Ground-Based Mobile Measurements to Track Urban Methane Emissions from Natural Gas in 12 Cities across Eight Countries

To mitigate methane emission from urban natural gas distribution systems, it is crucial to understand local leak rates and occurrence rates. To explore urban methane emissions in cities outside the U.S., where significant emissions were found previously, mobile measurements were performed in 12 cities across eight countries. The surveyed cities range from medium size, like Groningen, NL, to large size, like Toronto, CA, and London, UK. Furthermore, this survey spanned across European regions from Barcelona, ES, to Bucharest, RO. The joint analysis of all data allows us to focus on general emission behavior for cities with different infrastructure and environmental conditions. We find that all cities have a spectrum of small, medium, and large methane sources in their domain. The emission rates found follow a heavy-tailed distribution, and the top 10% of emitters account for 60-80% of total emissions, which implies that strategic repair planning could help reduce emissions quickly. Furthermore, we compare our findings with inventory estimates for urban natural gas-related methane emissions from this sector in Europe. While cities with larger reported emissions were found to generally also have larger observed emissions, we find clear discrepancies between observation-based and inventory-based emission estimates for our 12 cities.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Integrating wearables and modelling for monitoring rehabilitation following total knee joint replacement

BACKGROUND AND OBJECTIVE

Wearable inertial devices integrated with modelling and cloud computing have been widely adopted in the sports sector, however, their use in the health and medical field has yet to be fully realised. To date, there have been no reported studies concerning the use of wearables as a surrogate tool to monitor knee joint loading during recovery following a total knee joint replacement. The objective of this study is to firstly evaluate if peak tibial acceleration from wearables during gait is a good surrogate metric for computer modelling predicted functional knee loading; and secondly evaluate if traditional clinical patient related outcomes measures are consistent with wearable predictions.

METHODS

Following ethical approval, four healthy participants were used to establish the relationship between computer modelling predicted knee joint loading and wearable measured tibial acceleration. Following this, ten patients who had total knee joint replacements were then followed during their 6-week rehabilitation. Gait analysis, wearable acceleration, computer models of knee joint loading, and patient related outcomes measures including the Oxford knee score and range of motion were recorded.

RESULTS

A linear correlation (R² of 0.7-0.97) was observed between peak tibial acceleration (from wearables) and musculoskeletal model predicted knee joint loading during gait in healthy participants first. Whilst patient related outcome measures (Oxford knee score and patient range of motion) were observed to improve consistently during rehabilitation, this was not consistent with all patient's tibial acceleration. Only those patients that exhibited increasing peak tibial acceleration over 6-weeks rehabilitation were positively correlated with the Oxford knee score (R² of 0.51 to 0.97). Wearable predicted tibial acceleration revealed three patients with a consistent knee loading, five patients with improving knee loading, and two patients with declining knee loading during recovery. Hence, 20% of patients did not present with satisfactory joint loading following total knee joint replacement and this was not detected with current patient related outcome measures.

CONCLUSIONS

The use of inertial measurement units or wearables in this study provided additional insight into patients who were not exhibiting functional improvements in joint loading, and offers clinicians an 'off-site' early warning metric to identify potential complications during recovery and provide the opportunity for early intervention. This study has important implications for improving patient outcomes, equity, and for those who live in rural regions.

Prevalence and whole genome-based phylogenetic, virulence and antibiotic -resistance characteristics of nasal -Staphylococcus aureus in healthy Swiss horses

