Observation of Seven Astrophysical Tau Neutrino Candidates with IceCube

We report on a measurement of astrophysical tau neutrinos with 9.7 yr of IceCube data. Using convolutional neural networks trained on images derived from simulated events, seven candidate ν_{τ} events were found with visible energies ranging from roughly 20 TeV to 1 PeV and a median expected parent ν_{τ} energy of about 200 TeV. Considering backgrounds from astrophysical and atmospheric neutrinos, and muons from π^{±}/K^{±} decays in atmospheric air showers, we obtain a total estimated background of about 0.5 events, dominated by non-ν_{τ} astrophysical neutrinos. Thus, we rule out the absence of astrophysical ν_{τ} at the 5σ level. The measured astrophysical ν_{τ} flux is consistent with expectations based on previously published IceCube astrophysical neutrino flux measurements and neutrino oscillations.

The Nitrous Oxide Project: assessment of advocacy and national directives to deliver mitigation of anaesthetic nitrous oxide

The environmental emissions attributed to anaesthetic nitrous oxide across the NHS are comparable to the carbon dioxide released by 135,000 flights from Frankfurt to New York. Much of these emissions are attributable to cumbersome and inadequately managed piped systems, resulting in excessive loss and waste. Since 2020, multiple hospital sites have been engaging with the Nitrous Oxide Project, a quality improvement method supporting a 'lean systems' approach to the provision of nitrous oxide. This review considers the frameworks supporting medical gas management in UK healthcare systems, and the impact of professional advocacy and medical gas stewardship to drive anaesthetic nitrous oxide mitigation in the NHS. Nitrous oxide mitigation efforts by grassroots and professional advocacy networks are enhanced through national centralised emission monitoring, distribution of data, technical information and provision of quality analysis. Given the climate harms of nitrous oxide, concerted efforts should be made to rationalise its use, and resources should be committed to supporting this at local, regional and national levels.

Towards co-design of rehabilitation technologies: a collaborative approach to prioritize usability issues

Introduction

Early stakeholder engagement is critical to the successful development and translation of rehabilitation technologies, a pivotal step of which is usability testing with intended end-users. To this end, several methods employ end-user feedback to identify usability and implementation issues. However, the process of prioritizing identified issues seldom leverages the knowledge and expertise of the range of stakeholders who will ultimately affect the demand and supply of a device. This paper describes a novel method to prioritize end-user feedback using transdisciplinary stakeholder consultation and address it in subsequent product development. The proposed approach was demonstrated using a case study relating to the development of a novel technology for neural recovery after spinal cord injury.

Method

Feedback from five individuals with chronic spinal cord injury was collected during two-hour usability evaluation sessions with a fully functional high-fidelity system prototype. A think-aloud and semi-structured interview protocol was used with each participant to identify usability and acceptability issues relating to the system in a 3-phase approach. Phase 1 involved extracting usability issues from think-aloud and semi-structured interview data. Phase 2 involved rating the usability issues based on their significance, technical feasibility, and implementation priority by relevant internal and external stakeholders. Finally, Phase 3 involved aggregating the usability issues according to design and implementation elements to facilitate solution generation, and these solutions were then raised as action tasks for future design iterations.

Results

Sixty usability issues representing nine facets of usability were rated. Eighty percent of issues were rated to be of moderate to high significance, 83% were rated as being feasible to address, and 75% were rated as addressable using existing project resources. Fifty percent of the issues were rated to be a high priority for implementation. Evaluation of the grouped issues identified 21 tasks which were mapped to the product roadmap for integration into future design iterations.

Discussion

This paper presents a method for meaningful transdisciplinary stakeholder engagement in rehabilitation technology development that can extended to other projects. Alongside a worked example, we offer practical considerations for others seeking to co-develop rehabilitation technologies.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Specialist multidisciplinary input maximises rare disease diagnoses from whole genome sequencing

Diagnostic whole genome sequencing (WGS) is increasingly used in rare diseases. However, standard, semi-automated WGS analysis may overlook diagnoses in complex disorders. Here, we show that specialist multidisciplinary analysis of WGS, following an initial 'no primary findings' (NPF) report, improves diagnostic rates and alters management. We undertook WGS in 102 adults with diagnostically challenging primary mitochondrial disease phenotypes. NPF cases were reviewed by a genomic medicine team, thus enabling bespoke informatic approaches, co-ordinated phenotypic validation, and functional work. We enhanced the diagnostic rate from 16.7% to 31.4%, with management implications for all new diagnoses, and detected strong candidate disease-causing variants in a further 3.9% of patients. This approach presents a standardised model of care that supports mainstream clinicians and enhances diagnostic equity for complex disorders, thereby facilitating access to the potential benefits of genomic healthcare. This research was made possible through access to the data and findings generated by the 100,000 Genomes Project: http://www.genomicsengland.co.uk .

Safety and efficacy of a biodegradable implant releasing tenofovir alafenamide for vaginal protection in a macaque model

OBJECTIVES

To advance the initiative of ending the global epidemic, long-lasting HIV protection is needed through sustained release of antiretroviral drugs for months to years. We investigated in macaques the safety and efficacy of biodegradable polycaprolactone implants releasing tenofovir alafenamide for HIV pre-exposure prophylaxis (PrEP).

METHODS

Implants were administered subcutaneously in the arm using a contraceptive trocar. Efficacy against vaginal simian-HIV (SHIV) infection was investigated in six pigtailed macaques that received two tenofovir alafenamide implants (0.35 mg/day), one in each arm, for a total release rate of tenofovir alafenamide at 0.7 mg/day. Macaques were exposed to SHIV twice weekly for 6 weeks. Statistical analyses were used to compare outcome with eight untreated controls. Histological assessments were performed on skin biopsies collected near implantation sites.

RESULTS

Median (range) tenofovir diphosphate level in PBMCs was 1519 (1068-1898) fmol/106 cells. All macaques with tenofovir alafenamide implants were protected against vaginal SHIV infection. In contrast, 7/8 controls were infected after a median of 4 SHIV exposures (P = 0.0047). Histological assessment of tissues near tenofovir alafenamide implant sites showed inflammation and necrosis in 5/6 animals, which were not evident by visual inspection.

