Cardiac resternotomy after cardiac surgery in kids: CRACK the chest

OBJECTIVE

Emergent resuscitation of postoperative paediatric cardiac surgical patients requires specialised skills and multidisciplinary teamwork. Bedside resternotomy is a rare but life-saving procedure and few studies focus on ways to prepare providers and improve performance. We created a multidisciplinary educational intervention that addressed teamwork and technical skills. We aimed to evaluate the efficiency of the intervention to decrease time to perform critical tasks and improve caregiver comfort.

METHODS

A simulation-based, in situ resternotomy educational intervention was implemented. Pre-intervention data were collected. Educational aids were used weekly during day and night nursing huddles over a three-month period. All ICU charge nurses had separate educational sessions with study personnel and were required to demonstrate competency in all the critical tasks. Post-intervention simulations were performed after intervention and at 6 months and post-intervention surveys were performed.

RESULTS

A total of 186 providers participated in the intervention. There was a decrease in time to obtain defibrillator, setup resternotomy equipment and internal defibrillator paddles and deliver sedation and fluid (all p < 0.05). Time to escort family from the room and obtain blood was significantly decreased after intervention (p < 0.05). There was no difference in time to first dose of epinephrine, defibrillator pads on the patient, or time to call the cardiovascular surgeon or blood bank. Providers reported increased comfort in identifying equipment needed for resternotomy (p < 0.01) and setting up the internal defibrillator paddles (p < 0.01).

CONCLUSIONS

Implementation of a novel educational intervention increased provider comfort and decreased time to perform critical tasks in an emergent resternotomy scenario.

Technological Aspects of Nanoemulsions for Post-harvest Preservation of Fruits and Vegetables

Recent times have witnessed a growing demand for sustainable technology for food preservation that can retain its freshness, promises lower contents of additives and preservatives, safe consumption, eco-friendly milder processing technologies and eco-friendlier packaging solutions. Application of Biopolymers has served as the most sustainable and viable option to its synthetic counterparts. These biopolymers have been incorporated to develop biodegradable packaging like edible films and coatings owing to their biological origin. Nanoemulsion technology offers a leap forward to upgrade the features of conventional biodegradable packaging items. The present review discusses various trends and perspectives of nanoemulsion technology in post-harvest preservation for enhancing the shelf life of fresh fruits and vegetables. It investigates the interconnectedness between food preservation techniques, biodegradable packaging materials made from biopolymers, and nanoemulsions. It further addresses the preservation challenges post-harvest and underscores the limitations of conventional preservation methods, advocating for eco-friendly alternatives with a specific focus on the potential of nanoemulsions in enhancing food safety and quality. This review elaborates on the composition, formulation techniques, nanoemulsion products and role of nanoemulsions in the management of foodborne pathogens. Furthermore, it examines the potential health hazards linked to the use of nanoemulsions and stresses the significance of a regulatory framework for food safety. In conclusion, this review offers insights into the promising prospects of using nanoemulsions in food preservation.

A holistic approach to performance prediction in collegiate athletics: player, team, and conference perspectives

Predictive sports data analytics can be revolutionary for sports performance. Existing literature discusses players' or teams' performance, independently or in tandem. Using Machine Learning (ML), this paper aims to holistically evaluate player-, team-, and conference (season)-level performances in Division-1 Women's basketball. The players were monitored and tested through a full competitive year. The performance was quantified at the player level using the reactive strength index modified (RSImod), at the team level by the game score (GS) metric, and finally at the conference level through Player Efficiency Rating (PER). The data includes parameters from training, subjective stress, sleep, and recovery (WHOOP straps), in-game statistics (Polar monitors), and countermovement jumps. We used data balancing techniques and an Extreme Gradient Boosting (XGB) classifier to predict RSI and GS with greater than 90% accuracy and a 0.9 F1 score. The XGB regressor predicted PER with an MSE of 0.026 and an R2 of 0.680. Ensemble of Random Forest, XGB, and correlation finds feature importance at all levels. We used Partial Dependence Plots to understand the impact of each feature on the target variable. Quantifying and predicting performance at all levels will allow coaches to monitor athlete readiness and help improve training.

Diffusion MRI correlation with p16 status and prediction for tumor progression in locally advanced head and neck cancer

Purpose

To investigate p16 effects on diffusion image metrics and associations with tumor progression in patients with locally advanced head and neck cancers.

Methods

Diffusion images pretreatment and after 20 Gy (2wk) of RT were analyzed in patients with cT4/N3 p16+ oropharynx cancer (OPSCC) (N=51) and locoregionally advanced head and neck squamous cell carcinoma (LAHNSCC) (N=28), enrolled onto a prospective adaptive RT trial. Mean ADC values, subvolumes with ADC <1.2 um2/ms (TVLADC), and peak values of low (µL) and high (µH) components of ADC histograms in primary and total nodal gross tumor volumes were analyzed for prediction of freedom from local, distant, or any progression (FFLP, FFDP or FFLRDP) using multivariate Cox proportional-hazards model with clinical factors. P value with false discovery control <0.05 was considered as significant.

Results

With a mean follow up of 36 months, 18 of LAHNSCC patients and 16 of p16+ OPSCC patients had progression. After adjusting for p16, small µL and ADC values, and large TVLADC of primary tumors pre-RT were significantly associated with superior FFLRDP, FFLP and FFDP in the LAHNSCC (p<0.05), but no diffusion metrics were significant in p16+ oropharynx cancers. Post ad hoc analysis of the p16+ OPSCC only showed that large TVLADC of the total nodal burden pre-RT was significantly associated with inferior FFDP (p=0.05).

Conclusion

ADC metrics were associated with different progression patterns in the LAHNSCC and p16+ OPSCC, possibly explained by differences in cancer biology and morphology. A deep understanding of ADC metrics is warranted to establish imaging biomarkers for adaptive RT in HNSCC.