INTRODUCTION

A total of 100 nasal swabs were collected from healthy horses in Switzerland between January 2020 and August 2020. The samples were taken from horses at 40 different stables in 12 different cantons and screened for both methicillin-resistant (MRSA) and methicillin-susceptible S. aureus (MSSA) using selective agar plates. S. aureus were tested for antibiotic susceptibility by measurement of the minimal inhibitory concentration (MIC) and for virulence factors, antibiotic resistance genes and phylogenetic characteristics using whole genome sequence analysis. Ten horses were found to be positive (10 %, CI: 95 %, 0,0552 - 0,1744) for S. aureus, and four of them harboured MRSA (4 %, CI: 95 %, CI: 1,5 % - 9 %). The MRSA were detected in horses from three different stables in the same region of one canton and MSSA were detected in horses from five different cantons. All the MRSA isolates were genetically related (ST398-t011-IVa), while the MSSA were diverse (ST1-t127/t398/t1508, ST816-t1294, ST133-t1403, ST30-t012). MRSA showed resistance to penicillin (blaZ), cefoxitin (mecA), trimethoprim (dfrK), gentamicin, kanamycin (aac(6')-Ie - aph(2'')-Ia), and tetracycline (tet(M)). MSSA were resistant to either none or one of the antibiotics tested like penicillin (blaZ) and erythromycin (erm(T)). Virulence genes were more abundant in MSSA than in MRSA. This study provides first insight into the prevalence and type of S. aureus in healthy Swiss horses and reveals a source of strains, which may cause infections in both horses and humans.

Laboratory Testing Patterns by Day of Hospital Stay for Medical and Surgical Hospitalizations

Introduction/Objective

Studies of laboratory test utilization and costs by specific hospital day of stay (DOS) have yet to be widely published. Evaluation of laboratory test use by DOS would be helpful to better predict laboratory test reduction as hospital length of stay (LOS) is shortened, since testing on the final day of hospitalization is likely to differ from the average daily figures.

Methods/Case Report

Using an internal cost accounting database, we evaluated laboratory tests and costs by hospital DOS over one year (2017) at a large health system (N=133,139 hospital days). To evaluate changes over the first days of hospitalization, we set day 1 of hospitalization as a baseline and determined subsequent days as a percentage of day 1 figures. We also calculated laboratory variable cost as a percent of aggregate variable costs per DOS. We limited our analysis to the first week of hospitalization. We employed Medicare Severity Diagnosis Related Groups (MSDRG), used by the US Centers for Medicare and Medicaid Services (CMS), to aggregate hospital encounters into medical or surgical hospitalizations using MSDRG grouping methods.

Results (if a Case Study enter NA)

For medical inpatient stays, average laboratory tests (variable costs) were 10.8 ($74.11) on day 1, 7.7 ($38.53) on day 2, and 5.8 ($23.75) on day 3, with little change over the next four hospital DOS. Laboratory testing, as a percent of day 1 testing, for days 2-7 was: 70.7%, 53.4%, 54.3%, 54.5%, 55.1%, and 54.0%. Laboratory variable costs represented 7.8% of aggregate variable costs on hospital day 1 and declined sequentially over days 2-7: 5.6%, 4.3%, 3.9%, 3.8%, 3.8%, and 3.5%. For surgical hospitalizations, average laboratory tests (variable costs) were 18.2 ($130.02) on day 1, 11.9 ($57.38) on day 2, and 8.4 ($35.32) on day 3. As with medical stays, there was little change over the next four hospital DOS. Laboratory testing, as a percent of day 1 testing, for days 2-7 was: 65.6%, 46.1%, 44.6%, 46.3%, 45.9%, and 44.9%. Laboratory variable costs represented 3.2% of aggregate variable costs on hospital day 1 and remained essentially unchanged over the following days (range 3.3%-3.7%).

Conclusion

Laboratory variable costs are highest on the first day of hospitalization and decline over subsequent days to flatten by day 3.

Inactivation of SARS-CoV-2 isolates from lineages B.1.1.7 (Alpha), P.1 (Gamma) and B.1.110 by heating and UV irradiation

Currently, the rapid global spread of SARS-CoV-2 is related to G clade (including GH, GR, GRY and GV clades), which are associated with more than 98 % of sequenced viral isolates worldwide. The unprecedented velocity of spread of SARS-CoV-2 outbreak represents a critical need for prevention strategies. Vaccines are recently being available and antiviral drugs have shown limited efficacy in COVID-19 patients. Thus, it is needed to know how to reduce the infectivity of the virus by different physicochemical conditions in order to prevent exposure to contaminated material.

This work describes heating and irradiating UV-C light procedures to reduce the infectivity of SARS-CoV-2 belonging to different three lineages. Results of physicochemical treatment showed no differences among viral lineages. Analytical conditions for efficient inactivation of SARS-CoV-2 were determined.

