A closed surgical intensive care unit organization improves cardiac surgical patient outcomes

Background

Intensive care unit (ICU) organization is a critical factor in optimizing patient outcomes. ICU organization can be divided into "OPEN" (O) and "CLOSED" (C) models, where the specialist or intensivist, respectively, assumes the role of primary physician. Recent studies support improved outcomes in closed ICUs, however, most of the available data is centered on ICUs generally or on subspecialty surgical patients in the setting of a subspecialized surgical intensive care unit (SICU). We examined the impact of closing a general SICU on patient outcomes following cardiac and ascending aortic surgery.

Methods

A retrospective cohort of patients following cardiac or ascending aortic surgery by median sternotomy was examined at a single academic medical center one year prior and one year after implementation of a closed SICU model. Patients were divided into "OPEN" (O; n=53) and "CLOSED" (C; n=73) cohorts.

Results

Cohorts were comparable in terms of age, race, and number of comorbid conditions. A significant difference in male gender (O: 60.4% vs. C: 76.7%, P=0.049), multiple procedure performed (O: 13.21% vs. C: 35.62%, P=0.019), and hospital readmission rates was detected (O: 39.6% vs. C: 9.6%, P=0.0003). Using a linear regression model, a closed model SICU organization decreased SICU length of stay (LOS). Using a multivariate logistic regression, being treated in a closed ICU decreased a patient's likelihood of having an ICU LOS greater than 48 hours.

Conclusions

Our study identified a decreased ICU LOS and hospital readmission in cardiac and ascending aortic patients in a closed general SICU despite increased procedure complexity. Further study is needed to clarify the effects on surgical complications and hospital charges.

Incidence of Red Cell Antibody Formation Following Massive Transfusion Protocol: Experience of a Single Institution

BACKGROUND

Injured patients in hemorrhagic shock have a survival benefit with massive transfusion protocol (MTP). While there are many published studies on the transfusion management of massively bleeding patients, the risk of alloimmunization in patients that have received products during an MTP activation is relatively unknown. Therefore, we sought to determine the frequency of new antibody formation in MTP patients that received blood products from an uncrossmatched megapack.

MATERIALS AND METHODS

We conducted a retrospective data review of patients who underwent an MTP activation for trauma resuscitation between May 2014 and July 2020. Data were collected from patients who met the following criteria: MTP was activated, the patients received at least one unit of packed red blood cells, one unit of fresh frozen plasma, one unit of platelets, and had a repeat type and screen within 6 weeks of transfusion. These inclusion criteria resulted in 28 patients over the 6-year timeframe.

RESULTS

Overall, the risk of alloimmunization secondary to MTP is 3.6% in our trauma patient population. The newly developed antibodies post-MTP are considered clinically significant, meaning they can cause hemolysis if exposed to donor red blood cells containing those antigens.

DISCUSSION

Blood products should be given preferentially over crystalloids to acutely bleeding patients to prevent ischemic injury during an MTP activation despite the risk of alloimmunization. In our single-institution study, the alloimmunization rate in massive transfusions where patients receive uncrossmatched red blood cells is similar to those receiving crossmatched red blood cells.

COVID-19 Monoclonal Antibody Administration Linked to Drop in Blood Pressure: A Retrospective Cohort Study

This study reports on hemodynamic changes observed during monoclonal antibody (mAb) administration for patients with severe acute respiratory distress syndrome-coronavirus-2. Findings from this study may have implications for patient safety. Hemodynamic data from 705 patients who received subcutaneous or intravenous mAb therapy during February 1, 2021-September 30, 2021 in clinics in Arkansas, USA were reviewed. Descriptive statistics and paired t-tests were used to assess blood pressure before and after treatment. Results showed 386 (54.7%) patients experienced a drop in systolic blood pressure (SBP) or diastolic blood pressure (DBP) >5 mmHg. The average drop in SBP was 9.2 mmHg for those patients. Two hundred and eighty-one (39.9%) patients experienced a drop in SBP of >10 mmHg with an average drop in SBP of 12.0 mmHg. The Emergency Use Authorization for mAb does not list hypotension as a contraindication for treatment. Our findings suggest mAb therapy should be administered in an environment where vitals are monitored.

The Impact of the COVID-19 Pandemic on Respiratory Illness Admissions at a Single Academic Institution in Arkansas

BACKGROUND

The first reported COVID-19 case in Arkansas was on 11 March 2020, two months after the first reported case in the United States. We sought to analyze rates of respiratory illness and influenza tests during the 2019/2020 influenza season compared to pre-pandemic years to assess whether there were higher rates of respiratory illness than expected, which may suggest undiagnosed COVID-19 cases.

METHODS

Using data collected from the data warehouse of the largest hospital in Arkansas, ICD-9 and ICD-10 codes related to respiratory illness were identified for 1 October to 1 May 2017-2020.

RESULTS

We identified 25,747 patients admitted with respiratory illness during the study. We found no significant difference in the rate of monthly admissions with respiratory illness between seasons (p = 0.14). We saw a significant increase in the number of influenza tests ordered in 2019/2020 (p < 0.01).

CONCLUSIONS

The rate of hospitalizations with respiratory illness did not significantly increase during the 2019/2020 season; however, influenza testing increased without a statistically significant difference in positivity rate. The increase in ordered influenza tests indicates an increased clinical suspicion, which may suggest a rise in pre-hospital viral illness associated with COVID-19.

Assessing how routes to diagnosis vary by the age of patients with cancer: a nationwide register-based cohort study in Denmark

BACKGROUND

Older patients with cancer have poorer prognosis compared to younger patients. Moreover, prognosis is related to how cancer is identified, and where in the healthcare system patients present, i.e. routes to diagnosis (RtD). We investigated whether RtD varied by patients' age.

