Association between COVID-19 exposure and autonomic nervous system dysfunction in apparently healthy adults: an observational study

OBJECTIVE

Coronavirus disease (COVID-19) is a respiratory disease caused by SARS-CoV-2, which complicates the functioning of multiple systems, including the autonomic nervous system (ANS), causing dysautonomia. Investigation of dysautonomia and its association with exposure to COVID-19 is limited in healthy people. Therefore, the study aimed to investigate the relationship between ANS dysautonomia and coronavirus exposure and compare the ANS function between exposed and non-exposed to COVID-19.

SUBJECTS AND METHODS

The study involved 141 participants, with a mean age of 18-24.5 years, 83% male (49.6% exposed to COVID-19). The ANS was measured using a composite autonomic symptom scale (COMPASS-31) questionnaire and heart rate variability (HRV) using photoplethysmography. Exposure to COVID-19 was investigated using two national health-status tracking and COVID-19 exposure applications, "Sehhaty" and "Twakkalna".

RESULTS

A significantly inverse weak correlation between COMPASS-31 scores and COVID-19 exposure (r=-0.2, p=0.04). No significant association was found between HRV and COVID-19 exposure. COMPASS-31 scores for the exposed group (median=15, n=70) were significantly higher than those for the non-exposed group (median=12, n=71), U=1,913.5, p=0.03. Height (r=-0.4, p=0.002) and gender (r=0.3, p=0.001) were moderately correlated with COMPASS-31 among the exposed group.

CONCLUSIONS

These findings indicated that exposure to COVID-19 was associated with poorer ANS scores measured via COMPASS-31. Additionally, exposure to COVID-19 resulted in higher dysautonomia symptoms than non-exposed. Height and gender differences contribute to the severity of dysautonomia among exposed people.

Adjusted estimate of the prevalence of hepatitis delta virus in 25 countries and territories

BACKGROUND & AIMS

Hepatitis delta virus (HDV) is a satellite RNA virus that requires the hepatitis B virus (HBV) for assembly and propagation. Individuals infected with HDV progress to advanced liver disease faster than HBV-monoinfected individuals. Recent studies have estimated the global prevalence of anti-HDV antibodies among the HBV-infected population to be 5-15%. This study aimed to better understand HDV prevalence at the population level in 25 countries/territories.

METHODS

We conducted a literature review to determine the prevalence of anti-HDV and HDV RNA in hepatitis B surface antigen (HBsAg)-positive individuals in 25 countries/territories. Virtual meetings were held with experts from each setting to discuss the findings and collect unpublished data. Data were weighted for patient segments and regional heterogeneity to estimate the prevalence in the HBV-infected population. The findings were then combined with The Polaris Observatory HBV data to estimate the anti-HDV and HDV RNA prevalence in each country/territory at the population level.

RESULTS

After adjusting for geographical distribution, disease stage and special populations, the anti-HDV prevalence among the HBsAg+ population changed from the literature estimate in 19 countries. The highest anti-HDV prevalence was 60.1% in Mongolia. Once adjusted for the size of the HBsAg+ population and HDV RNA positivity rate, China had the highest absolute number of HDV RNA+ cases.

CONCLUSIONS

We found substantially lower HDV prevalence than previously reported, as prior meta-analyses primarily focused on studies conducted in groups/regions that have a higher probability of HBV infection: tertiary care centers, specific risk groups or geographical regions. There is large uncertainty in HDV prevalence estimates. The implementation of reflex testing would improve estimates, while also allowing earlier linkage to care for HDV RNA+ individuals. The logistical and economic burden of reflex testing on the health system would be limited, as only HBsAg+ cases would be screened.

IMPACT AND IMPLICATIONS

There is a great deal of uncertainty surrounding the prevalence of hepatitis delta virus among people living with hepatitis B virus at the population level. In this study, we aimed to better understand the burden in 25 countries and territories, to refine techniques that can be used in future analyses. We found a lower prevalence in the majority of places studied than had been previously reported. These data can help inform policy makers on the need to screen people living with hepatitis B virus to find those coinfected with hepatitis delta virus and at high risk of progression, while also highlighting the pitfalls that other researchers have often fallen into.

Low Tesla MR Imaging for Spine with Hardware

PURPOSE/OBJECTIVE(S)

Acquiring MR images with minimized susceptibility artifacts is essential for spines with medical hardware to delineate clinical target volumes (CTVs) in radiation therapy for chordomas, chondrosarcomas, and other sarcomas. Since it can be more challenging to visualize the primary structures in high-tesla MR images due to metal-induced artifacts, we optimized imaging parameters to acquire high-quality, low-tesla MR images for clinical use.

MATERIALS/METHODS

OptimalMR imaging parameters were investigated under general guidelines for artifact reduction techniques by testing several 3D spin echo and gradient echo sequences in a 0.23-T MR scanner. A customized spine phantom was developed to acquire MR images for bony materials which included, 4-6 industrial titanium screws, an aluminum plate, and a superflab bolus. While the 3D b-FFE sequence was used to acquire MR images with a high signal-to-noise ratio, the other 3D T1-FFE, THRIVE, and DTSE sequences were applied to reduce susceptible artifacts to the medical hardware. The optimized parameters determined in the phantom test were applied to the 15 clinical cases, including patients with residual spinal tumors and fusion hardware. The low-tesla MR imaging technique was also used to scan sarcomas of the extremities and re-irradiation cases of spinal metastases.

RESULTS

The optimized low-tesla MR images in the spine were noticeably useful to guide CTV delineations for patients with medical hardware, especially for residual or recurrent tumors. The imaging technique to minimize susceptibility artifacts enabled a more defined separation of each hardware component from the spinal cord and CTVs. In spine metastasis cases, pre-irradiated target volumes were determined, reflecting property changes in the bone marrow.

