Redefining the molecular rejection states in 3230 heart transplant biopsies: Relationships to parenchymal injury and graft survival

The first-generation Molecular Microscope (MMDx) system for heart transplant endomyocardial biopsies used expression of rejection-associated transcripts (RATs) to diagnose not only T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR) but also acute injury. However, the ideal system should detect rejection without being influenced by injury, to permit analysis of the relationship between rejection and parenchymal injury. To achieve this, we developed a new rejection classification in an expanded cohort of 3230 biopsies: 1641 from INTERHEART (ClinicalTrials.gov NCT02670408), plus 1589 service biopsies added to improve the power of the machine learning algorithms. The new system used 6 rejection classifiers instead of RATs and generated 7 rejection archetypes: No rejection, 48%; Minor, 24%; TCMR1, 2.3%; TCMR2, 2.7%; TCMR/mixed, 2.7%; early-stage ABMR, 3.9%; and fully developed ABMR, 16%. Using rejection classifiers eliminated cross-reactions with acute injury, permitting separate assessment of rejection and injury. TCMR was associated with severe-recent injury and late atrophy-fibrosis and rarely had normal parenchyma. ABMR was better tolerated, seldom producing severe injury, but in later biopsies was often associated with atrophy-fibrosis, indicating long-term risk. Graft survival and left ventricular ejection fraction were reduced not only in hearts with TCMR but also in hearts with severe-recent injury and atrophy-fibrosis, even without rejection.

Molecular states associated with dysfunction and graft loss in heart transplants

BACKGROUND

We explored the changes in gene expression correlating with dysfunction and graft failure in endomyocardial biopsies.

METHODS

Genome-wide microarrays (19,462 genes) were used to define mRNA changes correlating with dysfunction (left ventricular ejection fraction [LVEF] ≤ 55) and risk of graft loss within 3 years postbiopsy. LVEF data was available for 1,013 biopsies and survival data for 779 patients (74 losses). Molecular classifiers were built for predicting dysfunction (LVEF ≤ 55) and postbiopsy 3-year survival.

RESULTS

Dysfunction is correlated with dedifferentiation-decreased expression of normal heart transcripts, for example, solute carriers, along with increased expression of inflammation genes. Many genes with reduced expression in dysfunction were matrix genes such as fibulin 1 and decorin. Gene ontology (GO) categories suggested matrix remodeling and inflammation, not rejection. Genes associated with the risk of failure postbiopsy overlapped dysfunction genes but also included genes affecting microcirculation, for example, arginase 2, which reduces NO production, and endothelin 1. GO terms also reflected increased glycolysis and response to hypoxia, but decreased VEGF and angiogenesis pathways. T cell-mediated rejection was associated with reduced survival and antibody-mediated rejection with relatively good survival, but the main determinants of survival were features of parenchymal injury. Both dysfunction and graft loss were correlated with increased biopsy expression of BNP (gene NPPB). Survival probability classifiers divided hearts into risk quintiles, with actuarial 3-year postbiopsy survival >95% for the highest versus 50% for the lowest.

CONCLUSIONS

Dysfunction in transplanted hearts reflects dedifferentiation, decreased matrix genes, injury, and inflammation. The risk of short-term loss includes these changes but is also associated with microcirculation abnormalities, glycolysis, and response to hypoxia.

The Efficacy and Safety of High Dose (10 mg) of Desloratadine (Dazit® 10) in the Treatment of Chronic Spontaneous Urticaria in India: A Phase III, Multicentric, Open-Label, Single-Arm Study

BACKGROUND

Chronic spontaneous urticaria (CSU) is a debilitating affliction that affects diverse quality of life (QoL) parameters such as sleep, self-esteem, and daily activities. Second-generation antihistamines, such as desloratadine, are more effective and safer in managing CSU. Desloratadine is a nonsedating, potent, and highly selective H1 receptor antagonist. At its daily dose of 5 mg, almost half of CSU patients do not show symptomatic improvement. European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA2LEN)/European Dermatology Forum (EDF) (EuroGuiDerm)/Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI) guidelines recommend increasing the dosage to up to four times in such nonresponsive patients. However, there is insufficient clinical evidence in Indian settings.

METHOD

We evaluated the efficacy and safety of 10 mg desloratadine (OD) in 256 nonresponsive patients with moderate to severe CSU. The primary outcome was the change in Urticaria Activity Score (UAS7) from baseline to four weeks. Additionally, change in Chronic Urticaria Quality of Life (CU-Q2oL) scores during the course of treatment was also evaluated.

RESULT

The mean UAS7 scores showed a significant reduction from 31.9 ± 4.8 at baseline to 18.2 ± 8.1 at the end of the study (p < 0.0001). The use of a higher dose of desloratadine also decreased the CU-Q2oL scores significantly from 59.8 ± 14.7 at baseline to 35.4 ± 10 at four weeks (p < 0.0001). The incidence of adverse events (AEs) possibly linked to the drug was low (1.6%), and no serious adverse events were reported.

