Application of advanced causal analyses to identify processes governing secondary organic aerosols

Understanding how different physical and chemical atmospheric processes affect the formation of fine particles has been a persistent challenge. Inferring causal relations between the various measured features affecting the formation of secondary organic aerosol (SOA) particles is complicated since correlations between variables do not necessarily imply causality. Here, we apply a state-of-the-art information transfer measure coupled with the Koopman operator framework to infer causal relations between isoprene epoxydiol SOA (IEPOX-SOA) and different chemistry and meteorological variables derived from detailed regional model predictions over the Amazon rainforest. IEPOX-SOA represents one of the most complex SOA formation pathways and is formed by the interactions between natural biogenic isoprene emissions and anthropogenic emissions affecting sulfate, acidity and particle water. Since the regional model captures the known relations of IEPOX-SOA with different chemistry and meteorological features, their simulated time series implicitly include their causal relations. We show that our causal model successfully infers the known major causal relations between total particle phase 2-methyl tetrols (the dominant component of IEPOX-SOA over the Amazon) and input features. We provide the first proof of concept that the application of our causal model better identifies causal relations compared to correlation and random forest analyses performed over the same dataset. Our work has tremendous implications, as our methodology of causal discovery could be used to identify unknown processes and features affecting fine particles and atmospheric chemistry in the Earth's atmosphere.

Emergence of Long-Range Angular Correlations in Low-Multiplicity Proton-Proton Collisions

This Letter presents the measurement of near-side associated per-trigger yields, denoted ridge yields, from the analysis of angular correlations of charged hadrons in proton-proton collisions at sqrt[s]=13  TeV. Long-range ridge yields are extracted for pairs of charged particles with a pseudorapidity difference of 1.4<|Δη|<1.8 and a transverse momentum of 1 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

First Measurement of the |t| Dependence of Incoherent J/ψ Photonuclear Production

The first measurement of the cross section for incoherent photonuclear production of J/ψ vector mesons as a function of the Mandelstam |t| variable is presented. The measurement was carried out with the ALICE detector at midrapidity, |y|<0.8, using ultraperipheral collisions of Pb nuclei at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. This rapidity interval corresponds to a Bjorken-x range (0.3-1.4)×10^{-3}. Cross sections are given in five |t| intervals in the range 0.04<|t|<1  GeV^{2} and compared to the predictions by different models. Models that ignore quantum fluctuations of the gluon density in the colliding hadron predict a |t| dependence of the cross section much steeper than in data. The inclusion of such fluctuations in the same models provides a better description of the data.

Seasonal variations in social contact patterns in a rural population in north India: Implications for pandemic control

Social contact mixing patterns are critical to model the transmission of communicable diseases, and have been employed to model disease outbreaks including COVID-19. Nonetheless, there is a paucity of studies on contact mixing in low and middle-income countries such as India. Furthermore, mathematical models of disease outbreaks do not account for the temporal nature of social contacts. We conducted a longitudinal study of social contacts in rural north India across three seasons and analysed the temporal differences in contact patterns. A contact diary survey was performed across three seasons from October 2015-16, in which participants were queried on the number, duration, and characteristics of contacts that occurred on the previous day. A total of 8,421 responses from 3,052 respondents (49% females) recorded characteristics of 180,073 contacts. Respondents reported a significantly higher number and duration of contacts in the winter, followed by the summer and the monsoon season (Nemenyi post-hoc, p<0.001). Participants aged 0-9 years and 10-19 years of age reported the highest median number of contacts (16 (IQR 12-21), 17 (IQR 13-24) respectively) and were found to have the highest node centrality in the social network of the region (pageranks = 0.20, 0.17). A large proportion (>80%) of contacts that were reported in schools or on public transport involved physical contact. To the best of our knowledge, our study is the first from India to show that contact mixing patterns vary by the time of the year and provides useful implications for pandemic control. We compared the differences in the number, duration and location of contacts by age-group and gender, and studied the impact of the season, age-group, employment and day of the week on the number and duration of contacts using multivariate negative binomial regression. We created a social network to further understand the age and gender-specific contact patterns, and used the contact matrices in each season to parameterise a nine-compartment agent-based model for simulating a COVID-19 epidemic in each season. Our results can be used to parameterize more accurate mathematical models for prediction of epidemiological trends of infections in rural India.

ψ(2S) Suppression in Pb-Pb Collisions at the LHC

The production of the ψ(2S) charmonium state was measured with ALICE in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV, in the dimuon decay channel. A significant signal was observed for the first time at LHC energies down to zero transverse momentum, at forward rapidity (2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

Measurement of the Lifetime and Λ Separation Energy of _{Λ}^{3}H

The most precise measurements to date of the _{Λ}^{3}H lifetime τ and Λ separation energy B_{Λ} are obtained using the data sample of Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV collected by ALICE at the LHC. The _{Λ}^{3}H is reconstructed via its charged two-body mesonic decay channel (_{Λ}^{3}H→^{3}He+π^{-} and the charge-conjugate process). The measured values τ=[253±11(stat)±6(syst)]  ps and B_{Λ}=[102±63(stat)±67(syst)]  keV are compatible with predictions from effective field theories and confirm that the _{Λ}^{3}H structure is consistent with a weakly bound system.

Measurement of the J/ψ Polarization with Respect to the Event Plane in Pb-Pb Collisions at the LHC

We study the polarization of inclusive J/ψ produced in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC in the dimuon channel, via the measurement of the angular distribution of its decay products. We perform the study in the rapidity region 2.5 Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

First Measurement of Antideuteron Number Fluctuations at Energies Available at the Large Hadron Collider

The first measurement of event-by-event antideuteron number fluctuations in high energy heavy-ion collisions is presented. The measurements are carried out at midrapidity (|η|<0.8) as a function of collision centrality in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV using the ALICE detector. A significant negative correlation between the produced antiprotons and antideuterons is observed in all collision centralities. The results are compared with a state-of-the-art coalescence calculation. While it describes the ratio of higher order cumulants of the antideuteron multiplicity distribution, it fails to describe quantitatively the magnitude of the correlation between antiproton and antideuteron production. On the other hand, thermal-statistical model calculations describe all the measured observables within uncertainties only for correlation volumes that are different with respect to those describing proton yields and a similar measurement of net-proton number fluctuations.

Enhanced Deuteron Coalescence Probability in Jets

The transverse-momentum (p_{T}) spectra and coalescence parameters B_{2} of (anti)deuterons are measured in p-p collisions at sqrt[s]=13  TeV for the first time in and out of jets. In this measurement, the direction of the leading particle with the highest p_{T} in the event (p_{T}^{lead}>5  GeV/c) is used as an approximation for the jet axis. The event is consequently divided into three azimuthal regions, and the jet signal is obtained as the difference between the toward region, that contains jet fragmentation products in addition to the underlying event (UE), and the transverse region, which is dominated by the UE. The coalescence parameter in the jet is found to be approximately a factor of 10 larger than that in the underlying event. This experimental observation is consistent with the coalescence picture and can be attributed to the smaller average phase-space distance between nucleons in the jet cone as compared with the underlying event. The results presented in this Letter are compared to predictions from a simple nucleon coalescence model, where the phase-space distributions of nucleons are generated using pythia8 with the Monash 2013 tuning, and to predictions from a deuteron production model based on ordinary nuclear reactions with parametrized energy-dependent cross sections tuned on data. The latter model is implemented in pythia8.3. Both models reproduce the observed large difference between in-jet and out-of-jet coalescence parameters, although the almost flat trend of the B_{2}^{Jet} is not reproduced by the models, which instead give a decreasing trend.

PHEOCHROMOCYTOMA, THE GREAT MASQUERADER, PRESENTING AS REVERSIBLE CARDIOMYOPATHY: PRIMUM NON NOCERE

Background

Pheochromocytoma, the great masquerader, can have a varied spectrum of clinical manifestations. It can often cause a diagnostic challenge despite the availability of modern investigation modalities.

