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.

Synthesis and Biological Evaluation of Biaryl Alkyl Ethers as Inhibitors of IDO1

Starting from the dialkylaniline indoleamine 2,3-dioxygenase 1 (IDO1) inhibitor lead 3 (IDO1 HeLa IC₅₀ = 7.0 nM), an iterative process of synthesis and screening led to cyclized analog 21 (IDO1 HeLa IC₅₀ = 3.6 nM) which maintained the high potency of 3 while addressing issues of lipophilicity, cytochrome P450 (CYP) inhibition, hERG (human potassium ion channel Kv11.1) inhibition, Pregnane X Receptor (PXR) transactivation, and oxidative metabolic stability. An x-ray crystal structure of a biaryl alkyl ether 11 bound to IDO1 was obtained. Consistent with our earlier results, compound 11 was shown to bind to the apo form of the enzyme.

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.

Fatty acid ethyl ester (FAEE) associated acute pancreatitis: An ex-vivo study using human pancreatic acini

BACKGROUND & AIM

Fatty acid ethyl esters (FAEEs), are produced by non-oxidative alcohol metabolism and can cause acinar cell damage and subsequent acute pancreatitis in rodent models. Even though experimental studies have elucidated the FAEE mediated early intra-acinar events, these mechanisms have not been well studied in humans. In the present study, we evaluate the early intra-acinar events and inflammatory response in human pancreatic acinar tissues and cells in an ex-vivo model.

METHODS

Experiments were conducted using normal human pancreatic tissues exposed to FAEE. Subcellular fractionation was performed on tissue homogenates and trypsin and cathepsin B activities were estimated in these fractions. Acinar cell injury was evaluated by histology and immunohistochemistry. Cytokine release from exposed acinar cells was evaluated by performing Immuno-fluorescence. Serum was collected from patients with AP within the first 72 h of symptom onset for cytokine estimation using FACS.

RESULTS

We observed significant trypsin activation and acinar cell injury in FAEE treated tissue. Cathepsin B was redistributed from lysosomal to zymogen compartment at 30 min of FAEE exposure. IHC results indicated the presence of apoptosis in pancreatic tissue at 1 & 2hrs of FAEE exposure. We also observed a time dependent increase in secretion of cytokines IL-6, IL-8, TNF-α from FAEE treated acinar tissue. There was also a significant elevation in plasma cytokines in patents with alcohol associated AP within 72 h of symptom onset.

CONCLUSION

Our data suggest that alcohol metabolites can cause acute acinar cell damage and subsequent cytokine release which could eventually culminant in SIRS.

Toward a uniform pathway in managing incidental lung nodules on computerised tomography [CT] coronary angiography; for a cost effective and safe outcome

Background

National Institute for Health and Care Excellence guidelines (NICE CG95) recommends computed tomography coronary angiography [CTCA] as the first line investigation for all patients with suspected typical or atypical angina irrespective of pre-test probability due to its excellent performance and cost effectiveness. However previous cost effectiveness analyses have not factored in the burden of lung nodules [LN] or extracardiac incidentalomas, which are commonly identified on CTCA.

Purpose

As we increasingly detect LN on CTCA scans, it is prudent that a uniform pathway is followed for surveillance of LN. The British Thoracic Society (BTS) has enabled evidence-based development of an algorithm for the management of LN which defines a cut off LN size of ≥5mm requiring further follow up. We aimed to assess the compliance of LN follow up in our patients according to radiology recommendation on CTCA reports and also to assess how well these recommendations adhere to BTS guidelines.

Method

117 patients who underwent CTCA as the initial diagnostic investigation were retrospectively identified from the rapid access chest pain clinic database. Data was collected during a 1 year period between January - December 2017. Data was analysed to determine whether appropriate surveillance pathway was followed for repeat imaging. According to BTS guidelines, nodules ≥5mm should have a systematic work up for surveillance and hence we have stratified our data based on the nodule size. In case of multiple nodules, the largest nodule size was considered.

Results

Out of 117 patients, 77% patients were female with average age 57.8±9.0 years. 40% patients were found to have incidental LN with an average size of 4.63±1.92mm; 44% had a history of cigarette smoking.

