Novel case of combination antibiotic therapy for treatment of a complicated polymicrobial urinary tract infection with one organism harboring a metallo-β-lactamase (MBL) in a pregnant patient

Carbapenem resistance due to metallo-beta-lactamases (MBLs) is a global phenomenon and an important challenge for antibiotic therapy (Boyd et al., 2020 [1]). While previous reports have demonstrated both in vitro and in vivo synergy using the combination of ceftazidime-avibactam and aztreonam against Stenotrophomonas maltophilia, an MBL-harboring organism, this treatment strategy has not been reported during pregnancy (Mojic et al., 2017 [2], [3], Mojica et al., 2016 [4], Alexander et al., 2020 [5]). We describe a 33-year-old pregnant female with polymicrobial, bilateral pyelonephritis caused by Stenotrophomonas maltophilia and other gram-negative bacteria. The organisms were eradicated with the combination of ceftazidime-avibactam and aztreonam followed by successful delivery with no observed adverse effects in either mother or child post-partum.

Engineering of a Fluorescent Protein for a Sensing of an Intrinsically Disordered Protein through Transition in the Chromophore State

Intrinsically disordered proteins (IDPs) not only play important roles in biological processes but are also linked with the pathogenesis of various human diseases. Specific and reliable sensing of IDPs is crucial for exploring their roles but remains elusive due to structural plasticity. Here, we present the development of a new type of fluorescent protein for the ratiometric sensing and tracking of an IDP. A β-strand of green fluorescent protein (GFP) was truncated, and the resulting GFP was further engineered to undergo the transition in the absorption maximum upon binding of a target motif within amyloid-β (Aβ) as a model IDP through rational design and directed evolution. Spectroscopic and structural analyses of the engineered truncated GFP demonstrated that a shift in the absorption maximum is driven by the change in the chromophore state from an anionic (460 nm) state into a neutral (390 nm) state as the Aβ binds, allowing a ratiometric detection of Aβ. The utility of the developed GFP was shown by the efficient and specific detection of an Aβ and the tracking of its conformational change and localization in astrocytes.

Color-Tuning Mechanism of the Lit Form of Orange Carotenoid Protein

Orange carotenoid protein (OCP) of photosynthetic cyanobacteria binds to ketocarotenoids noncovalently and absorbs excess light to protect the host organism from light-induced oxidative damage. Herein, we found that mutating valine 40 in the α3 helix of Gloeocapsa sp. PCC 7513 (GlOCP1) resulted in blue- or red-shifts of 6-20 nm in the absorption maxima of the lit forms. We analyzed the origins of absorption maxima shifts by integrating X-ray crystallography, homology modeling, molecular dynamics simulations, and hybrid quantum mechanics/molecular mechanics calculations. Our analysis suggested that the single residue mutations alter the polar environment surrounding the bound canthaxanthin, thereby modulating the degree of charge transfer in the photoexcited state of the chromophore. Our integrated investigations reveal the mechanism of color adaptation specific to OCPs and suggest a design principle for color-specific photoswitches.

Relation between sex and mortality after myocardial infarction in high-income and middle-income European countries

Background

The relationship between female sex and cardiovascular mortality in myocardial infarction (MI) is controversial. Most available data are from high-income countries (HIC) where baseline risk is lower and revascularization procedures are more likely, so the generalizability to other populations is unclear.

Purpose

The main goal of this study was to unravel the relation between patient-specific revascularization through percutaneous coronary intervention (PCI) and mortality among women and men.

Methods

Data were drawn from the ISACS-Archives (NCT04008173) which includes a large cohort of patients enrolled in 6 European HIC (Croatia, Italy, Lithuania, Hungary, Romania, and United Kingdom) and 7 middle-income countries (MIC; Bosnia & Herzegovina, Kosovo, Macedonia, Moldova, Montenegro, and Serbia). Participants were stratified by MI subtypes: STEMI and NSTEMI. The primary outcome was 30-day mortality. To yield unbiased sex estimates of the effects of MI on mortality we modeled covariates and outcomes by propensity score-based analytic methods. We calculated the women to men risk ratios (RRs) using weighting with estimates compared by test of interaction on the log scale.