Case

We present the case of a 38-year-old male who presented with uncontrolled hypertension for the past 10 years and heart failure for one year. The diagnosis of pheochromocytoma was missed in the initial setting, leading to a biopsy of the retroperitoneal mass. Fortunately, the patient survived the procedure. Subsequently, with the involvement of a multi-disciplinary team, he was optimized for surgery under strict cardiac monitoring. After the complete excision of the tumour, he showed significant improvement not only in his clinical symptoms but also in his cardiac status.

Conclusions

This case emphasizes the age-old medical phrase of 'Primum non nocere or first, do no harm'. Any invasive procedure in a pheochromocytoma can lead to a massive release of catecholamines causing a hypertensive crisis, pulmonary oedema, and even cardiac arrest. Any young patient presenting with hypertension or heart failure should be investigated for secondary causes. Cardiomyopathy due to pheochromocytoma is because of catecholamine overload and usually reverses or improves after curative surgery.

Implementation outcomes and strategies for delivering evidence-based hypertension interventions in lower-middle-income countries: Evidence from a multi-country consortium for hypertension control

Guidance on contextually tailored implementation strategies for the prevention, treatment, and control of hypertension is limited in lower-middle income countries (Lower-MIC). To address this limitation, we compiled implementation strategies and accompanying outcomes of evidence-based hypertension interventions currently being implemented in five Lower-MIC. The Global Research on Implementation and Translation Science (GRIT) Coordinating Center (CC) (GRIT-CC) engaged its global network sites at Ghana, Guatemala, India, Kenya, and Vietnam. Purposively sampled implementation science experts completed an electronic survey assessing implementation outcomes, in addition to implementation strategies used in their ongoing hypertension interventions from among 73 strategies within the Expert Recommendations for Implementing Change (ERIC). Experts rated the strategies based on highest priority to their interventions. We analyzed the data by sorting implementation strategies utilized by sites into one of the nine domains in ERIC and summarized the data using frequencies, proportions, and means. Seventeen implementation experts (52.9% men) participated in the exercise. Of Proctor's implementation outcomes identified across sites, all outcomes except for appropriateness were broadly assessed by three or more countries. Overall, 59 out of 73 (81%) strategies were being utilized in the five countries. The highest priority implementation strategies utilized across all five countries focused on evaluative and iterative strategies (e.g., identification of context specific barriers and facilitators) to delivery of patient- and community-level interventions, while the lowest priority was use of financial and infrastructure change strategies. More capacity building strategies (developing stakeholder interrelationships, training and educating stakeholders, and supporting clinicians) were incorporated into interventions implemented in India and Vietnam than Ghana, Kenya, and Guatemala. Although robust implementation strategies are being used in Lower -MICs, there is minimum use of financial and infrastructure change strategies. Our study contributes to the growing literature that demonstrates the use of Expert Recommendations for Implementing Change (ERIC) implementation strategies to deliver evidence-based hypertension interventions in Lower-MICs and will inform future cross-country data harmonization activities in resource-constrained settings.

Clinical effectiveness of alkasite versus nanofilled resin composite in the restoration of occlusal carious lesions in permanent molar teeth of children: a randomized clinical trial

PURPOSE

To evaluate and compare the clinical effectiveness of alkasite with nanofilled resin composite restorations for occlusal caries lesions in permanent molar teeth of children, at one-year follow-up.

METHODS

In this randomized controlled clinical trial with parallel design, 38 children aged 7-13 years with occlusal caries lesions on 59 first permanent molars were randomly allocated into two groups, Group 1: Filtek™ Z350XT (nanocomposite) and Group 2: Cention N^® (alkasite resin composite). The restorations were evaluated at one year using the United States Public Health Service (USPHS) criteria. Data were analyzed using Chi-square or Fisher's exact test.

RESULTS

All restorations had either Alpha or Bravo scores at one-year follow-up. In Group 1, all restorations scored Alpha, while one restoration each (3.6%) in Group 2 scored Bravo for fracture and marginal adaptation. All restorations in both groups scored Alpha for retention, secondary caries, and post-operative sensitivity. For anatomic form, all restorations in Group 1 scored Alpha, while three (10.7%) restorations in Group 2 had Bravo scores. For marginal discolouration, three restorations in both groups scored Bravo (11.5% and 10.7%, respectively). For surface roughness, one restoration (3.8%) in Group 1 and three restorations in Group 2 (10.7%) scored Bravo. The comparative results between the two groups for all the variables in the USPHS criteria were not statistically significantly different.

CONCLUSIONS

The performances of the nanofilled composite and alkasite were clinically acceptable and comparable. Alkasite can be an alternative material for the restoration of occlusal caries lesions in permanent molars of children.

CLINICAL TRIAL REGISTRATION

The clinical trial was registered at Clinical Trials Registry-India (CTRI Reg no: CTRI/2020/12/029830 Dated: 15/12/2020).

Clinical workflow of sonographers performing fetal anomaly ultrasound scans: deep-learning-based analysis

OBJECTIVE

Despite decades of obstetric scanning, the field of sonographer workflow remains largely unexplored. In the second trimester, sonographers use scan guidelines to guide their acquisition of standard planes and structures; however, the scan-acquisition order is not prescribed. Using deep-learning-based video analysis, the aim of this study was to develop a deeper understanding of the clinical workflow undertaken by sonographers during second-trimester anomaly scans.

METHODS

We collected prospectively full-length video recordings of routine second-trimester anomaly scans. Important scan events in the videos were identified by detecting automatically image freeze and image/clip save. The video immediately preceding and following the important event was extracted and labeled as one of 11 commonly acquired anatomical structures. We developed and used a purposely trained and tested deep-learning annotation model to label automatically the large number of scan events. Thus, anomaly scans were partitioned as a sequence of anatomical planes or fetal structures obtained over time.

RESULTS

A total of 496 anomaly scans performed by 14 sonographers were available for analysis. UK guidelines specify that an image or videoclip of five different anatomical regions must be stored and these were detected in the majority of scans: head/brain was detected in 97.2% of scans, coronal face view (nose/lips) in 86.1%, abdomen in 93.1%, spine in 95.0% and femur in 92.3%. Analyzing the clinical workflow, we observed that sonographers were most likely to begin their scan by capturing the head/brain (in 24.4% of scans), spine (in 23.2%) or thorax/heart (in 22.8%). The most commonly identified two-structure transitions were: placenta/amniotic fluid to maternal anatomy, occurring in 44.5% of scans; head/brain to coronal face (nose/lips) in 42.7%; abdomen to thorax/heart in 26.1%; and three-dimensional/four-dimensional face to sagittal face (profile) in 23.7%. Transitions between three or more consecutive structures in sequence were uncommon (up to 13% of scans). None of the captured anomaly scans shared an entirely identical sequence.

CONCLUSIONS

We present a novel evaluation of the anomaly scan acquisition process using a deep-learning-based analysis of ultrasound video. We note wide variation in the number and sequence of structures obtained during routine second-trimester anomaly scans. Overall, each anomaly scan was found to be unique in its scanning sequence, suggesting that sonographers take advantage of the fetal position and acquire the standard planes according to their visibility rather than following a strict acquisition order. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

945 Are Extended Criteria Donor Kidneys from 70 years-old and above Good Enough to Accept? A Single Centre Experience

Aim

As a result of increasing demand in recent years in organ donation and transplantation, the transplant community has been utilizing organs previously considered unsuitable for transplantation, including organs from extended criteria donors (ECD) and donors after circulatory arrest (DCD). This has led to higher rates of non-functioning and poorer outcomes, increasing the uncertainty when to accept or decline a donor organ. Our objective is to measure patient and graft outcomes of kidney transplants from ECDs aged 70 years and older.

Method

A retrospective study of 104 renal transplanted patients from ECDs between April 2010 and March 2014. Recipients referred to other centres were excluded from the study. Follow-up period was 7 years.