CONCLUSIONS

We demonstrated complete protection against vaginal SHIV infection with two implants releasing a total of 0.7 mg of tenofovir alafenamide per day. We also identified tenofovir diphosphate concentrations in PBMCs associated with complete vaginal protection. Consistent with previous findings, we observed adverse local toxicity and necrosis near the tenofovir alafenamide implant site. Improved tenofovir alafenamide implants that are safe and maintain high efficacy have the potential to provide long-lasting protection against vaginal HIV infection.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Characterizing Racial Differences of Mental Health Burdens, Psychosocial Determinants, and Impacts on HIV Prevention Outcomes Among Young Men Who have Sex With Men: a Community-based Study in Two U.S. Cities

Few studies examine racial differences (e.g., Black vs. White) regarding the psychosocial pathways linking mental health burdens and various HIV-related outcomes among young men who have sex with men (MSM) in the U.S. We conducted a community-based study to examine the racial differences of mental health burdens (e.g., depression, anxiety, stress), the psychosocial determinants (e.g., HIV stigma, homonegativity, resilience, social support, loneliness, housing/food security) and impact on HIV-related outcomes (e.g., event-level alcohol/drug use before sex, condomless insertive/receptive anal sex, recent HIV testing, and PrEP awareness/willingness/use) among young Black MSM (YBMSM; n = 209) and young White MSM (YWMSM; n = 109) from two cities (Nashville, TN and Buffalo, NY) in the United States. Overall, we found YBMSM were more likely (p < 0.05) to experience anxiety and depression compared to YWMSM. Among YBMSM, we found structural inequities (housing instability, food insecurity, internalized homonegativity) were positively associated with anxiety/depression/stress (p < 0.001); we also found anxiety/depression was associated with increased alcohol/drug use before sex, and stress was associated with reduced recent HIV testing and pre-exposure prophylaxis awareness/willingness/use. Among YWMSM, we found psychological buffers (perceived social support, resilience) were associated with reduced anxiety/depression/stress (p < 0.001); anxiety was associated with increased condomless insertive/receptive anal sex and recent HIV testing among this subgroup. YBMSM and YWMSM differed in psychosocial determinants and HIV-related consequences regarding their mental health. Our findings provide important implications for developing culturally and contextually tailored interventions to address mental health burdens and HIV prevention outcomes among young MSM at highest risk for HIV acquisition.

Suboptimal Follow-Up on HIV Test Results among Young Men Who Have Sex with Men: A Community-Based Study in Two U.S. Cities

Frequent HIV testing and knowledge of HIV serostatus is the premise before timely access to HIV prevention and treatment services, but a portion of young men who have sex with men (YMSM) do not always follow up on their HIV test results after HIV testing, which is detrimental to the implementation of HIV prevention and care among this subgroup. The comprehensive evaluation of factors associated with inconsistent follow-up on HIV test results may inform relevant interventions to address this critical issue among YMSM. To this end, we conducted a cross-sectional study in Nashville, Tennessee and Buffalo, New York from May 2019 to May 2020 to assess demographic, behavioral, and psychosocial correlates of inconsistent follow-up on HIV test results among YMSM. Of the 347 participants, 27.1% (n = 94) reported inconsistent follow-up on their HIV test results. Multivariable logistic regression showed that inconsistent follow-up on HIV test results was positively associated with condomless receptive anal sex, group sex, recreational drug use before or during sex, internalized homophobia, and stress; while negatively associated with housing stability, social support, and general resilience. Future HIV prevention intervention efforts should target these modifiable determinants to enhance the follow-up on HIV test results among YMSM.

Evidence and implication of interventions across various socioecological levels to address HIV testing uptake among men who have sex with men in the United States: A systematic review

Objectives

Strengthening HIV testing uptake is critical to curtail the HIV epidemics among men who have sex with men in the United States. Despite the implementation of various interventions to promote HIV testing among men who have sex with men, few aggregated evidence is presented to reflect the "lessons learned" and inform future directions. The objective of this systematic review is to comprehensively summarize published studies that described, tested, and evaluated outcomes (e.g. efficacy, effectiveness, acceptability, feasibility and/or qualitative opinions) associated with an HIV testing intervention and identify gaps as well as opportunities to inform the design and implementation of future interventions to enhance HIV testing uptake among men who have sex with men in the United States.

Methods

We followed the PRISMA guidelines and conducted a systematic review of articles (published by 23 July 2021) by searching multiple databases (PubMed, MEDLINE, Web of Science and PsycINFO).

Results

Among the total number of 3505 articles found through multiple databases, 56 papers were included into the review. Interventional modules that demonstrated acceptability, feasibility and efficacy to improve HIV testing uptake among men who have sex with men include: HIV self-testing, interpersonal-level (e.g. peer-led, couple-based) interventions, personalized interventions and technology-based interventions (e.g. mHealth). Aggregated evidence also reflects the lack of individualized interventions that simultaneously address time-varying needs across multiple socioecological levels (e.g. individual, interpersonal, community, structural and societal).

Conclusion

Development of interventions to improve HIV testing rates and frequency of men who have sex with men has proliferated in recent years. Our review presents important implications in sustaining and improving interventions to address HIV testing uptake among men who have sex with men in the United States.

Distinct myeloid antigen presenting cells dictate differential fates of tumor-specific CD8 T cells in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDA) contains numerous protumor myeloid cells at the expense of antitumor dendritic cells (cDC1s). We identify that tumor antigenicity is a major determinant of myeloid composition and functionality. Neoantigen-tumors contained pro-tumor macrophages and a paucity of cDC1s whereas neoantigen+ tumors accumulate cDC1s via Xcr1 signaling and macrophages exhibit a diminished role. Effective immunotherapies increased splenic cDC1s, which were required for endogenous T cell expansion following α-PD-L1 and transferred effector and memory T cells. Batf3−/− mice, which lack cDC1s, failed to spontaneously generate tumor-specific CD8 T cells and were resistant to T cell therapy and α-PD-L1. In contrast, agonistic α-CD40 exhibited partial benefit in Batf3−/− mice and expanded atypical tumor-specific CD8 T cells. Monocyte depletion abrogated atypical tumor-specific CD8 T cell priming yet enhanced α-CD40-mediated antitumor activity in Batf3−/− mice. In contrast, α-Gr1 abrogated the therapeutic benefit of CD40 agonist in Batf3−/− mice. In sum, our study supports that CD40 agonist promotes a cDC1-dependent antitumor immunity and a monocyte-dependent protumor arm of immune system. These results further underscore an essential antigen presenting role for cDC1s in the expansion and differentiation of naïve, effector, and memory T cells into Klrg1+ potent cytotoxic effector T cells capable of targeting pancreatic cancer.