Tolerability profile of topical cannabidiol and palmitoylethanolamide: a compilation of single-centre randomized evaluator-blinded clinical and in vitro studies in normal skin

BACKGROUND

An increasing number of studies have investigated the adverse effect profile of oral cannabinoids; however, few studies have provided sufficient data on the tolerability of topical cannabinoids in human participants.

AIM

To assess the tolerability profile of several commercial topical formulations containing cannabidiol (CBD) and palmitoylethanolamide (PEA) on the skin of healthy human participants.

METHODS

Three human clinical trials and one in vitro study were conducted. The potential for skin irritation, sensitization and phototoxicity of several products, were assessed via patch testing on healthy human skin. The products assessed included two formulations containing CBD and PEA, one containing hemp seed oil and four concentrations of CBD alone. Ocular toxicity was tested using a traditional hen's egg chorioallantoic membrane model with three CBD, PEA and hemp seed oil formulations.

RESULTS

There was no irritation or sensitization of the products evident via patch testing on healthy participants. Additionally, mild phototoxicity of a hemp seed oil product was found at the 48-h time point compared with the negative control. The in vitro experiment demonstrated comparable effects of cannabinoid products with historically nonirritating products.

CONCLUSION

These specific formulations of CBD- and PEA-containing products are nonirritating and nonsensitizing in healthy adults, and further encourage similar research assessing their long-term safety and efficacy in human participants with dermatological diseases. There are some limitations to the study: (i) external validity may be limited as formulations from a single manufacturer were used for this study, while vast heterogeneity exists across unregulated, commercial CBD products on the market; and (ii) products were assessed only on normal, nondiseased human skin, and therefore extrapolation to those with dermatological diseases cannot be assumed.

Vaccination with Detoxified Leukocidin AB Reduces Bacterial Load in a Staphylococcus aureus Minipig Deep Surgical Wound Infection Model

Vaccines against Staphylococcus aureus have eluded researchers for >3 decades while the burden of staphylococcal diseases has increased. Early vaccine attempts mainly used rodents to characterize preclinical efficacy, and all subsequently failed in human clinical efficacy trials. More recently, leukocidin AB (LukAB) has gained interest as a vaccine antigen. We developed a minipig deep surgical wound infection model offering 3 independent efficacy readouts: bacterial load at the superficial and at the deep-seated surgical site, and dissemination of bacteria. Due to similarities with humans, minipigs are an attractive option to study novel vaccine candidates. With this model, we characterized the efficacy of a LukAB toxoid as vaccine candidate. Compared to control animals, a 3-log reduction of bacteria at the deep-seated surgical site was observed in LukAB-treated minipigs and dissemination of bacteria was dramatically reduced. Therefore, LukAB toxoids may be a useful addition to S. aureus vaccines and warrant further study.

AIRMESS - Academy of International Regenerative Medicine & Surgery Societies: recommendations in the use of platelet-rich plasma (PRP), autologous stem cell-based therapy (ASC-BT) in androgenetic alopecia and wound healing

INTRODUCTION

Many investigations showed that platelet-rich plasma (PRP), human follicles stem cells (HFSCs), and adipose-derived stem cells (ASCs), considered autologous stem cell-based therapy (ASC-BT), are effective for hair regrowth (HR) in patients affected by androgenetic alopecia and for wound healing (WH). The aim of this article is to analyze the in vitro and in vivo impact of different PRP, HFSCs, and ASCs preparation methods on HR and in WH.

AREAS COVERED

The analyzed data intended to clarify the molecular mechanism in which PRP, HFSCs, and ASCs are involved, the clinical use and related indications, fully respecting the European rules. Comparative studies between different systems of PRP, HFSCs, and ASCs preparation revealed differences in terms of HR and WH.

EXPERT OPINION

Despite a lack of standardized protocols, there is convincing evidence with objective measurement modalities that display positive outcomes of ASC-BT in HR and WH.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Background

The clinical course of COVID-19 critically ill patients, during their admission in the intensive care unit (UCI), including medical and infectious complications and support therapies, as well as their association with in-ICU mortality has not been fully reported.