CONCLUSION

Results indicated improvements in the disease severity as well as its positive impact on participants' QoL. This study confirms the efficacy and safety of daily use of a twofold dose of desloratadine in nonresponsive moderate to severe CSU patients.

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

INTRODUCTION

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

Disparities in Inpatient Care Including Receipt of Radiotherapy and Mortality in Unhoused Adults with Cancer in the United States

PURPOSE/OBJECTIVE(S)

Cancer is the second leading cause of death among unhoused individuals in the United States. This study aims to assess inpatient care and outcomes of unhoused vs. housed adults with cancer. We hypothesize that unhoused patients receive less intensive care than housed patients during hospitalization.

MATERIALS/METHODS

All hospitalized adults age ≥18 with a principal cancer diagnosis were identified in the 2016-2020 National Inpatient Sample (NIS). Logistic regression models tested for associations between housing status and primary outcomes: care management (i.e., receipt of invasive procedures, systemic therapy, or radiation therapy [RT]) and inpatient death. Adjusted analyses accounted for patient demographics, socioeconomic status, comorbidities, and potential interactions between housing status and length of stay (LOS).

RESULTS

A total of 9,030 unhoused and 2,758,693 housed hospitalized adults with cancer were included in this study. At baseline, there were significant (p<0.05) differences in age <65 years (77% unhoused vs. 41% housed), male sex (75% vs. 53%), race (Black, 25% vs. 13%; White, 58% vs. 71%), and insurance type (Private, 6% vs. 27%; Medicaid, 53% vs. 11%) between groups. There were also differences in the prevalence of certain cancer histologies, including lung (17% vs. 14%) and liver (8% vs. 3%) cancer. Additionally, while comorbidities such as congestive heart failure (18% vs. 15%) and HIV (10% vs. 1%) were more common among unhoused patients, other conditions such as autoimmune disease (21% vs. 26%) and diabetes mellitus (38% vs. 43%) were more common among housed patients. Compared to housed patients, unhoused patients had longer LOS (median 6 vs. 4 days), with 62% hospitalized for ≥5 days (vs. 46%). On adjusted analysis, unhoused patients were less likely to undergo invasive procedures (48% vs. 58%; aOR [95% CI], 0.34 [0.27-0.42]) or receive systemic therapy (6% vs. 8%; 0.41 [0.20-0.85]) while inpatient. There were no significant differences in odds of receipt of RT (2% vs. 1%; 0.85 [0.21-3.41]) or odds of inpatient death (4% vs. 6%; 0.78 [0.52-1.15]) between groups.

CONCLUSION

In this first nationally representative analysis of housing status among hospitalized adults with cancer, unhoused adults were significantly less likely to receive invasive procedures or systemic therapy while inpatient, despite a higher prevalence of certain aggressive cancers and serious comorbidities compared to housed adults. Although there were no significant differences in the receipt of RT or death, disparities in inpatient management among unhoused patients highlight missed opportunities to promote equitable cancer care in this vulnerable population.

Role of pinch in Argon impurity transport in ohmic discharges of Aditya-U Tokamak

We present experimental results of the trace argon impurity puffing in the ohmic plasmas of Aditya-U tokamak performed to study the argon transport behaviour. Argon line emissions in visible and Vacuum Ultra Violet (VUV) spectral ranges arising from the plasma edge and core respectively are measured simultaneously. During the experiments, space resolved brightness profile of Ar1+ line emissions at 472.69 nm (3p44s 2P3/2-3p44p 2D3/2), 473.59 nm (3p44s 4P5/2-3p44p 4P3/2), 476.49 nm (3p44s 2P1/2-3p44p 2P3/2), 480.60 nm (3p44s 4P5/2-3p44p 4P5/2) are recorded using a high resolution visible spectrometer. Also, a VUV spectrometer has been used to simultaneously observe Ar13+ line emission at 18.79 nm (2s22p 2P3/2-2s2p2 2P3/2) and Ar14+ line emission at 22.11 nm (2s2 1S0-2s2p 1P1). The diffusivity and convective velocity of Ar are obtained by comparing the measured radial emissivity profile of Ar1+ emission and the line intensity ratio of Ar13+ and Ar14+ ions, with those simulated using the impurity transport code, STRAHL. Argon diffusivities ~ 12 m2/s and ~ 0.3 m2/s have been observed in the edge (ρ > 0.85) and core region of the Aditya-U, respectively. The diffusivity values both in the edge and core region are found to be higher than the neo-classical values suggesting that the argon impurity transport is mainly anomalous in the Aditya-U tokamak. Also, an inward pinch of ~ 10 m/s mainly driven by Ware pinch is required to match the measured and simulated data. The measured peaked profile of Ar density suggests impurity accumulation in these discharges.

Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-antinociception balance in paediatric craniotomies: a prospective observational study

INTRODUCTION

Analgesia Nociception Index (ANI) as a monitor of peri-operative nociception-anti-nociception balance has not been studied in paediatric neurosurgery. The objectives were to study the correlation between ANI (Mdoloris Education system) and revised FLACC (r-FLACC) score for the prediction of acute postoperative pain in paediatric population undergoing elective craniotomies and to compare the changes in ANI values with heart rate (HR), mean arterial pressure (MAP) and surgical plethysmographic index (SPI) during various time points of intraoperative noxious stimulation and before and after opioid administration.

METHODS

This prospective observational pilot study included 14 patients between 2 and 12 years of age undergoing elective craniotomies. HR, MAP, SPI, ANI instantaneous (ANIi) and ANI mean (ANIm) values were recorded intraoperatively and before and after opioid administration. Postoperatively HR, MAP, ANIi and ANIm, and pain scores (r-FLACC scale) were recorded.

RESULTS

There was a statistically significant negative correlation between ANIi and ANIm with r-FLACC during the time course of PACU stay (r =  - 0.89, p < 0.001 and r =  - 0.88 and p < 0.001 respectively). Intraoperatively, in patients with ANIi values < 50, with additional fentanyl administration, there was an increasing trend in values beyond 50, which was statistically significant (p < 0.05) at 3, 4, 5 and 10 min. The trend in changes of SPI after opioid administration was not found to be significant for patients irrespective of the baseline SPI values.

CONCLUSION

The ANI is a reliable tool for objective assessment of acute postoperative pain as assessed by r-FLACC in children undergoing craniotomies for intracranial lesions. It may be used as a guide to nociception-antinociception balance during the peri-operative period in this population.

Thoracic Aortic Injuries Following Intra-Aortic Balloon Pump Placement: A Retrospective Case Series

Thoracic aortic injuries from intra-aortic balloon pump (IABP) are rare, and no publications exist in the context of patients awaiting heart transplantation. We present a single-institution case series involving five patients out of 107 who sustained thoracic aortic injuries following IABP placement awaiting heart transplantation. The goal of this study is to describe the characteristics of patients, presenting symptoms, treatment and the impact of these injuries on their suitability for transplantation.

DESIGN

Retrospective, single-institution study through chart review of five patients with known thoracic aortic injuries following IABP placement awaiting heart transplant.

SETTING

Tertiary care academic teaching hospital with all patients requiring cardiac ICU admission.

PATIENTS

All five patients were diagnosed with advanced heart failure awaiting heart transplantation.

INTERVENTIONS

Each patient had an IABP placed while awaiting transplant.

MEASUREMENTS AND MAIN RESULTS

Five patients (4.6%) out of a total of 107 supported with IABP awaiting heart transplantation were identified with thoracic aortic injury. Three underwent transplantation and subsequently received thoracic endovascular aortic repair, and they are doing well with a mean follow-up of 6 months. One patient died acutely and the other did not require intervention.

CONCLUSIONS

IABP-related aortic injuries may be more common in patients awaiting transplantation and that endovascular therapy is a suitable treatment modality with no immediate impact on transplantation outcomes. Pooled data from multiple centers may help identify patients risk profile to potentially design an algorithm that can more quickly identify these injuries.

Safety and efficacy of cobimetinib plus atezolizumab in patients with solid tumors: a phase II, open-label, multicenter, multicohort study

BACKGROUND

Although introduction of immune checkpoint inhibitors has revolutionized the treatment of cancer, their response rates are generally low. Preclinical and early phase clinical data suggest that MEK inhibition may sensitize tumors to immune checkpoint inhibitors by upregulating tumor antigen expression, programmed death-ligand 1 (PD-L1) expression, and tumor T-cell infiltration. We evaluated the efficacy and safety of cobimetinib plus atezolizumab in patients with advanced solid tumors in the open-label, multicohort phase II COTEST study.

PATIENTS AND METHODS

This analysis of the COTEST trial included patients from cohorts 1-4 [1-3: anti-programmed cell death protein 1 (PD-1)/PD-L1 treatment-naive patients; 4: patients with disease progression on anti-PD-1/anti-PD-L1 treatment] who received cobimetinib 60 mg once daily for the first 21 days and intravenous infusions of atezolizumab 840 mg on days 1 and 15 of each 28-day cycle. Efficacy endpoints included objective response rate, overall survival, progression-free survival (PFS), and disease control rate.

RESULTS

Overall, 77 patients were enrolled in cohorts 1-4 (78% male; median age 62.8 years). Objective response rate was 20% in cohort 1 [squamous cell carcinoma of the head and neck (SCCHN)], 30% in cohort 2 (urothelial carcinoma), and 18% in cohort 3 (renal cell carcinoma); there were no responders among 20 patients in cohort 4 (SCCHN). The disease control rates in cohorts 1-4 were 50%, 40%, 24%, and 25%, respectively. The median PFS was 5.5, 3.4, 3.4, and 3.6 months in cohorts 1-4, respectively, and the median overall survival was 16.8, 18.7, 21.7, and 7.7 months, respectively. Most adverse events were of grade 1/2 and were manageable.