METHODS

This population-based national cohort study used Danish registry data. Patients were categorized into age groups and eight mutually exclusive RtD. We employed multinomial logistic regressions adjusted for sex, region, diagnosis year, cohabitation, education, income, immigration status and comorbidities. Screened and non-screened patients were analysed separately.

RESULTS

The study included 137,876 patients. Both younger and older patients with cancer were less likely to get diagnosed after a cancer patient pathways referral from primary care physician compared to middle-aged patients. Older patients were more likely to get diagnosed via unplanned admission, death certificate only, and outpatient admission compared to younger patients. The patterns were similar across comorbidity levels.

CONCLUSIONS

RtD varied by age groups, and middle-aged patients were the most likely to get diagnosed after cancer patient pathways with referral from primary care. Emphasis should be put on raising clinicians' awareness of cancer being the underlying cause of symptoms in both younger patients and in older patients.

Noninferiority of Subcutaneous Versus Intravenous Casirivimab/Imdevimab for Outpatient Treatment of SARS-CoV-2 in a Real-World Setting

Monoclonal antibody (mAb) therapy has emerged as one of the mainstay treatment options for SARS-CoV-2. To improve speed of delivery and decrease bedside nursing needs, subcutaneous (SC) delivery of mAbs has been explored as an alternative to standard intravenous (IV) administration. To date, data regarding the effectiveness of SC compared with IV mAb are lacking. This retrospective cohort analysis conducted between April 2021 and August 2021 compared hospitalization rates among patients receiving IV versus SC administration of casirivimab/imdevimab (Regen-COV) at a single institution in Arkansas. Casirivimab/imdevimab was a promising mAb therapy utilized during the height of the Delta variant surge of the SARS-CoV-2 pandemic. Before resistance developed by the Omicron variant, casirivimab/imdevimab was utilized for outpatient treatment of SARS-CoV-2 patients at risk of deterioration. Primary outcomes of this investigation were the 30-day post-treatment rate of hospitalization and intensive care unit (ICU) care during hospitalization. There was no increased risk of hospitalization or ICU care with SC administration compared with IV administration. As SARS-CoV-2 continues to mutate into variants such as Omicron and develop resistance to existing mAbs, these preliminary findings of noninferiority of SC versus IV warrant ongoing investigation into SC administration of other mAbs.

OP0037 USE OF PRIMARY HEALTHCARE AND RADIOLOGICAL IMAGING PRECEDING A DIAGNOSIS OF RHEUMATOID ARTHRITIS: A DANISH NATIONWIDE COHORT STUDY

Background

Focus on early diagnosis and treatment initiation is key in rheumatoid arthritis (RA) to prevent permanent joint damage and systemic manifestations. Increased use of healthcare services before an RA diagnosis can be seen as a proxy for symptom presentation and the actions taken by healthcare professionals, and thus indicate an opportunity for earlier diagnosis. However, little is known about where and when people use healthcare services before an RA diagnosis.

Objectives

To explore the pattern in use of healthcare services during the 12 months preceding a diagnosis of RA in Denmark.

Methods

We conducted a population-based cohort study using data from Danish national registries. For every patient diagnosed with RA in 2014-2018 we matched ten reference persons from the Danish general population without RA, listed in the same general practice and with same age and sex. Healthcare use was defined as: daytime face to face contacts to general practice, contacts to private practicing physiotherapists.

We estimated the monthly healthcare use for patients with RA and reference persons in the 12 months preceding the diagnosis, and we compared their healthcare use by incidence rate ratios (IRR) for each month, adjusted for sociodemographic characteristics and comorbidity.

Results

7,427 patients with RA and 74,270 reference persons were included in the study. The median age was 62 years (interquartile interval (IQI): 51-71), and 65% were women. Patients with RA had an average of 0.5 contacts per month in general practice from 12 months until six months prior to the diagnosis (Figure 1); this number increased from six months before the diagnosis to an average of one contact in the last month before the diagnosis. Reference persons had an average of 0.4 contacts per months throughout the entire study period. Compared to their references, patients with RA had statistically significantly more contacts during all 12 months before the diagnosis date; IRR increased from 1.25 (95% CI: 1.19-1.30) to 2.63 (2.55-2.71) during the study period.

Patients with RA also had statstistically significantly more contacts to physiotherapists compared to their references throughout the entire study period, and increasing contact rates from eight months before the diagnosis. This was primarily driven by more contacts in women with RA compared to their references.

Conclusion

Patients with RA had more contacts to general practice and physiotherapists in all 12 months preceding the RA diagnosis compared to references and these contact rates increased further the last six to eight months in patients with RA. This indicates symptom presentation for several months before the RA is diagnosed, and it indicates that a window of opportunity exists to expedite referral to specialist care and the diagnosis of RA.

Disclosure of Interests

None declared.

PEGylated Gold Nanoparticle Toxicity in Cardiomyocytes: Assessment of Size, Concentration, and Time Dependency

Gold Nanoparticles (GNPs) have shown promising capabilities for use in many in-vivo applications such as gene and drug delivery, photothermal ablation of tumors, and tracking in many imaging modalities. Yet GNPs have thus far had limited use in cardiovascular medicine. Polyethylene glycol functionalized (PEGylated) GNPs have been extensively studied in a wide array of in vitro and in vivo models with results showing no apparent toxicity, but to our knowledge an investigation has never been performed to determine direct cardiomyocyte toxicity. In this study, we assessed if PEGylated GNPs exhibited direct toxicity to a primary culture of neonatal rat cardiomyocytes in order to establish PEGylated GNPs for potential future use in cardiovascular medicine applications. We present novel results that demonstrate both a particle size and concentration dependent relationship on cell viability. Cell viability was found to be significantly enhanced for many concentrations and sizes as compared to the control and increased linearly as a function of particle diameter. Additionally, viability increased in a parabolically dependent manner as a function of decreasing particle concentration. These new results could advance understanding of nanoparticle-cell interactions and lead to the development of new applications involving the use of gold nanoparticles in cardiovascular medicine.

