reporting abdominal radiographs. This study assessed interobserver agreement in the clinical setting between reporting radiographers and a consultant radiologist compared to an expert gastrointestinal radiologist in a District General Hospital. Major discordant reports affecting patient management were also examined.

METHODS

126 abdominal radiographs reported by 3 RRs in clinical practice were randomly selected and reported by a consultant radiologist and index gastrointestinal radiologist. The reports of the RRs and consultant radiologist were compared against the reports made by the index radiologist for agreement by a colorectal consultant surgeon. All 126 reports were scored as being in either complete agreement, minor disagreement or major disagreement which would have resulted in a change to patient management.

RESULTS

There was no significant difference in overall agreement between the consultant radiologist (CR) and RRs when compared to the index radiologist (CR: n = 90/126, 71.4% and RRs: n = 94/126, 74.6%. p = 0.57). Major disagreements were found, but there was no significant difference between both groups (CR: n = 23/126, 18.3% and RRs: n = 17/126, 13.5%. p = 0.30).

CONCLUSION

RRs can report abdominal radiographs to a comparable level of agreement as a consultant radiologist in the clinical setting. There was no significant difference in reports deemed to affect patient management.

IMPLICATIONS FOR PRACTICE

This study addresses the gap in assessing the performance of RRs reporting abdominal radiographs. This small scale study indicates that radiographers could provide additional support in the reporting of abdominal radiographs. This would help to reduce radiologist workload and enhance the role of the reporting radiographer.

CLASSIFICATION

Agreement between reporting radiographers and radiologists interpreting and reporting abdominal radiographs.

Changes in coral reef community structure along a sediment gradient in Fouha Bay, Guam

High sedimentation rates have well-documented, deleterious impacts on coral reefs. However, few previous studies have attempted to quantitatively describe a coral reef community across a large continuous sediment gradient. In this study distinct benthic assemblages in Fouha Bay, Guam, were identified using a Moving Window Analysis conducted along a two-order of magnitude sediment gradient, with transition boundaries that were generally consistent with sediment thresholds identified in the literature. Coral richness dropped exponentially with increasing sedimentation rate. Richness was nearly three times greater in assemblages with sedimentation rates <10 mg cm^-2 d^-1 compared to assemblages experiencing rates between 10 and 50 mg cm^-2 d^-1, and nearly 30 times greater than assemblages experiencing rates between 50 and 100 mg cm^-2 d^-1. No corals were found in assemblages with sedimentation rates >110 mg cm^-2 d^-1. Reducing sedimentation in this area could result in a shift of more diverse and abundant coral assemblages toward the head of the bay.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Facial discoid dermatosis: A cosmetically disfiguring and challenging condition to treat

Facial discoid dermatosis (FDD) is a recently described condition comprising discrete facial papulo‐squamous lesions. We report three cases that clinically and histologically resemble FDD and demonstrate its resistance to treatment. Awareness of this new clinical entity will allow early diagnosis and the ability to make patients aware that there is unlikely to be a successful treatment. However, our study suggests that although FDD can persist for many years, it appears to remain stable.

Genetics of HLA Peptide Presentation and Impact on Outcomes in HLA-Matched Allogeneic Hematopoietic Cell Transplantation

Minor histocompatibility antigens (mHAs), recipient-derived peptide epitopes presented on the cell surface, are known to mediate graft-versus-host disease (GVHD); however, there are no current methods to associate mHA features with GVHD risk. This deficiency is due in part to the lack of technological means to accurately predict, let alone confirm, the tremendous number of potential mHAs in each individual transplant. Previous studies have shown that different HLA molecules present varying fractions of candidate peptide epitopes; however, the genetic "distance" between HLA-matched donors and recipients is relatively constrained. From these 2 observations, it is possible that the HLA type for a donor-recipient pair (DRP) would provide a surrogate measurement of the number of predicted mHAs, which could be related to GVHD risk. Because different HLA molecules present variable numbers of peptide antigens, a predicted cumulative peptide-binding efficiency can be calculated for individual DRP based on the pair's HLA type. The purpose of this study was to test whether cumulative peptide-binding efficiency is associated with the risk of acute GVHD (aGVHD) or relapse. In this retrospective Center for International Blood and Marrow Transplant Research study, a total of 3242 HLA-matched DRPs were analyzed for predicted cumulative peptide-binding efficiency using their HLA types and were divided into tertiles based on their scores. Univariable and multivariable analyses was performed to test for associations between cumulative peptide-binding efficiency for DRPs, divided into the HLA-matched related donor (MRD) and HLA-matched unrelated donor (MUD) cohorts, and the primary outcomes of aGVHD and relapse. Secondary outcomes investigated included overall survival, disease-free survival, and transplantation-related mortality. Using a computationally generated peptidome as a test dataset, the tested series of HLA class I displayed peptide-binding frequencies ranging from 0.1% to 3.8% of the full peptidome, and HLA class II molecules had peptide-binding frequencies of 12% to 77% across the HLA-DRB1 allotypes. By increasing binding efficiency tertile, the cumulative incidence of aGVHD at 6 months for MUD patients was 41%, 41%, and 45% for HLA class I (P = .336) and 44%, 41%, and 42% for HLA class II (P = .452). The cumulative incidences of relapse at 3 years for MUD transplant recipients were 36%, 38%, and 38% for HLA class I (P = .533) and 37%, 37%, and 38% for HLA class II (P = .896). The findings were similar for MRD transplant recipients. Multivariable analysis did not identify any impact of peptide-binding efficiency on aGVHD or relapse in MUD or MRD transplant recipients. Whereas GVHD is mediated by minor antigen mismatches in the context of HLA-matched allo-HCT, peptide-binding efficiency, which was used as a surrogate measurement for predicted number of binding antigens, did not provide additional clinical information for GVHD risk assessment. The negative result may be due to the limitations of this surrogate marker, or it is possible that GVHD is driven by a subset of immunogenic mHAs. Further research should be directed at direct mHA epitope and immunogenicity prediction.