Oral Nirmatrelvir and Ritonavir for Coronavirus Disease 2019 in Vaccinated, Nonhospitalized Adults Aged 18-50 Years

BACKGROUND

The effects of nirmatrelvir/ritonavir (NMV/r [Paxlovid]) on coronavirus disease 2019 (COVID-19) outcomes in younger vaccinated adults are unclear. The objective of this study was to assess if NMV/r use in vaccinated adults aged ≤50 years is associated with improved outcomes and to identify beneficial and nonbeneficial subgroups.

METHODS

In this cohort study, we generated 2 propensity-matched cohorts of 2547 patients from an 86 119-person cohort assembled from the TriNetX database. Patients in 1 cohort received NMV/r, and patients in the matched control cohort did not. The main outcome was composite of all-cause emergency department visits, hospitalization, and mortality.

RESULTS

The composite outcome was detected in 4.9% of the NMV/r cohort and 7.0% of the non-NMV/r cohort (odds ratio, 0.683 [95% confidence interval, .540-.864]; P = .001), indicating a 30% relative risk reduction. The number needed to treat (NNT) for the primary outcome was 47. Subgroup analyses found significant associations for patients with cancer (NNT = 45), cardiovascular disease (NNT = 30), and both conditions (NNT = 16). No benefit was found for patients with only chronic lower respiratory disorders (asthma/chronic obstructive pulmonary disease [COPD]) or without serious comorbidities. Thirty-two percent of NMV/r prescriptions in the overall database were for 18- to 50-year-olds.

CONCLUSIONS

NMV/r use in vaccinated adults aged 18-50 years, especially with serious comorbidities, was associated with reduced all-cause hospital visits, hospitalization, and mortality in the first 30 days of COVID-19 illness. However, NMV/r in patients without significant comorbidities or with only asthma/COPD had no association of benefit. Therefore, identifying high-risk patients should be a priority and overprescription should be avoided.

Pelvis Treatment Plan Dose Comparison for Proton Therapy Using Single Energy and Dual Energy Computed Tomography Simulation Methods

PURPOSE/OBJECTIVE(S)

In proton therapy, plan robustness is ameliorated by expanding the irradiation volume beyond the target, in order to mitigate setup and proton range uncertainties (RU). A byproduct of this expansion is elevated doses to surrounding organs at risk (OARs) which reduce some of the benefits associated with proton therapy. Dual-energy CT (DECT) has been shown in multiple phantom and animal tissue studies to reduce RU without compromising plan robustness. This study quantifies dosimetric differences between single-energy CT (SECT) and DECT for pelvis patients treated with intensity modulated proton therapy (IMPT).

MATERIALS/METHODS

Under IRB approval, SECT and DECT scans from 25 IMPT pelvis patients were acquired using a CT scanner. Clinical plans were generated on the SECT images using robust optimization settings of 3.5% RU and 5 mm setup uncertainty in a treatment planning system. Subsequently, the clinical plans were recomputed on the corresponding DECT generated SPR-map images. For each patient, target coverage, mean and maximum OAR doses were compared for both image sets.

RESULTS

Comparison of two plans showed systematic differences in target minimum dose (D99%) and V100%. Variations as high as 3.1% with DECT were observed in D99% indicating target under-dosage. On average, use of SECT overestimated V100% by 2.4% when compared to DECT. Since all clinical plans were optimized robustly to meet V95% coverage, higher agreement (<1%) was achieved for V95% (99.9±0.2%), and D95% (99.6±0.3%). DECT relative to SECT indicated slightly higher OAR maximum doses for femoral heads (2.3±2.78%), penile bulb/external genital (1.33±4.00%) and large bowel (0.5±1.25%). Similarly, higher mean dose was observed to rectum (2.08±4.88%), bladder (1.41±0.25%), femoral heads (1.18±6.61%) and penile bulb/external genital (1.78±5.74%) for DECT relative to SECT.

CONCLUSION

Our results show a disparity between evaluated SECT and DECT target and OAR dosimetric parameters. Given the higher accuracies in proton range estimation associated with the use of DECT, its use can imply a potential for more conformal proton plans as well as higher TPS computed target coverage and OAR dose accuracy, both of which enhance overall treatment quality.

The emerging role of lipid nanosystems and nanomicelles in liver diseases

Nanoparticles (NPs) exhibit remarkable potential in the diagnosis and treatment of various liver ailments, including primary liver cancer or hepatocellular carcinoma (HCC), liver cirrhosis, viral hepatitis, and alcoholic and non-alcoholic liver diseases. High surface area-to-volume ratio with distinct physicochemical and bio-pharmaceutical properties have contributed numerous benefits to NPs, such as high intracellular uptake and efficient drug delivery capabilities stemming from their ability to encapsulate a diverse range of drugs. Lipid-based nanosystems have demonstrated significant potential as reliable and efficient transport vehicles for a variety of actives, including small interfering RNA, targeting the liver, owing to their excellent in vivo compatibility, biodegradable nature, and non-toxic properties. Multiple aspects of various lipid-based materials, lipid nanosystems like solid lipid NPs, nanovesicles such as nanoemulsions, liposomes, and nanomicelles for liver-specific active targeting have been comprehensively reviewed. Ongoing and completed clinical trials of lipid nanosystems developed for HCC, hepatic fibrosis, and hepatitis are tabulated. Types of receptors and ligands typically used for active liver targeting in HCC are extensively discussed. The US FDA's recent approval for the use of Onpattro (Patisiran) injection to treat polyneuropathy in adult patients is indicative of the rapid development of lipid nanosystems employed for hepatic targeting. Nanoemulsions loaded with diagnostic imaging agents for multi-modal liver imaging were briefly discussed. Emerging technologies are being developed to integrate desirable properties of nanoparticles (NPs), including high stability, efficient drug loading, opsonization avoidance, active liver targeting, and facilitation of endosomal escape. Clinical translations of many lipid NPs for drug and gene therapy applications targeting different liver diseases are expected in the near future.

Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client's evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.

Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data

OBJECTIVES

To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD).

DESIGN

Secondary analysis of data collected for the Death One Hour After Terminal Extubation study.

SETTING

Nine U.S. hospitals.

PATIENTS

Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021).