Increases in Violence and Changes in Trauma Admissions During the COVID Quarantine

BACKGROUND

The COVID-19 pandemic caused an abrupt change to societal norms. We anecdotally noticed an increase in penetrating and violent trauma during the period of stay-at-home orders. Studying these changes will allow trauma centers to better prepare for future waves of COVID-19 or other global catastrophes.

METHODS

We queried our institutional database for all level 1 and 2 trauma activations presenting from the scene within our local county from March 18 to May 21, 2020 and matched time periods from 2016 to 2019. Primary outcomes were overall trauma volume, rates of penetrating trauma, rates of violent trauma, and transfusion requirements.

RESULTS

The number of penetrating and violent traumas at our trauma center during the period of societal quarantine for the COVID-19 pandemic was more than any historical total. During the COVID-19 time period, we saw 39 penetrating traumas, while the mean value for the same time period from 2016 to 2019 was 26 (P = .03). We saw 45 violent traumas during COVID; the mean value from 2016 to 2019 was 32 (P = .05). There was also a higher rate of trauma patients requiring transfusion in the COVID cohort (6.7% vs 12.2%).

DISCUSSION

Societal quarantine increased the number of penetrating and violent traumas, with a concurrent increased percentage of patients transfused. Despite this, there was no change in outcomes. Given the continuation of the COVID-19 pandemic, quarantine measures could be re-implemented. Data from this study can help guide expectations and utilization of hospital resources in the future.

Distribution of natural and anthropogenic radionuclides in sediments from the Vefsnfjord, Norway

Areas in central Norway were heavily contaminated with fallout from the Chernobyl accident in 1986. In this study, we assess ¹³⁷Cs in surface sediments and sediment cores collected in the Vefsnfjord in Nordland county. Concentrations of ¹³⁷Cs in surface sediments ranged from 159 to 191 Bq kg^-1 dry weight (d.w.). Sub-surface peaks of ¹³⁷Cs were observed in all cores, with a maximum concentration of 432 Bq kg^-1 d.w. Given that little is known about the distribution of naturally occurring radionuclides in Norwegian fjords and coastal areas, a better understanding of the total burden of radioactivity is important for the Norwegian fishing and aquaculture industries. Therefore, analyses of the natural radionuclides ⁴⁰K, ²²⁶Ra, ²²⁸Ra and ²¹⁰Pb were included in the study. Analyses of total sulphur (TS), total carbon (TC), total organic carbon (TOC) and grain size distribution have been performed to provide a sedimentologic context for interpreting the radionuclide results.

Evaluating the Routine Use of Head Computed Tomography Angiography in Blunt Cerebrovascular Trauma

BACKGROUND

The aim of this study was to evaluate a protocol change that mandated routine incorporation of head computed tomography angiography (CTA) for the work-up of suspected blunt cerebrovascular injury (BCVI) at an academic Level I trauma center.

METHODS

The BCVI screening guidelines at our institution changed in 2018 to include the addition of a head CTA for all patients receiving a neck CTA as part of our BCVI screening guidelines. We performed a retrospective chart review of patients between 2018 and 2019 who were 18 years or older and met screening criteria for BCVI based on our institutional guidelines. The head CTAs of this cohort were assessed for findings that could potentially alter the course of the patients' treatment.

RESULTS

A total of 319 patients fit this criterion and had a head CTA as part of their trauma workup. Findings that could potentially alter a patient's clinical course were identified in 6.6% (n = 21) of the head CTA's. These included decreased arterial perfusion (n = 9), active bleeds (n = 6), vessel occlusions (n = 1), aneurysms (n = 1), and vasospasms (n = 2). Of these 21 patients, 8 had clinically significant findings that affected their course of management (2.5% of total sample). They also had a higher mortality rate and ISS compared to the rest of the cohort.

CONCLUSIONS

In patients with clinically suspected BCVI, the addition of head CTA to the existing BCVI screening guideline identified clinically significant vascular abnormalities that affected management in 2.5% of cases.

Geochronology of sediment cores from the Vefsnfjord, Norway

The sedimentary environment is a repository and carrier for a variety of pollutants, and sediment transport from land to coastal areas is an important environmental process. In the present study, we use ²¹⁰Pb/²²⁶Ra and ¹³⁷Cs in sediment cores to assess sediment supply rates at four sites within the Vefsnfjord in Nordland county, Norway. This area was highly affected by fallout from the Chernobyl accident in 1986 and inventories of ¹³⁷Cs in the fjord are much higher than in many other Norwegian fjords. Sedimentation rates between 0.042 and 0.25 g cm^-2 y^-1 (0.060 and 0.38 cm y^-1) were determined using a combination of the Constant Rate of Supply (CRS) and Constant Flux:Constant Sedimentation rate (CF:CS) models. Well-defined ¹³⁷Cs concentration peaks were used as a supplementary tool to the ²¹⁰Pb dating methods.

Long-term adaptive versus maladaptive remodelling of the pulmonary autograft after the Ross operation

OBJECTIVES

Following the Ross operation, the pulmonary autograft undergoes structural changes (remodelling). We sought to determine the extent, nature and possible determinants of long-term remodelling in the different components of the pulmonary autograft.

