Advanced mapping of inorganic treatments on porous carbonate stones by combined synchrotron radiation high lateral μXRPD and μXRF

Understanding the effects of consolidating inorganic mineral treatments on carbonate stones of cultural heritage, and on the nature and distribution of newly formed products within the matrix, poses a significant challenge in Heritage Science and Conservation Science. Existing analytical methods often fail to deliver spatial and compositional insights into the newly formed crystalline phases with the appropriate high lateral resolution. In this study, we explore the capabilities and limitations of synchrotron radiation (SR) micro-X-ray powder diffraction (μXRPD) mapping combined with micro-X-ray fluorescence (μXRF) to give insight into compounds formed following the application of ammonium oxalate (AmOx) and diammonium phosphate-based (DAP) solutions on porous carbonate stone. Ultimately, the integration of μXRPD mapping and μXRF analysis proved itself a powerful asset in providing precise qualitative and quantitative data on the newly formed phases, in the case of both calcium oxalates (CaOxs) and calcium phosphates (CaPs), and their complex stratigraphic distribution, thus opening a new route for applications to a more comprehensive study of inorganic treatments applied to carbonate substrates.

Trauma THOMPSON: Clinical Decision Support for the Frontline Medic

INTRODUCTION

U.S. Military healthcare providers increasingly perform prolonged casualty care because of operations in settings with prolonged evacuation times. Varied training and experience mean that this care may fall to providers unfamiliar with providing critical care. Telemedicine tools with audiovisual capabilities, artificial intelligence (AI), and augmented reality (AR) can enhance inexperienced personnel's competence and confidence when providing prolonged casualty care. Furthermore, implementing offline functionality provides assistance options in communications-limited settings. The intent of the Trauma TeleHelper for Operational Medical Procedure Support and Offline Network (THOMPSON) is to develop (1) a voice-controlled mobile application with video references for procedural guidance, (2) audio narration of each video using procedure mentoring scripts, and (3) an AI-guided intervention system using AR overlay and voice command to create immersive video modeling. These capabilities will be available offline and in downloadable format.

MATERIALS AND METHODS

The Trauma THOMPSON platform is in development. Focus groups of subject matter experts will identify appropriate procedures and best practices. Procedural video recordings will be collected to develop reference materials for the Trauma THOMPSON mobile application and to train a machine learning algorithm on action recognition and anticipation. Finally, an efficacy evaluation of the application will be conducted in a simulated environment.

RESULTS

Preliminary video collection has been initiated for tube thoracostomy, needle decompression, cricothyrotomy, intraosseous access, and tourniquet application. Initial results from the machine learning algorithm show action recognition and anticipation accuracies of 20.1% and 11.4%, respectively, in unscripted datasets "in the wild," notably on a limited dataset. This system performs over 100 times better than a random prediction.

CONCLUSIONS

Developing a platform to provide real-time, offline support will deliver the benefits of synchronous expert advice within communications-limited and remote environments. Trauma THOMPSON has the potential to fill an important gap for clinical decision support tools in these settings.

Novel Use of Seraph-100™ Blood Purification Therapy in Heat Stroke

The Seraph-100™ is a purification filter that blunts cytokine storm, providing a more favorable environment to establish immune homeostasis. We present a novel case of compassionate use of Seraph filter in a young, healthy active duty service member with heat injury-induced massive inflammatory response. The patient is a previously healthy 26-year-old male with altered mental status, tachycardia, fever to 40.3 °C, and hypotension after losing consciousness during a 4-mile run. He had a history of one heat injury in college and took no medications or supplements. Initial workup demonstrated hemoconcentration, leukocytosis, and hyperkalemia. He was intubated, received isotonic crystalloid fluid, and was admitted to the intensive care unit. The patient developed vasopressor-resistant shock and multiorgan failure with rhabdomyolysis requiring continuous renal replacement therapy. The addition of the Seraph resulted in improved hemodynamic stability, decreased inflammatory markers, and improved organ function. Approximately 1 week after the final Seraph treatment, the patient had an abrupt massive lower gastrointestinal bleed and was transitioned to comfort care by family. We present the novel use of Seraph in the setting of multiorgan failure and hyperinflammatory state due to heat injury. The patient's vasopressor refractory distributive shock was believed to be secondary to heat stroke-induced massive inflammatory response, leading to a trial of Seraph therapy. This case demonstrates that the Seraph filter has the potential to improve hemodynamic instability and reduce cytokine storm in nonsepsis patients.

80. SARS-CoV-2 infection is associated with decreased reported physical fitness in a US military longitudinal cohort

Background

COVID-19 may have deleterious effects on the fitness of active duty US military service members. We seek to understand the long-term functional consequences of SARS-CoV-2 infection in this critical population, and in other military healthcare beneficiaries.

Methods

The Epidemiology, Immunology, and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) study is a longitudinal cohort study to describe the outcomes of SARS-CoV-2 infection in US Military Health System beneficiaries. Subjects provided information about difficulties experienced with daily activities, exercise, and physical fitness performance via electronic surveys. Subjects completed surveys at enrollment and at 1, 3, 6, 9, and 12 months.