A prospective, observational study of the performance of MEWS, NEWS, SIRS and qSOFA for early risk stratification for adverse outcomes in patients with suspected infections at the emergency department

BACKGROUND

Many patients with suspected infection are presented to the emergency Department. Several scoring systems have been proposed to identify patients at high risk of adverse outcomes.

METHODS

We compared generic early warning scores (MEWS and NEWS) to the (SIRS) criteria and quick Sequential Organ Failure Assessement (qSOFA), for early risk stratification in 1400 patients with suspected infection in the ED. The primary study end point was 30-day mortality.

RESULTS

The AUROC of the NEWS score for predicting 30-day mortality was 0.740 (95% Confidence Interval 0.682- 0.798), higher than qSOFA (AUROC of 0.689, 95% CI 0.615- 0.763), MEWS (AUROC 0.643 (95% CI 0.583-0.702) and SIRS (AUROC 0.586, 95%CI 0.521 - 0.651). The sensitivity was also highest for NEWS⋝ 5 (sensitivity 75,8% specificity of 67,4%).

CONCLUSION

Among patients presenting to the ED with suspected infection, early risk stratification with NEWS (cut-off of ⋝5) is more sensitive for prediction of mortality than qSOFA, MEWS or SIRS, with adequate specificity.

Specific Class I HLA Supertypes but Not HLA Zygosity or Expression Are Associated with Outcomes following HLA-Matched Allogeneic Hematopoietic Cell Transplant: HLA Supertypes Impact Allogeneic HCT Outcomes

Maximizing the probability of antigen presentation to T cells through diversity in HLAs can enhance immune responsiveness and translate into improved clinical outcomes, as evidenced by the association of heterozygosity and supertypes at HLA class I loci with improved survival in patients with advanced solid tumors treated with immune checkpoint inhibitors. We investigated the impact of HLA heterozygosity, supertypes, and surface expression on outcomes in adult and pediatric patients with acute myeloid leukemia (AML), myelodysplastic syndrome, acute lymphoblastic leukemia, and non-Hodgkin lymphoma who underwent 8/8 HLA-matched, T cell replete, unrelated, allogeneic hematopoietic cell transplant (HCT) from 2000 to 2015 using patient data reported to the Center for International Blood and Marrow Transplant Research. HLA class I heterozygosity and HLA expression were not associated with overall survival, relapse, transplant-related mortality (TRM), disease-free survival (DFS), and acute graft-versus-host disease following HCT. The HLA-B62 supertype was associated with decreased TRM in the entire patient cohort (hazard ratio [HR], 0.79; 95% CI, 0.69 to 0.90; P = .00053). The HLA-B27 supertype was associated with worse DFS in patients with AML (HR = 1.21; 95% CI, 1.10 to 1.32; P = .00005). These findings suggest that the survival benefit of HLA heterozygosity seen in solid tumor patients receiving immune checkpoint inhibitors does not extend to patients undergoing allogeneic HCT. Certain HLA supertypes, however, are associated with TRM and DFS, suggesting that similarities in peptide presentation between supertype members play a role in these outcomes. Beyond implications for prognosis following HCT, these findings support the further investigation of these HLA supertypes and the specific immune peptides important for transplant outcomes.