METHODS

Ten pulmonary autografts and 12 normal control valves (6 pulmonary and 6 aortic) were examined by conventional histology, immunocytochemistry and electron microscopy. The structural changes were quantified by morphometry.

RESULTS

The leaflets from free-standing root replacement valves demonstrated thickening to levels comparable to the normal aortic leaflets, largely due to the addition of a thin layer of 'neointima' formed of radial elastic fibres, collagen bundles and glycoaminoglycans, on the ventricular aspect of the leaflets. The leaflets of valves from sub-coronary implantation demonstrated a significantly thicker fibroelastic layer on the ventricularis and calcium deposition in the fibrosa. The media of the explanted valves showed increased number of lamellar units to levels comparable to normal aortic roots. Electron microscopy of valves inserted as free-standing roots showed increased organization into continuous layers. However, intralamellar components showed varying degrees of 'disorganization' in comparison to those in the normal aortic media. In addition, there was a marked increase in the number of vasa vasorum with thickened arteriolar wall in the outer media and adventitia.

CONCLUSIONS

Following the Ross operation, in the very long term, all components of the autograft showed varying degrees of remodelling, which was judged to be largely adaptive. Defining the type, determinants and possible functional effects of remodelling could help in understanding and optimizing the results of the Ross operation.

OP0159-HPR IMPACT OF NON-PHARMACOLOGICAL INTERVENTIONS TARGETING SLEEP DISTURBANCES OR DISORDERS IN PATIENTS WITH INFLAMMATORY ARTHRITIS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMISED TRIALS

Background:

Patients with inflammatory arthritis (IA) often present limitations in daily life due to unpredictability, severity and chronicity of the disease, reduced functional ability and health-related quality of life. Moreover, sleep disturbances or disorders have been reported in up to 40-90% of patients with IA [1-3]. Sleep disturbances are further associated with pain, fatigue, mental well-being and disease activity [4]. As chronic us of hypnotic drugs are associated with tolerance and side effects, there is growing interest in non-pharmacological management to improve sleep.

Objectives:

With a systematic review and meta-analysis, our primary objective was to evaluate the evidence of non-pharmacological interventions targeting sleep in patients with IA. Primary outcome was sleep domains, while secondary objectives were based on the core outcome domains for IA trials and harms.

Methods:

Following protocol closure, a systematic search was undertaken in MEDLINE, CENTRAL, PsycINFO, CINAHL, ClinicalTrials.gov, ACR and EULAR in September 2020. Eligible studies were randomised trials with adults with IA and concomitant sleep disturbances or disorders, comparing a non-pharmacological intervention targeting sleep disturbances or disorders to another non-pharmacological intervention, a pharmacological intervention or standard care. Screening of titles, abstracts, and subsequent full text assessment were conducted independently by two reviewers using the Covidence tool. Randomisation, blinding, and adequacy of analyses was assessed using the Cochrane’s RoB tool and the overall quality of evidence was rated using GRADE methodology. Disagreements were resolved at consensus meetings with last authors. Effect sizes for continuous outcomes were based on the standardised mean difference (SMD), combined using standard random-effects meta-analysis (all with 95% CIs).

Results:

Six trials (308 patients) were included in the quantitative synthesis. Two trials included patients with the sleep disorder insomnia and the remaining four trials included patients with sleep disturbances. Sleep domains were measured with Pittsburgh Sleep Quality Index (PSQI) or Insomnia Severity index (ISI). Three trials reported improvement on sleep following foot reflexology, auricular plaster therapy, and exercise. The overall meta-analysis presented in the figure of forest plot for self-reported sleep suggests that non-pharmacological interventions have a potentially large effect size of -0.80 (95% CI, -1.33 to -0.28) on sleep. However, the quality of the evidence was assessed as corresponding to low, given that the body of the evidence was rated down twice, due to serious study limitations and inconsistency.

Conclusion:

Although the effect of non-pharmacological interventions targeting sleep disturbances or the sleep disorder insomnia was statistically highly significant, the implication for clinical practice is questionable because of the overall quality evidence. None of the core outcomes used in contemporary IA trials have indicated clinical benefit in favour of non-pharmacological interventions targeting sleep disturbances or disorders.

In conclusion, more rigorous research on non-pharmacological management of sleep disturbances and disorders is urgently needed, also aimed at specific sleep disorders, in order to fully reveal the clinical utility of these novel treatment options. At this point, non-pharmacological treatment of sleep disturbances or disorders is promising and potentially highly effective, and may have the potential to persistently decrease the symptom burden and increase the quality of life of patients with IA.

References:

[1]Li et al., Psychol Health Med. 2019 Sep;24(8):911-924

[2]Haugeberg et al., Arthritis Res Ther. 2020 Aug 26;22(1):198

[3]Wali et al., J Clin Sleep Med. 2020 Feb 15;16(2):259-265

[4]Løppenthin et al., Clin Rheumatol. 2015 Dec;34(12):2029-39

Disclosure of Interests:

Kristine Marie Latocha: None declared, Katrine Løppenthin: None declared, Safa Al-Bazy: None declared, Tannie Albrechtsen: None declared, Helle Jensen: None declared, Mikkel Østergaard Speakers bureau: Abbvie, Celgene, Eli-Lilly, Janssen, Novartis, Pfizer, Roche, Sanofi and UCB, Consultant of: Abbvie, BMS, Boehringer-Ingelheim, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi and UCB, Grant/research support from: Abbvie, BMS, Merck, Celgene, Novartis, Poul Jennum: None declared, Bente Appel Esbensen: None declared, Robin Christensen: None declared