Results

5,910 subjects completed survey fitness questions, 3,244 (55%) of whom tested SARS-CoV-2 positive at least once during the period of observation. Over 75% of subjects were young adults and over half were male (Table 1). 1,093 (34.3%) of SARS-CoV-2-positive subjects reported new or increased difficulty exercising compared to 393 (14.8%) SARS-CoV-2 negative subjects (p < 0.01) (Table 2). The most commonly reported symptoms related to problems with exercise and activities were dyspnea and fatigue. Among the active-duty members who answered the question about their service-mandated physical fitness test scores, 43.2% of SARS-CoV-2-positive participants reported that their scores had worsened in the study period, compared with 24.3% of SARS-CoV-2 negative participants. Among SARS-CoV-2-positive subjects, reports of difficulty exercising and performing daily activities were highest within one month of the first positive test, decreasing in prevalence among the cohort only slightly to 24% and 18%, respectively, at 12 months (Figure 1).

Conclusion

A substantial proportion of military service-members in this cohort have reported impairment of their service-mandated physical fitness scores after COVID-19; this proportion is significantly higher than those who are SARS-CoV-2 negative and persists to 12 months in many; similar complaints were reported among non-active duty. Further objective evaluation of post-COVID fitness impairment in this population is warranted.

Disclosures

Ryan C. Maves, MD, AiCuris: Grant/Research Support|Sound Pharmaceuticals: Grant/Research Support|Trauma Insights, LLC: Advisor/Consultant Julia S. Rozman, n/a, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response David R. Tribble, DrPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Simon Pollett, MBBS, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Mark P. Simons, PhD, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

1056. Correlates of Omicron SARS-CoV-2 viral load: diagnostic and clinical implications

Background

Omicron SARS-CoV-2 infections are associated with less frequent olfactory sensory loss and a predominance of pharyngitis symptoms compared to prior variants, with proposed diagnostic implications. We examined whether such symptomology predicts a higher RNA abundance in the oropharynx. We further investigated how age, symptom-day, vaccination history and clinical severity correlate with viral load to inform clinical prognostication and transmission modeling.

Methods

The EPICC study is a longitudinal cohort of COVID-19 cases enrolled through U.S military medical treatment facilities. Demographic and clinical characteristics were measured with interviews and surveys. Nasopharyngeal (NP), oropharyngeal (OP) and nasal swabs (NS) were collected for SARS-CoV-2 qPCR and sequence genotyping. Multivariable linear regression models were fit to estimate the effect of anatomical site on SARS-CoV-2 RNA abundance (a proxy for viral load), adjusting for sampling time, vaccine history and host age.

Results

We analyzed 77 sequence-confirmed Omicron cases; no BA.2 cases were detected. The median age was 38.8 years. 81.8% were vaccinated and 15.6% cases were hospitalized. 80.0%, 21.8%, and 65.5% reported nasal congestion, loss of smell or taste, and sore throat, respectively. The median RNA abundance was lowest in OP swabs (p < 0.001) (Fig 1). Linear regression confirmed that OP sampling was associated with lower viral load (p < 0.001). We further noted that greater age and symptom-day were independent correlates of viral load (Table 1). By bivariate analysis there was a trend toward lower RNA abundance in vaccinated subjects (p = 0.35). RNA abundance (at any site) was substantially higher in hospitalized (10634 N2 genome equivalents [GE]/reaction) versus outpatient cases (1419 N1 GE/reaction) but this was not statistically significant (p = 0.26). Fig 1.

1066. Precision phenotyping of “long COVID” through machine learning

Background

Characterizing, diagnosing, and caring for “long COVID” patients has proven to be challenging due to heterogenous symptoms and broad definitions of these post-acute sequelae. Here, we take a machine learning approach to identify discrete clusters of long COVID symptoms which may define specific long COVID phenotypes.

Figure 1: (A) Principal component analysis followed by K-means clustering identified three groups of participants. (B) Heatmap depicting three distinct clusters (high values are in red and low value are in blue); Cluster 1 exhibits sensory symptoms (e.g., loss of smell and/or taste), Cluster 2 exhibits fatigue and difficulty thinking (e.g., changes in ability to think) symptoms, and Cluster 3 exhibits difficulty breathing and exercise intolerance symptoms. (C) Clinical and demographic characteristics of 97 military health system beneficiaries by identified clusters

Methods

The Epidemiology, Immunology, and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) study is a longitudinal COVID-19 cohort study with data and biospecimens collected from 10 military treatment facilities and online recruitment. Demographic and clinical characteristics were collected using case report forms and surveys completed at enrollment and at 1, 3, 6, 9, and 12 months. For this analysis, we identified those who reported any moderate to severe persistent symptoms on surveys collected 6-months post-COVID-19 symptom onset. Using the survey responses, we applied principal component analysis (PCA) followed by unsupervised machine learning clustering algorithm K-means to identify groups with distinct clusters of symptoms.