Results

At 7 years follow up, graft survival among recipients from ECDs older were 42.5%(n=17/40) while from ECDs younger were 58% (n=37/64) (P = 0.1594). Death censored graft survival (patient died with functioning graft). ECDs older death censored graft survival was 80% (n=32/40) and 82.8% (n=53/64) for ECDs younger (P = 0.7963).

Patient survival

70.3% of recipients from ECDs younger and 60% of recipients from ECDs older were alive at seven years post-transplant. (P = 0.2945).

Conclusions

There was no significant difference between the two cohorts in graft and patient survival. The use of kidneys from donors aged ≥70 years has yielded generally satisfactory results when compared to younger ECDs 50–69 years old donors.

P-070 Comparison of Microfluidic Sperm Sorting (MFSS) versus Physiological Intracytoplasmic Sperm Injection (PICSI) versus Density Gradient versus Swim Up in high DNA fragmentation index sperm samples

Study question

To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) over other technique in patient with high DNA fragmentation index (DFI) sperm samples?

Summary answer

Microfluidic is not only correlated with better DNA integrity but also with the better reproductive outcome.

What is known already

DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage.

In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage

Study design, size, duration

A prospective randomised study was conducted from 1st January 2019 to 1st December 2021. Four hundred patients were randomised by computer generated list and divided into 4 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI), Group C (n = 100), sperm were processed by density gradient and Group D (n = 100), sperm were processed by swim-up technique.

Participants/materials, setting, methods

The study period included all normozoospermic patients with high DNA fragmentation index (&gt;25%) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. All the 3 groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate, clinical pregnancy rate and miscarriage rate.

Main results and the role of chance

Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar among all 4 groups.

Among 4 groups, There was a statistically significant increase observed in Group A (Microfluidic Sperm Sorting), day 3 grade A embryo development rate (60% vs. 42% vs. 38% vs. 40%, p-0.016) and clinical pregnancy rate (62% vs. 46% vs. 41% vs 43%, p-0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78% vs. 76% vs. 78%, p-0.80) comparing group B, group C and group D. But significantly higher miscarriage rate (12% vs. 11% vs. 25%, 12%) observed in density gradient (Group C) technique.

Limitations, reasons for caution

Larger randomised control studies are needed to strengthen these results.

Wider implications of the findings

We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI, Density Gradient and Swim-up techniues. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate.

Trial registration number

MCDH/2019/35

Hypertriton Production in p-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The study of nuclei and antinuclei production has proven to be a powerful tool to investigate the formation mechanism of loosely bound states in high-energy hadronic collisions. The first measurement of the production of _{Λ}^{3}H in p-Pb collisions at sqrt[s_{NN}]=5.02  TeV is presented in this Letter. Its production yield measured in the rapidity interval -1<y<0 for the 40% highest-multiplicity p-Pb collisions is dN/dy=[6.3±1.8(stat)±1.2(syst)]×10^{-7}. The measurement is compared with the expectations of statistical hadronization and coalescence models, which describe the nucleosynthesis in hadronic collisions. These two models predict very different yields of the hypertriton in charged particle multiplicity environments relevant to small collision systems such as p-Pb, and therefore the measurement of dN/dy is crucial to distinguish between them. The precision of this measurement leads to the exclusion with a significance larger than 6.9σ of some configurations of the statistical hadronization model, thus constraining the theory behind the production of loosely bound states at hadron colliders.

Burden, patterns, and impact of multimorbidity in North India: findings from a rural population-based study

Aim

To estimate the prevalence, socio-demographic determinants, common disease combinations, and health impact of multimorbidity among a young rural population.

Methods

We conducted a cross-sectional survey among participants aged ≥30 years in rural Punjab, North India, from Jan 2019 to April 2019. Multimorbidity was defined as the coexistence of ≥two conditions using a 14-condition tool validated in India. We also calculated a multimorbidity-weighted index (MWI), which provides a weight to each disease based on its impact on physical functioning. Logistic regression was conducted to evaluate the association with sociodemographic variables, mental health (PHQ-9), physical functioning (ADL scale), and self-rated health (SRH).

Results

We analyzed data from 3213 adults [Mean age 51.5 (±13), 54% women]. Prevalence of single chronic condition, multimorbidity, and MWI was 28.6, 18% and − 1.9 respectively. Age, higher wealth index and ever use alcohol were significantly associated with multimorbidity. Overall, 2.8% of respondents had limited physical functioning, 2.1% had depression, and 61.5% reported low SRH. Poorer health outcomes were more prevalent among the elderly, women, less educated, and those having lower wealth index and multimorbidity, were found to be significantly associated with poor health outcomes.

Conclusions

The burden of multimorbidity was high in this young rural population, which portends significant adverse effects on their health and quality of life. The Indian health system should be reconfigured to address this emerging health priority holistically, by adopting a more integrated and sustainable model of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13495-0.

AB1015 SUSTAINED SYNERGISTIC EFFECT ON BONE MINERAL DENSITY TREND WITH SHORT TERM COMBINATION OF TERIPARATIDE AND DENOSUMAB FOLLOWED BY DENOSUMAB ALONE IN POSTMENOPAUSAL WOMEN - A SINGLE INDIAN CENTRE EXPERIENCE

Background

Use of Teriparatide (PTH) with Denosumab (Dmab) have shown to have a synergistic effect on the bone mineral density (BMD) of both Hip and Spine1 because Dmab completely inhibits the PTH induced bone resorption and does not interfere with the bone formation.

Objectives

Since PTH has a limited period of approved use, a short term (6 months) use of PTH in combination with Dmab followed by continued use of Dmab may show a sustained synergistic effect of the combination.

Methods

The BMD trends from real time data from a central dual-energy x-ray absorptiometry (DXA) at our centre in India was studied retrospectively to see if the effect was sustained. Women with postmenopausal osteoporosis who were treated with a combination of Dmab 60 mg via subcutaneous injection (sc) at 6 monthly interval along with PTH 20 mcg sc daily for the first 6 months (Combo), followed by Dmab alone for the next six months were inculded in the study group. Average BMD at L2, L3 and L4 (sp BMD), and Right and Left Hip (hip BMD) were studied from before treatment (a BMD), after the Combo treatment (b BMD) and after 6 months of the second injection of Dmab (c BMD). The mean percentage trend change between a-b BMD and b-c BMD were evaluated. Out of the patients treated with the protocol, 25 were randomly chosen for the retrospective analysis. The least significant change (LSC) 2 from a single centre DXA was used to validate the findings.

Results

The percentage change after the treatment for 6 months with the Combo was found to be 5.22% in the Spine (LSC= 2.6%)2 and 4.13% in the hip (LSC=3.6%)2. The trend after use of Dmab alone was 5.39% in the spine and 2.93% in the hip showing sustained synergistic effect of the Combo for at least 6 months with the use of Dmab alone. The effect was more profound in the spine than the hip. A p>0.05 was considered statistically significant. Table 1 shows the percentage BMD changes.

Table 1.

Percentage BMD changes

BMD trend (n=25)sp BMD (LSC – 2.6%)hip BMD (LSC – 3.6%)a-b BMD5.22%4.13%b-c BMD5.39%2.93%

sp BMD - Mean of L2,L3 & L4 Spine BMD, hip BMD - Mean of Right and Left Hip BMD, a-b BMD - Percent change in BMD from before treatment to 6 months of PTH & Dmab, b-c BMD -Percentage change in BMD form after 6 of Dmab & PTH to next 6 mths Dmab alone and LSC – Least significant change from a single DXA machine.

Conclusion

These findings suggest that a short term combination of Dmab and PTH for 6 months followed by Dmab alone shows sustained synergistic effect on the BMD trend which was more profound in the spine than the hip.

This would help in judicious and cost effective utilisation of the limited period of PTH use.