Objective

This study aimed to describe clinical characteristics and clinical course of ICU COVID-19 patients, and to determine risk factors for ICU mortality of COVID-19 patients.

Methods

Prospective, multicentre, cohort study that enrolled critically ill COVID-19 patients admitted into 30 ICUs from Spain and Andorra. Consecutive patients from March 12th to May 26th, 2020 were enrolled if they had died or were discharged from ICU during the study period. Demographics, symptoms, vital signs, laboratory markers, supportive therapies, pharmacological treatments, medical and infectious complications were reported and compared between deceased and discharged patients.

Results

A total of 663 patients were included. Overall ICU mortality was 31% (203 patients). At ICU admission non-survivors were more hypoxemic [SpO₂ with non-rebreather mask, 90 (IQR 83–93) vs 91 (IQR 87–94); p < 0.001] and with higher sequential organ failure assessment score [SOFA, 7 (IQR 5–9) vs 4 (IQR 3–7); p < 0.001]. Complications were more frequent in non-survivors: acute respiratory distress syndrome (ARDS) (95% vs 89%; p = 0.009), acute kidney injury (AKI) (58% vs 24%; p < 10⁻¹⁶), shock (42% vs 14%; p < 10⁻¹³), and arrhythmias (24% vs 11%; p < 10⁻⁴). Respiratory super-infection, bloodstream infection and septic shock were higher in non-survivors (33% vs 25%; p = 0.03, 33% vs 23%; p = 0.01 and 15% vs 3%, p = 10⁻⁷), respectively. The multivariable regression model showed that age was associated with mortality, with every year increasing risk-of-death by 1% (95%CI: 1–10, p = 0.014). Each 5-point increase in APACHE II independently predicted mortality [OR: 1.508 (1.081, 2.104), p = 0.015]. Patients with AKI [OR: 2.468 (1.628, 3.741), p < 10⁻⁴)], cardiac arrest [OR: 11.099 (3.389, 36.353), p = 0.0001], and septic shock [OR: 3.224 (1.486, 6.994), p = 0.002] had an increased risk-of-death.

Conclusions

Older COVID-19 patients with higher APACHE II scores on admission, those who developed AKI grades II or III and/or septic shock during ICU stay had an increased risk-of-death. ICU mortality was 31%.

Patient-Specific Three-Dimensional-printed Instrumentation for Radius Lengthening Osteotomy by a Volar Approach in Epiphysiodesis Sequelae: A Case Report

Introduction:

Patient-specific guides are used in the correction of malunion sequelae in adult distal radius fractures. They allow a tridimensional correction of radial glenoid orientation. However, lengthening is small in those indications. Distal radius epiphysiodesis correction is much rarer and patient-specific guide after three-dimensional (3D) planning has never been reported for this indication in the literature.

Case Report:

We report the case of a 16-year-old teenager with a chronic painful wrist and an ulnar positive variance after a post-traumatic epiphysiodesis sequela of the radius. The radius was 11mm shorter than the ulna. An anatomic reconstruction was decided with a lengthening of the radius. Pre-operative planning and patient-specific guide allowed to control an important radial lengthening, to limit the morbidity of the iliac crest bone graft harvesting, to shape the graft precisely, and to maintain a correct radial glenoid orientation despite the important soft tissue tension. Clinical and radiological results at 6 months showed a complete disappearance of pain, optimal objective and subjective functional scores, and an improvement in the distal ulnar variance (7mm). The teenager went back to sport without limitation or pain.

Conclusion:

3Dplanning and intraoperative patient-specific guides in radial epiphysiodesis sequelae allow achieving 3D accurate measures of the graft and of the deformation, guiding the position and the orientation of the distal metaphysis cut of the radius, and limiting the morbidity of the iliac graft harvesting. In that case, it allowed restoring the full function of the wrist without remaining pain.