Results

Of 1299 subjects with 6-month survey responses, 97 (7.47%) reported moderate to severe persistent symptoms. Among these subjects, three clusters were identified using PCA (Figure 1A). Cluster 1 is characterized by sensory symptoms (loss of taste and/or smell), Cluster 2 by fatigue and difficulty thinking, and Cluster 3 by difficulty breathing and exercise intolerance (Figure 1B). More than half of these subjects (57%) were female, 64% were 18-44 years old, and 64% had no comorbidities at enrollment (Figure 1C). Those in the sensory symptom cluster were all outpatients at the time of initial COVID-19 presentation (p &lt; 0.01). The difficulty breathing and exercise intolerance symptom-clusters had a higher proportion of older participants (Age group ≥ 45-64) with more comorbidities (CCI ≥ 1-2).

Conclusion

We identified three distinct ‘long COVID’ phenotypes among those with moderate to severe COVID-19 symptoms at 6-months post-symptom onset. With further validation and characterization, this framework may allow more precise classification of long COVID cases, and potentially improve the diagnosis, prognosis, and treatment of post- infectious sequelae.

Disclosures

Ryan C. Maves, MD, AiCuris: Grant/Research Support|Sound Pharmaceuticals: Grant/Research Support|Trauma Insights, LLC: Advisor/Consultant Julia S. Rozman, n/a, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Mark P. Simons, PhD, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response David R. Tribble, DrPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Simon Pollett, MBBS, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

1102. The Host Response to SARS-CoV-2 Infection Differs by Age

Background

Infection with SARS-CoV-2 and the resulting host immune response has been primarily characterized in middle and older aged populations due to a higher incidence of symptoms in these age groups. Due to reduced severity of disease, children were poorly studied and assumed to be less frequently infected compared to older age groups. We measured the viral load and adaptive immune response across the age-spectrum to define the age-dependent viral and host responses.

Methods

From March 2020-March 2022, we enrolled individuals across the age spectrum who presented to U.S. military medical treatment facilities with COVID-19-like symptoms. In this longitudinal cohort study, demographic and clinical data were collected in addition to nasopharyngeal swabs and peripheral blood. Magnitude of viral RNA was measured by quantitative PCR (qPCR) from nasopharyngeal samples and SARS-CoV-2-specific IgG antibodies were measured from blood with multiplex microsphere immunoassays.

Results

4,768 SARS-CoV-2 positive participants were enrolled, among whom 42, 64, 89, 380, 948 and 245 individuals were in age brackets 0-4y, 5-11y, 12-17y, 18-44, 45-64y, and &gt;65y, respectively. Viral load as measured by qPCR was determined to be similar across age groups within the first week post symptom onset. The magnitude of the IgG antibody response against the spike protein was also compared across age groups at early and convalescent time points and was higher in those over the age of 65 years.

Conclusion

Early viral load during acute infection did not correlate with age in individuals who experienced COVID-19. These findings diverge from other respiratory viruses, such as respiratory syncytial virus and influenza where children tend to have higher viral loads. In contrast, the magnitude of the antibody response against the spike protein correlated with older age at acute and convalescent time points. Together our data suggest that the host response against SAR-CoV-2 differs with age and is not associated with the acute viral load. Defining age-dependent immunity against SARS-CoV-2 has the potential to identify key immunologic responses that can be used to optimize treatment and vaccine strategies.

Disclosures

Julia S. Rozman, n/a, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Ryan C. Maves, MD, AiCuris: Grant/Research Support|Sound Pharmaceuticals: Grant/Research Support|Trauma Insights, LLC: Advisor/Consultant Mark P. Simons, PhD, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response David Tribble, MD, DrPH, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response Simon Pollett, MBBS, Astra Zeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

24h SCAI stage reclassification to predict outcome. Insights from the prospective Altshock-2 registry

Background

Cardiogenic shock (CS) includes several phenotypes of congestion or hypoperfusion with heterogenous hemodynamic features. Timely prognostication with scoring tools is warranted to identify patients requiring escalation to mechanical circulatory support (MCS) and to avoid futility.

Purpose

Accordingly, we explored the role of the updated Society for Cardiovascular Angiography and Interventions (SCAI) stages classification on in-hospital mortality using a prospective national registry.

Methods

The Altshock-2 Registry includes 237 patients with CS of all etiologies enrolled between March 2020 and February 2022 in 11 Italian Centers. Patients were classified according to the admission SCAI stages (assigned prospectively and independently updated according to the most recently released version); 24-hour re-assessment was prospectively performed in 201 patients. In-hospital mortality was evaluated for association with admission and 24 hours SCAI stages adjusted for the most relevant clinical covariates.

Results

Of the 237 patients included, 20 (8.4%) had SCAI shock stage B, 132 (55.8%) SCAI stage C, 60 (25.3) SCAI stage D and 25 (10.5%) SCAI stage E. Patients in stage B had the worst reclassification at 24-hours, with 42% of them showing worsened status and only 8% improving. In-hospital mortality was 38%. The revised SCAI stages at baseline were not independently associated with in-hospital mortality, whereas the SCAI classification at 24-h correctly and independently predicted mortality (the rate of in-hospital death was 18% for patients in SCAI shock stage B, 27% for SCAI shock stage C, 64% for SCAI shock stage D, 100% for SCAI shock stage E). At the multivariate analysis (adjusted for age, gender, eGFR, inotropic score and MCS) only SCAI classification at 24-hour evaluation was an independent predictor of in-hospital mortality (OR and 95% CI were, respectively, 3.32, 0.36–30.63, p=0.290 for SCAI stage C and 13.07, 1.69–146.3 for SCAI stage D, with E perfectly predicting because all patients died).