References

[1]Tsai JN et al: Teriparatide and denosumab, alone or combined, in women with postmenopausal osteoporosis: the DATA study randomised trial. Lancet. 2013; 382: 50-56

[2]Shepherd JA1, Lu Y. A generalized least significant change for individuals measured on different DXA systems.

Disclosure of Interests

None declared

AB1028 REGRESSIVE BONE MINERAL DENSITY TRENDS SEEN WITH DELAY IN FOLLOW UP OF DENOSUMAB TREATMENT DUE TO THE PANDEMIC INDUCED LOCKDOWN - A SINGLE CENTRE INDIAN EXPERIENCE

Background

Denosumab (Dmab), a fully human monoclonal antibody that inhibits receptor activator of nuclear factor kappa-β ligand (RANKL), which selectively inhibits osteoclastogenesis can be used for a long period unlike the relatively short period with Teriparatide.1-2 However the effects of Dmab can quickly regress if the treatment is delayed.3

Objectives

The pandemic led to multiple prolonged lockdowns since March 2020 to Jan 2022 in India. This resulted in follow up Dmab treatment delays. The retrospective study was aimed to look for the effect of the delays.

Methods

The bone mineral density (BMD) trends from the central dual-energy x-ray absorptiometry (DXA) at our centre were studied. The trends of patients under Dmab for one year and delay in follow up for 10 - 12 months for the forth dose were evaluated. 21 postmenopausal women who had been under treatment with Dmab 60 mg subcutaneous injection at 6 monthly interval for one year followed up with such delays. 6 were excluded because of history of sars-cov-2 infection and glucocorticoid use. In the study group of 15 (n=15), the mean BMD at L2, L3 & L4 (sp BMD) and Right and Left Hip (hip BMD) were studied from before treatment (a BMD), 6 months after 1st and at the time of 2nd injection (b BMD), 6 months of the 2nd and at the time of 3 rd injection of Dmab (c BMD), and that due to delay in follow up of 10-12 months (d BMD). The mean percentage trend change between a-b, b-c, and c-d BMDs was evaluated. The least significant change (LSC) 4 from a single centre DXA was used to validate the findings.

Results

The mean percentage change after the treatment for the 1st 6 months of Dmab (a-b BMD) was 4.08% and 3.60% and the second injection resulted in a further change (b-c BMD) of 5.98% and 4.52% in the sp BMD & hip BMD respectively. The delay in follow up of 10-12 months resulted in a change (c-d BMD) of -7.81% in the sp BMD and -2.96% in the hip BMD. The LSC from a single centre DXA is 2.6% and 3.6% for sp BMD and hip BMD respectively. A p>0.05 was considered statistically significant. Table 1 shows the BMD changes.

Table 1.

Percentage BMD changes

BMD trend (n=15)sp BMD (LSC – 2.6%)hip BMD (LSC – 3.6%)a-b BMD4.08%3.60%b-c BMD5.98%4.52%c-d BMD-7.81%-2.96%

sp BMD - Mean of L2,L3 & L4 Spine BMD, hip BMD - Mean of Right and Left Hip BMD, a-b BMD - Percent change in BMD from before to 6 months after Ist & at the time of 2nd Dmab, b-c BMD - Percentage change in BMD 6 months after 2nd & at the time of 3rd Dmab, c-d BMD - Percentage change in BMD after 3rd Dmab & follow up after delay of 10-12 months and LSC – Least significant change.

Conclusion

These findings suggest that regressive trend in BMD are seen when the treatment with Dmab is delayed even as early as 10 to 12 months. It was seen much faster in the spine compared to the hip.

It is therefore advised that short term treatment with Dmab without follow up could lead to loss of all gains and may also worsen the osteoporosis.

References

[1]Anastasilakis A.D., Polyzos S.A., Makras P. Therapy of Endocrine Disease: Denosumab vs bisphosphonates for the treatment of postmenopausal osteoporosis. Eur. J. Endocrinol. 2018;179:R31–R45. doi: 10.1530/EJE-18-0056.

[2]Anastasilakis A.D., Polyzos S.A., Yavropoulou M.P., Makras P. Combination and sequential treatment in women with postmenopausal osteoporosis. Expert Opin. Pharmacother. 2020;21:477–490. doi: 10.1080/14656566.2020.1717468.

[3]Bone H.G., Bolognese M.A., Yuen C.K., Kendler D.L., Miller P.D., Yang Y.-C., Grazette L., Martin J.S., Gallagher J.C. Effects of Denosumab Treatment and Discontinuation on Bone Mineral Density and Bone Turnover Markers in Postmenopausal Women with Low Bone Mass. J. Clin. Endocrinol. Metab. 2011;96:972–980. doi: 10.1210/jc.2010-1502.

[4]Shepherd JA1, Lu Y. A generalized least significant change for individuals measured on different DXA systems.

Disclosure of Interests

None declared

Improving care for hypertension and diabetes in india by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care

Background

The growing burden of hypertension and diabetes is one of the major public health challenges being faced by the health system in India. Clinical Decision Support Systems (CDSS) that assist with tailoring evidence-based management approaches combined with task-shifting from more specialized to less specialized providers may together enhance the impact of a program. We sought to integrate a technology “CDSS” and a strategy “Task-shifting” within the Government of India’s (GoI) Non-Communicable Diseases (NCD) System under the Comprehensive Primary Health Care (CPHC) initiative to enhance the program’s impact to address the growing burden of hypertension and diabetes in India.

Methods

We developed a model of care “I-TREC” entirely calibrated for implementation within the current health system across all facility types (Primary Health Centre, Community Health Centre, and District Hospital) in a block in Shaheed Bhagat Singh (SBS) Nagar district of Punjab, India. We undertook an academic-community partnership to incorporate the combination of a CDSS with task-shifting into the GoI CPHC-NCD system, a platform that assists healthcare providers to record patient information for routine NCD care. Academic partners developed clinical algorithms, a revised clinic workflow, and provider training modules with iterative collaboration and consultation with government and technology partners to incorporate CDSS within the existing system.

Discussion

The CDSS-enabled GoI CPHC-NCD system provides evidence-based recommendations for hypertension and diabetes; threshold-based prompts to assure referral mechanism across health facilities; integrated patient database, and care coordination through workflow management and dashboard alerts. To enable efficient implementation, modifications were made in the patient workflow and the fulcrum of the use of technology shifted from physician to nurse.

Conclusion

Designed to be applicable nationwide, the I-TREC model of care is being piloted in a block in the state of Punjab, India. Learnings from I-TREC will provide a roadmap to other public health experts to integrate and adapt their interventions at the national level.

Trial registration

CTRI/2020/01/022723.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08025-y.

Polarization of Λ and Λ[over ¯] Hyperons along the Beam Direction in Pb-Pb Collisions at sqrt[s]_{NN}=5.02 TeV

The polarization of the Λ and Λ[over ¯] hyperons along the beam (z) direction, P_{z}, has been measured in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV recorded with ALICE at the Large Hadron Collider (LHC). The main contribution to P_{z} comes from elliptic flow-induced vorticity and can be characterized by the second Fourier sine coefficient P_{z,s2}=⟨P_{z}sin(2φ-2Ψ_{2})⟩, where φ is the hyperon azimuthal emission angle and Ψ_{2} is the elliptic flow plane angle. We report the measurement of P_{z,s2} for different collision centralities and in the 30%-50% centrality interval as a function of the hyperon transverse momentum and rapidity. The P_{z,s2} is positive similarly as measured by the STAR Collaboration in Au-Au collisions at sqrt[s_{NN}]=200  GeV, with somewhat smaller amplitude in the semicentral collisions. This is the first experimental evidence of a nonzero hyperon P_{z} in Pb-Pb collisions at the LHC. The comparison of the measured P_{z,s2} with the hydrodynamic model calculations shows sensitivity to the competing contributions from thermal and the recently found shear-induced vorticity, as well as to whether the polarization is acquired at the quark-gluon plasma or the hadronic phase.