A simple method for SARS-CoV-2 detection by rRT-PCR without the use of a commercial RNA extraction kit

The World Health Organization (WHO) has declared a pandemic caused by a new coronavirus named SARS-CoV-2. The growing demand for commercial kits used for automated extraction of SARS-CoV-2 RNA, a key step before rRT-PCR diagnosis, could cause a shortage of stocks that hinders the rapid processing of samples.

Although the recommendation is to use automated methods for nucleic acid extraction, alternatives are necessary to replace commercial kits. However, these alternatives should be as reliable as automated methods.

This work describes a simple method to detect SARS-CoV-2 from specimens collected in different preservation media. Samples were previously inactivated by heating and precipitating with a PEG/NaCl solution before rRT-PCR assays for Orf1ab, N and S genes. The new method was compared with an automated protocol of nucleic acid extraction. Both procedures showed similar analytical results. Consequently, this simple and inexpensive method is a suitable procedure for laboratory diagnosis of SARS-CoV-2 infection.

Retrograde vs spot botulinium toxin facial injection

BACKGROUND

In this study we have based our research on botulinium toxin injection via targeted neuromuscular end plate zones, specifically in muscles with diffuse distribution of the latter. The muscular surface anatomical variety was also taken into consideration with thorough pre-injection examination of every subject.

METHOD

With consideration of the facial muscles anatomical variation and neuromuscular bundle distribution, we have applied the method of retrograde botulinium toxin injection on a series of 10 patients on the right side of the face with the left side as a control side, it was injected in a regular perpendicular manner in order to conclude the efficacy of targeted motor end zone injection. Using an auto-injecting syringe, we have delivered 6 Allergan units per zone (frontalis, glabellar lines of corrugator supercilii and orbicularis oculi crow's feet).

RESULTS

On control day 8 we have noticed a more prominent effect mainly on the level of the orbicularis oculi muscle and the corrugator supercilii muscle on 9 out of 10 patients. Nine patients out of 10 needed the delivery of an additional 6 Allergan units per zone on the control side's glabellar lines and crow's feet rhytids. Where 1 out of 10 patients needed the reinjection of the control side on the glabellar lines zone.

CONCLUSION

The musculature of the face varies when it comes to neuromuscular plate distribution. Muscles with scattered distribution patterns show an optimal response to botulinum toxin injections when delivered in a retrograde manner. This has allowed us to achieve of optimal results while minimizing injection sites and hence pain, the use of lower dosage and hence treatment cost, as well as lowering the unwanted product dissemination to the neighboring mimic muscles.

Patient characteristics, clinical course and factors associated to ICU mortality in critically ill patients infected with SARS-CoV-2 in Spain: A prospective, cohort, multicentre study

Antecedentes

No se ha reportado plenamente la evolución clínica de los pacientes críticos de COVID-19 durante su ingreso en la unidad de cuidados intensivos (UCI), incluyendo las complicaciones médicas e infecciosas y terapias de soporte, así como su asociación con la mortalidad en UCI.

Objetivo

El objetivo de este estudio es describir las características clínicas y la evolución de los pacientes ingresados en UCI por COVID-19 y determinar los factores de riesgo de la mortalidad en UCI de dichos pacientes.

Métodos

Estudio prospectivo, multicéntrico y de cohorte, que incluyó a los pacientes críticos de COVID-19 ingresados en 30 UCI de España y Andorra. Se incluyó a los pacientes consecutivos del 12 de marzo al 26 de mayo del 2020 si habían fallecido o habían recibido el alta de la UCI durante el periodo de estudio. Se reportaron los datos demográficos, los síntomas, los signos vitales, los marcadores de laboratorio, las terapias de soporte, terapias farmacológicas y las complicaciones médicas e infecciosas, realizándose una comparación entre los pacientes fallecidos y los pacientes dados de alta.