M.R. is supported by National Institutes of Health (NIH) T32 AI 007313 E.J.S. is supported by NIH T35 AI118620 I.M.S. is supported by NIH R01 CA249393, R01 CA255039, Department of Defense #PA200286, an American Association for Cancer Research (AACR) Pancreatic Cancer Action Network Career Development Award (17-20-25-STRO), an AACR Pancreatic Cancer Action Network Catalyst Award (19-35-STRO), American Cancer Society Institutional Research Grant (124166-IRG-58-001-55-IRG65).

Fast Evaluation of Viral Emerging Risks (FEVER): A computational tool for biosurveillance, diagnostics, and mutation typing of emerging viral pathogens

Viral pathogens can rapidly evolve, adapt to novel hosts, and evade human immunity. The early detection of emerging viral pathogens through biosurveillance coupled with rapid and accurate diagnostics are required to mitigate global pandemics. However, RNA viruses can mutate rapidly, hampering biosurveillance and diagnostic efforts. Here, we present a novel computational approach called FEVER (Fast Evaluation of Viral Emerging Risks) to design assays that simultaneously accomplish: 1) broad-coverage biosurveillance of an entire group of viruses, 2) accurate diagnosis of an outbreak strain, and 3) mutation typing to detect variants of public health importance. We demonstrate the application of FEVER to generate assays to simultaneously 1) detect sarbecoviruses for biosurveillance; 2) diagnose infections specifically caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); and 3) perform rapid mutation typing of the D614G SARS-CoV-2 spike variant associated with increased pathogen transmissibility. These FEVER assays had a high in silico recall (predicted positive) up to 99.7% of 525,708 SARS-CoV-2 sequences analyzed and displayed sensitivities and specificities as high as 92.4% and 100% respectively when validated in 100 clinical samples. The D614G SARS-CoV-2 spike mutation PCR test was able to identify the single nucleotide identity at position 23,403 in the viral genome of 96.6% SARS-CoV-2 positive samples without the need for sequencing. This study demonstrates the utility of FEVER to design assays for biosurveillance, diagnostics, and mutation typing to rapidly detect, track, and mitigate future outbreaks and pandemics caused by emerging viruses.

Comparative Pharmacokinetics and Local Tolerance of Tenofovir Alafenamide (TAF) From Subcutaneous Implant in Rabbits, Dogs, and Macaques

The administration of antiretrovirals (ARVs) for HIV pre-exposure prophylaxis (PrEP) is highly efficacious and may benefit from new long-acting (LA) drug delivery approaches. This paper describes a subcutaneous, reservoir-style implant for the LA delivery of tenofovir alafenamide (TAF) and documents the preclinical assessment of implant safety and pharmacokinetics (PK) in New Zealand White (NZW) rabbits (3 groups of n = 5), beagle dogs (2 groups of n = 6), and rhesus macaques (2 groups of n = 3). Placebo implants were placed in rabbits (n = 10) and dogs (n = 12). Implant parameters, including selection of the TAF form, choice of excipient, and PCL formulation were tuned to achieve targeted concentrations of the active anabolite of TAF, tenofovir diphosphate (TFV-DP), within peripheral blood mononuclear cells (PBMCs) and mucosal tissues relevant to HIV transmission. Sustained concentrations of TFV-DP in PBMCs over 100 fmol/10⁶ cells were achieved in all animal species indicating that the implants effectively delivered TAF for 3-6 months. Unlike placebo implants without TAF, all active implants resulted in local adverse events (AEs) proximal to the implant ranging in severity from mild to moderate and included dermal inflammation and necrosis across all species. Despite these AEs, the implant performed as designed and achieved a constant drug release profile, supporting the continued development of this drug delivery platform.

Toxicological safety of VOHO Hemp Oil; a supercritical fluid extract from the aerial parts of hemp

VOHO Hemp Oil (Verdant Nature LLC (in collaboration with HempFusion)) is an extract of the aerial parts of hemp (Cannabis sativa L) manufactured using a supercritical CO2 extraction process. The results of four safety studies are reported here including a bacterial reverse mutation assay, an in vivo mammalian micronucleus study, a maximum tolerated dose study in rats and a 90-day repeat dose subchronic toxicity study in rats. VOHO Hemp oil can contain up to 30% phytocannabinoids and less than 0.2% is tetrahydrocannabinol (THC). VOHO Hemp Oil was found to be non-mutagenic in the bacterial reverse mutation assay and was negative for inducing micronuclei in the rat bone marrow micronucleus assay. The maximum tolerated dose in male and female Wistar rats was 2250 mg/kg bw/day. A 90-day repeat dose study was conducted in male and female Wistar rats according to OECD Guideline 408 and included a 21-day recovery period. The doses used in the study were 0, 25, 90 and 324 mg/kg bw per day in the main study, and in the recovery phase a control and 324 mg/kg bw/day group were included. One mortality was reported during the study, a high dose female, and test substance-related adverse clinical signs were reported in the high dose group. Other test substance-related changes noted in the high dose group included changes in body weights, activated partial thromboplastin time (APTT) values, and in absolute and relative organ weights. Based on the results of the study, the no observed adverse effect level (NOAEL) for VOHO Hemp Oil was determined to be 90 mg/kg bw/day in both male and female Wistar rats.

Development and uptake of the National Heart Foundation of Australia Smart Heart Guideline App

Background

Many organisations have developed Smartphone mobile applications (apps) to improve access and uptake of clinical guidelines, including the European Society of Cardiology and the American Heart Foundation. The National Heart Foundation of Australia publish clinical guidelines in collaboration with the Cardiac Society of Australia and New Zealand. We aimed to develop an app for three national guidelines: 1) the Australian clinical guidelines for the prevention and detection of atrial fibrillation 2018; 2) the Australian clinical guidelines for the detection and management of heart failure in Australia 2018; and 3) the Australian clinical guidelines for the management of acute coronary syndromes 2016.