Results

The cohort consisted of 22,087 patients with MI (30.2% women). Patient outcomes varied according to the subtype of MI. Females was associated with a greater excess risk of 30-day mortality in STEMI (RR: 1.94; 95% CI: 1.71–2.21) compared with NSTEMI (RR: 1.12; 95% CI: 0.95–1.50; P interaction <0.001). Coronary revascularization reduced the incidence of death among women and men in the overall population. Despite this, the primary outcome of 30-day mortality remained higher in women than men with STEMI (RR: 2.38; 95% CI: 2.00–2.82) whereas it was comparable across sexes in patients with NSTEMI (RR: 1.21; 95% CI: 0.79–1.83; P interaction=0.002). Sex differences in mortality from STEMI were more significant in MIC compared with HIC (RRs: 2.30; 95% CI: 1.98–2.68 vs. 1.36; 95% CI: 1.05–1.75; P interaction <0.001). The sex gap in mortality was mitigated by the use of revascularization therapy (RRs: 2.05; 95% CI: 1.68–2.50 in MIC vs. 2.17; 95% CI: 1.48–3.18 in HIC; P interaction=0.40)

Conclusion

Women presenting with STEMI have worse early mortality rates than their male counterparts in both HIC and MIC even in patients undergoing revascularization. By contrast, sex differences are attenuated or no longer apparent in NSTEMI. With no information on the type of MI on admission, sex differences in early outcomes are difficult to be fully understood.

Funding Acknowledgement

Type of funding sources: None.

Resistance to inflammation underlies enhanced fitness in clonal hematopoiesis

[Figure: see text].

Acute heart failure: a mechanism underscoring sex differences in outcomes following acute coronary syndromes

Background

It remains uncertain whether female sex is itself a strong risk factor for worse outcomes in acute coronary syndromes (ACS).

Purpose

We hypothesized that sex differences in vulnerability to heart failure after ACS may modify the association between sex and outcomes.

Methods

Data were drawn from the ISACS-Archives network of registries. The study population consisted of 87,812 patients with known time from symptom onset to hospital presentation. Participants were stratified by ACS subtypes: STEMI and NSTE-ACS Data on presenting heart failure symptoms were collected from medical record abstraction. Heart failure was categorized as Killip class >2. Time from symptom onset to hospital presentation was categorized as early (≤120 minutes) or late (>120 minutes). Primary outcome measure was 30-day mortality. Estimates were performed using a parametric balancing strategy by weighting and compared by test of interaction on the log scale.

Results

Among the study sample, 30922 (35.2%) patients were women. Patient outcomes varied according to subtype of ACS. The mortality rates at 30-days were significantly higher among women vs men in STEMI (RR:1.65; 95% CI: 1.56–1.73) compared with NSTE-ACS (RR:1.18; 95% CI: 1.09–1.28; P interaction <0.0001). Similarly, the women vs men RR of heart failure was higher in STEMI (RR: 1.24; 95% CI: 1.20–1.29) compared with NSTE-ACS (RR:1.02; 95% CI: 0.97–1.08; P interaction <0.0001). Sex difference in heart failure rates with STEMI presentation were independent (P<0.0001) of early (34.3% in women vs 24.2% in men) or late (35.5% in women vs 30.7% in men) hospital presentation. The same finding was not seen in NSTE-ACS patients. Overall, women presenting with heart failure was had higher 30-day mortality than did their male counterparts with heart failure (29.8% vs 25.5%; RR: 1.24; 95% CI: 1.17–1.31).

Conclusions

Women exhibit substantially more vulnerability to heart failure in STEMI than men: a greater percentage of women have heart failure, and women with heart failure have higher 30-day mortality than men with heart failure. This finding was not seen in NSTE-ACS. heart failure on initial assessment is a key feature to explain the sex gap in mortality after ACS.

Funding Acknowledgement

Type of funding sources: None.

Statins for primary prevention among elderly men and women

Background

The debate about statins in primary prevention of cardiovascular (CV) disease is still alive, especially in old and very old adults.

Purpose

We undertook a propensity match-weighted cohort study to investigate whether statin treatment recommendations translate into improved cardiovascular (CV) outcomes in the current routine clinical care of the elderly.

Methods

We included in our analysis 5,619 people aged 65 years or older from the ISACS (International Survey of Acute Coronary Syndrome) Archives (NCT04008173) who presented to hospital with a first manifestation of CV disease. Participants were stratified as statin users versus nonusers and as old (65 to 75 years) versus very old (76 years or over) adults. We estimated the effects of statins on the most severe clinical manifestation of CV disease, namely ST segment elevation myocardial infarction (STEMI), using inverse probability of treatment weighting models. Estimates were compared by test of interaction on the log scale.