Quantification of regional murine ozone-induced lung inflammation using [18F]F-FDG microPET/CT imaging

Ozone (O₃) is a highly potent and reactive air pollutant. It has been linked to acute and chronic respiratory diseases in humans by inducing inflammation. Our studies have found evidence that 0.05 ppm of O₃, within the threshold of air quality standards, is capable of inducing acute lung injury. This study was undertaken to examine O₃-induced lung damage using [¹⁸F]F-FDG (2-deoxy-2-[¹⁸F]fluoro-D-glucose) microPET/CT in wild-type mice. [¹⁸F]F-FDG is a known PET tracer for inflammation. Sequential [¹⁸F]F-FDG microPET/CT was performed at baseline (i.e. before O₃ exposure), immediately (0 h), at 24 h and at 28 h following 2 h of 0.05 ppm O₃ exposure. The images were quantified to determine O₃ induced spatial standard uptake ratio of [¹⁸F]F-FDG in relation to lung tissue density and compared with baseline values. Immediately after O₃ exposure, we detected a 72.21 ± 0.79% increase in lung [¹⁸F]F-FDG uptake ratio when compared to baseline measures. At 24 h post-O₃ exposure, the [¹⁸F]F-FDG uptake becomes highly variable (S.D. in [¹⁸F]F-FDG = 5.174 × 10^–4 units) with a 42.54 ± 0.33% increase in lung [¹⁸F]F-FDG compared to baseline. At 28 h time-point, [¹⁸F]F-FDG uptake ratio was similar to baseline values. However, the pattern of [¹⁸F]F-FDG distribution varied and was interspersed with zones of minimal uptake. Our microPET/CT imaging protocol can quantify and identify atypical regional lung uptake of [¹⁸F]F-FDG to understand the lung response to O₃ exposure.

Incidence, Risk Factors, and Outcomes of Patients Who Develop Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infections in the First 100 Days After Allogeneic Hematopoietic Stem Cell Transplant

IMPORTANCE

Patients undergoing hematopoietic stem cell transplant (HSCT) are at risk for bloodstream infection (BSI) secondary to translocation of bacteria through the injured mucosa, termed mucosal barrier injury-laboratory confirmed bloodstream infection (MBI-LCBI), in addition to BSI secondary to indwelling catheters and infection at other sites (BSI-other).

OBJECTIVE

To determine the incidence, timing, risk factors, and outcomes of patients who develop MBI-LCBI in the first 100 days after HSCT.

DESIGN, SETTING, AND PARTICIPANTS

A case-cohort retrospective analysis was performed using data from the Center for International Blood and Marrow Transplant Research database on 16 875 consecutive pediatric and adult patients receiving a first allogeneic HSCT from January 1, 2009, to December 31, 2016. Patients were classified into 4 categories: MBI-LCBI (1481 [8.8%]), MBI-LCBI and BSI-other (698 [4.1%]), BSI-other only (2928 [17.4%]), and controls with no BSI (11 768 [69.7%]). Statistical analysis was performed from April 5 to July 17, 2018.

MAIN OUTCOMES AND MEASURES

Demographic characteristics and outcomes, including overall survival, chronic graft-vs-host disease, and transplant-related mortality (only for patients with malignant disease), were compared among groups.

RESULTS

Of the 16 875 patients in the study (9737 [57.7%] male; median [range] age, 47 [0.04-82] years) 13 686 (81.1%) underwent HSCT for a malignant neoplasm, and 3189 (18.9%) underwent HSCT for a nonmalignant condition. The cumulative incidence of MBI-LCBI was 13% (99% CI, 12%-13%) by day 100, and the cumulative incidence of BSI-other was 21% (99% CI, 21%-22%) by day 100. Median (range) time from transplant to first MBI-LCBI was 8 (<1 to 98) days vs 29 (<1 to 100) days for BSI-other. Multivariable analysis revealed an increased risk of MBI-LCBI with poor Karnofsky/Lansky performance status (hazard ratio [HR], 1.21 [99% CI, 1.04-1.41]), cord blood grafts (HR, 2.89 [99% CI, 1.97-4.24]), myeloablative conditioning (HR, 1.46 [99% CI, 1.19-1.78]), and posttransplant cyclophosphamide graft-vs-host disease prophylaxis (HR, 1.85 [99% CI, 1.38-2.48]). One-year mortality was significantly higher for patients with MBI-LCBI (HR, 1.81 [99% CI, 1.56-2.12]), BSI-other (HR, 1.81 [99% CI, 1.60-2.06]), and MBI-LCBI plus BSI-other (HR, 2.65 [99% CI, 2.17-3.24]) compared with controls. Infection was more commonly reported as a cause of death for patients with MBI-LCBI (139 of 740 [18.8%]), BSI (251 of 1537 [16.3%]), and MBI-LCBI plus BSI (94 of 435 [21.6%]) than for controls (566 of 4740 [11.9%]).

