The genomic evolutionary dynamics and global circulation patterns of respiratory syncytial virus

Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infection in young children and the second leading cause of infant death worldwide. While global circulation has been extensively studied for respiratory viruses such as seasonal influenza, and more recently also in great detail for SARS-CoV-2, a lack of global multi-annual sampling of complete RSV genomes limits our understanding of RSV molecular epidemiology. Here, we capitalise on the genomic surveillance by the INFORM-RSV study and apply phylodynamic approaches to uncover how selection and neutral epidemiological processes shape RSV diversity. Using complete viral genome sequences, we show similar patterns of site-specific diversifying selection among RSVA and RSVB and recover the imprint of non-neutral epidemic processes on their genealogies. Using a phylogeographic approach, we provide evidence for air travel governing the global patterns of RSVA and RSVB spread, which results in a considerable degree of phylogenetic mixing across countries. Our findings highlight the potential of systematic global RSV genomic surveillance for transforming our understanding of global RSV spread.

A type I interferon regulatory network for human plasmacytoid dendritic cells based on heparin, membrane-bound and soluble BDCA-2

Plasmacytoid dendritic cells (pDCs) produce type I interferons (IFNs) after sensing viral/bacterial RNA or DNA by toll-like receptor (TLR) 7 or TLR9, respectively. However, aberrant pDCs activation can cause adverse effects on the host and contributes to the pathogenesis of type I IFN-related autoimmune diseases. Here, we show that heparin interacts with the human pDCs-specific blood dendritic cell antigen 2 (BDCA-2) but not with related lectins such as DCIR or dectin-2. Importantly, BDCA-2-heparin interaction depends on heparin sulfation and receptor glycosylation and results in inhibition of TLR9-driven type I IFN production in primary human pDCs and the pDC-like cell line CAL-1. This inhibition is mediated by unfractionated and low-molecular-weight heparin, as well as endogenous heparin from plasma, suggesting that the local blood environment controls the production of IFN-α in pDCs. Additionally, we identified an activation-dependent soluble form of BDCA-2 (solBDCA-2) in human plasma that functions as heparin antagonist and thereby increases TLR9-driven IFN-α production in pDCs. Of importance, solBDCA-2 levels in the serum were increased in patients with scrub typhus (an acute infectious disease caused by Orientia tsutsugamushi) compared to healthy control subjects and correlated with anti-dsDNA antibodies titers. In contrast, solBDCA-2 levels in plasma from patients with bullous pemphigoid or psoriasis were reduced. In summary, this work identifies a regulatory network consisting of heparin, membrane-bound and solBDCA-2 modulating TLR9-driven IFN-α production in pDCs. This insight into pDCs function and regulation may have implications for the treatment of pDCs-related autoimmune diseases.

Adamantinoma-Like Ewing Sarcoma Mimicking Merkel Cell Carcinoma in the Parotid Gland: A Diagnostic Pitfall

Adamantinoma-like Ewing sarcoma (ALES) is a newly described rare entity, which shows EWSR1::FLI1 rearrangement characteristic of Ewing sarcoma. This can be diagnostically challenging as it manifests histologically with epithelial differentiation and has diffuse keratin expression as well as p40 and p60 positivity. We hereby report a case of ALES in a 33-year-old woman with a past medical history of breast carcinoma who presented with a right-sided parotid mass. CT scan of the neck showed a heterogenous mass within the superficial lobe, measuring 17 mm in diameter for which the patient underwent superficial parotidectomy. Histopathology of the mass revealed a malignant neoplasm formed of solid nests, cords and sheets of cells with minimal cytoplasm and monomorphic nuclei with granular chromatin and indistinct nucleoli. Brisk mitotic activity and tumor necrosis were also present. The tumor showed strong and diffuse reactivity for pankeratin (clone AE1/AE3) and keratin 20, both in a dot-like pattern, raising the suspicion of metastatic Merkel cell carcinoma; however, molecular studies showed EWSR1::FLI1 rearrangement, supporting the diagnosis of ALES. In summary, it is prudent to have knowledge about this entity to avoid its misdiagnosis as other malignancies of the head and neck region which exhibit a different clinical course, prognosis and hence treatment modalities.

Guideline for the management of myasthenic syndromes

Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.

Orientia tsutsugamushi: A life between escapes

The life cycle of the mite-borne, obligate intracellular pathogen Orientia tsutsugamushi (Ot), the causative agent of human scrub typhus, differs in many aspects from that of other members of the Rickettsiales order. Particularly, the nonlytic cellular exit of individual Ot bacteria at the plasma membrane closely resembles the budding of enveloped viruses but has only been rudimentarily studied at the molecular level. This brief article is focused on the current state of knowledge of escape events in the life cycle of Ot and highlights differences in strategies of other rickettsiae.

Definitive and Salvage Radiotherapy Compared to Other Modalities for Laryngeal Carcinoma in Situ

PURPOSE/OBJECTIVE(S)

We sought to analyze survival endpoints for laryngeal carcinoma in situ (CIS) undergoing definitive radiotherapy (RT) compared to other modalities.

MATERIALS/METHODS

Usingour prospectively maintained head and neck cancer database, we identified laryngeal CIS patients treated between 6/2001 and 12/2021. We excluded low-grade dysplasia, CIS with any synchronous invasive squamous cell carcinoma (SCC) within 3 months of the initial CIS biopsy and cases with inadequate follow up. Patients were offered either definitive RT, CO2/KTP laser ablation, photodynamic therapy (PDT) or any sort of therapeutic excision. After first line treatment, follow-up includes visits every 3-6 months with laryngoscopy and biopsies as appropriate. For recurrent CIS beyond 6 months of first line treatment, we reported salvage therapies received and long-term outcomes were reported. Using Kaplan-Meier curves and log-rank test we investigated recurrence free (RFS), progression to invasive SCC free (IFS) and overall (OS) survival across treatment groups. Patients managed with salvage RT were compared to first line RT recipients.

RESULTS

Atotal of 85 CIS cases were included: median age 65 years (IQR: 55-74), 73 males (85%) and 70 white (82.4%). 86% had a history of smoking with median pack year of 38 (IQR: 20-55) and 66% had a history of alcohol use. CIS was glottic in most of the cases (90.6%: 66% unilateral, 21% bilateral & 13% involved commissure); with only 9.4% in the supraglottic region. RT was used in 49.4% (n = 42) after biopsy (55%) or surgery (45%) with median dose of 63 Gy/28 fractions, mainly by 3D conformal RT (76%). The remaining 50.6% (n = 43) got therapeutic excision alone (commonly microflap excision) (46.5%), CO2/KTP laser (32.6%) or PDT (20.9%). Demographics and clinicopathological details were non-different between RT and non-RT patients except for Charlson comorbidity index: median 2 (IQR 1-3) in non-RT vs 1 (IQR 0-2) in 1ry RT; p = 0.007. After a median follow-up of 4.8 years (IQR 3.5), 51.8% had recurrent disease, 21.2% progressed to invasive SCC and 9.4% had laryngectomies mainly for invasive SCC after RT. First line RT had improved 2-(83% vs 39%) and 5-(74% vs 22%) year RFS vs non-RT therapies (p<0.001). Nevertheless, 2- and 5-year IFS (89% vs 98% and 80% vs 79%) and OS (92% vs 93% and 81% vs 77%) were non-significant among both (p>0.05 for all). Among non-RT cases with CIS recurrences, 12/35 (34%) had salvage RT. Following RT, salvage RT patients had similar 2- and 5-year RFS (81% vs 83% and 81% vs 74%) and IFS (81% vs 89% and 81% vs 80%) compared to first line RT (p>0.05 for all). All cases with CIS recurrences were salvaged successfully with 100% living with no CIS at latest follow-up.