Among patient with nodules, 22 (19%) had CT thorax to assess interval change and interestingly 16 (73%) had persisting LN; whereas in 4 (18%), the LN resolved and only 2 (9%) showed increase in LN size. Repeat CT chest was advised for these 2 patients; 1 was advised to undergo biopsy which eventually ruled out malignancy. 6 patients (5%) from group 1 were recommended for repeat CT despite having LN size &lt;5mm.

In the remaining 25 patients (21%) with LN, 15 (60%) did not have further surveillance imaging even though this was recommended by the reporting radiologist. Of these only 3 (12%) had LN ≥5mm which qualified for surveillance CT.

Conclusion

CTCA frequently detects incidentalomas especially LN which cannot be overlooked and require further imaging irrespective of the primary presentation. Our findings also suggest a discrepancy on surveillance CT recommendation against the current BTS guidelines, with potential significant impact on the overall cost effectiveness of CTCA. A systematic approach to LN surveillance could be best achieved with a multidisciplinary team approach (e.g. referral pathway to nodule MDT) and adherence to a standard guideline.

Lung nodule surveillance following CTCA

Funding Acknowledgement

Type of funding source: None

Evaluation of a Chemiluminescence Method for Measuring Alkaline Phosphatase Activity in WholeMilk of Multiple Species and Bovine Dairy Drinks: Interlaboratory Study

Alkaline phosphatase (ALP) is a ubiquitous enzyme in milk with timetemperature destruction similar to that of certain pathogens destroyed in pasteurization. Measurement of ALP to indicate proper pasteurization is a common practice. Recently the public health level for ALP was decreased to 350 mU/L, a level below the sensitivity of older colorimetric ALP methods. This study was conducted within the structure of the International Dairy Federation and the International Organization for Standardization to evaluate the reproducibility of the chemiluminescence method (Charm PasLite) for ALP at 50, 100, 350, and 500 mU/L in whole milk of multiple species to meet new regulations in the United States and proposed regulations in the European Union (EU). Fifteen laboratories from 8 countries evaluated bovine, goat, sheep, and buffalo milk, bovine skim milk, 20% fat cream, and 2% fat chocolate milk. At ALP levels of 350 and 500 mU/L, the average relative standard deviation for repeatability (RSDr) was 7.5%, and the average relative standard deviation of reproducibility was (RSDR) 15%. For ALP at 100 and 50 mU/L, the average RSDr values were 10.5 and 12.6%, respectively, and the average RSDR values were 18 and 25%, respectively. The limit of detection was 20 mU/L. Results are comparable to those obtained with other enzymatic photo-activated system methods such as the fluorometric method. Results indicate that the method is suitable for measuring ALP in the milk of multiple species and in dairy drinks at U.S. and proposed EU levels.

Detection of Botulinal Neurotoxins A, B, E, and F by Amplified Enzyme-Linked Immunosorbent Assay: Collaborative Study

An amplified enzyme-linked immunosorbent assay (amp-ELISA) was compared with the AOAC Official Method 977.26 for detection of Clostridium botulinum and its toxins in foods. Eleven laboratories participated and the results of 10 laboratories were used in the study. Two anaerobic culture media, tryptone peptone glucose yeast extract (TPGY) and cooked meat medium (CMM) were used to generate toxic samples with types A, B, E, and F botulinal strains. Nonbotulinal clostridia were also tested. The toxicity of each botulinal culture was determined by the AOAC method, and the cultures were then diluted, if necessary, to high (about 10 000 minimal lethal dose [MLD]/mL) and low (about 100 MLD/mL) test samples. The overall sensitivity of detection in TPGY and CMM cultures with the amp-ELISA was 94.7% at about 100 MLD/mL and 99.6% for samples with ≥10 000 MLD/mL toxicity. The amp-ELISA detection sensitivity for low toxin samples was 92.3% in TPGY and 99.4% in CMM. The false-positive rate ranged from 1.5% for type A to 28.6% for type F in TPGY, and from 2.4% for type A to 11.4% for type F in CMM. Most of the cross-reactivity was due to detection of other botulinal types, especially in high toxin samples. The amp-ELISA could be used to screen suspect cultures for botulinal toxins. Positive amp-ELISA samples would be confirmed by the AOAC reference method.