MEASUREMENTS AND MAIN RESULTS

Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/F io2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) ( n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) ( n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD.

CONCLUSIONS

Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.

Caffeine addiction and determinants of caffeine consumption among health care providers: a descriptive national study

OBJECTIVE

Caffeine is the most commonly used psychostimulant compound with a long history of worldwide consumption. Consuming low to moderate doses of caffeine is generally safe and quite beneficial; however, several clinical studies show that high doses could be toxic.  Additionally, caffeine users can become dependent on the drug and find themselves unable to reduce consumption despite impending and recurrent health problems associated with continued use. This study was conducted to explore the prevalence, determinants, and positive and negative effects of caffeine consumption among governmental health care providers (HCPs) who were caffeine users. It aims to determine the frequency of caffeine dependence and addiction in the Kingdom of Saudi Arabia (KSA) in January 2020.

SUBJECTS AND METHODS

This cross-sectional study recruited 600 randomly selected HCPs from all regions of KSA, who fulfilled the selection criteria through a self-administrated, online-validated questionnaire composed of three main parts using the DSM-IV to diagnose dependence and probable addiction.

RESULTS

The majority of the studied HCPs were females (67.8%), nonsmokers (82.0%), and Saudis (80.5%), with a mean age of 35 years. According to the DSM-IV, the prevalence of caffeine consumption was 94.3%. Caffeine dependence was reported in 270 (47.7%), while 345 (60.9%) were diagnosed as addicts. The most commonly consumed caffeine-containing substances were coffee and its variants/types (70%), tea (59%), and chocolate (52%), with each person spending about 220 SR per week on them. The main reported adverse effects, in descending order, were sleep disturbances, stomach problems, and cardiac symptoms. The most positive effects reported of caffeine consumption were feeling active, alert, confident, and happy. These findings were significantly affected by sex, occupation, and general health.

CONCLUSIONS

Caffeine use, dependence, and addiction are common among government HCPs in KSA. Caffeine has both positive and negative effects on this population and further research is necessary to better understand the long-term consequences of caffeine consumption.

Detection of SARS-CoV-2 IgG antibodies and inflammatory cytokines in saliva-a pilot study

Objective

The pandemic caused by SARS-CoV-2 virus continues to have a profound effect worldwide. However, COVID-19 induced oral facial manifestations have not been fully described. We conducted a prospective study to demonstrate feasibility of anti-SARS-CoV-2 IgG and inflammatory cytokine detection in saliva. Our primary objective was to determine whether COVID-19 PCR positive patients with xerostomia or loss of taste had altered serum or saliva cytokine levels compared to COVID-19 PCR positive patients without those oral symptoms. Our secondary objective was to determine the correlation between serum and saliva COVID-19 antibody levels.

Materials and methods

For cytokine analysis, saliva and serum were obtained from 17 participants with PCR-confirmed COVID-19 infection at three sequential time points, yielding 48 saliva samples and 19 paired saliva-serum samples from 14 of the 17 patients. For COVID-19 antibody analyses, an additional 27 paired saliva-serum samples from 22 patients were purchased.

Results

The saliva antibody assay had 88.64% sensitivity [95% Confidence Interval (CI) 75.44%, 96.21%] to detect SARS-CoV-2 IgG antibodies compared to serum antibody. Among the inflammatory cytokines assessed - IL-6, TNF-α, IFN-γ, IL-10, IL-12p70, IL-1β, IL-8, IL-13, IL-2, IL-5, IL-7 and IL-17A, xerostomia correlated with lower levels of saliva IL-2 and TNF-α, and elevated levels of serum IL-12p70 and IL-10 (p < 0.05). Loss of taste was observed in patients with elevated serum IL-8 (p < 0.05).

Conclusions

Further studies are needed to construct a robust saliva-based COVID-19 assay to assess antibody and inflammatory cytokine response, which has potential utility as a non-invasive monitoring modality during COVID-19 convalescence.

Oral Nirmatrelvir and Ritonavir in Nonhospitalized Vaccinated Patients With Coronavirus Disease 2019

BACKGROUND

Treatment of coronavirus disease 2019 (COVID-19) with nirmatrelvir plus ritonavir (NMV-r) in high-risk nonhospitalized unvaccinated patients reduced the risk of progression to severe disease. However, the potential benefits of NMV-r among vaccinated patients are unclear.

METHODS

We conducted a comparative retrospective cohort study using the TriNetX research network. Patients ≥18 years of age who were vaccinated and subsequently developed COVID-19 between 1 December 2021 and 18 April 2022 were included. Cohorts were developed based on the use of NMV-r within 5 days of diagnosis. The primary composite outcome was all-cause emergency room (ER) visit, hospitalization, or death at a 30-day follow-up. Secondary outcomes included individual components of primary outcomes, multisystem symptoms, COVID-19-associated complications, and diagnostic test utilization.

RESULTS

After propensity score matching, 1130 patients remained in each cohort. A primary composite outcome of all-cause ER visits, hospitalization, or death in 30 days occurred in 89 (7.87%) patients in the NMV-r cohort compared with 163 (14.4%) patients in the non-NMV-r cohort (odds ratio: .5; 95% confidence interval: .39-.67; P < .005) consistent with 45% relative risk reduction. A significant reduction in multisystem symptom burden and subsequent complications, such as lower respiratory tract infection, cardiac arrhythmia, and diagnostic radiology testing, were noted in NMV-r-treated patients. There was no apparent increase in serious complications between days 10 and 30.

CONCLUSIONS

Treatment with NMV-r in nonhospitalized vaccinated patients with COVID-19 was associated with a reduced likelihood of ER visits, hospitalization, or death. Complications and overall resource utilization were also decreased.