CONCLUSION

The MR images acquired using the optimized parameters showed minimal artifacts to scan spine patients with hardware. By using the low-tesla MR images, spinal chordoma and chondrosarcoma patients could be treated to improve tumor control probabilities with minimized complications.

Diagnostic Accuracy of Clinical Pathways for Suspected Acute Myocardial Infarction in the Out-of-Hospital Environment

STUDY OBJECTIVE

Chest pain is one of the most common reasons for emergency ambulance calls. Patients are routinely transported to the hospital to prevent acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of clinical pathways in the out-of-hospital environment. The Troponin-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors, Troponin score require cardiac troponin (cTn) measurement, whereas the History and ECG-only Manchester Acute Coronary Syndromes decision aid and History, ECG, Age, Risk Factors score do not.

METHODS

We conducted a prospective diagnostic accuracy study at 4 ambulance services and 12 emergency departments between February 2019 and March 2020. We included patients who received an emergency ambulance response in whom paramedics suspected AMI. Paramedics recorded the data required to calculate each decision aid and took venous blood samples in the out-of-hospital environment. Samples were tested using a point-of-care cTn assay (Roche cobas h232) within 4 hours. The target condition was a diagnosis of type 1 AMI, adjudicated by 2 investigators.

RESULTS

Of 817 included participants, 104 (12.8%) had AMI. Setting the cutoff at the lowest risk group, Troponin-only Manchester Acute Coronary Syndromes had 98.3% sensitivity (95% confidence interval 91.1% to 100%) and 25.5% specificity (21.4% to 29.8%) for type 1 AMI. History, ECG, Age, Risk Factors, Troponin had 86.4% sensitivity (75.0% to 98.4%) and 42.2% specificity (37.5% to 47.0%); History and ECG-only Manchester Acute Coronary Syndromes had 100% sensitivity (96.4% to 100%) and 3.1% specificity (1.9% to 4.7%), whereas History, ECG, Age, Risk Factors had 95.1% sensitivity (88.9% to 98.4%) and 12.1% specificity (9.8% to 14.8%).

CONCLUSION

With point-of-care cTn testing, decision aids can identify patients at a low risk of type 1 AMI in the out-of-hospital environment. When used alongside clinical judgment, and with appropriate training, such tools may usefully enhance out-of-hospital risk stratification.

AWARENESS AND KNOWLEDGE OF OBSTRUCTIVE SLEEP APNEA AMONG THE POPULATION OF THE AL-BAHA REGION OF SAUDI ARABIA: A CROSS-SECTIONAL STUDY

Obstructive sleep apnea (OSA) is a known sleep-disordered breathing, with known morbidity and mortality, that affects a lot of people worldwide. In Saudi Arabia, the prevalence of OSA is estimated to be around 8.8% among adult males and 5.1% among adult females. The research is a cross-sectional study design conducted in the Al-Baha region; Saudi Arabia in 385 participants. To evaluate the knowledge and awareness of OSA, the study utilized a validated and reliable adapted Arabic version of the OSA questionnaire. The degree of consciousness and understanding regarding OSA demonstrated a noteworthy connection with varying levels of education and a favorable family history of OSAS (p<0.05). The regression analyses unveiled that people with a familial OSA background had a 2.565-fold increased likelihood of identifying daytime fatigue as a symptom of OSA (p<0.05). The study reported an insufficient level of awareness and knowledge of OSA among the Saudi Arabian population. Various factors, including gender, education, and family history of OSA, may affect the awareness and knowledge of this condition.

The Ability of Emergency Medical Service Staff to Predict Emergency Department Disposition: A Prospective Study

Purpose

Paramedics' decision to notify receiving hospitals and transport patients to an appropriate healthcare facility is based on the Prediction of Intensive Care Unit (ICU) and Hospital Admissions guide. This study aimed to assess the paramedics' gestalt on both ward and ICU admission.

Patients and Methods

A prospective study was conducted at King Abdulaziz Medical City between September 2021 and March 2022. Paramedics were asked several questions related to the prediction of the patient's hospital outcome, including emergency department (ED) discharge or hospital admission (ICU or ward). Additional data, such as the time of the ambulance's arrival and the staff years of experience, were collected. The categorical characteristics are presented by frequency and percentage for each category.

Results

This study included 251 paramedics and 251 patients. The average age of the patients was 62 years. Of the patients, 32 (12.7%) were trauma, and 219 (87.3%) were non-trauma patients. Two-thirds of the patients (n=171, 68.1%) were predicted to be admitted to the hospital, and 80 (31.8%) of the EMS staff indicated that the patient do not need a hospital or an ambulance. The sensitivity, specificity, PPV, and NPV of the emergency medical service (EMS) staffs' gestalt for patient admission to the hospital were, respectively (77%), (33%), (16%), and (90%). Further analysis was reported to defend the EMS staffs' gestalt based on the level of EMS staff and the nature of the emergency (medical vs trauma), are reported.

Conclusion

Our study reports a low level of accurately predicting patient admission to the hospital, including the ICU. The results of this study have important implications for enhancing the accuracy of EMS staff predictive ability and ensuring that patients receive appropriate care promptly.

Evaluation of the psychological distress and mental well-being of pre-hospital care providers in Saudi Arabia during COVID-19

Background

Pre-hospital care providers are the first line of contact when emergencies occur. They are at high risk of mental health disorders associated with trauma and stress. The magnitude of their stress could increase during difficult times such as the COVID-19 pandemic.

Objectives

This study reports on the state of mental well-being and the degree of psychological distress among pre-hospital care workers (paramedics, emergency medical technicians, doctors, paramedic interns and other healthcare practitioners) during the COVID-19 pandemic in Saudi Arabia.

