The utility of rested prolactin sampling in the evaluation of hyperprolactinaemia

BACKGROUND AND AIMS

Serum prolactin levels may be elevated by venepuncture stress. We investigated the utility of a rested prolactin sample, obtained through an indwelling venous cannula, in preventing the overdiagnosis of hyperprolactinaemia.

METHODS

Patients at our institution undergo serial prolactin sampling, usually over 40 min, when investigating hyperprolactinaemia. We retrospectively reviewed all serial prolactin sampling performed during a 3-year period. Patients with possible medication-induced hyperprolactinaemia and macroprolactin interference were excluded. We assessed the effect of venepuncture-associated stress on hyperprolactinaemia with the main outcome being normalisation of serum prolactin at the end of serial sampling.

RESULTS

Ninety-three patients with documented hyperprolactinaemia (range 360-1690 mU/L) were included in the analysis. Prolactin decreased during serial sampling in 73 patients (78%), suggesting a prevalent effect of venepuncture stress. The final prolactin sample was normal in 50 patients (54%), consistent with stress hyperprolactinaemia rather than pathological hyperprolactinaemia. Patients with a referral prolactin result greater than two times the upper reference limit (URL) were less likely (15%) to have a normal prolactin result on serial sampling. Measurement of a single rested prolactin sample from an indwelling cannula showed the same diagnostic utility as serial sampling.

CONCLUSION

Serum prolactin results are frequently elevated by the stress of venepuncture. Confirmation of pathological hyperprolactinaemia in a rested sample obtained from an indwelling venous cannula is recommended in patients with mild hyperprolactinaemia, particularly when the referral prolactin is less than two times the URL.

War and disaster are forcing a major rethink around mass casualty management

Mass casualty events (MASCAL) do not follow the same rules as typical major incidents. In the West at least, the latter often occur in stable, networked trauma systems, whereas MASCAL are characterised by overwhelming numbers of patients, compounded by protracted scene and transport times, decompensated response systems and significant disruption to infrastructure, command and control.This paper describes the 8Ds approach being taken by the UK Defence Medical Services and the North Atlantic Treaty Organization Emergency Medicine Panel framework to approach MASCAL. The eight domains were derived from literature about management of casualties in the World Wars, and also from approaches taken by civilian health systems as they struggle to manage increasing demand. They are: distribute; decompress; delay; delegate; deliver faster and deliver better; dynamic levels of care; and de-escalate These domains will allow a structured approach to research and innovate around MASCAL, informing better guidelines for their management.

Correlation of ACR TI-RADS and Patient Outcomes in a Real-World Cohort Presenting for Thyroid Ultrasonography

Context

The American College of Radiology Thyroid Image Reporting and Data System (ACR TI-RADS) was developed to predict malignancy risk in thyroid nodules using ultrasound features. TI-RADS was derived from a database of patients already selected for fine-needle aspiration (FNA), raising uncertainty about applicability to unselected patients.

Objective

We aimed to assess the effect of ACR TI-RADS reporting in unselected patients presenting for thyroid ultrasound in a real-world setting.

Methods

Records for all patients presenting for thyroid ultrasonography in Canterbury, New Zealand, were reviewed across two 18-month periods, prior to and after implementation of TI-RADS reporting. Patient outcomes were compared between the 2 periods. Malignancy rates were calculated for nodules 10 mm or larger with a definitive FNA or histology result.

Results

A total of 1210 nodules were identified in 582 patients prior to implementation of TI-RADS; 1253 nodules were identified in 625 patients after implementation of TI-RADS. TI-RADS category was associated with malignancy rate (0% in TR1 and TR2, 3% in TR3, 5% in TR4, 12% in TR5; P = .02); however, 63% of nodules were graded TR3 or TR4, for which malignancy rate did not meaningfully differ from baseline risk. After implementation of TI-RADS there was a small reduction in the proportion of patients proceeding to FNA (49% vs 60%; P < .01) or surgery (14% vs 18%; P < .05), with no difference in cancer diagnoses (3% vs 4%, not significant).

Conclusion

TI-RADS category is associated with malignancy rate and may alter clinical decision-making in a minority of patients; however, it is nondiscriminatory in the majority of nodules. In this study of unselected patients, nodules classified as TR5 and thus considered "highly suspicious" for cancer had only a modest risk of malignancy.

Two Cases of Adrenal Malignancy With Macroscopic Fat

The presence of macroscopic fat on computed tomography (CT) imaging has been traditionally regarded as an indication that an adrenal lesion is likely to be a benign myelolipoma, for which further investigation is not usually required. Two cases are described where an adrenal lesion was eventually found to be malignant on histology (adrenocortical carcinoma in the first case, undifferentiated sarcoma in the second case), despite the presence of macroscopic fat on CT. In both cases there were other clinical and radiological indicators of potential malignant pathology. These cases add to increasing awareness in the literature that malignant adrenal tumors may rarely contain macroscopic fat, emphasizing a need for clinical vigilance.

Quality of life (QoL) in patients with heart failure with preserved ejection fraction (HFpEF): a systematic review

Introduction

Heart failure with preserved ejection fraction (HFpEF) is associated with significant clinical unmet need as mortality and morbidity rates are high despite current treatments. Patient-reported quality of life (QoL) is an important and clinically relevant endpoint in patients with HF so understanding the impact of HFpEF on QoL is essential.

Purpose

The aim of this systematic review was to identify and summarize data on QoL in HFpEF.