Cardiovascular Drug Interactions With Nirmatrelvir/Ritonavir in Patients With COVID-19: JACC Review Topic of the Week

Nirmatrelvir-ritonavir (NMVr) is used to treat symptomatic, nonhospitalized patients with coronavirus disease-2019 (COVID-19) who are at high risk of progression to severe disease. Patients with cardiovascular risk factors and cardiovascular disease are at a high risk of developing adverse events from COVID-19 and as a result have a higher likelihood of receiving NMVr. Ritonavir, the pharmaceutical enhancer used in NMVr, is an inhibitor of the enzymes of CYP450 pathway, particularly CYP3A4 and to a lesser degree CYP2D6, and affects the P-glycoprotein pump. Co-administration of NMVr with medications commonly used to manage cardiovascular conditions can potentially cause significant drug-drug interactions and may lead to severe adverse effects. It is crucial to be aware of such interactions and take appropriate measures to avoid them. In this review, we discuss potential drug-drug interactions between NMVr and commonly used cardiovascular medications based on their pharmacokinetics and pharmacodynamic properties.

The Role of Oral Health in the Acquisition and Severity of SARS-CoV-2: A Retrospective Chart Review

Objective

Studies have shown that gingival crevices may be a significant route for SARS-CoV-2 entry. However, the role of oral health in the acquisition and severity of COVID-19 is not known.

Design

A retrospective analysis was performed using electronic health record data from a large urban academic medical center between 12/1/2019 and 8/24/2020. A total of 387 COVID-19 positive cases were identified and matched 1:1 by age, sex, and race to 387 controls without COVID-19 diagnoses. Demographics, number of missing teeth and alveolar crestal height were determined from radiographs and medical/dental charts. In a subgroup of 107 cases and controls, we also examined the rate of change in alveolar crestal height. A conditional logistic regression model was utilized to assess association between alveolar crestal height and missing teeth with COVID-19 status and with hospitalization status among COVID-19 cases.

Results

Increased alveolar bone loss, OR = 4.302 (2.510 - 7.376), fewer missing teeth, OR = 0.897 (0.835-0.965) and lack of smoking history distinguished COVID-19 cases from controls. After adjusting for time between examinations, cases with COVID-19 had greater alveolar bone loss compared to controls (0.641 ± 0.613 mm vs 0.260 ± 0.631 mm, p < 0.01.) Among cases with COVID-19, increased number of missing teeth OR = 2.1871 (1.146- 4.174) was significantly associated with hospitalization.

Conclusions

Alveolar bone loss and missing teeth are positively associated with the acquisition and severity of COVID-19 disease, respectively.

Family structure and substance use in 6,178 American Indian youth: a cross-sectional study

OBJECTIVE

Adolescents from single-parent families are at significantly higher risk of substance use compared to those from mother-father families. More than half of American Indian (AI) children live in single-parent families, the second highest percentage among all groups. Given the paucity of research pertaining to the role of family structure and substance use in the AI population, we sought to examine this relationship.

MATERIALS AND METHODS

Data from this study were obtained from the Substance Use Among American Indian Youth: Epidemiology and Etiology, [US], 2015-2020 study. Response variables of interest included age at first substance use, number of substances used, ever-use of substance, and substance use type (i.e., alcohol, cigarette, marijuana, etc.).

RESULTS

Living in a father-only or mother-only setting showed a similar pattern of drug use. There was a significant increase in the risk of cigarette, alcohol and marijuana use. For cigarettes, the odds ratio was (OR = 2.60, 95% CI 1.80-3.75) in father-only setting compared to (OR = 1.42, 95% CI 1.13-1.78) for mother only setting. Alcohol use showed (OR = 1.72, 95% CI 1.19-2.50 and OR = 1.40, 95% CI 1.12-1.74) for father-only and mother-only respectively and marijuana use showed (OR = 1.59, 95% CI 1.10-2.30 and OR = 1.54, 95% CI -1.24-1.92) for father-only and mother-only respectively.

CONCLUSIONS

Disturbed family structure is associated with increased risk of substance use among AI youth. This indicates the importance and need for policy and community level interventions to reduce youth substance exposure.

Outcomes of patients presenting with Guillain-Barre Syndrome at a tertiary care center in India

Background

The Guillain-Barre Syndrome (GBS), also known as acute idiopathic polyneuritis, is a critical acquired condition associated with preceding nonspecific infection or triggering factors like trauma, surgery, or vaccination. GBS is currently the most frequent cause of acute flaccid paralysis in India. This study evaluates the short-term and in-hospital outcomes in different subtypes of GBS.

Methods

A prospective observational study was conducted at V.S. Hospital, Ahmedabad, from September 2015 to December 2017. Patients above the age of 12 were included. Patients having other underlying neurological conditions, as well as immunodeficiency disorders, were excluded. The patients were classified into different subtypes of GBS, and functional outcomes were recorded on admission and discharge according to Hughes Scoring System. All statistical analyses were performed by using SPSS software.

Results

Out of 50 patients, 35 (70%) were males. The mean age was of 37.18 +/− 18.35 years. 25 (50%) patients had a preceding infection. 88% of patients presented with cranial nerve (CN) involvement had a Hughes Score of >/= 3 (p = 0.0087). They had less improvement of Hughes Score on discharge (0.13 +/− 0.04) as compared to the patients without cranial nerve involvement (0.38 +/− 0.08) (p = 0.008). Respiratory involvement was associated with a higher Hughes Score (p = 0.005) on admission. 85% of patients diagnosed with an axonal subtype of GBS had a Hughes Score of >/= 3 (p = 0.06) compared to 74% patients with demyelinating subtype. Axonal subtype required double period (11 +/− 2.34) to show improvement as compared to demyelinating subtype (6 +/− 1.2) (p = 0.020). Irrespective of the subtypes, in two different treatment cohorts (PLEX vs IVIG), there was no difference in short term functional outcomes measured by improvement in the Hughes scores (p = 0.89).

Conclusions

Early cranial nerve and respiratory involvement in patients presenting with GBS are associated with poor outcomes warranting immediate critical care involvement. In our study, amongst all the subtypes, axonal had poor clinical outcomes. Further clinical trials on the Indian subpopulation will help us evaluate the impact of different treatment modalities on this disease.