Conclusions

The revised SCAI stage classification may improve prognostication only at 24-hour evaluation. Aggressive treatment (either pharmacological or with MCS escalation) should be tailored in order to achieve prompt clinical improvement within the first 24-hours; refractory SCAI stage E at 24 hours portends dismal prognosis.

Funding Acknowledgement

Type of funding sources: None.

A blemish on bipolar disorder: aggressive behaviour

Introduction

Many studies have searched for an association between violence and psychiatric diagnoses, without providing a confirmative result.

Objectives

We have sought to deepen this topic, analysing different aspects of aggressivity, focusing on a specific diagnosis and its particular phases of illness, and looking for a correlation between psychiatric co-diagnoses and outpatients’ visits adherence.

Methods

We studied 151 bipolar type I inpatients presenting complaint, past medical and family history; we collected information about lifetime hetero/self-aggressive behaviours, irritability, agitation, suicide attempts, alcohol, or substance abuse.

Results

The overall aggressivity in our sample resulted in 11.92% of cases, while the number of aggressive episodes during euthymia decreased to 2.64%, close to the population without psychiatric disorders. Personality disorders and alcohol abuse appeared to be the main risk factors for irritability [Fig. 1]; substance abuse for both irritability and hetero-aggressive behaviour [Fig. 2]. We observed that subjects who displayed better compliance to follow-up visits exhibited a significant lower aggressive behaviour than less adherent subjects. Moreover, our data disconfirm the common conception that correlates the presence of psychotic features to violence.

Conclusions

Studying aggressive in a bipolar population, we observed that the rare episodes of aggressiveness were condensed in active phases of illness and mainly related to alcohol or substance abuse, while violent acts during long periods of wellbeing appear in line with those of the general population. We are confident our data might be helpful in deconstructing the stigma that a psychiatric diagnosis equals to violent behaviour.

Disclosure

No significant relationships.

Clinical efficacy and tolerability of Esketamine: a case series

Introduction

Esketamine is a novel antidepressant approved by the FDA in 2019 in the form of an intranasal spray, recommended for Treatment-Resistant Depression (TRD). The intranasal spray system appears to be more manageable than intravenous ketamine infusion. It contains ketamine’s S- isomer which is four-fold more potent for the NMDA receptor.

Objectives

The aim of this case series is to describe our clinical experience in the use of Esketamine.

Methods

6 TRD patients (3 men; 3 women) were recruited in San Raffaele Turro Hospital from March 2021. All patients (2 bipolar and 4 unipolar) were diagnosed with a Major Depressive Episode according to DSM-5 criteria, resistant to at least two antidepressants. Initially, Esketamine was administrated twice weekly for one month; afterward, it was administrated once weekly for a month; finally, it was administrated once weekly or every two weeks for a month. Clinical scales (HAM-D, YMRS, SSI, HAM-A, MADRS, CADSS) were administrated to assess symptoms and sides effects before and after each administration on a weekly basis.

Results

Three patients out of six showed an improvement in depressive symptoms: two patients had remission (final HAM-D score < 8); one patient had a clinical response (final HAM-D score < 50 % respect baseline value). Three patients withdrew the treatment: two for perceived inefficacy, after 16 and 19 administrations, one for personal reasons.

Conclusions

The use of Esketamine in our TRD patients showed good effectiveness and tolerability but randomized controlled clinical trials are needed to confirm our findings.

Disclosure

No significant relationships.

Resistance or pseudo-resistance?

Introduction

Treatment-Resistant Depression continues to represent a great challenge for clinicians.

Objectives

We investigated patients with history of resistance, assessing prognostic factors, response to treatments, and remission over time.

Methods

We recruited 202 unipolar and bipolar depressed inpatients. According to anamnestic backgrounds, patients were assigned to: A) Non-resistant : responders, with no characteristics of resistance in the current episode. B) Resistant: resistant to two antidepressant trials of adequate doses and duration. C) Pseudo-resistant : non-responders, not classifiable as Resistant because of inadequate trials. During hospitalization, patients were treated by clinical judgment, following a rehabilitation program.

Results

Table 1 Non-resistant (111) Resistant (54) Pseudo-resistant (35) p-value Age 59.1±11.9 63.0±12.6 57.0±11.3 0.036* Episodes of illness 3.8±2.1 4.0±1.9 3.0±1.8 0.036* Personality disorders 27.0% 18.9% 48.6% 0.009** Therapies: 0.014** SSRI 62.4% 40.4% 69.7% SNRI 19.8% 42.3% 15.1% TCA 17.8% 17.3% 15.1% Augmentation 24.3% 38.9% 17.1% 0.05** Remission 76.5% 59.5% 81.2% CvsB:0.045** CvsA:0.587**

On the day of admission, non-responders were 44.5% of the sample, but 39.3% of them did not meet the Resistant criteria, defining the Pseudo-resistant group. Pseudo-resistant differed from others by younger age, fewer illness episodes, higher rate of personality disorders, and different therapies during hospitalization [Fig.1,2,3]. Pseudo-resistant remission rate, significantly greater than Resistant one, was comparable to Non-resistant [Tab.1]. *Kruskal-Wallis Test **Chi-Squared Test

Conclusions

This study outlines a new group of depressed patients that, apparently drug-resistant, displays the same outcome as responders when treated with first-line drugs during hospitalization, certainly taking benefit from the psychoeducational program. Quick recognition of these patients could be crucial to giving optimal care.