Methods

Systematic searches of Medline, Medline Epub Ahead of Print (In-Process & Other Non-Indexed Citations), Embase, and EBM Reviews were conducted in October 2021. Congress proceedings from the past 3 years and reference lists of included publications were also searched. Publications were screened against eligibility criteria by title/abstract and then by full text. Eligibility criteria included clinical studies of any design reporting baseline QoL in adults with HFpEF published from 2016 onwards.

Results

The electronic database search identified 6,403 articles on HFpEF. After screening, 35 full publications reporting HFpEF and QoL were included. Study designs included observational cohort (n=17), cross-sectional (n=3), and post-hoc analyses of interventional studies (n=15). Tools used to measure QoL included KCCQ (n=17), MLHFQ (n=12), EQ-5D-VAS (n=8), SF-12 (n=2), SF-36 (n=2), and EHFSQ-1 (n=1). Health-state utility values (HSUVs) were captured using EQ-5D in four studies. HSUVs in HFpEF ranged from 0.67–0.74, indicating a substantial QoL burden. Eleven studies using various instruments compared QoL in patients with HFpEF vs non-HFpEF (Table 1). Of these, five reported statistically significantly poorer QOL in HFpEF vs non-HFpEF, one reported statistically significantly poorer QOL in non-HFpEF vs HFpEF and five found no statistically significant difference between HF subtypes. Four studies compared QoL in men vs women with three reporting statistically significantly worse QoL in women. Three studies examined the impact of comorbidities, and all reported statistically significantly poorer QoL in patients with comorbid atrial fibrillation, diabetes, or metabolic syndrome. Two studies examined the effect of age; one reported that, vs elderly patients (age ≥85 years), younger patients (age ≤55 years) with HFpEF had statistically significantly worse QoL despite having fewer comorbidities; in contrast, the second study reported that younger patients (age ≤55 years) had statistically significantly better QoL than elderly patients (age ≥75 years). Two studies reported on hospitalizations, with one reporting no difference in QoL between patients who had previously been hospitalized and those who had not and the other reporting that readmission for HF correlated with QoL.

Conclusions

QoL burden among HFpEF patients is substantial. QoL may be affected by age, comorbidities, gender, and prior hospitalization, and may be associated with poorer outcomes. QoL in HFpEF is generally poorer than in non-HFpEF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

POS1432 SHORT-TERM RISK OF OSTEOPOROSIS IN ADULTS TREATED WITH CORTICOSTEROIDS: AN OBSERVATIONAL STUDY

Background:

Exposure to corticosteroids is recognised to increase the risk of osteoporosis.

Objectives:

Our aim was to evaluate patients’ short-term absolute risk of osteoporosis over the course of their first continuous exposure to corticosteroids.

Methods:

This was an observational study using UK data from the Clinical Practice Research Datalink. Adult patients were selected if exposed to systemic corticosteroids for any condition and had no prior osteoporosis. Non-exposed adults matched on age, sex, and disease burden were selected from the general population. Patients were followed from their first exposure to corticosteroid to the earlier of 90 days following the end of continuous prescribing or for a maximum of three years. Cohorts were categorised by age (18-42 years, 43-67 and 68-92 years), BMI (underweight, normal overweight, obese and obese+) and gender. Absolute risk rates were calculated for each of these categories.

Results:

In total, 573,056 exposed patients were matched 1:1 to non-exposed controls. Mean age was 52 years; 57% were female. The mean and median days’ supply were 50.9 and 13 days, respectively. Underweight females aged 68-92 years exposed to corticosteroids had the highest absolute risk of osteoporosis (70.9 per 1000 patient years (PKPY)); in matched non-exposed controls this was 26.6 PKPY. Generally, following their first continuous exposure to corticosteroids, patients taking steroids had greater risk of osteoporosis compared with those in the same age, sex and BMI category never exposed to corticosteroids.

Conclusion:

Whilst it is understood that exposure to corticosteroids increases the risk of osteoporosis, there are large differences in risk in accordance with age, sex and BMI. Alternatives to corticosteroids are urgently needed.

MaleFemaleSteroid-exposedNever exposedSteroid-exposedNever exposedAge groupBMI groupPatientsAbsolute rate (per 1,000 patient years)PatientsAbsolute rate (per 1,000 patient years)p-valuePatientsAbsolute rate (per 1,000 patient years)PatientsAbsolute rate (per 1,000 patient years)p-value18-421: Underweight1,2422.01,1950.00.56613,0794.53,4860.90.13612: Normal18,7982.219,6380.0<0.000142,2340.947,3400.10.00493: Overweight16,5362.615,1140.00.000124,8930.524,0090.10.23824: Obese +10,3110.68,4530.00.287426,6000.620,3200.30.461443-671: Underweight1,25427.46830.00.00402,42030.91,99018.50.11412: Normal27,0378.626,5692.0<0.000145,46715.950,4236.1<0.00013: Overweight42,4284.343,8720.7<0.000142,62010.843,2534.1<0.00014: Obese +31,4782.530,8520.80.000745,3396.039,8762.4<0.000168-921: Underweight93630.343210.30.15051,53270.91,23926.60.00032: Normal15,89111.315,0214.5<0.000118,30842.318,71718.6<0.00013: Overweight21,3717.323,1371.8<0.000119,14926.219,76012.9<0.00014: Obese +11,2165.611,3961.90.002114,45320.013,6148.7<0.0001

Disclosure of Interests:

Ellen Berni Consultant of: Employed by Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies., Philip Ambery Shareholder of: AstraZeneca, Employee of: AstraZeneca, Samuel Adamsson Eryd Shareholder of: AstraZeneca, Employee of: AstraZeneca, Sara Jenkins-Jones Consultant of: Employed by Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies., Mary Brown Shareholder of: AstraZeneca, Employee of: AstraZeneca, Carol Astbury Shareholder of: AstraZeneca, Employee of: AstraZeneca, Phillip Hunt Shareholder of: AstraZeneca, Employee of: AstraZeneca, Craig Currie Consultant of: Director of Pharmatelligence, which carries out consultancy work for AstraZeneca and other pharmaceutical companies

Vitamin D supplementation in pregnancy: A word of caution. Familial hypercalcaemia due to disordered vitamin D metabolism

Disorders of vitamin D metabolism have only recently become more widely recognized. In 2011, a series reported six children with familial idiopathic infantile hypercalcaemia, a condition in which patients develop hypercalcaemia following bolus vitamin D supplementation due to mutations in CYP24A1, formerly known as 24-hydroxylase. This is the chief enzyme in the catabolism of 1,25-dihydroxyvitamin D3 (calcitriol) to inactive 1,24,25-(OH)3D3. Isolated cases of loss of function CYP24A1 mutations have been reported across a wide spectrum of ages, including three cases first identified during pregnancy in the context of vitamin D supplementation. We describe a family in which two siblings had hypercalcaemia due to a disorder of calcitriol catabolism as a result of compound heterozygous loss of function mutations of CYP24A1, including a novel mutation K351Nfs*21. The index case, who has kindly given written informed consent for this report, was a female in her mid-20s presenting with symptomatic hypercalcaemia precipitated by vitamin D supplementation in her first pregnancy. In a subsequent pregnancy, she remained normocalcaemic in the absence of supplementation. Her asymptomatic brother was identified through cascade screening. Upregulation of calcitriol production in pregnancy, particularly when combined with vitamin D supplementation, can unmask previously unidentified disorders of vitamin D metabolism. This report emphasizes the importance of screening of family members and the need for caution with vitamin D supplementation in pregnancy.

Imputation of Assay Bioactivity Data Using Deep Learning

We describe a novel deep learning neural network method and its application to impute assay pIC₅₀ values. Unlike conventional machine learning approaches, this method is trained on sparse bioactivity data as input, typical of that found in public and commercial databases, enabling it to learn directly from correlations between activities measured in different assays. In two case studies on public domain data sets we show that the neural network method outperforms traditional quantitative structure-activity relationship (QSAR) models and other leading approaches. Furthermore, by focusing on only the most confident predictions the accuracy is increased to R² > 0.9 using our method, as compared to R² = 0.44 when reporting all predictions.

Nursing and medical contribution to Defence Healthcare Engagement: initial experiences of the UK Defence Medical Services

Introduction

The WHO Constitution enshrines ‘…the highest attainable standard of health as a fundamental right of every human being.’ Strengthening delivery of health services confers benefits to individuals, families and communities, and can improve national and regional stability and security. In attempting to build international healthcare capability, UK Defence Medical Services (DMS) assets can contribute to the development of healthcare within overseas nations in a process that is known as Defence Healthcare Engagement (DHE).

Methods

In the first bespoke DMS DHE tasking, a team of 12 DMS nurses and doctors deployed to a 1000-bedded urban hospital in a partner nation and worked alongside indigenous healthcare workers (doctors, nurses and paramedical staff) during April and May 2016. The DMS nurses focused on nursing hygiene skills by demonstrations of best practice and DMS care standards, clinical leadership and female empowerment. A Quality Improvement Programme was initiated that centred on hand hygiene (HH) compliance before and after patient contact, and the introduction of peripheral cannula care and surveillance.

Results

After a brief induction on the ward, it was apparent that compliance with HH was poor. Peripheral cannulas were secured with adhesive zinc oxide tape and no active surveillance process (such as venous infusion phlebitis (VIP) scoring) was in place. After intensive education and training, initial week-long audits were undertaken and repeated after a further 2 weeks of training and coworking. In the second audit cycle, HH compliance had increased to 69% and VIP scoring compliance to 99%. In the final audit cycle, it was noted that nursing compliance with HH (75/98: 77%) was significantly higher than the doctors’ HH compliance (76/200: 38%); p<0.0001.

Conclusions

DHE is a long-term collaborative process based on the establishment and development of comprehensive relationships that can help transform indigenous healthcare services towards patient-centred systems with a focus on safety and quality of care. Short deployments to allow clinical immersion of UK healthcare workers within indigenous teams can have an immediate impact. Coworking is a powerful method of demonstrating standards of care and empowering staff to institute transformative change. A multidisciplinary group of Quality Improvement Champions has been identified and a Hospital Oversight Committee established, which will offer the prospect of longer term sustainability and development.

Temporal and geospatial trends of pediatric cancer incidence in Nebraska over a 24-year period

BACKGROUND

Data from the Surveillance, Epidemiology, and End Results (SEER) revealed that the incidence of pediatric cancer in Nebraska exceeded the national average during 2009-2013. Further investigation could help understand these patterns.

METHODS

This retrospective cohort study investigated pediatric cancer (0-19 years old) age adjusted incidence rates (AAR) in Nebraska using the Nebraska Cancer Registry. SEER AARs were also calculated as a proxy for pediatric cancer incidence in the United States (1990-2013) and compared to the Nebraska data. Geographic Information System (GIS) mapping was also used to display the spatial distribution of cancer in Nebraska at the county level. Finally, location-allocation analysis (LAA) was performed to identify a site for the placement of a medical center to best accommodate rural pediatric cancer cases.