CONCLUSION

Laryngeal CIS can be treated with a wide range of modalities including 1ry RT which has better recurrence free survival. Nevertheless, non-RT recurrent CIS can be salvaged successfully with many options including RT with equivalent long-term results.

Impaired systemic nucleocapsid antigen clearance in severe COVID-19

The circulating nucleocapsid (NCP) antigen of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is detectable in coronavirus disease-2019 (COVID-19) patients. To better understand the biology of disease severity, we investigated NCP clearance kinetics in hospitalized COVID-19 patients. Serum NCP was quantified using a commercial NCP-specific enzyme-linked immunoassay in hospitalized COVID-19 patients (n = 63) during their hospital stay. Results were correlated to COVID-19 disease severity, inflammation parameters, antibody response, and results of SARS-CoV-2 PCR from nasopharyngeal swabs. We demonstrate that NCP antigen levels in serum remained elevated in 21/45 (46.7%) samples from patients in intensive care units (ICU) after >8 days postdiagnosis. The proportion of ICU patients with detectable antigenemia declined only gradually from 84.6% to 25.0% over several weeks. This was in contrast to complete NCP clearance in all non-ICU patients after 8 days, and also in contrast to mucosal clearance of the virus as measured by PCR. Antigen clearance was associated with higher IgG against S1 but not NCP. Clearance of NCP antigenemia is delayed in >40% of severely ill COVID-19 patients. Thus, NCP antigenemia detected after 8 days post COVID-19 diagnosis is a characteristic of patients requiring intensive care. Prospective trials should further investigate NCP antigen clearance kinetics as a mechanistic biomarker.

Nirsevimab binding-site conservation in respiratory syncytial virus fusion glycoprotein worldwide between 1956 and 2021: an analysis of observational study sequencing data

BACKGROUND

Nirsevimab is an extended half-life monoclonal antibody to the respiratory syncytial virus (RSV) fusion protein that has been developed to protect infants for an entire RSV season. Previous studies have shown that the nirsevimab binding site is highly conserved. However, investigations of the geotemporal evolution of potential escape variants in recent (ie, 2015-2021) RSV seasons have been minimal. Here, we examine prospective RSV surveillance data to assess the geotemporal prevalence of RSV A and B, and functionally characterise the effect of the nirsevimab binding-site substitutions identified between 2015 and 2021.

METHODS

We assessed the geotemporal prevalence of RSV A and B and nirsevimab binding-site conservation between 2015 and 2021 from three prospective RSV molecular surveillance studies (the US-based OUTSMART-RSV, the global INFORM-RSV, and a pilot study in South Africa). Nirsevimab binding-site substitutions were assessed in an RSV microneutralisation susceptibility assay. We contextualised our findings by assessing fusion-protein sequence diversity from 1956 to 2021 relative to other respiratory-virus envelope glycoproteins using RSV fusion protein sequences published in NCBI GenBank.

FINDINGS

We identified 5675 RSV A and RSV B fusion protein sequences (2875 RSV A and 2800 RSV B) from the three surveillance studies (2015-2021). Nearly all (25 [100%] of 25 positions of RSV A fusion proteins and 22 [88%] of 25 positions of RSV B fusion proteins) amino acids within the nirsevimab binding site remained highly conserved between 2015 and 2021. A highly prevalent (ie, >40·0% of all sequences) nirsevimab binding-site Ile206Met:Gln209Arg RSV B polymorphism arose between 2016 and 2021. Nirsevimab neutralised a diverse set of recombinant RSV viruses, including new variants containing binding-site substitutions. RSV B variants with reduced susceptibility to nirsevimab neutralisation were detected at low frequencies (ie, prevalence <1·0%) between 2015 and 2021. We used 3626 RSV fusion-protein sequences published in NCBI GenBank between 1956 and 2021 (2024 RSV and 1602 RSV B) to show that the RSV fusion protein had lower genetic diversity than influenza haemagglutinin and SARS-CoV-2 spike proteins.

INTERPRETATION

The nirsevimab binding site was highly conserved between 1956 and 2021. Nirsevimab escape variants were rare and have not increased over time.

FUNDING

AstraZeneca and Sanofi.

T-cell-derived TNF-α and a cluster of immunological parameters from plasma allow a separation between SARS-CoV-2 convalescent versus vaccinated elite athletes

Guidelines for medical clearing after SARS-CoV-2 infection in elite athletes do not include T-cell immunity aspects despite its relevance in the course of COVID-19 disease. Therefore, we aimed to analyze T-cell-related cytokines before and after in-vitro activation of CD4⁺ T-cells. We sampled professional indoor sports athletes at medical clearing after SARS-CoV-2 infection obtaining clinical, fitness data, and serological data including CD4⁺ T-cell cytokines. All data were analyzed by principal component analysis and 2 × 2 repeated measures ANOVA. CD4⁺ T-cells were sampled for cell culture activation with anti-CD3/anti-CD28 tetramers. At medical clearing, CD4⁺ T-cells from convalescent athletes secreted increased levels of TNF-α 72 h after in-vitro activation compared to vaccinated athletes. IL-18 levels in plasma were elevated and a cluster of parameters differentiated convalescent from vaccinated athletes by 13 parameters at the timepoint of medical clearing. All clinical data indicate infection is resolved, while increased TNF-α may reflect altered proportions of peripheral T-cells as a hangover of infection.

Efficiency analysis of rapid antigen test based SARS-CoV-2 in hospital contact tracing and screening regime: test characteristics and cost effectiveness

In the context of the current SARS-CoV-2 pandemic, reliable and cost-efficient screening and testing strategies are crucial to prevent disease transmission and reduce socioeconomic losses. To assess the efficiency of a rapid antigen test (RAT)-based SARS-CoV-2 contact-tracing and screening regime, we conducted a retrospective analysis of RAT and polymerase chain reaction (PCR) test data over a 1-year period, assessed test characteristics and estimated cost-effectiveness. The RAT had a sensitivity of 70.2% overall and 89.3% for people with a high risk of infectivity. We estimated inpatient treatment and quarantined healthcare worker costs of over € 5860.83, whereas the cost of identifying one SARS-CoV-2 positive person by RAT for our patient cohort was € 1210.75. In contrast, the estimated respective PCR cost was € 5043.32. Therefore, a RAT-based contract tracing and screening regime may be an efficient and cost-effective way to contribute to the early identification and prevention of SARS-CoV-2 transmission.

Serum proteomics hint at an early T-cell response and modulation of SARS-CoV-2-related pathogenic pathways in COVID-19-ARDS treated with Ruxolitinib

Background

Acute respiratory distress syndrome (ARDS) in corona virus disease 19 (COVID-19) is triggered by hyperinflammation, thus providing a rationale for immunosuppressive treatments. The Janus kinase inhibitor Ruxolitinib (Ruxo) has shown efficacy in severe and critical COVID-19. In this study, we hypothesized that Ruxo's mode of action in this condition is reflected by changes in the peripheral blood proteome.

Methods

This study included 11 COVID-19 patients, who were treated at our center's Intensive Care Unit (ICU). All patients received standard-of-care treatment and n = 8 patients with ARDS received Ruxo in addition. Blood samples were collected before (day 0) and on days 1, 6, and 10 of Ruxo treatment or, respectively, ICU admission. Serum proteomes were analyzed by mass spectrometry (MS) and cytometric bead array.

Results

Linear modeling of MS data yielded 27 significantly differentially regulated proteins on day 1, 69 on day 6 and 72 on day 10. Only five factors (IGLV10-54, PSMB1, PGLYRP1, APOA5, WARS1) were regulated both concordantly and significantly over time. Overrepresentation analysis revealed biological processes involving T-cells only on day 1, while a humoral immune response and complement activation were detected at day 6 and day 10. Pathway enrichment analysis identified the NRF2-pathway early under Ruxo treatment and Network map of SARS-CoV-2 signaling and Statin inhibition of cholesterol production at later time points.