Purpose

To develop a mobile app for Australian health professionals to improve access and uptake of national cardiac clinical guidelines.

Methods

A national health professional mobile app online survey was developed and distributed in 2017. Survey items included the frequency of searching for information about the prevention or management of cardiovascular disease, the methods of searching, and the likelihood of using an Australian-specific mobile app to access clinical guidelines. Following analysis of survey responses, a software developer was contracted to develop the app, which included user-testing. The Smart Heart Guidelines App was registered with the regulatory body in Australia, the Therapeutic Goods Administration, and made freely available from October 2019 on iOS and Android operating systems. The app was promoted using electronic direct mail, social media techniques (Twitter and LinkedIn), on our organisation's website and via printed flyers and materials at regional and national event stands at conferences. Data from the Apple App Store was analysed between 1 October 2019 – 1 October 2020 to evaluate app use.

Results

The health professional survey (respondents n=504; nurses 39%, allied health professionals 26%; GP/cardiologist 9%; researcher 8%; other 18%) showed most (n=447; 89%) reported accessing the Heart Foundation's resources electronically. The majority (n=355; 70%) reported they would be likely to use an Australian-specific app. Data from the Apple App Store indicated over 30,300 impressions (the number of times the Smart Heart App appeared in an App Store search) during the first year the app was available. This resulted in approximately 4,400 app downloads, with consistent “search-to-download rates” throughout the year (monthly average rate 22%). Of the downloads, 3,200 (82%) were a direct result of searching for the Smart Heart App, indicating promotional activities were effective.

Conclusion

Development of the Smart Heart Guideline App in Australia was indicated by health professionals to improve access to national cardiac clinical guidelines. Consistent app downloads and use during the first-year support further research, development, promotion, and evaluation of the app.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The National Heart Foundation of Australia

Intracranial pressure directly predicts headache morbidity in idiopathic intracranial hypertension

Objective

Headache is the predominant disabler in idiopathic intracranial hypertension (IIH). The aim was to characterise headache and investigate the association with intracranial pressure.

Methods

IIH:WT was a randomised controlled parallel group multicentre trial in the United Kingdom investigating weight management methods in IIH. Participants with active IIH (evidenced by papilloedema) and a body mass index (BMI) ≥35 kg/m² were recruited. At baseline, 12 months and 24 months headache characteristics and quality of life outcome measures were collected and lumbar puncture measurements were performed.

Results

Sixty-six women with active IIH were included with a mean age of 32.0 years (SD ± 7.8), and mean body mass index of 43.9 ± 7.0 kg/m². The headache phenotype was migraine-like in 90%. Headache severity correlated with ICP at baseline (r = 0.285; p = 0.024); change in headache severity and monthly headache days correlated with change in ICP at 12 months (r = 0.454, p = 0.001 and r = 0.419, p = 0.002 respectively). Cutaneous allodynia was significantly correlated with ICP at 12 months. (r = 0.479, p < 0.001). Boot strap analysis noted a positive association between ICP at 12 and 24 months and enabled prediction of both change in headache severity and monthly headache days. ICP was associated with significant improvements in quality of life (SF-36).

Conclusions

We demonstrate a positive relationship between ICP and headache and cutaneous allodynia, which has not been previously reported in IIH. Those with the greatest reduction in ICP over 12 months had the greatest reduction in headache frequency and severity; this was associated with improvement of quality of life measures.

Trial registration

This work provides Class IIa evidence of the association of raised intracranial pressure and headache. ClinicalTrials.gov number, NCT02124486.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01321-8.

Differences in obstetrical care and outcomes associated with the proportion of the obstetrician's shift completed

BACKGROUND

Understanding and improving obstetrical quality and safety is an important goal of professional societies, and many interventions such as checklists, safety bundles, educational interventions, or other culture changes have been implemented to improve the quality of care provided to obstetrical patients. Although many factors contribute to delivery decisions, a reduced workload has addressed how provider issues such as fatigue or behaviors surrounding impending shift changes may influence the delivery mode and outcomes.

OBJECTIVE

The objective was to assess whether intrapartum obstetrical interventions and adverse outcomes differ based on the temporal proximity of the delivery to the attending's shift change.

STUDY DESIGN

This was a secondary analysis from a multicenter obstetrical cohort in which all patients with cephalic, singleton gestations who attempted vaginal birth were eligible for inclusion. The primary exposure used to quantify the relationship between the proximity of the provider to their shift change and a delivery intervention was the ratio of time from the most recent attending shift change to vaginal delivery or decision for cesarean delivery to the total length of the shift. Ratios were used to represent the proportion of time completed in the shift by normalizing for varying shift lengths. A sensitivity analysis restricted to patients who were delivered by physicians working 12-hour shifts was performed. Outcomes chosen included cesarean delivery, episiotomy, third- or fourth-degree perineal laceration, 5-minute Apgar score of <4, and neonatal intensive care unit admission. Chi-squared tests were used to evaluate outcomes based on the proportion of the attending's shift completed. Adjusted and unadjusted logistic models fitting a cubic spline (when indicated) were used to determine whether the frequency of outcomes throughout the shift occurred in a statistically significant, nonlinear pattern RESULTS: Of the 82,851 patients eligible for inclusion, 47,262 (57%) had ratio data available and constituted the analyzable sample. Deliveries were evenly distributed throughout shifts, with 50.6% taking place in the first half of shifts. There were no statistically significant differences in the frequency of cesarean delivery, episiotomy, third- or fourth-degree perineal lacerations, or 5-minute Apgar scores of <4 based on the proportion of the shift completed. The findings were unchanged when evaluated with a cubic spline in unadjusted and adjusted logistic models. Sensitivity analyses performed on the 22.2% of patients who were delivered by a physician completing a 12-hour shift showed similar findings. There was a small increase in the frequency of neonatal intensive care unit admissions with a greater proportion of the shift completed (adjusted P=.009), but the findings did not persist in the sensitivity analysis.