RESULTS

The AAR of pediatric cancers was 173.3 per 1,000,000 in Nebraska compared to 167.1 per 1,000,000 in SEER. The AAR for lymphoma was significantly higher in Nebraska (28.1 vs. 24.6 per 1,000,000; p = 0.009). For the 15-19 age group, the AAR for the 3 most common pediatric cancers were higher in Nebraska (p < 0.05). Twenty-three counties located >2 h driving distance to care facilities showed at least a 10% higher incidence than the overall state AAR. GIS mapping identified a second potential treatment site that would alleviate this geographic burden.

CONCLUSIONS

Regional differences within Nebraska present a challenge for rural populations. Novel use of GIS mapping to highlight regional differences and identify solutions for access to care issues could be used by similar states.

Measurement of the [Formula: see text] production cross-section in proton-proton collisions via the decay [Formula: see text]

The production of the [Formula: see text] state in proton-proton collisions is probed via its decay to the [Formula: see text] final state with the LHCb detector, in the rapidity range [Formula: see text] and in the meson transverse-momentum range [Formula: see text]. The cross-section for prompt production of [Formula: see text] mesons relative to the prompt [Formula: see text] cross-section is measured, for the first time, to be [Formula: see text] at a centre-of-mass energy [Formula: see text] using data corresponding to an integrated luminosity of 0.7 fb[Formula: see text], and [Formula: see text] at [Formula: see text] using 2.0 fb[Formula: see text]. The uncertainties quoted are, in order, statistical, systematic, and that on the ratio of branching fractions of the [Formula: see text] and [Formula: see text] decays to the [Formula: see text] final state. In addition, the inclusive branching fraction of [Formula: see text]-hadron decays into [Formula: see text] mesons is measured, for the first time, to be [Formula: see text], where the third uncertainty includes also the uncertainty on the [Formula: see text] inclusive branching fraction from [Formula: see text]-hadron decays. The difference between the [Formula: see text] and [Formula: see text] meson masses is determined to be [Formula: see text].

Three-year experience with access to nationally funded growth hormone (GH) replacement for GH-deficient adults

OBJECTIVE

Treatment of growth hormone (GH)-deficient adults with GH has been shown to improve a range of metabolic abnormalities and enhance quality of life. However, the results of access to nationally funded treatment have not been reported.

DESIGN

Retrospective case series auditing nationally funded treatment of defined GH-deficient adults in New Zealand, with carefully designed entry and exit criteria overseen by a panel of endocrinologists.

PATIENTS

Applications for 201 patients were assessed and 191 approved for funded treatment over the initial 3 years since inception. The majority had GH deficiency following treatment of pituitary adenomas or tumours adjacent to the pituitary.

RESULTS

After an initial 9-month treatment period using serum IGF-I measurements to adjust GH dosing, all patients reported a significant improvement in quality of life (QoL) score on the QoL-AGHDA(®) instrument (baseline (95%CI) 19 (18-21), 9 months 6 (5-7.5)), and mean serum IGF-I SD scores rose from -3 to zero. Mean waist circumference decreased significantly by 2.8 ± 0.6 cm. The mean maintenance GH dose after 9 months of treatment was 0.39 mg/day. After 3 years, 17% of patients had stopped treatment, and all of the remaining patients maintained the improvements seen at 9 months of treatment.

CONCLUSION

Carefully designed access to nationally funded GH replacement in GH-deficient adults was associated with a significant improvement in quality of life over a 3-year period with mean daily GH doses lower than in the majority of previously reported studies.

Bending the curve: force health protection during the insertion phase of the Ebola outbreak response

After >10 years of enduring operations in Iraq and Afghanistan, Defence Strategic Direction is returning to a contingency posture. As the first post-Afghanistan operation, in September 2014, a UK Joint Inter-Agency Task Force deployed to Sierra Leone in response to the Ebola virus disease (EVD) epidemic in West Africa. The aims were expanding treatment capacity, assisting with training and supporting host nation resilience. The insertion phase of this deployment created a unique set of challenges for force health protection. In addition to the considerable risk of tropical disease and trauma, deployed personnel faced the risks of working in an EVD epidemic. This report explores how deployed medical assets overcame the difficulties of mounting a short-notice contingent operation in a region of the world with inherent major climatic and health challenges.

Measurement of Bc+ Production in Proton-Proton Collisions at √[s]=8 TeV

Production of Bc+ mesons in proton-proton collisions at a center-of-mass energy of 8 TeV is studied with data corresponding to an integrated luminosity of 2.0  fb-1 recorded by the LHCb experiment. The ratio of production cross sections times branching fractions between the Bc+→J/ψπ+ and B+→J/ψK+ decays is measured as a function of transverse momentum and rapidity in the regions 0<pT<20  GeV/c and 2.0<y<4.5. The ratio in this kinematic range is measured to be (0.683±0.018±0.009)%, where the first uncertainty is statistical and the second systematic.

Force protection in contingency operations: an evaluation of temperature monitoring in Sierra Leone

OBJECTIVES

The deployment of the UK-led Joint Inter-Agency Taskforce to Sierra Leone in September 2014 brought the era of contingency operations into focus. Daily health screening of such deployed personnel forms a key element of medical force protection. We have performed a service evaluation of an existing screening programme and detail the comparison of the two thermometers used in this role.

METHODS

Data from the existing screening programme were used to inform a sample size required to enable statistically and clinically significant differences to be detected between the two interchangeably used thermometer systems in use. A prospective service evaluation on these devices was then carried out over a 10-day period and the data analysed by parametric tools. 10 personnel had their temperature recorded by both devices at the same time by a single operator every day.

RESULTS

For the screened population, a mean temperature of 36.55°C and SD of 0.32°C was revealed. Powered to 80% with a two-tailed α of 0.05, the evaluation of the two thermometers revealed no significant difference between recordings taken with either device (p=0.115). The low SD meant that a pyrexial patient (>37.5°C) would require a recording over 3 SD from the population mean.