Methods

The study was a cross-sectional survey study in Saudi Arabia. A questionnaire was distributed among pre-hospital care workers in Saudi Arabia during the first wave of the COVID-19 pandemic. The questionnaire was based on the Kessler Psychological Distress Scale (K10) and the World Health Organization Well-Being Index (WHO-5).

Results

In total, 427 pre-hospital care providers completed the questionnaire; 60% of the respondents had scores of more than 30 in the K10 and were likely to have a severe disorder. The WHO-5 showed a similar percentage of respondents with a score of more than 50 and coded as having poor well-being.

Conclusions

The findings of this study provide evidence around mental health and well-being for pre-hospital care workers. They also highlight the need to better understand the quality of mental health and well-being for this population and to provide appropriate interventions to improve their quality of life.

Acute upper respiratory infections admissions in England and Wales

Acute respiratory infections block the bronchial and/or nasal systems' airways. These infections may present in a variety of ways, from minor symptoms like the common cold to more serious illnesses like pneumonia or lung collapse. Acute respiratory infections cause over 1.3 million infant deaths under the age of 5 each year throughout the world. Among all illnesses, respiratory infections make for 6% of the worldwide disease burden. We aimed to examine the admissions related to acute upper respiratory infections admissions in England and Wales for the period between April 1999 and April 2020. This was an ecological study using publicly available data extracted from the Hospital Episode Statistics database in England, and the Patient Episode Database for Wales for the period between April 1999 and April 2020. The acute upper respiratory infections-related hospital admissions were identified using the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems 5th Edition (used by National Health Service [NHS] to classify diseases and other health conditions) (J00-J06). The total annual number of admissions for various reasons increased by 1.09-fold (from 92,442 in 1999 to 193,236 in 2020), expressing an increase in hospital admission rate of 82.5% (from 177.30 [95% confidence interval {CI}: 176.15-178.44] in 1999 to 323.57 [95%CI: 322.13-325.01] in 2020 per 100,000 persons, P < .01). The most common causes were acute tonsillitis and acute upper respiratory infections of multiple and unspecified sites, which accounted for 43.1% and 39.4%, respectively. Hospital admissions rate due to acute upper respiratory infections increased sharply during the study period. The rates of hospital admissions were higher among those in the age group below 15 and 75 years and above for the majority of respiratory infections, with a higher incidence in females.

External validation of the Manchester Acute Coronary Syndromes ECG risk model within a pre-hospital setting

OBJECTIVES

The Manchester Acute Coronary Syndromes ECG (MACS-ECG) prediction model calculates a score based on objective ECG measurements to give the probability of a non-ST elevation myocardial infarction (NSTEMI). The model showed good performance in the emergency department (ED), but its accuracy in the pre-hospital setting is unknown. We aimed to externally validate MACS-ECG in the pre-hospital environment.

METHODS

We undertook a secondary analysis from the Pre-hospital Evaluation of Sensitive Troponin (PRESTO) study, a multi-centre prospective study to validate decision aids in the pre-hospital setting (26 February 2019 to 23 March 2020). Patients with chest pain where the treating paramedic suspected acute coronary syndrome were included. Paramedics collected demographic and historical data and interpreted ECGs contemporaneously (as 'normal' or 'abnormal'). After completing recruitment, we analysed ECGs to calculate the MACS-ECG score, using both a pre-defined threshold and a novel threshold that optimises sensitivity to differentiate AMI from non-AMI. This was compared with subjective ECG interpretation by paramedics. The diagnosis of AMI was adjudicated by two investigators based on serial troponin testing in hospital.

RESULTS

Of 691 participants, 87 had type 1 AMI and 687 had complete data for paramedic ECG interpretation. The MACS-ECG model had a C-index of 0.68 (95% CI: 0.61 to 0.75). At the pre-determined cut-off, MACS-ECG had 2.3% (95% CI: 0.3% to 8.1%) sensitivity, 99.5% (95% CI: 98.6% to 99.9%) specificity, 40.0% (95% CI: 10.2% to 79.3%) positive predictive value (PPV) and 87.6% (87.3% to 88.0%) negative predictive value (NPV). At the optimal threshold for sensitivity, MACS-ECG had 50.6% sensitivity (39.6% to 61.5%), 83.1% specificity (79.9% to 86.0%), 30.1% PPV (24.7% to 36.2%) and 92.1% NPV (90.4% to 93.5%). In comparison, paramedics had a sensitivity of 71.3% (95% CI: 60.8% to 80.5%) with 53.8% (95% CI: 53.8% to 61.8%) specificity, 19.7% (17.2% to 22.45%) PPV and 93.3% (90.8% to 95.1%) NPV.

CONCLUSION

Neither MACS-ECG nor paramedic ECG interpretation had a sufficiently high PPV or NPV to 'rule in' or 'rule out' NSTEMI alone.

Morphology and molecular phylogeny of trypanorhynchid metacestodes infecting commercial fish of the Mediterranean Sea

ABSTRACT Members of the order Trypanorhyncha are cestode parasites that are frequently found infecting the muscles of several marine fish species, affecting fish health, and resulting in consumers’ rejection of fish. Fifty-two specimens of marine fish were freshly caught throughout the year 2020 from boat landing sites at the Alexandria coast along the Mediterranean Sea in Egypt, including the grey trigger fish Balistes carolinensis (F: Balistidae); the mottled grouper Mycteroperca rubra (F: Serranidae) and the common sole Solea vulgaris (F: Soleidae). Blastocysts were isolated and ruptured; the generated pleurocerci were described morphologically and morphometrically by light and scanning electron microscopy. Also, multiple-sequence alignment was performed, and a phylogenetic tree was constructed following maximum likelihood analysis of the 18s and 28s ribosomal RNA sequences of the recovered worms. Thirty fish were infected; the infection was recorded as blastocysts embedded in fish flesh. Three different parasitic species were recovered and classified morphologically as Gymnorhynchus isuri, Pseudotobothrium dipsacum and Heteronybelinia estigmena. The taxonomic position of these parasites was justified by molecular analysis of their 18s and 28s rRNAs, which revealed high percentages of homology with species recovered from the GenBank. The accession numbers ON157059, ON139663 and ON139662 were respectively assigned to the recovered parasites after their deposition in GenBank. The results obtained from the molecular analyses confirmed the morphological records of the recovered parasites. Since metacestodes are found in the musculature of infected fish specimens, it is necessary to remove these areas in the commercialization of fish.