Is pulmonary metastasectomy beneficial in head and neck squamous cell carcinoma? A review of literature

Metastatic head and neck squamous cell carcinoma (HNSCC) has traditionally carried a dismal prognosis; however with advances in care, it has been shown that pulmonary metastasectomy is a viable therapeutic option in selected patients, palliating symptoms and improving survival. With the increasing incidence of human papilloma virus-related HNSCC and better availability of minimal access surgery, there is a need to better understand the role of pulmonary metastasectomy in the treatment of HNSCC. This article summarizes the literature on indications, results, surgical options and approaches, clinical dilemmas, and controversies associated with pulmonary metastasectomy in HNSCC, to identify suitable candidates and optimize outcomes.

Strontium fails to induce Ca2+ release and activation in human oocytes despite the presence of functional TRPV3 channels

STUDY QUESTION

Are the transient receptor potential cation channels vanilloid 3 (TRPV3) present and able to mediate strontium (Sr²⁺) induced artificial activation in human oocytes?

SUMMARY ANSWER

Sr²⁺ did not induce Ca²⁺ rises or provoke activation in human oocytes, however, mRNA for the TRPV3 channel was present in metaphase II (MII) human oocytes after IVM and TRPV3 agonists induced Ca²⁺ rises and oocyte activation, demonstrating the channels were functional.

WHAT IS KNOWN ALREADY

Selective activation of TRPV3 by agonists induces Ca²⁺ entry and promotes mouse oocyte activation, and the absence of TRPV3 channels in mouse oocytes prevents Sr²⁺ mediated artificial activation. Sr²⁺ is sometimes used to overcome fertilization failure after ICSI in the clinic, but its efficiency is still controversial and the mechanism(s) of how it mediates the Ca²⁺ flux has not been studied yet in human.

STUDY DESIGN, SIZE, DURATION

The protein distribution (n = 10) and mRNA expression level (n = 19) of the TRPV3 channels was investigated in human MII oocytes after IVM. The Sr²⁺ (10 mM) and TRPV3 agonists (200 μM 2-aminoethoxydiphenyl borate [2-APB] and 200 μM carvacrol)-induced Ca²⁺ response was analyzed in human (n = 15, n = 16 and n = 16, respectively) and mouse oocytes (n = 15, n = 19 and n = 26, respectively). The subsequent embryonic developmental potential following the parthenogenetic activation using these three agents was recorded in human (n = 10, n = 9 and n = 9, respectively) and mouse (n = 20 per agent) oocytes, by determining pronucleus, or 2-cell and blastocyst formation rates.

PARTICIPANTS/MATERIALS, SETTING, METHODS

MII oocytes from B6D2F1 mice (6–10 weeks old) as well as human IVM oocytes and IVO oocytes (from patients aged 25–38 years old) with aggregates of smooth endoplasmic reticulum clusters were used. The expression of TRPV3 channels was determined by immunofluorescence staining with confocal microscopy and RT-PCR, and the temporal evolution of intracellular Ca²⁺ concentration was measured by time-lapse imaging after exposure to Sr²⁺ and TRPV3 agonists (2-APB and carvacrol). Artificial activation efficiency was assessed using these agents.

MAIN RESULTS AND THE ROLE OF CHANCE

Sr²⁺ did not promote Ca²⁺ oscillations or provoke activation in human oocytes. Transcripts of TRPV3 channels were present in IVM MII human oocytes. TRPV3 protein was expressed and distributed throughout the ooplasm of human oocytes, rather than particularly concentrated in plasma membrane as observed in mouse MII oocytes. Both agonists of TRPV3 (2-APB and carvacrol), promoted a single Ca²⁺ transient and activated a comparable percentage of more than half of the exposed human oocytes (P > 0.05). The agonist 2-APB was also efficient in activating mouse oocytes, however, significantly fewer mouse oocytes responded to carvacrol than 2-APB in both the Ca²⁺ analysis and activation test (P < 0.001).

LIMITATIONS REASONS FOR CAUTION

The availability of fresh IVO matured oocytes in human was limited. Data from TRPV3 knockout model are not included.

WIDER IMPLICATIONS OF THE FINDINGS

The benefit of clinical application using Sr²⁺ to overcome fertilization failure after ICSI requires further validation.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by FWO-Vlaanderen, China Scholarship Council and Special Research Fund from Ghent University (Bijzonder Onderzoeksfonds, BOF). No competing interests are declared.