Conclusion

Our results indicate that the mechanism of action of Ruxo in COVID-19-ARDS can be related to both known effects of this drug as a modulator of T-cells and the SARS-CoV-2-infection.

What makes a supraglottic airway device effective?

Ahead of Print article withdrawn by publisher.

Contemporary diagnostics for medically relevant fastidious microorganisms belonging to the genera Anaplasma, Bartonella, Coxiella, Orientia, and Rickettsia

Many of the human infectious pathogens—especially the zoonotic or vector-borne bacteria—are fastidious organisms that are difficult to cultivate because of their strong adaption to the infected host culminating in their near-complete physiological dependence on this environment. These bacterial species exhibit reduced multiplication rates once they are removed from their optimal ecological niche. This fact complicates the laboratory diagnosis of the disease and hinders the detection and further characterization of the underlying organisms, e.g. at the level of their resistance to antibiotics due to their slow growth. Here, we describe the current state of microbiological diagnostics for five genera of human pathogens with a fastidious laboratory lifestyle. For Anaplasma spp., Bartonella spp., Coxiella burnetii, Orientia spp. and Rickettsia spp., we will summarize the existing diagnostic protocols, the specific limitations for implementation of novel diagnostic approaches and the need for further optimization or expansion of the diagnostic armamentarium. We will reflect upon the diagnostic opportunities provided by new technologies including mass spectrometry and next-generation nucleic acid sequencing. Finally, we will review the (im)possibilities of rapidly developing new in vitro diagnostic tools for diseases of which the causative agents are fastidiously growing and therefore hard to detect.

A comparison of face-to-face, brochure- and video-assisted anesthesia interviews: a qualitative randomized survey study

BACKGROUND

Previous studies showed mixed results for patient satisfaction by supplementing the pre-anesthetic assessment with written or audio-visual materials. We hypothesize that an audio-visual aid or a brochure in addition to face-to-face interview, leads to improved patient satisfaction and shortens the pre-anesthetic assessment duration.

METHODS

We randomly assigned 1051 patients scheduled for pre-anesthetic assessment to three different groups: face-to-face pre-anesthetic interview alone (Group 1), videos before the interview (Group 2), and brochure before the interview (Group 3). All patients were asked to complete a post-interview questionnaire assessing patient satisfaction, knowledge gain, prior experience with anesthesia, and quality of supplementary media.

RESULTS

The use of additional materials immediately before the pre-anesthetic interview did increase the overall patient satisfaction (F(2, 1003) = 3.10, p <0 .05, ƞ² = 0.006) but not the interview satisfaction (F(2, 1011) = 0.756, p >0 .05) nor information gain (procedure explanations F(2, 987) = 0.400, p > 0.05) or quality of answered questions (F(2, 1029) = 0.769, p > 0.05). A statistically significant effect on interview satisfaction (F(13,996) = 5.15, p < 0.01., ƞ² = 0.063), overall satisfaction (F(13,988) = 4.25, p < 0.01., ƞ² = 0.053) and given explanations (F(13, 972) = 3.132, p < 0.001, ƞ² = 0.04) was associated with the explanation of different anesthetic techniques by the provider. No differences of response quality between the anesthesiologists was found (F(13, 1014) = 1.494, p > 0.05).

CONCLUSIONS

Additional information imparted in the form of an educational brochure or videos immediately before the pre-anesthetic assessment and interview does not lead to higher patient satisfaction.

Introduction of a Power Law Time-Temperature Equivalent Formulation for the Description of Thermorheologically Simple and Complex Behavior

In this work, a conceptual framework is suggested for analyzing thermorheologically simple and complex behavior by using just one approach. Therefore, the linear relation between master time and real time which is required in terms of the time-temperature superposition principle was enhanced to a nonlinear equivalent relation. Furthermore, we evaluate whether there is any relation among well-known existing time-temperature equivalent formulations which makes it possible to generalize different existing formulations. For this purpose, as an example, the power law formulation was used for the definition of the master time. The method introduced here also contributes a further framework for a unification of established time-temperature equivalent formulations, for example the time-temperature superposition principle and time-temperature parameter models. Results show, with additional normalization conditions, most of the developed time-temperature parameter models can be treated as special cases of the new formulation. In the aspect of the arrow of time, the new defined master time is a bended arrow of time, which can help to understand the corresponding physical meaning of the suggested method.

The janus-kinase inhibitor ruxolitinib in SARS-CoV-2 induced acute respiratory distress syndrome (ARDS)

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes COVID-19 (coronavirus disease 2019), which is associated with high morbidity and mortality, especially in elder patients. Acute respiratory distress syndrome (ARDS) is a life-threatening complication of COVID-19 and has been linked with severe hyperinflammation. Dexamethasone has emerged as standard of care for COVID-19 associated respiratory failure. In a non-randomized prospective phase II multi-center study, we asked whether targeted inhibition of Janus kinase-mediated cytokine signaling using ruxolitinib is feasible and efficacious in SARS-CoV-2- induced ARDS with hyperinflammation. Sixteen SARS-CoV-2 infected patients requiring invasive mechanical ventilation for ARDS were treated with ruxolitinib in addition to standard treatment. Ruxolitinib treatment was well tolerated and 13 patients survived at least the first 28 days on treatment, which was the primary endpoint of the trial. Immediate start of ruxolitinib after deterioration was associated with improved outcome, as was a lymphocyte-to-neutrophils ratio above 0.07. Together, treatment with the janus-kinase inhibitor ruxolitinib is feasible and might be efficacious in COVID-19 induced ARDS patients requiring invasive mechanical ventilation. The trial has been registered under EudraCT-No.: 2020-001732-10 and NCT04359290.

CCR2 Deficiency Impairs Ly6Clo and Ly6Chi Monocyte Responses in Orientia tsutsugamushi Infection

Orientia (O.) tsutsugamushi, the causative agent of scrub typhus, is a neglected, obligate intracellular bacterium that has a prominent tropism for monocytes and macrophages. Complications often involve the lung, where interstitial pneumonia is a typical finding. The severity of scrub typhus in humans has been linked to altered plasma concentrations of chemokines which are known to act as chemoattractants for myeloid cells. The trafficking and function of monocyte responses is critically regulated by interaction of the CC chemokine ligand 2 (CCL2) and its CC chemokine receptor CCR2. In a self-healing mouse model of intradermal infection with the human-pathogenic Karp strain of O. tsutsugamushi, we investigated the role of CCR2 on bacterial dissemination, development of symptoms, lung histology and monocyte subsets in blood and lungs. CCR2-deficient mice showed a delayed onset of disease and resolution of symptoms, higher concentrations and impaired clearance of bacteria in the lung and the liver, accompanied by a slow infiltration of interstitial macrophages into the lungs. In the blood, we found an induction of circulating monocytes that depended on CCR2, while only a small increase in Ly6Chi monocytes was observed in CCR2-/- mice. In the lung, significantly higher numbers of Ly6Chi and Ly6Clo monocytes were found in the C57BL/6 mice compared to CCR2-/- mice. Both wildtype and CCR2-deficient mice developed an inflammatory milieu as shown by cytokine and inos/arg1 mRNA induction in the lung, but with delayed kinetics in CCR2-deficient mice. Histopathology revealed that infiltration of macrophages to the parenchyma, but not into the peribronchial tissue, depended on CCR2. In sum, our data suggest that in Orientia infection, CCR2 drives blood monocytosis and the influx and activation of Ly6Chi and Ly6Clo monocytes into the lung, thereby accelerating bacterial replication and development of interstitial pulmonary inflammation.