Imbalanced prostanoid release mediates cigarette smoke-induced human pulmonary artery cell proliferation

BACKGROUND

Pulmonary hypertension is a common and serious complication of chronic obstructive pulmonary disease (COPD). Studies suggest that cigarette smoke can initiate pulmonary vascular remodelling by stimulating cell proliferation; however, the underlying cause, particularly the role of vasoactive prostanoids, is unclear. We hypothesize that cigarette smoke extract (CSE) can induce imbalanced vasoactive prostanoid release by differentially modulating the expression of respective synthase genes in human pulmonary artery smooth muscle cells (PASMCs) and endothelial cells (PAECs), thereby contributing to cell proliferation.

METHODS

Aqueous CSE was prepared from 3R4F research-grade cigarettes. Human PASMCs and PAECs were treated with or without CSE. Quantitative real-time RT-PCR and Western blotting were used to analyse the mRNA and protein expression of vasoactive prostanoid syhthases. Prostanoid concentration in the medium was measured using ELISA kits. Cell proliferation was assessed using the cell proliferation reagent WST-1.

RESULTS

We demonstrated that CSE induced the expression of cyclooxygenase-2 (COX-2), the rate-limiting enzyme in prostanoid synthesis, in both cell types. In PASMCs, CSE reduced the downstream prostaglandin (PG) I synthase (PGIS) mRNA and protein expression and PGI2 production, whereas in PAECs, CSE downregulated PGIS mRNA expression, but PGIS protein was undetectable and CSE had no effect on PGI2 production. CSE increased thromboxane (TX) A synthase (TXAS) mRNA expression and TXA2 production, despite undetectable TXAS protein in both cell types. CSE also reduced microsomal PGE synthase-1 (mPGES-1) protein expression and PGE2 production in PASMCs, but increased PGE2 production despite unchanged mPGES-1 protein expression in PAECs. Furthermore, CSE stimulated proliferation of both cell types, which was significantly inhibited by the selective COX-2 inhibitor celecoxib, the PGI2 analogue beraprost and the TXA2 receptor antagonist daltroban.

CONCLUSIONS

These findings provide the first evidence that cigarette smoke can induce imbalanced prostanoid mediator release characterized by the reduced PGI2/TXA2 ratio and contribute to pulmonary vascular remodelling and suggest that TXA2 may represent a novel therapeutic target for pulmonary hypertension in COPD.

Antibacterial Effects of Commiphora gileadensis Methanolic Extract on Wound Healing

Commiphora gileadensis (CG) is a small tree distributed throughout the Middle East. It was traditionally used in perfumes in countries in this area. In Saudi Arabia, it was used to treat wounds burns and as an antidote to scorpion stings. This study aimed to evaluate the antimicrobial activity and cutaneous wound healing efficiency of the CG extracts using microbiological tests, rate of wound contraction and histopathological changes. CG plant were extracted using the methanol extraction technique; then, the methanolic extract was characterized using liquid chromatography coupled with mass spectrometry (LC−MS). Afterwards, a six-millimetre (mm) excision wound was induced in 60 male Balb/c mice. Mice were classified into two classes; each class consisted of three groups of 10 mice. In the non-infected wound class, the group I was assigned as control and received normal saline. Group II received gentamicin treatment, and group III treated with CG-methanolic extract. In the Staphylococcus aureus-infected class, group IV received normal saline, and groups V and VI were treated with gentamicin and CG-methanolic extract, respectively. The colonization of infected wounds was determined using colony-forming units (CFUs), and the percentage of wound contraction was measured in all groups. Finally, the histopathologic semi-quantitative determination of wound healing was evaluated by inflammatory cell infiltration, the presence of collagen fibres and granulation tissue, and the grade of re-epithelization. Composition analysis of the methanolic extract confirmed the presence of a high amount of ceramide (69%) and, to a lesser extent, hexosylceramide (18%) and phosphatidylethanolamine (7%) of the total amount. Additionally, there was a statistically significant difference between the percentage of wound contraction in the CG-treated and control groups in both Staphylococcus aureus-infected and non-infected wounds (p < 0.01). The colonization of the infected wounds was lower in the group treated with CG than in the control group (p < 0.01). In both non-infected and infected wounds, the CG-treated group showed significant statistical differences in inflammatory cell infiltration, collagen fibres, re-epithelization and granulation tissue formation compared with the control group (p < 0.01). The CG extract possesses antibacterial and anti-inflammatory properties that induce wound healing.

Relentless Hypoxia in a Patient With Carcinoid Syndrome

Patent foramen ovale (PFO) in patients with carcinoid heart disease (CHD) may result in hypoxia due to the presence of large right (R) to left (L) intracardiac shunts leading to hypoxia and worsening clinical condition. Percutaneous closure of the PFO can normalize oxygen saturation, relieve symptoms, and lessens left-sided heart valves involvement.

We describe a case of a 70-year-old female patient with a history of small bowel neuroendocrine tumor on monthly octreotide infusion presented with worsening exertional dyspnea and hypoxia secondary to R to L intracardiac shunt through the PFO. The decision was made to close the PFO percutaneously with Amplatzer (Plymouth, MN: Abbott) PFO occluder device which resulted in immediate normalization of oxygen saturation and relief of her dyspnea.