CONCLUSIONS AND RELEVANCE

In this cohort study, MBI-LCBI, in addition to any BSIs, were associated with significant morbidity and mortality after HSCT. Further investigation into risk reduction should be a clinical and scientific priority in this patient population.

Survival outcomes of allogeneic hematopoietic cell transplants with EBV-positive or EBV-negative post-transplant lymphoproliferative disorder, A CIBMTR study

BACKGROUND

Post-transplant lymphoproliferative disorders (PTLD) are associated with significant morbidity and mortality following allogeneic hematopoietic cell transplant (alloHCT). Although most PTLD is EBV-positive (EBV^pos ), EBV-negative (EBV^neg ) PTLD is reported, yet its incidence and clinical impact remain largely undefined. Furthermore, factors at the time of transplant impacting survival following PTLD are not well described.

METHODS

Between 2002 and 2014, 432 cases of PTLD following alloHCT were reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). After exclusions, 267 cases (EBV^pos  = 222, 83%; EBV^neg  = 45, 17%) were analyzed.

RESULTS

Two hundred and eight patients (78%) received in vivo T-cell depletion (TCD) with either anti-thymocyte globulin (ATG) or alemtuzumab. Incidence of PTLD was highest using umbilical cord donors (UCB, 1.60%) and lowest using matched related donors (MRD, 0.40%). Clinical features and histology did not significantly differ among EBV^pos or EBV^neg PTLD cases except that absolute lymphocyte count recovery was slower, and CMV reactivation was later in EBV^neg PTLD [EBV^pos 32 (5-95) days versus EBV^neg 47 (10-70) days, P = .016]. There was no impact on survival by EBV status in multivariable analysis [EBV^neg RR 1.42, 95% CI 0.94-2.15, P = .097].

CONCLUSIONS

There is no difference in survival outcomes for patients with EBV^pos or EBV^neg PTLD occurring following alloHCT and 1-year survival is poor. Features of conditioning and use of serotherapy remain important.

Bacterial blood stream infections (BSIs), particularly post-engraftment BSIs, are associated with increased mortality after allogeneic hematopoietic cell transplantation

We analyzed CIBMTR data to evaluate the incidence of non-relapse mortality (NRM) and association with overall survival (OS) for Bacterial blood stream infections (BSIs) occurring within 100 days of alloHCT in 2 different phases: pre/peri engraftment (BSI very early phase, BSI-VEP) and BSI post engraftment (BSI occurring between 2 weeks after engraftment and Day100, late early phase, BSI-LEP). Of 7,128 alloHCT patients, 2,656 (37%) had ≥1 BSI by day100. BSI-VEP, BSI-LEP, BSI-Both constituted 56% (n=1492), 31% (n=824), and 13% (n=340) of total BSI, respectively. Starting in 2009 we observed a gradual decline in BSI incidence through 2012 (61% to 48%). Patients with BSI-VEP were more likely to receive a myeloablative conditioning (MAC) regimen with total body irradiation (TBI). NRM was significantly higher in patients with any BSI (RR 1.82 95CI 1.63–2.04 for BSI-VEP, RR 2.46, 95%CI 2.05–2.96 for BSI-LEP, and RR 2.29, 95%CI 1.87–2.81 for BSI-Both) compared with those without BSI. OS was significantly lower in patients with any BSI compared with patients without BSI (RR 1.36, 95%CI 1.26–1.47 for BSI-VEP; RR 1.83, 95%CI 1.58–2.12 for BSI-LEP: RR 1.66, 95%CI 1.43–1.94 for BSI-Both). BSIs within day100 after alloHCT are common and remain a risk factor for mortality.

It's not as bad as you think: menopausal representations are more positive in postmenopausal women

INTRODUCTION

The menopausal transition is associated with underlying hormonal changes that can contribute to a range of physical and emotional symptoms. Psycho-social factors including attitudes and internal representations play a central role in women's experience of the menopause, but very little is known about how representations might differ across menopausal stages.

METHODS

A sample of 387 women aged 40-60 completed a postal questionnaire that included the menopausal representations questionnaire, the emotional representation subscale adapted from the illness perception questionnaire, and data on menopausal status.

RESULTS

Significant differences across menopausal stages were found for both cognitive [F(2, 381) = 4.32, p < .05, η² = 0.022], and emotional [F(2, 381) = 9.70, p < .01, η² = 0.048] menopausal representations. Postmenopausal women had a significantly more positive cognitive representations of the menopause relative to perimenopausal women (standardised mean difference = 0.25, p > .05). Postmenopausal women held a significantly more positive emotional representation of the menopause than both premenopausal (standardised mean difference = 0.56, p < .05) and perimenopausal (standardised mean difference = 0.43, p < .05) women.