Results

The risk of STEMI was much lower in statin users than in nonusers in both patients aged 65 to 75 years (14.7% absolute risk reduction; relative risk [RR] ratio: 0.55, 95% CI 0.45 to 0.66) and those aged 76 years and older (13.3% absolute risk reduction; RR ratio: 0.58, 95% CI 0.46 to 0.72). Estimates were similar in patients with and without history of hypercholesterolemia (interaction test; p value= 0.2408). Proportional reductions in STEMI diminished with female sex in the old (p for interaction=0.002), but not in the very old age (p for interaction=0.26). We also observed a remarkable reduction in the risk of 30- day mortality from STEMI with statin therapy in both age groups (10.2% absolute risk reduction; RR ratio: 0.39; 95% CI 0.23 – 0.68 for patients aged 76 or over and 3.8% absolute risk reduction; RR ratio 0.37; 95% CI 0.17 – 0.82 for patients aged 65 to 75 years old; interaction test, p value=0.4570).

Conclusion

Preventive statin therapy in the elderly reduces the risk of STEMI with benefits in mortality from STEMI, irrespective of the presence of a history of hypercholesterolemia. This effect persists after the age of 76 years. Benefits are less pronounced in women.

Funding Acknowledgement

Type of funding sources: None.

Intraindividual Comparison between the Contrast-Enhanced Golden-Angle Radial Sparse Parallel Sequence and the Conventional Fat-Suppressed Contrast-Enhanced T1-Weighted Spin-Echo Sequence for Head and Neck MRI

BACKGROUND AND PURPOSE

The golden-angle radial sparse parallel-volumetric interpolated breath-hold (GRASP-VIBE) sequence is a recently introduced imaging technique with high resolution. This study compared the image quality between conventional fat-suppressed T1-weighted TSE and GRASP-VIBE after gadolinium enhancement in the head and neck region.

MATERIALS AND METHODS

Data from 65 patients with clinical indications for head and neck MR imaging between September 2020 and January 2021 were retrospectively reviewed. Two radiologists assessed the overall image quality, overall artifacts, and image conspicuities in the oropharynx, hypopharynx, and cervical lymph nodes according to 5-point scores (best score: 5). Interobserver agreement was assessed using weighted κ statistics. The SNR and contrast-to-noise ratio were calculated and compared between the 2 sequences using a paired Wilcoxon signed rank test.

RESULTS

The analysis included 52 patients (mean age, 60 [SD, 14 ] years; male, 71.2% [37/52]) who were mostly diagnosed with head and neck malignancies (94.3% [50/52]). κ statistics ranged from slight agreement in cervical lymph node conspicuity (κ = 0.18) to substantial agreement in oropharyngeal mucosal conspicuity (κ = 0.80) (κ range, 0.18-0.80). Moreover, GRASP-VIBE demonstrated significantly higher mean scores in overall image quality (4.68 [SD, 0.41] versus 3.66 [SD, 0.73]), artifacts (4.47 [SD, 0.48] versus 3.58 [SD, 0.71]), oropharyngeal mucosal conspicuity (4.85 [SD, 0.41] versus 4.11 [SD, 0.79]), hypopharyngeal mucosal conspicuity (4.84 [SD, 0.34] versus 3.58 [SD, 0.81]), and cervical lymph node conspicuity (4.79 [SD, 0.32] versus 4.08 [SD, 0.64]) than fat-suppressed T1-weighted TSE (all, P < .001). Furthermore, GRASP-VIBE demonstrated a higher SNR (22.8 [SD, 11.5] versus 11.3 [SD, 5.6], P < .001) and contrast-to-noise ratio (4.7 [SD, 5.4] versus 2.3 [SD, 2.7], P = .059) than fat-suppressed T1-weighted TSE.

CONCLUSIONS

GRASP-VIBE provided better image quality with fewer artifacts than conventional fat-suppressed T1-weighted TSE for the head and neck regions.