CONCLUSION

Clinically significant differences in obstetrical interventions and outcomes do not seem to exist based on the temporal proximity to the attending physician's shift change. Future work should attempt to directly study unit culture and provider fatigue to further investigate opportunities to improve obstetrical quality of care, and additional studies are needed to corroborate these findings in community settings.

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

Review of neurological rehabilitation for Multiple Sclerosis in the British Military

Multiple sclerosis (MS) is a progressive neurological disorder, classically presenting in working age adults, including those in the Armed Forces. The Defence Medical Rehabilitation Centre (DMRC) Stanford Hall offers vocationally focused neurorehabilitation services for service personnel (SP) with MS, with the goal to minimise disability, maximise independence and remain able to work.This paper has two aims. First, it briefly provides a clinical update of MS, focusing on pathology, presentation, diagnosis and management. Finally, it will describe the role of DMRC and data from the last decade in the management of MS.Our findings suggest not all SP with MS are being referred to DMRC, and some of those who do have significant delays, potentially impacting on patient support, symptom management and occupational outcomes. It is hoped that this paper will improve awareness and recognition of MS for Armed Forces personnel.

How New Mexico Leveraged a COVID-19 Case Forecasting Model to Preemptively Address the Health Care Needs of the State: Quantitative Analysis

BACKGROUND

Prior to the COVID-19 pandemic, US hospitals relied on static projections of future trends for long-term planning and were only beginning to consider forecasting methods for short-term planning of staffing and other resources. With the overwhelming burden imposed by COVID-19 on the health care system, an emergent need exists to accurately forecast hospitalization needs within an actionable timeframe.

OBJECTIVE

Our goal was to leverage an existing COVID-19 case and death forecasting tool to generate the expected number of concurrent hospitalizations, occupied intensive care unit (ICU) beds, and in-use ventilators 1 day to 4 weeks in the future for New Mexico and each of its five health regions.

METHODS

We developed a probabilistic model that took as input the number of new COVID-19 cases for New Mexico from Los Alamos National Laboratory's COVID-19 Forecasts Using Fast Evaluations and Estimation tool, and we used the model to estimate the number of new daily hospital admissions 4 weeks into the future based on current statewide hospitalization rates. The model estimated the number of new admissions that would require an ICU bed or use of a ventilator and then projected the individual lengths of hospital stays based on the resource need. By tracking the lengths of stay through time, we captured the projected simultaneous need for inpatient beds, ICU beds, and ventilators. We used a postprocessing method to adjust the forecasts based on the differences between prior forecasts and the subsequent observed data. Thus, we ensured that our forecasts could reflect a dynamically changing situation on the ground.

RESULTS

Forecasts made between September 1 and December 9, 2020, showed variable accuracy across time, health care resource needs, and forecast horizon. Forecasts made in October, when new COVID-19 cases were steadily increasing, had an average accuracy error of 20.0%, while the error in forecasts made in September, a month with low COVID-19 activity, was 39.7%. Across health care use categories, state-level forecasts were more accurate than those at the regional level. Although the accuracy declined as the forecast was projected further into the future, the stated uncertainty of the prediction improved. Forecasts were within 5% of their stated uncertainty at the 50% and 90% prediction intervals at the 3- to 4-week forecast horizon for state-level inpatient and ICU needs. However, uncertainty intervals were too narrow for forecasts of state-level ventilator need and all regional health care resource needs.

CONCLUSIONS

Real-time forecasting of the burden imposed by a spreading infectious disease is a crucial component of decision support during a public health emergency. Our proposed methodology demonstrated utility in providing near-term forecasts, particularly at the state level. This tool can aid other stakeholders as they face COVID-19 population impacts now and in the future.

Clinical Implementation of Second-generation Minimally Invasive Image-guided Cochlear Implantation Surgery

OBJECTIVE

Minimally invasive, image-guided cochlear implantation (CI) surgery consists of drilling a precise tunnel from the surface of the mastoid cortex through the facial recess to target the scala tympani. In the first set of clinical trials of this technique, heat-induced facial nerve paresis (House-Brackmann II/VI) occurred on a patient on the last day of the initial trial which was scheduled to be halted secondary to a change in the regulatory requirements dictated by the 2012 the Food and Drug Administration Safety and Innovation Act requiring Investigational Device Exemption approval for previously exempted customized medical device testing. To address this adverse event, extensive changes were made to the drilling protocol; additionally, a custom insertion tool was developed. To address the Food and Drug Administration Safety and Innovation Act, an Investigational Device Exemption was submitted and, subsequently approved. Herein is described our first clinical implementation of the modified technique.

PATIENT

Seventy-year-old with profound, postlingual sensorineural hearing loss who had previously undergone right CI via traditional approach in 2015.

INTERVENTION

Minimally invasive image-guided left CI.

MAIN OUTCOME MEASURE

Time of intervention, final location of CI electrode array within cochlea.

RESULTS

Surgery took 155 minutes of which the largest components (in descending order) were soft tissue work, closure, and drilling. Full scala tympani insertion with angular insertion depth of 557 degrees of the electrode array was achieved. There were no complications, and the patient had an uneventful recovery and activation.

CONCLUSIONS

Minimally invasive, image-guided CI surgery is achievable and reduces the mastoid depression associated with traditional CI surgery.

CLINICALTRIALSGOV INFORMATION

Study NCT03101917, Microtable Microstereotactic Frame and Drill Press and Associated Method for Cochlear Implantation.

LEVEL OF EVIDENCE

Case Report.