Prevalence of vitamin D deficiency among patients attending Post COVID-19 follow-up clinic: a cross-sectional study

OBJECTIVE

Post-COVID-19 syndrome appears to be a multi-organ illness with a broad spectrum of manifestations, occurring after even mild acute illness. Limited data currently available has suggested that vitamin D deficiency may play a role in COVID-19 cases. However, to our knowledge, no study has examined the frequency of vitamin D deficiency in post-COVID-19 cases and its effect on the symptom severity. The aim of this study is to both screen the frequency of vitamin D deficiency in post-COVID-19 syndrome patients and to study its relation to persistent symptoms.

PATIENTS AND METHODS

A cross-sectional, single-center study was conducted involving all cases attending post-COVID-19 follow-up clinic from November 2020 to May 2021. Complete history, clinical examination, and laboratory analysis [kidney functions, serum calcium, C-reactive protein, serum ferritin, Serum 25-(OH) vitamin D] was done as well as HRCT chest.

RESULTS

The study included 219 post-COVID-19 cases, 84% had deficient vitamin D levels (< 20 ng/dL); 11.4% had insufficient level (20-30 ng/dL) and only 4.9 % reported normal level. There was no link between levels of vitamin D with either the acute or post-COVID-19 symptoms in the studied groups.

CONCLUSIONS

Despite the prevalence of vitamin D deficiency among the study population, no association was observed between the levels of vitamin D and post-COVID-19 symptoms. It appears that post-COVID-19 syndrome pathophysiology involves a more complex interaction with the immune system. Dedicated clinical trials are advised to better study vitamin D levels and the related disease severity in COVID-19 patients.

P010 Clinico-epidemiological characteristics and outcomes of Juvenile Idiopathic Arthritis (JIA) patients in Kenya: data from the KAPRI registry

Background

Pediatric rheumatic diseases pose a significant disease burden upon children and their families (1–3). They lead to physical disability and diminished quality of life (1–3). Determination of the burden and clinical characteristics of these diseases is a critical first step to improving access to care and optimizing use of existing health systems for the well-being of these patients (4). This is in line with the goal of the Bone and Joint decade (2000–2010) aimed at increasing recognition and understanding of the impact of musculoskeletal diseases (5,6). The Kenya Pediatric Rheumatology Registry (KAPRI) offers a unique opportunity to pioneer and spearhead a systematic and organized format to inform policy and better healthcare provision. Our objective was to determine the patient characteristics, clinical features and outcomes of Juvenile Idiopathic Arthritis (JIA) patients assessed at the Aga Khan University Medical College East Africa from March 2019 to December 2020.

Methods

Data of JIA patients on age, gender, laboratory and clinical features at diagnosis and treatment options offered were extracted from the database. A further detailed chart review was undertaken to determine the proportion of patients who achieved remission or minimally active diseases.

Results

Among the 207 patients enrolled thus far, 16 (7.7%) were diagnosed to have JIA. Majority of the patients were females (75%; n = 12) with a mean age of 7 years and 3 months (Range : 1 year—13 years 7 months).

All patients had joint pain and swelling as the initial presenting complaints. Majority of the patients had polyarticular JIA (75%, n = 12). The other 4 patients were oligoarticular (n = 2) and systemic JIA (n = 2). Among the polyarticular JIA patients (n = 12), only 3 (25%) were rheumatoid factor (RF) positive and 1 was antinuclear antibody (ANA) positive. The oligoarticular and systemic JIA patients were all negative for antinuclear antibody, rheumatoid factor and cyclic citrullinated peptide antibodies (anti-ccp). Seven patients (43.8%) required biological therapies; tocilizumab (n = 2: systemic JIA), adalimumab (n = 2: polyarticular JIA), etanercept (n = 2: polyarticular JIA) andtofacitnib (n = 1: polyarticular JIA). One patient with systemic JIA on tocilizumab developed herpes simplex which was successfully managed with oral acyclovir. All the other patients did not develop any infections, allergic reactions or any other untoward events as adverse outcomes following the use of biological therapies. Five patients have attained remission as illustrated in the table below. Two patients have been lost to follow up.

Conclusion

Seronegative polyarticular JIA was the predominant form of JIA observed with a predilection to affect more girls and boys. Over a period of 2 years, remission has been attained among 31.25% of the patients (5 of 16) with use of synthetic disease modifying anti-rheumatic drugs and biological therapies.

1511 A Review of Non-Surgical Management of Hand Osteoarthritis

Introduction

Hand osteoarthritis (OA) is a common musculoskeletal condition leading to pain and loss of function. Current treatment aims to target the symptoms of hand OA involving a combination of non-surgical and surgical interventions. During the COVID-19 pandemic, there has been a renewed interest in conservative management. The purpose of this article is to review non-surgical therapies in hand OA, their mechanism of action and efficacy.

Method

An online search of PubMed for articles between 1st January 2004- 1st February 2020 was performed according to specific terms and agreed inclusion criteria.

Results

The search produced 289 results of which 28 met the inclusion criteria comprising 13 RCTs, 8 systematic reviews, 5 clinical trials and 2 international guidelines.

Conclusions

Topical NSAIDs remain first-line pharmacological agents in the management of hand OA. Increasingly, oral NSAIDs have been recommended however their use must be balanced against their potential adverse effects. Supplementation with chondroitin sulfate may help to delay the structural damage in hand OA, which may reduce the need for oral NSAIDs. Intra-articular injections of hyaluronic acid and corticosteroids are effective treatments and provide longer symptomatic relief, additionally hyaluronic acid may improve function over a longer period of time. Targeted hand exercises are widely recommended however may only provide short-term improvements and vary according to the different subtypes of hand OA. In summary, there are multiple conservative management options for hand OA which should be considered prior to operative intervention given the current restrictions on surgical practice.