Disclosure

No significant relationships.

Manic patients and sleep management: the role of polysomnography in clinical practice

Introduction

Sleep plays a key role in the pathogenesis and clinic of mood disorders. However, few studies have investigated electroencephalographic sleep parameters during the manic phases of Bipolar Disorder (BD).

Objectives

Sleep management is a priority objective in the treatment of the manic phases of BD and the polysomnographic investigation can be a valid tool both in the diagnostic phase and in monitoring clinical progress.

Methods

Twenty-one patients affected by BD, manic phase, were subjected to sleep monitoring via PSG in the acute phase (at the entrance to the ward) and in the resolution phase (near discharge). All participants were also clinically evaluated using Young Manic Rating Scale (YMRS) Pittsburgh Sleep Quality Index (PSQI), Morningness-eveningness Questionnaire (MEQ) at different timepoints.

Results

Over the hospitalization time frame there was an increase in quantity (Total Sleep Time) and an improvement in the quality and effectiveness of sleep (Sleep Efficiency). In addition, from the point of view of the EEG structure, clinical improvement was accompanied by an increase in the percentage of REM sleep.

Conclusions

Sleep monitoring by PSG can be a valuable tool in the clinical setting both in the diagnostic phase, “objectively” ascertaining the amount of sleep, and in the prognostic phase, identifying electroencephalographic characteristics that can predict the patient’s progress and response to drug therapy. The improvement in effectiveness and continuity of sleep and the change in its structure that accompanies the resolution of manic symptoms also testifies how the regularization of the sleep-wake rhythm is to be considered a priority in treating manic phases.

Disclosure

No significant relationships.

Long-term incidence of cardiac device complications with intrathoracic versus extrathoracic venous access: results from the PLACE (Planning Lead Access for Cardiac Electrostimulation) study

Funding Acknowledgements

Type of funding sources: None.

Introduction

Optimal venous access is crucial in successful cardiac device implantation. Most commonly used accesses are subclavian or axillary vein puncture and cephalic vein cutdown. The extrathoracic access has the advantage of reducing the risk of pneumothorax and lead disfunction; thus, this approach is recommended as the first choice approach.

Purpose

The aim of our retrospective registry was to evaluate the incidence of long-term device complications (pneumothorax, lead rupture or displacement, hematoma, infection or bleeding) with different venous approaches in four high-volume centers in Italy.

Methods

We collected data from implantation and device complications during follow up using available electronic records from each center.

Results

We included 4443 patients, mean age 73±11 years. Median follow up was 118 months (IC range 59-198 months). The incidence of any complication was 7.7 %, without difference between intrathoracic and extrathoracic access (7.8% vs 7.7% respectively, p=0.70). However, lead rupture was more frequent in the intrathoracic group (5.3% vs 1.4%, p=0.04).

Conclusion

In experienced, high-volume centers, the use of intrathoracic vein puncture in the case of unsuitable extrathoracic access may represent a safe alternative of venous access in patients undergoing cardiac device implantation, although associated with a higher occurrence of lead rupture.

Subclinical myocardial dysfunction identified with speckle tracking echocardiography in young adults patients recovered from asymptomatic or mildly symptomatic SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial strain assessed with speckle tracking echocardiography is a sensitive marker of cardiac dysfunction, with long-term prognostic value in many cardiac conditions. Both left ventricular global longitudinal strain (LV-GLS) and right ventricular longitudinal strain (RV-LS) were affected by severe SARS-CoV 2 infection but little is known about cardiac involvement in patients with asymptomatic/mild disease that did not require hospitalization. 

Aim

To assess if subclinical myocardial dysfunction could be identified using LV-GLS and RV-LS in patients with previous asymptomatic/mild SARS-CoV 2 infection.

Methods

40 young adults patients (70% males, mean age 24.4 ± 8.4 years), who had a confirmed diagnosis of SARS-CoV-2 infection and were asymptomatic or only mildly symptomatic, without previous known comorbidities/cardiovascular risk factors, were retrospectively included. Patients underwent standard transthoracic echocardiogram and speckle tracking echocardiographic study at least 3 months after diagnosis. A total of 44 age, sex, and body surface area comparable healthy subjects were used as control group. 

Results

LV-GLS was within normal limits but significantly lower in the cases group compared to controls (-22.7 ± 1.6% vs. -25.7 ± 2.3%; p &lt; 0.001). Left ventricular ejection fraction (63.3 ± 4.1% vs 63.9 ± 4.6%; p = 0.5), tricuspid annular plane systolic excursion (24.3 ± 3.7 vs. 23.7 ± 3.3; p = 0.5) and RV-LS (-23.2 ± 3 vs. -23.6 ± 2.7; p = 0.6) were comparable between the two groups.