DISCUSSION

Women's emotional and cognitive representations of the menopause are more positive among postmenopausal women, compared to women in the late premenopausal stage. This is consistent with the affective forecasting theory, which proposes the tendency to overestimate the intensity and duration of emotional reactions to future events. Given the association between representations and bothersomeness of menopausal symptoms, clinicians should educate women about their expectations, and challenge their negative beliefs about the menopause.

Educational Preparation and Perceived Proficiency of Nurses Working in Oncology Units at the University College Hospital, Ibadan, Nigeria

Background: Cancer is a malignant pathologic disorder, which poses a global threat to the health and survival of an individual, both young and old. Globally, nurses are considered very vital in all aspects of cancer control due to their impact on the quality of care outcomes which is greatly influenced by specialized training in oncology nursing. However, in Nigeria and some parts of Africa, there is dearth of information and documentation on the nurses' educational preparation and proficiency of nurses in delivery of oncology care. Aim: This study assessed educational preparation and perceived proficiency of nurses working in oncology units at University College Hospital, Ibadan to provide information oncology nursing training of these nurses as well as their perceived proficiency. Methods: The study used a descriptive cross-sectional design. Permission and clearance were obtained from the Joint University of Ibadan/UCH ethical review committee and subsequently head nurses in each unit and the nurses that participated. A purposive sampling method was used for selection of participants and a structured questionnaire with reliability coefficient value of 0.94 was used for data collection. Data were entered using SPSS version 20 and data analysis was done using descriptive and inferential statistics. Results: A total of 104 nurses working in oncology units fully participated in the study. For age, mean ± SD was 35 years ± 6. 54.4% of respondents had diploma professional training in general nursing as their highest level of education. Most of the respondents 88.5% did not have certification in oncology nursing, 77.9% had no form of specialized training in oncology care. The only exposure to oncology nursing training for most of the participants was during their basic training in nursing and midwifery schools but duration of exposure could not be ascertained. Most 64.4% of respondents felt their exposure to oncology nursing care wasn't adequate. 62.7% affirmed there was no educational institution that caters for specialized oncology training in their locality. However, 55.8% of the respondents considered themselves as highly proficient in giving oncology care. There was no statistically significant association between years of experience in oncology care and perceived proficiency χ2 value χ2 = 3.05, pv = 0.11. Conclusion: This findings revealed the training in oncology nursing among nurses is not adequate as the only oncology nursing training exposure was at the basic nursing schools. Hence the need to establish oncology nursing training programs for nurses in cancer care in Nigeria. This will go a long way to influence cancer control.

Maintenance DFMO Increases Survival in High Risk Neuroblastoma

High risk neuroblastoma (HRNB) accounts for 15% of all pediatric cancer deaths. Despite aggressive therapy approximately half of patients will relapse, typically with only transient responses to second-line therapy. This study evaluated the ornithine decarboxylase inhibitor difluoromethylornithine (DFMO) as maintenance therapy to prevent relapse following completion of standard therapy (Stratum 1) or after salvage therapy for relapsed/refractory disease (Stratum 2). This Phase II single agent, single arm multicenter study enrolled from June 2012 to February 2016. Subjects received 2 years of oral DFMO (750 ± 250 mg/m² twice daily). Event free survival (EFS) and overall survival (OS) were determined on an intention-to-treat (ITT) basis. 101 subjects enrolled on Stratum 1 and 100 were eligible for ITT analysis; two-year EFS was 84% (±4%) and OS 97% (±2%). 39 subjects enrolled on Stratum 2, with a two-year EFS of 54% (±8%) and OS 84% (±6%). DFMO was well tolerated. The median survival time is not yet defined for either stratum. DFMO maintenance therapy for HRNB in remission is safe and associated with high EFS and OS. Targeting ODC represents a novel therapeutic mechanism that may provide a new strategy for preventing relapse in children with HRNB.

Outcomes after Second Hematopoietic Cell Transplantation in Children and Young Adults with Relapsed Acute Leukemia

Children with acute leukemia who relapse after hematopoietic cell transplantation (HCT) have few therapeutic options. We studied 251 children and young adults with acute myelogenous or lymphoblastic leukemia who underwent a second HCT for relapse after their first HCT. The median age at second HCT was 11 years, and the median interval between first and second HCT was 17 months. Most of the patients (n = 187; 75%) were in remission, received a myeloablative conditioning regimen (n = 157; 63%), and underwent unrelated donor HCT (n = 230; 92%). The 2-year probability of leukemia-free survival (LFS) was 33% after transplantation in patients in remission, compared with 19% after transplantation in patients not in remission (P = .02). The corresponding 8-year probabilities were 24% and 10% (P = .003). A higher rate of relapse contributed to the difference in LFS. The 2-year probability of relapse after transplantation was 42% in patients in remission and 56% in those in relapse (P = .05). The corresponding 8-year probabilities were 49% and 64% (P = .04). These data extend the findings of others showing that patients with a low disease burden are more likely to benefit from a second transplantation. Late relapse led to a 10% decrement in LFS beyond the second year after second HCT. This differs from first HCT, in which most relapses occur within 2 years after HCT.