Resultados

Se incluyó a un total de 663 pacientes. La mortalidad general en UCI fue del 31% (203 pacientes). Al ingreso en UCI los no supervivientes eran más hipoxémicos (SpO₂ con mascarilla de no reinhalación, de 90 [RIC 83-93] vs. 91 [RIC 87-94]; p < 0,001] y con mayor puntuación en la escala SOFA-Evaluación de daño orgánico secuencial (SOFA, 7 [RIC 5-9] vs. 4 [RIC 3-7]; p <0,001]). Las complicaciones fueron más frecuentes en los no supervivientes: síndrome de distrés respiratorio agudo (SDRA) (95% vs. 89%; p = 0,009), insuficiencia renal aguda (IRA) (58% vs. 24%; p < 10^–6), shock (42% vs. 14%; p < 10^–13) y arritmias (24% vs. 11%; p < 10^–4). Las superinfecciones respiratorias, infecciones del torrente sanguíneo y los shock sépticos fueron más frecuentes en los no supervivientes (33% vs. 25%; p = 0,03, 33% vs. 23%; p = 0,01 y 15% vs. 3%, p = 10^–7, respectivamente). El modelo de regresión multivariable reflejó que la edad estaba asociada a la mortalidad y que cada año incrementaba el riesgo de muerte en un 1% (IC del 95%: 1-10, p = 0,014). Cada incremento de 5 puntos en la escala APACHE II predijo de manera independiente la mortalidad (odds ratio [OR]: 1,508 [1,081, 2,104], p = 0,015). Los pacientes con IRA (OR: 2,468 [1,628, 3,741], p < 10^–4)], paro cardiaco (OR: 11,099 [3,389, 36,353], p = 0,0001] y shock séptico [OR: 3,224 [1,486, 6,994], p= 0,002) tuvieron un riesgo de muerte incrementado.

Conclusiones

Los pacientes mayores de COVID-19 con puntuaciones APACHE II más altas al ingreso, que desarrollaron IRA en grados ii o iii o shock séptico durante la estancia en UCI tuvieron un riesgo de muerte incrementado. La mortalidad en UCI fue del 31%.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

P5753Jailed pressure wire to assess the side branch result for bifurcation lesions treated by provisional stenting strategy: iFR as a new index

Purpose

To analyze the feasibility and efficacy of the jailed pressure wire technique for bifurcation lesions treated by provisional stenting strategy and to assess the physiological side branch (SB) result using instantaneous wave free ratio (iFR).

Methods

Between June 2017 and December 2018, 50 patients who presented a bifurcation lesion considered appropriate for provisional stenting strategy were included in the study. Pressure wire was passed to side branch before treatment. Main vessel (MV) and side branch (SB) was predilated at the operator criteria. iFR determination was obtained in the SB baseline and after MV stenting (leaving the pressure wire jailed). Afterwards, the wire was removed to MV ostium to discard the possibility of drift. SB postdilation was performed if SB iFR was less than 0,89 (according to vessel thresholds established in clinical trials), evaluating the result by a new iFR determination.

Results

The mean age was 64±10 years. Sixteen patients (32%) had diabetes. Clinical presentation was stable angina in 26 patients (52%), non-STEMI in 19 patients (38%) and STEMI (non culprit lesion) in 5 patients (10%). The most frequent bifurcation type according to Medina classifications was 1,1,0 (21 patients, 42%). Seventeen patients (34%) had a true bifurcation lesion. The MV and SB reference diameter was 3,0±0,5 mm and 2,25±0,5 mm respectively. Most of the bifurcations were located at the left anterior descending artery/diagonal branch (27 bifurcations, 54%). Ten patients (20%) presented a distal left main bifurcation. Baseline SB iFR was 0,78±0,2. Under continuous SB iFR monitoring MV stenting was performed by trapping the pressure wire. After MV stenting, the SB iFR changed to 0,90±0,1. We confirmed the presence of drift in 5 patients (10%). In these cases, recalibration of the wire and SB rewiring was performed in 4 cases. In the remaining patient, rewiring was not possible even using specific coronary wires.

According to SB IFR, postdilation was necessary in 14 patients (28%). Final SB iFR was 0,94±0,03. A second stent was not necessary in any patient because final SB iFR was higher than 0.89 in all cases. We observed discordance between angiographic and physiological result in 17 cases (34%). All the wires could be removed. Forty wires (80%) were microscopically analyzed. Some grade of microscopic damage was found in 32 wires (80%), all of them distal to the pressure sensor. However, only one of these wires (2%) presented severe damage, and no case of fracture was observed.