The EAR Motif in the Arabidopsis MADS Transcription Factor AGAMOUS-Like 15 Is Not Necessary to Promote Somatic Embryogenesis

AGAMOUS-like 15 (AGL15) is a member of the MADS domain family of transcription factors (TFs) that can directly induce and repress target gene expression, and for which promotion of somatic embryogenesis (SE) is positively correlated with accumulation. An ethylene-responsive element binding factor-associated amphiphilic repression (EAR) motif of form LxLxL within the carboxyl-terminal domain of AGL15 was shown to be involved in repression of gene expression. Here, we examine whether AGL15's ability to repress gene expression is needed to promote SE. While a form of AGL15 where the LxLxL is changed to AxAxA can still promote SE, another form with a strong transcriptional activator at the carboxy-terminal end, does not promote SE and, in fact, is detrimental to SE development. Select target genes were examined for response to the different forms of AGL15.

Guided vs. non-guided insertion of Ambu AuraGain™ in edentulous patients

BACKGROUND

Supraglottic airway devices perform more poorly and have lower oropharyngeal leak pressure in edentulous patients than in patients with teeth. The Ambu Aura Gain is a newer second generation supraglottic airway device.

OBJECTIVE

This randomized clinical trial assessed the oropharyngeal leak pressure in edentulous patients using the Ambu Aura Gain with a gastric tube for insertion guidance and without insertion guidance.

MATERIAL AND METHODS

Patients with ASA (American Society of Anesthesiology) physical status I-III were recruited. Primary outcome was oropharyngeal leak pressure after insertion. Secondary outcome parameters were oropharyngeal leak pressure 15 min and 30 min after insertion, insertion time, insertion attempts and glottis view through flexible fiberscope.

RESULTS

In this study 72 patients aged between 51 and 90 years (mean 73 years) were randomly allocated to the "with guidance" (n = 36) or the "without guidance" group (n = 36). Mean (SD) oropharyngeal leak pressure in "with guidance" and "without guidance" group was 24 cm H₂O and 24 cm H₂O (ns), respectively. A difference was found in mean insertion time with guidance versus without guidance group 52 s (45 s) vs. 26 s (15 s) (p < 0.001). No difference was found in any of the other secondary outcome parameters.

CONCLUSION

A guided insertion technique does not improve oropharyngeal leak pressure of the Ambu AuraGain™ in edentulous patients. As the only difference is an increase in insertion time this technique is of no benefit for this population.

Development and characterization of an indirect ELISA to detect SARS-CoV-2 spike protein-specific antibodies

The current Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) pandemic is a public health emergency of international concern. Sensitive and precise diagnostic tools are urgently needed. In this study, we developed a SARS-CoV-2 spike (S1) protein enzyme-linked immunosorbent assay (ELISA) to detect SARS-CoV-2-specific antibodies. The SARS-CoV-2 S1 ELISA was found to be specific [97.8% (95% CI, 96.7% - 98.5%)], reproducible and precise (intra-assay coefficient of variability (CV) 5.3%, inter-assay CV 7.9%). A standard curve and the interpolation of arbitrary ELISA units per milliliter served to reduce the variability between different tests and operators. Cross-reactivity to other human coronaviruses was addressed by using sera positive for MERS-CoV- and hCoV HKU1-specific antibodies. Monitoring antibody development in various samples of twenty-three and single samples of twenty-nine coronavirus disease 2019 (COVID−19) patients revealed seroconversion and neutralizing antibodies against authentic SARS-CoV-2 in all cases. The comparison of the SARS-CoV-2 (S1) ELISA with a commercially available assay showed a better sensitivity for the in-house ELISA.

The results demonstrate a high reproducibility, specificity and sensitivity of the newly developed ELISA, which is suitable for the detection of SARS-CoV-2 S1 protein-specific antibody responses.

•

A highly sensitive and specific SARS-CoV-2 S1 ELISA was developed.

•

A standard curve is included to reduce variability between assays and operators.

•

Excellent intra-assay coefficient of variability (CV) 5.3%, inter-assay CV 7.9%.

•

Good correlation to the virus neutralization test VNT₁₀₀.

Retinal Ependymoma: A Rare Extra-Axial Presentation

Introduction/Objective

Ependymomas are well-demarcated and slow-growing neuroepithelial neoplasms that comprise 3–9% of primary CNS tumors. The vast majority of ependymomas arise either intracranially, mostly in children, or in the spinal cord and are associated with ependymal lining. Histologic hallmarks are perivascular pseudorosettes, ependymal rosettes and alternating zones of nuclear crowding and nuclear free zones composed of coarse cell processes. In high grade ependymomas increased mitoses, necrosis and nuclear pleomorphism may be seen.

Methods

We present the case of a 63-year-old woman in with a past medical history of retinopathy of prematurity, glaucoma and right eye enucleation. She presented with a painful blind left eye refractory to medical treatment and subsequently underwent left eye enucleation.

Results

On histologic examination, an incidental retinal ependymoma was identified. The neoplastic cells were fusiform and had long coarsely fibrillar cell processes. Characteristic periodicity of nuclear crowding and scarcity was observed. In places, neoplastic cell processes extended radially to delicate and sometimes hyalinized blood vessels, forming so-called perivascular pseudorosettes. Definite ependymal rosettes were not recognized in the examined sections. Stigmata of chronicity were found, such as ischemic type necrosis, blood vessels with dystrophic calcifications and foci of ossification replete with fibroadipose tissue in the marrow spaces.

The neoplastic cells labeled with antibodies against glial fibrillary acidic protein (GFAP), thus confirming glial lineage in the neoplastic cell. Additionally, there was scattered intracytoplasmic expression of epithelial membrane antigen (EMA) in a dot-like or circular pattern. The latter is well described in ependymomas and often used to support the diagnosis.

Conclusion

Ependymomas rarely occur at extracranial sites, such as the chest, abdomen and pelvis. We are presenting the fourth case of retinal ependymoma reported in literature. The tumor had classical immunomorphologic findings.

Salivary gland hyalinizing clear-cell carcinoma with cutaneous metastasis: A rare and deceptive tumor

Clear-cell carcinoma (CCC) is an uncommon malignant tumor of minor salivary glands. It characteristically has a low-grade morphology and a favorable outcome by most reports. An EWSR1-ATF1 fusion can be detected in the majority of cases. We present a rare case of CCC, which had an aggressive course with the development of cutaneous metastases. Practicing dermatopathologists should be aware of this tumor given its low-grade appearance and histopathologic resemblance to other primary cutaneous adnexal and metastatic neoplasms.

Real-world dosimetric comparison between CyberKnife SBRT and HDR brachytherapy for the treatment of prostate cancer

PURPOSE

High-dose-rate (HDR) brachytherapy (BRT) and stereotactic body radiotherapy (SBRT) are currently the two treatment options for definitive radiotherapy of prostate cancer, employing extreme hypofractionation. There are only very few studies comparing their dosimetry, all using computed tomography for treatment planning. We present here a real-word dosimetric comparison between SBRT and ultrasound-based virtual HDR-BRT, with both imaging modalities coming from the same patient.

METHODS AND MATERIALS

Patients with prostate cancer on a prospective trial evaluating the toxicity of robotic-based SBRT were treated to a total dose of 35 Gy in 5 fractions. Fifteen patients were included in this analysis. During ultrasound-based fiducial implantation, a three-dimensional data set as in real HDR-BRT procedure was acquired. Virtual HDR-BRT plans were generated and various organs at risk and prostate dosimetric parameters were evaluated.

RESULTS

Concerning prostate, SBRT achieved significant higher D₉₈, V₃₅ Gy, and V_37.5 Gy coverage, whereas virtual HDR-BRT achieved significant higher intratumoral doses reflected in the V₄₂ Gy and V_52.5 Gy. Rectal D_max, V₃₆ Gy, and V₂₉ Gy were significantly lower for HDR-BRT with no difference as for V₁₈ Gy. SBRT was significantly inferior regarding bladder dosimetry (D_max, V₃₆ Gy, V₁₈ Gy), whereas urethra D_max and V₄₄ Gy where significantly higher at the expense of HDR-BRT.