DISCUSSION

Evaluations of medical force protection will carry increasing consequence as the UK deploy on short notice operations to regions of considerable endemic threat. Presence of pyrexia is a key early indicator of illness affecting deployed personnel, and two different thermometer types are provided for this function. We have shown for the first time with statistical and clinical significance that the two thermometers used in contingency force protection are interchangeable. The narrow variance is reassuring and confirms that the chosen trigger (>37.5°C) would warrant further investigation in the pyrexial patient.

Education and Ebola: initiating the cascade of emergency healthcare training

In response to the 2014 Ebola virus outbreak in West Africa, the UK deployed a Joint Inter-Agency Task Force to Sierra Leone. As well as constructing Ebola treatment units, the force supported a rapidly upscaled mass programme of training for host nation healthcare workers in basic knowledge of Ebola and personal protective equipment. A bespoke training course was developed in collaboration with the WHO and other partners over a period of 2 weeks, taught to 119 trainers the following week, and then cascaded to over 4000 Ebola workers over the following month. This article describes curriculum design, content delivery and assessment of this unique Training The Trainers course delivered in austere circumstances. Key learning points are highlighted and supplementary material is provided to inform future deployed clinical education initiatives.

Measurement of the semileptonic CP asymmetry in B0-B[over ¯]0 mixing

The semileptonic CP asymmetry in B0-B[over ¯]0 mixing, a(sl)(d), is measured in proton-proton collision data, corresponding to an integrated luminosity of 3.0  fb-1, recorded by the LHCb experiment. Semileptonic B0 decays are reconstructed in the inclusive final states D-μ+ and D*-μ+, where the D- meson decays into the K+π-π- final state and the D*- meson into the D[over ¯]0(→K+π-)π- final state. The asymmetry between the numbers of D(*)-μ+ and D(*)+μ- decays is measured as a function of the decay time of the B0 mesons. The CP asymmetry is measured to be a(sl)(d)=(-0.02±0.19±0.30)%, where the first uncertainty is statistical and the second systematic. This is the most precise measurement of a(sl)(d) to date and is consistent with the prediction from the standard model.

Precision measurement of the mass and lifetime of the Ξb⁻ baryon

We report on measurements of the mass and lifetime of the Ξ(b)⁻ baryon using about 1800 Ξ(b)⁻ decays reconstructed in a proton-proton collision data set corresponding to an integrated luminosity of 3.0  fb⁻¹ collected by the LHCb experiment. The decays are reconstructed in the Ξ(b)⁻→Ξ(c)⁰π⁻, Ξ(c)⁰→pK⁻K⁻π⁺ channel and the mass and lifetime are measured using the Λ(b)⁰→Λ(c)⁺π⁻ mode as a reference. We measure M(Ξ(b)⁻)-M(Λ(b)⁰)=178.36±0.46±0.16  MeV/c², (τ(Ξ(b)⁻)/τ(Λ(b)⁰)=1.089±0.026±0.011, where the uncertainties are statistical and systematic, respectively. These results lead to a factor of 2 better precision on the Ξ(b)⁻ mass and lifetime compared to previous best measurements, and are consistent with theoretical expectations.

Measurement of the CP-violating phase ϕs in Bs(0)→Ds(+)Ds(-) decays

We present a measurement of the CP-violating weak mixing phase ϕs using the decay Bs(0)→Ds(+)Ds(-) in a data sample corresponding to 3.0 fb(-1) of integrated luminosity collected with the LHCb detector in pp collisions at center-of-mass energies of 7 and 8 TeV. An analysis of the time evolution of the system, which does not use the constraint |λ|=1 to allow for the presence of CP violation in decay, yields ϕs=0.02±0.17(stat)±0.02(syst)  rad, |λ|=0.91(-0.15)(+0.18)(stat)±0.02(syst). This result is consistent with the standard model expectation.

Measurement of the B¯s⁰ meson lifetime in Ds⁺π⁻ decays

We present a measurement of the ratio of the B¯s⁰ meson lifetime, in the flavor-specific decay to Ds⁺π⁻, to that of the B¯⁰ meson. The pp collision data used correspond to an integrated luminosity of 1  fb(-1), collected with the LHCb detector, at a center-of-mass energy of 7 TeV. Combining our measured value of 1.010±0.010±0.008 for this ratio with the known B¯⁰ lifetime, we determine the flavor-specific B¯s⁰ lifetime to be τ(B¯s⁰ )=1.535±0.015±0.014  ps, where the uncertainties are statistical and systematic, respectively. This is the most precise measurement to date, and is consistent with previous measurements and theoretical predictions.

Observation of overlapping spin-1 and spin-3 D0K- resonances at mass 2.86 GeV/c2

The resonant substructure of B(s)(0) → D(0)K(-)π(+) decays is studied using a data sample corresponding to an integrated luminosity of 3.0 fb(-1) of pp collision data recorded by the LHCb detector. An excess at m(D(0)K(-))≈ 2.86 GeV/c(2) is found to be an admixture of spin-1 and spin-3 resonances. Therefore, the D(sJ)*(2860)(-) state previously observed in inclusive e(+)e(-) → D(0)K(-)X and pp → D(0)K(-)X processes consists of at least two particles. This is the first observation of a heavy flavored spin-3 resonance, and the first time that any spin-3 particle has been seen to be produced in B decays. The masses and widths of the new states and of the D(s2)*(2573)(-) meson are measured, giving the most precise determinations to date.