Immune thrombocytopenia secondary to tuberculosis: a case and review of literature

Immune thrombocytopenia (ITP) is an auto-immune condition that results in isolated thrombocytopenia associated with possibly lethal haemorrhage. In its secondary form, ITP can be triggered by many infectious and non-infectious conditions. Secondary ITP associated with tuberculosis (TB) has rarely been described in the literature. We report on a 22-year-old patient presenting with hypermenorrhoea and petechiae due to ITP secondary to tuberculous lymphadenitis. Normalisation of thrombocytopenia was only achieved after initiation of anti-tuberculosis treatment following failure of thrombocyte substitution and immune-modulatory treatment. A search of the literature available on TB-associated ITP identified 50 cases published between 1964 and 2016. We reviewed all cases using suggested case definitions on the likelihood of association between ITP and TB. A broad spectrum of TB sites was reported to be associated with ITP, and anti-tuberculosis treatment was the most effective therapy for platelet count normalisation. Time from initiation of anti-tuberculosis treatment to platelet count recovery ranged from 2 days to 3 months. In endemic regions, TB should be considered as an underlying cause of ITP. Early diagnosis of TB and initiation of anti-tuberculosis treatment appears crucial for rapid platelet count recovery, and can reduce the risks associated with long-term immunosuppression, transfusions and the time at risk for haemorrhage.

Association of Systemic Inflammatory and Anti-inflammatory Responses with Adverse Outcomes in Acute Pancreatitis: Preliminary Results of an Ongoing Study

INTRODUCTION

This paper reports preliminary data of an ongoing study that evaluates the association of systemic inflammatory response (SIRS) with early severe acute pancreatitis (ESAP) and compensatory anti-inflammatory response syndrome (characterized by HLA-DR down-regulation) with infected pancreatic necrosis (IPN).

METHODS

Consecutive patients presenting within 72 h of symptom onset with organ dysfunction and/or local complications were included. Following parameters were recorded: demographics, etiology, SIRS, APACHE II, creatinine, BUN. Circulating IL-8, IL-6, IL-10, TNF-alpha concentrations and expression of HLA-DR and IL-10 by qRT-PCR in PBMCs were measured. Strength of associations of cytokine concentration and HLA-DR/IL-10 expression with outcomes was expressed as Hedges' G and relative risk (95% CI).

RESULTS

Twenty-eight patients (10 MSAP; 18 SAP) fulfilled inclusion criteria. Twelve patients had ESAP and eight presented with organ failure. Admission SIRS worsened in eight (28.6%) patients over 48 h. Sixteen (57.1%) patients developed primary IPN. Twenty-one (75%) patients had HLA-DR down-regulation during the first week, which persisted to the second week in 12 (42.9%) patients. IL-8, IL-6, and TNF-α progressively increased from healthy controls to MAP to MSAP to SAP. IL-6 and TNF-α was higher in the patients who developed ESAP (p = 0.01 and 0.05, respectively). Patients who died within the first week also had a significantly elevated concentration of IL-6 and TNF-α (p = 0.02 and 0.01, respectively). The relative risk (95% CI) of developing primary IPN with persistent HLA-DR down-regulation till the second week of illness was 11.3 (1.6-82.4; p = 0.01).

CONCLUSIONS

Our study objectively demonstrates significant association of ESAP and early mortality with primary cytokine response, and development of IPN with persistent HLA-DR down-regulation.

Randomized trial of a dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sensor-augmented pump therapy

AIMS

To test whether adjusting insulin and glucagon in response to exercise within a dual-hormone artificial pancreas (AP) reduces exercise-related hypoglycaemia.

MATERIALS AND METHODS

In random order, 21 adults with type 1 diabetes (T1D) underwent three 22-hour experimental sessions: AP with exercise dosing adjustment (APX); AP with no exercise dosing adjustment (APN); and sensor-augmented pump (SAP) therapy. After an overnight stay and 2 hours after breakfast, participants exercised for 45 minutes at 60% of their maximum heart rate, with no snack given before exercise. During APX, insulin was decreased and glucagon was increased at exercise onset, while during SAP therapy, subjects could adjust dosing before exercise. The two primary outcomes were percentage of time spent in hypoglycaemia (<3.9 mmol/L) and percentage of time spent in euglycaemia (3.9-10 mmol/L) from the start of exercise to the end of the study.