Pattern of Male Hypogonadism and Outcome of Treatment in South Rajasthan

Male reproductive functions are governed by hypothalamic pituitary testicular axis. If any component of this axis malfunctions, then hypogonadism will develop which is characterized by ill-defined secondary sexual features and low serum testosterone. The common patterns seen are primary and secondary testicular failure in the young; and late onset hypogonadism in the elderly. All such cases can be virilized and managed by androgen supplementation. Spermatogenesis can be induced by use of appropriate gonadotropins in selected cases. The aim of the study was to find out the pattern, management and outcome of male hypogonadism.

MATERIAL

It was a prospective questionnaire based observational study, carried out on infertile hypogonadic males, attending medicine outdoor at medical college hospital from January 2015 to December 2020. There were 50 males with hypogonadic features, cases of late onset of hypogonadism were excluded. Sexual maturity rating, semen analysis, serum testosterone and FSH level were estimated in all patients at baseline and at 6 months duration of treatment. Testicular biopsy, Karyotyping and MRI brain were performed in selected cases. Azoospermic patients having hypogonadotropic hypogonadism were treated with long-acting testosterones and gonadotropins.

OBSERVATION

The study subjects were infertile azoospermic males. On the basis of serum FSH and testosterone levels, they were classified into two groups. Group A (n=42) cases were hypergonadotropic hypogonadism or primary testicular failure; of these 32 were Klinefelter syndrome (XXY), 7 chronic orchitis and 3 empty scrotal syndrome including one case of anorchia. These patients also developed other systemic illnesses in addition to hypogonadism. Group B (n=8) hypogonadotropic hypogonadism or secondary testicular failure; of these 2 were Kallman syndrome and the rest were idiopathic. After testosterone replacement all patients were virilized and there was marked improvement in libido and androgenization.

CONCLUSION

The study brings out that primary testicular failure is more common than secondary testicular failure. Both pattern of hypogonadism should receive lifelong androgen replacement therapy; otherwise, they will be a basket of multiple systemic disorders. Presently testosterone undecanoate once in every three months is the agent of choice.

Measurement of the Groomed Jet Radius and Momentum Splitting Fraction in pp and Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

This article presents groomed jet substructure measurements in pp and Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector. The soft drop grooming algorithm provides access to the hard parton splittings inside a jet by removing soft wide-angle radiation. We report the groomed jet momentum splitting fraction, z_{g}, and the (scaled) groomed jet radius, θ_{g}. Charged-particle jets are reconstructed at midrapidity using the anti-k_{T} algorithm with resolution parameters R=0.2 and R=0.4. In heavy-ion collisions, the large underlying event poses a challenge for the reconstruction of groomed jet observables, since fluctuations in the background can cause groomed parton splittings to be misidentified. By using strong grooming conditions to reduce this background, we report these observables fully corrected for detector effects and background fluctuations for the first time. A narrowing of the θ_{g} distribution in Pb-Pb collisions compared to pp collisions is seen, which provides direct evidence of the modification of the angular structure of jets in the quark-gluon plasma. No significant modification of the z_{g} distribution in Pb-Pb collisions compared to pp collisions is observed. These results are compared with a variety of theoretical models of jet quenching, and provide constraints on jet energy-loss mechanisms and coherence effects in the quark-gluon plasma.

Measurement of Prompt D^{0}, Λ_{c}^{+}, and Σ_{c}^{0,++}(2455) Production in Proton-Proton Collisions at sqrt[s]=13 TeV

The p_{T}-differential production cross sections of prompt D^{0}, Λ_{c}^{+}, and Σ_{c}^{0,++}(2455) charmed hadrons are measured at midrapidity (|y|<0.5) in pp collisions at sqrt[s]=13  TeV. This is the first measurement of Σ_{c}^{0,++} production in hadronic collisions. Assuming the same production yield for the three Σ_{c}^{0,+,++} isospin states, the baryon-to-meson cross section ratios Σ_{c}^{0,+,++}/D^{0} and Λ_{c}^{+}/D^{0} are calculated in the transverse momentum (p_{T}) intervals 2<p_{T}<12 and 1<p_{T}<24  GeV/c. Values significantly larger than in e^{+}e^{-} collisions are observed, indicating for the first time that baryon enhancement in hadronic collisions also extends to the Σ_{c}. The feed-down contribution to Λ_{c}^{+} production from Σ_{c}^{0,+,++} is also reported and is found to be larger than in e^{+}e^{-} collisions. The data are compared with predictions from event generators and other phenomenological models, providing a sensitive test of the different charm-hadronization mechanisms implemented in the models.

The impact of omalizumab on paid and unpaid work productivity among severe Japanese cedar pollinosis (JCP) patients

AIMS

Japanese cedar pollinosis (JCP) is a form of seasonal allergic rhinitis that affects 38.8% of the Japanese population. Particularly severe and most severe symptoms among JCP patients can lead to impairments of paid work productivity and unpaid work activities. Indeed, the current standard of care (SoC) is not always able to relieve these symptoms. Omalizumab, a novel JCP treatment recently approved in Japan, provides an effective add-on therapy to the SoC. This study estimates the effect of omalizumab on paid and unpaid work activities (i.e. its social impact) in patients with severe and most severe JCP symptoms in Japan.

METHODS

The impact of omalizumab was estimated through a one-year static cohort model using the Work Productivity and Activity Impairment Allergy Specific (WPAI-AS) questionnaire derived from a clinical trial on omalizumab enrolling patients with severe and most severe JCP symptoms, which had been conducted in Japan. This effect was quantified using Japanese official statistics on employment and time use. The human capital approach and the proxy good approach were employed to monetize paid and unpaid work activities, respectively. A sensitivity analysis was implemented to account for modeling structural uncertainties.

RESULTS

Our results show that the use of omalizumab might reduce the paid and unpaid work productivity losses due to severe and most severe JCP by nearly one-third. In the severe symptom period of three weeks, 36.6 million hours of lost paid and unpaid work hours could be avoided, which sums up to a monetized productivity loss of 728.3 million USD.

CONCLUSIONS

Omalizumab could provide substantial benefits in terms of paid and unpaid work activities in patients with severe and most severe JCP. Our results also highlight the importance of considering unpaid work in estimating productivity costs due to poor health.

Measurement of the Cross Sections of Ξ_{c}^{0} and Ξ_{c}^{+} Baryons and of the Branching-Fraction Ratio BR(Ξ_{c}^{0}→Ξ^{-}e^{+}ν_{e})/BR(Ξ_{c}^{0}→Ξ^{-}π^{+}) in pp Collisions at sqrt[s]=13 TeV

The p_{T}-differential cross sections of prompt charm-strange baryons Ξ_{c}^{0} and Ξ_{c}^{+} were measured at midrapidity (|y|<0.5) in proton-proton (pp) collisions at a center-of-mass energy sqrt[s]=13  TeV with the ALICE detector at the LHC. The Ξ_{c}^{0} baryon was reconstructed via both the semileptonic decay (Ξ^{-}e^{+}ν_{e}) and the hadronic decay (Ξ^{-}π^{+}) channels. The Ξ_{c}^{+} baryon was reconstructed via the hadronic decay (Ξ^{-}π^{+}π^{+}) channel. The branching-fraction ratio BR(Ξ_{c}^{0}→Ξ^{-}e^{+}ν_{e})/BR(Ξ_{c}^{0}→Ξ^{-}π^{+})=1.38±0.14(stat)±0.22(syst) was measured with a total uncertainty reduced by a factor of about 3 with respect to the current world average reported by the Particle Data Group. The transverse momentum (p_{T}) dependence of the Ξ_{c}^{0}- and Ξ_{c}^{+}-baryon production relative to the D^{0} meson and to the Σ_{c}^{0,+,++}- and Λ_{c}^{+}-baryon production are reported. The baryon-to-meson ratio increases toward low p_{T} up to a value of approximately 0.3. The measurements are compared with various models that take different hadronization mechanisms into consideration. The results provide stringent constraints to these theoretical calculations and additional evidence that different processes are involved in charm hadronization in electron-positron (e^{+}e^{-}) and hadronic collisions.