Moreover, in the infection group, there were 25 subjects (30.1% vs 9.6% in the control group, p &lt; 0.001) with a regional peak systolic strain of the left ventricle below -16% in at least two segments. At multivariable logistic regression corrected for age, gender and body surface area, previous SARS-CoV-2 infection was an independent predictor of reduced LV-GLS values (p &lt; 0.001).

Conclusion

SARS-CoV-2 infection may affect left ventricular deformation in 30% of young adults patients despite an asymptomatic or only mildly symptomatic acute illness. 

Speckle tracking echocardiography could help in early identification of patients with subclinical cardiac involvement. Since long-term complications of COVID-19 are not yet known, myocardial deformation imaging could be important for risk stratification, treatment and planning of long-term follow-up.

Early improvement of cardiac performance after atrial fibrillation direct current cardioversion

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common arrhythmia and one of the most prevalent cardiac disease. Restoring sinus rhythm improves long-term systolic and diastolic function, quality of life and relieve symptoms in patients with symptomatic AF.

Purpose

The aim of the study was to evaluate the early effects of AF direct current cardioversion on myocardial deformation using speckle-tracking echocardiography.

Methods

51 patients with persistent AF who underwent successful direct current cardioversion were enrolled (age: 70 ± 9 years; men: 72.5%). Patients with ischemic, dilatative, hypertrophic cardiomyopaties, valvular heart disease, previous cardiac interventions were excluded from the study. Left ventricular ejection fraction was 55.2 ± 7.0%. A transthoracic echocardiography was performed one day before the successful cardioversion and 6 hours after, employing 2d standard echocardiography and speckle-tracking technique to evaluate left atrial, left ventricular and free-wall right ventricular longitudinal strain.

Results

Restoration of sinus rhythm led to a reduction of the heart rate (83 ± 14 vs 70 ± 13 bpm, p &lt; 0.001). After about six hours from successful AF direct current cardioversion, we highlighted an increase in left ventricular filling pressure estimated with the ratio E/E’ (8.19 ± 0.29 vs 9.34 ± 0.41, p = 0.0016). A significant increase in left atrial longitudinal strain (10.47 ± 0.64% vs 19.76 ± 1.01%, p &lt; 0.001, Figure A) and in left ventricular longitudinal strain (-13.10 ± 0.60% vs -15.86 ± 0.51%, p &lt; 0.001, Figure C) were noticed; also the free wall right ventricular longitudinal strain increased (-12.06 ± 1.16% vs -15.86 ± 1.29%, p = 0.047, Figure B).

Conclusion

Restoring sinus rhythm improves cardiac performance as evidenced by the increase in either left atrial and bi-ventricular longitudinal strain, suggesting an amelioration even if after early time. Abstract Figure

Lumacaftor/ivacaftor in cystic fibrosis: effects on glucose metabolism and insulin secretion

PURPOSE

The question whether the new cystic fibrosis transmembrane conductance regulator (CFTR) modulator drugs aimed at restoring CFTR protein function might improve glucose metabolism is gaining attention, but data on the effect of lumacaftor/ivacaftor treatment (LUMA/IVA) on glucose tolerance are limited. We evaluated the variation in glucose metabolism and insulin secretion in CF patients homozygous for Phe508del CFTR mutation after one-year treatment with LUMA/IVA in comparison to patients with the same genotype who did not receive such treatment.

METHODS

We performed a retrospective case-control study on 13 patients with a confirmed diagnosis of CF, homozygous for the Phe508del CFTR mutation, who received LUMA/IVA for one year (cases) and 13 patients with identical genotype who did not receive this treatment (controls). At the beginning and conclusion of the follow-up, all subjects received a modified 3 h OGTT, sampling at baseline, and at 30 min intervals for plasma glucose, serum insulin, and c-peptide concentrations to evaluate glucose tolerance, and quantify by modeling beta-cell insulin secretion responsiveness to glucose, insulin clearance and insulin sensitivity.

RESULTS

LUMA/IVA did not produce differences in glucose tolerance, insulin secretory parameters, clearance and sensitivity with respect to matched controls over one-year follow-up.

CONCLUSION

We found no evidence of improvements in glucose tolerance mechanisms in patients with CF after one-year treatment with LUMA/IVA.

I'm No Superman: fostering physician resilience through guided group discussion of Scrubs

BACKGROUND

Almost half of trainees experience burnout during their career. Despite the Accreditation Council on Graduate Medical Education (ACGME) recommendation that training programs enact well-being curricula, there is no proven method of addressing this difficult topic.

METHODS

We created a curriculum addressing physician resiliency and well-being, designed for an Internal Medicine Residency Program. This curriculum utilized episodes from a medical television series, Scrubs, to facilitate a monthly, 1-h faculty guided discussion group. We collected informal feedback and abbreviated Maslach Burnout Inventories (aMBI) monthly and conducted a formal focus group after 6 months to gauge its effectiveness.

RESULTS

The curriculum was successfully conducted for 12 months with each session averaging 18-20 residents. Residents reported high satisfaction, stating it was more enjoyable and helpful than traditional resiliency training. 19 of 24 residents (79 %) completed a baseline aMBI, and 17 of 20 residents (85 %) who attended the most recent session completed the 6-month follow-up, showing a non-significant 1-point improvement in all subsets of the aMBI.