Test of lepton universality using b+ → K+ℓ+ℓ- decays

A measurement of the ratio of the branching fractions of the B(+) → K(+)μ(+)μ(-) and B(+) → K(+)e(+)e(-) decays is presented using proton-proton collision data, corresponding to an integrated luminosity of 3.0 fb(-1), recorded with the LHCb experiment at center-of-mass energies of 7 and 8 TeV. The value of the ratio of branching fractions for the dilepton invariant mass squared range 1 < q(2) < 6 GeV(2)/c(4) is measured to be 0.745(-0.074)(+0.090)(stat) ± 0.036(syst). This value is the most precise measurement of the ratio of branching fractions to date and is compatible with the standard model prediction within 2.6 standard deviations.

First observation of a baryonic Bc+ decay

A baryonic decay of the B(c)(+) meson, B(c)(+) → J/ψppπ(+), is observed for the first time, with a significance of 7.3 standard deviations, in pp collision data collected with the LHCb detector and corresponding to an integrated luminosity of 3.0 fb(-1) taken at center-of-mass energies of 7 and 8 TeV. With the B(c)(+) → J/ψπ(+) decay as the normalization channel, the ratio of branching fractions is measured to be B(B(c)(+) → J/ψppπ(+))/B(B(c)(+) → J/ψπ(+)) = 0.143(-0.034)(+0.039)(stat) ± 0.013(syst). The mass of the B(c)(+) meson is determined as M(B(c)(+) = 6274.0 ± 1.8(stat) ± 0.4(syst) MeV/c(2), using the B(c)(+) → J/ψppπ(+) channel.

Evidence for CP violation in B+ → ppK+ decays

Three-body B+ → ppK+ and B(+) → ppπ(+) decays are studied using a data sample corresponding to an integrated luminosity of 3.0 fb(-1) collected by the LHCb experiment in proton-proton collisions at center-of-mass energies of 7 and 8 TeV. Evidence of CP violation in the B(+) → ppK(+) decay is found in regions of the phase space, representing the first measurement of this kind for a final state containing baryons. Measurements of the forward-backward asymmetry of the light meson in the pp rest frame yield A(FB)(ppK(+),m(pp)<2.85 GeV/c(2)) = 0.495 ± 0.012 (stat) ± 0.007 (syst) and A(FB)(ppπ(+),m(pp) <2.85 GeV/c(2)) = -0.409 ± 0.033 (stat) ± 0.006 (syst). In addition, the branching fraction of the decay B(+) → Λ(1520)p is measured to be B(B(+) → Λ(1520)p) = (3.15 ± 0.48 (stat) ± 0.07 (syst) ± 0.26 (BF)) × 10(-7), where BF denotes the uncertainty on secondary branching fractions.

First measurement of the charge asymmetry in beauty-quark pair production

The difference in the angular distributions between beauty quarks and antiquarks, referred to as the charge asymmetry, is measured for the first time in bb pair production at a hadron collider. The data used correspond to an integrated luminosity of 1.0 fb(-1) collected at 7 TeV center-of-mass energy in proton-proton collisions with the LHCb detector. The measurement is performed in three regions of the invariant mass of the bb system. The results obtained are A(C)(bb))(40<M(bb))<75 GeV/c(2)) = 0.4 ± 0.4 ± 0.3%, A(C)(bb))(75<M(bb)) < 105 GeV/c(2)) = 2.0 ± 0.9 ± 0.6%, A(C)(bb)(M(bb)) > 105 GeV/c(2)) = 1.6 ± 1.7 ± 0.6%, where A(C)(bb)) is defined as the asymmetry in the difference in rapidity between jets formed from the beauty quark and antiquark, where in each case the first uncertainty is statistical and the second systematic. The beauty jets are required to satisfy 2 < η < 4, E(T) >20 GeV, and have an opening angle in the transverse plane Δ ϕ > 2.6 rad. These measurements are consistent with the predictions of the standard model.

Precision measurement of the mass and lifetime of the Ξ(b)(0) baryon

Using a proton-proton collision data sample corresponding to an integrated luminosity of 3 fb(-1) collected by LHCb at center-of-mass energies of 7 and 8 TeV, about 3800 Ξ(b)(0) → Ξ(c)(+)π(-), Ξ(c)(+)) → pK(-)π(+) signal decays are reconstructed. From this sample, the first measurement of the Ξ(b)(0) baryon lifetime is made, relative to that of the Λ(b)(0) baryon. The mass differences M(Ξ(b)(0))-M(Λ(b)(0)) and M(Ξ(c)(+))-M(Λ(c)(+)) are also measured with precision more than 4 times better than the current world averages. The resulting values are τ(Ξ(b)(0))/τ(Λ)(b)(0)) = 1.006 ± 0.018 ± 0.010,M(Ξ(b)(0))-M(Λ(b)(0)) = 172.44 ± 0.39 ± 0.17 MeV/c(2),M(Ξ(c)(+))-M(Λ(c)(+)) = 181.51 ± 0.14 ± 0.10 MeV/c(2),where the first uncertainty is statistical and the second is systematic. The relative rate of Ξ(b)(0) to Λ(b)(0) baryon production is measured to be f(Ξ)(b)(0))/f(Λ)(b)(0))B(Ξ(b)(0) → Ξ(c)(+)π(-))/B(Λ(b)(0) → Λ(c)(+)π(-))B(Ξ(c)(+) → pK(-)π(+))/B(Λ(c)(+) → pK(-)}π(+)) = (1.88 ± 0.04 ± 0.03) × 10(-2),where the first factor is the ratio of fragmentation fractions, b → Ξ(b)(0) relative to b → Λ(b)(0). Relative production rates as functions of transverse momentum and pseudorapidity are also presented.