After a mean follow up time of 10±6 months only one patient (2%) presented a major cardiac adverse event (acute coronary syndrome due to voluntary cessation of dual antiplatelet therapy).

Conclusions

The use of jailed pressure wire to monitor SB results for bifurcations treated by provisional stenting seems to be safe. The iFR index seems to provide new physiological information about the significance of the SB stenosis.

Implication of obesity on motion, posture and internal stress of the foot: an experimental and finite element analysis

Obesity causes increased loading on the foot which can damage the soft tissue and bone ultimately leading to foot problems. Experimental and computational methods were used to analyse the chain of biomechanical changes in the lower limb due to obesity. The experimental study shows some changes in foot posture and gait where obese subjects were more likely to have pronated feet, smaller joint angles in the sagittal and frontal planes, smaller cadence, and smaller stride length. Anatomically correct finite element models generated on obese subjects showed increased and altered internal and plantar stress.  Altered foot posture was identified as a key indicator of increased internal stress indicating the importance of foot posture correction.

Can 5-methylcytosine analogues with extended alkyl side chains guide DNA methylation?

5-Methylcytosine (^MeC) is an endogenous modification of DNA that plays a crucial role in DNA-protein interactions, chromatin structure, epigenetic regulation, and DNA repair. ^MeC is produced via enzymatic methylation of the C-5 position of cytosine by DNA-methyltransferases (DNMT) which use S-adenosylmethionine (SAM) as a cofactor. Hemimethylated CG dinucleotides generated as a result of DNA replication are specifically recognized and methylated by maintenance DNA methyltransferase 1 (DNMT1). The accuracy of DNMT1-mediated methylation is essential for preserving tissue-specific DNA methylation and thus gene expression patterns. In the present study, we synthesized DNA duplexes containing MeC analogues with modified C-5 side chains and examined their ability to guide cytosine methylation by the human DNMT1 protein. We found that the ability of 5-alkylcytosines to direct cytosine methylation decreased with increased alkyl chain length and rigidity (methyl > ethyl > propyl ∼ vinyl). Molecular modeling studies indicated that this loss of activity may be caused by the distorted geometry of the DNA-protein complex in the presence of unnatural alkylcytosines.

Abatement of chlorinated compounds in groundwater contaminated by HCH wastes using ISCO with alkali activated persulfate

In this work, in situ chemical oxidation (ISCO) with alkali activated persulfate has been tested for the elimination of HCH isomers and other chlorinated compounds in groundwater from Sabiñanigo (Sardas landfill), which was contaminated by solid and liquid wastes illegally dumped in the area by a company producing lindane. Due to the site lithology and the type of pollutants found in groundwater (HCHs and chlorobenzenes) alkali (NaOH) activated persulfate (PS) was selected as oxidant. The influence of variables such as PS concentration (42-200mM) and NaOH:PS molar ratio (2:1 to 4:1) on chlorinated compound abatement has been studied and a kinetic model to predict the composition of all chlorinated organic compounds (COCs) in the aqueous phase with time was obtained. It was found that a fast initial hydrodechlorination reaction took place in which HCH isomers reacted to trichlorobenzenes (mainly 1,2,4 TCB) at pH≥12. Mono-, di-, tri and tetrachlorobenzenes remaining were oxidized without producing aromatic intermediates. At the condition tested a first order kinetic model for COCs and PS concentration was obtained. Zero order alkali concentration was obtained while pH was being kept at 12 for the whole reaction time.