Traumatic bilateral ureteral tear in a pregnant woman after a motor vehicle crash: a case report

Bilateral ureteropelvic junction (UPJ) tears are rare. Trauma can obscure this diagnosis. The objective of this case report is to highlight the rapid diagnosis of this injury and care in the case of pregnancy. A 22-year-old pregnant female was ejected from her car and presented with abdominal pain. The patient got a computed tomography (CT)-chest, abdomen, pelvis (CT-CAP) revealing bilateral ureteral injury, which was confirmed on retrograde cystoscopy. Her injuries were treated with nephrostomy tubes with plans for definitive repair after pregnancy. Fetus remained stable throughout her care and the patient was discharged with no complications. Due to the rapid diagnosis and effective stabilization, the patient and fetus recovered well from the injuries and multiple procedures. While there are many explanations for bilateral UPJ tears, deceleration and hyperextension seem to be the two major mechanisms of this injury.

Nursing teamwork in the care of older people: A mixed methods study

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

P2844Novel temperature guided irrigated ablation catheter: reproducibility of procedural efficiencies and acute success to isolate the pulmonary veins from two multicenter, feasibility studies

Background/Introduction

The novel catheter with 6 thermocouples for real-time temperature monitoring during irrigated radiofrequency ablation was designed to potentially enhance safety and effectiveness of the Smart Touch Surround Flow (STSF) catheter by incorporating real-time temperature sensing. A supplementary, novel algorithm was developed to modulate power to maintain target temperature during high power/short duration ablation (90W, 4s).

Purpose

This sub-analysis was performed to examine consistency and reproducibility of the procedural efficiencies and acute success of the novel catheter with optimized temperature control and microelectrodes in treating paroxysmal atrial fibrillation (PAF) across multiple sites from two initial feasibility studies, in standard (QMODE) and high power/short duration (QMODE+) temperature-control ablation modes.

Methods

The QDOT-MICRO (QMODE, NCT02944968; N=42) and QDOT-FAST (QMODE+, NCT03459196; N=52) studies were both prospective, non-randomized multi-center, clinical investigations completed across 6 and 7 centers, respectively, in Europe. Procedural efficiencies and acute success (PVI via entrance block) was examined across sites within the study.

Results

In the QDOT-MICRO study, median procedure time (105–155 min), RF ablation time (27.7–39.5 min), and fluoroscopy times (2.2–8 min) during QMODE ablation were similar across the 6 sites. In QMODE+ ablation, median procedure time, RF ablation time, and fluoroscopy times all fall within (84–134 min), (4.8–9.7 min) and (1.1–9.6 min), respectively, across the 7 sites. Fluid delivery by the study catheter was low in both studies: QDOT-MICRO 547±278mL (mean ± SD); QDOT-FAST 382±299. mL (mean ± SD); which is 39.1 and 57.4% lower, respectively, than reported in the SMART SF trial. Esophageal temperature probe was used in the majority of patients (30/42 for QDOT MICRO and 51/52 for QDOT-FAST). Acute PVI was successful in 100% of patients in both studies with no deaths or unanticipated AEs.

Conclusion(s)

In both feasibility studies, procedural efficiencies were reproducible across study sites in both QMODE and QMODE+, with 100% acute success and good safety outcomes. Efficiencies are likely to improve with further experience. These results need to be confirmed in larger trials.

Acknowledgement/Funding

Both Studies are Company Sponsored Studies funded by Biosense Webster, Inc.

Association of Transcatheter Aortic Valve Replacement With 30-Day Renal Function and 1-Year Outcomes Among Patients Presenting With Compromised Baseline Renal Function: Experience From the PARTNER 1 Trial and Registry

Importance

The frequency of baseline renal impairment among high-risk and inoperable patients with severe aortic stenosis undergoing a transcatheter aortic valve replacement (TAVR) and the effect of TAVR on subsequent renal function are, to our knowledge, unknown.

Objective

To determine the effect of TAVR among patients with baseline renal impairment.

Design, Setting, and Participants

This substudy of patients with baseline renal impairment (estimated glomerular filtration rate [eGFR] ≤ 60 mL/min) and paired baseline and 30-day measures of renal function undergoing TAVR in the PARTNER 1 trial and continued access registries was conducted in 25 centers in the United States and Canada.

Main Outcomes and Measures

Patients were categorized with improved eGFR (30-day follow-up eGFR≥10% higher than baseline pre-TAVR), worsened eGFR (≥10% lower), or no change in renal function (neither). Baseline characteristics, 30-day to 1-year all-cause mortality, and repeat hospitalization were compared. Multivariable models were constructed to identify predictors of 1-year mortality and of improvement/worsening in eGFR.