Polysaccharide conjugates surpass monosaccharide ligands in hepatospecific targeting - Synthesis and comparative in silico and in vitro assessment

Ligands with the polysaccharide headgroups have been recently reported by our group to possess enhanced interaction with asialoglycoprotein receptor (ASGPR) in silico as compared to ligands having galactose moieties. This enhanced interaction is a result of the polymer's backbone support in anchoring the ligand in a specific orientation within the bilayer. In this paper, we have attempted to provide an in vitro proof of concept by performing a comparative evaluation of polysaccharide and monosaccharide-based ligands. Docking was performed to understand interaction with ASGPR in silico. Agarose and galactose conjugates with behenic acid were synthesized, purified, and characterized to yield biocompatible hepatospecific ligands which were incorporated into nanoliposomes. Cellular internalization of these targeted liposomes was studied using confocal microscopy and flow cytometry. The toxicity potential was assessed in vivo. Results indicated that the polysaccharide-based ligand increased cellular uptake due to better interaction with the receptor as compared to ligand bearing a single galactose group. In addition to developing novel liver targeting ligands, the study also established proof of concept that has been suggested by earlier in silico investigations. The approach can be used to design targeting ligands and develop formulations with improved targeting efficacy.

AB0729 CLINICO-EPIDEMIOLOGICAL PROFILE OF JUVENILE IDIOPATHIC ARTHRITIS (JIA) PATIENTS IN KENYA; DATA FROM THE KENYA PEDIATRIC RHEUMATOLOGY (KAPRI) REGISTRY

Background:

Pediatric rheumatic diseases are chronic illnesses that impart a significant disease burden upon societies (1-3). Determination of the burden and clinical characteristics of these diseases is a critical first step to improving access to care and optimizing use of existing health systems for the well-being of these patients (4-6). A pediatric rheumatology registry is critical in defining the spectrum, clinical characteristics, outcomes and responses of various interventions for pediatric rheumatic diseases. Given that none exists in Kenya, the Kenya Pediatric Rheumatology Registry (KAPRI) registry offers a platform to generate this much needed data in sub-Sahara Africa.

Objectives:

Our objective was to determine the baseline patient characteristics, clinical features and outcomes of the Juvenile Idiopathic Arthritis (JIA) patients assessed at the Aga Khan University Medical College East Africa who were enrolled into the KAPRI registry from inception in March 2019 to December 2020.

Methods:

All patients with an ICD 10 M code diagnosis of Juvenile Arthritis were selected from the KAPRI registry database. Age, gender, laboratory and clinical features at diagnosis and treatment options offered were extracted from the database. A further detailed chart review was undertaken to determine the proportion of patients who achieved remission or minimally active diseases.

Results:

Among the 207 patients enrolled thus far, 16 (7.7%) were diagnosed to have JIA. Majority of the patients were females (75%; n=12) with a mean age of 7 years and 3 months (Range:1 year – 13 years 7 months).

All patients had joint pain and swelling as the initial presenting complaints. Majority of the patients had polyarticular JIA (75%, n=12). The other 4 patients were oligoarticular (n=2) and systemic JIA (n=2). Among the polyarticular JIA patients (n=12), only 3 (25%) were rheumatoid factor (RF) positive and 1 was antinuclear antibody (ANA) positive. The oligoarticular and systemic JIA patients were all negative for antinuclear antibody, rheumatoid factor and cyclic citrullinated peptide antibodies (anti-ccp). Seven patients (43.8%) required biological therapies; tocilizumab (n=2: systemic JIA), adalimumab (n=2: polyarticular JIA), etanercept (n=2: polyarticular JIA) and tofacitnib (n=1: polyarticular JIA). One patient with systemic JIA on tocilizumab developed herpes simplex which was successfully managed with oral acyclovir. All the other patients did not develop any infections, allergic reactions or any other untoward events as adverse outcomes following the use of biological therapies. Five patients have attained remission as illustrated in the Table 1 below. Two patients have been lost to follow up.

Conclusion:

Seronegative polyarticular JIA was the predominant form of JIA observed with a predilection to affect more girls and boys. Over a period of 2 years, remission has been attained among 31.25% of the patients (5 of 16) with use of synthetic disease modifying anti-rheumatic drugs and biological therapies.

References:

[1]Moorthy LN, Peterson MG, Hassett AL, Lehman TJ. Burden of childhood onset arthritis. Pediatr Rheumatol Online J. 2010;8:20.

[2]Minden K, Niewerth M, Listing J, et al. The economic burden of juvenile idiopathic arthritis-results from the German paediatric rheumatologic database. Clin Exp Rheumatol. 2009;27(5):863–9.

[3]Bernatsky S, Duffy C, Malleson P, Feldman DE, St Pierre Y, Clarke AE. Economic impact of juvenile idiopathic arthritis. Arthritis Rheum. 2007;57(1):44–8.

[4]Migowa A, Colmegna I, Hitchon C, Were E, Ng’ang’a E, Ngwiri T, et al. The spectrum of rheumatic in-patient diagnoses at a pediatric hospital in Kenya. Pediatric Rheumatology (2017)

[5]Woolf AD. The bone and joint decade 2000–2010. Ann Rheum Dis. 2000; 59(2):81–2.

[6]Scott C, Webb K. Pediatric rheumatology in sub-Saharan Africa. Rheumatology (Oxford). 2014;53(8):1357–8.

Disclosure of Interests:

None declared

A proposed "Radiological Evaluation Score for Bone Tumors" (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor

BACKGROUND

Although radiographs have been widely used in the evaluation of patients with suspected bone tumors, the lack of an objective radiological assessment method leads to a challenge in reaching correct diagnosis. The study aimed to propose a Radiological Evaluation Score for Bone Tumors (REST) which includes eight radiological factors [characteristics, content, cortical breach, distinctiveness, distribution, periosteal reaction, fracture, and soft tissue swelling] to form a single score along with its validation by multidisciplinary observers.

METHODS

We reviewed the radiographs of 100 patients with a primary bone tumor which were selected at random from the database between January 2017 and January 2019 of a tertiary cancer center. Four reviewers (two orthopedic oncologists and two surgical oncologists) independently assessed the radiographs, based on the reporting system of REST. We constituted two groups according to the probable diagnosis of bone tumor (suspected benign tumor and suspected malignant tumor).