Assessment of genetic variation in Apis mellifera jemenitica (Hymenoptera: Apidae) using Cytochrome Oxidase I gene sequences

The Arabian Honeybee Apis mellifera jemenitica is endemic to the Arabian Peninsula. It is highly adapted to temperature extremes and drought dominating the region. In this study, the mitochondrial Cytochrome Oxidase I (COI) was analyzed in 133 specimens of A. m. jemenitica from eight localities along the Red Sea cost of Saudi Arabia. Results revealed 33 synonymous, and 6 non-synonymous mutations within the COI sequences, resulting in change of 4 amino acids. Phylogenetic analysis based on either type of mutations revealed two main haplogroups accounting for 94% of the samples. In total Eighteen new haplotypes were identified and uploaded in the genebank, Fourteen of them are restricted to one/both haplogroups. All haplotypes identified in this study clustered with reference COI sequences of the sub-lineag Z (African Lineage). However one Haplotype (MW428270) represents high COI variability compared to other haplotypes and may resemble different evolutionary sub-lineage. Tajima's Neutrality Test (Ps = 0.025; D = -1.5) indicated population size expansion that took place after selective sweep and/or purifying selection.

PP23 Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for chest pain patients. A systematic review abstract

Introduction

Chest pain is one of the most common reasons for ambulance callouts and presentation to Emergency Departments (EDs). Differentiating patients with serious conditions (e.g. acute coronary syndrome [ACS]) from the majority, who have self-limiting, non-cardiac conditions is extremely challenging. This causes over-triage and over-use of healthcare resources. We aimed to systematically review existing evidence on the accuracy of emergency telephone triage to detect ACS or life-threatening conditions associated with chest pain.

Methods

We conducted a systematic review in accordance with PRISMA guidelines. Two independent investigators searched the Embase, Medline, and Cinahl databases for relevant papers. We included retrospective and prospective cohort studies written in English and investigating EMS telephone triage for chest pain patients linked with final diagnosis of ACS. Studies were summarised in a narrative format as the data were not suitable for meta-analysis.

Result

In total, 553 studies were identified from the literature search and cross-referencing. After excluding 550 studies, three were eligible for inclusion. Among those 3 studies, there are different prediction models developed by authors with variation in variables to detect ACS. The result showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions although they are used to triage sign and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions and therefore it showed better sensitivity and NPV.

Conclusion

EMS dispatch systems accuracy for ACS and life-threatening conditions associated with chest pain is good. Since the dispatch tools were built to triage ambulance response priority based on sign and symptoms, this led to over triage among non-life-threatening chest pain patients. Over triage were slightly reduced by deriving prediction models and showed better sensitivity.

Accuracy of emergency medical services (EMS) telephone triage in identifying acute coronary syndrome (ACS) for patients with chest pain: a systematic literature review

OBJECTIVE

To systematically appraise the available evidence to determine the accuracy of decision aids for emergency medical services (EMS) telephone triage of patients with chest pain suspected to be caused by acute coronary syndrome (ACS) or life-threatening conditions.

DESIGN

Systematic review.

DATA SOURCES

Electronic searches were performed in Embase 1974, Medline 1946 and CINAHL 1937 databases from 3 March 2020 to 4 March 2020.

ELIGIBILITY CRITERIA

The review included all types of original studies that included adult patients (>18 years) who called EMS with a primary complaint of chest pain and evaluated dispatch triage priority by telephone. Outcomes of interest were a final diagnosis of ACS, acute myocardial infarction or other life-threatening conditions.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data on study design, population, study period, outcome and all data for assessment of accuracy, including cross-tabulation of triage priority against the outcomes of interest. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 assessment tool.

RESULTS

Searches identified 553 papers, of which 3 were eligible for inclusion. Those reports described the evaluation of three different prediction models with variation in the variables used to detect ACS. The overall results showed that dispatch triage tools have good sensitivity to detect ACS and life-threatening conditions, even though they are used to triage signs and symptoms rather than diagnosing the patients. On the other hand, prediction models were built to detect ACS and life-threatening conditions, and therefore, prediction models showed better sensitivity and negative predictive value than dispatch triage tools.

CONCLUSION

We have identified three prediction models for telephone triage of patients with chest pain. While they have been found to have greater accuracy than standard EMS dispatch systems, prospective external validation is essential before clinical use is considered.

PROSPERO REGISTRATION NUMBER

This systematic review was pre-registered on the International prospective register of systematic reviews (PROSPERO) database (reference CRD42020171184).

Favorable response to carbamazepine therapy in genetically proven myoclonus-dystonia child

Background

Myoclonus dystonia (MDS) is a dominantly inherited genetic disorder caused by loss-of-function mutations in the epsilon sarcoglycan gene (SGCE).

Case presentation

We here in report a twenty months old Saudi boy who presented to us with a concern that the child is unable to walk properly. On assessment, he was flexing his left arm and left leg that usually followed by a back-ward fall. Diagnosis of dystonia induced with initiation of movement was suggested that later on proven genetically to be pathogenic mutation of sarcoglycan gene. Carbamazepine therapy was initiated with dramatic response. Response was maintained at 4 years follow up.

Conclusions

Our patient and the other previously reported cases might highlight the response of SGCE mutations to carbamazepine therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-021-00986-w.

Returning to Sport After Anterior Cruciate Ligament Reconstruction in Physically Active Individuals

Background

Physically active individuals are susceptible to sports injuries, one of which is anterior cruciate ligament (ACL) injury. ACL injury can be managed conservatively or by surgical reconstruction. Returning to sport (RTS) after ACL injury is one of the main goals of ACL reconstruction (ACLR). However, rates of return vary and can be affected by several factors. The objectives of this study were to estimate the rate of return and to identify the factors that might affect RTS after ACLR. 