Resorbable additively manufactured scaffold imparts dimensional stability to extraskeletally regenerated bone

Dimensionally stable vertical bone regeneration outside of the existing bony envelope is a major challenge in the field of orofacial surgery. In this study, we demonstrate that a highly porous, resorbable scaffold fabricated using additive manufacturing techniques enables reproducible extra-skeletal bone formation and prevents bone resorption. An additively manufactured medical grade polycaprolactone (mPCL) biphasic scaffold mimicking the architecture of the jaw bone, consisting of a 3D-printed outer shell overlying an inner highly porous melt electrowritten scaffold, was assessed for its ability to support dimensionally stable bone regeneration in an extraskeletal ovine calvarial model. To investigate bone formation capacity (stage 1), 7 different constructs placed under a protective dome were assessed 8 weeks post-implantation: Empty control, Biphasic scaffold with hydrogel (PCL-Gel), PCL-Gel with 75 or 150 μg of BMP-2 (PCL-BMP-75 and PCL-BMP-150), hydrogel only (Gel), Gel containing 75 or 150 μg of BMP-2 (Gel-BMP-75 and Gel-BMP-150). To assess dimensional stability (stage 2), in a separate cohort, 5 animals were similarly implanted with 2 samples of each of the Gel-BMP-150 and PCL-BMP-150 groups, and after 8 weeks of healing, the protective domes were removed and titanium implants were placed in the regenerated bone and allowed to heal for a further 8 weeks. Bone formation and osseointegration were assessed using micro-computed tomography, histology and histomorphometry. In stage 1, enhanced bone formation was found in the BMP-2 containing groups, especially the PCL-BMP constructs whereby regeneration of full bone height was achieved in a reproducible manner. There was no significant bone volume increase with the higher dose of BMP-2. In the dimensional stability assessment (stage 2), after the rtemoval of the protective dome, the biphasic scaffold prevented bone resorption whereas in the absence of the scaffold, the bone previously formed in the hydrogel underwent extensive resorption. This was attributed to the space maintenance properties and dimensional stability of the biphasic scaffold. Titanium implants osseointegrated into the newly formed bone within the biphasic scaffolds. In conclusion, additively manufactured biphasic scaffolds functionalized with BMP-2 facilitated dimensionally stable bone regeneration that supported dental implant osseointegration.

Stress in Parents of Children With Genetically Determined Leukoencephalopathies: A Pilot Study

Genetically determined leukoencephalopathies comprise a group of rare inherited white matter disorders. The majority are progressive diseases resulting in early death. We performed a cross-sectional pilot study including 55 parents from 36 families to assess the level of stress experienced by parents of patients with genetically determined leukoencephalopathies, aged 1 month to 12 years. Thirty-four mothers and 21 fathers completed the Parenting Stress Index-4th Edition. One demographic questionnaire was completed per family. Detailed clinical data was gathered on all patients. Statistical analysis was performed with total stress percentile score as the primary outcome. Mothers and fathers had significantly higher stress levels compared with the normative sample; 20% of parents had high levels of stress whereas 11% had clinically significant levels of stress. Mothers and fathers had comparable total stress percentile scores. We identified pediatric behavioral difficulties and gross motor function to be factors influencing stress in mothers. Our study is the first to examine parental stress in this population and highlights the need for parental support early in the disease course. In this pilot study, we demonstrated that using the Parenting Stress Index-4th Edition to assess stress levels in parents of patients with genetically determined leukoencephalopathies is feasible, leads to valuable and actionable results, and should be used in larger, prospective studies.

Decoupling Steerability from Diameter: Helical Dovetail Laser Patterning for Steerable Needles

The maximum curvature of a steerable needle in soft tissue is highly sensitive to needle shaft stiffness, which has motivated use of small diameter needles in the past. However, desired needle payloads constrain minimum shaft diameters, and shearing along the needle shaft can occur at small diameters and high curvatures. We provide a new way to adjust needle shaft stiffness (thereby enhancing maximum curvature, i.e. "steerability") at diameters selected based on needle payload requirements. We propose helical dovetail laser patterning to increase needle steerability without reducing shaft diameter. Experiments in phantoms and ex vivo animal muscle, brain, liver, and inflated lung tissues demonstrate high steerability in soft tissues. These experiments use needle diameters suitable for various clinical scenarios, and which have been previously limited by steering challenges without helical dovetail patterning. We show that steerable needle targeting remains accurate with established controllers and demonstrate interventional payload delivery (brachytherapy seeds and radiofrequency ablation) through the needle. Helical dovetail patterning decouples steerability from diameter in needle design. It enables diameter to be selected based on clinical requirements rather than being carefully tuned to tissue properties. These results pave the way for new sensors and interventional tools to be integrated into high-curvature steerable needles.

The D2 and D3 Sublineages of Human Papilloma Virus 16-Positive Cervical Cancer in Guatemala Differ in Integration Rate and Age of Diagnosis

Human papillomavirus (HPV) 16 displays substantial sequence variation; four HPV16 lineages (A, B, C, and D) have been described as well as multiple sublineages. To identify molecular events associated with HPV16 carcinogenesis, we evaluated viral variation, the integration of HPV16, and somatic mutation in 96 cervical cancer samples from Guatemala. A total of 65% (62/96) of the samples had integrated HPV16 sequences and integration was associated with an earlier age of diagnosis and premenopausal disease. HPV16 integration sites were broadly distributed in the genome, but in one tumor, HPV16 integrated into the promoter of the IFN regulatory factor 4 (IRF4) gene, which plays an important role in the regulation of the IFN response to viral infection. The HPV16 D2 and D3 sublineages were found in 23% and 30% of the tumors, respectively, and were significantly associated with adenocarcinoma. D2-positive tumors had a higher rate of integration, earlier age of diagnosis, and a lower rate of somatic mutation, whereas D3-positive tumors were less likely to integrate, had later age of diagnosis, and exhibited a higher rate of somatic mutation. In conclusion, Guatemalan cervical tumors have a high frequency of very high-risk HPV16 D2 and D3 sublineages harboring distinct histology, which may help guide future therapeutic strategies to target the tumor and reduce recurrence. SIGNIFICANCE: This study details the biological and molecular properties of the most pathogenic forms of HPV16, the cause of the majority of cervical cancers.

Abstract NG12: Mechanisms governing efficacy of combination CD40 agonist and anti-PD-L1 in pancreatic ductal adenocarcinoma

Background: Pancreatic ductal adenocarcinoma (PDA) is a lethal malignancy that is resistant to conventional therapies including monotherapy using PD-1 or PD-L1 inhibition. Combination agonistic anti-CD40 and PD-1/PD-L1 blockade have clinical promise in advanced cancer patients including PDA. The underlying mechanism(s) driving the therapeutic effects of this combination are ill-defined. Here, we create a syngeneic PDA animal model and utilize various genetic tools to assess how CD40 agonist, PD-L1 blockade or the combination impact tumor antigen-specific T cells using fluorescently-labeled peptide:MHC tetramers and cells in the tumor microenvironment. Molecular analyses of tumor cell escape variants is also performed.