Λ_{c}^{+} Production and Baryon-to-Meson Ratios in pp and p-Pb Collisions at sqrt[s_{NN}]=5.02 TeV at the LHC

The prompt production of the charm baryon Λ_{c}^{+} and the Λ_{c}^{+}/D^{0} production ratios were measured at midrapidity with the ALICE detector in pp and p-Pb collisions at sqrt[s_{NN}]=5.02  TeV. These new measurements show a clear decrease of the Λ_{c}^{+}/D^{0} ratio with increasing transverse momentum (p_{T}) in both collision systems in the range 2<p_{T}<12  GeV/c, exhibiting similarities with the light-flavor baryon-to-meson ratios p/π and Λ/K_{S}^{0}. At low p_{T}, predictions that include additional color-reconnection mechanisms beyond the leading-color approximation, assume the existence of additional higher-mass charm-baryon states, or include hadronization via coalescence can describe the data, while predictions driven by charm-quark fragmentation processes measured in e^{+}e^{-} and e^{-}p collisions significantly underestimate the data. The results presented in this Letter provide significant evidence that the established assumption of universality (colliding-system independence) of parton-to-hadron fragmentation is not sufficient to describe charm-baryon production in hadronic collisions at LHC energies.

Experimental Evidence for an Attractive p-ϕ Interaction

This Letter presents the first experimental evidence of the attractive strong interaction between a proton and a ϕ meson. The result is obtained from two-particle correlations of combined p-ϕ⊕ p[over ¯]-ϕ pairs measured in high-multiplicity pp collisions at sqrt[s]=13  TeV by the ALICE Collaboration. The spin-averaged scattering length and effective range of the p-ϕ interaction are extracted from the fully corrected correlation function employing the Lednický-Lyuboshits approach. In particular, the imaginary part of the scattering length vanishes within uncertainties, indicating that inelastic processes do not play a prominent role for the p-ϕ interaction. These data demonstrate that the interaction is dominated by elastic p-ϕ scattering. Furthermore, an analysis employing phenomenological Gaussian- and Yukawa-type potentials is conducted. Under the assumption of the latter, the N-ϕ coupling constant is found to be g_{N-ϕ}=0.14±0.03(stat)±0.02(syst). This work provides valuable experimental input to accomplish a self-consistent description of the N-ϕ interaction, which is particularly relevant for the more fundamental studies on partial restoration of chiral symmetry in nuclear medium.

A model for national assessment of barriers for implementing digital technology interventions to improve hypertension management in the public health care system in India

BACKGROUND

There is substantial interest in leveraging digital health technology to support hypertension management in low- and middle-income countries such as India. The potential for healthcare infrastructure and broader context to support such initiatives in India has not been examined. We evaluated existing healthcare infrastructure to support digital health interventions and examined epidemiologic, socioeconomic, and geographical contextual correlates of healthcare infrastructure in 544 districts covering 29 states and union territories across India.

METHODS

The study was a cross-sectional analysis of India's Fourth District Level Household and Facility Survey (DLHS-4; 2012-2014), the most up-to-date nationally representative district-level healthcare infrastructure data. Facilities were the unit of analysis, and analyses accounted for clustering within states. The main outcome was healthcare system infrastructural context to implement hypertension management programs. Domains included diagnostics (functional BP instrument), medications (anti-hypertensive medication in stock), essential clinical staff (e.g., staff nurse, medical officer, pharmacist), and IT specific infrastructure (regular power supply, internet connection, computer availability). Descriptive analysis was conducted for infrastructure indicators based on the Indian Public Health Standards, and logistic regression was conducted to estimate the association between epidemiologic and geographical context (exposures) and the composite measure of healthcare system.

RESULTS

Data from 32,215 government facilities were analyzed. Among lowest-tier subcenters, 30% had some IT infrastructure, while at the highest-tier district hospitals, 92% possessed IT infrastructure. At mid-tier primary health centres and community health centres, IT infrastructure availability was 28 and 51%, respectively. For all but sub-centres, the availability of essential staff was lower than the availability of IT infrastructure. For all but district hospitals, higher levels of blood pressure, body mass index, and urban residents were correlated with more favorable infrastructure. By region, districts in Western India tended towards having the best prepared health facilities.

CONCLUSIONS

IT infrastructure to support digital health interventions is more frequently lacking at lower and mid-tier healthcare facilities compared with apex facilities in India. Gaps were generally larger for staffing than physical infrastructure, suggesting that beyond IT infrastructure, shortages in essential staff impose significant constraints to the adoption of digital health interventions. These data provide early benchmarks for state- and district-level planning.

Changes in mitral regurgitation following acute myocardial infarction: early and long-term follow-up

Background

Mitral regurgitation (MR) is commonly observed following acute myocardial infarction (MI). Localised left ventricular (LV) remodelling in the region of papillary muscles together with impaired myocardial contractility promote MR. There is a paucity of long-term follow-up studies to determine whether the severity of MR observed post-MI, changes with time.

Purpose

This study retrospectively followed up patients with MR detected following acute MI (AMI) to investigate changes in MR severity with time and assess for pre-discharge predictors of MR regression or progression.

Methods

Clinical records of 1000 patients admitted with AMI between 2016 and 2017 to a single centre were retrospectively interrogated. One hundred and nine patients met the inclusion criteria of MR on pre-discharge transthoracic echocardiography (TTE) and follow-up TTE scans. Echocardiographic parameters were investigated to determine predictors of progression or regression at follow-up. Patients were divided according to those who had early follow-up TTE (within 1-year) and late follow-up TTE (beyond 1-year).

Results

Early follow-up TTE was performed in 73 patients at a median of 6 (IQR 3–9) months. Patients had a mean age of 69±13 years and were predominantly male 50/73 (68%). At baseline, relative MR severities were: 49/73 (67%) mild MR, 23/73 (32%) moderate MR and 1 (1%) severe MR. At follow-up, MR had completely resolved in 18/73 (23%) patients, while 39/73 (53%) had mild MR, 15/73 (21%) moderate MR and 1 (1%) severe MR. Compared to patients with no resolution of MR, those with completel resolution were younger (mean age 62±16 vs 72±11 years; p=0.015) but there were no other significant differences between the groups. Resolution at early follow-up did not significantly influence long-term mortality rates. Late follow-up TTE was performed in 69 patients at a median 2.4 (IQR 2–3.2) years. Pre-discharge, 49/69 (71%) patients had mild MR and 20/69 (29%) moderate MR. At follow-up, MR had completely resolved in 18/69 (26%), and amongst patients with persistent MR, proportion of severities were: 37/69 (54%) mild MR, 11/69 (16%) moderate MR and 3/69 (4%) severe MR. Patients with progression of mild MR were more likely to have lower left ventricular ejection fraction (LVEF: 47±15 vs 57±12%; p=0.010) and greater indexed left ventricular end-systolic volume (LVESVi: 37±23 vs 25±14 ml/m2; p&lt;0.001) on pre-discharge TTE. Resolution of MR at late follow-up was associated with a reduction in long-term mortality [deaths: 2/55 (3%) vs 3/14 (21%); p=0.022] at a mean follow-up of 4.2 years from MI.

Conclusion

MR observed following AMI completely resolved in approximately one-quarter of patients at 6-month and 2-year follow-up. Progression of mild MR at long-term follow-up appears to be associated with increased mortality and is predicted by lower LVEF and greater LVESVi pre-discharge.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular assist device therapy improves severe secondary mitral regurgitation without mitral valve repair

Background

Severe secondary mitral regurgitation (MR) worsens prognosis in patients with medically managed heart failure (HF). In patients treated by left ventricular assist device (LVAD), it is unclear whether severe MR should be corrected at time of LVAD implantation.