Methods

This was a cross-sectional study, including individuals who had an ACLR. Participants were sent an online survey included questions about their injury, sport participation, International Knee Documentation Committee form (IKDC), and the Tampa Scale for Kinesiophobia (TSK-11). Participants who had their surgery in the period between January 2011 to December 2018 and participated in sports regularly were included. Descriptive statistics were performed. Chi-square and student t-tests were performed to explore the differences between participants who returned and the ones that did not. 

Results

A total of 93 participants were included. The majority (69.9%) were playing soccer before the injury. Though more than half (61.3%) returned to sports, only 29% participated at the same level before the injury. Fear of reinjury was the most frequent reason for delaying or not returning (30%), followed by pain (29). Significantly better IKDC (p=0.002) and TSK-11 (p<0.001) scores were noted in participants who had returned to sports. On the other hand, participants’ age, body mass index (BMI), time from injury to surgery, time since surgery, and times of sports participation per week were not found to be significantly different between those who returned versus those who did not.

Conclusion

The participants in this study had a low rate of return with fear of reinjury being the most common reason not to return. However, a participant’s IKDC and TSK-11 scores were associated factors for RTS, thus optimizing those factors after surgery is crucial. 

Healthy Eating and Active Living for Diabetes-Glycemic Index (HEALD-GI): A Pragmatic Randomized Controlled Trial

Objectives

Rigorous evidence is needed to support uptake of recommendations to include low glycemic index (GI) foods in daily meal planning as an effective dietary self-care strategy for people with type 2 diabetes (T2D). We evaluated the effectiveness of a 12-week web-based GI-targeted nutrition education intervention on dietary intakes and GI-related knowledge among adults with T2D.

Methods

Participants were randomized to a control group (n = 34) that received standard printed copies of Canada's Food Guide and Diabetes Canada's GI resources or an intervention group (n = 33) that received those same materials, plus an online platform with six self-directed learning modules and supplementary print material. Each module consisted of a customized video, links to reliable websites, chat rooms, and quizzes. Evidence-based GI concept information included GI values of foods and advice for low-GI shopping, recipes, and cooking tips by a Registered Dietitian. Preferred supports through email, text messaging, phone calls, or postal mail to reinforce participants’ learning were also provided. The primary outcome, average daily dietary GI intake, was assessed using 3-day food records. Additional measures including GI knowledge and self-efficacy, glycated hemoglobin A1c, lipids, systolic blood pressure, body mass index, waist circumference, and computer proficiency, were assessed at baseline and at three months post-intervention.

Results

Participants (N = 67) were 64% men; mean (standard deviation [SD]) age 69.5 (9.3) years, with mean diabetes duration of 19.0 (13.7) years, BMI 30.1 (5.7) kg/m2 and A1c 7.1 (1.2)% at baseline. Mean daily GI intake decreased in the intervention group by 2.79 (7.77) compared to a 0.76 (6.48) increase in the control group (adjusted mean difference [95% CI]; −3.77 [−6.95, −0.58]). Mean GI knowledge 2.14 [0.59, 3.69], understanding of GI concept 1.65 [0.85, 2.44] and self-efficacy for consuming low-GI foods 1.29 [0.51, 2.07] increased among the intervention group (P &lt; 0.01) compared with the control group.

Conclusions

Web-based GI-targeted education program improved the quality of carbohydrate consumption among adults with T2D and may have been mediated through increases in knowledge and self-efficacy. Web-based nutrition education may be an effective alternative in this population.

Funding Sources

Canadian Foundation for Dietetic Research.

A268 PREOPERATIVE EUS-GUIDED FNA IS ASSOCIATED WITH BETTER OVERALL SURVIVAL IN RESECTABLE PANCREATIC CANCER WHEN COMPARED TO UPFRONT SURGERY WITHOUT PREOPERATIVE TISSUE ACQUISITION: A SYSTEMIC REVIEW AND META-ANALYSIS

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the standard of care in advanced pancreatic cancer. In resectable disease, preoperative EUS-FNA can help to identify benign etiology and other cancers while preventing unnecessary surgery. However, concerns regarding tumor seeding and pancreatitis have led some experts to advocate for upfront surgery without tissue sampling.

Aims

To conduct a systematic review and meta-analysis of the risks and benefits of performing pre-operative EUS-FNA in patients with suspected, resectable pancreatic cancer.

Methods

A literature search was performed up to April 2019 using MEDLINE, EMBASE, and ISI Web of Knowledge databases with terms specified for pancreatic neoplasm and FNA. All fully published adult studies that compared preoperative EUS-FNA to EUS without FNA in resectable pancreatic cancer for short- and long-term outcomes were included. Results were reported as Odds ratios (OR) or weighted mean differences (WMD) with 95% confidence intervals (CI) using a random effects model. Heterogeneity, publication bias and quality of studies were evaluated. Sensitivity analyses were performed. The primary outcome is overall survival. Secondary outcomes include cancer free survival, tumor recurrence and seeding, and post FNA adverse events.

Results

An initial search yielded 2814 citations. Six retrospective studies were included with 1155 patients in the EUS-FNA group vs 2067 patients in the comparator group. Overall survival was reported in three studies (n=2701: 796 EUS-FNA, 1905 non-FNA). Patients with preoperative EUS-FNA had better overall survival compared to the non-FNA group (WMD, 4.40 months [0.02 to 8.78]). In adenocarcinoma patients (2 studies, n=2050), there was no significant difference in overall survival (WMD, 2.94 months [-3.87 to 9.74]). Cancer-free survival did not differ significantly between the two groups (WMD, 2.08 months [-2.22 to 6.38]). Moreover, EUS with FNA was not associated with increased rates of tumor recurrence (OR, 0.55 [0.30–1.02]) or peritoneal carcinomatosis (OR, 0.81 [0.56–1.18]). Post-FNA pancreatitis was rare (1.7%), with all patients treated conservatively. Sensitivity analyses yielded similar findings across the different outcomes tested.