Methods: We recently developed a high-throughput orthotopic syngeneic KPC pancreatic cancer mouse model that expresses a novel model neoantigen in B6 mice described in Burrack et al., Cell Reports, 2019. We create fluorescently labeled peptide:H-2Db tetramers to track the fate of endogenous pancreatic tumor-antigen specific CD8+ T cells over time. Here, we use this model alone or mixed at a 1:1 ratio of KPC tumor cells that do not express the neoantigen to examine how agnostic anti-CD40 (a single dose, clone FGK145), anti-PDL1 (3 doses, clone 10F.932), or the combination impact tumor growth in the pancreas over time using bioluminescent imaging and high-resolution ultrasound. We use multiparameter flow cytometry to investigate how anti-CD40 +/- PD-L1 blockade impacts the phenotype, longevity and functionality of tetramer-binding T cells over time. We assess how other immune cell lineages are altered systemically and in the tumor microenvironment by quantifying myeloid subpopulations, B cells, NK cells and regulatory T cells following therapy. We use Batf3-/- mice and XCR1VenusDTR mice to assess the role of conventional type I dendritic cells (cDC1s) on therapeutic efficacy. We employ both cytokine and chemokine reporter strains to identify how anti-CD40 +/- PD-L1 blockade impacts inflammatory gene expression in immune cells enriched the tumor microenvironment. We examine the persistence and location of tetramer-binding T cells in the pancreas, lung and liver of mice following tumor eradication. Additionally, we re-derive resistant tumor cells from mice and evaluate the integrity of MHC class I antigen processing and presentation pathways. Finally, single cell sequencing is performed to assess the traits of subpopulations of tumor-antigen specific T cells that correlate with enhanced antitumor activity following therapy.

Results: We show that anti-CD40 or anti-PD-L1 monotherapy have significant yet transient antitumor effects in mice with neoantigen+ PDA with distinct effects on tumor specific T cells. Objective responses occur in 100% of the monotherapy treated mice and survival is significantly prolonged. However, tumors recur in 100% of these animals. Tumor escape variants defective in MHC class I protein and Tap1 gene expression following IFN-gamma treatment ultimately emerge. In contrast, combination agonistic anti-CD40 + PD-L1 blockade synergize therapeutically resulting in cures in 60% of the animals and formation of pancreas resident memory T cells that specifically bind tetramer and express CD49a and CD103 following tumor eradication. Mechanistically, the combination selectively expands conventional type 1 dendritic cells (cDC1s) in the spleens and tumors of tumor-bearing animals. cDC1s in PDA are CD11c+MHCII+ and express CD8, CD103 and Xcr1. Using Batf3-/- mice or an Xcr1venusDTR transient cDC1 depletion model, we demonstrate a striking dependency on cDC1s for therapeutic benefit with anti-CD40 or PD-L1 blockade. Unexpectedly, we find that the expansion of cDC1s in pancreatic tumor-bearing animals is partially dependent on Xcr1 expression by DCs. Anti-CD40+PD-L1 blockade significantly expand the number of tetramer-binding T cells that express KLRG1 in PDA. The tetramer-binding T cells remain PD-1+ yet have lower expression of Lag3 and have heightened polyfunctionality as measured by cytokine production. Further studies using chemokine and cytokine reporter models, we uncover key differences in how anti-CD40 and anti-PD-L1 impact inflammatory gene expression by antigen presenting cells in PDA. Finally, we demonstrate the requirement for tumor neoantigen expression for efficacy because in mice that have tumors containing a 50:50 mixture of neoantigen+ pancreatic tumor cells with neoantigen- pancreatic tumor cells, combination anti-CD40 + PD-L1 blockade results in elimination of predominantly those tumor cells that express the neoantigen. Further single cell sequencing data on how this combination impacts tumor-antigen specific T cell subpopulations as well as epitope spreading will be discussed.

Conclusions: These findings reveal for the first time to our knowledge that anti-CD40 + PD-L1 blockade synergize via the expansion of cDC1s in pancreatic tumor-bearing animals. Instead of anti-CD40 promoting priming of neoantigen-specific T cells, we find that this combination promotes the systemic expansion and intratumoral accumulation of KLRG1+ tumor-specific T cells that eradicate PDA and form pancreas resident CD49a+CD103+ memory T cells.

Citation Format: Adam L. Burrack, Meagan R. Rollins, Ellen J. Spartz, Jackson F. Raynor, Iris Wang, Jason Mitchell, Tsuneyasu Kaisho, Brian Fife, Ross Kedl, Stephen Shen, Ingunn M. Stromnes. Mechanisms governing efficacy of combination CD40 agonist and anti-PD-L1 in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr NG12.

0038 The Effects of Morning Blue Light Therapy on Insomnia Severity and PTSD Symptoms in a Clinical Sample

Introduction

Individuals with Post Traumatic Stress Disorder (PTSD) often present with insomnia, which may exacerbate other symptoms of the disorder. Morning Blue Light Therapy (BLT) can regulate circadian rhythms and may even improve sleep and mood in individuals with major depressive disorder. However, it is unclear whether morning BLT could also be an effective treatment for the insomnia associated with PTSD. We investigated whether 6 weeks of daily morning BLT would improve insomnia severity and symptom presentation in individuals with PTSD in comparison to a placebo condition of amber light (ALT). We hypothesized that changes in insomnia severity would correlate with improvement in PSTD symptom severity.

Methods

Forty-one participants with a clinical diagnosis of PTSD were randomized to receive 6 weeks of either daily morning BLT (n=22) or ALT (n=19). Insomnia and PTSD symptom severity were evaluated at pre- and post-treatment using the Insomnia Severity Index (ISI) and the Clinician-Administered PTSD Scale (CAPS) for DSM-5, respectively.