RESULTS

The mean score in the suspected benign tumor group was 1.1 (range 0-3, 95% CI 0.8-1.3) and in malignant tumor group was 6.1 (range 2-8, 95% CI 5.8-6.4). A receiver operator characteristic (ROC) curve for REST was with a cutoff of 3.5, with the most diagnostic value area under curve (AUC) of 0.99. The sensitivity was 98% and specificity was 100% with a positive predictive value of 100% and a negative predictive value of 98%. The inter-observer correlation coefficient was 0.985 (p value < 0.05), and Fleiss kappa value for the prediction of the benign or malignant lesion was 0.97 (p value < 0.05). The characteristics and content of tumor, cortical erosion, distinctiveness, distribution, periosteal reaction, and soft tissue mass had a significant correlation with the aggressiveness of bone lesion p value < 0.05.

CONCLUSIONS

The Radiological Evaluation Score for Bone Tumors (REST) is a structured reporting and objective method for the assessment of radiographs in patients with suspected bone tumors. This method is a reliable and helpful tool for clinicians in their outdoor patient department to differentiate a radiograph of a suspected benign tumor from a malignant bone tumor.

435 A Prospective Study of Post-operative Surgical Site Infection

Introduction

Organ specific surgical site infections are those that involve any part of the anatomy other than the incised body wall layer opened or manipulated during an operation. The proper understanding of bacteriology and mode of infections has surely reduced the incidence of wound infection, but it is not totally controlled.

Method

A total of 582 consecutive patient undergoing major and minor surgeries between March 2010 and October 2011 were included in the study. Detail history, physical examination, laboratory and radiological investigation according to Performa with special reference to any factor that could lead to postoperative infection – Age, sex, socioeconomic status, nutrition was recorded. Initial assessment of intra operative findings divided these cases into clean, clean contaminated, contaminated and dirty SSI.

Result

A total of 582 patients out of these, 100 have SSI, SSI rate in our hospital was found to be 17.18% including all classes of wounds. Coagulase positive staphylococci were responsible for a majority of SSIs and mixed infections were quite common. The other microorganism responsible for SSIs were E.coli, Coagulase negative staphylococci, Pseudomonas and Proteus etc.

Conclusions

The data from our study suggests a need to control modifiable risk factor responsible for development of SSI.

721 Imaging for Suspected Bowel Obstruction in Pennine Acute Trust (PAT): A Comparison with the National Audit of Small Bowel Obstruction’s (NASBO) recommendations

Background

NASBO recommends Computed Topography (CT) over plain abdominal X-ray (AXR) for the investigation of bowel obstruction (BO). AXR is routinely used within PAT for investigation of BO which may be exposing patients to unnecessary radiation and adding unnecessary cost to the service.

Method

A retrospective audit collected data on patients with CT confirmed BO between July 2019 and February 2020. This looked at the percentage of patients who had both CT and AXR to investigate BO. The cost of these AXRs and the percentage of these AXRs that were normal were also calculated.

Results

A search identified 141 patients with CT proven BO. 81/141(57.4%) patients had both AXR and CT as a part of their initial investigations. Of those patients 26/81(32.1%) had no AXR features suggestive of BO. Only 12/81(14.8%) of those patients had serial AXRs following initial imaging. The cost for one AXR is £34.15 which means £2766.15 was spent on potentially unnecessary AXRs within this period.

Conclusions

PAT is performing potentially unnecessary AXRs which is exposing patients to unnecessary radiation and costing the trust. Plain AXRs do not rule out BO. We have recommended an investigation flowchart to PAT A&E departments to reduce unnecessary AXRs being performed.

Prognosticating patients with necrotising otitis externa based on response to treatment

INTRODUCTION

Necrotising otitis externa (NOE) is a severe infection of the temporal bone. The traditional severity based staging system does not fully prognosticate all patients with NOE. We hypothesise that a patient response staging system would more accurately capture the disease process and guide prognosis.

METHODS

We carried out a retrospective notes review of patients diagnosed with NOE from January 2017 to December 2018 in a regional tertiary referral centre. Patient outcomes from our proposed patient response staging system were compared to a modified previously published severity based Gleeson staging system with patients requiring prolonged treatment classified as having a poor outcome.

RESULTS

A total of 34 patients were treated for NOE. The majority were male (n=24) and had diabetes (n=25). Patients with the most severe Gleeson staging did not have the worst outcome. Daily delay in resolution of otorrhoea was associated with an increased need for more than six weeks of treatment. Rapid responders are patients who had resolution of otalgia, otorrhoea and C-reactive protein normalisation within 14 days, and all were cured following standard 6 weeks of treatment.

CONCLUSIONS

The Gleeson staging system was valuable in assessing the extent of disease and all early Gleeson staged patients had good outcomes. However, patients with higher severity staging on the Gleeson system did not necessarily require prolonged treatment. There is a role for a joint approach in staging patients based on both modified Gleeson and treatment response, which would subsequently guide prognosis, duration of treatment and early diagnosis of potential fungal NOE.

Strongyloidiasis Of Duodenum Clinically Mimicking As Celiac Disease: A Case Report

Casestudy

Strongyloides stercoralis is classified as a roundworm or nematode. S. stercoralis is unique and different from other intestinal nematodes because of its ability to complete its life cycle within the host through an asexual auto infective cycle, allowing the infection to persist in the host indefinitely. It is usually asymptomatic can be symptomatic in immunocompromised individual leading to disseminated disease. Serology and stool microscopy are the investigations of choice. Though histopathology is the gold standard it is invasive procedure and has its own complication. strongyloidiasis is easily treatable with oral anthelminthic drugs. To date, only a limited number of cases has been published in our part of the world.

Strongyloidiasis is often asymptomatic in immunocompetent individuals. We present the case of a 34-year old man from hilly region of Nepal with complaints of on and off abdominal pain since one and half year. Over the last week his symptoms worsened with bilious vomiting, nausea, abdominal pain, loss of appetite and weight loss. Patient was short statured with multiple pruritic lesions over skin. A clinical diagnosis of celiac disease was suspected clinically. Blood examination was performed shows Microcytic Hypochromic Anemia with mild increase in eosinophils. Stool examination and serology was performed it was negative. An endoscopic biopsy from duodenum was performed and histopathologic examination revealed gastrointestinal strongyloidiasis.