Safety and immunogenicity of a pentavalent meningococcal conjugate vaccine containing serogroups A, C, Y, W, and X in healthy adults: a phase 1, single-centre, double-blind, randomised, controlled study

BACKGROUND

Invasive meningococcal disease is an important public health problem, especially in sub-Saharan Africa. After introduction of MenAfriVac in 2010, Neisseria meningitidis serogroup A disease has been almost eliminated from the region. However, serogroups C, W, Y, and X continue to cause disease outbreaks. We assessed the NmCV-5 pentavalent meningococcal conjugate vaccine targeting A, C, Y, W, and X serogroups in a first-in-man, phase 1 study.

METHODS

We did a single-centre, double-blind, randomised controlled trial at a research clinic in Baltimore (MD, USA). Participants were healthy adults aged 18-45 years with no history of meningococcal vaccination or previous meningococcal infection. We randomly assigned participants (1:1:1) by an SAS-generated random schedule to a single, 0·5 mL, intramuscular injection of aluminium-phosphate adjuvanted NmCV-5, non-adjuvanted NmCV-5, or control (the quadrivalent meningococcal conjugate vaccine Menactra). The randomisation sequence used a permuted block design with randomly chosen block sizes of three and six. The vaccines were prepared, labelled, and administered with procedures to ensure participants and study personnel remained masked to treatment. After vaccination, participants were observed in the clinic for 60 min for adverse reactions. Participants recorded daily temperature and injection site or systemic reactions at home and returned to the clinic for follow-up visits on days 7, 28, and 84 for safety assessments; blood samples were also collected on day 7 for safety laboratory assessment. A phone call contact was made 6 months after vaccination. Serum was collected before vaccination and 28 days after vaccination for immunological assessment with a rabbit complement-dependent serum bactericidal antibody (rSBA) assay. The primary objective was an intention-to-treat assessment of safety, measuring local and systemic reactogenicity over 7 days, unsolicited adverse events through 28 days, and serious adverse events over 6 months. The secondary objective for the assessment of immunogenicity, was a per-protocol analysis of rSBA before and 28 days after vaccination. This trial is registered with ClinicalTrials.gov, number NCT02810340.

FINDINGS

Between Aug 17, 2016, and Feb 16, 2017, we assigned 20 participants to each vaccine. All vaccines were well-tolerated. Pain was the most common local reaction, occurring in 12 (60%), ten (50%), and seven (35%) participants in the adjuvanted NmCV-5, non-adjuvanted NmCV-5, and control groups, respectively. Headache was the most common systemic reaction, occurring in five (25%), three (15%), and three (15%), respectively. Most solicited reactogenicity adverse reactions were mild (60 [74%] of 81) and all were self-limiting. None of the differences in proportions of individuals with each solicited reaction was significant (p>0·300 for all comparisons) between the three vaccination groups. There were no serious adverse events and 19 unsolicited non-serious adverse events in 14 (23%) participants. Both adjuvanted and non-adjuvanted NmCV-5 elicited high rSBA titres against all five meningococcal serogroups. The pre-vaccination geometric mean titres (GMTs) ranged from 3·36 to 53·80 for the control, from 6·28 to 187·00 for the adjuvanted vaccine, and from 4·29 to 350·00 for the non-adjuvanted vaccine, and the post-vaccination GMT ranged from 3·14 to 3214 for the control, from 1351 to 8192 for the adjuvanted vaccine, and from 1607 to 11 191 for the non-adjuvanted vaccine. Predicted seroprotective responses (ie, an increase in rSBA titres of eight times or more) for the adjuvanted and non-adjuvanted NmCV-5 were similar to control responses for all five serogroups.

INTERPRETATION

The adjuvanted and non-adjuvanted NmCV-5 vaccines were well tolerated and did not produce concerning adverse effects and resulted in immune responses that are predicted to confer protection against all five targeted serogroups of invasive meningococcal disease. Further clinical testing of NmCV-5 is ongoing, and additional clinical trials are necessary to confirm the safety and immunogenicity of NmCV-5 in target populations.

FUNDING

UK Department for International Development.