CONCLUSIONS

Cobimetinib plus atezolizumab had moderate activity in patients with anti-PD-1/PD-L1 treatment-naive SCCHN and urothelial carcinoma, and weak activity in anti-PD-1/PD-L1 treatment-naive renal cell carcinoma, and no activity in checkpoint inhibitor-treated patients.

Gamma Knife Radiosurgery in Partially Embolised Arteriovenous Malformations: Management Dilemmas and Outcomes

Introduction

The role of Gamma Knife radiosurgery (GKRS) in partially embolized arteriovenous malformations (AVMs) has always remained a subject of debate. The aim of this study was to evaluate the efficacy of GKRS in partially embolized AVMs and to analyze factor that influence its obliteration.

Methods

This was a retrospective study from a single institute performed over a period of 12 years (2005-2017). It included all patients who underwent GKRS for partially embolized AVMs. Demographic characteristics, treatment profiles, and clinical and radiological data were obtained during treatment and follow-up. Obliteration rates and factors affecting the same were sought and analyzed.

Results

A total of 46 patients with a mean age of 30 years (range: 9-60 years) were included in the study. Follow-up imaging was available for 35 patients either by digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). We found complete AVM obliteration in 21 patients (60%): one had near total obliteration (>90% obliteration), 12 had subtotal obliteration (<90%), and one had no change in the volume following GKRS. Following embolization alone, an average of 67% of the AVM volume was obliterated which resulted in an average 79% final obliteration rate after Gamma Knife radiosurgery. Mean duration to complete obliteration was found to be 3.45 years (range: 1-10 years). There was a significant difference (P = 0.04) in the mean interval between embolization and GKRS among cases with complete obliteration (12 months) and those with incomplete obliteration (36 months). There was no significant difference (P = 0.49) in the average obliteration rate between the ARUBA-eligible unruptured AVMs (79.22%) and ruptured AVMs (79.04%). Bleeding after GKRS during the latency period had a negative impact on obliteration (P = 0.05). Other factors like age, sex, Spetzler-Martin (SM)-grade, Pollock Flickinger score (PF-score), nidus volume, radiation dose, or presentation before embolization had no significant influence on obliteration. Three patients had permanent neurological deficits after embolization and none after radiosurgery. Six out of nine patients (66%) presenting with seizures were seizure-free after the treatment. Hemorrhage was noted in three patients following combined treatment and were managed non-surgically.

Conclusion

Obliteration rates in partially embolized AVM after Gamma Knife are inferior when compared to Gamma Knife alone; moreover with volume staging and/or dose staging being increasingly plausible due to the new ICON machine, embolization may be completely replaced. However we have shown that in complicated and carefully chosen AVMs, embolization followed by GKRS is a valid modality of management. This study represents a real-world picture of individualized AVM treatment depending on patient choices and resources available.

Initial results from near-infrared spectroscopy on ADITYA-U tokamak

Spectroscopy in vacuum ultraviolet (VUV) and visible ranges plays an important role in the investigation and diagnosis of tokamak plasmas. However, under harsh environmental conditions of fusion grade devices, such as ITER, VUV-visible systems encounter many issues due to the degradation of optical components used in such systems. Here, near-infrared (NIR) spectroscopy has become an effective tool in understanding the edge plasma dynamics. Considering its importance, a NIR spectroscopic diagnostic has been developed and installed on the ADITYA-U tokamak. The system consists of a 0.5 m spectrometer having three gratings with different groove densities, and it is coupled with a linear InGaAs photodiode array. Radiation from the ADITYA-U edge plasma has been collected using a collimating lens and optical fiber combination and transported to the spectrometer. The spectrum in the NIR range from the ADITYA-U plasma has been recorded using this system, in which Pa_β and Pa_γ along with many spectral lines from neutral and singly ionized impurities have been observed. The influxes of H and C have been estimated from measurements. The H influx value is found to be 2.8 × 10¹⁶ and 1.9 × 10¹⁶ particles cm^-2 s^-1 from neutral hydrogen lines H_α and Pa_β, respectively, and the C influx value is found to be 3.5 × 10¹⁵ and 2.9 × 10¹⁵ particles cm^-2 s^-1 from the neutral carbon and singly ionized carbon, respectively. A good agreement is seen between these results and the results obtained by using a routine photomultiplier tube based diagnostic.

Does vitamin D supplementation reduce COVID-19 severity?: a systematic review

BACKGROUND

The evidence regarding the efficacy of vitamin D supplementation in reducing severity of COVID-19 is still insufficient. This is partially due to the lack of primary robust trial-based data and heterogeneous study designs.

AIM

This evidence summary, aims to study the effect of vitamin D supplementation on morbidity and mortality in hospitalized COVID-19 patients.Design: Evidence summary of systematic reviews.

METHODS

For this study, systematic reviews and meta-analysis published from December 2019 to January 2022 presenting the impact of vitamin D supplementation on COVID-19 severity were screened and selected from PubMed and Google scholar. After initial screening, 10 eligible reviews were identified and quality of included reviews were assessed using AMSTAR and GRADE tools and overlapping among the primary studies used were also assessed.