CONCLUSIONS

This novel, low-cost, easily implemented curriculum addressed resiliency and burn-out in an Internal Medicine Residency. It was extremely well received and can easily be expanded to other training programs or to providers outside of training.

Basal and stimulated calcitonin for the diagnosis of medullary thyroid cancer: updated thresholds and safety assessment

PURPOSE

Reliable cut-offs for basal (bCT) and calcium stimulated calcitonin (casCT) are needed for an early and accurate diagnosis of medullary thyroid cancer (MTC).

PATIENTS AND METHODS

Fifty-four new patients with nodular goiter were enrolled and analysed together with those previously published by our group for a total of 135 cases. bCT and casCT were measured by a highly sensitive method and the results compared with histological findings. In a subgroup of patients, cardiac rhythm was recorded before and during the calcium test.

RESULTS

In both females (F) and males (M), there was a significant correlation between tumor size and bCT levels (P < 0.001). The receiver operating characteristic plot analyses showed that, for bCT, the new cut-off points able to separate non-MTC from MTC patients were > 30 (F) and > 34 pg/mL (M), whereas the best casCT thresholds were > 79 (F) and > 466 pg/mL (M). bCT was shown to harbour a high accuracy, though some cases were diagnosed only upon stimulation test. Importantly, combining bCT, below or above the cut-offs, with casCT above the cut-offs, all the MTC cases were correctly identified. A reversible sinus bradycardia was observed in 9% of cases during the test.

CONCLUSIONS

Refined cut-offs for bCT and casCT in patients with nodular goiter are reported. Sensitive bCT was shown to have a high accuracy, but the combination with casCT data was needed to identify all MTC cases. The reliability and safety of calcium test strongly favour the routine use of CT determination in nodular thyroid disease.

Industry funding of patient groups: a systematic review

Background

Patient groups play an important role in health care and policy. Concerns have been raised about the financial ties between the pharmaceutical industry and patient groups, because of potential threats to the groups' independence. We conducted a systematic review to synthesise studies that explored pharmaceutical or medical device industry funding of patient groups.

Methods

We searched Medline, Embase, Web of Science, Scopus and Google Scholar (from inception to January 2018). We included observational studies reporting at least one of the following outcomes: prevalence of industry funding; proportion of industry funded patient groups which disclosed information about this funding; association between industry funding and organisational positions on health and policy issues. We carried out duplicate independent data extraction and assessed study quality.

Results

26 cross-sectional studies were included. Fifteen studies assessed the prevalence of industry funding, which ranged from 20% (12/61) to 83% (86/104). The proportion of patient groups which disclosed funding information on their websites was low (27% [95% CI: 24%-31%]). Few patient groups had formal policies governing corporate sponsorship (range from 2% (2/125) to 64% (175/274)). Among the few studies examining funding status versus organisational position, industry sponsored groups tend to hold positions consistent with sponsors' interests.

Conclusions

We found widespread indications of industry funding of patient groups. Transparency of funding is inadequate and the prevalence of policies governing corporate sponsorship is low. Research on policy impact is still limited. Considering the important role that patient groups play in health, strategies to prevent biases that may favour commercial interests above those of patients need to be implemented.

Key messages

Industry funding of patient groups is common in high income countries. Transparency of funding is inadequate and the prevalence of policies governing corporate sponsorship is low. Considering the important role that patient groups play in health care and policy, strategies to prevent biases that may favour commercial interests above those of patients need to be implemented.

Isolated limb perfusion for soft tissue sarcoma: Current practices and future directions. A survey of experts and a review of literature

Soft tissue sarcomas constitute 1% of adult malignant tumors. They are a heterogeneous group of more than 50 different histologic types. Isolated limb perfusion is an established treatment strategy for locally advanced sarcomas. Since its adoption for sarcomas in 1992, after the addition of TNFα, few modifications have been done and although indications for the procedure are essentially the same across centers, technical details vary widely. The procedures mainly involves a 60 min perfusion with melphalan and TNFα under mild hyperthermia, achieving a limb preservation rate of 72-96%; with an overall response rates from 72 to 82.5% and an acceptable toxicity according to the Wieberdink scale. The local failure rate is 27% after a median follow up of 14-31 months compared to 40% of distant recurrences after a follow up of 12-22 months. Currently there is no consensus regarding the benefit of ILP per histotype, and the value of addition of radiotherapy or systemic treatment. Further developments towards individualized treatments will provide a better understanding of the population that can derive maximum benefit of ILP with the least morbidity.

Molecular markers for the classification of cytologically indeterminate thyroid nodules

BACKGROUND

The diagnosis of indeterminate lesions of the thyroid is a challenge in cytopathology practice. Indeed, up to 30% of cases lack the morphological features needed to provide definitive classification. Molecular tests have been developed to assist in the diagnosis of these indeterminate cases. The first studies dealing with the preoperative molecular evaluation of FNA samples focused on the analysis of BRAF^V600E or on the combined evaluation of two or three genetic alterations. The sensitivity of molecular testing was then improved through the introduction of gene panels, which became available for clinical use in the late 2000s. Two different categories of molecular tests have been developed, the 'rule-out' methods, which aim to reduce the avoidable treatment of benign nodules, and the 'rule-in' tests that have the purpose to optimize surgical management. The genetic evaluation of indeterminate thyroid nodules is predicted to improve patient care, particularly if molecular tests are used appropriately and with the awareness of their advantages and weaknesses. The main disadvantage of these tests is the cost, which makes them rarely used in Europe. To overcome this limitation, customized panels have been set up, which are able to detect the most frequent genetic alterations of thyroid cancer.