Type B valvular and supravalvular pulmonic stenosis with aberrant pre-pulmonic right coronary artery diagnosed by non-electrocardiography-gated, multislice computed tomography in a Boston terrier

Pulmonic stenosis (PS) is a common congenital heart disease in dogs. It may be associated with an aberrant coronary artery (CA) in brachycephalic breeds. If present, a CA anomaly must be identified before pulmonic valvuloplasty. A 1.7-year-old Boston terrier was referred for a grade V/VI systolic heart murmur and exercise intolerance. Echocardiography revealed combined type B valvular and supravalvular PS; an aberrant CA was also suspected. Non-electrocardiography (ECG)-gated, 160-multislice computed tomographic angiography (CTA) confirmed severe right ventricular wall hypertrophy, a hypoplastic pulmonic valve annulus, and severe supravalvular PS with a marked main pulmonary artery bulge; a single left coronary ostium with an anomalous pre-pulmonic right CA was also identified. Surgical correction with pulmonic valvuloplasty and pulmonary artery patch angioplasty under cardiopulmonary bypass was planned. The patient died intraoperatively due to profound hypotension after weaning from extracorporeal circulation. However, this is the first case report in which type B valvular and supravalvular PS with an aberrant pre-pulmonic right CA was diagnosed by non-ECG-gated, 160-multislice CTA in a Boston terrier, showing a similar level of image quality to ECG-gated CTA. Thus, in PS cases, high-slice CTA may be helpful to determine if CA anomalies are present and to establish a therapeutic plan.

Edwardsiella tarda, a rare human pathogen isolated from a perihepatic abscess: Implications of transient versus long term colonization of the gastrointestinal tract

Although gastroenteritis is the most commonly described manifestation of Edwardsiella tarda infection, the pathogenesis and transient or long-term colonization of the gastrointestinal tract of this organism in human disease is not clear. We describe a rare manifestation of E. tarda infection in a perihepatic abscess in the setting of a patient with perforated cholecystitis and its successful eradication following antibiotic treatment.

Novel double beta-lactam therapy for Granulicatella adiacens infective endocarditis

Granulicatella adiacens, a nutritionally variant streptococci (NVS) is a well described organism associated with endocarditis. Previously communicated cases have documented the use of double beta-lactam therapy with ampicillin and ceftriaxone to treat patients with infective endocarditis due to Enterococcus faecalis and Streptocossus pneumoniae. We describe the first case of Granulicatella adiacens infective endocarditis in a patient successfully treated with the combination of intravenous ampicillin and ceftriaxone and document their synergistic activity.

A novel xeno-organoid approach: exploring the crosstalk between human iPSC-derived PGC-like and rat testicular cells

Specification of germ cell-like cells from induced pluripotent stem cells has become a clinically relevant tool for research. Research on initial embryonic processes is often limited by the access to foetal tissue, and in humans, the molecular events resulting in primordial germ cell (PGC) specification and sex determination remain to be elucidated. A deeper understanding of the underlying processes is crucial to describe pathomechanisms leading to impaired reproductive function. Several protocols have been established for the specification of human pluripotent stem cell towards early PGC-like cells (PGCLC), currently representing the best model to mimic early human germline developmental processes in vitro. Further sex determination towards the male lineage depends on somatic gonadal cells providing the necessary molecular cues. By establishing a culture system characterized by the re-organization of somatic cells from postnatal rat testes into cord-like structures and optimizing efficient PGCLC specification protocols, we facilitated the co-culture of human germ cell-like cells within a surrogate testicular microenvironment. Specified conditions allowed the survival of rat somatic testicular and human PGCLCs for 14 days. Human cells maintained the characteristic expression of octamer-binding transcription factor 4, SRY-box transcription factor 17, and transcription factor AP-2 gamma and were recovered from the xeno-organoids by cell sorting. This novel xeno-organoid approach will allow the in vitro exploration of early sex determination of human PGCLCs.

Anterior skull base olfactory tumours, which is what? A case report and review

Intracranial schwannomas not originating from cranial nerves are rare. In this paper, we report a case of a 50-year-old male who presented with worsening headaches, diplopia and nausea over two years. Radiological imaging revealed a large tumour arising from the olfactory groove region with a preoperative diagnosis of olfactory groove meningioma (OGM). Intraoperatively, the tumour originated from the region of the attachment of the falx to the crista galli. The patient recovered without complication and histopathology reported an unexpected diagnosis of WHO Grade 1 schwannoma. However, as olfactory groove schwannomas (OGSs) cannot be distinguished from olfactory ensheathing cell tumours (OECTs), it is possible that the tumour could have been either an OGS or an OECT. Distinguishing between OGSs, OECTs and OGMs preoperatively is difficult. OGMs exhibit distinct histopathological features from OGSs/OECTs, however, OGSs and OECTs currently cannot be distinguished from each other. Here, we review the literature to discuss the differentiating features and cellular origins of these three tumours.