CONCLUSIONS

HDR-BRT is superior regarding rectum and bladder dosimetry, with SBRT being superior relative to urethra dosimetry. A randomized study is warranted to define the best extreme hypofractionated modality.

Global molecular diversity of RSV - the "INFORM RSV" study

Background

Respiratory syncytial virus (RSV) is a global cause of severe respiratory morbidity and mortality in infants. While preventive and therapeutic interventions are being developed, including antivirals, vaccines and monoclonal antibodies, little is known about the global molecular epidemiology of RSV. INFORM is a prospective, multicenter, global clinical study performed by ReSViNET to investigate the worldwide molecular diversity of RSV isolates collected from children less than 5 years of age.

Methods

The INFORM study is performed in 17 countries spanning all inhabited continents and will provide insight into the molecular epidemiology of circulating RSV strains worldwide. Sequencing of > 4000 RSV-positive respiratory samples is planned to detect temporal and geographical molecular patterns on a molecular level over five consecutive years. Additionally, RSV will be cultured from a subset of samples to study the functional implications of specific mutations in the viral genome including viral fitness and susceptibility to different monoclonal antibodies.

Discussion

The sequencing and functional results will be used to investigate susceptibility and resistance to novel RSV preventive or therapeutic interventions. Finally, a repository of globally collected RSV strains and a database of RSV sequences will be created.

0255 Comparing Performance, Fatigue and Sleepiness Between Short-Haul And Ultra Long-Haul Commercial Airline Operations

Introduction

Safety performance indicators (SPIs) are used in aviation to determine if a trip that is non-compliant with federal regulations is safe to fly. Exemptions to regulations can be granted if a safety case demonstrates that the SPIs for an alternative means of compliance (AMOC; i.e., a trip outside regulations) are non-inferior to SPIs for a safety standard operation (SSO; i.e. a trip compliant with regulations). Through this process, it has previously been suggested that ultra-long-range flights are non-inferior to long-range flights due to increased sleep opportunity. We determined whether SPIs for non-compliant ultra-long-range (ULR) trips are non-inferior to those for compliant short-haul (SH) trips.

Methods

Performance, fatigue, and sleepiness were assessed at the top of descent (TOD) of flight segments using the Psychomotor Vigilance Task (PVT), Samn-Perelli (SP) fatigue scale, and Karolinska Sleepiness Scale (KSS), respectively. Data were analyzed using non-inferiority testing. Two different ULR trips with different TOD times (ULR trip 1: n=81; ULR trip 2: n=22) were compared to two types of SH trips, including one trip that contained one or more all-night flights (SH trip 1: n=48) and one trip with zero all-night flights (SH trip 2: n=47).

Results

Non-inferiority was found for the SPIs at most comparison points. For example, comparing the SPIs for ULR trip 2 and SH trip 1 at final TOD, non-inferiority was found for all SPIs. In contrast, comparing the SPIs for ULR trip 1 and SH trip 1 at final TOD, non-inferiority was found for SP and KSS, while non-inferiority for PVT was only suggested.

Conclusion

The findings suggest that the AMOC trips are as safe as or safer than the compliant SH trips. This raises questions regarding the structure of SH trips and how differences in the structures play a role in performance, fatigue and sleepiness.

Support

United Airlines

0244 Examining Pilot Safety Performance Indicators at Critical Phases of Flight Across Multiple Flight Legs During Commercial Airline Trips

Introduction

Prior simulation and operational studies have started to address whether the number of consecutive flight segments negatively affects cognitive performance, fatigue, and sleepiness, without reaching a clear consensus. This study expands this literature by determining whether there are significant changes in cognitive performance, fatigue, and sleepiness at critical phases of flight across multiple flight segments, while accounting for the number of segments, flight direction, trip day, and time-of-day.

Methods

Fifty commercial airline pilots were studied. Each pilot flew two separate short-haul trips, each ranging from 1–4 days and 1–10 flight segments. Cognitive performance, fatigue, and sleepiness were assessed at top-of-climb (TOC) and top-of-descent (TOD) of each flight segment and each trip day. Cognitive performance, fatigue, and sleepiness were assessed using Psychomotor Vigilance Task (PVT) speed, Samn-Perelli (SP) ratings, and Karolinska Sleepiness Scale (KSS) ratings, respectively. Data were analyzed using Wilcoxon t-tests and verified using ANOVAs.

Results

Mean PVT speed (Cohen’s d =0.57), SP ratings (Cohen’s d = 0.73), and KSS ratings (Cohen’s d = 0.63) were significantly worse at TOD than TOC (p &lt; 0.001); and, significantly varied across flight segments (p&lt;0.001). Cognitive performance, fatigue, and sleepiness were consistently and significantly degraded around the fifth flight segment, improved around the sixth to eighth flights segments, and were subsequently degraded around the eighth to tenth flight segments.

Conclusion

The results indicate that cognitive performance, fatigue, and sleepiness vary across flight segments, trip day, and phase of flight. Results suggest that these safety performance indices degrade after five segments, and further degrade after eight flight segments. The results presented could be used to inform future airline scheduling and regulation.

Support

This work has been supported by United Airlines.

Determinants of burden in caregivers of patients with exacerbating schizophrenia

Purpose

Restriction in involuntary hospital admission and reduced lengths of inpatient stay increase burden on relatives of individuals with schizophrenia. This study aims at assessing the relationship between caregiver burden and behavioural disturbances of the affected, e.g. threats, nuisances, but also substance use and aggression. Two weeks before the last hospitalisation of the affected are considered as being the most burdensome period for relatives.

Subjects and methods

Sixty-four relatives of schizophrenic patients were assessed by the semi-structured “Interview for Measuring the Burden on the Family”. Subscales and total scales of burden were calculated. Predictors were identified by regression analyses.

Results

The most important predictor of burden is burden in the relationship between caregiver and the affected representing the changes in the relationship occurring in acute illness. Threats, nuisances, time spent with the affected, and burden due to restricted social life and leisure activities were additional predictors, but not aggression or substance abuse. Eighty-five percent of the cases could be assigned correctly.

Discussion and conclusions

To better encounter burden, relatives should learn to cope with disturbing behaviour of and altered relationship to the affected, but also with their own needs. Finally, relatives must be included in the decision whether or not an affected person should be hospitalised.

A case report of a late left atrial appendage perforation 4 months after occluder implant: reason for or caused by a resuscitation?

Background

Atrial fibrillation (AF) is a common disease and can lead to cardioembolic stroke. Stroke prevention according to the CHA₂DS₂VASc score is achieved via oral anticoagulation. In recent years, interventional occlusion of the left atrial appendage (LAA) has become a common alternative. Besides showing non-inferiority in large trials compared with warfarin interventional LAA occlusion can lead to serious adverse events with most of them occurring peri-interventionally.

Case summary

A 75-year-old man with AF and recurrent gastrointestinal bleedings was referred for an interventional closure of the LAA. The intervention was successful with an ABBOTT^® Amulet device. Four months later, the patient had to be resuscitated. Return of spontaneous circulation occurred after 10 min. On hospital arrival, echocardiography revealed a pericardial tamponade and 2 L of blood were drained. A coronary angiogram revealed a lesion with active leakage of contrast agent in the proximal circumflex artery. The patient was transferred to the cardiac surgery department immediately. Intra-operatively a perforation of the tissue at the basis of the LAA close to the left main coronary artery was discovered. The occluder was excised and the LAA was closed by endocardial sutures.

Discussion

In this report, we review the literature concerning interventional LAA occlusion and the reported cases of LAA perforation. Retrospectively, it remains unclear whether the perforation caused the resuscitation or was induced by it. To our knowledge, this is the first reported case of a laceration of a coronary artery by an occlusion device.