RESULTS

The number of primary studies included in the systematic reviews ranged from 3 to 13. Meta-analysis of seven systematic reviews showed strong evidence that vitamin D supplementation reduces the risk of mortality (Odds ratio: 0.48, 95% CI: 0.346-0.664; P < 0.001) in COVID patients. It was also observed that supplementation reduces the need for intensive care (Odds ratio: 0.35; 95%CI: 0.28-0.44; P < 0.001) and mechanical ventilation (Odds ratio: 0.54; 95% CI: 0.411-0.708; P < 0.001) requirement. The findings were robust and reliable as level of heterogeneity was considerably low. However the included studies were of varied quality. Qualitative analysis showed that supplements (oral and IV) are well tolerated, safe and effective in COVID patients.

CONCLUSION

The findings of this study show that vitamin D supplementation is effective in reducing the COVID-19 severity. Hence, vitamin D should be recommended as an adjuvant therapy for COVID-19.However, more robust and larger trials are required to substantiate it further.

Adverse events associated with PentaRay Mapping Catheter – MAUDE database analysis

Background

The 20 pole PentaRay Mapping Catheter is a high-definition mapping catheter with five soft, flexible spines providing better and faster acquisition. Despite its design, the catheter is not without glitches.

Objective

We queried the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database for adverse events related to the use of the PentaRay mapping catheter.

Methods

The Manufacturer and User Facility Device Experience (MAUDE) database was searched for reports received between October 1, 2019, to October 31, 2021, to capture all adverse events associated with PentaRay mapping catheter using the term “PentaRay” in the “brand name” section. The adverse events were adjudicated to various categories based on the review of the event description for each medical device report (MDR).

Results

A total of 159 events were reported in 148 MDRs during the study period. The most common device related issues were: damaged splines 18.2% (n=29), device entrapment 17% (n=27), thrombus on device 15.1% (n=24), foreign material on splines 8.8% (n=14), sensor error 3.8% (n=6). Of the patient related events, 13.8% (n=22) were pericardial effusion, 5% (n=8) cardiac arrest, 1.2% (n=2) coronary vasospasm/STEMI, 0.6% (n=1) heart block, 0.6% (n=1) air embolism, 0.6% (n=1) tear in pulmonary veins. These events lead to procedure abortion 27.7% (n=44) and procedural delay 11.3% (n=18).

Conclusion

Several issues have been reported with the PentaRay mapping catheter leading to to procedure abortion, delay and patients related adverse events. Understanding and troubleshooting may help improve patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Initial results from time-resolved LaBr based hard x-ray spectrometer for ADITYA-U tokamak

Runaway electrons (REs) are passively studied by hard x-ray (HX) emissions generated by REs. A LaBr₃(Ce) detector-based HX spectroscopic diagnostic (operational within ∼75 keV to 3.5 MeV) has been set up on the ADITYA-U. The diagnostic acquisition software utility is upgraded to obtain the temporal evolution of the HX spectrum to understand the RE energy distribution in plasma during its various phases. The peak position moves to lower energy for Ohmically heated discharges (200-80 keV), indicating a relative increase in the thermal particle content in the plasma. The peak position of RE energy shows a decreasing tendency with increasing n_e with Ne gas puffing and termination of the electron cyclotron resonance pulse.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

P-059 Effect of outcome of microfluidic sperm sorter and conventional swim-up technique on DNA integrity of the sperm

Study question

Does the approach of sperm preparation technique plays any role in sperm DNA Integrity

Summary answer

Outcome of the semen sample is directly proportional to the choice of preparation technique. Microfluidics improves sperm selection and results in better sperm DNA integrity

What is known already

Microfluidic systems are promising tools for fluid manipulation that can noninvasively separate motile sperm with higher hydrodynamics profile from the lower ones. It also enables to manipulate micro swimmers as compared to the traditional methods that to without centrifugation .As it is already known that Semen analysis and preparation is one of the most important aspects in andrology and microfluidics can improve sperm analysis and selection, therefore increasing the ART success rates

Study design, size, duration

Comparative study from July 2019 to Dec 2021 in IVF unit of IKDRC Hospital .A total number of 900 patients were enrolled in the study and were randomized by using computer generated list then divided into two groups, Group A contains 460 samples and Group B having 440 samples.

Participants/materials, setting, methods

Group A (n = 460) sample was prepared by using Microfluidic sperm Sorting technique and Group B (n = 440) sample was prepared by conventional Swim up technique. Samples were analyzed according to WHO 2010 laboratory manual for examination and processing of human sperm, including all normozoospermic samples. Primary outcomes of the study was DNA Fragmentation index (DFI) and it was evaluated by using sperm chromatin dispersion (SCD) test and secondary outcomes was Progressive motility .