Purpose

To evaluate impact of LVAD therapy on severe and non-severe secondary MR over 1 year.

Methods

Retrospective single centre study of consecutive patients who underwent HeartMate (HM)2 or HM3 LVAD implantation between January 2011 and March 2020.

Results

Of 155 patients, 20 were excluded due to LVAD exchange (n=10), mitral valve repair (n=1), or inaccessible pre-LVAD echocardiography (n=9). Based on multiparametric grading, 29/135 patients had severe secondary MR and 106/135 had non-severe secondary MR (including none). Severe MR patients were more often female [10/29 (34%) vs 11/106 (10%); p=0.002] but were of similar age (54±12 vs 55±9 years; p=0.624), size (27±5 vs 27±4 kg/m2; p=1.0), with equivalent renal function (53±22 vs 55±20 ml/min/1.73m2; p=0.641) and median pre-operative NT-proBNP [4076 (IQR 206–5438) vs 4914 (IQR 2706–7518) ng/L; p=0.488]. There were similar proportions of patients with ischaemic aetiology [16/29 (55%) vs 66/106 (62%); p=0.488) and those receiving HM2 [11/29 (38%) vs 32/106 (30%)] and HM3 [18/29 (62%) vs 74/106 (70%); p=0.575] LVAD. Echocardiography before LVAD implantation demonstrated similar left ventricular (LV) size (LV end-diastolic volume: 133±44 vs 118±50ml/m2; p=0.145, end-systolic volume: 107±41 vs 96±59ml/m2; p=0.348) and LV ejection fraction (17±9 vs 17±7%; p=1.0). Severe MR patients had significantly greater (p&lt;0.001) MR by proximal isovolumetric surface area (0.93±0.27 vs 0.60±0.16cm), vena contracta (0.79±0.32 vs 0.57±0.18cm), regurgitant volume (47±25 vs 24±12ml), and fraction (54±15 vs 37±13%). Follow-up (f/u) echocardiography was performed at a median 222 days (range 356 days). Patients who received cardiac transplantation before f/u echocardiography were excluded. Relative severities of MR at f/u were: none = 12 (46%), mild = 8 (31%), moderate = 5 (19%), severe = 1 (4%) amongst patients with severe MR pre-LVAD, and none = 55 (58%), mild = 26 (27%), moderate = 13 (14%), severe = 1 (1%) amongst patients with non-severe MR pre-LVAD. At 1-year, after excluding all patients who underwent cardiac transplantation (severe MR n=4; non-severe MR n=2), rates of HF hospitalisation [5/25 (20%) vs 16/104 (15%); p=0.575] and all-cause mortality [2/25 (18%) vs 22/104 (21%); p=0.129)] were similar, irrespective of pre-LVAD MR severity. No patient who died during follow-up had severe MR prior to death.

Conclusion

LVAD improves severe secondary MR in 96% of cases, resulting in 1-year rates of HF hospitalisation and mortality similar to patients without severe MR pre-LVAD. These data suggest mitral valve surgery at time of LVAD implantation is not warranted.

Funding Acknowledgement

Type of funding sources: None.

Multiharmonic Correlations of Different Flow Amplitudes in Pb-Pb Collisions at sqrt[s_{NN}]=2.76 TeV

The event-by-event correlations between three flow amplitudes are measured for the first time in Pb-Pb collisions, using higher-order symmetric cumulants. We find that different three-harmonic correlations develop during the collective evolution of the medium when compared to correlations that exist in the initial state. These new results cannot be interpreted in terms of previous lower-order flow measurements since contributions from two-harmonic correlations are explicitly removed in the new observables. A comparison to Monte Carlo simulations provides new and independent constraints for the initial conditions and system properties of nuclear matter created in heavy-ion collisions.

P–084 Microfluidic Sperm Sorting (MFSS) technique versus Physiological Intracytoplasmic Sperm Injection (PICSI) technique in high DNA fragmentation index sperm samples

Study question

To evaluate the effectiveness of using Microfluidic Sperm Sorting (MFSS) technique and Physiological Intracytoplasmic Sperm Injection (PICSI) technique in patient with high DNA fragmentation index (DFI) sperm samples.

Summary answer

Sperm selected by microfluidic sorting are associated with significant increase in day 3 grade A embryo development rate, clinical pregnancy rate over PICSI.

What is known already

DNA damage is unrecognisable in living sperm prior to insemination and an increased sperm DNA fragmentation index has been associated with lower fertilization rates, impaired embryo development and reduced pregnancy rates. Standard semen processing techniques are associated with centrifugation, which may induce reactive oxygen species and DNA damage. In strategies to minimize sperm DNA fragmentation, Physiological ICSI can relatively reduce sperm DNA fragmentation by 67.9% (Parmegiani et al., 2010) while new technique Microfluidic sperm sorter technique also demonstrate sperm selection with significantly reduced DNA damage.

Study design, size, duration

A prospective randomised study was conducted from 1st August 2019 to 31st December 2020. Two hundred patients were randomised by computer generated list and divided into 2 groups. Group A (n = 100) , in which sperm were processed by microfluidic sperm sorter (MFSS) while in group B (n = 100), sperm were selected by Physiological Intracytoplasmic Sperm Injection (PICSI) technique and morphologically normal motile sperm were injected by Intracytoplasmic sperm injection (ICSI) technique in all mature oocytes.

Participants/materials, setting, methods

The study period included all normozoospermic patients with high DNA fragmentation index (&gt;25% ) while oligospermic, asthenozoospermic samples, patients with poor ovarian reserve and advanced age were excluded from the study. All A grade embryos were vitrified and transferred in frozen embryo replacement cycle. Both groups were compared on the basis of fertilisation rate, day 3 grade A embryo development rate , clinical pregnancy rate and miscarriage rate.

Main results and the role of chance

Cycle characteristics (female age, length of stimulation, gonadotrophin dose, number of oocytes and number of transferred embryos) were similar in both groups. Between the 2 groups, There was a significant increase observed in day 3 grade A embryo development rate (60% vs. 42%, p–0.016) and clinical pregnancy rate (62% vs. 46%, p–0.049), while no statistical significant difference observed in fertilisation rate (82% vs. 78%, p–0.80) and miscarriage rate ( 12% vs. 11%, p- 1). Limitations, reasons for caution: Larger randomised control studies are needed to strengthen these results.

Wider implications of the findings: We have demonstrated that sperm sorted by microfluidic helps in selection of sperm with better DNA integrity over Physiological ICSI. Using it in routine practice can help in reducing the negative effect of reactive oxygen species and thus improve pregnancy rate and live birth rate.

Trial registration number

MCDH/2019/31

Soft-Dielectron Excess in Proton-Proton Collisions at sqrt[s]=13 TeV

A measurement of dielectron production in proton-proton (pp) collisions at sqrt[s]=13  TeV, recorded with the ALICE detector at the CERN LHC, is presented in this Letter. The data set was recorded with a reduced magnetic solenoid field. This enables the investigation of a kinematic domain at low dielectron (ee) invariant mass m_{ee} and pair transverse momentum p_{T,ee} that was previously inaccessible at the LHC. The cross section for dielectron production is studied as a function of m_{ee}, p_{T,ee}, and event multiplicity dN_{ch}/dη. The expected dielectron rate from hadron decays, called hadronic cocktail, utilizes a parametrization of the measured η/π^{0} ratio in pp and proton-nucleus collisions, assuming that this ratio shows no strong dependence on collision energy at low transverse momentum. Comparison of the measured dielectron yield to the hadronic cocktail at 0.15<m_{ee}<0.6  GeV/c^{2} and for p_{T,ee}<0.4  GeV/c indicates an enhancement of soft dielectrons, reminiscent of the "anomalous" soft-photon and soft-dilepton excess in hadron-hadron collisions reported by several experiments under different experimental conditions. The enhancement factor over the hadronic cocktail amounts to 1.61±0.13(stat)±0.17(syst,data)±0.34(syst,cocktail) in the ALICE acceptance. Acceptance-corrected excess spectra in m_{ee} and p_{T,ee} are extracted and compared with calculations of dielectron production from hadronic bremsstrahlung and thermal radiation within a hadronic many-body approach.