Inhibitory effect of alpha-lipoic acid on mitochondrial dysfunction and interleukin-8 expression in interleukin-1beta-stimulated ataxia teleangiectasia fibroblasts

Ataxia telangiectasia (A-T) is an inherited neurodegenerative disease caused by mutation in the ataxia telangiectasia mutated (ATM) gene, leading to loss of function in the encoded protein ATM. Because ATM functions to reduce oxidative stress by up-regulating antioxidant enzymes, oxidative stress is a prevalent A-T phenotype and a mediator of the inflammation that drives A-T pathology. Reactive oxygen species (ROS) levels and the expression of pro-inflammatory cytokine interleukin-8 (IL-8) were higher in A-T cells than in normal cells. ROS are related to mitochondrial dysfunction and activation of nuclear factor kappa B (NF-κB) to induce IL-8 expression. Alpha-lipoic acid (α-LA), a naturally occurring thiol compound, shows an antioxidant effect in various cells. This study is aimed to determine if α-LA confers protection against NF-κB activation, IL-8 expression, and mitochondrial dysfunction in A-T cells which are exposed to the inflammatory cytokine IL-1β. A-T fibroblasts were treated with or without α-LA. The levels of intracellular and mitochondrial ROS, mRNA and protein levels of IL-8, mitochondrial membrane potential (MMP), ATP levels, and DNA binding activity of NF-κB were determined. As a result, IL-1β increased NF-κB activation, IL-8 expression, intracellular and mitochondrial ROS levels, but decreased MMP and ATP level in A-T cells. Pretreatment of A-T cells with α-LA inhibited IL-1β-induced activation of NF-κB, IL-8 expression, and mitochondrial dysfunction by reducing ROS levels. In conclusion, supplementation with α-LA may be beneficial for reducing the oxidative stress-induced mitochondrial dysfunction and IL-8 production associated with A-T.

AB1121 IMPLEMENTING HIGH VALUE CARE IN INPATIENT ANTINUCLEAR ANTIBODY TESTING

Background:

Antinuclear Antibody (ANA) testing forms the basis on which many rheumatological diseases are subsequently diagnosed. ANA testing quantifies the dilution of plasma to produce the titer and staining pattern and this can be a part of an ANA order set that reflexively cascades to sub-serology if positive. Studies have shown that a low titer ANA may potentially translate into an erroneous diagnosis: if one estimates a 1 percent prevalence of ANA associated disease in the general population then 30% of those individuals would have a false positive result of ANA detected at 1:40 titer [1]. We theorized that there is no need for several methods to coexist within a single inpatient hospital setting especially since diagnostic value of staining patterns alone is limited.

Objectives:

To compare the utility and yield of “ANA screening reflex to profile” (ARP) and “ANA reflex to titer” (ART) order sets in the inpatient setting of a community tertiary care hospital. We aim to identify the appropriateness of the ANA testing ordered including cost-effectiveness of ordering ARP over ART in order to implement the identified quality measures towards improving utilization of ANA testing.

Methods:

We identified all inpatient ANA reflex testing orders performed at Community Regional Medical Center, Fresno, California completed between 11/2018 till 07/2019. This included ART and ARP orders with 6 sub-serologies: SSA, SSB, dsDNA, Smith, Scl-70 and U1RNP. A Health Information Management report was generated which included patient’s age, gender, length of hospital stay, dates of testing ordered, principal diagnosis and type of ANA testing ordered. Descriptive statistics were computed and analyzed.

Results:

We reviewed a total of 1,012 ANA lab orders performed between 11/01/2018 until 07/30/2019 performed on 700 patients. According to the laboratory standard using Immunofluorescence Assay, an ANA titer starting from 1:40 is reported as positive. Out of the 1,012 tests, 334 tests were positive i.e. 33%. The ART order by itself contributed to 29.9% of the positive testing while ARP formed 70% of the positive testing. 56 of the 910 ARP (6%) performed had one or more sub-serology antibody positive while in 178 ARP orders (20%) only the ANA titer was positive with negative serology. The most common sub-serology antibody noted positive was dsDNA forming 54% of the positive serology results. Multiple testing was noted with 218 orders of ARP and ART being ordered on the same patient within the same week, which shows 21.5% of ANA lab orders were repetitive. Length of stay was noted to be more than 3 days for 89% of the patients who had repetitive testing, majority of those tests (99%) on the same day by the same medical provider. It cost $5.0 for an ART order that resulted negative and $5.0 for an ARP panel that resulted negative. It cost $10.0 for those patients who had both ART and ARP ordered with negative results. A positive ART result added $12.0 additional to the cost of each positive ANA profile ($67.36) when both tests were ordered together.