Main results and the role of chance

DNA fragmentation index is significantly lower in group A where Microfluidic Sperm Sorting technique (MFSS )is used than in group B where conventional swim up technique is use (10.06% vs 34.2%, p&lt;0.0001) significant values implies that DNA integrity is better in group A than in group B and progressive motility was also found to be significantly higher in group A as compared to group B (57.6%vs16.9%, p &lt;0.001).

Limitations, reasons for caution

As sample size was smaller, larger randomized control studies are needed to strengthen these results and all normal samples were used for the analysis and preparation , abnormal parameters were not involved .

Wider implications of the findings

According to our study the samples prepared by Microfluidic technique have higher DNA integrity than samples prepared by Swim up technique. Lower DNA Fragmentation index in microfluidics outcome indicates lower DNA damage. Choice of technique for the preparation of semen sample also plays a key role in better sperm selection.

Trial registration number

N/A

1078 AUDIT TO IMPROVE APPLICATION OF THE MENTAL CAPACITY ACT ON GERIATRIC WARDS

Introduction

The Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) are put in place to protect the rights of capacitous patients to make decisions, and in those not deemed to have capacity, the latter ensures that any restrictions are in the patient’s best interests, are appropriate and proportionate. The objective of this audit was to assess whether these tools were being appropriately employed across the four Complex Medical Units (CMU) in the John Radcliffe Hospital, in a patient population in which dementia and delirium are prevalent.

Method

Audit of patient records on CMU wards (first cycle on 15/8/21 n = 74, second cycle on 31/10/21 (n = 74) before and after presentation of the initial audit results. All inpatients were assessed for: AMTS, completion of a MCA (for those with AMTS&lt;8, or an AMTS not done as too unwell), DoLs applications if indicated. Across the wards, baseline patient characteristics and demographics were equal. In the first audit, there were only 16% patients (6) with an MCA out of a possible 38 patients who fulfilled the criteria and out of these, and 2 had a DOLS (5%). After training, involving a presentation given by us about the findings of our audit, together with high level discussions between consultants and registrars, there were 43% patients with an MCA (15 patients), and 14% had appropriate DOLS (5 patients), out of 35 patients. This therefore shows clear improvement in the situation on our wards.

Conclusion

This audit has improved the recognition of patients in whom a capacity assessment is required and the documentation of a MCA being done. Going forward, we suggest all geriatric medicine wards should discuss and audit MCA and DOLS to ensure patients’ rights are suitably protected.

Trends in ECT (Electroconvulsive Therapy) Utilization During Pregnancy and Post-Partum Period: National Inpatient Sample 2002-2015

Introduction

The use of Electroconvulsive therapy (ECT) during pregnancy and in the post-partum period is a critical decision for both providers and their patients. ECT utilization during this critical period needs to be better understood to assess the need and allocate resources for this valuable treatment option.

Objectives

1) To evaluates baseline characteristics and analyze ECT utilization trends for pregnant and post-partum patients hospitalized in the US. 2) To provide insight into ECT use among inpatient pregnant women with different age groups with various comorbid psychiatric disorders.

Methods

The study used the 2002-2015 National (Nationwide) Inpatient Sample (NIS) data. Descriptive statistical and trend analyses were conducted to evaluate data.

Results

A study found that a total of 924 pregnancy-related hospitalizations required ECT treatment; 92.2% of these ECTs were conducted in urban hospitals. The mean age of women was 30.3 years, and the majority (71%) were of the White race. Mood disorders (major depressive disorder- 51.9% and bipolar disorder- 37.9%) accounted for the most common comorbid psychiatric illnesses. The payer source (Medicare/Medicaid vs. Private Insurance) was almost equal (47.9 vs. 46.8). Though not statistically significant, the trend analysis showed that the proportion of ECTs during pregnancy out of the total ECT performed for the year almost doubled (0.24% to 0.47%) from 2008 to 2015.

Conclusions

Though not statistically significant, the use of ECT in pregnant women has increased in 2015 compared to 2002. Results will help clinicians, policymakers, and various stakeholders to optimize ECT utilization, reimbursement and ultimately improve clinical outcomes.

Disclosure

No significant relationships.

Suicide in Adolescents with Mood Disorders

Introduction

Adolescents patients presenting with mood disorders, including disruptive mood dysregulation disorder (DMDD), often present with the comorbid disorders such as oppositional defiant disorder (ODD) and attention-deficit hyperactivity disorder (ADHD).

Objectives

1) Evaluate the association between suicide in adolescents and various mood disorders. 2) To study the impact of comorbid conditions in DMDD on suicide ideation and attempt in adolescents.

Methods

We used 2016-2017 National Inpatient Sample dataset to select patients with mood disorders. Rao Scott adjusted Chi-Square test used to compare the groups with SPSS v26.