Impact of smoking on pathological features in oral cavity squamous cell carcinoma

OBJECTIVES

We sought to determine whether smokers with oral cavity squamous cell carcinoma (OCSCC) have tumors with more adverse pathological features than in nonsmokers and whether or not these are predictive of outcomes.

MATERIALS AND METHODS

We retrospectively identified 163 patients with American Joint Committee on Cancer stages I-IVa OCSCC diagnosed between 2005 and 2015 and treated with curative intent. A pathological risk score (PRS) was calculated using the National Comprehensive Cancer Network adverse risk factors: positive margin, extracapsular extension of lymph node metastases, pT3 or pT4 primary, N2 or N3 nodal disease, perineural invasion, and lymphovascular space invasion. Multivariable models were constructed to determine the independent predictors of overall survival (OS), recurrence-free survival (RFS), and PRS.

RESULTS

A total of 108 (66.26%) were smokers and 55 nonsmokers. Three-year actuarial OS and RFS were 62% and 68% in smokers and 81% and 69% in nonsmokers, respectively (P = 0.06 and P = 0.63). Smokers were more likely to have advanced disease stage and tumors with aggressive pathological features than nonsmokers. Smokers had significantly worse PRS (mean ± standard deviation; 2.38 ± 2.19, median; 2.00) than nonsmokers (0.89 ± 1.21, 0.00) (P < 0.001). Older age, higher PRS, and smoking status were independent predictors of OS. Smoking or PRS did not predict for worse RFS. On multivariate analysis, independent predictors of PRS were smoking status and grade (P < 0.001).

CONCLUSION

In patients with OCSCC, smokers have more aggressive disease as evidenced by more adverse pathological features than nonsmokers. Moreover, smoking is an independent predictor of OS but not RFS. The PRS is a significant predictor of OS and needs validation in the future studies.

Lead, zinc, and copper redistributions in soils along a deposition gradient from emissions of a Pb-Ag smelter decommissioned 100 years ago

Sourcing and understanding the fate of anthropogenic metals in a historical contamination context is challenging. Here we combined elemental and isotopic (Pb, Zn, Cu) analyses with X-ray Absorption Spectroscopy (XAS) measurements (Zn) to trace the fate, in undisturbed soil profiles, of historical metal contamination emitted by a 167-year-old Pb-Ag smelter decommissioned 100 years ago located in the Calanques National Park (Marseilles, France). Lead isotopic measurements show that entire soil profiles were affected by 74 years of Pb emissions up to ~7 km from the smelter under the main NNW wind, and indicate particulate transfer down to 0.8 m at depth. This vertical mobility of anthropogenic Pb contrasts with previous studies where Pb was immobilized in surface horizons. The contribution of anthropogenic Pb to the total Pb concentration in soil was estimated at 95% in surface horizons, and 78% in the deepest horizons. Zinc isotopic signatures of past emissions that are enriched in light isotopes compared to the natural geological background (-0.70 ± 0.04‰ and -0.15 ± 0.02‰, respectively), were detected only in the surface horizons of the studied soils. Using XAS analyses, we showed that anthropogenic Zn was transformed and immobilized in surface horizons as Zn-Layered Double Hydroxide, thus favoring the enrichment in heavy isotopes in these surface horizons. No clear evidence of copper contamination by the smelter was found and Cu isotopes point to a bedrock origin and a natural distribution of Cu concentrations.

Evaluation of historical atmospheric pollution in an industrial area by dendrochemical approaches

We conducted a dendrochemical study in order to evaluate the exposure of territories and populations to different types of pollutants and to characterise the history of pollution in one of the most intensely industrialised areas of Europe: the industrial port zone of Fos, also heavily urbanised. To perform the study, two tree species have been selected, Pinus halepensis and Populus nigra, on a rural plot located roughly 20 km away from the industrial harbour, an urban plot located in the city of Fos-sur-Mer and an industrial plot. Our study indicated that poplar was a more relevant model for the dendrochemical studies, exhibiting a higher bioaccumulation capacity than pine except for Hg, Sb and Mn. Moreover, thanks to this work, we observed significant exposure of the trees in the urban and industrial areas to As, Cd, Co, Cu, Mo, Sb, Zn, Al, Ca, and Mg, highlighting the exposure of the territory and populations living in the vicinity of the industrial harbour. The temporal variability of the concentrations measured in the tree rings corresponds to the increasing industrialisation of the territory as well as to the evolution of the industrial processes. Thus, this project highlighted the exposure of the Gulf of Fos to atmospheric emissions (industrial, road and urban) of the industrial harbour as well as the changes over time. It also pointed out the relevance of using dendrochemistry to measure atmospheric exposure of metals and metalloids and its temporal variability.

Oropharyngeal leak pressure of the LMA Protector™ vs the LMA Supreme™; a prospective, randomized, controlled clinical trial

BACKGROUND

Clinical characteristics such as oropharyngeal leak pressure (OLP) and ventilation peak pressure are important factors for successful use of supraglottic airway devices in general anaesthesia. We hypothesized that the LMA Protector™ compared to the LMA Supreme™ may develop a higher OLP, which could be of clinical significance.

METHODS

Ninety-six patients were randomized to the LMA Protector™ or LMA Supreme™ groups. We measured oropharyngeal leak pressure within 5 minutes after insertion of the supraglottic airway device with a standardized cuff pressure at 60 cm H₂ O. Secondary parameters, such as insertion time of the supraglottic airway device, the number of attempts inserting the supraglottic airway device and the gastric tube, volume of gastric contents, and maximum airway pressure, as well as pulse oximetry throughout the operation were measured. Further, blood staining after removal of the supraglottic airway device and postoperative airway morbidity 3 hours after surgery were determined.

RESULTS

The mean difference of oropharyngeal leak pressure was 5.2 (95% CI 2.8-7.6), ie, 30.9 (7.4) cmH₂ O for the LMA Protector™ vs 25.6 (4.4) cmH₂ O for the LMA Supreme™ (P < 0.001; mean(SD)). Similarly, there was a mean difference between OLP and maximal ventilation peak pressure 5.6 (95% CI 3.1-8.2) ie 19.6 (7.7) cmH₂ O for the LMA Protector™ vs 14.0 (4.4) cmH₂ O for the LMA Supreme™ (P < 0.001). No difference was found between the groups for other secondary parameters, as well as postoperative airway morbidity.

CONCLUSION

The LMA Protector™ enabled a higher OLP compared to the LMA Supreme™. This finding may be important for patients requiring a higher peak pressure for sufficient supraglottic airway device ventilation.

Fiberoptic intubation of severely obese patients through supraglottic airway: A prospective, randomized trial of the Ambu® AuraGain™ laryngeal mask vs the i-gel™ airway

INTRODUCTION

Airway management in severely obese patients remains a challenging issue for anaesthetists and may lead to life-threatening situations. Supraglottic airway devices, such as the i-gel™ or the AuraGain™, were developed, with the possibility to ventilate the patient or use them as a conduit for endotracheal intubation.

METHODS

In our randomized prospective trial, we hypothesized a 10 seconds faster fiberoptic trans-device intubation time through the AuraGain™ laryngeal mask compared to the i-gel™ laryngeal mask in severely obese patients. We randomly assigned 44 patients to the AuraGain or i-gel group and measured trans-device intubation time after 5 minutes of successful ventilation through the device. Secondary parameters relating to the trans-device intubation success, oropharyngeal leak pressure, and parameters regarding insertion of the supraglottic airway devices were measured. Postoperative airway morbidity was determined 5 hours after surgery.

RESULTS

Mean (SD) intubation time was 55.7 (5.8) seconds for the AuraGain™ vs 54.1 (8.5) for i-gel™ mask (95% CI -2.7 to 5.9; P = 0.474), respectively, on a mean body mass index (BMI) of 39.4 kg/m² in the AuraGain™ group vs 38.9 kg/m² in i-gel™ group. No difference could be found in the other studied parameters.