196 Fertilization Rate in Superovulated Criolla Goats Following Artificial Insemination or Natural Mating

The Criolla breed is a local genetic resource, distributed in Patagonia, Argentina, whose primary production is meat. In the Criolla goat, efforts were made to locate productively superior males and to conserve their genetic material. Studies were carried on the feasibility of obtaining superior offspring through the implementation of embryo transfer programs. We assessed the fertilization rate and embryo production following AI with frozen semen or natural mating in Criolla goats subjected to a superovulation program. During the breeding season (May, 41° S), 26 Criolla goats were treated for oestrus with sponges (60 mg of medroxyprogesterone acetate, Progespon®, Syntex, Buenos Aires, Argentina) placed for 13 days. Goat donors were superovulated with a total of 80 mg of porcine (p)FSH (Folltropin V®, Bioniche, Ontario, Canada) every 12 h in 6 decreasing doses (18, 18, 14, 14, 8, and 8 mg) during the last 3 days of progestagen treatment. A dose of 125 μg of cloprostenol (Estrumate®, Schering-Plough, Quebec, Canada) was given in conjunction with the first dose of pFSH. Oestrus detection was performed every 12 h, starting at 24 h after sponge removal. Females were considered to be in oestrus if they passively accepted buck mounting. Goats were randomly assigned to the following treatments: (1) natural mating (NM, n = 12): donors detected in oestrus were individually mated with one proven fertile buck at oestrus and 12 h post-oestrus; does were remove from the male in between (Conventionally accepted treatment); (2) AI (n = 14): donors detected in oestrus were inseminated 12 ± 2 h after the onset of oestrus by laparoscopy with frozen-thawed semen (200 × 106 spermatozoa) from the same fertile buck. Embryo recovery was done by surgical prepubic laparotomy at Day 8 after sponge removal. Superovulation response was estimated by counting the number of corpora lutea (CL). Analysis of variance was used to compare fertilization rate (total number of embryos recovered for each animal, expressed as a proportion of the total number of embryos/oocytes recovered) and embryo production between treatments. Results were expressed as mean ± SEM. Statistical significance was accepted at P < 0.05. A total of 92.3% goats were recorded in oestrus (24/26) between 24 and 48 h after sponge removal (10 and 14 goats for NM and AI, respectively). An average of 16.6 ± 2.0 CL (range: 2–32) was observed in response to superovulation treatment. The recovery rate of embryos/oocytes was 60.0 ± 6.9%. No statistical difference was observed in the fertilization rate (52.1 ± 12.1 and 68.6 ± 12.1% for AI and NM, respectively) or the number of total (6.8 ± 2.0 and 4.8 ± 2.4 for AI and NM, respectively) and transferable embryos (5.6 ± 1.4 and 4.0 ± 1.7 for AI and NM, respectively) between treatments (P > 0.05). In conclusion, fertilization rates did not differ following laparoscopic insemination with frozen semen compared to natural mating in superovulated Criolla goats.

Accuracy of genomic within-family selection in aquaculture breeding programmes

In aquaculture breeding programmes, selection within families cannot be applied for traits that cannot be recorded on the candidates (e.g., disease resistance or fillet quality). However, this problem can be overcome if genomic evaluation is used. Within-family genomic evaluation has been proposed for these programmes as large family sizes are available and substantial levels of linkage disequilibrium (LD) within families can be attained with a limited number of markers even in populations in global linkage equilibrium. Here, we compare by computer simulation: (i) within-family and population-wide LD; and (ii) the accuracy of within-family genomic selection when genomic evaluations are carried out either at the population level or within families. The population simulated was composed by a varying number of families of full-sibs (half for training and half for testing). The results indicate that, to practice within-family selection, performing the genomic evaluation separately for each family using only molecular information from the family could be recommended for populations either in linkage equilibrium or with a low level of disequilibrium.

[The eyelid-cheek junction]

The eyelid-cheek junction is a key area which generates many comments: from looking tired to looking good or rested, without forgetting charm, beauty, and a youthful appearance. In spite of many interesting medical and surgical procedures, treating this area is sometimes difficult and results are not always up to our expectations. Standardized blepharoplasty, which has often been improperly used, has shown its limits. Since the latest refinements, lipostructure has revolutionised blepharoplasty and serving as a reference, it has become an established technique. Subperiostal mediofacial lift allows outstanding results at the cost of a certain technical aggressiveness. Aesthetic medicine proposes worthy alternative and/or appropriate complementary solutions. Different procedures we dispose of have been reviewed together with their assets and their limits. A codification of therapeutic indications is proposed. The positioning of the eyelid-cheek clinical junction in relation with the low orbital bone rim influences our strategy in choosing the appropriate technique.