Exploring what is important to patients with regards to quality of life after experiencing a lower limb reconstructive procedure: a qualitative evidence synthesis

BACKGROUND

Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction surgery on patients' quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This review aimed to synthesise qualitative evidence to identify what is important to patients requiring, undergoing, or following reconstructive surgery for lower limb conditions.

METHODS

MEDLINE, Embase, PsychINFO and Cinahl were searched from inception until November 2020. Studies were included if they employed qualitative research methods, involved patients requiring, undergoing or following lower limb reconstruction and explored patients' experiences of care, treatment, recovery and QOL. Mixed methods studies that did not separately report qualitative findings, mixed population studies that were not separately reported and studies in languages other than English were excluded. Included studies were analysed using thematic synthesis. The Critical Appraisal Skills Programme qualitative studies checklist was used to undertake quality assessment.

RESULTS

Nine studies met the inclusion criteria. The thematic synthesis identified two overarching themes: (1) areas of living key to QOL for lower limb reconstruction patients and (2) moving towards a new normal. The way in which lower limb reconstruction affects an individual's QOL and their recovery is complex and is influenced by a range of inter-related factors, which will affect patients to varying degrees depending on their individual circumstances. We identified these factors as: pain, daily functioning and lifestyle, identity, income, emotional wellbeing, support, the ability to adapt and adjust and the ability to move forwards.

CONCLUSIONS

The way patients' QOL is affected after a lower limb reconstruction is complex, may change over time and is strongly linked to their recovery. These findings will aid us in developing a conceptual framework which identifies the outcomes important to patients and those that should be included in a PROM. Further research is then required to establish whether the range of factors we identified are captured by existing PROMs. Depending on the outcome of this work, a new PROM for patients following lower limb reconstruction may be required.

Elliptic Flow of Electrons from Beauty-Hadron Decays in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The elliptic flow of electrons from beauty hadron decays at midrapidity (|y|<0.8) is measured in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The azimuthal distribution of the particles produced in the collisions can be parametrized with a Fourier expansion, in which the second harmonic coefficient represents the elliptic flow, v_{2}. The v_{2} coefficient of electrons from beauty hadron decays is measured for the first time in the transverse momentum (p_{T}) range 1.3-6  GeV/c in the centrality class 30%-50%. The measurement of electrons from beauty-hadron decays exploits their larger mean proper decay length cτ≈500  μm compared to that of charm hadrons and most of the other background sources. The v_{2} of electrons from beauty hadron decays at midrapidity is found to be positive with a significance of 3.75  σ. The results provide insights into the degree of thermalization of beauty quarks in the medium. A model assuming full thermalization of beauty quarks is strongly disfavored by the measurement at high p_{T}, but is in agreement with the results at low p_{T}. Transport models including substantial interactions of beauty quarks with an expanding strongly interacting medium describe the measurement within uncertainties.

Left ventricular function and clinical heart failure after myocardial infarction revascularized with percutaneous coronary intervention - comparison between STEMI and NSTEMI in modern practice

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVSD) is a common consequence of myocardial infarction (MI). Data from historic series identified LVSD in up to 60% of patients post-MI. However, in modern practice, with high-sensitivity cardiac biomarkers leading to early detection of MI and widespread use of early revascularization, the prevalence of LVSD in the acute phase of MI and its impact on subsequent clinical heart failure remains unknown.

Purpose

To ascertain the prevalence of LVSD on pre-discharge echocardiography and its impact on subsequent clinical heart failure after type 1 MI treated with percutaneous coronary intervention (PCI) in a UK tertiary cardiac centre.

Methods

A retrospective electronic patient records review of consecutive patients with type 1 MI treated with PCI between January 2016 - December 2017. Patients treated conservatively or with surgical revascularization were excluded.

Results

1000 consecutive patients were identified and 948/1000 who had an inpatient echocardiogram prior to discharge were included in this analysis – 413 ST elevation MI (STEMI) and 535 non-ST elevation (NSTEMI). Median door to balloon time for STEMI was 42 minutes (IQR 28-79). Median time from symptom onset to intervention for NSTEMI was 3 days (IQR 1-6). LVSD was defined as left ventricular ejection fraction (LVEF) &lt;50% on transthoracic echocardiogram carried out during the hospital episode. LVSD was significantly more prevalent in patients with STEMI compared to NSTEMI (37.4% vs 17.3%, p &lt; 0.001). Median LVEF was significantly lower in the STEMI population (55%, IQR 45-60) compared to patients with NSTEMI (60%, IQR 54-65), p &lt; 0.001. However, rates of clinical heart failure at index presentation with MI did not vary significantly between STEMI and NSTEMI patients (6.1% vs 4.9%, p = 0.414). In stepwise multivariate regression models: age, peak troponin and previous coronary artery bypass grafting were predictors of LVEF, whereas LVEF and previous MI were predictors of clinical heart failure

Patients with LVSD on pre-discharge echocardiography had significantly higher rates of 30-day readmission with heart failure (2.9% vs 0.7%, p = 0.017), 30-day all-cause mortality (6.1% vs 2%, p = 0.001), 30-day cardiac mortality (5.7% vs 1%, p &lt; 0.001) and 2-year all-cause mortality (5.7% vs 1.6%, p = 0.001). However, at 2-years, there was no difference in hospital readmission with heart failure (0.8% vs 0.3%, p = 0.276). There were no significant differences between STEMI and NSTEMI patients for these endpoints.

Conclusions

Early revascularisation with PCI has led to a reduction in the prevalence of early LVSD post-MI compared to historical data. However, the presence of LVSD remains a powerful predictor of adverse clinical outcomes. Despite lower rates of LVSD on pre-discharge echocardiography in patients with NSTEMI compared with STEMI, the incidence of subsequent clinical heart failure is similar. This however may be underestimated due to survival bias.

Efficacy of Low-Frequency Repetitive Transcranial Magnetic Stimulation in Ischemic Stroke: A Double-Blind Randomized Controlled Trial

Objective

To investigate the role of low-frequency repetitive transcranial magnetic stimulation (rTMS) along with conventional physiotherapy in the functional recovery of patients with subacute ischemic stroke.

Design

Double-blind, parallel group, randomized controlled trial.

Setting

The outpatient department of a tertiary hospital participants: first ever ischemic stroke patients (N=96) in the previous 15 days were recruited and were randomized after a run-in period of 75±7 days into real rTMS (n=47) and sham rTMS (n=49) groups.

Intervention

Conventional physical therapy was given to both the groups for 90±7 days postrecruitment. Total 10 sessions of low-frequency rTMS on contralesional premotor cortex was administered to real rTMS group (n=47) over a period of 2 weeks followed by physiotherapy regime for 45-50 minutes.

Main Outcome Measures

The primary efficacy outcomes were change in modified Barthel Index (mBI) score (pre- to postscore) and proportion of participants with mBI score more than 90, measured at 90±7 days postrecruitment. The secondary outcomes were change in Fugl-Meyer Assessment–upper extremity, Fugl-Meyer Assessment–lower extremity, Hamilton Depression Scale, modified Rankin Scale, and National Institute of Health and Stroke Scale (pre- to post-rTMS) scores at 90±7 days post recruitment.

Results

Modified intention to treat analysis showed a significant increase in the mBI score from pre- to post-rTMS in real rTMS group (4.96±4.06) versus sham rTMS group (2.65±3.25). There was no significant difference in proportion of patients with mBI>90 (55% vs 59%; P=.86) at 3 months between the groups.

Conclusion

In patients with subacute ischemic stroke, 1-Hz low-frequency rTMS on contralesional premotor cortex along with conventional physical therapy resulted in significant change in mBI score.