Results

Both groups showed a significant decrease in their PTSD symptom severity (p&lt;0.001) and insomnia severity (p&lt;0.001) over the 6-week treatment period. However, improvement in insomnia severity significantly predicted improvements in PTSD symptom severity for the BLT group only (BLT: r =0.542, p=0.009; ALT: r=-0.095, p=0.699). The difference between the two correlation coefficients was significant (Z=-2.07, p=0.039).

Conclusion

The results suggest that morning BLT may be effective in improving PTSD symptoms by regulating the circadian rhythm and improving sleep. While ALT also led to improved PTSD symptom severity, it appears that those changes cannot be explained by improved sleep and may have other underlying mechanisms (e.g., placebo effect). Morning BLT may be a promising adjunctive method to bolster current treatment approaches for PTSD. Because of its ease of administration, it could be easily added to ongoing treatment as usual. This approach warrants further research.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

0081 Habitual Sleep Duration is Negatively Correlated with Emotional Reactivity within the Rostral Anterior Cingulate Cortex in Individuals with PTSD

Introduction

Sleep difficulties, such as insomnia, are highly prevalent in individuals with Post-Traumatic Stress Disorder (PTSD). However, sleep deprivation can also increase emotional reactivity to positive (as well as negative) stimuli. While the effects of sleep loss on emotional perception healthy individuals has been documented, it remains unclear how lack of sleep in individuals with PTSD may affect their emotional reactivity to positive stimuli. We hypothesized that lower habitual sleep duration would be associated with greater functional brain activation changes in response to subliminally presented happy faces in brain areas of the reward network, such as the rostral anterior cingulate cortex (rACC).

Methods

Thirty-nine individuals with DSM-5 confirmed PTSD were administered the Pittsburgh Sleep Quality Index (PSQI) as a measure of their average nightly sleep duration over the past month. Participants then underwent fMRI imagining while viewing subliminal presentations of faces displaying happiness, using a backward masked facial affect paradigm to minimize conscious awareness of the expressed emotion. Brain activation to masked happy expressions was regressed against sleep duration in SPM12.

Results

There was a negative correlation between habitual sleep duration and activation within the rACC in response to the masked happy faces (x=14,y=40,z=0; k=102, pFWE-corr= 0.008).

Conclusion

Individuals with PTSD who average less sleep at night showed greater emotional reactivity, as indexed by greater functional brain activation changes within an area of the reward network, than individuals who obtained more sleep per night. Future research involving actual sleep duration manipulation will be necessary to determine whether this finding reflects the well-known antidepressant effect of sleep deprivation or a form of greater emotional expression error monitoring among traumatized patients when lacking sleep. Regardless, these findings suggest that insufficient sleep could affect unconsciously perceived emotion in faces and potentially affect social and emotional responses among individuals with PTSD.

Support

US Army Medical Research and Materiel Command: W81XWH-14-1-0570

CD8 T cell immunosurveillance and elimination of HIV target cells in the female reproductive tract

HIV infection is thought to establish in a single founder CD4 T cell in the genital mucosa, however, an effective CD8 T cell-based vaccine must enable timely surveillance of all mucosal CD4 T cells within the first few days after HIV exposure. The HVTN 502 (STEP) vaccine trial employed a CD8 T cell based vaccine that while promising in animal studies, did not protect human vaccinees from mucosal HIV acquisition. We hypothesize that the quantity of mucosal HIV-specific CD8 T cells is a critical determinant of tissue immunosurveillance and was insufficient to adequately survey and eliminate HIV target cells in the STEP trial. To test our hypothesis, we applied intravital mucosal imaging to visualize how efficiently CD8 T cells survey CD4 T cells in the murine uterus. Based on CD8-CD4 T cell contact rates, a density of 4 (0.8%) HIV-specific mucosal CD8 T cells/mm2 would be required to survey all mucosal CD4 T cells within 2 days. However, vaccinees in the STEP trial had ELISPOT readings of ≥55 spot-forming units/106 blood leucocytes or approximately 0.09% mucosal HIV-specific CD8 T cells, which is 10 fold lower than the required density. Surveillance efficiency was directly correlated with the number of CD8 T cells and was independent of target cell numbers. Upon antigen recognition in the context of MHC-I on CD4 T cells, CD8 T cells formed kinapses with CD4 T cells in an LFA-1/ICAM-1 dependent manner, facilitating tethering and prolonged tracking. Direct killing of CD4 T cells by single or multiple CD8 T cells occurred by 3h after antigen presentation. We conclude that CD8 T cells are capable of rapid tissue surveillance and killing of CD4 T cell targets, and that sub-optimal numbers of HIV-specific CD8 T cells may have contributed to the failure of the STEP trial.

Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations

Cancer and cardiovascular (CV) disease are the most prevalent diseases in the developed world. Evidence increasingly shows that these conditions are interlinked through common risk factors, coincident in an ageing population, and are connected biologically through some deleterious effects of anticancer treatment on CV health. Anticancer therapies can cause a wide spectrum of short- and long-term cardiotoxic effects. An explosion of novel cancer therapies has revolutionised this field and dramatically altered cancer prognosis. Nevertheless, these new therapies have introduced unexpected CV complications beyond heart failure. Common CV toxicities related to cancer therapy are defined, along with suggested strategies for prevention, detection and treatment. This ESMO consensus article proposes to define CV toxicities related to cancer or its therapies and provide guidance regarding prevention, screening, monitoring and treatment of CV toxicity. The majority of anticancer therapies are associated with some CV toxicity, ranging from asymptomatic and transient to more clinically significant and long-lasting cardiac events. It is critical however, that concerns about potential CV damage resulting from anticancer therapies should be weighed against the potential benefits of cancer therapy, including benefits in overall survival. CV disease in patients with cancer is complex and treatment needs to be individualised. The scope of cardio-oncology is wide and includes prevention, detection, monitoring and treatment of CV toxicity related to cancer therapy, and also ensuring the safe development of future novel cancer treatments that minimise the impact on CV health. It is anticipated that the management strategies discussed herein will be suitable for the majority of patients. Nonetheless, the clinical judgment of physicians remains extremely important; hence, when using these best clinical practices to inform treatment options and decisions, practitioners should also consider the individual circumstances of their patients on a case-by-case basis.