Conclusion:

Our study findings reflect the need for using higher yield ANA testing that has been standardized. It demonstrated that physicians ordering the testing were not familiar with the ART vs. ARP, and the laboratory orders needed to be re-structured. We removed the ART from the inpatient Electronic Medical Record i.e. Epic system so that only the ARP order remained. This would prevent repetitive testing and reduce healthcare costs through reduction by at least $12.0 per positive ANA result and may also translate into reduced length of hospital stay. We were able to add Centromere Antibody (Ab) to the ANA profile sub serologies to standardize it further as it is an important part of Scleroderma diagnosis.

References:

[1]Range of antinuclear antibodies in “healthy” individuals. AU, Tan EM, et al. Arthritis Rheum. 1997; 40(9):1601

Disclosure of Interests:

None declared

P6419Machine learning in critical care: the role of diabetes and age in acute coronary syndromes

Background

Patients with diabetes and non-ST elevation acute coronary syndrome (NSTE-ACS) have an increased risk of mortality and adverse outcomes following percutaneous coronary intervention (PCI).

Purpose

We aimed to investigate the impact of early, within 24 hours PCI compared with only routine medical treatment on clinical outcomes in a large international cohort of patients with NSTE-ACS and diabetes.

Methods

We identified 1,250 patients with diabetes and NSTE-ACS from a registry-based population between October 2010 and April 2016. The primary endpoint was 30-day all-cause mortality. The secondary endpoint was the composite outcome of 30-day all-cause mortality and left ventricular dysfunction (ejection fraction <40%). We undertook analyses to explore the heterogeneity of treatment effects using meta-classification (MC) algorithms followed by propensity score matching and inverse-probability-of-treatment weighting (IPTW) from a landmark of 24 hours from hospitalization.

Results

Of 1,250 NSTE-ACS first-day survivors with diabetes (median age 67 years; 59%, men), 470 (37.6%) received early PCI and 780 routine medical treatment. The overall 30-day all-cause mortality rates were higher in the routine medical treatment than the early PCI group (6.3% vs. 2.5%). The prediction results of the MC algorithms accounted for only one interaction term that was statistically significant: age ≥65 years. After propensity-matched analysis as well as IPTW, early PCI was associated with reduced 30-day all-cause mortality in the older age (OR: 0.35; 95% CI: 0.14 to 0.92 and 0.43; 95% CI: 0.21 to 0.86, respectively), whereas younger age had no association with the primary endpoint. Similar results were also obtained for the secondary endpoint.

Conclusions

Among patients with diabetes hospitalized for NSTE-ACS, an early, within 24 hours, PCI strategy is associated with reduced odds of 30-day mortality only for patients aged 65 years or over. MC algorithms provide accurate identification of treatment effect modifiers.

A longitudinal analysis of the relationships among daytime dysfunction, fatigue, and depression in college students

OBJECTIVE

To examine the longitudinal trajectory of daytime dysfunction (DD) and its relationship with fatigue by depression status in university students.

PARTICIPANTS

243 students completed online surveys from September- December 2016.

METHODS

Surveys were conducted at three time points over a semester period: the beginning of the semester, the end of mid-term and the end of the semester.

RESULTS

Results indicated that the DD significantly increased in all students over the semester. Students with depression showed a higher initial level of DD and faster rate of change compared to those without depression. A faster rate of change of DD predicted a higher level of end-semester fatigue.

CONCLUSIONS

Depression is related to a higher initial level of DD and its faster rate change which in turn, predicted end-semester fatigue, identifying one of the possible pathways through which depression impacts the functioning and health of affected students.

CT features of extrahepatic arterioportal fistula in two cats

Two cats presented with large volume ascites and the cause was suspected to be portal hypertension. On contrast CT they both showed enhancement of the main portal vein during the arterial phase and an anomalous connection between the celiac artery and extrahepatic portal vasculature, prompting a diagnosis of extrahepatic arterioportal fistula. An extrahepatic arterioportal fistula is a connection between any artery and the portal vein outside the liver and, to our knowledge, this is the first report in cats.