Results

Of the 821 participants, 401 (48.8%) were women and the mean (SD) age for participants with improved, unchanged, or worsening eGFR was 84.90 (6.91) years, 84.37 (7.13) years, and 85.39 (6.40) years, respectively. The eGFR was 60 mL/min or lower among 821 patients (72%), of whom 345 (42%) improved, 196 (24%) worsened, and 280 (34%) had no change at 30 days. There were no differences in baseline age, body mass index, diabetes, chronic obstructive pulmonary disease, coronary artery disease, peripheral arterial disease, hypertension, pulmonary hypertension, renal or liver disease, New York Heart Association III/IV symptoms, transaortic gradient, left ventricular ejection fraction, or procedural characteristics. The group with improved eGFR had more women, nonsmokers, and a lower cardiac index. Those with worsening eGFR had a higher median Society of Thoracic Surgeons score and left ventricle mass. From 30 days to 1 year, those with improved eGFR had no difference in mortality or repeat hospitalization. Those with worsening eGFR had increased mortality (25.5% vs 19.1%, P = .07) but no significant increases in repeat hospitalization or dialysis. Predictors of improved eGFR were being female (odds ratio [OR], 1.38; 95% CI, 1.03-1.85; P = .03) and nonsmoking status (OR, 1.49; 95% CI, 1.11-1.01; P = .01); predictors of worsening eGFR were baseline left ventricle mass (OR, 1.00; 95% CI, 1.00-1.01; P = .01), smoking (OR, 1.51; 95% CI, 1.06-2.14; P = .02), and age (OR, 1.03; 95% CI, 1.00-1.05; P = .05); and predictors of 1-year mortality were baseline left ventricular ejection fraction (OR, 0.98; 95% CI, 0.97-0.99; P = .003), baseline eGFR (OR, 0.98; 95% CI, 0.96-0.99; P < .001), and worsening eGFR vs no change in eGFR (OR, 1.51; 95% CI, 1.02-2.24; P = .04).

Conclusions and Relevance

Baseline renal impairment was frequent among patients who underwent TAVR. While improved eGFR did not improve 1-year outcomes, worsening eGFR was associated with increased mortality.

Trial Registration

clinicaltrials.gov Identifier: NCT00530894.

Performance changes of venous valves following tissue treatment with novel in vitro system

OBJECTIVES

The purpose of this study is to test venous valve performance and identify differences between native tissue and replacement devices developed with traditional tissue treatment methods using a new in vitro model with synchronized hemodynamic parameters and high-speed valve image acquisition.

METHODS

An in vitro model mimicking the venous circulation to test valve performance was developed using hydrostatic pressure driven flow. Fresh and glutaraldehyde-treated vein segments were placed in the setup and opening/closing of the valves was captured by a high-speed camera. Hemodynamic data were obtained using synchronized hardware and virtual instrumentation.

RESULTS

Geometric orifice area and opening/closing time of the valves was evaluated at the same hemodynamic conditions. A reduction in geometric orifice area of 27.2  ± 14.8% (p < 0.05) was observed following glutaraldehyde fixation. No significant difference in opening/closing time following chemical fixation was observed.

CONCLUSIONS

The developed in vitro model was shown to be an effective method for measuring the performance of venous valves. The observed decrease in geometric orifice area following glutaraldehyde treatment indicates a decrease in flow through the valve, demonstrating the consequences of traditional tissue treatment methods.

Novel Clinical Needs Finding Course Brings Biomedical Engineering Students Together with Regional Medical Campus Students, Residents, and Faculty to Solve Real-World Problems

Biomedical engineering is the fastest growing engineering field in the United States, preparing a generation of skilled problem-solvers who, together with healthcare professionals, drive the momentum of novel technologies for prevention, detection, treatment, and monitoring of disease. It is important to the education of biomedical engineers that the dialogue between healthcare professionals and schools of engineering is seamless, constant, and interactive. Lack of sustainable discourse between those who produce technologies and those who use them could reduce the applicability and relevance of the biomedical engineering education1,2. Reciprocally, for healthcare professionals to optimally harness the expertise of their engineering colleagues, a direct interaction is required. The department of Biomedical Engineering (BMEG) is one of the largest departments within the College of Engineering at the University of Arkansas, with approximately 70 students graduating annually. Established in 2012, as the first and only biomedical engineering program in the state of Arkansas, the department is establishing itself as one of the premier research departments on campus. The department prides itself in its commitment to diversity and has been successful in attracting diverse groups of students to enter the field of science and engineering.  In the spring of 2018, the BMEG undergraduate student body had the highest percentage of female and underrepresented minorities within the college of engineering—53% female and 37% minority. The University of Arkansas for Medical Sciences (UAMS) is the only allopathic medical school in the state of Arkansas. In 2007, UAMS established UAMS-Northwest as a regional campus in Fayetteville. UAMS-Northwest extends UAMS’ medical education, research, and clinical mission. UAMS-Northwest has ~250 students in the colleges of medicine, nursing, pharmacy, and health professions, as well as 48 family medicine and internal medicine residents. UAMS-Northwest is located more than 200 miles from the main UAMS campus in Little Rock but is only one mile from Arkansas’ land grant university, the University of Arkansas. This proximity of the regional medical campus to the land grant university provides opportunities for collaboration that can benefit the students of both institutions. This article provides an overview of the implementation and preliminary assessment of a novel Clinical Needs Finding course that was recently instituted as a collaboration between the Department of Biomedical Engineering and the University of Arkansas for Medical Sciences– Northwest Campus.

Rural-Urban Variation in Time to Diagnosis and Treatment of Colorectal or Breast Cancer in Victoria, Australia