Utility values for childhood obesity interventions: a systematic review and meta-analysis of the evidence for use in economic evaluation

Rigorous estimates of preference-based utilities are important inputs into economic evaluations of childhood obesity interventions, yet no published review currently exists examining utility by weight status in paediatric populations. A comprehensive systematic literature review and meta-analysis was therefore undertaken, pooling data on preference-based health state utilities by weight status in children using a random-effects model. Tests for heterogeneity were performed, and publication bias was assessed. Of 3,434 potentially relevant studies identified, 11 met our eligibility criteria. Estimates of Cohen's d statistic suggested a small effect of weight status on preference-based utilities. Mean utility values were estimated as 0.85 (95% uncertainty interval [UI] 0.84-0.87), 0.83 (95% UI 0.81-0.85), 0.82 (95% UI 0.79-0.84) and 0.83 (95% UI 0.80-0.86) for healthy weight, overweight, obese and overweight/obese states, respectively. Meta-analysis of studies reporting utility values for both healthy weight and overweight/obese participants found a statistically significant weighted mean difference (0.015, 95% UI 0.003-0.026). A small but statistically significant difference was also estimated between healthy weight and overweight participants (0.011, 95% UI 0.004-0.018). Study findings suggest that paediatric-specific benefits of obesity interventions may not be well reflected by available utility measures, potentially underestimating cost-effectiveness if weight loss in childhood/adolescence improves health or well-being.

Abstract CT073: Peds-plan, pediatric precision laboratory advanced neuroblastoma therapy: Molecular guided therapy for high risk neuroblastoma at diagnosis

BACKGROUND: While the poor prognosis for high risk neuroblastoma (HRNB) underscores the need for new treatment strategies, the elucidation of specific biologic subsets of neuroblastoma suggests a way to improve disease management. The identification of agents that target specific molecular pathways associated with the development or progression of diseases holds promise. The hypotheses for this study were that: 1) the incorporation of a targeted therapy, selected based upon upfront genomic interrogation of the tumor, into standardized induction chemotherapy for HRNB is feasible and may increase the PR/CR/VGPR response rate at the end of Induction therapy; and 2) that the addition of DFMO as maintenance therapy during and for 2 years after the completion of immunotherapy is safe and may decrease the relapse rate.

METHODS: A prospective, multicenter feasibility pilot clinical trial in subjects with newly diagnosed HRNB within the Beat Childhood Cancer Consortium. At diagnosis, patients' tumors underwent DNA exome and RNA sequencing which were analyzed within a molecular tumor board to identify the single best drug out of 6 targeted agents to be added to cycles 3-6 of induction chemotherapy. After consolidation with ASCT and radiation, the patients received DFMO along with standard dinutuximab and retinoic acid and DFMO for 2 years after immunotherapy. Patients were evaluated for additional toxicities with the addition of targeted agents and DFMO in addition to induction response.

RESULTS: The pilot study of 20 eligible patients has shown this process to be feasible. To date, 20 patients have completed induction through immunotherapy portions of the study. The combination of targeted agent with chemotherapy was shown to be safe without any unexpected toxicities. Delays experienced between induction cycles were less than 2 weeks and related to surgery, infection, or thrombocytopenia. The induction response demonstrated an 88% CR/VGPR/PR rate, which suggests improvement over historical 80%. In addition, the combination of DFMO with dinutuximab and retinoic acid was well tolerated and safe without additional toxicities.

CONCLUSION: The pilot study of 20 patients has shown the process of sequencing and the addition of a targeted agent to upfront chemotherapy is feasible and safe without any unexpected toxicities.

Citation Format: Jacqeline Kraveka, Valerie Brown, William Ferguson, Genevieve Bergendahl, William Roberts, Jessica Foley, Deanna Mitchell, Javier Oesterheld, Michael Isakoff, Kathleen Neville, Randal Wada, Jawhar Rawwas, Gina Hanna, Abhinav Beeravally Nagulapally, Jeffrey Bond, Jeffrey Trent, William Hendricks, Sarah Byron, Giselle L. Saulnier Sholler. Peds-plan, pediatric precision laboratory advanced neuroblastoma therapy: Molecular guided therapy for high risk neuroblastoma at diagnosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr CT073.

[A woman with swelling and blue-red discolouration of the leg]

A 61-year-old woman presented with a sudden marked swelling and blue-red discolouration of her entire left leg. The diagnosis phlegmasia cerulea dolens was made. This is an extreme case of lower-extremity deep venous thrombosis that can cause critical limb ischaemia and possible limb loss.