Results

In this study, 15195 patients were in the DMDD group (Mean age:12.1,F: 38%) and 219205 in the ‘other mood disorders’ group (Mean age:14.4,F:67%). The odds of SI/SA were two times more in patients with the ‘other type of mood disorder’ (OR:2.07, 95%CI: 1.77-2.14). Patients with the primary diagnosis of DMDD sub-classified into four groups (Group 1: DMDD only (n=5160), Group 2: DMDD+ADHD (n=7240), Group 3: DMDD +ODD (n=700), and Group 4: DMDD+ADHD+ODD (n=2095). SI/SA was prevalent in 30.8%, 26.0%, 22.9% and 26.3% in Group 1, 2, 3 and 4 respectively (p: 0.03). SI/SA was more prevalent in females compared to males (31.3% vs. 25.2%). An increase of 1 year in age was associated with a higher SI/SA (OR:1.05, 95%CI:1.01-1.08, 0.01). The SI/SA odds were 5% more in female patients (OR:1.27, p:0.01).

Conclusions

The study reveals that the risk of suicide ideation or suicide attempt is almost twice in the adolescent with mood disorders without DMDD compared to the DMDD group.

Disclosure

No significant relationships.

Bullying victimization in children and adolescents and its impact on academic outcomes

Introduction

Bullying is a serious problem in schools because of the negative impact on a child’s educational outcomes, especially academic achievement. However, the underlying mechanisms and causes are unknown.

Objectives

To evaluate the educational outcomes, and psychiatric comorbidities in children and adolescents who are victims of bullying

Methods

We used 2018–2019 Nationwide Survey of Children’s Health (NSCH) dataset for the study. The participants were children and adolescents (age: 6-17 years, n = 42,790). Data was stratified into two groups: 1) never bullied 2) bullied more than once. Prevalence of different educational outcomes were compared between the groups.

Results

In the never bullied group 21,015 participants were included, and in the bullied more than once group 21,775 participants were included. More females were in the bullied group compared to never bullied group (50.4% vs 47.5%, p=0.006). More White non- Hispanic individuals were in bullied group in contrast to never bullied group (56.7% vs 43.9%, p< 0.001). Individuals whose health status was fair, or poor were bullied more (2.4% vs 1.4%, p=<0.001). Individuals in bullied group were more likely to be repeating the grades compared to the never bullied group (7.1% vs 5.9%, p:0.039). Individuals who were missing >=11 school days, and sometimes or never engaged in school were observed more in bullied group compared to never bullied group (5.9% vs 3.2% and 20.3% vs 10.6% p < 0.001).

Conclusions

Our findings suggest that bullying victimization could be a risk factor and associated with decreased academic outcomes.

Disclosure

No significant relationships.

Bright Light Therapy for MDD in Children and Adolescents: a narrative review of literature

Introduction

Major Depressive Disorder (MDD) is a common mood disorder diagnosed in children and adolescents. Bright light therapy has been effective for seasonal affective disorders, however its role in the treatment of MDD is under studied.

Objectives

Our objective is to evaluate if bright light therapy (BLT) is a practical approach in treating Child and Adolescents having MDD.

Methods

We performed an extensive literature search using a wide range of MeSH terms in PubMed, PubMed Central and Google Scholar. We reviewed the literature for studies (published between 1983-2021) assessing the efficacy of BLT in the treatment of MDD in children and adolescents.

Results

The final search results yielded 8 randomized clinical trials and 1 case report from 1983 to 2021. BLT showed a superior effect in children and adolescents with MDD compared to the control group in the majority of the randomized trials and a case report. In six studies BLT showed good effect, however in a study by Magnusson et al. and Sonis et al., found a milder degree of improvement in depression symptoms when compared to the control group. In the majority of the studies, patients’ age range was 7 years 18 and in most of the studies, patients were not on antidepressants.

Conclusions

The use of BLT in children and adolescents suffering from MDD can be a promising alternative method of biological treatment, which is effective as well as well tolerated. Future long-term studies on large sample size are necessary in this field.

Disclosure

No significant relationships.

Association of Psilocybin Use in Adolescents with Major Depressive Episode

Introduction

Psilocybin is a psychedelic drug found in mushrooms, often referred to as magic mushrooms due to its visual and auditory hallucinations effects upon ingestion. It is a Schedule I drug per DEA, and the FDA has not approved psilocybin for medicinal purposes. However, recent studies have shown promising therapeutic use to treat depression.

Objectives

To identify current use, prevalence, and its association with depression in adolescents.

Methods

The National Survey on Drug Use and Health survey data from 2008-18 studied adolescent data (12-17 years), who responded, “ever used psilocybin (mushrooms)” and “lifetime major depressive episode (MDE).” The association between the psilocybin use and MDE status was analyzed in SAS 9.4 through multivariate logistic regression for odds ratio (OR) and 95% confidence interval (CI).

Results

A total of 172745 adolescents were included in this study, of which 2469 ever used psilocybin in their lifetime, and 170276 responded no lifetime use. The psilocybin ever lifetime users were 17 years old (42%vs.17%,p<0.001), male (60%vs.51%,p<0.001), and non-Hispanic White (71%vs.55%,p<0.001) in comparison to non-users. Among psilocybin user group, 31% of respondents had lifetime MDE, compared to 16% of the lifetime psilocybin non-user group participants (p<0.001). The odds of association of psilocybin use among participants with MDE were 2.17 times compared to those without MDE (CI: 1.93-2.44,p<0.001).