Background: Rural-urban disparities in cancer outcomes are found in many countries, though these vary by cancer type. In Victoria, Australia, survival is poorer for rural patients with colorectal cancer, but not breast cancer. Delayed diagnosis and treatment may contribute to disparities, but previous studies have not compared the timeliness of rural and urban pathways to treatment of these common cancers. Aim: We investigated whether time to diagnosis and treatment differed for rural and urban patients with colorectal or breast cancer in Victoria, Australia. Methods: Population-based, cross-sectional surveys examining events and dates on the pathway to treatment completed by patients aged ≥ 40 and approached within six months of diagnosis, their general practitioner (GP) and specialist. Data were collected from 2013 to 2014 as part of the International Cancer Benchmarking Partnership, Module 4. Six intervals were explored: patient (symptom to presentation), primary care (presentation to referral), diagnostic (presentation/screening to diagnosis), treatment (diagnosis to treatment), health system (presentation to treatment) and total intervals (symptom/screening to treatment). Rural-urban differences were examined for each cancer using quantile regression (50th, 75th and 90th percentiles) models including age, gender, health insurance and socioeconomic status. Results: 433 colorectal (48% rural) and 489 breast (42% rural) patients, 621 GPs and 370 specialists completed surveys. Compared with urban patients, symptomatic colorectal cancer patients from rural areas had a significantly longer total interval at all percentiles: 50th (18 days longer, 95% confidence interval (CI): 9-27), 75th (53, 95% CI: 47-59) 90th (44, 95% CI: 40-48). These patients also had longer health system intervals, ranging 7-85 days longer. This appeared mostly due to longer diagnostic intervals (range: 6-54 days longer). Results were similar when including screen-detected cases. In contrast, breast cancer intervals were similar for rural and urban patients, except the patient interval, which was shorter for rural patients. Conclusion: Consistent with variation in survival, we found longer total and diagnostic intervals for rural compared with urban patients with colorectal cancer, but not breast cancer. The lack of rural-urban differences observed for breast cancer suggest that inequities in the timeliness of colorectal cancer pathways can be ameliorated, and may improve clinical outcomes. Indeed, based on previous research, delays observed in this study could result in stage progression and hence reduced survival. From our results, interventions targeting the time from presentation to colorectal cancer diagnosis in rural populations should be pursued. Countries seeking to understand cancer disparities in their local context may also consider using a pathways approach to identify possible targets for policy intervention.

Novel method for emboli analog formation towards improved stroke retrieval devices

BACKGROUND

Unsuccessful recanalization attempts in stroke patients have been associated with fibrin-rich thromboemboli linking retrieval mechanism performance and clot composition. To continue development of stroke retrieval mechanisms, the material properties of cerebral thromboemboli must be replicated; however, current methods for emboli analog formation lack quantitative measurements for both material stiffness and composition of cerebral thromboemboli. This study investigates emboli analog (EA) formation to mimic the material stiffness and composition of cerebral thromboemboli to develop new retrieval mechanisms.

METHODS

To induce static and dynamic environments for clot replication, a 9:1 ratio of porcine whole blood and 2.45% calcium chloride remained stationary or rotated at 34, 50 and 80 RPM. Histology and a custom MATLAB code provided composition analysis results. Likewise, quantitative results from biomechanical testing were obtained for direct comparison of the material stiffness of cerebral thromboemboli.

RESULTS

Fibrin/platelet content as well as material stiffness increased due to increasing rotational speed. Approximately 11% of the biomechanical testing results exhibited nonlinearity after an initial yield point, of which 60% were from statically formed EAs. Those formed at 50 RPM were most similar in material stiffness to thromboemboli extracted from carotid endarterectomy (CEA) procedures (p = 0.97).

CONCLUSIONS

The dynamically formed EAs may be altered to obtain a range of fibrin/platelet to erythrocyte ratios. The proposed methodology for EA formation offers a platform for continued development of retrieval mechanism prototypes.

Insights into the genetic architecture of morphological traits in two passerine bird species

Knowledge about the underlying genetic architecture of phenotypic traits is needed to understand and predict evolutionary dynamics. The number of causal loci, magnitude of the effects and location in the genome are, however, still largely unknown. Here, we use genome-wide single-nucleotide polymorphism (SNP) data from two large-scale data sets on house sparrows and collared flycatchers to examine the genetic architecture of different morphological traits (tarsus length, wing length, body mass, bill depth, bill length, total and visible badge size and white wing patches). Genomic heritabilities were estimated using relatedness calculated from SNPs. The proportion of variance captured by the SNPs (SNP-based heritability) was lower in house sparrows compared with collared flycatchers, as expected given marker density (6348 SNPs in house sparrows versus 38 689 SNPs in collared flycatchers). Indeed, after downsampling to similar SNP density and sample size, this estimate was no longer markedly different between species. Chromosome-partitioning analyses demonstrated that the proportion of variance explained by each chromosome was significantly positively related to the chromosome size for some traits and, generally, that larger chromosomes tended to explain proportionally more variation than smaller chromosomes. Finally, we found two genome-wide significant associations with very small-effect sizes. One SNP on chromosome 20 was associated with bill length in house sparrows and explained 1.2% of phenotypic variation (V_P), and one SNP on chromosome 4 was associated with tarsus length in collared flycatchers (3% of V_P). Although we cannot exclude the possibility of undetected large-effect loci, our results indicate a polygenic basis for morphological traits.

Assertive Interventions for First Episode Psychoses: The Danish Experience

Early Intervention services with team-based intensive case management and family involvement are superior to standard treatment in reducing psychotic and negative symptoms and comorbid substance abuse and improving social functioning and user satisfaction. The results of the OPUS-trial will be presented together with meta-analyses based on similar trials. The implementation of OPUS all over Denmark will be presented together with the Danish OPUS-fidelity study. Specialized elements are being are being developed such as inclusion of new methods in CBT for psychotic and negative symptoms, neurocognitive and social cognitive training programs, interventions for supported employment and focus on physical health. Results of long term follow-up studies indicate that the prognosis of first episode psychosis is very diverse with the extremes represented by one group being well functioning and able to quit medication without relapse; and another group having a long term chronic course of illness with a need for support to maintain daily activities. The Danish TAILOR-trial–testing dose reduction versus maintenance therapy will be presented. It will be of immense value to be able to intervene in risk groups identified in the premorbid phase, and there are few examples of ongoing trial for children of parent with schizophrenia and bipolar disorder.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Balloon Versus Computed Tomography Sizing of the Aortic Annulus for Transcatheter Aortic Valve Replacement and the Impact of Left Ventricular Outflow Tract Calcification and Morphology on Sizing

OBJECTIVES

To evaluate the role of balloon annular sizing in transcatheter aortic valve replacement (TAVR).