Personalized Prognostic Risk Score for Long-Term Survival for Children with Acute Leukemia after Allogeneic Transplantation

We studied leukemia-free (LFS) and overall survival (OS) in children with acute myeloid (AML, n = 790) and acute lymphoblastic leukemia (ALL, n = 1096) who underwent transplantation between 2000 and 2010 and who survived for at least 1 year in remission after related or unrelated donor transplantation. Analysis of patient-, disease-, and transplantation characteristics and acute and chronic graft-versus-host disease (GVHD) was performed to identify factors with adverse effects on LFS and OS. These data were used to develop risk scores for survival. We did not identify any prognostic factors beyond 4 years after transplantation for AML and beyond 3 years for ALL. Risk score for survival for AML includes age, disease status at transplantation, cytogenetic risk group, and chronic GVHD. For ALL, the risk score includes age at transplantation and chronic GVHD. The 10-year probabilities of OS for AML with good (score 0, 1, or 2), intermediate (score 3), and poor risk (score 4, 5, 6, or 7) were 94%, 87%, and 68%, respectively. The 10-year probabilities of OS for ALL were 89% and 80% for good (score 0 or 1) and poor risk (score 2), respectively. Identifying children at risk for late mortality with early intervention may mitigate some excess late mortality.

Active transport and obesity prevention - A transportation sector obesity impact scoping review and assessment for Melbourne, Australia

Given the alarming prevalence of obesity worldwide and the need for interventions to halt the growing epidemic, more evidence on the role and impact of transport interventions for obesity prevention is required. This study conducts a scoping review of the current evidence of association between modes of transport (motor vehicle, walking, cycling and public transport) and obesity-related outcomes. Eleven reviews and thirty-three primary studies exploring associations between transport behaviours and obesity were identified. Cohort simulation Markov modelling was used to estimate the effects of body mass index (BMI) change on health outcomes and health care costs of diseases causally related to obesity in the Melbourne, Australia population. Results suggest that evidence for an obesity effect of transport behaviours is inconclusive (29% of published studies reported expected associations, 33% mixed associations), and any potential BMI effect is likely to be relatively small. Hypothetical scenario analyses suggest that active transport interventions may contribute small but significant obesity-related health benefits across populations (approximately 65 health adjusted life years gained per year). Therefore active transport interventions that are low cost and targeted to those most amenable to modal switch are the most likely to be effective and cost-effective from an obesity prevention perspective. The uncertain but potentially significant opportunity for health benefits warrants the collection of more and better quality evidence to fully understand the potential relationships between transport behaviours and obesity. Such evidence would contribute to the obesity prevention dialogue and inform policy across the transportation, health and environmental sectors.

Self-compassion, attitudes to ageing and indicators of health and well-being among midlife women

OBJECTIVES

Attitudes to ageing exert a powerful influence on health and well-being, yet surprisingly little research has examined factors that contribute to the formation of these attitudes. The aim of this study was to consider the potential role of self-compassion in predicting attitudes to ageing, which in turn contribute to positive and negative mental well-being and self-reported health.

METHOD

This was a cross-sectional study using data from 517 midlife women aged between 40 and 60. Structural equation modelling was used to examine the relationships between self-compassion, three facets of attitudes to ageing and well-being outcomes.

RESULTS

Together, self-compassion and attitudes to ageing explained between 36% and 67% of the variance in well-being. Self-compassion was a strong predictor of attitudes towards psychosocial loss, physical change and psychological growth (β range: .22-.51). Furthermore, the relationship between self-compassion and well-being outcomes was partially mediated by attitudes to physical change.

CONCLUSION

Self-compassion may be a modifiable internal resource to promote healthy attitudes to ageing in midlife, when ageing becomes personally relevant. Moreover, attitudes towards physical change may help explain how self-compassion promotes well-being among midlife women.

Saccade Programming in Strabismic Suppression

Individuals with strabismus frequently show a suppression phenomenon in which part of the visual input in one eye is apparently ignored when both eyes are seeing, although the eye may have normal vision when used monocularly. This is often described as an adaptive response to avoid diplopia. We have examined two patients with microstrabismus (angle of squint less than 5 deg) who show strong suppression but with only mild amblyopia. We studied saccade generation in the two eyes using a red — green anaglyph display which allowed us to present stimuli independently to each eye.

When single targets were presented in the suppressing eye, saccadic responses usually occurred. However the latencies of these saccades were increased with respect to those elicited from the normal eye (by about 70 ms for one subject and 270 ms for the other). The amplitudes of the saccades were less consistent than those of the normal eye, and saccades were sometimes made in the opposite direction to the target. We also investigated the remote distractor effect. This effect is found consistently in normal subjects and consists of an increase in the latency of a target-elicited saccade when a distractor is simultaneously presented elsewhere in the visual field. When distractors were presented in the suppressing eye, they had no effect on the latency of saccades to a simultaneous target in the other eye. We conclude that visual stimulation in a suppressing eye has no rapid access to the saccadic system.