CONCLUSIONS

Time for intubation through both supraglottic airway devices was similar. Attributed to fast possibility of securing the airway with both supraglottic airway devices, we believe that both, AuraGain™ and i-gel™, can be a good alternative in the airway management in obese patients.

The ProSeal Laryngeal Mask Airway in Prone Patients: A Retrospective Audit of 245 Patients

The use of the classic laryngeal mask airway (classic LMA) in the prone position is controversial, but the ProSeal laryngeal mask airway (ProSeal LMA) maybe more suitable as it forms a better seal and provides access to the stomach. In the following retrospective audit, we describe our experience with the insertion of, and maintenance of anaesthesia with, the ProSeal LMA in 245 healthy adults in the prone position by experienced users. The technique involved (1) the patient adopting the prone position with the head to the side and the table tilted laterally; (2) preoxygenation to end-tidal oxygen >90%; (3) induction of anaesthesia with midazolam/alfentanil/propofol; (4) facemask ventilation (5) a single attempt at digital insertion and if unsuccessful a single attempt at laryngoscope-guided, gum elastic bougie-guided insertion; (6) gastric tube insertion; (7) maintenance of anaesthesia with sevoflurane/O2/N2O; (8) volume controlled ventilation at 8-12 ml/kg; (9) emergence from anaesthesia in the supine position; and (10) removal of the ProSeal LMA when awake. Facemask ventilation was always successful. ProSeal LMA insertion was successful in all patients: 237 with digital insertion and eight with bougie-guided insertion. Ventilation was successful in all patients. Gastric tube insertion was successful in all patients. Correctable partial airway obstruction occurred in three patients, but there was no hypoxia, hypercapnoea, displacement, regurgitation, gastric insufflation or airway reflex activation. Our findings suggest that the insertion of and maintenance of anaesthesia with the ProSeal LMA is feasible in the prone position by experienced users.

Residual Protein Contamination of ProSeal™ Laryngeal Mask Airways after Two Washing Protocols

The risk of prion protein cross-infection has focussed attention on the potential hazards of protein contamination of re-usable medical devices. This study determined the frequency of protein contamination of ProSeal™ laryngeal mask airways (PLMA) after two cleaning procedures and tested the hypothesis that the combination of hand- and machine-washing removes protein contamination more effectively than hand-washing alone. After clinical use fifty-four PLMAs were randomly allocated to be washed by hand or by hand then machine. All PLMAs were then autoclaved at 134°C for 4 minutes. After processing, each PLMA was immersed in a 1.2% solution of erythrosin B and examined for uptake of stain. The site (outer surface, bowl and edges of the cuff, airway and drain tube, finger strap) and severity (nil/mild/moderate/severe) of staining was scored by a blinded observer. There were no differences in the site or severity of staining between the two cleaning procedures. Staining was detected on 89% of PLMAs that were hand-washed and 78% of PLMAs that were hand-, then machine-washed (P=0.27). When staining occurred, it was mild in 98%, moderate in 2% and was never severe. Staining was more frequent on the edge than at any other location (all comparisons: P≤0.01). The strap never had any staining. We conclude that residual contamination of PLMAs with protein deposits is common even when machine-washing is used to augment hand-washing before autoclaving. The infection risk associated with these deposits remains to be determined.

Gum Elastic Bougie-guided Insertion of the ProSeal™ Laryngeal Mask Airway

We tested the hypothesis that gum elastic-bougie-guided insertion of the ProSeal™ Laryngeal Mask Airway is more frequently successful than introducer tool guided insertion after failed digital insertion. One hundred anaesthetized patients (ASA 1-2, aged 18 to 80 years) were randomized for the second insertion attempt using either the gum elastic bougie-guided or introducer tool techniques. The bougie-guided technique involved priming the drain tube with the bougie, placing the bougie in the oesophagus using laryngoscope guidance, digital insertion along the palato-pharyngeal curve, and bougie removal. The introducer tool technique involved attaching the introducer tool, single-handed rotation along the palatopharyngeal curve, and introducer tool removal. Failed insertion was classified as (i) failed passage into the pharynx, (ii) malposition, or (iii) ineffective ventilation. Any blood staining was documented. Insertion was more frequently successful (50/50 vs 15/50, P=0.0002) and faster (35±17s vs 54±45s, mean±SD, P=0.006) with the bougie-guided technique. All failed insertions with the introducer tool technique were successful with the bougie-guided technique. The aetiology of failed insertion was similar for the digital and introducer tool techniques in 94% (33/35) of patients. There was no blood staining on the bougie, laryngoscope or introducer tool at removal, but blood staining was more common on the Proseal laryngeal mask airway with the introducer tool technique (9/50 vs 2/50, P=0.03). We conclude that the gum elastic bougie-guided insertion has a higher success rate and causes less trauma than the insertion tool insertion technique after failed digital insertion of the Proseal Laryngeal Mask Airway.

Positive Pressure versus Pressure Support Ventilation at Different Levels of PEEP Using the ProSeal™ Laryngeal Mask Airway

We compared positive pressure ventilation with pressure support ventilation at different levels of positive end expiratory pressure (PEEP) using the ProSeal laryngeal mask airway (PLMA). Forty-two anaesthetized adults (ASA 1-2, aged 19 to 63 years) underwent positive pressure ventilation and then pressure support ventilation each with PEEP set at 0, 5 and 10 cmH2O in random order. Pressure support ventilation was with the inspired tidal volume (VTInsp) set at 7 ml/kg and the respiratory rate adjusted to maintain the end-tidal CO2 (ETCO2) at 40 mmHg. Pressure support ventilation was with pressure support set at 5 cmH2O above PEEP and initiated when inspiration produced a 2 cmH2O reduction in airway pressure. Tidal volumes were similar during positive pressure and pressure support ventilation with PEEP, but were higher for the former without PEEP. Respiratory rate and peak inspiratory flow rate were higher during pressure support than positive pressure ventilation (all P<0.001). Peak airway pressure (Ppaw), mean airway pressure (Mpaw), peak expiratory flow rate, and expired airway resistance were lower during pressure support than positive pressure ventilation (all P<0.001). With PEEP set at 10 cmH2O, ETCO2 was lower for pressure support than positive pressure ventilation. During positive pressure ventilation, there was an increase in Ppaw, Mpaw and dynamic compliance (Cdyn) with increasing levels of PEEP (all P<0.01). During pressure support ventilation, there was an increase in inspired and expired tidal volume, Ppaw, peak inspiratory and expiratory flow rates and Cdyn, and a reduction in ETCO2, work of breathing, and expired airway resistance with increasing levels of PEEP (all P<0.01). There were no differences in SpO2, non-invasive mean arterial pressure, heart rate or leak fraction. We conclude that pressure support ventilation provides equally effective gas exchange as positive pressure ventilation during PLMA anaesthesia with or without PEEP at the tested settings. During pressure support, PEEP increases ventilation and reduces work on breathing without increasing leak fraction.

Differential regulation of transcription by the NURR1/NUR77 subfamily of nuclear transcription factors

NURR1 is an orphan member of the nuclear receptor superfamily of transcription factors that shares close sequence homology to the orphan nuclear receptor and immediate early gene product NUR77(NGF1 beta). The physiological role of NURR1 has not been established in mammalian cells. However, the observation that NURR1 and NUR77 interact with at least one common enhancer element (AAAAGGTCA), together with their partly overlapping but differential expression patterns in mammalian tissues, suggests that these proteins may have both shared and independent transcription regulatory functions. To identify potential target genes that may be regulated by NURR1, we analyzed its DNA binding properties to potential cis-acting enhancer elements. Using point mutagenesis of the AAAAGGTCA motif, we have identified three additional sequences that bind specifically to both NURR1 and NUR77, one of which serves as a functional enhancer element. Comparative analysis of the transcription regulatory properties of NURR1 and NUR77 indicates that the proteins can display opposing transregulatory activities that are influenced by the specific cis-acting sequences to which they bind. Our results indicate that the transcriptional responses of specific target genes to the NURR1/NUR77 subfamily may be differentially regulated by the relative cellular levels of NURR1 and NUR77 and influenced by the specific enhancer sequences that mediate their activity. Finally, we have identified several potential target genes of neuronal and neuroendocrine origin whose promoters contain this element.