RESULTS

The mean (95% confidence interval) times spent in hypoglycaemia (<3.9 mmol/L) after the start of exercise were 0.3% (-0.1, 0.7) for APX, 3.1% (0.8, 5.3) for APN, and 0.8% (0.1, 1.4) for SAP therapy. There was an absolute difference of 2.8% less time spent in hypoglycaemia for APX versus APN (p = .001) and 0.5% less time spent in hypoglycaemia for APX versus SAP therapy (p = .16). Mean time spent in euglycaemia was similar across the different sessions.

CONCLUSIONS

Adjusting insulin and glucagon delivery at exercise onset within a dual-hormone AP significantly reduces hypoglycaemia compared with no adjustment and performs similarly to SAP therapy when insulin is adjusted before exercise.

Review of spectrum and sensitivity of bacterial bloodstream isolates in children with malignancy: A retrospective analysis from a single center

BACKGROUND

Febrile neutropenia is a life-threatening emergency in pediatric cancer patients. Its management is based on established guidelines that emphasize on prompt action. Consideration of local microbiologic spectrum and its susceptibility is pivotal in devising a rational protocol.

AIMS

To study the spectrum of bacterial isolates and its antibiotic sensitivity profile in bloodstream infections (BSIs) of pediatric cancer patients.

SETTINGS AND DESIGN

Retrospective study.

MATERIALS AND METHODS

This study was conducted at a tertiary cancer center for pediatric cancer patients. Blood culture samples sent during the evaluation of patients with clinical diagnosis of febrile neutropenia during the year of 2013 were analyzed. The microbiological and antibiotic sensitivity patterns were studied.

RESULTS

A total of 27 isolates represented BSIs out of 412 blood cultures sent (6.5%). These were predominantly Gram-negative (92%) with Klebsiella contributing to the majority of them. Extended spectrum beta-lactamase production was seen in 59% of all isolates. Multidrug resistance phenotype was seen in 48%, extreme drug resistance in 32% and pan drug resistance in 16% of Gram-negative isolates. Klebsiella predominated in all of these isolates. Mortality resulted in 15% isolates, majorly contributed by Klebsiella. Colistin was the most sensitive antibiotic (75% sensitivity) and in significant number of cases the only salvage option.

CONCLUSION

Gram-negative bacteria are the most common etiologic agents. The emergence of drug resistant strains of Klebsiella and the poor sensitivity of most of these strains to common first choice empiric agents is alarming. Low prevalence of Gram-positive organisms questions the routine use of empiric vancomycin.

X-ray and radio emission from the luminous supernova 2005kd

SN 2005kd is among the most luminous supernovae (SNe) to be discovered at X-ray wavelengths. We have re-analysed all good angular resolution (better than 20 arcsec full width at half-maximum point spread function) archival X-ray data for SN 2005kd. The data reveal an X-ray light curve that decreases as t ^-1.62±0.06. Our modelling of the data suggests that the early evolution is dominated by emission from the forward shock in a high-density medium. Emission from the radiative reverse shock is absorbed by the cold dense shell formed behind the reverse shock. Our results suggest a progenitor with a mass-loss rate towards the end of its evolution of ≥4.3 × 10^-4 M_⊙ yr^-1, for a wind velocity of 10 km s^-1, at 4.0 × 10¹⁶ cm. This mass-loss rate is too high for most known stars, except perhaps hypergiant stars. A higher wind velocity would lead to a correspondingly higher mass-loss rate. A luminous blue variable star undergoing a giant eruption could potentially fulfill this requirement, but would need a high mass-loss rate lasting for several hundred years, and need to explain the plateau observed in the optical light curve. The latter could perhaps be due to the ejecta expanding in the dense circum-stellar material at relatively small radii. These observations are consistent with the fact that Type IIn SNe appear to expand into high-density and high mass-loss rate environments, and also suggest rapid variability in the wind mass-loss parameters within at least the last 5000 yr of stellar evolution prior to core-collapse.