CONCLUSIONS

In the present review, the most recent available versions of commercial molecular tests and of custom, non-commercial panels are described. Their characteristics and accuracy in the differential diagnosis of indeterminate nodules, namely Bethesda classes III (Atypical follicular lesion of undetermined significance, AUS/FLUS) and IV (Suspicious for follicular neoplasm, FN/SFN) are fully analyzed and discussed.

Use of a mobile application for self-management of pancreatic enzyme replacement therapy is associated with improved gastro-intestinal related quality of life in children with Cystic Fibrosis

BACKGROUND

Most patients with cystic fibrosis (CF) suffer from pancreatic insufficiency (PI), leading to fat malabsorption, malnutrition, abdominal discomfort and impaired growth. Pancreatic enzyme replacement therapy (PERT) is effective, but evidence based guidelines for dose adjustment are lacking. A mobile app for self-management of PERT was developed in the context of the HORIZON 2020 project MyCyFAPP. It contains an algorithm to calculate individual PERT-doses for optimal fat digestion, based on in vitro and in vivo studies carried out in the same project. In addition, the app includes a symptoms diary, educational material, and it is linked to a web tool allowing health care professionals to evaluate patient's data and provide feedback.

METHODS

A 6-month open label prospective multicenter interventional clinical trial was performed to assess effects of using the app on gastro-intestinal related quality of life (GI QOL), measured by the CF-PedsQL-GI (shortened, CF specific version of the Pediatric Quality of Life Inventory, Gastrointestinal Symptoms Module).

RESULTS

One hundred and seventy-one patients with CF and PI between 2 and 18 years were recruited at 6 European CF centers. Self-reported CF-PedsQL-GI improved significantly from month 0 (M0) (84.3, 76.4-90.3) to month 6 (M6) (89.4, 80.35-93.5) (p< 0.0001). Similar improvements were reported by parents. Lower baseline CF-PedsQL-GI was associated with a greater improvement at M6 (p < 0.001).

CONCLUSIONS

The results suggest that the MyCyFAPP may improve GI QOL for children with CF. This tool may help patients to improve self-management of PERT, especially those with considerable GI symptoms.

Haloperidol, risperidone and quetiapine in the treatment of acute severe manic episode in bipolar disorder: The experience at the mood disorder unit in Milan

Introduction

Patients affected by severe manic episode, often with delusional symptoms, are commonly treated with a combination of mood stabilizers, antipsychotics and other sedatives. The choice of a specific drug, dose and term is still debated.

Objectives

A naturalistic study on a sample of 84 inpatients affected by acute severe mania treated with a combination therapy.

Aims

To compare efficacy and tolerability of haloperidol/risperidone/quetiapine in association with lithium and/or valproate.

Methods

Eighty-four bipolar inpatients affected by a manic episode according to DSM-5 criteria. Drugs administered according to our best practice. Clinical course weekly monitored with Young Mania Rating Scale (YMRS) for 4weeks. Extrapiramidal side effects (EPSE) monitored with Saint Hans Rating Scale (SHRS).

Results

Twenty-five men (29.76%) and 59 women (70.24%); mean age 43.37 ± 13.58 years. Mean YMRS score T0 40.27 ± 9.04. Forty-one patients (48.81%) treated with haloperidol (3.4 mg/die); 16 (19.05%) with risperidone (4.3 mg/die); 27 (32.14%) with quetiapine (438 mg/die). The 3 groups showed no difference regarding clinical characteristics and YMRS basal scores. Chi2 analysis confirmed an higher response rate (50% of reduction of YMRS final score compared to T0) with haloperidol (χ2 = 14.88; P = 0.00). The repeated-measures model analysis showed a significant decrease (P < 0.05) in YMRS scores in haloperidol vs. risperidone vs. quetiapine patients for all time points from second week. No statistical difference for EPSE was found.

Conslusions

We suggest that haloperidol could be advisable in the treatment of severe mania, with rapid efficacy, even with low doses. Occurrence of EPSE was not considerable during the acute treatment. Studies with a larger sample size, randomization, fixed doses, double blind design are needed.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Acute Respiratory Failure

Acute respiratory distress syndrome (ARDS) is a condition affecting critically ill patients, characterized by pulmonary inflammation and defects in oxygenation due to either direct or indirect injury to the lungs. These guidelines will define the diagnosis and management of ARDS, particularly among combat casualties and patients in the deployed environment. The cornerstone of management of ARDS involves maintaining adequate oxygenation while avoiding further pulmonary injury through lung-protective ventilation. Additional strategies for advanced respiratory failure, such as prone positioning, neuromuscular blockade, and extracorporeal membrane oxygenation will be reviewed here as well. Particularly important to the care of the patient with ARDS in the deployed environment is a familiarity with the challenges and indications for transport/aeromedical evacuation.