Conclusions

We identified a significant association between psilocybin use and MDE among adolescents, which raises public health concerns about its illegal use, abuse, and toxicity potential. Future clinical studies should assess its clinical safety, efficacy, and addictive properties.

Disclosure

No significant relationships.

Fate of polycyclic aromatic compounds from diluted bitumen spilled into freshwater limnocorrals

Diluted bitumens (dilbits) are produced by mixing highly viscous bitumen with lighter petroleum products to facilitate transport. The unique physical and chemical properties of dilbit may affect the environmental fate and effects of dilbit-derived chemical compounds when spilled. To further explore this, we monitored experimental spills of Cold Lake Winter Blend (CLWB) dilbit for 70 days in limnocorrals installed in a freshwater boreal lake. A regression design with 2 controls and 7 treatments was used to assess the fate and behaviour of polycyclic aromatic compounds (PACs) as they partitioned from the dilbit into the air, water column and sediments. Treatments ranged from 1.5 to 180 L of CLWB, resulting in oil:water ratios ranging between 1:71000 to 1:500 (v:v). We began to detect elevated concentrations of PACs as early as 6 h post-addition in the air, 12 h post-addition in the water column, and 15-28 d post-addition in the sediments. By the end of the experiment, concentrations of PACs had largely declined in the water column but remained elevated in the sediments. Our results demonstrate that under conditions typical of temperate boreal lakes, only a small proportion of PACs from dilbit enters the aquatic system, but even so, may produce concentrations of ecotoxicological concern, especially in the sediments, which is the ultimate sink for dilbit-derived PACs.

Comparison of Biochemical Parameters in Patients with Hepatitis B, C, and Dual Hepatitis B and C in Northwest Pakistan

The leading causes of hepatitis are viral infections, Hepatitis B virus (HBV) and Hepatitis C virus (HCV). Millions of people have been infected with these deadly viral infections worldwide, and in Pakistan, every tenth person is infected with these viruses. Different populations respond with different rates to infectious diseases due to host genomic differences. To evaluate and compare the biochemical parameters in different types of hepatitis (Hepatitis B, C, and Co-infection) and different ethnic groups, a total of 200 pre-screened patients were recruited from District Headquarters Teaching Hospital Dera Ismail Khan and Tank. Blood samples (5ml) were taken from patients and were assayed for biochemical parameters, including four liver function tests (LFTs) and two renal function tests (RFTs). In 200 patients, the mean scores of Alanine transaminase (ALT) were 376±335, 315±265, and 478±519 IU/L in HBV, HCV, and co-infected patients, respectively. Moreover, the mean score of ALT was 31±7.2 IU/l in the normal control group. All other biochemical parameters demonstrated elevated levels in co-infection, HBV, and HCV, respectively, except total proteins. The RFTs showed a threshold or upper normal limit (UNL); nonetheless, when compared to normal control subjects, RFTs parameters were high in infected patients, as compared to normal control. Ethnicity wise comparison of parameters indicated that Pushtoon ethnic group indicated a high degree of severity of HBV infection and co-infection, as compared to Saraiki and Rajpoot ethnic groups, while Saraiki ethnic group showed a higher severity of HCV than both of Pushtoon and Rajpoot. Rajpoot ethnic group was least affected than both Pushtoon and Saraiki ethnic groups. Co-infected patients were more severely affected, as compared to HBV and HCV patients. The ethnicity-wise study provided evidence that different ethnic groups showed different degrees of severity. There may be some genetic background involved in hepatitis B and C viral infection due to which all three ethnic groups showed different degrees of severity. In gender-wise comparisons, male patients were more affected than female patients.

Large Variation in Heart Transplant Selection Practices During the COVID-19 Pandemic

Purpose

A growing proportion of transplant donors and recipients have a history of COVID infection. Transplant societies issued guidelines to support decisions regarding donor selection and recipient activation after COVID infection, but outcome data are still limited. This study sought to characterize heterogeneity in current clinical practice and opinions regarding cardiac donation after recipient or donor COVID infection.

Methods

An online survey was distributed to heart transplant clinicians through a professional society message board and social media. Responses were collected between September 29 and October 18, 2021.

Results

204 healthcare professionals from diverse geographic regions (North and South America, Europe, Middle East, Asia and Australia) completed the survey, including 143 (70%) transplant cardiologists, 42 (21%) cardiac surgeons and 19 (9%) other heart transplant clinicians. 80% of clinicians felt COVID vaccine should be mandatory before transplant. There was significant variation in clinical practice for donor acceptance and recipient management, including several scenarios directly addressed by society guidelines - see Figure 1 for a sample of responses.

Conclusion

There is significant variation in the clinical approach to common scenarios following donor or recipient COVID infection. This reflects continued uncertainty with post-transplant outcomes impacted by pre-transplant COVID infection. Granular outcome data are needed to better inform clinical decisions.