Conclusions

In this meta-analysis, preoperative EUS-FNA in resectable pancreatic cancer was associated with significantly greater overall survival when compared to the non-FNA group with no significant difference in rate of tumour recurrence and/or peritoneal seeding. These findings are limited by the retrospective nature of the included studies; randomized controlled trials are needed to confirm these results.

Funding Agencies

None

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid

Supplemental Digital Content is available in the text.

Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG.

Diagnostic accuracy of the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid with a point-of-care cardiac troponin assay

OBJECTIVE

Point-of-care (POC) cardiac troponin (cTn) assays have a rapid turnaround time but are generally less sensitive than laboratory-based assays. Previous research found that the Abbott i-Stat cardiac troponin I (cTnI) assay has good diagnostic accuracy when used with the Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid and serial sampling over 3 hours. Accuracy of other assays may differ. We therefore evaluated the diagnostic accuracy of a different POC cTnI assay with serial sampling over 3 hours, both with T-MACS and when used alone.

METHODS

In a prospective diagnostic accuracy study at eight EDs in England (July 2015-October 2017), we collected clinical data from consenting adults with suspected ACS at the time of assessment in the ED. Blood samples were drawn on arrival and 3 hours later for POC cTnI (Cardio 3 Triage, Alere). The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI), based on reference standard serial laboratory-based cTn testing. We calculated test characteristics for POC cTnI using the limit of detection (LoD, 0.01 µg/L) and the T-MACS decision aid.

RESULTS

Of 347 participants, 59 (14.9%) had AMI. With serial POC cTnI testing over 3 hours, POC cTnI at the LoD cut-off ruled out AMI in 193 (55.6%) patients with 98.1% sensitivity (95% CI 89.9% to 100.0%) and 99.5% negative predictive value (NPV, 95% CI 96.5% to 99.9%). T-MACS ruled out AMI in 117 (33.7%) patients with 98.1% sensitivity (95% CI 89.9% to 100%) and 99.2% NPV (95% CI 94.3% to 99.9%). T-MACS ruled in AMI with 97.9% specificity (95% CI 95.8% to 99.5%) and 83.7% positive predictive value (95% CI 70.6% to 91.7%).

CONCLUSIONS

With serial sampling over 3 hours, the Alere Cardio 3 Triage cTnI assay has relatively high NPV for AMI using either the LoD cut-off alone or the T-MACS decision aid. However, wide CIs around the measures of diagnostic accuracy mean that further prospective testing of this strategy is required before clinical implementation.

TRIAL REGISTRATION NUMBER

UKCRN 18000.

Enhanced electrochemical performance of α-MoO3/graphene nanocomposites prepared by an in situ microwave irradiation technique for energy storage applications

Nanoparticles of α-molybdenum oxide (α-MoO₃) are directly grown on graphene sheets using a surfactant-free facile one step ultrafast in situ microwave irradiation method.

PRe-hospital Evaluation of Sensitive TrOponin (PRESTO) Study: multicentre prospective diagnostic accuracy study protocol

INTRODUCTION

Within the UK, chest pain is one of the most common reasons for emergency (999) ambulance calls and the most common reason for emergency hospital admission. Diagnosing acute coronary syndromes (ACS) in a patient with chest pain in the prehospital setting by a paramedic is challenging. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision rule is a validated tool used in the emergency department (ED) to stratify patients with suspected ACS following a single blood test.We are seeking to evaluate the diagnostic accuracy of the T-MACS decision aid algorithm to 'rule out' ACS when used in the prehospital environment with point-of-care troponin assays. If successful, this could allow paramedics to immediately rule out ACS for patients in the 'very low risk' group and avoid the need for transport to the ED, while also risk stratifying other patients using a single blood sample taken in the prehospital setting.

METHODS AND ANALYSIS

We will recruit patients who call emergency (999) ambulance services where the responding paramedic suspects cardiac chest pain. The data required to apply T-MACS will be prospectively recorded by paramedics who are responding to each patient. Paramedics will be required to draw a venous blood sample at the time of arrival to the patient. Blood samples will later be tested in batches for cardiac troponin, using commercially available troponin assays. The primary outcome will be a diagnosis of acute myocardial infarction, established at the time of initial hospital admission. The secondary outcomes will include any major adverse cardiac events within 30 days of enrolment.

ETHICS AND DISSEMINATION

The study obtained approval from the National Research Ethics Service (reference: 18/ES/0101) and the Health Research Authority. We will publish our findings in a high impact general medical journal.

TRIAL REGISTRATION NUMBER

Registration number: ClinicalTrials.gov, study ID: NCT03561051.

Freestanding flexible, pure and composite form of reduced graphene oxide paper for ammonia vapor sensing

Metal oxides based graphene nanocomposites were used for ammonia vapour sensing. The self-assembly process was adopted to prepare freestanding flexible pure rGO, CeO₂-rGO and SnO₂-rGO composite papers. The structural studies confirmed the formation of rGO composite papers. The ammonia vapor sensing was demonstrated using an impedance analyzer at different humidity levels as well as concentration. The CeO₂-rGO composite paper achieved a sensitivity of 51.70 ± 1.2%, which was higher than that of pure rGO and SnO₂-rGO composite paper. Both the surfaces (top and bottom) of the papers are active in efficiently sensing ammonia, which makes the present work unique. The results reveal that metal oxide/rGO papers can be effectively utilized in real time sensor application.