Piscine mycobacteriosis - Involvement of bacterial species and reflection in pathology

INTRODUCTION

Piscine mycobacteriosis is a lethal disease with zoonotic potential, found worldwide in both fresh and marine fish. More than 20 strains of Mycobacterium spp. are known to persist in fish so far, but the pathogenicity is currently unknown for most of them. However, M. marinum is reported as one of the most pathogenic agents for fish and is involved in zoonotic cases. We examined 47 different cases from two zoological gardens, where fish tuberculosis was identified or previously suspected during the last ten years. We collected PCR and sequencing data, which were then compared to previously collected clinical data and pathology. The clinical signs caused by Mycobacterium spp. were similar in all the cases, except for cases infected by M. marinum, which lacked the presence of skin lesions. Lesions seen in histology caused by M. marinum tended to be more acute and severe compared lesions caused by other Mycobacterium spp. The majority of M. marinum cases have been reported within marine fish. In contrast to previous studies we detected this species to be the predominant bacteria present within freshwater fish. Interestingly, we detected M. holsaticum in one of the seawater systems used in this project, being the first report of this Mycobacterium species shown to be present in a fish.

Repeated in-field radiosurgery for locally recurrent brain metastases: Feasibility, results and survival in a heavily treated patient cohort

Purpose

Stereotactic radiosurgery (SRS) is an established primary treatment for newly diagnosed brain metastases with high local control rates. However, data about local re-irradiation in case of local failure after SRS (re-SRS) are rare. We evaluated the feasibility, efficacy and patient selection characteristics in treating locally recurrent metastases with a second course of SRS.

Methods

We retrospectively evaluated patients with brain metastases treated with re-SRS for local tumor progression between 2011 and 2017. Patient and treatment characteristics as well as rates of tumor control, survival and toxicity were analyzed.

Results

Overall, 32 locally recurrent brain metastases in 31 patients were irradiated with re-SRS. Median age at re-SRS was 64.9 years. The primary histology was breast cancer and non-small-cellular lung cancer (NSCLC) in respectively 10 cases (31.3%), in 5 cases malignant melanoma (15.6%). In the first SRS-course 19 metastases (59.4%) and in the re-SRS-course 29 metastases (90.6%) were treated with CyberKnife^® and the others with Gamma Knife. Median planning target volume (PTV) for re-SRS was 2.5 cm³ (range, 0.1–37.5 cm³) and median dose prescribed to the PTV was 19 Gy (range, 12–28 Gy) in 1–5 fractions to the median 69% isodose (range, 53–80%). The 1-year overall survival rate was 61.7% and the 1-year local control rate was 79.5%. The overall rate of radiological radio-necrosis was 16.1% and four patients (12.9%) experienced grade ≥ 3 toxicities.

Conclusions

A second course of SRS for locally recurrent brain metastases after prior local SRS appears to be feasible with acceptable toxicity and can be considered as salvage treatment option for selected patients with high performance status. Furthermore, this is the first study utilizing robotic radiosurgery for this indication, as an additional option for frameless fractionated treatment.

Collaborative and partnership research for improvement of health and social services: researcher's experiences from 20 projects

BACKGROUND

Getting research into policy and practice in healthcare is a recognised, world-wide concern. As an attempt to bridge the gap between research and practice, research funders are requesting more interdisciplinary and collaborative research, while actual experiences of such processes have been less studied. Accordingly, the purpose of this study was to gain more knowledge on the interdisciplinary, collaborative and partnership research process by investigating researchers' experiences of and approaches to the process, based on their participation in an inventive national research programme. The programme aimed to boost collaborative and partnership research and build learning structures, while improving ways to lead, manage and develop practices in Swedish health and social services.

METHODS

Interviews conducted with project leaders and/or lead researchers and documentation from 20 projects were analysed using directed and conventional content analysis.

RESULTS

Collaborative approaches were achieved by design, e.g. action research, or by involving practitioners from several levels of the healthcare system in various parts of the research process. The use of dual roles as researcher/clinician or practitioner/PhD student or the use of education designed especially for practitioners or 'student researchers' were other approaches. The collaborative process constituted the area for the main lessons learned as well as the main problems. Difficulties concerned handling complexity and conflicts between different expectations and demands in the practitioner's and researcher's contexts, and dealing with human resource issues and group interactions when forming collaborative and interdisciplinary research teams. The handling of such challenges required time, resources, knowledge, interactive learning and skilled project management.

CONCLUSIONS

Collaborative approaches are important in the study of complex phenomena. Results from this study show that allocated time, arenas for interactions and skills in project management and communication are needed during research collaboration to ensure support and build trust and understanding with involved practitioners at several levels in the healthcare system. For researchers, dealing with this complexity takes time and energy from the scientific process. For practitioners, this puts demands on understanding a research process and how it fits with on-going organisational agendas and activities and allocating time. Some of the identified factors may be overlooked by funders and involved stakeholders when designing, performing and evaluating interdisciplinary, collaborative and partnership research.

Clinical Results of Mean GTV Dose Optimized Robotic-Guided Stereotactic Body Radiation Therapy for Lung Tumors

Introduction

We retrospectively evaluated the efficacy and toxicity of gross tumor volume (GTV) mean dose optimized stereotactic body radiation therapy (SBRT) for primary and secondary lung tumors with and without robotic real-time motion compensation.

Materials and methods

Between 2011 and 2017, 208 patients were treated with SBRT for 111 primary lung tumors and 163 lung metastases with a median GTV of 8.2 cc (0.3–174.0 cc). Monte Carlo dose optimization was performed prioritizing GTV mean dose at the potential cost of planning target volume (PTV) coverage reduction while adhering to safe normal tissue constraints. The median GTV mean biological effective dose (BED)₁₀ was 162.0 Gy₁₀ (34.2–253.6 Gy₁₀) and the prescribed PTV BED₁₀ ranged 23.6–151.2 Gy₁₀ (median, 100.8 Gy₁₀). Motion compensation was realized through direct tracking (44.9%), fiducial tracking (4.4%), and internal target volume (ITV) concepts with small (≤5 mm, 33.2%) or large (>5 mm, 17.5%) motion. The local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity were analyzed.

Results

Median follow-up was 14.5 months (1–72 months). The 2-year actuarial LC, PFS, and OS rates were 93.1, 43.2, and 62.4%, and the median PFS and OS were 18.0 and 39.8 months, respectively. In univariate analysis, prior local irradiation (hazard ratio (HR) 0.18, confidence interval (CI) 0.05–0.63, p = 0.01), GTV/PTV (HR 1.01–1.02, CI 1.01–1.04, p < 0.02), and PTV prescription, mean GTV, and maximum plan BED₁₀ (HR 0.97–0.99, CI 0.96–0.99, p < 0.01) were predictive for LC while the tracking method was not (p = 0.97). For PFS and OS, multivariate analysis showed Karnofsky Index (p < 0.01) and tumor stage (p ≤ 0.02) to be significant factors for outcome prediction. Late radiation pneumonitis or chronic rip fractures grade 1–2 were observed in 5.3% of the patients. Grade ≥3 side effects did not occur.

Conclusion

Robotic SBRT is a safe and effective treatment for lung tumors. Reducing the PTV prescription and keeping high GTV mean doses allowed the reduction of toxicity while maintaining high local tumor control. The use of real-time motion compensation is strongly advised, however, well-performed ITV motion compensation may be used alternatively when direct tracking is not feasible.