Observation of the resonant character of the Z(4430)(-) state

Resonant structures in B^{0}→ψ^{'}π^{-}K^{+} decays are analyzed by performing a four-dimensional fit of the decay amplitude, using pp collision data corresponding to 3  fb^{-1} collected with the LHCb detector. The data cannot be described with K^{+}π^{-} resonances alone, which is confirmed with a model-independent approach. A highly significant Z(4430)^{-}→ψ^{'}π^{-} component is required, thus confirming the existence of this state. The observed evolution of the Z(4430)^{-} amplitude with the ψ^{'}π^{-} mass establishes the resonant nature of this particle. The mass and width measurements are substantially improved. The spin parity is determined unambiguously to be 1^{+}.

Measurement of charged particle multiplicities and densities in [Formula: see text] collisions at [Formula: see text]TeV in the forward region

Charged particle multiplicities are studied in proton-proton collisions in the forward region at a centre-of-mass energy of [Formula: see text]TeV with data collected by the LHCb detector. The forward spectrometer allows access to a kinematic range of [Formula: see text] in pseudorapidity, momenta greater than [Formula: see text] and transverse momenta greater than [Formula: see text]. The measurements are performed using events with at least one charged particle in the kinematic acceptance. The results are presented as functions of pseudorapidity and transverse momentum and are compared to predictions from several Monte Carlo event generators.

Endocrine encephalopathy

The diagnosis of Hashimoto's encephalopathy is made when no other cause is found for an acute encephalopathic illness, in the presence of positive thyroid autoantibodies, and is supported by a response to steroid therapy. A 59-year-woman developed an encephalopathic illness with mixed aphasia, global weakness and generalised seizures requiring intubation and ICU admission. Extensive imaging and laboratory investigations looking for an underlying cause for the encephalopathy were unremarkable. Thyroid autoantibodies were strongly positive, raising the possibility of Hashimoto's encephalopathy. Thyroid function testing showed profound primary hypothyroidism. The patient was commenced on high-dose methyprednisolone, with prompt cessation of seizure activity. Thyroxine replacement was commenced, with the methyprednisolone switched to oral prednisone and slowly weaned. The patient had no further seizures and ultimately made a full recovery.

Measurement of [Formula: see text] polarisation in [Formula: see text] collisions at [Formula: see text] = 7 TeV

The polarisation of prompt [Formula: see text] mesons is measured by performing an angular analysis of [Formula: see text] decays using proton-proton collision data, corresponding to an integrated luminosity of 1.0[Formula: see text], collected by the LHCb detector at a centre-of-mass energy of 7 TeV. The polarisation is measured in bins of transverse momentum [Formula: see text] and rapidity [Formula: see text] in the kinematic region [Formula: see text] and [Formula: see text], and is compared to theoretical models. No significant polarisation is observed.

Measurement of the [Formula: see text] meson lifetime using [Formula: see text] decays

The lifetime of the [Formula: see text] meson is measured using semileptonic decays having a [Formula: see text] meson and a muon in the final state. The data, corresponding to an integrated luminosity of [Formula: see text], are collected by the LHCb detector in [Formula: see text] collisions at a centre-of-mass energy of 8 TeV. The measured lifetime is [Formula: see text]where the first uncertainty is statistical and the second is systematic.

Observation of photon polarization in the b→sγ transition

This Letter presents a study of the flavor-changing neutral current radiative B±→K±π∓π±γ decays performed using data collected in proton-proton collisions with the LHCb detector at 7 and 8 TeV center-of-mass energies. In this sample, corresponding to an integrated luminosity of 3  fb-1, nearly 14 000 signal events are reconstructed and selected, containing all possible intermediate resonances with a K±π∓π± final state in the [1.1,1.9]  GeV/c2 mass range. The distribution of the angle of the photon direction with respect to the plane defined by the final-state hadrons in their rest frame is studied in intervals of K±π∓π± mass and the asymmetry between the number of signal events found on each side of the plane is obtained. The first direct observation of the photon polarization in the b→sγ transition is reported with a significance of 5.2σ.

Lessons learned from the design and implementation of myocardial infarction adjudication tailored for HIV clinical cohorts

We developed, implemented, and evaluated a myocardial infarction (MI) adjudication protocol for cohort research of human immunodeficiency virus. Potential events were identified through the centralized Centers for AIDS Research Network of Integrated Clinical Systems data repository using MI diagnoses and/or cardiac enzyme laboratory results (1995-2012). Sites assembled de-identified packets, including physician notes and results from electrocardiograms, procedures, and laboratory tests. Information pertaining to the specific antiretroviral medications used was redacted for blinded review. Two experts reviewed each packet, and a third review was conducted if discrepancies occurred. Reviewers categorized probable/definite MIs as primary or secondary and identified secondary causes of MIs. The positive predictive value and sensitivity for each identification/ascertainment method were calculated. Of the 1,119 potential events that were adjudicated, 294 (26%) were definite/probable MIs. Almost as many secondary (48%) as primary (52%) MIs occurred, often as the result of sepsis or cocaine use. Of the patients with adjudicated definite/probable MIs, 78% had elevated troponin concentrations (positive predictive value = 57%, 95% confidence interval: 52, 62); however, only 44% had clinical diagnoses of MI (positive predictive value = 45%, 95% confidence interval: 39, 51). We found that central adjudication is crucial and that clinical diagnoses alone are insufficient for ascertainment of MI. Over half of the events ultimately determined to be MIs were not identified by clinical diagnoses. Adjudication protocols used in traditional cardiovascular disease cohorts facilitate cross-cohort comparisons but do not address issues such as identifying secondary MIs that may be common in persons with human immunodeficiency virus.