TBX18 overexpression enhances pacemaker function in a rat subsidiary atrial pacemaker model of sick sinus syndrome

KEY POINTS

The sinoatrial node (SAN) is the primary pacemaker of the heart. SAN dysfunction, or 'sick sinus syndrome', can cause excessively slow heart rates and pauses, leading to exercise limitation and syncope, currently treated by implantation of an electronic pacemaker. 'Biopacemaking' utilises gene therapy to restore pacemaker activity by manipulating gene expression. Overexpressing the HCN pacemaker ion channel has been widely used with limited success. We utilised bradycardic rat subsidiary atrial pacemaker tissue to evaluate alternative gene targets: the Na+ /Ca2+ exchanger NCX1, and the transcription factors TBX3 and TBX18 known to be involved in SAN embryonic development. TBX18 overexpression restored normal SAN function, as assessed by increased rate, improved heart rate stability and restoration of isoprenaline response. TBX3 and NCX1 were not effective in accelerating the rate of subsidiary atrial pacemaker tissue. Gene therapy targeting TBX18 could therefore have the potential to restore pacemaker function in human sick sinus syndrome obviating electronic pacemakers.

ABSTRACT

The sinoatrial node (SAN) is the primary pacemaker of the heart. Disease of the SAN, sick sinus syndrome, causes heart rate instability in the form of bradycardia and pauses, leading to exercise limitation and syncope. Biopacemaking aims to restore pacemaker activity by manipulating gene expression, and approaches utilising HCN channel overexpression have been widely used. We evaluated alternative gene targets for biopacemaking to restore normal SAN pacemaker physiology within bradycardic subsidiary atrial pacemaker (SAP) tissue, using the Na+ /Ca2+ exchanger NCX1, and the transcription factors TBX3 and TBX18. TBX18 expression in SAP tissue restored normal SAN function, as assessed by increased rate (SAN 267.5 ± 13.6 bpm, SAP 144.1 ± 8.6 bpm, SAP-TBX18 214.4 ± 14.4 bpm; P < 0.001), improved heart rate stability (standard deviation of RR intervals fell from 39.3 ± 7.2 ms to 6.9 ± 0.8 ms, P < 0.01; root mean square of successive differences of RR intervals fell from 41.7 ± 8.2 ms to 6.1 ± 1.2 ms, P < 0.01; standard deviation of points perpendicular to the line of identity of Poincaré plots (SD1) fell from 29.5 ± 5.8 ms to 7.9 ± 2.0 ms, P < 0.05) and restoration of isoprenaline response (increases in rates of SAN 65.5 ± 1.3%, SAP 28.4 ± 3.4% and SAP-TBX18 103.3 ± 10.2%; P < 0.001). These changes were driven by a TBX18-induced switch in the dominant HCN isoform in SAP tissue, with a significant upregulation of HCN2 (from 1.01 × 10-5  ± 2.2 × 10-6 to 2.8 × 10-5  ± 4.3 × 10-6 arbitrary units, P < 0.001). Biophysically detailed computer modelling incorporating isoform-specific HCN channel electrophysiology confirmed that the measured changes in HCN abundance could account for the observed changes in beating rates. TBX3 and NCX1 were not effective in accelerating the rate of SAP tissue.

BET 1: Prehospital cardiac troponin testing to 'rule out' acute coronary syndromes using point of care assays

A shortcut review of the literature was carried out to establish whether prehospital point of care (POC) troponin tests are reliable and accurate enough to detect acute coronary syndrome (ACS) in adult patients.Nine papers were found to be relevant to the clinical question following the below-described search strategies. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of those best papers are tabulated. It is concluded that based on the currently available evidence, POC troponin assays are insufficiently sensitive to 'rule out' ACS in the prehospital environment.

The variation in quality and content of patient-focused health information on the Internet for otitis media

BACKGROUND

When symptoms of otitis media appear, parents and patients often access the Internet for health information. We study the content and quality of health information in parent-patient-focused websites for otitis media.

METHODS

We searched the 3 search engines (Google, Yahoo, and Bing) using "otitis media" and "middle ear infection" then reviewed the top 30 hits for each search. We included sites that were focused on providing patient-patient information about otitis media. A variety of instruments were used to assess website content and quality.

RESULTS

In 35 included websites, there was considerable variation in content, with the average site having 11 out of 15 informational items potentially useful to parents and patients on otitis media (range 4-15). Across included websites, the mean DISCERN score was 47 out of 80 (low to medium quality), 16 (46%) were HONcode certified, and 8 (23%) fulfilled all the JAMA benchmark criteria. The average website was written at a 9th/10th-grade reading level.

CONCLUSION

The content and quality of health information for otitis media in parent-and-patient-focused websites is highly variable. Although easy-to-read, high-quality websites with complete content are available, the average website sites is difficult to read without a high school education and is difficult to use. Consideration should be given to adopting a standard approach for presenting disease-specific information to parents and patients.

Successful treatment of gastrointestinal mucormycosis in an adult with acute leukemia: case report and literature review

Mucormycosis has emerged as an important cause of invasive fungal infection in patients with hematologic malignancies. Gastrointestinal mucormycosis is an unusual presentation of this invasive fungal infection, and it causes considerable morbidity and mortality. Such outcomes are due in part to a nonspecific presentation that results in delays in diagnosis and treatment. Successful treatment of gastrointestinal mucormycosis involves surgical debridement and appropriate antifungal therapy.

Megawatt-scale average-power ultrashort pulses in an enhancement cavity

We investigate power scaling of ultrashort-pulse enhancement cavities. We propose a model for the sensitivity of a cavity design to thermal deformations of the mirrors due to the high circulating powers. Using this model and optimized cavity mirrors, we demonstrate 400 kW of average power with 250 fs pulses and 670 kW with 10 ps pulses at a central wavelength of 1040 nm and a repetition rate of 250 MHz. These results represent an average power improvement of one order of magnitude compared to state-of-the-art systems with similar pulse durations and will thus benefit numerous applications such as the further scaling of tabletop sources of hard x rays (via Thomson scattering of relativistic electrons) and of soft x rays (via high harmonic generation).