BACKGROUND

Multidetector cardiac computed tomography (MDCT) is the gold standard for aortic annular sizing in TAVR. Balloon sizing is increasingly used in patients with borderline annular size and severe calcification. A comparison between these two techniques is needed.

METHODS

We retrospectively compared baseline characteristics and 30-day outcomes of patients undergoing balloon-expandable TAVR using annular MDCT or balloon sizing. Paravalvular leak (PVL) rates were compared adjusting for access site, valve generation, size, and valve calcification.

RESULTS

A total of 205 patients underwent TAVR with MDCT (n = 110) or balloon sizing (n = 95). Balloon-sized patients were older (83 years vs 81 years; P=.03), had more valve calcification (60.2% vs 30.9%; P<.001), and underwent more minimalist TAVR (61.1% vs 40%; P=.03). Although we found no difference between balloon and MDCT sizing in rates of acute renal failure (3.2% vs 0.9%; P=.34), annular rupture (1.1% vs 1.8%; P>.99), ≥ mild PVL by angiography (40% vs 35.5%; P=.57), or 30-day transthoracic echocardiography (40.7% vs 29.3%; P=.78), balloon-sized patients had a higher aortic regurgitation index (≥25) of 74.4% vs 54.1% (P=.01). Thirty-day rates of ≥ moderate PVL were 7.0% with balloon and 5.7% with MDCT sizing (P=.34). Balloon sizing recommended a different valve size in 34.0% of patients who underwent both methods (n = 50). A different recommendation occurred more often in patients with moderate/severe annular calcification (50.0% vs 33.3%; P=.01) and non-tubular left ventricular outflow tracts (LVOTs) (70.6% vs 30.3%; P=.01).

CONCLUSION

Balloon sizing can be a complement to MDCT for annular sizing in TAVR, especially in patients with moderate/severe annular calcification, borderline annular size, and non-tubular LVOT.

Sex-linked inheritance, genetic correlations and sexual dimorphism in three melanin-based colour traits in the barn owl

Theory states that genes on the sex chromosomes have stronger effects on sexual dimorphism than genes on the autosomes. Although empirical data are not necessarily consistent with this theory, this situation may prevail because the relative role of sex-linked and autosomally inherited genes on sexual dimorphism has rarely been evaluated. We estimated the quantitative genetics of three sexually dimorphic melanin-based traits in the barn owl (Tyto alba), in which females are on average darker reddish pheomelanic and display more and larger black eumelanic feather spots than males. The plumage traits with higher sex-linked inheritance showed lower heritability and genetic correlations, but contrary to prediction, these traits showed less pronounced sexual dimorphism. Strong offspring sexual dimorphism primarily resulted from daughters not expressing malelike melanin-based traits and from sons expressing femalelike traits to similar degrees as their sisters. We conclude that in the barn owl, polymorphism at autosomal genes rather than at sex-linked genes generate variation in sexual dimorphism in melanin-based traits.

Leg ischaemia before circulatory arrest alters brain leucocyte count and respiratory chain redox state

OBJECTIVES

Remote ischaemic preconditioning and its neuroprotective abilities are currently under investigation and the method has shown significant effects in several small and large animal studies. In our previous studies, leucocyte filtration during cardiopulmonary bypass reduced cerebrocortical adherent leucocyte count and mitigated cerebral damage after hypothermic circulatory arrest (HCA) in piglets. This study aimed to obtain and assess direct visual data of leucocyte behaviour in cerebral vessels after hypothermic circulatory arrest following remote ischaemic preconditioning.

METHODS

Twelve native stock piglets were randomized into a remote ischaemic preconditioning group (n = 6) and a control group (n = 6). The intervention group underwent hind-leg ischaemia, whereas the control group received a sham-treatment before a 60-min period of hypothermic circulatory arrest. An intravital microscope was used to obtain measurements from the cerebrocortical vessel in vivo. It included three sets of filters: a violet filter to visualize microvascular perfusion and vessel diameter, a green filter for visualization of rhodamine-labelled leucocytes and an ultraviolet filter for reduced nicotinamide adenine dinucleotide (NADH) analysis. The final magnification on the microscope was 400. After the experiment, cerebral and cerebellar biopsies were collected and analysed with transmission electron microscope by a blinded analyst.

RESULTS

In the transmission electron microscope analysis, the entire intervention group had normal, unaffected rough endoplasmic reticulum's in their cerebellar tissue, whereas the control group had a mean score of 1.06 (standard deviation 0.41) (P = 0.026). The measured amount of adherent leucocytes was lower in the remote ischaemic preconditioning group. The difference was statistically significant at 5, 15 and 45 min after circulatory arrest. Statistically significant differences were seen also in the recovery phase at 90 and 120 min after reperfusion. Nicotinamide adenine dinucleotide autofluorescence had statistically significant differences at 10 min after cooling and at 120 and 180 min after hypothermic circulatory arrest.

CONCLUSIONS

Remote ischaemic preconditioning seems to provide better mitochondrial respiratory chain function as indicated by the higher NADH content. It simultaneously provides a reduction of adherent leucocytes in cerebral vessels after hypothermic circulatory arrest. Additionally, it might provide some degree of cellular organ preservation as implied by the electron microscopy results.