Conclusion

Helminthic infections can clinically mimic large number of non-neoplastic and neoplastic diseases like celiac sprue, IBD, GI malignancy etc. The present case highlights the importance of basic investigation like multiple stool examination in patient with GI symptoms before subjecting the patient to invasive procedures.

Computed tomographic indications for occult skull fractures in paediatric head trauma diagnosed at the time of wound closure under general anaesthesia

Children with head injuries commonly present to the emergency department with forehead lacerations, and are frequently referred to the oral and maxillofacial team. Assessing the Glasgow coma scale (GCS) and neurological status of these patients is particularly challenging and there remains marked ambiguity regarding the use of computed tomographic (CT) imaging in children who have no obvious signs of traumatic brain injury. We present a case series of three patients who presented to our unit with forehead lacerations following a fall. All had a normal GCS, no obvious neurological signs, and all were listed for wound closure under general anaesthesia. Intraoperatively they were found to have underlying skull fractures that necessitated emergency CT whilst under general anaesthesia. Retrospective analysis was performed. Current guidelines and the literature were reviewed to identify factors that may help to identify occult skull fractures in the context of paediatric head trauma. Despite the subsequent discovery of skull fractures under general anaesthesia, none of our patients would have satisfied the present absolute indications for CT in the current guidelines. A number of helpful factors are not common in the UK guidelines but are present in others, including the presence of an appreciable haematoma and lacerations greater than 5 cm, amongst others. The assessment of paediatric patients with head trauma often remains a challenge when assessing for features such as headache, focal neurology, and amnesia. A high index of suspicion, formal examination under anaesthesia, and communication with the radiology department, are imperative if we are to avoid missing an occult injury that could potentially result in brain injury.

Two-Dimensional Binary Honeycomb Layer Formed by Ag and Te on Ag(111)

Inspired by the unique properties of graphene, research efforts have broadened to investigations of various other two-dimensional materials with the aim of exploring their properties for future applications. Our combined experimental and theoretical study confirms the existence of a binary honeycomb structure formed by Ag and Te on Ag(111). Low-energy electron diffraction shows sharp spots which provide evidence of an undistorted AgTe layer. Band structure data obtained by angle-resolved photoelectron spectroscopy are closely reproduced by first-principles calculations, using density functional theory (DFT). This confirms the formation of a honeycomb structure with one Ag and one Te atom in the unit cell. In addition, the theoretical band structure reproduces also the finer details of the experimental bands, such as a split of one of the AgTe bands.

Phase 2 study of the Exportin 1 inhibitor selinexor in patients with recurrent gynecological malignancies

BACKGROUND

Selinexor is an oral inhibitor of the nuclear export protein Exportin 1 (XPO1) with demonstrated antitumor activity in solid and hematological malignancies. We evaluated the efficacy and safety of selinexor in heavily pretreated, recurrent gynecological malignancies.

METHODS

In this phase 2 trial, patients received selinexor (35 or 50 mg/m2 twice-weekly [BIW] or 50 mg/m2 once-weekly [QW]) in 4-week cycles. Primary endpoint was disease control rate (DCR) including complete response (CR), partial response (PR) or stable disease (SD) ≥12 weeks. Secondary endpoints were progression-free survival (PFS), overall survival (OS) and safety.

RESULTS

114 patients with ovarian (N = 66), endometrial (N = 23) or cervical (N = 25) cancer were enrolled. Median number of prior regimens for ovarian, endometrial and cervical cancer was 6 (1-11), 2 (1-5), and 3 (1-6) respectively. DCR was 30% (ovarian 30%; endometrial 35%; cervical 24%), which included confirmed PRs in 8%, 9%, and 4% of patients with ovarian, endometrial, and cervical cancer respectively. Median PFS and OS for patients with ovarian, endometrial and cervical cancer were 2.6, 2.8 and 1.4 months, and 7.3, 7.0, and 5.0 months, respectively. Common Grade 3/4 adverse events (AEs) were thrombocytopenia (17%), fatigue (14%), anemia (10%), nausea (9%) and hyponatremia (9%). Patients with ovarian cancer receiving 50 mg/m2 QW had fewer high-grade AEs with similar efficacy as BIW treatment.

CONCLUSIONS

Selinexor demonstrated single-agent activity and disease control in patients with heavily pretreated ovarian and endometrial cancers. Side effects were a function of dose level and treatment frequency, similar to previous reports, reversible and mitigated with supportive care.

Short duration of untreated psychosis enhances negative symptom remission in extended early intervention service for psychosis

OBJECTIVE

To test whether duration of untreated psychosis (DUP) < 3 months, recommended by the World Health Organization/International Early Psychosis Association, enhances the effects of an extended early intervention service (EEIS) on symptom remission.

METHOD

We examined data from a randomized controlled trial in which patients who received 2 years of treatment in EIS for psychosis were subsequently randomized to either 3 years of EEIS or 3 years of regular care (RC). Using a DUP cut-off ≤ 12 weeks (approximately < 3 months), patients were split into two groups. Length of positive, negative and total symptom remission were the outcomes.

RESULTS

Patients (N = 217) were mostly male (68%) with schizophrenia spectrum disorder (65%); 108 (50%) received EEIS (58 had DUP ≤12 weeks; 50 had DUP >12 weeks). Interaction between treatment condition (EEIS vs. RC) and DUP cut-off ≤ 12 weeks was only significant in multiple linear regression model examining length of negative symptom remission as the outcome (adjusted β = 36.88 [SE = 15.88], t = 2.32, P = 0.02). EEIS patients with DUP ≤12 weeks achieved 25 more weeks of negative symptom remission than EEIS patients with DUP >12 weeks.

CONCLUSION

Having a short DUP may be critical in deriving long-term benefits from EIS for psychosis, including EEIS settings. This work empirically supports policy recommendations of reducing DUP <3 months.