Search for Majorana neutrinos in B- → π+ μ- μ- decays

A search for heavy Majorana neutrinos produced in the B- → π+ μ- μ- decay mode is performed using 3  fb(-1) of integrated luminosity collected with the LHCb detector in pp collisions at center-of-mass energies of 7 and 8 TeV at the LHC. Neutrinos with masses in the range 250 to 5000 MeV and lifetimes from zero to 1000 ps are probed. In the absence of a signal, upper limits are set on the branching fraction B(B- → π+ μ- μ-) as functions of neutrino mass and lifetime. These limits are on the order of 10(-9) for short neutrino lifetimes of 1 ps or less. Limits are also set on the coupling between the muon and a possible fourth-generation neutrino.

Measurement of the Bs(0) → Ds-Ds+ and Bs(0) → D-Ds+ effective lifetimes

The first measurement of the effective lifetime of the B(s)(0) meson in the decay B(s)(0) → Ds-Ds+ is reported using a proton-proton collision data set, corresponding to an integrated luminosity of 3 fb(-1), collected by the LHCb experiment. The measured value of the B(s)(0) → Ds-Ds+ effective lifetime is 1.379 ± 0.026 ± 0.017 ps, where the uncertainties are statistical and systematic, respectively. This lifetime translates into a measurement of the decay width of the light B(s)(0) mass eigenstate of ΓL = 0.725 ± 0.014 ± 0.009 ps(-1). The B(s)(0) lifetime is also measured using the flavor-specific B(s)(0)→ D-Ds+ decay to be 1.52 ± 0.15 ± 0.01 ps.

Observation of B(s)(0) → J/ψ f1(1285) decays and measurement of the f1(1285) mixing angle

Decays of B(s)(0) and B(0) mesons into J/ψ π+π-π+π- final states, produced in pp collisions at the LHC, are investigated using data corresponding to an integrated luminosity of 3 fb-1 collected with the LHCb detector. B(s)(0) → J/ψ f1(1285) decays are seen for the first time, and the branching fractions are measured. Using these rates, the f1(1285) mixing angle between strange and nonstrange components of its wave function in the qq structure model is determined to be ±(24.0-2.6-0.8+3.1+0.6)°. Implications on the possible tetraquark nature of the f1(1285) are discussed.

Measurements of indirect CP asymmetries in D0 → K- K+ and D0 → π- π+ decays

A study of indirect CP violation in D0 mesons through the determination of the parameter AΓ is presented using a data sample of pp collisions, corresponding to an integrated luminosity of 1.0  fb(-1), collected with the LHCb detector and recorded at the center-of-mass energy of 7 TeV at the LHC. The parameter AΓ is the asymmetry of the effective lifetimes measured in decays of D0 and D0 mesons to the CP eigenstates K- K+ and π- π+. Fits to the data sample yield AΓ(KK)=(-0.35±0.62±0.12)×10(-3) and AΓ(ππ)=(0.33±1.06±0.14)×10(-3), where the first uncertainties are statistical and the second systematic. The results represent the world's best measurements of these quantities. They show no difference in AΓ between the two final states and no indication of CP violation.

Measurement of CP violation in the phase space of B± → K+ K- π± and B± → π+ π- π± decays

The charmless decays B± → K+ K- π± and B± → π+ π- π± are reconstructed in a data set of pp collisions with an integrated luminosity of 1.0  fb(-1) and center-of-mass energy of 7 TeV, collected by LHCb in 2011. The inclusive charge asymmetries of these modes are measured to be A(CP)(B± → K+ K- π±) = -0.141±0.040  (stat)±0.018 (syst)±0.007(J/ψ K±) and A(CP)(B± → π+ π- π±) = 0.117±0.021 (stat)±0.009 (syst)±0.007(J/ψ K±), where the third uncertainty is due to the CP asymmetry of the B± → J/ψK± reference mode. In addition to the inclusive CP asymmetries, larger asymmetries are observed in localized regions of phase space.

Measurement of D0-D0 mixing parameters and search for CP violation using D0 → K+ π- decays

Measurements of charm mixing parameters from the decay-time-dependent ratio of D0 → K+ π- to D0 → K- π+ rates and the charge-conjugate ratio are reported. The analysis uses data, corresponding to 3  fb(-1) of integrated luminosity, from proton-proton collisions at 7 and 8 TeV center-of-mass energies recorded by the LHCb experiment. In the limit of charge-parity (CP ) symmetry, the mixing parameters are determined to be x'2=(5.5±4.9)×10(-5), y'=(4.8±1.0)×10(-3), and RD=(3.568±0.066)×10(-3). Allowing for CP violation, the measurement is performed separately for D0 and D0 mesons yielding AD=(-0.7±1.9)%, for the direct CP-violating asymmetry, and 0.75<|q/p|<1.24 at the 68.3% confidence level, for the parameter describing CP violation in mixing. This is the most precise determination of these parameters from a single experiment and shows no evidence for CP violation.

Measurement of J/ψ polarization in pp collisions at [Formula: see text]

An angular analysis of the decay J/ψ→μ+μ- is performed to measure the polarization of prompt J/ψ mesons produced in pp collisions at [Formula: see text]. The dataset corresponds to an integrated luminosity of 0.37 fb-1 collected with the LHCb detector. The measurement is presented as a function of transverse momentum, pT, and rapidity, y, of the J/ψ meson, in the kinematic region 2 Collapse

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