Motivators and deterrents to blood donation among Black South Africans: a qualitative analysis of focus group data

BACKGROUND AND OBJECTIVES

South Africa has a markedly skewed representation where the majority of blood (62%) is presently collected from an ethnically White minority. This study seeks to identify culturally specific factors affecting motivation of donors in South Africa.

MATERIALS AND METHODS

We performed a qualitative study to evaluate motivators and deterrents to blood donation among Black South Africans. A total of 13 focus groups, comprising a total of 97 Black South Africans, stratified by age and geographic location were conducted. Transcripts of the interviews were analysed using a coding framework by Bednall & Bove.

RESULTS

Participants made 463 unique comments about motivators focusing primarily on promotional communications (28%), incentives (20%) and prosocial motivation (16%). Participants made 376 comments about deterrents which focused primarily on fear (41%), negative attitudes (14%) and lack of knowledge (10%).

CONCLUSION

Although prosocial motivation (altruism) was the most frequently mentioned individual motivator, promotional communication elicited more overall comments by participants. As reported by many authors, fear and lack of awareness were strong deterrents, but scepticism engendered by perceived racial discrimination in blood collection were unique to the South African environment.

The pro-apoptotic role of autophagy in breast cancer

BACKGROUND

Autophagy is a catabolic process that has a vital role in cancer progression and treatment. Current chemotherapeutic agents, which target autophagy, result in growth inhibition in many cancer types. In this study, we examined the role of autophagy in breast cancer (BCa) patients as well as BCa cell lines.

METHODS

Tissue microarray was used to detect the expression of an autophagy marker, LC3B in BCa patients (normal/hyperplasia=8; grade-I=15, grade-II=84, and grade-III=27) and BCa cell lines. To modulate the activation of autophagy, we used novel herbal compound nimocinol acetate (NA) in BCa cell lines and the anticancer activity was measured by phenotypic and molecular analysis.

RESULTS

LC3B is highly expressed in tumours as compared with normal tissues. Activation of LC3B in NA-treated BCa (MCF-7 and MDA-MB-231) cells was evident as compared with other autophagy makers. Further, our results confirmed that NA-transcriptionally regulates LC3B (as confirmed by mRNA levels and reporter assay), which resulted in the formation of acidic autophagy vesicles and autolysosomes in BCa cells. Nimocinol acetate inhibited mTOR-mediated pro-survival signalling that resulted in inhibition of growth in BCa cells without affecting normal breast epithelial cells. Downregulation of LC3B expression by siRNA significantly inhibited the anticancer effects of NA in BCa cells.

CONCLUSIONS

Together, our results suggest that LC3B is highly expressed in BCa tissues and increasing the threshold of LC3B activation dictates the pro-apoptotic function, which in turn, suppresses the growth of BCa cells. Nimocinol acetate could be a potential agent for treatment of BCa.

Development of the hearing protection assessment (HPA-2) questionnaire

BACKGROUND

Noise-induced hearing loss (NIHL) remains an important occupational health issue as the second most commonly self-reported occupational injury or illness. The incorrect and inconsistent use of hearing protection devices (HPDs) compromises their effectiveness in preventing NIHL.

AIMS

To describe the development of an easily administered yet robust questionnaire to investigate factors that influence HPD use.

METHODS

A hearing protection assessment (HPA-2) questionnaire was developed using items based on themes identified in our previous research. These fell into two classes: supports and barriers to wearing HPD, which formed two scales within the questionnaire. The questionnaire, which also included demographic items, was administered to workers from 34 manufacturing companies. The internal consistency of the scales was tested, and factor analysis was conducted to investigate the underlying structure of the scales.

RESULTS

Of the 1053 questionnaires distributed, 555 completed questionnaires were received giving a response rate of 53%. The Cronbach's alpha for the barriers scale (α = 0.740) and supports scale (α = 0.771) indicated strong internal reliability of the questionnaire. The supports and barriers were further described as five key factors (risk justification, HPD constraints, hazard recognition, behaviour motivation and safety culture) that influence hearing protection behaviour. Workers who reported always using HPDs had more supports across these factors, while those who did not always wear HPDs reported more barriers.

CONCLUSIONS

The HPA-2 questionnaire may be useful in both research and interventions to understand and motivate hearing protection behaviour by identifying and targeting supports and barriers to HPD use at different levels of the ecological model.